Every finding on record at Portside Health & Rehab Center

Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop/implement a baseline care plan for two of 43 residents in the survey sample, Resident #176 (R176) and R177. The findings include: 1. A. The facility failed to develop a baseline care plan to include PTSD (post-traumatic stress disorder) for R176. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/3/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and eating. Section I: PTSD yes. PTSD is listed on R176's problem list. A review of the baseline care plan dated 11/26/24 did not reveal PTSD as a problem. A review of the physician order dated 12/5/24 revealed, Buspar 7.5 mg po twice daily. An interview was conducted on 12/11/24 at 2:05 PM with LPN (licensed practical nurse) #1. When asked if there should be specific care outlined for a resident with a diagnosis of PTSD, LPN #1 stated, yes, there should be. When asked where that care would be documented, LPN #1 stated, it would be in the care plan. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. A review of the facility's Interim Baseline Care Plan policy, reveals, Within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will be used until the comprehensive assessment and care plan is developed by the interdisciplinary team. No further information was provided prior to exit. 1.B. The facility failed to develop a baseline care plan to include monitoring of anticoagulation therapy for R176. A review of the physician's order dated 11/27/24 revealed, Eliquis 5 mg po twice daily. A review of the MAR did not reveal evidence of anticoagulation monitoring. On 12/11/24 at 2:05 PM, an interview was conducted with LPN (licensed practical nurse) #1, when asked if anticoagulation monitoring should be on the care plan, LPN #1 stated, yes, we should be monitoring for bleeding and bruising. When asked if a physician's order is required, LPN #1 stated, no, it is nursing practice. On 12/12/24 at 8:16 AM, an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated residents who receive anticoagulant medication such as Eliquis should have a physician's order for nurses to monitor for a risk of bleeding every shift. LPN #4 stated nurses' evidence this monitoring is done by signing off the order on the MAR (medication administration record). On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 2. A. The facility failed to develop a baseline care plan to include dialysis for R177. R177 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), convulsions and atrial fibrillation. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/2/24, coded the resident as scoring a 01 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers and eating. Section I: ESRD checked and Section O: oxygen: yes. A review of the baseline care plan dated 11/27/24 did not reveal dialysis as a problem/approach. A review of the physician order dated 11/27/24 revealed, Dialysis Monday, Wednesday, Friday at 9:00 AM. An interview was conducted on 12/11/24 at 2:05 PM with LPN (licensed practical nurse) #1. When asked if there should be specific care outlined for a resident with a diagnosis of ESRD, receiving dialysis, LPN #1 stated, yes, there should be. When asked where that care would be documented, LPN #1 stated, it would be in the care plan. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. A review of the facility's Interim Baseline Care Plan policy, reveals, Within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will be used until the comprehensive assessment and care plan is developed by the interdisciplinary team. No further information was provided prior to exit. 2. B. The facility failed to develop a baseline care plan to include oxygen therapy for R177. A review of the baseline care plan dated 11/27/24 did not reveal oxygen therapy as a problem/approach. A review of the physician orders dated 12/1/24 revealed, Oxygen: Administer oxygen(O2) via nasal cannula (NC)continuously at: 2lpm via nasal cannula. An interview was conducted on 12/11/24 at 2:05 PM with LPN (licensed practical nurse) #1. When asked if there should be specific care outlined for a resident receiving oxygen therapy, LPN #1 stated, yes, there should be. When asked where that care would be documented, LPN #1 stated, it would be in the care plan. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 2. C. The facility failed to implement a baseline care plan to for fluid restriction for R177. A review of the baseline care plan dated 11/27/24 revealed, PROBLEM: Resident has increased nutrition/hydration risk related to therapeutic diet/fluid restriction, ESRD/HD dependent. APPROACH: Provide fluids per ordered restriction. A review of the physician order dated 11/29/24 revealed, Fluid Restriction 1200cc/24hr. Special Instructions: 1200ccFluid Restriction Dietary to give 840cc BRKFST=360CC, LUNCH= 240CC, DINNER=240CC. Nursing to give 360cc: 1 SHIFT=180CC, 2 SHIFT=180CC. A review of the November and December MAR (medication administration record) revealed, 180 cc fluid restriction exceeded on day/evening shift on 11/30, 12/1, 12/2, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10 and 12/11; 180 cc fluid restriction exceeded on evening shift on 11/29, 11/30, 12/2, 12/3, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10 and 12/11. An interview was conducted on 12/12/24 at 9:30 AM with LPN (licensed practical nurse) #2. When asked if the fluid restriction orders had not been followed, had the care plan been implemented, LPN #2 stated, no, it was not implemented. On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for four of 43 residents in the survey sample, Residents #23, #70, #10 and #20. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence a bed inspection prior to the use of bed rails. On 12/9/24 at 8:04 p.m., an observation was made of R23 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 9:39 a.m. revealed R23 in bed with bilateral upper bed rails in place. A physician's order dated 11/25/24 for R23 documented Bedrails as tolerated r/t (related to) bed mobility. An enabler-restraint observation for R23 dated 11/21/24 documented the use of 1/4 side rails bilaterally. The assessment failed to evidence a bed inspection for safety. The comprehensive care plan for R23 failed to evidence the use of bed rails. A review of the facility's bed and rail maintenance evaluation book documented all facility beds inspected on 12/10/24. On 12/11/24 at 12:35 p.m., an interview was conducted with OSM (other staff member) #3, the maintenance director who stated that to his knowledge bed inspections were conducted quarterly or at a minimum annually. OSM #3 stated that he had searched for any inspections of the beds and was not able to find anything, so he and his staff had conducted facility wide inspections on 12/10/24. The facility policy Bed Identification and Safety Inspection Policy revised 1/25/24 documented in part, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the resident's functional abilities. Whenever a bed/side rail or grab/enabler bar or anything else is attached to the bedframe or added to the bed environment/system, evaluation of the entrapment zones as laid out below will occur . Inspections will be completed annually and as needed when bed/mattress configuration changes. The inspection checklists will be kept in a separate binder or tab kept current by environmental services/ maintenance. The checklists will be kept for a minimum of 3 years . On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 2. For Resident #70 (R70), the facility staff failed to evidence a bed inspection prior to the use of bed rails. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with bilateral upper bed rails in place. A physician order dated 8/14/24 for R70 documented Bedrails as tolerated. An enabler-restraint observation for R70 dated 11/21/24 documented the use of 1/4 side rails bilaterally. The assessment failed to evidence a bed inspection for safety. The comprehensive care plan for R70 failed to evidence the use of bed rails. A review of the facility's bed and rail maintenance evaluation book documented all facility beds inspected on 12/10/24. On 12/11/24 at 12:35 p.m., an interview was conducted with OSM (other staff member) #3, the maintenance director who stated that to his knowledge bed inspections were conducted quarterly or at a minimum annually. OSM #3 stated that he had searched for any inspections of the beds and was not able to find anything, so he and his staff had conducted facility wide inspections on 12/10/24. On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 3. For Resident #10 (R10), the facility staff failed to evidence a bed inspection prior to the use of bed rails. On 12/9/24 at 8:24 p.m., an observation was made of R10 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 9:28 a.m. revealed R10 in bed with bilateral upper bed rails in place. An enabler-restraint observation for R10 dated 11/21/24 documented the use of 1/4 side rails bilaterally. The assessment failed to evidence a bed inspection for safety. The comprehensive care plan for R10 documented in part, Bed rails to be used as ordered. Approach Start Date: 06/12/2024 . The physician orders for R10 failed to evidence an order for bed rails. A review of the facility's bed and rail maintenance evaluation book documented all facility beds inspected on 12/10/24. On 12/11/24 at 12:35 p.m., an interview was conducted with OSM (other staff member) #3, the maintenance director who stated that to his knowledge bed inspections were conducted quarterly or at a minimum, annually. OSM #3 stated that he had searched for any inspections of the beds and was not able to find anything, so he and his staff had conducted facility wide inspections on 12/10/24. On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 4. For Resident #20 (R20), the facility staff failed to evidence a bed inspection prior to the use of bed rails. On 12/9/24 at 7:59 p.m., an observation was made of R20 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 8:39 a.m. revealed R20 in bed with bilateral upper bed rails in place. A physician order dated 9/20/24 for R20 documented Bedrails on bilateral sides as tolerated. An enabler-restraint observation for R20 dated 11/21/24 documented the use of 1/4 side rails bilaterally. The assessment failed to evidence a bed inspection for safety. The comprehensive care plan for R20 failed to evidence the use of bed rails. A review of the facility's bed and rail maintenance evaluation book documented all facility beds inspected on 12/10/24. On 12/11/24 at 12:35 p.m., an interview was conducted with OSM (other staff member) #3, the maintenance director who stated that to his knowledge bed inspections were conducted quarterly or at a minimum annually. OSM #3 stated that he had searched for any inspections of the beds and was not able to find anything, so he and his staff had conducted facility wide inspections on 12/10/24. On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for four of 43 residents, R25, R124, R125 and R10. The findings include: 1. The facility failed to provide an accurate assessment including dialysis treatment for R25. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), Sepsis and bilateral osteoarthritis. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 10/18/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for transfer/dressing/toileting and eating. Section O: dialysis not checked. A review of the comprehensive care plan dated 11/27/24 revealed, PROBLEM: Resident has increased nutrition /hydration risk related to: ESRD and diet / fluid restriction. APPROACH: Dialysis Monday, Wednesday and Friday. A review of the physician orders dated 10/12/24 revealed, dialysis in center 11:00 AM chair time, pick up at 10:30am, M_W_F. Davita dialysis in centerHarborview. M-W-FSpecial Instructions: 11amchairtime, pick up at 10:30am, M_W_F An interview was conducted with LPN (licensed practical nurse) #5, the MDS coordinator. When asked to review R25's 10/18/24 MDS, LPN #5 stated, he was not coded for dialysis and that will be modified. When asked the standard for completing a MDS, LPN #5 stated, we use the RAI (resident assessment instrument). On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 2. The facility failed to provide an accurate assessment including discharge disposition for R124 on the 10/31/24 MDS. During the closed record review, R124 was identified for review for hospitalization . MDS dated [DATE] coded the resident as discharge disposition to short term hospital. Resident #124 was admitted to the facility on [DATE] with diagnosis that included but were not limited to gangrene, osteomyelitis, Diabetes and below the knee amputation. A review of the progress note dated 10/31/24 at 9:42 PM revealed, Resident was discharged from facility, with wife present, completed antibiotic no noted toxicity symptoms, vitals within normal limits, educated on all order discharge instruction and follow up appointments, verbalized understanding, skin check completed, left via vehicle. An interview was conducted with LPN (licensed practical nurse) #5, the MDS coordinator. When asked to review R124's 10/18/24 MDS, LPN #5 stated, he was coded for hospitalization under Section A, when he went home with wife and that will be modified. When asked the standard for completing a MDS, LPN #5 stated, we use the RAI (resident assessment instrument). On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 3. The facility failed to provide an accurate assessment including discharge disposition for R125. During the closed record review, R125 was identified for review for hospitalization . MDS dated [DATE] coded the resident as discharge disposition to home. Resident #125 was admitted to the facility on [DATE] with diagnosis that included but were not limited to infection and post spinal surgery. A review of the progress note dated 10/31/24 revealed, Resident's husband met her at the doctor's office. Resident was transferred to the hospital as the doctor did not feel that her surgical site was healing properly. An interview was conducted with LPN (licensed practical nurse) #5, the MDS coordinator. When asked to review R125's 10/18/24 MDS, LPN #5 stated, she was coded to go home and she went to the hospital from the doctor's office and that will be modified. When asked the standard for completing a MDS, LPN #5 stated, we use the RAI (resident assessment instrument). On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 42106 4. For Resident #10 (R10), the facility staff failed to complete the pain assessment interview of section J of the MDS (minimum data set) assessment. Review of the annual MDS with an ARD (assessment reference date) of 9/12/2024, R10 was assessed as scoring 7 out of 15 on the BIMS (brief interview for mental status) assessment indicating that they were moderately impaired for making daily decisions. Section J documented in part, J0200. Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea). Enter Code. 0. No (resident is rarely/never understood). Skip to and complete J0800, Indicators of Pain or Possible Pain . Section J0800 was observed to be blank. On 12/12/24 at 8:41 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. LPN #5 stated that when completing Section J, they always interviewed or attempted the interview for pain. She stated that the interview was done to determine whether the resident had pain. LPN #5 reviewed Section J of R10's annual MDS with the ARD of 9/12/24 and stated that she would have to investigate why it was not completed. On 12/12/24 at 9:11 a.m., LPN #5 stated that she had reviewed the MDS and R10 was not interviewed for the pain interview portion of Section J, and they should have been. She stated that she thought that it was an oversight. According to the RAI (resident assessment instrument) manual version 1.19.1, effective 10/1/24, pages J-4 through J-5 documented in part, .Health-related Quality of Life: Most residents who are capable of communicating can answer questions about how they feel. Obtaining information about pain directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying pain. Planning for Care: Interview allows the resident's voice to be reflected in the care plan. Information about pain that comes directly from the resident provides symptom-specific information for individualized care planning . Coding Instructions Attempt to complete the interview with all residents . On 12/12/24 at approximately 2:09 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for four of 43 residents in the survey sample, Residents #15, #75, #8, and #70. The findings include: 1. For Resident #15 (R15), the facility staff failed to implement the resident's comprehensive care plan for anticoagulant therapy. R15's comprehensive care plan dated 8/15/24 documented, (R15) is on Anticoagulant therapy .assess/document/report to nurse/MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs). A review of R15's clinical record revealed a physician's order dated 11/12/24 for Eliquis (1) 5 mg (milligrams) twice a day for atrial fibrillation. A review of R15's MARs (medication administration records) for November 2024 and December 2024 revealed the resident was administered Eliquis 5 mg two times a day 11/12/24 through 12/11/24. Further review of R15's clinical record (including physician's orders, MARs, and nurses' notes for November 2024 and December 2024) failed to reveal the resident was monitored for side effects (bleeding) from Eliquis. On 12/12/24 at 8:16 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated residents who receive anticoagulant medication such as Eliquis should have a physician's order for nurses to monitor for a risk of bleeding every shift. LPN #4 stated nurses evidence this monitoring is done by signing off the order on the MAR. On 12/12/24 at 8:29 a.m., another interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of the care plan is, For the patient and their care throughout the facility. LPN #4 stated nurses can reference residents' care plans to ensure they are implemented. On 12/12/24 at 2:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Care Planning Policy documented, D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. No further information was presented prior to exit. Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds& 42183 2. The facility staff failed to develop the comprehensive care plan for anticoagulation monitoring for Resident #75. Resident #75 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), diabetes and cardiovascular accident. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/17/24, coded the resident as scoring a 06 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section N-medications coded the resident as anticoagulant-yes. A review of the comprehensive care plan dated 9/11/24 revealed, no evidence of anticoagulation monitoring. A review of the physician orders dated 12/24/22 revealed, Eliquis 2.5mg po twice a day. An interview was conducted on 12/12/24 at 10:30 AM with RN (registered nurse) #1. When asked the purpose of the care plan, RN #1 stated, to outline the care needs for each resident. When asked if anticoagulation monitoring should be included on the care plan, RN #1 stated yes, it should be included. When asked what should be included, RN #1 stated, monitoring for signs of bleeding, bruising, making sure there are fall preventions in place. On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit. 27660 3. For Resident #8 (R8), the facility staff failed to implement the care plan to give blood pressure medications per the physician orders. The comprehensive care plan dated, 8/27/24, documented in part, Problem: Resident has risk of cardiovascular complications related to dx (diagnosis) of HF (heart failure), hypertension (high blood pressure), respiratory failure and anemia. The Approach documented in part, Administer medications as ordered. An interview was conducted with R8 on 12/3/24 at 11:53 a.m. She stated she didn't get her blood pressure medications as ordered. The physician orders dated, 3/4/24, documented, Amlodipine tablet; 2.5 mg (milligram); 1 tablet by mouth at bedtime for HTN (high blood pressure) hold for SBP (systolic blood pressure) < (less than) 110. Carvedilol tablet 6.5 mg; Give 1 tablet two times a day. Hold if systolic B/P (blood pressure) < 110 or Pulse < 60. The October 2024 MAR (medication administration record) documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Amlodipine: 10/6/24 - BP (blood pressure) - 102/78 10/29/24 - nothing was documented as given. Carvedilol: 10/6/24 - BP - 102/78 10/24/24 - nothing was documented for the morning dose. 10/29/24 - nothing was documented for the evening dose. The November 2024 MAR documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Amlodipine: 11/5/24 - BP - 109/57 11/9/24 - BP - 107/59 11/18/24 - BP 109/73 11/25/24 - BP - 103/61 Carvedilol: 11/5/24 - evening dose - BP - 109/57 11/6/24 - morning dose - BP - 109/57 11/9/24 - evening dose - BP - 107/59 11/18/24 - evening dose - BP - 109/73 11/22/24 - morning dose - Pulse - 59 11/25/24 - evening dose - BP 103/61 The December 2024 MAR documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Carvedilol: 12/4/24 - morning dose - nothing was documented. On 12/12/24 at 8:29 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of the care plan is, For the patient and their care throughout the facility. LPN #4 stated nurses can reference residents' care plans to ensure they are implemented. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a692044.html (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697042.html 2.b. For Resident #8 (R8), the facility staff failed to implement the care plan to give insulin per the physician orders. The comprehensive care plan dated, 8/26/24, documented in part, Problem: Resident has potential for complications of hypo/hyperglycemia (low and high blood sugars) d/t (due to) dx (diagnosis) of diabetes mellitus. The Approach documented in part, Administer medications as ordered. The physician order dated, 8/11/24, documented in part, Humalog Kwik Pen Insulin (insulin lispro) (a short acting insulin to treat diabetes) (3), administer before meals and at bedtime. Amount to administer: If blood sugar is less than 60, call MD (medical doctor) If blood sugar is 150 - 199. give 2 units If blood sugar is 200 - 249, give 4 units If blood sugar is 250 - 299, give 6 units If blood sugar is 300 - 349, give 8 units If blood sugar is 350 - 400, give 10 units If blood sugar is greater than 400, give 10 units If blood sugar is greater than 400, call MD. The October 2024 MAR documented the above order. On 10/14/24 for the 7:00 a.m. to 9:00 a.m. dose, the box was blank. The November 2024 MAR documented the above order. On 11/1/24 for the 4:15 p.m. to 6:45 p.m. dose, the box was blank. On 11/2/24, 11/6/24 and 11/15/24, the box was blank for the 7:00 a.m. to 9:00 a.m. dose. The physician order dated, 3/29/24, documented. The December 2024 MAR documented the above order. On 12/5/24 for the 7:00 a.m. to 9:00 a.m. dose, the box was blank. The physician order dated, 3/29/24, documented, Humalog U - 100 insulin (insulin lispro) (short acting insulin to treat diabetes) (3) solution; 100 units/mL (milliliter); Administer 15 units, subcutaneously three times a day. The October 2024 MAR documented the above order. On 10/14/24 at 8:00 a.m. and 10/24/24 at 12:00 p.m. there was a blank in the box for administration. The November 2024 MAR documented the above order. On 11/2/24, 11/6/24 and 11/15/24 at 8:00 a.m. there were blanks in the box for administration. The December 2024 MAR documented the above order. On 12/6/24 at 8:00 a.m. there was a blank in the box for administration. The physician order dated, 8/11/24, documented, Insulin glargine - yfgn (long-acting insulin to treat diabetes) (4); administer 30 units subcutaneously every morning between 8:00 a.m. and 11:00 a.m. Insulin glargine - yfgn; administer 45 units subcutaneously at bedtime. The October 2024 MAR documented the above orders. On 10/24/24 for the morning dose, there was a blank in the box for administration. On 10/29/24 at bedtime, there was a blank in the box for administration. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html 42106 4. For Resident #70 (R70), the facility staff failed to develop the comprehensive care plan to include the use of an elbow splint. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed. R70 was observed with limited range of motion (ROM) in the right hand. No splinting device was observed in use. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with no splinting device and limited ROM in the right hand. The comprehensive care plan for R70 failed to address the limited range of motion or use of any splinting devices. The most recent OT (occupational therapy) evaluation and plan of treatment dated 8/14/24-9/11/24 documented treatments including but not limited to splinting and increasing finger flexion. The evaluation documented a right upper extremity contracture and impairment of the right hand. Under Recommendations it documented Splint/Orthotic Recommendations: It is recommended the patient wear an elbow extension splint on right elbow for during daily tasks in order to inhibit abnormal reflex patterns, develop/establish wearing schedule, inhibit abnormal positions and adapt/modify splint device. The OT discharge summary for R70 dated 9/11/24 documented in part, .Maximum potential achieved, referred for RNP (restorative nursing program) .Discharge Recommendations: RNP, splinting . The physician's orders for R70 failed to evidence an order for the use of a splinting device. On 12/11/24 at 11:49 a.m., an interview was conducted with OSM (other staff member) #1, the director of rehab. OSM #1 stated that they were not currently working with R70 but had seen them in the past. She stated that R70 was last discharged from OT on 9/11/24 with recommendations for restorative nursing and splinting. On 12/11/24 at approximately 12:00 p.m., a request was made to ASM (administrative staff member) #5, administrative support for evidence of splint therapy for R70 from 9/11/24 to the present. On 12/11/24 at approximately 3:00 p.m., ASM #5 provided a Therapy Education Form for R70 which documented a therapy referral to nursing for splinting for 1-2 hours daily and bilateral upper extremity exercises with movement in all planes within the patient's abilities to begin on 9/26/24. A Restorative Nursing Program Manual dated 9/11/24 for R70 documented instructions for restorative nursing staff for the resident's ability to perform tasks and assistance needed. The documents provided failed to evidence documentation of splinting completed by staff as recommended by therapy at discharge from services. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3 who stated that the purpose of the care plan was to show the goals of care for the resident and the things they needed to do to help the resident reach their goals. She stated that the interdisciplinary team developed the care plan. On 12/12/24 at 8:29 a.m., an interview was conducted with LPN #4. LPN #4 stated the purpose of the care plan was for the patient and their care throughout the facility. LPN #4 stated that she would expect a splint to be on the care plan so that everyone knew what to do for care of the resident. On 12/12/24 at 9:15 a.m., an interview was conducted with CNA (certified nursing assistant) #4, restorative aide who stated that R70 had orders for a splint to the right arm/elbow and for range of motion/stretching exercises. She stated that the other restorative aide recently resigned, and she was not aware of the treatment for R70 until today and she had completed the treatment that morning. She stated that the documentation was placed in the medical record under the POC (plan of care) charting. Review of the POC documentation for R70 documented the passive range of motion last completed for R70 on 10/31/24 and splinting last completed on 10/28/24. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to review and/or revise the comprehensive care plan for four of 43 residents in the survey sample, Residents #23, #70, #20 and #89. The findings include: 1. For Resident #23 (R23), the facility staff failed to revise the care plan for the use of bed rails. On 12/9/24 at 8:04 p.m., an observation was made of R23 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 9:39 a.m. revealed R23 in bed with bilateral upper bed rails in place. The comprehensive care plan for R23 documented in part, Problem Start Date: 08/07/2024. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential, Resident is ADL deficit based on limited ability to maintain grooming/personal hygiene r/t (related to) dx. (diagnoses) of CVA (cerebrovascular accident), Hemiplegia, Anemia, Dementia and contracture of muscles- multiple sites. Edited: 09/12/2024. The care plan for R23 failed to evidence the use of bed rails. A physician's order dated 11/25/24 for R23 documented Bedrails as tolerated r/t (related to) bed mobility. An enabler-restraint observation for R23 dated 11/21/24 documented the use of 1/4 side rails bilaterally as an enabler to assist with proper body alignment, posture, assisting with ADLs, defining the boundaries of the bed for the resident, and to increase the feeling of safety and security. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3 who stated that the purpose of the care plan was to show the goals of care for the resident and the things they needed to do to help the resident reach their goals. She stated that the interdisciplinary team reviewed and revised the care plan and that bed rails should be on the care plan because the staff would need to know the reason why the resident had the bed rails. The facility policy Comprehensive Care Planning Policy revised 3/2/21 documented in part, .The Resident Care Conference meets as scheduled to discuss each resident, review the previous Care Plan and to finalize the development of the current care plan. Adjustments are made by the interdisciplinary team to ensure that all programs and identified category of needs are addressed and that the plan is oriented toward preventing a decline in functioning. Plans for discharge are reviewed, revised and addressed accordingly . There may be additional problem areas not triggered by the MDS, which will need to be addressed in the Care Plan . On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 2. For Resident #70 (R70), the facility staff failed to revise the comprehensive care plan for the use of bed rails. A. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with bilateral upper bed rails in place. The comprehensive care plan for R70 documented in part, Problem Start Date: 09/24/2024. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential, Resident has ADL self-care deficit based on dx. (diagnoses) of Anoxic brain damage, Functional Quadriplegia, muscle weakness, Anemia, and Epilepsy. Created: 09/24/2024. The care plan for R70 failed to evidence the use of bed rails. A physician order dated 8/14/24 for R70 documented Bedrails as tolerated. An enabler-restraint observation for R70 dated 11/21/24 documented the use of 1/4 side rails bilaterally as an enabler to assist with proper body alignment, posture, assisting with ADLs, defining the boundaries of the bed for the resident, and to increase the feeling of safety and security. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3 who stated that the purpose of the care plan was to show the goals of care for the resident and the things they needed to do to help the resident reach their goals. She stated that the interdisciplinary team reviewed and revised the care plan and that bed rails should be on the care plan because the staff would need to know the reason why the resident had the bed rails. On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 3. For Resident #20 (R20), the facility staff failed to revise the comprehensive care plan for the use of bed rails. On 12/9/24 at 7:59 p.m., an observation was made of R20 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 8:39 a.m. revealed R20 in bed with bilateral upper bed rails in place. The comprehensive care plan for R20 documented in part, Problem Start Date: 08/06/2024. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential, Resident has an ADL self-care deficit based on hx. (history) of muscle weakness, Anemia, Depression, Anxiety, limited ROM (range of motion), and Lupus. Edited: 12/09/2024. The care plan for R20 failed to evidence the use of bed rails. A physician order dated 9/20/24 for R20 documented Bedrails on bilateral sides as tolerated. An enabler-restraint observation for R20 dated 11/21/24 documented the use of 1/4 side rails bilaterally as an enabler to assist with proper body alignment, posture, assisting with ADLs (activities of daily living), defining the boundaries of the bed for the resident, and to increase the feeling of safety and security. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3 who stated that the purpose of the care plan was to show the goals of care for the resident and the things they needed to do to help the resident reach their goals. She stated that the interdisciplinary team reviewed and revised the care plan and that bed rails should be on the care plan because the staff would need to know the reason why the resident had the bed rails. On 12/11/24 at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit. 27660 4. For Resident #89, the facility staff failed to review and revise the comprehensive care plan for the use of an indwelling catheter. The comprehensive care plan dated, 7/11/24, documented in part, Problem: Urinary Incontinence: Incontinence d/t (due to) dx (diagnosis) of muscle weakness, lack of coordination, dementia and Alzheimer's. The Approach failed to evidence any documentation related to the use of an indwelling catheter. On 12/10/24 at 8:45 a.m. Resident was observed in bed, an indwelling catheter bag was noted hanging off the bedframe. The physician orders dated, 7/8/24, documented, Change foley (indwelling) catheter as needed. 18 fr (french) 10 cc (cubic centimeters). Special Instructions: Document catheter (french) and balloon (ml - milliliters) size inserted PRN (as needed). Further review of the physician orders failed to evidence an order for indwelling catheter care. Review of the MAR for October, November and December 2024, failed to evidence documentation of indwelling catheter care. An interview was conducted with LPN (licensed practical nurse) #4 on 12/12/24 at 8:10 a.m., LPN #4 stated the purpose of the care plan is, For the patient and their care throughout the facility. LPN #4 stated nurses can reference residents' care plans to ensure they are implemented. The care plan is updated throughout the resident's stay for a change in condition or any updates to their care. On 12/12/24 at 1:39 p.m. ASM (administrative staff member) #2, the director of nursing, stated the facility had no evidence of indwelling catheter care for R89. ASM #1, the administrator, and ASM #2, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit.

Based on resident interview, observation, staff interview, and clinical record review, it was determined the facility staff failed to administer medications and/or treatments per the physician orders for two of 43 residents in the survey sample, Residents #32 and #8. The findings include: 1. For Resident #32 (R32), the facility staff failed to apply treatments, to include benzocaine (1) and telfa (non-stick dressing), to the resident's legs per the physician order. An interview was conducted with R32 on 12/10/24 at 2:25 p.m. The resident stated he had vascular wounds on both of his legs. He stated the facility runs out of the non-adhesive dressings and then when they are done the next time, the dressings they have put on sticks to the wounds and when pulled off, even after the nurse wets them with wound cleanser, it pulls off the healing tissue. The physician order dated 3/6/24, documented, Clean left leg with DWC (wound cleanser), pat dry, apply benzocaine to wound bed, place telfa pad, ABD (abdominal pad) and gauze daily and PRN (as needed). Clean right leg with DWC, pat dry, apply benzocaine to wound bed, place telfa pad, ABD and gauze every night and PRN. Observation was made of LPN (licensed practical nurse) #7, the wound care nurse, on 12/11/24 at 2:28 p.m., perform the dressing changes on R32's bilateral legs. Resident #32 was premedicated with pain medication prior to the dressing change. The resident had his eyes closed when we entered the room. LPN #7 started with the left leg. The current dressing was dated 12/11/24 - 7P - 7 a. LPN #7 removed the gauze wrap. She then proceeded to remove the ABD. The dressing stuck to the resident's open areas and proceeded to bleed from two of the open areas. The resident stated, ouch, when the dressing was removed. There was no telfa dressing on the leg. LPN #7 proceeded to clean the leg with wound cleanser, patted the leg dry and applied the telfa pads, ABD and gauze wrap. LPN #7 proceeded to change the dressing on the right leg. She removed the gauze wrap and ABD pad. Again, there was no telfa pad on the resident's leg and one open area proceeded to bleed. The resident stated, ouch, when the dressing was removed. LPN #7 proceeded to clean the right leg with wound cleanser, patted it dry and applied the telfa pads, ABD and gauze. When asked if the resident was to have any ointments applied to the wounds, LPN #7 stated, no, it's just cleaning the area and applying the telfa, ABD and gauze wrap. Observation was made on 12/11/24 at 3:03 p.m. with RN (registered nurse) #1 of the treatment cart on R32's unit. There were no telfa pads on the cart. RN #1 stated that if the nurse's don't have it on the cart, they can go to the supply room or even to the other unit to find them. When asked if she has ever run out of the telfa pads, RN #1 stated, no. The facility policy, Skin and Wound Care Best Practices, documented in part, Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (1) Benzocaine topical is a local anesthetic. It temporarily eases minor skin irritations and pain by blocking pain signals. This information was obtained from the following website: https://www.goodrx.com/benzocaine/what-is. 2 a. For Resident #8 (R8), the facility staff failed to administer amlodipine (1) and carvedilol (2), both used to treat high blood pressure per the physician orders. An interview was conducted with R8 on 12/3/24 at 11:53 a.m. She stated she didn't get her blood pressure medications as ordered. The physician orders dated, 3/4/24, documented, Amlodipine tablet; 2.5 mg (milligram); 1 tablet by mouth at bedtime for HTN (high blood pressure) hold for SBP (systolic blood pressure) < (less than) 110. Carvedilol tablet 6.5 mg; Give 1 tablet two times a day. Hold if systolic B/P (blood pressure) < 110 or Pulse < 60. The October 2024 MAR (medication administration record) documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Amlodipine: 10/6/24 - BP (blood pressure) - 102/78 10/29/24 - nothing was documented as given. Carvedilol: 10/6/24 - BP - 102/78 10/24/24 - nothing was documented for the morning dose. 10/29/24 - nothing was documented for the evening dose. The November 2024 MAR documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Amlodipine: 11/5/24 - BP - 109/57 11/9/24 - BP - 107/59 11/18/24 - BP 109/73 11/25/24 - BP - 103/61 Carvedilol: 11/5/24 - evening dose - BP - 109/57 11/6/24 - morning dose - BP - 109/57 11/9/24 - evening dose - BP - 107/59 11/18/24 - evening dose - BP - 109/73 11/22/24 - morning dose - Pulse - 59 11/25/24 - evening dose - BP 103/61 The December 2024 MAR documented the above orders. On the following days, times and blood pressure and pulse readings, the medications were administered: Carvedilol: 12/4/24 - morning dose - nothing was documented. The comprehensive care plan dated, 8/27/24, documented in part, Problem: Resident has risk of cardiovascular complications related to dx (diagnosis) of HF (heart failure), hypertension (high blood pressure), respiratory failure and anemia. The Approach documented in part, Administer medications as ordered. An interview was conducted with LPN (licensed practical nurse) #4 on 12/12/24 at 8:10 a.m. When asked how she evidenced that she has given a medication, LPN #4 stated its signed on the eMAR with my initials. LPN #4 was asked if a medication has parameters for its administration, LPN #4 stated you take the blood pressure and/or pulse and hold the medication if it is outside of the parameters and document why it wasn't given. The facility policy, Physician/Provider Orders, failed to evidence documentation of the administration of medications. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a692044.html (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697042.html 2.b. For Resident #8 (R8), the facility staff failed to administer insulin per the physician orders. An interview was conducted with R8 on 12/3/24 at 11:53 a.m. She stated she doesn't get her insulin all the time. The physician order dated, 8/11/24, documented in part, Humalog Kwik Pen Insulin (insulin lispro) (a short acting insulin to treat diabetes) (3), administer before meals and at bedtime. Amount to administer: If blood sugar is less than 60, call MD (medical doctor) If blood sugar is 150 - 199. give 2 units If blood sugar is 200 - 249, give 4 units If blood sugar is 250 - 299, give 6 units If blood sugar is 300 - 349, give 8 units If blood sugar is 350 - 400, give 10 units If blood sugar is greater than 400, give 10 units If blood sugar is greater than 400, call MD. The October 2024 MAR documented the above order. On 10/14/24 for the 7:00 a.m. to 9:00 a.m. dose, the box was blank. The November 2024 MAR documented the above order. On 11/1/24 for the 4:15 p.m. to 6:45 p.m. dose, the box was blank. On 11/2/24, 11/6/24 and 11/15/24, the box was blank for the 7:00 a.m. to 9:00 a.m. dose. The physician order dated, 3/29/24, documented. The December 2024 MAR documented the above order. On 12/5/24 for the 7:00 a.m. to 9:00 a.m. dose, the box was blank. The physician order dated, 3/29/24, documented, Humalog U - 100 insulin (insulin lispro) (short acting insulin to treat diabetes) (3) solution; 100 units/mL (milliliter); Administer 15 units, subcutaneously three times a day. The October 2024 MAR documented the above order. On 10/14/24 at 8:00 a.m. and 10/24/24 at 12:00 p.m. there was a blank in the box for administration. The November 2024 MAR documented the above order. On 11/2/24, 11/6/24 and 11/15/24 at 8:00 a.m. there were blanks in the box for administration. The December 2024 MAR documented the above order. On 12/6/24 at 8:00 a.m. there was a blank in the box for administration. The physician order dated, 8/11/24, documented, Insulin glargine - yfgn (long-acting insulin to treat diabetes) (4); administer 30 units subcutaneously every morning between 8:00 a.m. and 11:00 a.m. Insulin glargine - yfgn; administer 45 units subcutaneously at bedtime. The October 2024 MAR documented the above orders. On 10/24/24 for the morning dose, there was a blank in the box for administration. On 10/29/24 at bedtime, there was a blank in the box for administration. The comprehensive care plan dated, 8/26/24, documented in part, Problem: Resident has potential for complications of hypo/hyperglycemia (low and high blood sugars) d/t (due to) dx (diagnosis) of diabetes mellitus. The Approach documented in part, Administer medications as ordered. An interview was conducted with LPN (licensed practical nurse) #4 on 12/12/24 at 8:10 a.m. When asked how she evidenced that she has given a medication, LPN #4 stated it's signed on the eMAR with my initials. LPN #4 was asked if a medication has parameters for its administration, LPN #4 stated you take the blood pressure and/or pulse and hold the medication if it is outside of the parameters and write a progress note. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697021.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for one of 43residents, R177. The findings include: The facility failed to provide monitoring for fluid restriction and intake for R177. R177 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), convulsions and atrial fibrillation. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/2/24, coded the resident as scoring a 01 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers and eating. Section I: ESRD checked and Section O: oxygen: yes. A review of the baseline care plan dated 11/27/24 revealed, PROBLEM: Resident has increased nutrition/hydration risk related to therapeutic diet/fluid restriction, ESRD/HD dependent. APPROACH: Provide fluids per ordered restriction. A review of the physician order dated 11/29/24 revealed, Fluid Restriction 1200cc/24hr. Special Instructions: 1200ccFluid Restriction Dietary to give 840cc BRKFST=360CC, LUNCH= 240CC, DINNER=240CC. Nursing to give 360cc: 1 SHIFT=180CC, 2 SHIFT=180CC. A review of the November and December MAR (medication administration record) revealed, 180 cc fluid restriction exceeded on day/evening shift on 11/30, 12/1, 12/2, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10 and 12/11; 180 cc fluid restriction exceeded on evening shift on 11/29, 11/30, 12/2, 12/3, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10 and 12/11. An interview was conducted on 12/12/24 at 9:30 AM with LPN (licensed practical nurse) #2. When shown R177's MAR fluid restriction documentation and asked if the fluid restriction orders had been followed, LPN #2 stated, no, they have not been. It may be that the agency nurses did not know how to document this. On 12/12/24 at 2:10 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. A review of the facility's Intake and Output policy revealed, when intake is being recorded for fluid restrictions purposes, the licensed nurse will verify the resident has received the recommended amount and will investigate any variances. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure residents were free from unnecessary medications for two of 43 residents in the survey sample, Residents #15, and #176. The findings include: 1. For Resident #15 (R15), the facility staff failed to monitor the resident for side effects from the anticoagulant (blood thinning) medication Eliquis (1). A review of R15's clinical record revealed a physician's order dated 11/12/24 for Eliquis 5 mg (milligrams) twice a day for atrial fibrillation. A review of R15's MARs (medication administration records) for November 2024 and December 2024 revealed the resident was administered Eliquis 5 mg two times a day 11/12/24 through 12/11/24. Further review of R15's clinical record (including physician's orders, MARs, and nurses' notes for November 2024 and December 2024) failed to reveal the resident was monitored for side effects from Eliquis. On 12/12/24 at 8:16 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated residents who receive anticoagulant medication such as Eliquis should have a physician's order for nurses to monitor for a risk of bleeding every shift. LPN #4 stated nurses evidence this monitoring is done by signing off the order on the MAR. On 12/12/24 at 2:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Anticoagulation Policy documented, On admission, nursing will identify individuals who are currently anticoagulated. Residents will be monitored for possible complications associated with anticoagulation and providers will be promptly notified of any such complications. No further information was presented prior to exit. Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds& 42183 2.The facility staff failed to ensure R176 was free of unnecessary medications by monitoring anticoagulant as ordered. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/3/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and eating. Section N: anticoagulant: yes. A review of the physician's order dated 11/27/24 revealed, Eliquis 5 mg po twice daily. A review of the MAR did not reveal evidence of anticoagulation monitoring. On 12/11/24 at 2:05 PM, an interview was conducted with LPN (licensed practical nurse) #1, when asked if anticoagulation monitoring should be done, LPN #1 stated, yes, we should be monitoring for bleeding and bruising. When asked if a physician's order is required, LPN #1 stated, no, it is nursing practice. When asked where this should be documented, LPN #1 stated, it should be on the medication administration record. On 12/12/24 at 8:16 AM, an interview was conducted with LPN #4. LPN #4 stated residents who receive anticoagulant medication such as Eliquis should have a physician's order for nurses to monitor for a risk of bleeding every shift. LPN #4 stated nurses' evidence this monitoring is done by signing off the order on the MAR (medication administration record). On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain fans in a sanitary manner in one of one kitchen and dispose of expired supplements in one of two facility nourishment rooms. The findings include: A. On [DATE] at 6:38 p.m., an observation was made of the facility kitchen. Observation of the dishwasher area revealed two approximately 12-inch round fans hanging from the wall in the dishwasher area facing the passthrough dishwasher. Visible dust and rust was observed on the cage of both fans. On [DATE] at 11:48 a.m., observation of the two round fans in the dishwasher area of the kitchen revealed the same as above. On [DATE] at 12:10 p.m., an interview was conducted with OSM (other staff member) #6, dietary manager. OSM #6 stated that the dietary staff were responsible for cleaning dust off the fans and maintenance fixed the fans if they malfunctioned. He stated that they brushed them off when they were dusty, and they had a problem with condensation in the room which caused the rust on the fan cages and the vents. On [DATE] at 12:35 p.m., an interview was conducted with OSM #3, maintenance director. OSM #3 stated that he thought that maintenance would be responsible for cleaning the fan blades to remove dust and he was not sure if there was any schedule in place because he was new to the facility. OSM #3 stated that he had been at the facility for four weeks and had not had any requests to clean the fans in the kitchen or reports of rust on the cage until the survey. The facility policy Equipment Cleaning and Sanitation Policy revised [DATE] documented in part, The food and nutrition services staff will maintain a clean and sanitary environment in food service areas through compliance with a written, comprehensive cleaning schedule . B. On [DATE] at 10:00 a.m., an observation of the Unit two nourishment room revealed seven 8-ounce cartons of Novasource renal 19% nutritional supplement with a use by date of [DATE] located in a cabinet with other supplements and tube feeding products. On [DATE] at 10:08 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses checked the dates of the items in the refrigerator and the kitchen stocked the drinks and snacks. She stated that central supply stocked the supplements and the tube feedings. LPN #3 stated that all the supplements in the cabinet were available for use. On [DATE] at 10:11 a.m., an interview was conducted with OSM #10, central supply. OSM #10 stated that they checked supplies in the nutrition rooms once or twice a week. She stated that she checked the dates, threw away any expired supplies and restocked the items. OSM #10 observed the seven 8-ounce cartons of Novasource renal 19% and stated that it was slower to move than the others because there were only one or two residents who used it. She stated that it was past its use by date, and it should have been thrown away. The facility policy Nourishments and Supplements Policy revised [DATE] failed to evidence guidance on use by dates. On [DATE] at approximately 4:57 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern regarding the kitchen fans. On [DATE] at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern regarding the nourishment room on Unit two. No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure timely physician visits for 1 of 43 residents in the survey sample, Resident #127. The findings include: For Resident #127 (R127), the facility staff failed to evidence a physician visit between 6/8/21 and 10/14/21. A review of the clinical record for physician visits documented a physician progress note for R127 dated 6/8/21 and the next dated 10/14/21, 127 days without a physician's visit. On 12/12/24 at 10:15 a.m., an interview was conducted with ASM (administrative staff member) #6, medical doctor who stated that long term care residents were seen every 60 days for recertification visits and she and the nurse practitioner alternated the visits. A request was made for a policy for physician visits however none was provided by the facility prior to exit. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 43 residents in the sample Resident #176 (R176). The findings include: The facility failed to evidence provision of trauma informed care for Resident #176. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/3/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and eating. Section I: PTSD yes. PTSD is listed on R176's problem list. A review of the baseline care plan dated 11/26/24 did not reveal PTSD as a problem. A review of the physician order dated 12/5/24 revealed, Buspar 7.5 mg po twice daily. A review of the progress note dated 11/27/24 at 5:31 PM revealed, When given the PHQ9 questionnaire, patient responded to #9 that he did feel he would be better off dead what do I have to live for but that he would not do anything to hurt himself. This was reported to the SW, DON, ADON and unit manager nurse. A review of the progress note dated 11/27/24 at 6:05 PM revealed, S.W. met with resident this evening to discuss his PHQ interview with the Rehab Director, he stated to her he would be better on dead. When addressed the matter to resident, he to this writer Hell NO I'm not going to bring any harm to myself. But at times I say like that if that's the case I would have done something to myself long time ago. Writer did ask resident if he would like to have psych intervention or to be seen by a Chaplain. He stated: NO S.W. will continue provide supportive therapy weekly. Nursing Staff/ Social Worker will continue to monitor/document. A review of the physician note dated 12/5/24 revealed, Resident refused psychiatry consult, will try Buspar. An interview was conducted on 12/11/24 at 2:05 PM with LPN (licensed practical nurse) #1. When asked if there should be specific care outlined for a resident with a diagnosis of PTSD, LPN #1 stated, yes, there should be. When asked where that care would be documented, LPN #1 stated, it would be in the care plan. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. A review of the facility's Social Services policy, reveals, Social Services will assist in implementing interventions for the resident's needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including, but not limited to; Trauma, PTSD. No further information was provided prior to exit.

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to obtain a physician's order for oxygen administration for one of 43 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to obtain an order for the administration of oxygen (O2). The progress notes for R9 documented in part, - 11/23/2024 20:10 (8:10 p.m.) Resident in bed awake/alert and verbal. Resident has scattered rhonchi. Resident has O2 @ 2L/min (liters per minute) via NC (nasal cannula). IsoSource (enteral tube feeding) is not connected at this time per physician order. Staff will continue to monitor closely for any status change. - 12/07/2024 18:09 (6:09 p.m.) Resident completed ABT (antibiotic) for Pneumonia. No adverse reactions noted. Bed in low position, HOB (head of bed), and o2 running 2 L via nasal cannula. Will continue to monitor and report any changes in status. - 12/09/2024 20:20 (8:20 p.m.) During routine f/u (follow up) visit w/ MD [Name of physician], family concerns were addressed by NP [Name of nurse practitioner]/ MD [Name of physician]. Head to toe assessment completed; Resident observed w/ no c/o pain or discomfort, lethargic, slightly congested, VS WNL (vital signs within normal limits), on continuous 02 via nasal cannula . The re-admission assessment for R9 dated 12/2/24 for R9 documented the resident using oxygen at 2 lpm. Further review of R9's clinical record failed to reveal evidence an order for oxygen. On 12/12/24 at 8:30 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that residents receiving oxygen should have orders. She stated that they had standing orders that they used in emergencies but when a resident came in with oxygen the order was placed in the medical record so that the staff would know the prescribed rate for the oxygen, check the rate every shift and change the tubing every week. LPN #4 reviewed R9's orders and stated that she did not see an order in place and would make sure there was one placed. She stated that she knew R9 wore the oxygen continuously since they had been back from the hospital. The facility policy Oxygen Administration (All routes) Policy revised 7/30/24 documented in part, .POLICY: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer . On 12/12/24 at approximately 2:09 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for an indwelling catheter for one of 43 residents in the survey sample, Resident #89. The findings include: For Resident #89 (R89), the facility staff failed to evidence of providing catheter care. On 12/10/24 at 8:45 a.m. Resident was observed in bed, an indwelling catheter bag was noted hanging off the bedframe. the physician orders dated, 7/8/24, documented, Change foley (indwelling) catheter as needed. 18 fr (french) 10 cc (cubic centimeters). Special Instructions: Document catheter (french) and balloon (ml - milliliters) size inserted PRN (as needed). Further review of the physician orders failed to evidence an order for indwelling catheter care. Review of the MAR for October, November and December 2024, failed to evidence documentation of indwelling catheter care. Review of the comprehensive care plan dated, 7/11/24, documented in part, Problem: Urinary Incontinence: Incontinence d/t (due to) dx (diagnosis) of muscle weakness, lack of coordination, dementia and Alzheimer's. The Approach failed to evidence any documentation related to the use of an indwelling catheter. An interview was conducted with LPN (licensed practical nurse) #4 on 12/12/24 at 8:10 a.m. LPN #4 stated both the nurses and CNAs (certified nursing assistants) do indwelling catheter care. It is documented on the eMAR (electronic medication administration record) as there are orders for catheter care. On 12/12/24 at 1:39 p.m. ASM (administrative staff member) #2, the director of nursing, stated the facility had no evidence of indwelling catheter care for R89. ASM #1, the administrator, and ASM #2, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit.

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide services to maintain or improve mobility for one of 43 residents in the survey sample, Resident #70. The findings include: For Resident #70 (R70), the facility staff failed to follow therapy recommendations for the use of a splinting device. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed. R70 was observed with limited range of motion (ROM) in the right hand. No splinting device was observed in use. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with no splinting device and limited ROM in the right hand. The most recent OT (occupational therapy) evaluation and plan of treatment dated 8/14/24-9/11/24 documented treatments including but not limited to splinting and increasing finger flexion. The evaluation documented a right upper extremity contracture and impairment of the right hand. Under Recommendations it documented Splint/Orthotic Recommendations: It is recommended the patient wear an elbow extension splint on right elbow for during daily tasks in order to inhibit abnormal reflex patterns, develop/establish wearing schedule, inhibit abnormal positions and adapt/modify splint device. The OT discharge summary for R70 dated 9/11/24 documented in part, .Maximum potential achieved, referred for RNP (restorative nursing program) .Discharge Recommendations: RNP, splinting . The comprehensive care plan for R70 failed to address the limited range of motion or use of any splinting devices. The physician's orders for R70 failed to evidence an order for the use of a splinting device. On 12/11/24 at 11:49 a.m., an interview was conducted with OSM (other staff member) #1, the director of rehab. OSM #1 stated that they were not currently working with R70 but had seen them in the past. She stated that R70 was last discharged from OT on 9/11/24 with recommendations for restorative nursing and splinting. On 12/11/24 at approximately 12:00 p.m., a request was made to ASM (administrative staff member) #5, administrative support for evidence of splint therapy for R70 from 9/11/24 to the present. On 12/11/24 at approximately 3:00 p.m., ASM #5 provided a Therapy Education Form for R70 which documented a therapy referral to nursing for splinting for 1-2 hours daily and bilateral upper extremity exercises with movement in all planes within the patient's abilities to begin on 9/26/24. A Restorative Nursing Program Manual dated 9/11/24 for R70 documented instructions for restorative nursing staff for the resident's ability to perform tasks and assistance needed. The documents provided failed to evidence documentation of splinting completed by staff as recommended by therapy at discharge from services. On 12/12/24 at 9:15 a.m., an interview was conducted with CNA (certified nursing assistant) #4, restorative aide who stated that R70 had orders for a splint to the right arm/elbow and for range of motion/stretching exercises. She stated that the other restorative aide recently resigned, and she was not aware of the treatment for R70 until today and she had completed the treatment that morning. She stated that the documentation was placed in the medical record under the POC (plan of care) charting. Review of the POC documentation for R70 documented the passive range of motion last completed for R70 on 10/31/24 and splinting last completed on 10/28/24. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the concern. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence bed hold notice provided for a facility-initiated transfer for one of 43 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to evidence bed hold notice was provided to the responsible party for a facility-initiated transfer on 11/24/24. The progress notes for R9 documented in part, - 11/24/2024 09:00 Paramedics arrived and tended to resident while SN gave paramedics report. The resident continued to rapidly decline and resident was placed on a non-rebreather by paramedics. Facesheet, InterAct form, med list and DNR (do not resuscitate) form sent with resident which was emergently transported to [Name of hospital]. Report called to ER and to [Name of insurance company]. Message left with wife who is primary contact and legal representative. - 11/25/2024 0:31 (12:31 a.m.) This writer called [Name of hospital] for resident update. Per [Name of staff member] resident has been admitted to ICU (intensive care unit). Admitting diagnosis is aspiration pneumonia. Further review of the clinical record failed to reveal evidence that bed hold notice was provided to the responsible party for the transfer on 11/24/24. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nursing staff should send a bed hold notice with the resident when they transferred them to the hospital. She stated that they sent it with the face sheet, medication list, transfer form, orders and care plan. She stated that this was documented in the progress notes. On 12/11/24 at approximately 2:30 p.m., a request was made via written list to ASM (administrative staff member) #5, administrative support, for evidence of bed hold notice provided to the responsible party for the facility-initiated transfer on 11/24/24. On 12/12/24 at approximately 8:30 a.m., ASM #2, the director of nursing provided progress notes and an SBAR (situation, background, assessment, and recommendation) assessment for R9. The documents provided failed to evidence bed hold notice provided to the responsible party for the facility-initiated transfer on 11/24/24. The facility policy Bed Hold Letter Policy revised 9/26/20 documented in part, .Business Office or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties' certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. Medicaid Copy will be retained in resident's financial file. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence a written notification was provided to the resident and/or responsible party upon transfer to the hospital for three of 43 residents in the survey sample, Residents #16, #9, and #90. The findings include: 1. For Resident #16, the facility staff failed to evidence the resident and/or responsible party was provided a written notification upon transfer to the hospital on 11/4/24. The nurses note dated 11/4/24 at 9:11 a.m. documented, Writer was informed by AIDE that resident was vomiting. Upon assessment resident was vomiting up coffee ground emesis in a large amount. NP (nurse practitioner) and DR. (doctor) examined resident and recommended sending to the ER (emergency room ). Per NP resident had a previous incident earlier this morning with the same results. 911 was called and dispatched to the facility. (Name of responsible party) has been notified and he said that he would notify the sitter. Transfer paperwork, face sheet, DNR (do not resuscitate), transfer to hospital, SBAR (situation, background, assessment, response), care plan, order/medication, and bed hold has been sent with the resident. An interview was conducted with LPN (licensed practical nurse) #4 on 12/12/24 at 8:20 a.m. LPN #4 stated they do not give the resident and/or family anything in writing when the resident is transferred to the hospital. They call the family and notate it in the chart. The facility did not provide a policy related to the written notice provided to residents and/or responsible parties upon transfer to the hospital. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. 42106 2. For Resident #9 (R9), the facility staff failed to evidence written notification of transfer was provided to the responsible party for a facility-initiated transfer on 11/24/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/8/24, R9 was coded as being cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status) assessment. A review of R9's clinical record revealed the following progress note: 11/24/2024 09:00 Paramedics arrived and tended to resident while SN gave paramedics report. The resident continued to rapidly decline and resident was placed on a non-rebreather by paramedics. Facesheet, InterAct form, med list and DNR (do not resuscitate) form sent with resident which was emergently transported to [Name of hospital]. Report called to ER and to [Name of insurance company]. Message left with wife who is primary contact and legal representative. Further review of the clinical record failed to reveal evidence that written notification of transfer was provided to the responsible party for the transfer on 11/24/24. On 12/11/24 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nursing staff called the responsible party when a resident was transferred to the hospital but did not provide any written notification of transfer. On 12/11/24 at approximately 2:30 p.m., a request was made via written list to ASM (administrative staff member) #5, administrative support, for evidence of written notification of transfer provided to the responsible party for the facility-initiated transfer on 11/24/24. On 12/12/24 at approximately 8:30 a.m., ASM #2, the director of nursing provided progress notes and an SBAR (situation, background, assessment, and recommendation) assessment for R9. The documents provided failed to evidence written notification of transfer provided to the responsible party for the facility-initiated transfer on 11/24/24. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical services, and ASM #5, administrative support were made aware of the findings. No further information was provided prior to exit. 42183 3. The facility staff failed to evidence provision of required written RP (responsible party) notification at the time of discharge for Resident #90. Resident #90 was transferred to the hospital on 11/18/24. Resident #90 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colon cancer, dementia, falls and femur fracture. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/2/24, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 5/27/24 revealed, PROBLEM: Resident at risk for falling related to generalized weakness with dementia and history of colon cancer. APPROACH: Observe frequently and place in supervised area when out of bed. Encourage resident to assume a standing position slowly. Keep bed in lowest position with brakes locked. Always keep call light in reach. There was no evidence of provision of required written RP notification when Resident #90 was sent to the hospital on 11/18/24. A review of the progress note dated 11/18/24 at 2:40 AM, revealed, Resident had an unwitnessed fall in her room. Resident was heard by nurse screaming asking for help. Upon entering the room resident was found on the floor sitting on buttocks. When asked what happened resident stated that she did not know. Nurse did full head to toe assessment on resident to rule out any abnormalities. Resident's vitals reading at Bp:102/58, HR, 62, Temp: 97.9, O2 96% RA, and RR 18. Pain noted in right leg when nurse attempted to extend extremity. No other injuries noted. Family notified (daughter) and requested that resident be sent to ED for further observations. Hospital and physician notified of situation. Resident sent to the hospital with order, face sheet, care plan, and bed hold form. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. No further information was provided prior to exit.

Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for one of 43 residents in the survey sample, R25. The findings include: For R25, the facility staff failed to maintain the call light in a position where they could access it. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), Sepsis and bilateral osteoarthritis. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 10/18/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 11/27/24 revealed, PROBLEM: Resident has increased nutrition /hydration risk related to: ESRD and diet / fluid restriction. APPROACH: Dialysis Monday, Wednesday and Friday. On 12/10/24 at 9:43 AM, observation of call bell on floor between bed A & B. R25 when asked where his call bell was located, stated, not sure where this is. An interview was conducted on 12/10/24 at 9:50 AM with LPN (licensed practical nurse) #1. LPN #1 was asked to locate the call device for R25. LPN #1 found the call device on the floor between bed A and bed B. LPN #1 stated, here it is on the floor between the beds. I am going to clip this to your covers. When asked if R25's needs were accommodated when unable to reach call bell, LPN #1 stated, no, they were not. On 12/11/24 at 5:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president of operations was made aware of the above concerns. A review of the facility's Resident Communication and Call Light policy revealed in part, When the resident is in bed or confined to a chair, be sure the call light is within easy reach. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess a resident for the self-administration of medication for one of 43 residents in the survey sample, Resident #32. The findings include: For Resident #32, the facility staff failed to assess the resident for self-administration of medications, Breyna (1). Observation was made on 12/10/24 at 2:30 p.m. of the R32's room. The resident was observed to have his Breyna respiratory inhaler on the bedside table. He stated he keeps it there for when he needs it. The physician order dated, 3/4/24, documented, Breyna (budesonide - formoterol) HFA aerosol inhaler; 160 - 4.5 mcg (micrograms) per actuation; amt (amount) 2 puffs; Inhalation. Special Instruction: 2 puff inhale orally two times a day for COPD (1), rinse mouth with water after each use. Review of the clinical record, failed to evidence a physician order for the resident to self-administer his medication. Review of the clinical record failed to evidence an assessment for the self-administration of medications. Review of the comprehensive care plan dated 8/30/24, failed to evidence documentation for self-administration of medications. An interview was conducted with LPN (licensed practical nurse) #4, on 12/12/24 at 8:10 a.m. When asked if residents are allowed to keep medications at the bedside, LPN #4 stated medications, such as creams and ointments, can be left at the bedside if there is a physician order to do so. LPN #4 was asked if the resident needs to be assessed to keep medications at the bedside, she didn't know anything about that. She stated that the inhaler should not be kept at the bedside. ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing, were made aware of the above concern on 12/12/24 at 2:11 p.m. No further information was provided prior to exit. References: (1) Breyna - The combination of budesonide and formoterol is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma in adults and children 6 years of age and older. The combination of budesonide and formoterol is also used to treat chronic obstructive pulmonary (COPD; a group of diseases that affect the lungs and airways, that includes chronic bronchitis and emphysema) in adults. Budesonide is in a class of medications called steroids. It works by reducing swelling in the airways. Formoterol is in a class of medications called long-acting beta agonists ([NAME]). It works by relaxing and opening air passages in the lungs, making it easier to breathe. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a623022.html.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure one resident was safe from falling during ADL Care, which constituted harm for 1 of 8 residents (Resident #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 2/12/22. The resident was last discharged from the facility to a local hospital after a fall and returned 6/26/24. The resident's diagnoses included left hip fracture, distal right femur periprosthetic displaced comminuted fracture, anemia, muscle weakness, hypertension, and depression. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #4's cognitive abilities for daily decision making were intact. A fall risk assessment was conducted on 4/18/24. Resident #4 was categorized as requiring assistance or supervision for mobility, transfer, or ambulation. A review section GG (Functional Abilities and Goals) dated 5/4/24 of Resident #4's Minimum Data Set (MDS) coded the resident as dependent for rolling left to right, dependent for sit to lying, and dependent for lying to sitting on side of bed. A synopsis of an event dated 6/22/24 revealed that Certified Nursing Assistant (CNA) #1 was providing incontinent care to Resident #4 and needed clean linen. Prior to leaving the resident room to retrieve clean linen, CNA #1 positioned Resident #4 on her left side and told the resident to roll back to the middle of the bed if needed. While CNA #1 was out of the room, Resident #4 was attempting to roll back to the middle of the bed and fell out of the bed onto the floor resulting in a left hip fracture and distal right femur periprosthetic displaced comminuted fracture. On 8/1/24 at 1:30 PM an interview was conducted with Resident #4. Resident #4 stated that CNA #1 was providing incontinent care and needed clean linen. Resident #4 further stated that CNA #1 positioned her on her left side and told her that she was leaving the room and to roll to the middle of the bed if she needed too. Resident #4 voiced that she started to fall and was yelling for help. Resident #4 further voiced that she could no longer stay on the bed, fell off the bed and hit the floor. Resident #4 also stated that CNA #1 was out of the room between 3 to 4 minutes before she fell out of the bed. A review of Resident #4's nurses note dated 6/22/24 at 2:58 AM read that the resident was laying on her left side when CNA #1 finished incontinent care and exited room to get fresh linen. The nurses note further read that CNA #1 asked the resident to roll back to the middle of the bed, resident was attempting to roll back to the middle of the bed but instead pulled herself closer to the edge of the bed, her legs fell off the side of the bed which caused the rest of her body to fall as well. On 8/1/24 at 11:15 AM an interview was conducted with the Director of Nursing (DON). The DON stated that that Resident #4 is dependent regarding rolling left to right in the bed. The DON also stated that before the fall that occurred on 6/22/24, Resident #4 was dependent for mobility. The DON also voiced that the fall that occurred on 6/22/24 was due to CNA #1 leaving the room to get supplies while performing incontinent care. The DON further voiced that CNA #1 was an Agency CNA and was asked not to return to the facility or any of the (company name of associated nursing facilities) due to the unsafe practice that occurred. On 8/1/24 at 5:00 PM an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that CNA #1 left the resident room looking for clean linen and also left Resident #4 laying on her left side. LPN #1 also stated that CNA #1 performed an unsafe practice when she left the resident room, and this contributed to Resident #4 falling out of the bed. A review of the Discharge Summary from a local hospital dated 6/26/24 read Resident #4's discharge diagnosis as a left hip fracture and distal right femur periprosthetic displaced comminuted fracture. All residents who had experienced falls with major injuries since 3/18/24 were reviewed during the survey, no additional deficient practice was identified. The facility developed a five-point plan secondary to Resident #4's fall with a left hip fracture and distal right femur periprosthetic displaced comminuted fracture. 1. 100 percent education to all clinical staff regarding falls protocol including ensuring residents are left in a safe position prior to leaving the resident unattended. 2. The facility completed a 100 percent review of all residents requiring assistance with activities of daily living care in the bed and the need for additional interventions. 3. The Director of Nursing or designee to complete weekly audits that include 5 staff members audited weekly for 12 weeks for proper positioning while providing activities of daily living care. 4. The Director of Nursing or designee to complete weekly audits that include 5 residents audited weekly for 12 weeks for proper positioning while providing activities of daily living care. 5. Corrective action was completed on 7/8/24. All residents who had experienced falls with major injuries since 3/18/24 were reviewed during the survey, no additional deficient practice was identified. On 8/1/24 at approximately 6:40 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional [NAME] President of Operations, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information. It was determined that the facility implemented its Corrective Action Plan and there was sufficient evidence through the sampled resident observations and interviews that residents were left in a safe position prior to leaving the resident unattended per their assessments and care plan. It was determined that the facility corrected the noncompliance and was in substantial compliance as of their Allegation of Compliance (AOC) date, 7/8/24 and at the time of the current survey for the regulatory requirement, F-689.

Based on clinical record review, staff and resident interview and review of facility documents, it was determined that the facility staff failed to ensure 3 out of 42 residents (R#453, #457 and #456) in the survey sample had the opportunity to formulate an Advance Directive. The findings include: 1. Resident #453 was admitted to the nursing facility on 3/25/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was her own authorized representative. The Admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a total score of 15 which indicated the resident was moderately impaired in the cognitive skills for daily decision making. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not coded to possess behavioral or mood symptoms. On 3/30/21 at 1:10 p.m., Resident #453 stated she did not have an Advance Directive and had not been approached by any facility personnel about developing one. She stated she did not have a living will and wanted everything to be done for her if she had a medical emergency. On 4/1/21 at 3:30 p.m., an interview was conducted with the Administrator, Regional Supervisor of Clinical Services (RSCS) and Director of Nursing (DON). They stated if there was no Advance Directive upon admission, a member of the Path team (Administrator, DON, Business Office Manager, MDS/Case Manager and Social Worker) should ensure they meet with the resident and or family member as soon as possible within 3-5 days of admission to discuss pertinent information regarding the patient's wishes, give information on the components of an Advance Directive with an option to develop one if they so chose. They stated Resident #453 Path meeting was late, thus the right to formulate Advance Directive had not been addressed with the resident. The resident's base line care plan meeting was on 3/26/21 which did not evidence an advance directive or opportunity to develop one. 2. Resident #457 was admitted to the nursing facility on 3/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a total score of 15 which indicated the resident possessed intact cognitive skills for daily decision making. The resident was not coded to possess behavioral or mood symptoms. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/21 at 1:45 p.m., Resident #457 stated he was his own authorized representative and had a care plan meeting with several staff members and knew the Unit II Manager, Licensed Practical Nurse (LPN) #1 was a part of the base line care plan meeting (3/24/21). He said Advanced Directives or opportunity to develop one was not discussed, only his wishes to be a full code. On 4/1/21 at 3:30 p.m., an interview was conducted with the Administrator, Regional Supervisor of Clinical Services (RSCS) and Director of Nursing (DON). They stated if there was no Advance Directive upon admission, a member of the Path team (Administrator, DON, Business Office Manager, MDS/Case Manager and Social Worker) should ensure they meet with the resident and or family member as soon as possible within 3-5 days of admission to discuss pertinent information regarding the patient's wishes, give information on the components of an Advance Directive with an option to develop one if they so chose. 3. Resident #456 was admitted to the nursing facility on 3/24/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognitive skills for daily decision making. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not coded to possess behavioral or mood symptoms. On 3/30/21 at 2:30 p.m., Resident #456 stated she had not been approached by a staff person regarding either having an Advance Directive or the opportunity to meet with someone to develop one. On 4/1/21 at 3:30 p.m., an interview was conducted with the Administrator, Regional Supervisor of Clinical Services (RSCS) and Director of Nursing (DON). They stated if there was no Advance Directive upon admission, a member of the Path team (Administrator, DON, Business Office Manager, MDS/Case Manager and Social Worker) should ensure they meet with the resident and or family member as soon as possible within 3-5 days of admission to discuss pertinent information regarding the patient's wishes, give information on the components of an Advance Directive with an option to develop one if they so chose. They stated Resident #456 Path meeting was late, thus the right to formulate Advance Directive had not been addressed with the resident. The resident's base line care plan meeting was on 3/26/21 which did not evidence an advance directive or opportunity to develop one.

Based on staff interview, medical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide treatment and services for the management of a diabetic resident, that led to a hyperglycemic episode with a blood glucose (sugar)* level of over 600 on 3/17/20 which required hospitalization constituting harm for one of six residents in the survey sample, Resident #6. A plan of correction previously put into place by the facility was reviewed and accepted, therefore this harm level deficiency is cited as past non-compliance. The findings included; Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) prior to discharge on 3/17/20; was an admission assessment with an ARD (assessment reference date) of 2/10/20. Resident #6 was coded as being moderately impaired in cognitive function scoring 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #6's clinical record revealed that he was admitted to the facility on [DATE] with sliding scale insulin and Accuchecks (blood sugar checks). The following order was in place on 2/3/20: Humalog (1) Solution 100 unit/ml Inject per sliding scale if 151-199 = 3 units SQ (subcutaneous-under the skin); 200-249 = 6 units SQ; 250-299= 9 units SQ; 300-349 = 12 units; subcutaneously before meals and at bedtime for diabetes. This order for sliding scale insulin was d/c'd (discontinued on 2/11/20) by the Physician Assistant (PA). There was no evidence that Resident #6 was placed on any Accuchecks (blood sugar checks) after his sliding scale insulin was discontinued. Further review of Resident #6's February 2020 MAR (Medication Administration Record) revealed on 2/11/20 (last day of Accuchecks) Resident #6 did not require insulin at 8:00 a.m. and 11:30 a.m. The following note was documented by the Physician Assistant on 2/16/20 as a late entry for 2/11/20 Following up today regarding repeat labs including BMP (2), CBC (3), liver function studies .BMP (basic metabolic panel) significant for persistently elevated creatinine (4) of 2.53 (previously 2.35), BUN (blood urea nitrogen) (5) 34, potassium 4.8, sodium 141, glucose 128 mg/dL . Blood glucose is range from 99 to 216 mg/dL, averaging in the 150s to 160s most days .Repeat BMP, CBC .STAT (immediately) due to worsening renal function. Further review of Resident #6's POS (physician order [REDACTED]. This laboratory test was documented as completed on 2/25/20. Review of Resident #6's laboratory test (BMP) dated 2/25/20; revealed Resident #6 had a blood glucose level of 317. This laboratory test was not signed by the physician until 4/2/20 which was after the resident was discharged to the hospital on [DATE]. Review of a nursing note dated 3/17/20 documented the following: Resident appears lethargic. Blood Sugar check, result HI. (Name of PA) at facility. Resident evaluated by (Name of PA), order received to send resident to ER (emergency room ). Report given to ER. A note documented by the PA on 3/17/20 documented the following: ED (emergency department) transfer: Acutely altered mental status, critical [MEDICAL CONDITION] (high blood sugar), [MEDICAL CONDITION](elevated pulse) .Nursing staff reports at the patient's mental status has been declining over the past several days. He has become more lethargic and is refusing medications. He sleeps most of the day and his PO (by mouth) intake has been poor. His family took him to a doctors appointment yesterday and noticed that he seemed sluggish and lethargic. Blood glucose was checked today and was greater than 600. It was reassessed after 30 minutes and was still reading as greater than 600. He has a [DIAGNOSES REDACTED]. Most recent spot blood glucose check was performed three weeks ago was 130 mg/dL. He was not having his blood glucose checked regularly since he had remained well-controlled and was not taking any medications. Most recent labs performed 2/25 including BMP were accessed online today and reviewed. This was significant for elevated creatinine of 1.62 (sic, creatinine was 1.65 on 2/25 result), BUN 33 (sic; BUN was 22 on 2/25 result), potassium 3.7, sodium 141, glucose 317 mg/dL. It does not appear that any providers were made aware of these lab results, or that elevated glucose was addressed at that time, as the lab results were not scanned into his chart. On examination today, the patient is lying in bed in an obtunded state. Strong [MEDICATION NAME] (7) odor noted on his breath. Unable to wake patient up with sternal rub or verbal stimuli .pulse is mildly [MEDICAL CONDITION] at 103 bpm .Due to significant change in mentation, critical [MEDICAL CONDITION] of greater than 600 mg/dL, and [MEDICAL CONDITION] patient is being sent via 911 to the emergency room now . Review of Resident #6's comprehensive care plan for Diabetes documented the following on 2/27/20: The resident has diabetes mellitus .The resident will have no complications related to diabetes through next review date labs as ordered by doctor contact md (medical doctor) with any abnormalities . A late entry note by the Physician's Assistant on 3/19/20 for 2/11/20 documented the following: Late Entry Note: Note Text Addendum: Based on BG (blood sugar) reading remaining well controlled (150s-160s average) and HA1c of 5.4 %, sliding scale insulin as monotherapy is not recommended (Based on ADA (American Diabetes Association) . guidelines). Therefore, sliding scale insulin will be discontinued but Accuchecks should continue to be monitored regularly. Repeat BMP scheduled for 2/16/20. Review of Resident #6's hospital records was conducted. The History and Physical dated 3/17/20 documented the following: .brought from nursing home for altered mental status and [MEDICAL CONDITION]. Hyperosmolar Hyperglycemic (8) state, Altered mental status; likely secondary to the above; Acute on chronic Stage IV (four) [MEDICAL CONDITION]; likely secondary to the above, Leukocytosis (elevated white blood cells); could be secondary to the above; rule [MEDICAL CONDITION] (infection) .he was brought from nursing home for being altered and less responsive. Blood sugar read high, above the limit .In the ED his glucose was found above 1100 and with Leukocytosis of 20. He received IV (intravenous) fluids, IV insulin, empiric antibiotics .and is admitted for further management .3/17/20 at 3:49 p.m., H and P Labs .Glucose 1,158 (HH) .BUN 68 (H) (high) .Creatinine 3.51 (H) .Hemoglobin A1c 8.9 (H) est (estimated average glucose) 209. Review of the hospital discharge summary dated 3/24/20 documented the following: Discharge Diagnoses: [REDACTED]. 2. Acute on chronic metabolic [MEDICAL CONDITION] (9), now resolved. 3. Acute on Stage IV [MEDICAL CONDITION] .4. Leukocytosis, resolved . On 10/8/20 at 12:07 p.m., an interview was conducted with ASM (Administrative Staff Member) #4, the Physician Assistant. ASM #4 stated that she had discontinued Resident #6's SSI (sliding scale insulin) because his blood sugar had been stable and his HA1c was within normal limits on his last drawn laboratory test prior to 2/11/20. ASM #4 stated, If you look at the ADA guidelines, there was no indication for Accuchecks and SSI (sliding scale insulin). ASM #4 stated that she usually writes an order to continue blood sugar checks for a few weeks after sliding scale insulin is discontinued for her diabetic residents. ASM #4 stated that staff did not continue to monitor his blood sugar levels; but that it was not indicated per ADA guidelines. When asked how ASM #4 conveys orders to the nursing staff, ASM #4 stated that most of the time, she will discontinue and input orders directly into the computer system herself. ASM #4 stated, I find that doing it myself is necessary. When asked if she could recall inputting Resident #6's orders to d/c (discontinue) sliding scale insulin or if she gave the order to the nurse; ASM #4 stated that she could not recall. ASM #4 stated that it was her intention to have nursing staff monitor Resident #6's blood sugar levels after sliding scale insulin was discontinued. ASM #4 then stated that nursing staff also failed to make any providers aware of a critical glucose level on his 2/25/20 BMP test. ASM #4 stated that the elevated glucose was at a level of 329 (sic; sugar was actually at 317). ASM #4 stated that if she had seen that elevated blood sugar, she would have ordered additional monitoring at that time. When asked if the failure to continue blood sugar checks and the failure to report a critical lab caused Resident #6 harm; ASM #4 stated that she couldn't say; that if she had monitored Resident #6's blood sugars after the critical lab it probably would have been for a week or two anyway. When asked if she could have possibly seen a trend of sugar readings and ordered some sort of medication/treatment for [REDACTED].#4 stated that she couldn't say; that she wasn't sure the cause of his blood sugars being elevated because Resident #6 was discharged to the hospital on [DATE] and did not access to his hospital records. ASM #4 stated that Resident #6 may have had an infection; that she recalled the wound care physician saying his Stage 4 sacral ulcer was infected. Review of Resident #6's 3/17/20 wound care note and hospital records failed to evidence any infected wounds. On 10/8/20 at approximately 1:00 p.m., a telephone interview was conducted with RN (Registered Nurse) #1. When asked the process for obtaining ordered laboratory tests, RN #1 stated that once the physician orders [REDACTED]. RN #1 stated that laboratory tests are drawn in the early morning on 11-7 shift by the laboratory technician. RN #1 stated that the laboratory technician will check the lab book prior to drawing blood to determine which residents need lab work. RN #1 stated that once the lab tests is obtained, the nurse will document on the MAR/TAR (Medication Administration Record [REDACTED]. When asked how nurses know to follow up on a laboratory test that was recently drawn, RN #1 stated that nurses should get the information in report, and then they would follow up on the lab. RN #1 stated that the nurses can check the lab book to see if the technician had drawn the lab and can also check the laboratory computer system for the result. RN #1 stated that laboratory tests were usually faxed to the nursing station and if they receive an abnormal lab, they would immediately call the physician. RN #1 stated that from there, the physician would give orders; the nurses then file the lab into a communication book for the MD (Medical Doctor). When asked if nurses should document that the laboratory test was obtained and results were reviewed; or if the physician was made aware of an abnormal lab result, RN #1 stated, Me, personally will also do a nurse's note. When asked if the laboratory results were scanned into the electronic medical record once the results were reviewed by the physician, RN #1 stated that another staff member usually scanned laboratory results into the computer system. RN #1 could not recall the staff member responsible for scanning in lab results. RN #1 stated that the results that are scanned into the electronic health record have to be signed by the physician first. On 10/8/20 at 1:38 p.m., further interview was conducted with ASM #4 the PA. ASM #4 stated that she did recall discontinuing the insulin order herself. ASM #4 stated that she forgot to write an additional order for blood sugar checks. ASM #4 stated that when the facility was owned by a previous company; Accuchecks and sliding scale orders were separate orders. ASM #4 stated that Resident #6's Accucheck orders were attached to the sliding scale orders so when she discontinued sliding scale insulin Accuchecks were also discontinued. ASM #4 stated that she assumed Resident #6 had a separate order for Accuchecks already in the system. ASM #4 stated that that was her mistake however the critical glucose level should have been reported to the providers immediately and addressed. When asked how she determined that facility staff failed to report the critical glucose test to any providers; ASM #4 stated that on 3/17/20, when she assessed Resident #6, she noticed that his breath smelled of [MEDICATION NAME] and he was in a coma like state. ASM #4 went back to Resident #6's chart to look at recent labs and noticed the lab that was ordered for 2/25/20 was not in his clinical record. ASM #4 then stated that she had to look up the lab in the laboratory system and found the elevated glucose level. ASM #4 then stated that she went back to Resident #6's clinical record to see what his Accuchecks had been running and realized that no one was monitoring his blood sugar levels after the insulin was discontinued. On 10/8/20 at approximately 5:00 p.m., ASM (Administrative Staff Member) #1, the Administrator and ASM #2, the DON (Director of Nursing) were made aware of the potential for harm. Any additional information was requested at this time. On 10/9/20 at approximately at 1:17 p.m., ASM #1 and ASM #3, the corporate nurse provided a plan of correction that had been started in response to Resident #6's hyperglycemic episode. The following was documented: 1. On 3/17/20, resident, (Name of Resident #6) was sent out by ambulance to the hospital for a high blood sugar. The physician's assistant was in the facility and assessed him and sent him to the ER. The responsible party for the resident was notified. 2. The facility conducted a 100 percent audit of current residents with a [DIAGNOSES REDACTED]. Completed 3/31/20. The facility provided education to the physician (Medical Director), NP (Nurse Practitioner), and the PA (Physician's Assistant) on ordering and clarifying when blood sugars are to be checked. Completed via phone 4/2/20. Standing orders for blood sugars monitoring was put into place. 4/1/20. 3. Education was provided for the licensed nursing staff by the DON (Director of Nursing) and RDCS (Regional Director of Clinical Services) on Diabetes, Blood Glucose monitoring and follow through. Began 4/1/20. The education will also be provided to new hires during orientation. 4. Audit daily (M-F) of new admissions with a [DIAGNOSES REDACTED]. Audit daily (M-F) of new orders which may require blood glucose monitoring to ensure that blood glucose was scheduled correctly by DON or designee x 3 months. 5. 4/6/2020 Review of the facility audits and education revealed that the above plan of correction was implemented by facility staff. Further review of the education revealed that staff were also educated on reporting abnormal laboratory tests to the physician or provider on 3/28/20, 3/31/20, and 4/2/20. Facility Policy titled, Diabetic Protocol documents in part, the following: The provider and staff will work together to give the appropriate treatment to manage diabetes.the nurse shall assess/document and report the following: -Any signs and symptoms of infection (urine, skin/wound, upper respiratory etc.) or other acute illnesses; -Change in intake/thirst; -Neurological changes such as changes in level of consciousness or orientation; - Resident's age and gender; -Resident's blood sugar history over 48 hours. -Usual patterns (fluctuations, trends) of blood sugars over recent months; -Approximate intake over 24 hours; -Current medications; -Dose and time of most recent hyperglyemic agent given; -Recent labs e. Based on the preceding assessment, including cause and complications, the provider may order further interventions, which may include: treatment of [REDACTED]. f. The provider will follow up on any acute episodes associated with a significant blood glucose level changes and deterioration of previous glucose control and document resident's status at subsequent visits until the acute situation is resolved. g .the provider will order desired parameters for monitoring and reporting information related to diabetes and blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [REDACTED] Complaint deficiency. *Blood Glucose- The amount of glucose (sugar, measured in mg/dL) in your blood changes throughout the day and night. Your levels will change depending upon when, what and how much you have eaten, and whether or not you have exercised. Normal Blood Sugars normal fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dL. A normal blood sugar level two hours after eating is less than 140 mg/dL. Diabetes is diagnosed by any one of the following: Two consecutive fasting blood glucose tests that are equal to or greater than 126 mg/dL. Any random blood glucose that is greater than 200 mg/dL. An A1c test that is equal to or greater than 6.5 percent. A1c is an easy blood test that gives a three month average of blood sugars. A two-hour oral glucose tolerance test with any value over 200 mg/dL. This information was obtained from https://www.virginiamason.org/whatarenormalbloodglucoselevels. (1) Humalog- rapid acting insulin used to lower blood sugar. This information was obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ce8354f4-bf07-4923-8755-47f 62e4 (2) BMP (Basic Metabolic Panel) - A BMP is used to check several body functions and processes in the body. A BMP gives your doctor information about blood urea nitrogen (BUN), or how much nitrogen is in your blood to measure kidney function, creatinine, another indicator of kidney function, glucose, or blood sugar (having high or low blood sugar could both indicate pancreatic issues), carbon [MEDICATION NAME] (CO2), or [MEDICATION NAME], a gas that can indicate issues with your kidneys or lungs, calcium, which can indicate bone, kidney, or [MEDICAL CONDITION] issues (though sometimes not included in a BMP), sodium and potassium, minerals that indicates your body ' s overall fluid balance, chloride, an electrolyte that indicates fluid balance. This information was obtained from The National Institutes of Health. https://www.healthline.com/health/cmp-vs-bmp. (3) CBC (Complete Blood Count) -Your blood contains red blood cells (RBC), white blood cells (WBC), and platelets. Blood count tests measure the number and types of cells in your blood. This helps doctors check on your overall health. The tests can also help to diagnose diseases and conditions such as [MEDICAL CONDITION], infections, clotting problems, [MEDICAL CONDITION], and immune system disorders. This information was obtained from The National Institutes of Health. https://medlineplus.gov/bloodcounttests.html. (4) Creatinine-is a waste product made by your muscles as part of regular, everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your urine. If there is a problem with your kidneys, creatinine can build up in the blood and less will be released in urine. If blood and/or urine creatinine levels are not normal, it can be a sign of kidney disease. This information was obtained from https://medlineplus.gov/lab-tests/creatinine-test/. (5) BUN (Blood, Urea, Nitrogen) - Urea nitrogen is what forms when protein breaks down. A test can be done to measure kidney function by the amount of urea nitrogen in the blood. This information was obtained from https://medlineplus.gov/ency/article/ 4.htm. (6) Hemoglobin HA1c- The test results give you a picture of your average blood sugar level over the past two to three months. The higher the levels, the greater your risk of developing diabetes complications. The goal for most adults with diabetes is an HA1c that is less than 7%. HA1c test results are reported as a percentage. The higher the percentage, the higher your blood sugar levels over the past two to three months. This information was obtained from https://www.diabetes.org/a1c. (7) [MEDICATION NAME] - are chemicals that build up when your body starts to burn fat for energy. The most common cause of [MEDICATION NAME] in diabetics is insulin deficiency. Without enough insulin, glucose builds up in the blood stream and can't enter cells. The cells then burn fat instead of glucose. This information was obtained from https://beyondtype1.org/[MEDICATION NAME]. (8) Hyperosmolar [MEDICAL CONDITION]- A serious complication of diabetes mellitus, hyperosmolar hyperglycemi[DIAGNOSES REDACTED] (HHS) happens when blood sugar levels are very high for a long period of time. Symptoms of HHS can include extreme thirst, frequent urination, changes in your vision and confusion. HHS is an emergency . This information was obtained from https://my.clevelandclinic.org/health/diseases/ -hyperosmolar-hyperglycemic-syndrome. (9) Metabolic [MEDICAL CONDITION]- result from systemic illness, such as diabetes, liver disease, [MEDICAL CONDITION] and heart failure Metabolic encephalopathies usually develop acutely or subacutely and are reversible if the systemic disorder is treated. If left untreated, however, metabolic encephalopathies may result in secondary structural damage to the brain. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK /.

Based on observation, resident interview, staff interviews, clinical record review, and review of the facility policy the facility staff failed to identify a pressure ulcer and institute appropriate interventions, care and treatment for 1 of 42 residents (Resident #44), in the survey sample. The facility staff failed to identify Resident #44's sacral pressure ulcer prior to it advancing to a stage three pressure ulcer; which presented with 70% slough (non-viable) tissue, 30% granulation tissue and measured 0.8 centimeters x 1.0 centimeters x 0.1 centimeters, requiring surgical debridement (removal) to promote healing, which constituted harm. The findings included: Resident #44 was admitted to the nursing facility on 5/3/17, and readmitted to the facility 4/13/19, after an acute hospital stay. The current [DIAGNOSES REDACTED]. Resident #44's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #44's cognitive abilities for daily decision making were intact. The 3/15/19, MDS was coded for no mood or behavior problems. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with personal hygiene, dressing, and toileting and supervision of one person with eating. An interview was conducted with Resident #44 on 4/29/19 at approximately 11:00 a.m. The resident stated she was supposed to have a cream applied between her legs but it hadn't come in and the area was bothering her. On 4/29/19 at approximately 1:00 p.m. an observation was made of Resident #44's skin assessment performed by Licensed Practical Nurse-LPN #1, assisted by Certified Nursing Assistant-CNA #2. The skin assessment revealed a reddened rash in the groin area and to bilateral upper thighs; an open area was also observed to the resident's sacrum. The open area to the sacrum was very wet with whitish tissue surrounded by red tissue and yellowish slough tissue within the wound bed. The LPN #1 stated he would have the wound care nurse to thoroughly assess the opened sacral wound. Review of the physician order summary for (MONTH) 2019 revealed an order dated 4/22/19 for [MEDICATION NAME] 100,000 units/gram topical ointment. Apply to affected area four times daily. The [MEDICATION NAME] order was on the Medication Administration Record [REDACTED]. An interview was conducted with LPN #1. He stated the [MEDICATION NAME] had not been available for application and he had spoken with a pharmacy representative last on 4/29/19 concerning the order. The pharmacy representative asked do you still need it? LPN #1 responded yes and the pharmacy representative stated they would send it on the next run arriving 4/30/19. No pressure ulcer wound care orders were on the physician order summary until 4/30/19. The active care plan dated 3/18/19, had a problem which read; (name of resident) is at risk for pressure ulcer. Had actual pressure stage 3 sacral ulcer 12/11/18. The goal read; (name of resident) will remain free of skin breakdown over the next 90 days through 6/18/19. The interventions included; check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition. Do not massage skin over pressure areas. Perform nutritional screening, adjust diet/supplements as indicated to reduce the risk of skin breakdown. The Braden scale for predicting pressure ulcer risk dated 4/14/19 was 19, indicated the resident was a very high risk for the development of pressure ulcers. The re-admission nursing assessment dated [DATE], read the resident had good skin turgor, the skin was warm and dry, was without [MEDICAL CONDITION], had no pressure ulcers, no stasis ulcers and no surgical wounds. The weekly skin assessment dated [DATE], revealed no pressure ulcers. The weekly skin assessment dated [DATE], revealed no pressure ulcers. The weekly skin assessment dated [DATE], revealed no pressure ulcers. An interview was conducted with the wound care nurse 4/29/19 at approximately 4:35 p.m. The wound care nurse stated the wound care physician would be in 4/30/19 to assess the wound and implement the most appropriate treatment. A low air loss mattress was ordered 4/29/19. On 4/30/19 an interview was conducted with the wound care physician who stated the resident had a previous sacral pressure ulcer which had healed and took an extended period of time to heal. The wound care physician further stated the current sacral pressure ulcer appeared worse than it had ever presented but she was certain they would get it healed. The wound care physician's assessment of the sacral pressure ulcer is a follows; stage 3 pressure wound of the sacrum measuring (Length x Width x Depth) 0.8 centimeters x 1.0 centimeter x 0.1 centimeter with 70% slough tissue, 30 % granulation tissue and a light serous exudate. The wound care physician cleaned the sacral pressure ulcer with normal saline and anesthesia was achieved using topical [MEDICATION NAME], then with clean surgical technique curette was used to surgically excise 0.56 cubic centimeters of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissue was removed at a depth of 0.1 centimeter and healthy bleeding tissue was observed. Homeostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the assessment and plan section. The wound care physician pressure ulcer dressing wound care plan was for [MEDICATION NAME] (absorb exudate) sheet (thin), apply three times per week for thirty days, off-load the wound, reposition per facility protocol and follow-up by the wound care physician within seven days. An interview was conducted with the Director of Nursing on 5/1/19, at approximately 4:45 p.m. The Director of Nursing stated the expectation is for staff who care for the resident while bathing, providing incontinence care, and turning and repositioning to identify changes in the skin and report it immediately to the nurse on duty. The Director of Nursing also stated they have the Stop and Watch program to aid staff in reporting changes with a resident. The Director of Nursing further stated every Certified Nursing Assistant had been educated and know it is the facility's expectation to monitor for and report skin impairment. The Director of Nursing also stated the licensed nurses assess all resident's skin on admission and weekly to assure resident's skin is remains intact. The Director of Nursing stated Resident #44's last 4 weekly skin assessment had be viewed and neither identified any type of skin impairment. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). The facility's policy titled Registered Nurse and Licensed Practical Nurse Guidelines for Skin Integrity dated 3/6/17, read; Ensure completion of the Nursing Admission process and evaluate resident's risk factors by completing the Braden Risk Scale, Complete Weekly skin assessments for skin turgor, temperature, color and type, identification of [MEDICAL CONDITION] or open wounds, pressure ulcers/injury, stasis ulcer, surgical wounds or other skin problems. Under repositioning and mobilization the policy read; relieve pressure from bony prominences by assisting with turning and repositioning resident's at risk for pressure injury. Avoid positioning the resident on body areas with existing pressure injury. Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. On 5/1/19, the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated it was never reported and they were unaware the resident had the sacral pressure ulcer.

Based on observation, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to provide the necessary care and services to prevent pressure sore development and promote healing of a pressure sore for 2 of 25 residents in the survey sample, Resident #21 and #3. 1. Resident #21 developed a facility acquired advanced stage III pressure sore to the sacrum. The pressure sore was first identified by the wound care specialist during a routine assessment. The facility staff failed to implement treatments in a timely manner. The wound further deteriorated to a stage IV pressure sore resulting in harm. 2. The facility staff failed to follow the physician orders [REDACTED].#3's stage IV sacral pressure sore. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence (area), as a result of pressure,or pressure in combination with shear. National Pressure Ulcer Advisory Panel. The findings included: 1. Resident #21 entered the facility without a pressure sore and was discharged home on[DATE] with a stage IV pressure sore. Resident #21 was admitted to the facility on [DATE] for specialized rehabilitative services with a discharge plan to go home. The resident [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a progressive disorder of the nervous system that affects movement. The admission MDS (Minimum Data Set) with an assessment reference date (ARD) of 9/22/15 coded the resident as having long and short-term memory deficits; and severely impaired daily decision making skills. The resident required extensive assistance of two staff for bed mobility (turning and repositioning) and transfers. The resident was wheelchair bound. Under Skin Conditions the resident was coded as having a stage II pressure ulcer identified on admission 9/15/15 (this was an inaccurate coding). Under Section K. Nutritional Status the resident's weight was recorded as 178 pounds. The quarterly MDS with an ARD date of 12/13/15 recorded the resident's weight as 180 pounds. The MDS describes a stage II pressure ulcer as partial thickness loss of dermis, presenting as a shallow open area with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. The Nursing Admission Assessment Comprehensive dated 9/15/15 was reviewed. Under Skin, the resident was identified with red abrasions to both gluteal folds. The resident's skin was checked as having abrasions. M0445 Does the patient have a pressure ulcer? was marked No. The wound care specialist's (#1) initial assessment of the resident was on 9/16/15. The chief complaint was that the resident had a wound on their buttock. The focused wound exam indicated the etiology (source) of the wound was an infection. The right buttock wound measured 0.4 x 0.2 x 0.2 centimeters with 100% granulation tissue (healthy). The physician documented: Patient appears to have had a follicullitis leading to abscess and open area. Will start Hydrogel (a treatment), apply a dry protective dressing daily and Keflex (an antibiotic) 500 mg (milligrams) twice a day for 7 days. Folliculitis is a skin condition caused by an inflammation of one or more hair follicles in a limited area. A Hydrogel dressing is designed to hold moisture in the surface of the wound, providing the ideal environment for both cleaning the wound, and allowing the body to rid itself of necrotic tissue. The wound care specialist's (#2) follow up assessment was conducted on 9/25/15. The right buttock wound (follicullitis) was resolved. The resident presented with a new skin condition; a skin shear wound to the left buttock. The wound measured 1.5 x 0.5 x 0.1 centimeters. The treatment was to continue the Hydrogel with a foam dressing every day; and a follow up within 7 days. Skin Shear: an injury caused by applied force that tends to cause an opposite but parallel sliding motion of the planes of an object. Such motions cause tissues and blood vessels to move in such a way that blood flow may be interrupted, placing the patient at risk for pressure ulcers. An example of a shearing force is seen when a patient slumps in a chair; the skin around the buttocks is stretched by the movement and interferes with circulation. www.medical-dictionary.com On 10/1/15 the wound care specialist (#2) conducted the follow up assessment. During this evaluation the resident presented with a stage III pressure ulcer/sore to the sacrum. Etiology-pressure. The wound measured 3 x 2.5 x 0.1 centimeters, with 75% yellow necrotic tissue (dead) and 25% granulation (healthy tissue). The wound required surgical excisional debridement of subcutaneous tissue (to remove the dead tissue). The treatment was changed to include Santyl (an enzymatic [MEDICATION NAME] ointment), and a dry dressing every day. The wound care specialist documented under consent that she spoke with the responsible party who agreed to proceed with the procedure (debridement). The assessment and plan read, in part: Deteriorated due to generalized decline of patient: change dressing, optimize nutrition. According to the Treatment Administration Record for October 2016, the Santyl was not started until five days later, on 10/6/15. The MDS describes a stage III pressure ulcer as: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure (hide) the depth of tissue loss. May include undermining and tunneling. On 8/10/16 at 4:25 p.m., wound care specialist #2 was interviewed. She stated, I would not have expected the wound (shear) to have gotten worse. She stated there was no nutritional reason for the decline of the wound, stating,It became larger definitely got worse over that period of time .quite a bit larger . The wound care specialist was asked in her professional opinion based on the presentation of the wound how long do you believe the wound was like this, prior to her assessment on 10/1/15? She stated, At least three days . When asked if she would have expected the staff to have notified her of a change in condition of the wound, she stated, If there is a significant deterioration, yes, I would expect them to notify me. When asked did the wound have a significant deterioration she stated, Yes. She further stated, They know how to get a hold of me, I could have come in to see the wound sooner or change treatment. The wound care specialist stated the left buttock shear had enlarged, deteriorated and now was on the sacrum as a stage III pressure sore. The 10/1/15 assessment and plan that indicated the wound deteriorated due to a generalized decline of the patient was clarified. She stated the electronic program used for documentation includes this as a general response as to why a wound would deteriorate. She could not state what the generalized decline was. On 9/28/15 the Registered Dietician (RD) documented, weight down 10 lbs (pounds) since admission. Resident with good po (by mouth) intake; weight loss may be related to fluid shift as meds include [MEDICATION NAME] (a diuretic) . On 9/30/15 the RD documented the resident's recorded weight was 177 pounds. A second interview with the wound care specialist was conducted on 8/11/16 at 2:20 p.m. She was asked what would have caused the sacral wound to have deteriorated that rapidly? She stated, Usually from someone laying in one position too long it could have deteriorated if he laid on it for 24 hours or longer .unless he wasn't being turned, I rarely ever see it in someone being turned and repositioned. Review of the Nursing Daily Notes and TAR's from 9/25/15 through 10/1/15 failed to evidence the resident was turned and repositioned every two hours. The facility policy titled Pressure Ulcer Prevention revised 11/12/13 read, in part: Policy Statement: To prevent development of pressure ulcers. Turning and repositioning frequency is dependent on resident assessment and chart on TAR (treatment administration record). On 10/8/15 the wound care specialist assessed the wound. The wound had further deteriorated, and was now unstageable, the wound bed measured 4 x 5 x 0.1 centimeters and covered with 80% thick black necrotic tissue, 10% yellow necrotic tissue and 10% granulation tissue (healthy). A recommendation included to change the support surface (bed mattress) to a Group 2 mattress (an alternating pressure and low air loss mattresses and overlays). The Group 2 support surface was not ordered until 10/9/16; eight days after the stage III pressure sore was discovered and continued deterioration. According to the Quick Reference Guide for Clinicians Number 15 Pressure Ulcer Treatment from the U.S. Department of Health and Human Services read, in part: Managing Tissue Load-the goal of tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). Positioning techniques and support surfaces for patients in bed are important factors in the management of tissue loads. On 10/15/15 the wound care specialist assessed the wound. The wound was now a stage IV. The MDS describes a stage IV pressure sore as: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. A protein supplement (Prostat AWC-advance wound care daily) to aid in wound healing was not initiated until 10/15/15; fifteen days after the stage III pressure ulcer was identified on 10/1/15. In those 15 days the wound continued to deteriorate to an unstageable on 10/8/15, and a stage IV on 10/15/15. According to the Quick Reference Guide for Clinicians Number 15 Pressure Ulcer Treatment from the U.S. Department of Health and Human Services read, in part: Nutritional Assessment and Management .the goal of nutritional assessment and management is to ensure that the diet of the individual with a pressure ulcer contains nutrients adequate to support healing. The resident was followed weekly by the wound care specialist. The wound deteriorated, became infected and required additional excisional debridement on 10/8, 10/15, 10/22, 10/29, 11/5, 11/12, 11/18, 11/24, and 12/2/15. Treatment changes were ordered. The TAR's and MAR's (Treatment Administration Records and Medication Administration Records) were reviewed for compliancy with the recommendations/orders. Delay in treatment changes and medications were found as follows: 1. 10/1/15 Santyl order once a day; not started until 10/6/15. 2. 10/8/16 added [MEDICATION NAME] dressing (a foam absorbent dressing); not started until 10/15/15. 3. 10/15/15 added Dakins 1/4 strength once a day; not started until 10/19/15. Dakins' Solution® Quarter Strength is a broad-spectrum topical antimicrobial solution, effective [MEDICAL CONDITION], VRE, other bacteria, viruses, molds, fungi and yeast. Also used for odor control. 4. 10/22/15 increased Dakins to twice a day, and added the antifungal [MEDICATION NAME] 500 mg twice a day for 7 days to be placed into the wound bed due to wound odor and suspected infection. The [MEDICATION NAME] was applied only once, on 10/22/15, due to a transcription error. 5. 10/29/15 discontinued the Dakins solution added [MEDICATION NAME] 0.1% once a day (an antibiotic). The Dakins solution was not discontinued until 11/13/15. 6. 11/18/15 the [MEDICATION NAME] 0.1% was discontinued. The staff continued to administer the [MEDICATION NAME] until 11/25/15. 7. 11/18/15 [MEDICATION NAME] mg, added on 10/22/15, last dose was scheduled for 11/18/15. [MEDICATION NAME] ordered for an additional 14 days, and not restarted until 11/25/15. 8. 12/9/15 added Calcium alginate dressing once a day; was not started until 12/11/15. Calcium alginate is used for moderate to heavy exudate (drainage), including infected wounds. The above findings of the staff failing to implement orders in a timely manner as recommended was shared during a second interview with the wound care specialist conducted on 8/11/16 at 2:20 p.m. Her response was, That is a problem .the break is from the person who takes the order off . She stated the nurse prints out her notes and they are placed into orders. She stated, ultimately the primary care physician writes the order, but also has access to my notes. She stated she was not made aware of the aforementioned delay and/failure to follow treatment change orders for Resident #21. She also was asked why Prostat AWC was not started when the stage III pressure ulcer was first identified, she stated, Prostat recommendations are the responsibility of the dietician. On 8/11/16 at 5:30 p.m., the director of nursing (DON) was interviewed. The above findings was shared. The DON stated she would have expected the staff to have notified the physician of the deterioration of the wound, instead of the wound doctor discovering it first. She also stated she would have put a low air loss mattress in place as soon as the wound presented as a stage III. She stated the nurse does not need an order to initiate the change in mattress. She stated pressure sores are reviewed weekly at the standards of care meetings. She also stated that she was fairly new to the facility and identified there were concerns with pressure sores. She stated, There didn't seem to be a good system in place to identify and reporting of (pressure sores). I have since developed an action plan. The action plan included pressure ulcer prevention, identification, care and documentation. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Lupus is a chronic, [DIAGNOSES REDACTED] disease that can damage any part of the body (skin, joints, and/or organs inside the body). Chronic means that the signs and symptoms tend to last longer than six weeks and often for many years. www.lupus.org The current MDS (Minimum Data Set) with an assessment reference date of 5/18/16 coded the resident scoring a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Section M. Skin Condition coded the resident as having one stage IV pressure sore. The MDS describes a stage IV pressure sore as: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. The resident's pressure sore was being evaluated on a weekly basis by the wound care specialist. The current notes dated 8/10/16 describes the stage IV pressure sore as measuring 3.1 x 2 x 0.3 centimeters. The wound had 100% granulation tissue (healthy). The August 2016 TAR (treatment adminsitration record) evidenced the wound care specialist current treatment order dated 7/27/16 that read, Cleanse sacral wound with normal saline, apply algisite M (calcium alignate dressing) and dry dressing every day. The treatment was scheduled to be changed on the day shift. The August TAR evidenced initialed entries by the nurses that the dressing was changed every day. On 8/10/16 at 3:30 p.m., a dressing change observation of Resident #3's pressure sore was conducted with the licensed practical nurse (LPN#10) and wound care specialist. The nurse established a clean barrier, placed the dressing supplies on top of it, washed her hands and put on clean gloves. The sacral dressing was observed saturated with drainage and was dated as last changed on 8/8/16. The nurse was asked what was the dressing change frequency, she stated, Once a day. Further review of the TAR for August evidenced an inaccurate entry. The nurse initialed on 8/9/16 that the dressing was changed. The above findings was shared with the interim Administrator and the interim Director of Nursing during an end of day meeting conducted on 8/10/16 at 6:10 p.m. A follow up interview with the DON was conducted on 8/11/16. The DON stated, The nurse documented it was done and it wasn't. The DON stated the nurse was an agency nurse. The DON provided a copy of an email sent to the agency dated 8/10/16 at 9:24 p.m. The subject was DNR Staff (do not return). Listed on this email was the nurse who failed to change the dressing on 8/9/16 for Resident #3. The email read in part that this nurse along with another nurse were not allowed to come back to the facility due to failure to provide a dressing change.

Based on a complaint investigation, clinical record review, staff, family interview and facility documentation, the facility staff failed to ensure appropriate treatment and services were provided to prevent complications for 1 of 14 residents (Resident #111) in the survey sample who received gastrostomy tube feedings. Resident #111 was hospitalized in the ICU as a results of complications from Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, aspiration pneumonia and vomiting. The findings include: Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a PEG tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: "Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated." The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders to the MAR and left off, "then liquids after 6:00 PM if tolerated." [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition? With Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: "Call for any questions (phone number listed)." The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting, she aspirated feeding into her lungs. He stated, "I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has no where to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have." Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). There was a physician's orders [REDACTED]. On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to her discharge on 9/15/14 to the local hospital Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, "The resident was able to eat, she could get pleasure meals and her feeding." The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]. The Nutritional Assessment form dated 9/12/14 indicated the resident's current diet order as "Start [MEDICATION NAME] 1.5 at 5:00 PM Friday 1/2 can every 4 hours and on Sunday 1 can every 4 hours if residuals < 50 cc as ordered by the physician. Flushes as per physician's orders [REDACTED]." It was noted that a full RD assessment to follow. On 9/15/14 it was noted the resident had been discharged to the hospital. On 10/1/14 at 4:30 PM, CRD #1 was shown the [MEDICATION NAME] order for [MEDICATION NAME]. She interpreted the resident was supposed to have clear liquids if PEG feeding were tolerated and stated to the FSM, "I know you remember seeing the order slip that was sent to you for a diet change to clear liquids." The FSM stated, "No, I did not receive one," and proceeded to show this writer the diet that was being sent from the kitchen until the resident's discharge to the hospital on [DATE], "Pureed/level 1-double portions." The physician's orders [REDACTED]. CRD #1 calculated the calories Resident #111 received with the [MEDICATION NAME]'s PEG tube feeding orders. She stated with the 1/2 of [MEDICATION NAME] every four hours with free water and flushes the resident would have received 750 calories per 24 hours, 1,191 cc of water and 31.2 grams of protein. She calculated 1 can of [MEDICATION NAME] every four hours to equal 1,500 calories per 24 hours, 1,782 cc of water. CRD #1 stated based on the resident's height of 5 feet 5 inches and weight of 124 pounds, her calories would have been sufficient and within range between 1453-1863 calories without Ensure and the pureed diet. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only spoke to the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: "Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (Blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach." Though the pulse oximeter actually measures the saturation of oxygen in the blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. (mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: "Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (HR), 18 (Resp), 143/93 (BP), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called." The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurses' note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let the fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer and there was nothing about the resident on the 24 hour report. She said when she first encountered the resident, she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told him about the congestion and she ordered suction as needed, labs and a chest X-ray for "today". She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175 cc, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she was made aware of the high residuals and instructed her to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell you she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14, she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) "today". Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The Associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, "I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurse's are my eyes and ears. I expect them to assess and monitor these resident's closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs." During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, "Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift." Although the Corporate nurse repeatedly made this statement she also said, "I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't." The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either "then liquids after 6:00 PM if tolerated," or "clear liquids after 6:00 PM if tolerated." After some examination of the order they decided it meant, "then liquids after 6:00 PM." There was no where in the GI doctor's orders where he wrote to continue Ensure and the previous Pureed diet, as well as the Ensure. The "then liquids after 6:00 PM if tolerated" was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, "Call for any questions (phone number listed)." The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurse's notes were accurate regarding "no residuals" for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration)to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, "It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk." She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100 % of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50 % of her breakfast and lunch and 100 % of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for "a breathing difficulty". EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been "congested for several days". It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of "tube feeding appearing material", via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the Associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, "We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc." The goal was to "get her GI tract working again". The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, "I was worried (Resident #111's name) was going to die." Prevention of Aspiration Critically ill patients have an increased risk for aspirating oropharyngeal secretions and regurgitated gastric contents. For those who are tube-fed, aspiration of gastric contents is of greater concern. While witnessed large-volume aspirations occur occasionally, small-volume clinically silent aspirations are far more common. In the same study, risk for pneumonia was about 4 times greater in patients identified as frequent aspirators. Because no bedside tests are currently available to detect microaspirations, efforts to prevent or minimize aspiration take on added importance. Expected Practice Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated. For tube-fed patients, assess placement of the feeding tube at 4-hour intervals. For patients receiving gastric tube feedings, assess for gastrointestinal intolerance (residuals) to the feedings at 4-hour intervals. Tube-fed patients who experience frequent regurgitation and aspiration of gastric contents are at increased risk for poor respiratory outcomes. Guidelines developed jointly by the Society of Critical Care Medicine and the American Society for [MEDICATION NAME] and Enteral Nutrition recommend that patients be monitored for tolerance to enteral feedings by noting abdominal distention, complaints of abdominal pain, observing for passage of [MEDICATION NAME] and stool, and monitoring gastric residual volumes (http://www.aacn.org/wd/practice/content/practicealerts/aspiration-practice-alert.pcms?menu=practice). COMPLAINT DEFICIENCY

Based on a complaint investigation, clinical record review, staff and family interview and facility documentation, the facility staff failed to provide the necessary care and services to attain the highest practicable physical well-being for 2 of 14 residents (Residents #111, #104) in the survey sample. 1. The facility staff failed to monitor the bowel movements, assess and recognize the signs and symptoms of fecal impaction. Resident #111 was sent to the local hospital with a fecal impaction which was determined to have a direct correlation to complications from Perctaneous Endoscopic Gastrostomy (PEG) tube feedings; vomiting and high gastric residual volume resulted in aspiration pneumonia. 2. The facility staff failed to administer treatments as ordered by the physician for Resident #104. The findings include: 1. Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a Percutaneous Endoscopic Gastrostomy (PEG) tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed as always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident had the potential for alteration in elimination: Constipation. The goal the staff set for the resident was that they would promote soft, formed stools every three days during the next 90 days. Some of the approaches to implement this goal included monitor bowel sounds, vital signs and lab values, monitor for vomiting, abdominal distention, diarrhea and constipation. Document bowel movements on the Certified Nursing Assistant Activities of Daily Living (ADL) worksheets. If no bowel movements within three days, initiate Bowel Protocol. Monitor bowel movements every shift. The care plan indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: "Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated." The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders onto the MAR and left off, "then liquids after 6:00 PM if tolerated." [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition with Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: "Call for any questions (phone number listed)." The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting and she aspirated feeding into her lungs. He stated, "I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has nowhere to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have." Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to the time of her discharge on 9/15/14 to the local Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. The DON was asked how bowel movements (BM) were tracked and monitored for residents. She stated the Certified Nursing Assistants (CNA) write the BMs on the Bowel Movement Log and that was the only place for the licensed nurse to reference them. The DON referred to the Laxative Protocol guideline policy dated 4/8/14 during the interview and stated the licensed nurse was supposed to check all residents every day and if they do not have an adequate BM over two days, they would activate the bowel protocol on the third day and add their names to the laxative list and the 3/11 shift nurse would give all residents on the list 30 cc of Milk of Magnesia (MOM) and document all results before the end of her shift. If the residents did not have any results from the MOM by 2:00 AM the 11/7 nurse would give the resident a Fleet enema and document the results by the end of her shift. If no results on the 11/7 shift, the 7/3 shift nurse would then give a soap suds enema before getting the resident out of bed for the morning. She was shown the Bowel Movement Log and could only find the log for 9/2/14 through 9/7/14 and 9/15/14. The log indicated Resident #111 had a soft BM on the 3/11 shift 9/7/14. She also stated the BM log was not a part of the clinical record. On 10/2/14 at 10:00 AM, she produced the Activities of Daily Living (ADL) computer Data sheet and stated although she could not find the BM logs, the CNAs entered the BM information from the BM logs into the ADL Data log computer system. The ADL Data log recorded Resident #111 had small BMs on 9/9/14, 9/10/14, 9/11/14, 9/12/14 and 9/13/14. The computer record also recorded the resident was continent of bowel on 9/10/14 and 9/13/14. The DON stated the resident was always incontinent of bowel and bladder. She stated the information the CNA's entered into the system were small BM's but she expected the licensed nurse to do the daily review of the BM logs, question the CNA, follow-up and determine if the BMs were adequate. She also stated she relied on the nurse's notes to show assessment of bowel sounds, temperature, if resident was vomiting or not having normal stools. The DON stated the nurses do not look at the ADL Data logs because it was in the computer, but the BM records which are kept in a binder or on a clip board and could be reviewed at a glance. As mentioned above the BM logs after 9/7/14 to 9/14/14 could not be located. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, "The resident was able to eat, she could get pleasure meals and her feeding." The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]." A random interview was conducted with LPN #10 on 10/2/14 at 3:40 PM. She stated, "For a resident having an increase in temperature, vomiting, drooling, having little small stools or loose stools meaning the stool is oozing around the small harder or firmer stools, you would suspect a fecal impaction. If after two days, there is not a regular stool, especially if the resident is eating and drinking, I want the CNA to let me know. I'm supposed to be checking closely on residents that are bed bound and on pain medications. We use the BM logs to monitor BMs, as well as verbal information shift to shift and/or the 24 hour report." On 10/2/14 at 3:55 PM, the Unit Manager on Station I Registered Nurse (RN) #3 stated, "We are supposed to check the BM records and pay attention to the last time the resident had a BM, the type and amount. It is always good to error on the side of caution with those residents that are on narcotics and can't say much to you regarding pain and discomfort, just do an assessment. You would need to call the physician to disimpact the resident, but you could check for a fecal impaction. If they run a low grade temperature and vomit up food, even just a little with small BMs, there may be a back up of stool." The Attending Physician's Standing Orders (undated) indicated for residents with nausea/vomiting for more than two episodes in 8 hours to check the rectal vault for stool first. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only referred the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: "Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach." Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low(mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: "Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (heart rate), 18 (respirations), 143/93 (blood pressure), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called." The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurse's note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer. She said there was nothing about the resident on the 24 hour report. She said when she first encountered the resident she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told her about the congestion and she ordered suction as needed, labs and a chest X-ray for "today". She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she made the physician aware of the high residuals and was instructed to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the resident's O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell her she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14 she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) "today". Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, "I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurses are my eyes and ears. I expect them to assess and monitor these residents closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs." During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, "Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift." Although the Corporate nurse repeatedly made this statement she also said, "I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't." The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either "then liquids after 6:00 PM if tolerated," or "clear liquids after 6:00 PM if tolerated." After some examination of the order they decided it meant, "then liquids after 6:00 PM." No where in the GI doctor's orders were orders to continue Ensure and the previous Pureed diet, as well as the Ensure. The "then liquids after 6:00 PM if tolerated" was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, "Call for any questions (phone number listed)." The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurses' notes were accurate regarding "no residuals" for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration) to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, "It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk." She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100% of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50% of her breakfast and lunch and 100% of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for "a breathing difficulty". EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been "congested for several days". It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of "tube feeding appearing material", via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore, the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, "We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc." The goal was to "get her GI tract working again". The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, "I was worried (Resident #111's name) was going to die." A fecal impaction can be a large lump of dry hard stool that stays stuck in the rectum, most often seen in people who are constipated for a long time. You are more at risk for chronic constipation and fecal impaction if you do not move around much and spend much of you time in a chair or bed. Certain drugs that slow the passage of stool through the bowels, i.e., narcotic pain medications. Symptoms include abdominal bloating and cramping and pain, leakage of liquid or sudden episodes of watery diarrhea, small semi-formed stools, straining when trying to pass stools, bladder pressure or loss of bladder control, lower back pain, rapid heartbeat or light-headedness from straining to pass, vomiting. Prompt identifications and treatment minimizes complications such as bowel obstruction leading to aspiration, perforation and peritonitis. The health care worker should examine your stomach and rectum and check for a recent change in bowel habits. Treating a fecal impaction involv

Based on a complaint investigation, clinical record review, staff and family interview and facility documentation, the facility staff failed to provide the necessary care and services to attain the highest practicable physical well-being for 2 of 14 residents (Residents #111, #104) in the survey sample. 1. The facility staff failed to monitor the bowel movements, assess and recognize the signs and symptoms of fecal impaction. Resident #111 was sent to the local hospital with a fecal impaction which was determined to have a direct correlation to complications from Perctaneous Endoscopic Gastrostomy (PEG) tube feedings; vomiting and high gastric residual volume resulted in aspiration pneumonia. 2. The facility staff failed to administer treatments as ordered by the physician for Resident #104. The findings include: 1. Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a Percutaneous Endoscopic Gastrostomy (PEG) tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed as always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident had the potential for alteration in elimination: Constipation. The goal the staff set for the resident was that they would promote soft, formed stools every three days during the next 90 days. Some of the approaches to implement this goal included monitor bowel sounds, vital signs and lab values, monitor for vomiting, abdominal distention, diarrhea and constipation. Document bowel movements on the Certified Nursing Assistant Activities of Daily Living (ADL) worksheets. If no bowel movements within three days, initiate Bowel Protocol. Monitor bowel movements every shift. The care plan indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: "Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated." The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders onto the MAR and left off, "then liquids after 6:00 PM if tolerated." [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition with Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: "Call for any questions (phone number listed)." The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting and she aspirated feeding into her lungs. He stated, "I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has nowhere to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have." Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to the time of her discharge on 9/15/14 to the local Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. The DON was asked how bowel movements (BM) were tracked and monitored for residents. She stated the Certified Nursing Assistants (CNA) write the BMs on the Bowel Movement Log and that was the only place for the licensed nurse to reference them. The DON referred to the Laxative Protocol guideline policy dated 4/8/14 during the interview and stated the licensed nurse was supposed to check all residents every day and if they do not have an adequate BM over two days, they would activate the bowel protocol on the third day and add their names to the laxative list and the 3/11 shift nurse would give all residents on the list 30 cc of Milk of Magnesia (MOM) and document all results before the end of her shift. If the residents did not have any results from the MOM by 2:00 AM the 11/7 nurse would give the resident a Fleet enema and document the results by the end of her shift. If no results on the 11/7 shift, the 7/3 shift nurse would then give a soap suds enema before getting the resident out of bed for the morning. She was shown the Bowel Movement Log and could only find the log for 9/2/14 through 9/7/14 and 9/15/14. The log indicated Resident #111 had a soft BM on the 3/11 shift 9/7/14. She also stated the BM log was not a part of the clinical record. On 10/2/14 at 10:00 AM, she produced the Activities of Daily Living (ADL) computer Data sheet and stated although she could not find the BM logs, the CNAs entered the BM information from the BM logs into the ADL Data log computer system. The ADL Data log recorded Resident #111 had small BMs on 9/9/14, 9/10/14, 9/11/14, 9/12/14 and 9/13/14. The computer record also recorded the resident was continent of bowel on 9/10/14 and 9/13/14. The DON stated the resident was always incontinent of bowel and bladder. She stated the information the CNA's entered into the system were small BM's but she expected the licensed nurse to do the daily review of the BM logs, question the CNA, follow-up and determine if the BMs were adequate. She also stated she relied on the nurse's notes to show assessment of bowel sounds, temperature, if resident was vomiting or not having normal stools. The DON stated the nurses do not look at the ADL Data logs because it was in the computer, but the BM records which are kept in a binder or on a clip board and could be reviewed at a glance. As mentioned above the BM logs after 9/7/14 to 9/14/14 could not be located. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, "The resident was able to eat, she could get pleasure meals and her feeding." The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]." A random interview was conducted with LPN #10 on 10/2/14 at 3:40 PM. She stated, "For a resident having an increase in temperature, vomiting, drooling, having little small stools or loose stools meaning the stool is oozing around the small harder or firmer stools, you would suspect a fecal impaction. If after two days, there is not a regular stool, especially if the resident is eating and drinking, I want the CNA to let me know. I'm supposed to be checking closely on residents that are bed bound and on pain medications. We use the BM logs to monitor BMs, as well as verbal information shift to shift and/or the 24 hour report." On 10/2/14 at 3:55 PM, the Unit Manager on Station I Registered Nurse (RN) #3 stated, "We are supposed to check the BM records and pay attention to the last time the resident had a BM, the type and amount. It is always good to error on the side of caution with those residents that are on narcotics and can't say much to you regarding pain and discomfort, just do an assessment. You would need to call the physician to disimpact the resident, but you could check for a fecal impaction. If they run a low grade temperature and vomit up food, even just a little with small BMs, there may be a back up of stool." The Attending Physician's Standing Orders (undated) indicated for residents with nausea/vomiting for more than two episodes in 8 hours to check the rectal vault for stool first. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only referred the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: "Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach." Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low(mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: "Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (heart rate), 18 (respirations), 143/93 (blood pressure), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called." The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurse's note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer. She said there was nothing about the resident on the 24 hour report. She said when she first encountered the resident she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told her about the congestion and she ordered suction as needed, labs and a chest X-ray for "today". She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she made the physician aware of the high residuals and was instructed to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the resident's O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell her she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14 she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) "today". Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, "I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurses are my eyes and ears. I expect them to assess and monitor these residents closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs." During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, "Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift." Although the Corporate nurse repeatedly made this statement she also said, "I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't." The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either "then liquids after 6:00 PM if tolerated," or "clear liquids after 6:00 PM if tolerated." After some examination of the order they decided it meant, "then liquids after 6:00 PM." No where in the GI doctor's orders were orders to continue Ensure and the previous Pureed diet, as well as the Ensure. The "then liquids after 6:00 PM if tolerated" was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, "Call for any questions (phone number listed)." The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurses' notes were accurate regarding "no residuals" for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration) to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, "It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk." She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100% of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50% of her breakfast and lunch and 100% of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for "a breathing difficulty". EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been "congested for several days". It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of "tube feeding appearing material", via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore, the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, "We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc." The goal was to "get her GI tract working again". The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, "I was worried (Resident #111's name) was going to die." A fecal impaction can be a large lump of dry hard stool that stays stuck in the rectum, most often seen in people who are constipated for a long time. You are more at risk for chronic constipation and fecal impaction if you do not move around much and spend much of you time in a chair or bed. Certain drugs that slow the passage of stool through the bowels, i.e., narcotic pain medications. Symptoms include abdominal bloating and cramping and pain, leakage of liquid or sudden episodes of watery diarrhea, small semi-formed stools, straining when trying to pass stools, bladder pressure or loss of bladder control, lower back pain, rapid heartbeat or light-headedness from straining to pass, vomiting. Prompt identifications and treatment minimizes complications such as bowel obstruction leading to aspiration, perforation and peritonitis. The health care worker should examine your stomach and rectum and check for a recent change in bowel habits. Treating a fecal impaction involv

Based on a complaint investigation, clinical record review, staff, family interview and facility documentation, the facility staff failed to ensure appropriate treatment and services were provided to prevent complications for 1 of 14 residents (Resident #111) in the survey sample who received gastrostomy tube feedings. Resident #111 was hospitalized in the ICU as a results of complications from Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, aspiration pneumonia and vomiting. The finding include: Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a PEG tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: "Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated." The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders to the MAR and left off, "then liquids after 6:00 PM if tolerated." [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition? With Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: "Call for any questions (phone number listed)." The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting, she aspirated feeding into her lungs. He stated, "I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has no where to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have." Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). There was a physician's orders [REDACTED]. On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to her discharge on 9/15/14 to the local hospital Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, "The resident was able to eat, she could get pleasure meals and her feeding." The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]. The Nutritional Assessment form dated 9/12/14 indicated the resident's current diet order as "Start [MEDICATION NAME] 1.5 at 5:00 PM Friday 1/2 can every 4 hours and on Sunday 1 can every 4 hours if residuals < 50 cc as ordered by the physician. Flushes as per physician's orders [REDACTED]." It was noted that a full RD assessment to follow. On 9/15/14 it was noted the resident had been discharged to the hospital. On 10/1/14 at 4:30 PM, CRD #1 was shown the [MEDICATION NAME] order for [MEDICATION NAME]. She interpreted the resident was supposed to have clear liquids if PEG feeding were tolerated and stated to the FSM, "I know you remember seeing the order slip that was sent to you for a diet change to clear liquids." The FSM stated, "No, I did not receive one," and proceeded to show this writer the diet that was being sent from the kitchen until the resident's discharge to the hospital on [DATE], "Pureed/level 1-double portions." The physician's orders [REDACTED]. CRD #1 calculated the calories Resident #111 received with the [MEDICATION NAME]'s PEG tube feeding orders. She stated with the 1/2 of [MEDICATION NAME] every four hours with free water and flushes the resident would have received 750 calories per 24 hours, 1,191 cc of water and 31.2 grams of protein. She calculated 1 can of [MEDICATION NAME] every four hours to equal 1,500 calories per 24 hours, 1,782 cc of water. CRD #1 stated based on the resident's height of 5 feet 5 inches and weight of 124 pounds, her calories would have been sufficient and within range between 1453-1863 calories without Ensure and the pureed diet. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only spoke to the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: "Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (Blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach." Though the pulse oximeter actually measures the saturation of oxygen in the blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. (mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: "Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (HR), 18 (Resp), 143/93 (BP), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called." The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurses' note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let the fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer and there was nothing about the resident on the 24 hour report. She said when she first encountered the resident, she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told him about the congestion and she ordered suction as needed, labs and a chest X-ray for "today". She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175 cc, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she was made aware of the high residuals and instructed her to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell you she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14, she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) "today". Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The Associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, "I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurse's are my eyes and ears. I expect them to assess and monitor these resident's closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs." During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, "Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift." Although the Corporate nurse repeatedly made this statement she also said, "I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't." The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either "then liquids after 6:00 PM if tolerated," or "clear liquids after 6:00 PM if tolerated." After some examination of the order they decided it meant, "then liquids after 6:00 PM." There was no where in the GI doctor's orders where he wrote to continue Ensure and the previous Pureed diet, as well as the Ensure. The "then liquids after 6:00 PM if tolerated" was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, "Call for any questions (phone number listed)." The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurse's notes were accurate regarding "no residuals" for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration)to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, "It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk." She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100 % of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50 % of her breakfast and lunch and 100 % of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for "a breathing difficulty". EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been "congested for several days". It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of "tube feeding appearing material", via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the Associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, "We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc." The goal was to "get her GI tract working again". The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, "I was worried (Resident #111's name) was going to die." Prevention of Aspiration Critically ill patients have an increased risk for aspirating oropharyngeal secretions and regurgitated gastric contents. For those who are tube-fed, aspiration of gastric contents is of greater concern. While witnessed large-volume aspirations occur occasionally, small-volume clinically silent aspirations are far more common. In the same study, risk for pneumonia was about 4 times greater in patients identified as frequent aspirators. Because no bedside tests are currently available to detect microaspirations, efforts to prevent or minimize aspiration take on added importance. Expected Practice Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated. For tube-fed patients, assess placement of the feeding tube at 4-hour intervals. For patients receiving gastric tube feedings, assess for gastrointestinal intolerance (residuals) to the feedings at 4-hour intervals. Tube-fed patients who experience frequent regurgitation and aspiration of gastric contents are at increased risk for poor respiratory outcomes. Guidelines developed jointly by the Society of Critical Care Medicine and the American Society for [MEDICATION NAME] and Enteral Nutrition recommend that patients be monitored for tolerance to enteral feedings by noting abdominal distention, complaints of abdominal pain, observing for passage of [MEDICATION NAME] and stool, and monitoring gastric residual volumes (http://www.aacn.org/wd/practice/content/practicealerts/aspiration-practice-alert.pcms?menu=practice). COMPLAINT DEFICIENCY

Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing and prevent new pressure sores from developing for 1 of 21 residents (Resident #9) in the survey sample. Resident #9 was admitted with one Stage II pressure ulcer (sacrum) that progressed to a Stage III healed and reopened at a Stage II; and acquired two additional pressure ulcers, one (right outer heel) first identified at an advanced stage (unstageable) and a left trochanter/hip assessed at a Stage II that had healed, but not before it had progressed to a Stage III. Observations were made of the resident in one position over 2 hours. In addition, the facility staff could not demonstrate the attending physician consistently assessed, evaluated and dictated the clinical plan and care for the resident's most severe pressure ulcer, right outer foot. The findings include: Resident #9 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The hemoglobin A1C collected on 5/5/14 that measures stability of blood sugars over time was 6.0 (normal=4.8-5.9). The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed always incontinent of bowel and bladder. Resident #9 was coded to required extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. The resident was assessed at risk for pressure ulcers and had one unstageable pressure ulcer with slough/eschar that measured 8.5 centimeters (cm) long, 4 cm wide and .1 cm in depth. She was coded with a prior healed Stage IV pressure ulcer. The care plan upon admitted d 1/8/14 identified Resident #9 had one Stage II pressure ulcer and was at risk for developing additional ulcers. The goal the staff set for the resident was she would maintain healthy skin during the next 90 days. Some of the approaches to accomplish this goal included daily skin inspection during care for redness, blistering and irritation, turn and reposition every 2 hours, weekly body checks per licensed nurse, report changes in skin condition to charge nurse, pressure relief mattress, offer supplements as prescribed. The care plan dated 1/28/14 identified a right hip pressure ulcer, but there was no evidence of this area in the clinical record. The weekly skin inspection sheets dated 3/10/14 first identified a Stage III pressure ulcer on the left trochanter/hip. According to the Weekly Skin Condition Progress Report for wounds, tracking of a left hip pressure ulcer began a month later on 4/9/14, identified as a Stage II. A nurse's note dated 2/13/14 first indicated Calmeseptine ointment was applied to a reddened area on the left hip. The care plan dated 4/15/14 with a review date of 7/15/14 identified an unstageable pressure ulcer to the right outer foot and the left hip was now a Stage III. The goal the staff set for the resident was this ulcer would be healed within 90 days. Some of the approaches the staff would use to accomplish this goal included pressure relief mattress, turn and reposition every 2 hours, monitor for nutritional intake, utilize comfort aids such as pillows, increase protein intake and evaluate adequacy of calorie intake. The care plan dated 7/3/14 indicated [MEDICATION NAME] (antibiotic to treat bacterial infections) was ordered for an infected right outer foot for 10 days. There was a telephone order dated 6/24/14 for the [MEDICATION NAME] and Keflex (oral antibiotic to treat bacterial infections) 250 milligrams for 28 days. Hand written notes on the care plan dated 6/4/14 indicated the physician approved the wound care treatment protocols. The care plan notes dated 6/11/14 further indicated the left hip was slowly improving and the resident was receiving double meats and Prostat 30 cubic centimeters for 30 days. The facility's risk assessment tool indicated on admission (1/8/14) Resident #9 had a total score of 12; on 4/27/14 and 7/15/14, she had a total score of 11. Twelve and below represented the resident was at high risk of developing pressure ulcers. The Weekly Skin Condition Progress Wound Report indicated an right outer foot pressure ulcer was first identified on 2/26/14 as unstageable, measured 1.3 cm by (x) 1.0 cm with eschar present. The weekly measurements were recorded on the report and the right outer foot revealed an increase in size and possible infection. The chronology of the right outer foot in two week intervals indicated the following: On 3/12/14-2.5 cm x 2.0 cm, unstageable with eschar present. Treatment was Allevyn (protective foam dressing) to change every 72 hours. On 3/26/14-3.0 cm x 3.0 cm unstageable with eschar present. Treatment unchanged. On 4/9/14-3.0 cm x 4.0 cm unstageable with eschar present. Treatment changed to Skin Prep (liquid film forming protective agent). On 4/23/14-3.5 cm x 4.3 cm unstageable 100 percent (%) necrotic. Treatment unchanged. On 5/7/14-4.0 cm x 4.5 cm unstageable 100 % necrotic. Treatment unchanged. On 5/21/14-2.2 cm x 2.2 cm unstageable 100 % necrotic. Treatment unchanged. On 6/4/14-3.5 cm x 3.0 cm, 0.1 cm depth unstageable. Treatment unchanged. On 6/18/14-4.0 cm x 3.5 cm, 0.1 cm unstageable. Treatment unchanged with the exception of by mouth (PO) Keflex 250 milligrams (mg) x 28 days and topical [MEDICATION NAME] x 10 days order on 6/24/14. On 7/2/14-8.0 cm x 4.5 cm, 0.1 cm unstageable. Treatment unchanged. On 7/16/14-8.5 cm x 4.5 cm, 0.1 cm unstageable. Treatment unchanged. On 7/30/14-9.0 cm x 6.0 cm, 0.1 cm unstageable. The wound was debrided on 7/29/14, otherwise treatment unchanged. On 8/5/14-9.0 cm x 6.0 cm, 0.2 depth, unstageable 70 % necrotic with large amounts of exudate (drainage). The following observations of the Resident #9 were made: On 8/5/14 at 2:00 PM, Resident #9 was observed in bed on her right side, open heel Prevalon boots (a soft boot designed to lift the heel off of the mattress, minimizing pressure on the heel www.sageproducts.com) were in place to both lower legs and feet. Pillows were tucked at her back to hold her over on her right side. The right leg was totally contracted and drawn up to her chest and the resident was laying directly on the right outer foot. A pillow was observed between her thighs and one under her right knee. In addition, the right heel was observed pressed into the mattress. The left leg was not contracted and the lower extremity was floated with the use of pillows. The resident did not respond to or initiate conversation. On 8/5/14 at 2:20 PM, peri-care and a skin assessment was conducted with the assistance of Certified Nursing Assistant (CNA) #41. She was asked how the resident developed the right outer foot pressure ulcer. She stated it was because the resident's right leg was so contracted and it was hard to position her without avoiding pressure on the foot. She further said, "We try to keep her off the foot by placing her on the left side, but she then she gets a sore on the left hip. She does not communicate to tell us anything and she can't turn herself or hold herself over. We have to do everything." She stated the resident stayed in the position they placed her in until the she is repositioned by them again. The CNA stated, "We try to float the feet, but for the right contracted leg all we can do is put a pillow under her knee. That leg is so tight and bent all the way back." On 8/6/14 at 8:45 AM, Resident #9 was observed in the wheelchair in her room. A pillow was observed under her right shoulder. The Prevalon boots were in place, a pillow was under the right knee, but the heel of the right contracted leg made direct contact with the seat of the wheelchair. There was no pillow between her thighs. On 8/6/14 at 11:00 AM, Licensed Practical Nurse (LPN ) #21 assisted by CNA #43 (assigned CNA) and CNA #42 transferred Resident #9 from the wheelchair to the bed for wound care. When asked what type of wound the resident had on the right foot, LPN #21 stated, "With her right leg being so tightly contracted, the right outer foot was not protected from pressure and she needs to be repositioned every two hours." She added there was a re-opened Sacrum pressure ulcer, as well as the left outer hip which was now healed covered with Allevyn. The LPN removed the old dressing that had copious amounts of brown, gray and red drainage. The drainage and wound was malodorous. The area along the top of the wound had some red tissue, the center filled with brown slough and black eschar was observed at the portion closest to the side of the heel. The LPN cleaned the wound with normal saline, applied Santyl and covered with a saline soaked gauge secured with Kling wrap. She did not cover the saline soaked gauge with a dry dressing prior to the Kling wrap in accordance with the most recent physician's orders [REDACTED]. CNA #42 stated, "Those are probably old DTI's, I think we use skin prep on them just for protection, but I'm not sure." Skin prep was not applied at this time and review of the clinical record did not reveal an order for [REDACTED]. None of the weekly skin inspection reports indicated darkened heels. The sacral wound was undressed to reveal a Stage II red granulating (new tissue) tissue in the center. This wound was cleansed with normal saline, Solosite applied, covered with a dry gauze and secured with tape. The observation was in accordance with the current physician's orders [REDACTED]. The Weekly Skin Condition Progress Report indicated the resident was admitted with this wound that progressed to a Stage III on 2/5/14, 3.4 cm x 1.6 cm and 0.1 depth. The area healed on 7/2/14 and reopened on 7/23/14 1 cm x .5 cm and 0.1 depth. The current recorded measurements were dated 7/30/14 as 1.0 cm x .08 cm and 0.1 depth granulating and no odor. On 8/6/14 at 12:00 PM, Resident #9 was observed in bed positioned on her right side. The Prevalon boots were in place. A pillow was under the right knee and another floating the left heel. On 8/6/14 at 3:00 PM, the resident was observed in bed in the same position. On 8/6/14 at 4:30 PM, Resident #9 was observed positioned on her left side. The nurse in charged of Resident #9 was interviewed on 8/7/14 at 10:20 AM. She stated,"I was transferred to Unit I in March 2014 and started doing wound care, but (Director of Nursing's name) does the measurements now. When we had a unit manager, she did them. The wounds are pressure related. I do rounds and try to check on her positioning and she wears contraction boots now. If they have to take them off for a while, she is positioned with pillows." She stated other than an occasional 'yes' and 'no', the resident did not communicate. On 8/7/14 at 10:45 AM, and interview was conducted with CNA #43. She stated she had been working as a CNA at the nursing facility and although assignments rotated, she was very familiar with Resident #9 and was currently assigned to her. She stated a pillow was placed between the resident's thighs to keep her knees from touching, as well as under the contracted right knee. She said it was hard to reposition the resident because of her contracted right leg, but they were to float the heels even though she had Prevalon boots to both feet. She said she never wanted to leave the resident up in the chair or in any position for more than 3 hours. She stated, "(Resident #9's name) has a "horrible" pressure sore on the bony parts on the outside of her right foot." On 8/7/14 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). She stated she thought the right outer wound was first identified on 3/6/14 as unstageable with eschar and treatment was ordered which was Allevyn every 72 hours. She said it was assessed as pressure related because it was located on a bony prominence and the resident was on a pressure relief support surface. The Weekly Skin Condition Progress report indicated the right outer heel was first identified on 2/26/14 as unstageable with eschar. She stated she had not seen that documentation until the present interview, but was relying on the first physician's orders [REDACTED]. The nurse's notes did not indicate the physician was called and informed of the area until 3/6/14. According to the DON, the resident was admitted on [DATE] with gray foam boots and she removed them because the resident's feet would sweat and the foam compressed against the foot and she also felt the resident needed relief from them when they assessed the resident was in pain. She stated she changed to the Prevalon boot on 3/6/14. The DON further stated the Allevyn was discontinued on 4/4/14 and skin prep was started because the area was hard and necrotic. She said treatment was next changed on 6/12/14 to Santyl (topical [MEDICATION NAME] agent) and there was no change in treatment since. She did not mention the [MEDICATION NAME] (topical) and PO Keflex order on 6/24/14. She said on 7/29/14, she superficially surgically debrided the wound and treatment had not been changed since then because the necrotic areas were lifting. She stated the wound possessed a foul odor with heavy drainage. According to the DON she had training in sharp detriment over her years as a nurse, but no certification. During the above interview, she stated the resident was not seen by a wound care specialist because she was private pay and the family did not want to pay for the service. She stated the attending physician had not seen the wound, but depended on her assessments of all the wounds and her recommendations for treatment based on the facility's pressure ulcer protocols and she would write telephone orders. She said based on the physician's orders [REDACTED]. She said the left hip was considered healed as of 7/3/14 with just a protective dressing due to the fragility of the area. The DON further stated the resident was admitted with a Stage II sacral ulcer that also progressed to a Stage III with necrotic slough tissue. She said the Sacrum was considered healed on 7/2/14, but reopened to a Stage II on 7/23/14. When asked if there was consideration for a change in the support surface in light of multiple pressure ulcers, their stages and locations, the reopening of pressure ulcers, as well as the resident contractures, she stated, "We do not put residents on an alternating air mattress when all the staff needs to do is provide pressure relief to extremities. I depend on the use of pillows to do that." When asked if therapy had been considered to offer recommendations for positioning, she said, "The resident was already balled up when she came to us. We know what to do and we do not need Occupational Therapy (OT) for anything. It's just providing good positioning and turning every two hours." She was not able to provide an investigation into the any of the resident's wounds, but said during the interview, "These wounds were due to pressure and I am going to leave it alone, I do not have any investigations into any of them. I can say the right outer foot was avoidable." The DON stated Prostat was started on 1/20/14 and vitamin A, C and Zinc started on 4/10/14, as well as multivitamin with minerals started on 5/14/14. The DON stated the previous Registered Nurse (RN) Unit I Manager, who not longer worked for the facility, was responsible to perform the weekly wound assessments. She said she took over after the Unit Manager left. The DON stated she was serving as the acting Unit Manager until they found a qualified one. Among the performance issues brought to the Unit Managers attention on 4/14/14 were issues of immediate attention and improvement regarding unit rounding to ensure residents were turned and repositioned and excellent personal care was being provided. The performance issues did not improve and she was no longer employed by the facility as of 5/6/14. On 8/7/14 at 1:30 PM, the aforementioned issues were brought to the attention of the Administrator and re-addressed with the DON. Resident #9's attending physician who was also the facility's Medical Director was interviewed on 8/7/14 at 3:00 PM. He stated he did not remember when he last saw Resident #9's right outer foot, but knew it was an advanced stage wound and not healing well. He stated he had a Physician's Assistant (PA) student reviewing charts and he signed off on their notes. He stated the nurses call him with what a description and an update on the wound and usually the DON would tell him the treatment protocol then he gives the order for the recommended treatment. He stated he preferred the wound care doctor to make assessments and dictate treatment, but the family did not want to pay for it so besides the staff turning and repositioning residents, he depends on the nursing staff to provide good descriptions of the wound and he would give the necessary orders. He also stated a new physician had just started and would be able to help because with the responsibilities of his practice and the many residents at the facility he was short on time. Review of the physician's progress notes dated 1/10/14, the attending physician reviewed the systems and physical findings and noted there was a Stage II sacral decubitus ulcer and contractures. The next note was written on 3/21/14 and signed by the attending indicated that the PA student completed the progress note with mention of the sacral pressure ulcer. The attending hand wrote a note on the side "Right foot started on Keflex, follow up (f/u) with podiatry, vascular if needed." There was no evidence in the clinical record that this order was written, thus no follow-up by the podiatrist. The next progress note completed by the PA student and signed by the attending physician dated 5/30/14 only made mention of the Stage II coccyx and Stage III left trochanter. The [MEDICATION NAME] obtained on 5/23/14 was 13 (20-40=normal). Nutritional support was provided to include protein supplements, Vit A, C and Zinc. On 8/7/14 at 3:00 PM, two surveyors made an observation of Resident #9 in bed. The resident was laying on her back and the resident's right heel was visibly seen in the cut out heel portion of the Prevalon boot embedded in the mattress. The DON was immediately brought to the resident's bedside and shown the positioning of the resident. She stated the resident should not be on her back at all because of the sacral pressure ulcer and the heels should be floated with pillows regardless of whether the resident was wearing Prevalon boots or not. On 8/7/14 at 3:30 PM, the DON stated, "I know I said we don't place resident's on an alternating air mattresses when all they need is positioning of extremities, but it looks like I am going to have to place the resident on one for the sacral and due to the the contractures severity of the right outer foot, as well as the staff not positioning her properly and having difficulty with positioning her. I am also going to have Occupational Therapy screen the resident to explore any additional positioning recommendations; to tell us and instruct the CNA's. We can do that regardless of whether she is private pay or not." According to the facility's policy and procedures entitled Guidelines of Care-Pressure Sores revised 1/11/11, the facility would provide routine preventative and daily care including turning and repositioning, application of pressure reduction or relief devices, skin care and provision of care. The determination that development of a pressure sore was unavoidable may be made only if aggressive routine preventative and daily care; and appropriate preventative measures and care specific to the resident's unique risk factors were provided. Documented interventions would be on the care plan and if objectives were not met, alternative approaches would be developed. The policy and procedures entitled Standards and Required Characteristics-Skin condition revised 7/11/11 indicated residents with skin breakdown would show improvement and healing unless their medical condition makes healing unattainable. The facility's Pressure Ulcer Support Surface Matrix (undated) indicate the pressure relief mattress was appropriate for residents with Stage III and IV pressure ulcers and if no improvement in 14 days the alternating pressure mattresses would be implemented. The National Pressure Ulcer Advisory Panel (NPUAP) quick guidelines dated 2009 indicated the following: Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Pressure ulcers are under-detected in individuals with darkly pigmented skin because of areas of redness are not easily seen, frequency of inspection may need to be increased in response to any deterioration in overall condition. High pressures over bony prominences , for a short period of time, and low pressures over bony prominence for a long period of time are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure she/he is exposed to. Repositioning frequency is determined by eh individual's tissue tolerance, his/or her level of mobility, general medication condition, overall treatment objectives and assessments of the individual's skin. If not responding as expected to the repositioning regime, reconsider the frequency and method of repositioning. Repositioning should be influenced by the support surface. Avoid positioning on bony prominances and reposition in such a way that pressure is relieved or re-distributed. Limit time seated in a chair. Do not base the selection of a support surface solely on the perceived level of risk for pressure ulcer development or the category/stage of any existing pressure ulcers. Continue to turn and reposition regardless of support surface. Ensure heels are free from the surface of the bed and inspect heels regularly. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover " and should not be removed. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org).

2 Based on a complaint investigation, clinical record review, staff, family interview and facility documentation, the facility staff failed to ensure appropriate treatment and services were provided to prevent complications for 1 of 14 residents (Resident #111) in the survey sample who received gastrostomy tube feedings. Resident #111 was hospitalized in the ICU as a results of complications from Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, aspiration pneumonia and vomiting. The findings include: Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a PEG tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated. The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders to the MAR and left off, then liquids after 6:00 PM if tolerated. [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition® With Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: Call for any questions (phone number listed). The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting, she aspirated feeding into her lungs. He stated, I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has no where to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have. Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). There was a physician's orders [REDACTED]. On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to her discharge on 9/15/14 to the local hospital Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, The resident was able to eat, she could get pleasure meals and her feeding. The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]. The Nutritional Assessment form dated 9/12/14 indicated the resident's current diet order as Start [MEDICATION NAME] 1.5 at 5:00 PM Friday 1/2 can every 4 hours and on Sunday 1 can every 4 hours if residuals < 50 cc as ordered by the physician. Flushes as per physician's orders [REDACTED]. It was noted that a full RD assessment to follow. On 9/15/14 it was noted the resident had been discharged to the hospital. On 10/1/14 at 4:30 PM, CRD #1 was shown the [MEDICATION NAME] order for [MEDICATION NAME]. She interpreted the resident was supposed to have clear liquids if PEG feeding were tolerated and stated to the FSM, I know you remember seeing the order slip that was sent to you for a diet change to clear liquids. The FSM stated, No, I did not receive one, and proceeded to show this writer the diet that was being sent from the kitchen until the resident's discharge to the hospital on [DATE], Pureed/level 1-double portions. The physician's orders [REDACTED]. CRD #1 calculated the calories Resident #111 received with the [MEDICATION NAME]'s PEG tube feeding orders. She stated with the 1/2 of [MEDICATION NAME] every four hours with free water and flushes the resident would have received 750 calories per 24 hours, 1,191 cc of water and 31.2 grams of protein. She calculated 1 can of [MEDICATION NAME] every four hours to equal 1,500 calories per 24 hours, 1,782 cc of water. CRD #1 stated based on the resident's height of 5 feet 5 inches and weight of 124 pounds, her calories would have been sufficient and within range between 1453-1863 calories without Ensure and the pureed diet. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only spoke to the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (Blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach. Though the pulse oximeter actually measures the saturation of oxygen in the blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. (mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (HR), 18 (Resp), 143/93 (BP), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called. The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurses' note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let the fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer and there was nothing about the resident on the 24 hour report. She said when she first encountered the resident, she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told him about the congestion and she ordered suction as needed, labs and a chest X-ray for today. She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175 cc, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she was made aware of the high residuals and instructed her to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell you she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14, she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) today. Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The Associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurse's are my eyes and ears. I expect them to assess and monitor these resident's closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs. During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift. Although the Corporate nurse repeatedly made this statement she also said, I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't. The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either then liquids after 6:00 PM if tolerated, or clear liquids after 6:00 PM if tolerated. After some examination of the order they decided it meant, then liquids after 6:00 PM. There was no where in the GI doctor's orders where he wrote to continue Ensure and the previous Pureed diet, as well as the Ensure. The then liquids after 6:00 PM if tolerated was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, Call for any questions (phone number listed). The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurse's notes were accurate regarding no residuals for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration)to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk. She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100 % of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50 % of her breakfast and lunch and 100 % of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for a breathing difficulty. EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been congested for several days. It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of tube feeding appearing material, via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the Associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc. The goal was to get her GI tract working again. The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, I was worried (Resident #111's name) was going to die. Prevention of Aspiration Critically ill patients have an increased risk for aspirating oropharyngeal secretions and regurgitated gastric contents. For those who are tube-fed, aspiration of gastric contents is of greater concern. While witnessed large-volume aspirations occur occasionally, small-volume clinically silent aspirations are far more common. In the same study, risk for pneumonia was about 4 times greater in patients identified as frequent aspirators. Because no bedside tests are currently available to detect microaspirations, efforts to prevent or minimize aspiration take on added importance. Expected Practice Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated. For tube-fed patients, assess placement of the feeding tube at 4-hour intervals. For patients receiving gastric tube feedings, assess for gastrointestinal intolerance (residuals) to the feedings at 4-hour intervals. Tube-fed patients who experience frequent regurgitation and aspiration of gastric contents are at increased risk for poor respiratory outcomes. Guidelines developed jointly by the Society of Critical Care Medicine and the American Society for [MEDICATION NAME] and Enteral Nutrition recommend that patients be monitored for tolerance to enteral feedings by noting abdominal distention, complaints of abdominal pain, observing for passage of [MEDICATION NAME] and stool, and monitoring gastric residual volumes (http://www.aacn.org/wd/practice/content/practicealerts/aspiration-practice-alert.pcms?menu=practice). COMPLAINT DEFICIENCY

2 Based on a complaint investigation, clinical record review, staff and family interview and facility documentation, the facility staff failed to provide the necessary care and services to attain the highest practicable physical well-being for 2 of 14 residents (Residents #111, #104) in the survey sample. 1. The facility staff failed to monitor the bowel movements, assess and recognize the signs and symptoms of fecal impaction. Resident #111 was sent to the local hospital with a fecal impaction which was determined to have a direct correlation to complications from Perctaneous Endoscopic Gastrostomy (PEG) tube feedings; vomiting and high gastric residual volume resulted in aspiration pneumonia. 2. The facility staff failed to administer treatments as ordered by the physician for Resident #104. The findings include: 1. Resident #111 was admitted to the nursing facility on 1/8/14 with [DIAGNOSES REDACTED]. The resident had a Percutaneous Endoscopic Gastrostomy (PEG) tube inserted at the local hospital on [DATE] as an outpatient and returned to the nursing facility the same day. On 9/15/14, Resident #111 was transferred to the local hospital and subsequently diagnosed with [REDACTED]. The resident did not return to the nursing facility. A PEG is a procedure to make an opening between the skin of your belly and your stomach. A gastrostomy tube is placed into the stomach through the opening for liquid nutrition, fluid and medicines (http://www.asge.org/patients/patients.aspx?id=394). Resident #111 most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident with short and long term memory problems and severely impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance of two staff for bed mobility and transfers. She was assessed as always incontinent of bowel and bladder. Resident #111 was coded to require extensive assistance from one staff for bathing, eating, dressing and locomotion on and off the unit in a wheelchair. She was coded with limitations in range of motion for upper and lower extremities. Resident #111's revised care plan dated 7/15/14 indicated the resident had the potential for alteration in elimination: Constipation. The goal the staff set for the resident was that they would promote soft, formed stools every three days during the next 90 days. Some of the approaches to implement this goal included monitor bowel sounds, vital signs and lab values, monitor for vomiting, abdominal distention, diarrhea and constipation. Document bowel movements on the Certified Nursing Assistant Activities of Daily Living (ADL) worksheets. If no bowel movements within three days, initiate Bowel Protocol. Monitor bowel movements every shift. The care plan indicated the resident was on a textured modified diet. The care plan had not been revised to include PEG tube feedings or any other changes to her diet. The resident was on a [MEDICATION NAME] (opioid patch/narcotic) to be changed every three days for chronic pain and scheduled [MEDICATION NAME] (narcotic) every 6 hours. One of the side effects of both narcotics was constipation. The attending physician's progress notes dated 9/5/14 indicated the resident's appetite was poor and that he had ordered [MEDICATION NAME] on 9/2/14 to stimulate appetite and recommendation for a [MEDICATION NAME] (GI) consult with recommendation of a PEG tube placement pending family decision. The GI physician was consulted on 9/8/14. Upon closed record review of Resident #111, the resident had a newly inserted PEG tube as an outpatient on 9/12/14 and returned to the nursing facility with the following GI orders for PEG tube feedings dated 9/12/14 at 2:00 PM: Restrain hands for 24 hours, use abdominal binder for 24 hours. [MEDICATION NAME] 1/2 can every four hours, start at 6:00 PM (Friday 9/12/14) bolus with 100 cubic centimeters (cc) of water. Start 1 can every 4 hours on Sunday (9/14/14) AM if residuals are ok, < (less than) 50 cc, then liquids after 6:00 PM if tolerated. The Medication Administration Record (MAR) indicated the aforementioned orders, but did not fully transcribe the orders onto the MAR and left off, then liquids after 6:00 PM if tolerated. [MEDICATION NAME] 1.5 Cal is a calorically dense formula that provides Complete, Balanced Nutrition with Fiber and NutraFlora (abbott nutrition.com). The Hospital Outpatient Discharge Instructions/report by the [MEDICATION NAME] sent to the nursing facility indicated the same aforementioned orders for PEG feedings for nursing home, in addition to: Call for any questions (phone number listed). The [MEDICATION NAME] that inserted the PEG tube was interviewed via telephone on 10/1/14 at 5:45 PM. He stated Resident #111 was hospitalized after having aspirated tube feeding into the lungs due to over feeding. He stated the resident had a brand new PEG just over two days and it was apparent the nurses had not been checking residuals and along with eating a diet, drinking by mouth the resident vomiting and she aspirated feeding into her lungs. He stated, I did not intend for the resident to receive Ensure along with [MEDICATION NAME] and food. I wrote the orders for what she should have had after insertion of the tube and that was the [MEDICATION NAME], water flushes and liquids if the tube feeding was tolerated. Those were her total nutritional orders. The fecal impaction would cause her to vomit and aspirate feeding into her lungs because what she is taking in has nowhere to go but sit in her stomach into her esophagus, she'd vomit and it would go into her lungs, not to mention the food and ensure that I never intended her to have. Ensure Plus 120 cc three times a day (TID) with administration of her medications had been a previous physician's orders [REDACTED]. There was no indication in the clinical record that the nurses called the physician to clarify if the aforementioned orders should be continued or discontinued in light of the newly inserted PEG tube for enteral/nutritional feeding. Ensure plus is concentrated calories and protein and a source of complete balanced nutrition (abbottnutrition.com). On 10/1/14 at 1:00 PM, the Director of Nursing (DON) said she checked with the aides and nurses and saw for herself Resident #111 was eating well, had no problems swallowing, consumed solid food, Ensure three times a day, as well as [MEDICATION NAME] bolus tube feedings. The Activities of Daily Living (ADL) Data Reports indicated the resident was eating up to the time of her discharge on 9/15/14 to the local Emergency Department (ED) 50%, but mostly 100 % of her meals and snacks. The DON was asked how bowel movements (BM) were tracked and monitored for residents. She stated the Certified Nursing Assistants (CNA) write the BMs on the Bowel Movement Log and that was the only place for the licensed nurse to reference them. The DON referred to the Laxative Protocol guideline policy dated 4/8/14 during the interview and stated the licensed nurse was supposed to check all residents every day and if they do not have an adequate BM over two days, they would activate the bowel protocol on the third day and add their names to the laxative list and the 3/11 shift nurse would give all residents on the list 30 cc of Milk of Magnesia (MOM) and document all results before the end of her shift. If the residents did not have any results from the MOM by 2:00 AM the 11/7 nurse would give the resident a Fleet enema and document the results by the end of her shift. If no results on the 11/7 shift, the 7/3 shift nurse would then give a soap suds enema before getting the resident out of bed for the morning. She was shown the Bowel Movement Log and could only find the log for 9/2/14 through 9/7/14 and 9/15/14. The log indicated Resident #111 had a soft BM on the 3/11 shift 9/7/14. She also stated the BM log was not a part of the clinical record. On 10/2/14 at 10:00 AM, she produced the Activities of Daily Living (ADL) computer Data sheet and stated although she could not find the BM logs, the CNAs entered the BM information from the BM logs into the ADL Data log computer system. The ADL Data log recorded Resident #111 had small BMs on 9/9/14, 9/10/14, 9/11/14, 9/12/14 and 9/13/14. The computer record also recorded the resident was continent of bowel on 9/10/14 and 9/13/14. The DON stated the resident was always incontinent of bowel and bladder. She stated the information the CNA's entered into the system were small BM's but she expected the licensed nurse to do the daily review of the BM logs, question the CNA, follow-up and determine if the BMs were adequate. She also stated she relied on the nurse's notes to show assessment of bowel sounds, temperature, if resident was vomiting or not having normal stools. The DON stated the nurses do not look at the ADL Data logs because it was in the computer, but the BM records which are kept in a binder or on a clip board and could be reviewed at a glance. As mentioned above the BM logs after 9/7/14 to 9/14/14 could not be located. On 10/1/14 at 2:15 PM an interview was conducted with the two Corporate Registered Dieticians (CRD) and the Food Service Manager (FSM). CRD #1 stated, The resident was able to eat, she could get pleasure meals and her feeding. The FSM stated she would have to check to see what was being sent to the resident after insertion of a new PEG on 9/12/14, but said she would have followed the most recent and current physician's orders [REDACTED]. A random interview was conducted with LPN #10 on 10/2/14 at 3:40 PM. She stated, For a resident having an increase in temperature, vomiting, drooling, having little small stools or loose stools meaning the stool is oozing around the small harder or firmer stools, you would suspect a fecal impaction. If after two days, there is not a regular stool, especially if the resident is eating and drinking, I want the CNA to let me know. I'm supposed to be checking closely on residents that are bed bound and on pain medications. We use the BM logs to monitor BMs, as well as verbal information shift to shift and/or the 24 hour report. On 10/2/14 at 3:55 PM, the Unit Manager on Station I Registered Nurse (RN) #3 stated, We are supposed to check the BM records and pay attention to the last time the resident had a BM, the type and amount. It is always good to error on the side of caution with those residents that are on narcotics and can't say much to you regarding pain and discomfort, just do an assessment. You would need to call the physician to disimpact the resident, but you could check for a fecal impaction. If they run a low grade temperature and vomit up food, even just a little with small BMs, there may be a back up of stool. The Attending Physician's Standing Orders (undated) indicated for residents with nausea/vomiting for more than two episodes in 8 hours to check the rectal vault for stool first. The nurse's notes dated 9/12/14 at 2:43 PM indicated Resident #111 had returned to the nursing facility. The note only referred the wound rounds with the wound care physician. The nurse's notes dated 9/12/14 at 5:00 PM indicated the resident had no signs and symptoms of distress and tolerated the 1/2 can feedings well and medications by mouth, head of bed elevated, placement checked and will continue to monitor. The next nurse's notes dated 9/13/14 at 1:30 AM indicated the resident was in her room, resting with no signs of distress, vital signs were temp 98.7, pulse 82, respirations 18 and will continue to monitor. The nurse's notes dated 9/13/14 at 2:00 PM documented the resident was alert and verbal at times, the abdominal binder was in place, vital signs were within normal ranges. [MEDICATION NAME] 1.5 1/2 can bolus given with 100 cc water flush at 9:00 AM and 1:00 PM, positive placement, feeding tolerated without difficulty and head of bed elevated. Nurse's notes dated 9/13/14 7:00 PM indicated the resident's vital signs were within normal range, the resident was tolerating the tube feeding and placement was checked. There were no 11/7 nurse's notes on 9/13/14. The nurse's notes dated 9/14/14 at 1:45 PM indicated the resident was alert and verbal at times, [MEDICATION NAME] 1.5 one can was given at 9:00 AM and 1:00 PM, placement positive, tube feeding tolerated well and no tube feeding residuals. Vital signs were taken and all were within normal range. Nurse's notes dated 9/14/14 at 5:30 PM documented the resident's vital signs were within normal range, the resident rested throughout the shift, no signs of distress or discomfort. It was noted the PEG tube was in place, patent, the resident tolerated [MEDICATION NAME] 1.5 one can well, the head of the bed was elevated, no issues at this time and will continue to monitor. The next nurse's note was dated 9/15/14 at 1:00 AM and was documented as follows: Resident noted to be congested with minimal amount of yellow mucous and thin clear saliva coming out from side of mouth. Resident repositioned and head of bed elevated at 45 degrees. VS (vital signs) 98.2 (temperature), 77 (heart rate),18 (respirations), BP (blood pressure) 138/78, O2 (oxygen saturation) 98% on RA (room air). Residual checked before bolus feeding with residual amount 175 ml (milliliters). Bolus feedings held. MD aware. New orders chest X-ray, CBC and CMP today. [MEDICATION NAME] DM 10 cc (cubic centimeters) Q (every) 4 hrs x 7 days PRN (as needed). Resident noted of minimal amount of emesis. Suction x 1 done to sides of mouth. Tolerated well, [MEDICATION NAME] x 1 medicated for congestion. Resident resting in bed. HOB elevated 45 degrees. No distress noted. Call light within reach. Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low(mayoclinic.org/symptoms/hypoxemia/basics/definition/sym). The nurse's notes dated 9/15/14 at 5:00 AM indicated the following: Resident noted to have change in mental status. VS 101.5 (temperature) degrees, 96 (heart rate), 18 (respirations), 143/93 (blood pressure), O2 SAT 82% on RA-O2 at 5 liters/min given via nasal cannula. O2 Sat rapidly decreasing with labored breathing. 911 called. The nurse's notes dated 9/15/14 at 5:10 AM indicated that the emergency dispatchers had arrived and the resident was transported via stretcher to local hospital Emergency Department (ED). It was noted the physician was made aware, the Director of Nursing (DON), as well as the POA. The following interviews were conducted with nurses who provided care for Resident #111 and wrote some of the aforementioned nurse's note entries: On 10/1/14 at 3:30 PM, an interview was conducted with LPN #3. She stated she had the resident previous to the PEG tube insertion on the 7/3 shift when she was eating a mechanical/purred diet. She said she found the resident barely eating anything and would let fluid and food come out the sides of her mouth, which was why the tube was inserted. She stated she did not check for bowel sounds or anything related to an abdominal problem. On 10/1/14 at 3:40 PM, an interview was conducted with LPN #1. She said she cared for the resident on the 7/3 shift 9/12/14, 9/13/14 and 9/14/14. She stated although the resident did not come back on her shift after the PEG was inserted, she sent her out to the hospital to have the PEG inserted as an outpatient. She said on 9/13/14 she administered the 1/2 can of [MEDICATION NAME] and water flushes with no problems after checking placement and there were no residuals. She stated from her understanding the resident was not to have anything by mouth and she gave the medications and Ensure via PEG. She stated she was not told anything about her bowel movements, whether or not she was having them. She said the Certified Nursing Assistants (CNA) would record on the bowel movement log and inform the nurse if the BMs were not normal, were small or they weren't having any. She stated the resident was not in distress of any kind and she did not check for bowel sounds or abdominal distention. On 10/1/14 at 4:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. She stated she took care of the resident on the 3/11 shift 9/12/14, 9/13/14 and 9/14/14. She said she checked placement and residuals prior to administering the [MEDICATION NAME] feeding and water flushes. She stated there were no tube feeding residuals and the resident ate her pureed diet without difficulty, as well as the Ensure 120 cc with medications crushed in applesauce given by mouth. She stated the Ensure could be given either by mouth or by tube because it was all going into her stomach. She said she was not sure about whether the resident's abdomen was distended or not and had no reason to check about her whether she was having bowel movements and if so what type or amount. She stated the resident had an abdominal binder that was removed in the AM on 9/14/14. The LPN who wrote the 1:30 AM nurse's note on 9/13/14 at 1:30 AM was not available for interview, but documented there were no signs of distress and vital signs were within normal range. No further assessments were documented. On 10/1/14 at 8:51 PM, an interview was conducted with RN #4. She stated it was the first time she cared for Resident #111 on the 11/7 shift 9/15/14 and always worked on Station 2. She said no one said anything to her about the resident in report at shift change to include her PEG tube was newly inserted on 9/12/14 until addressed by this writer. She said there was nothing about the resident on the 24 hour report. She said when she first encountered the resident she was obviously congested, gurgling with what she thought at the time was mucous running out the side of her mouth. She said she repositioned the resident and checked her vital signs which were okay. She said she called the physician and told her about the congestion and she ordered suction as needed, labs and a chest X-ray for today. She stated she could not remember if she told the doctor the first time she spoke to her about the residuals, but they were over 50 and the resident was actively and consistently vomiting. She said when she checked residuals and they were 175, she stopped pulling out anymore because over 50 would mean she needed to hold the feeding. She said she contacted the physician at least 2-3 times that night and at one of those times, she made the physician aware of the high residuals and was instructed to make sure she held the tube feeding, applied oxygen and if no improvement send out 911. She stated the resident's O2 SATs were dropping, her BP was elevated and she had a high temperature. She said she didn't think about checking bowel sounds for a possible fecal impaction, but was dealing with the respiratory distress she found the resident in. RN #4 stated the resident was not verbal and couldn't tell her she was in pain. The 24 hour report noted on 9/11/14, Resident #111 was scheduled for PEG placement and on 9/12/14 she was out for PEG Placement. On 10/2/14 at 11:10 AM, an interview was conducted with Resident #111's associate attending physician. She stated the attending physician spoke to the family about insertion of a PEG tube due to the resident being thin with weight changes, in addition to pressure ulcers, and the family was in agreement with the plan. The associate attending physician stated she got a call at about 1:00 AM on 9/15/14 from Registered Nurse (RN #4) indicating the resident was congested and she instructed her to monitor closely. She stated the instructions to the RN was based on the information that was given to her so she ordered a pneumonia work-up with chest X-ray, complete blood count (CBC) and Complete Metabolic Panel (CMP) today. Additional orders included [MEDICATION NAME] DM 10 cc Q (every) 4 hours via the PEG times 7 days and suction as needed. During the interview, the associate attending physician stated approximately 2 hours later, she received another call from RN #4, informing her the PEG tube feeding residual was 50 cc and the pulse oximetry reading was in the 80's. She said she instructed the nurse to hold the feedings, place oxygen on the resident and if no better call 911. She said she was not told Resident #111's PEG tube was just inserted on Friday 9/12/14, but her instructions to the nurse would have been no different, based on the information given to her from RN #4. She said she was not told earlier at 1:00 AM that the tube feeding residual was 175 cc. The associate attending physician further stated she received a call from the local hospital ED physician on 9/15/14 around 6:00 AM or 7:00 AM that Resident #111 was being admitted to the ICU and they had, when the resident arrived at the ED, nasotracheal suctioned 1 and 1/2 liters (1,500 cc) of tube feeding and that the resident had aspirated some of the feeding into her lungs. She said the resident was diagnosed with [REDACTED]. On 10/2/14 at 11:30 AM, the Administrator, DON, Corporate Administrator and Corporate QA manager joined the interview. The associate attending physician stated the first time she spoke to RN #4 at 1:00 AM she wasn't told the resident had a PEG, only that she had some fluid coming out of her mouth and 2 hours later told about a 50 cc residual. During the interview, the physician re-told the aforementioned information to the Administrative group. She said, I am dumbfounded how if the nurses were checking residuals every four hours, that much feeding can be suctioned from the resident. This does not suddenly happen. It is clear someone wasn't checking residuals all along. The amount of feeding suctioned from the resident is equal to 10 cans of a mixture of Ensure, [MEDICATION NAME] and flushes. I was told initially the resident was not in distress at 1:00 AM, but obviously she had been heading that way for a few shifts. The nurses are my eyes and ears. I expect them to assess and monitor these residents closely, especially this resident with a new PEG. They need to be more vigilant. She would not be able to tolerate the amount of intake they were giving her and along with the fecal impaction, which was not identified by the nurses, the feeding could only go up and into the lungs. During the interview, the Corporate Quality Assurance (QA) nurse repeatedly stated, Something had to have been going on. This was not an acute event and not at all sudden on 9/15/14 11/7 shift. Although the Corporate nurse repeatedly made this statement she also said, I am reading the nurses' notes and feel the nurses wouldn't write the residuals were ok and less than 50 if they weren't. The DON affirmed what the Corporate QA nurse said and stated she also felt the nurses were properly checking residuals, but could not explain the large amount of feeding suctioned from the resident. She said the nurses were responsible to send the new diet change to the dietary department, but did not know what happened. Both the DON and Corporate QA nurse reviewed the [MEDICATION NAME] orders and stated they had problems reading the last portion of his order to be either then liquids after 6:00 PM if tolerated, or clear liquids after 6:00 PM if tolerated. After some examination of the order they decided it meant, then liquids after 6:00 PM. No where in the GI doctor's orders were orders to continue Ensure and the previous Pureed diet, as well as the Ensure. The then liquids after 6:00 PM if tolerated was not transcribed onto the MAR. According to the Corporate QA nurse, she said the physician should have written clearer orders. The DON stated she expected the nursing staff to call the physician and clarify his orders to include oral intake of food, continuation of Ensure and whether medications were to be given through the PEG. She said the 11/7 nurse was responsible to check that all orders were transcribed correctly and clarified if necessary, although any nurse could check orders. It was told to them the [MEDICATION NAME] stated he wrote the orders he wanted the resident to have regarding feeding and did not understand why it was interpreted any other way or why he wasn't called, as he directed in his discharge instructions, Call for any questions (phone number listed). The DON responded the nursing staff could have also followed up with the attending physician for concerns about feeding by mouth (PO) orders, but reiterated she felt the nurses' notes were accurate regarding no residuals for all shifts, reflected monitoring for any potential medical problems, as well as good assessments of the resident. Upon review of the MAR from 5:00 PM on 9/12/14 through the resident's discharge to the hospital on [DATE], it was recorded and signed off by the licensed nurses, Resident #111 received a total of 2,370 cc of [MEDICATION NAME] feedings (10 cans, 237 cc in each can), 840 cc of Ensure feedings (7 signed off for 120 cc each time) and 1,400 cc of water flushes (14 administered [MEDICATION NAME] feedings with 100 cc water flushes each administration) to total 4,610 cc (3,210 cc of [MEDICATION NAME] and Ensure) not to include the oral intake amount from the pureed diet and the liquids on the meal trays. According to the [MEDICATION NAME]'s orders dated 9/12/14, Resident #111 should have received the [MEDICATION NAME] and the water flushes with liquids if [MEDICATION NAME] was tolerated, but not the Ensure nor the pureed diet. On 10/2/14 at 3:30 PM an interview was conducted with the CNA (#4) who cared for the resident on 9/13/14 and 9/14/14. She stated she worked a double shift on both of those days (7/3 and 3/11). According to the CNA, the resident was listed on her assignment to be fed all three meals, breakfast, lunch, dinner and snack. She stated, It was no good, all she did was let the food and liquid run out the side of her mouth. She didn't eat hardly anything and she doesn't really talk. She said she did not tell the nurse about the problems she encountered while feeding the resident. The CNA was shown the Activities of Daily Living (ADL) Data Report for the days she was responsible to feed the resident on 9/13/14 and 9/14/14. It was recorded by CNA #4 the resident ate 100% of her breakfast, lunch, dinner and snack on 9/13/14. On 9/14/14, CNA #4 recorded the resident at 50% of her breakfast and lunch and 100% of her dinner. The CNA was not able to explain if the food and liquids ran out of the resident's mouth, how she consumed the amount recorded on the ADL Data Report. The Emergency Medical Services (EMS) 911 report indicated the resident was dispatched to the nursing facility on 9/15/14 at 5:30 AM for a breathing difficulty. EMS arrived at 5:38 AM and documented in their report the resident was laying in her bed, unresponsive, tachypneic (rapid breathing) with shallow respirations and audible rales without a stethoscope, with a stethoscope lungs were auscultated for course rales in all fields and O2 SATs were in the 60's treatment started with high flow O2. It was noted in the report that the nursing facility stated the resident had been congested for several days. It was noted over 1,000 cc of [DEVICE] food was suctioned from the resident. It was also noted the resident was covered in liquid feces all over her gown and on the sheets underneath her. According the the ED records, Resident #111 arrived at the local hospital ED on 9/15/14 at 5:58 AM in respiratory distress, O2 SATs in the 70's with limited respiratory effort, placed on [MEDICAL CONDITION], respirations 40, heart rate 114 and temperature 102 degrees. The ED report indicated the patient was suctioned for 1,500 cc of tube feeding appearing material, via nasal tracheal (NT) suctioning, that was located just pass the trachea and at the opening of the esophagus; therefore, the airway compromise was not due to congestion, but from overfeeding and aspiration of the tube feeds. The indwelling urinary catheter was draining scant amounts of urine. Lab results indicated the resident had [MEDICAL CONDITION] due to aspiration pneumonia of tube feeds. The resident was stabilized in the ED, started on IV fluids and IV antibiotics, and transferred to the ICU. She was monitored closely for intubation if needed. It was noted in the ED record, the associate attending physician was called and informed of the findings, condition of the resident and that her condition required admission to the ICU. The chest X-ray verified aspiration pneumonia with lab results supporting [MEDICAL CONDITION]. Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail (http://www.mayoclinic.org/diseases-conditions/sepsis/basics/definition/con- 900) . CT scan of the pelvis indicated the resident had a rectal fecal impaction, 8 centimeters (cm) by 5 cm, as well as moderate amounts of fecal material in the distal colon. The GI physician indicated in his notes dated 9/19/14 the resident recently had a PEG tube placement for nutritional needs on 9/12/14. It was documented she was discharged to the nursing facility and started on PEG tube feedings, but apparently had high residuals and was admitted to the local hospital with aspiration pneumonia. The PEG tube was verified by CT scan to be in place with no leakage. He noted the resident had a lot of stool in the colon with a fecal impaction and was being treated with enemas and laxatives. He documented the resident's tube feedings were still on hold because, We need to get her bowels moving. She was noted to have nausea and vomiting. She was being started on [MEDICATION NAME], as well as Fleet enemas. We can start her on PEG feeding slowly at 10-15 cc an hour, and gradually increase it depending on the results of her residuals. I would hold feedings should her residuals be greater than 50 cc. The goal was to get her GI tract working again. The hospital RD progress follow-up note dated 9/19/14 at 10:57 AM indicated it had been recommended to start enemas/disimpaction and start trickle tube feeds on the [MEDICATION NAME] feeding 10 cc/hour with a goal to resume enteral nutrition at 45 cc /hour. The resident was assessed to have had inadequate oral intake related to dysphagia and was NPO with PEG tube feeding. Resident #111 was discharged on [DATE] to another nursing facility. On 9/30/14 at 3:40 PM, an interview was conducted with Resident #111's Responsible Party (RP). She stated she was concerned when the ED physician informed her the resident had aspirated tube feeding and had to be admitted ICU and possibly go on a ventilator because of the severity of her aspiration pneumonia. She also stated the ED physician told her it was obvious the nursing facility was not adequately checking tube feeding residuals because of the amount of tube feeding suctioned from the resident. She stated, I was worried (Resident #111's name) was going to die. A fecal impaction can be a large lump of dry hard stool that stays stuck in the rectum, most often seen in people who are constipated for a long time. You are more at risk for chronic constipation and fecal impaction if you do not move around much and spend much of you time in a chair or bed. Certain drugs that slow the passage of stool through the bowels, i.e., narcotic pain medications. Symptoms include abdominal bloating and cramping and pain, leakage of liquid or sudden episodes of watery diarrhea, small semi-formed stools, straining when trying to pass stools, bladder pressure or loss of bladder control, lower back pain, rapid heartbeat or light-headedness from straining to pass, vomiti

Based on observations, staff interview and clinical record review the facility staff failed to provide the necessary care and services to 6 of 25 residents in the survey sample to attain or maintain their highest practical physical well being (Residents #20, #21, #8, #25, #5 and #6). The findings include: 1. The facility staff failed to monitor and identify an alteration in bowel elimination and constipation for Resident #20 in accordance with the care plan. The resident was sent to the hospital on [DATE] for a mental status change after a fall but was found to have and had emergency surgery for [REDACTED]. The resident subsequently died during this hospitalization on [DATE]. Resident #20 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] evidenced the Resident #2 was moderately impaired in the area of decision making for cognitive skills. The Resident was coded as requiring extensive assistance with one staff assistance for activities of daily living (ADL's) including eating, toileting, bathing and dressing. A review of Resident #20's Care Plan dated [DATE] evidenced the following Problem: Resident has a potential for alteration in bowel elimination (constipation) due to wanting to eat hotdog's, ice cream and danish most each meals, Approach: Monitor for vomiting, abnormal distention, diarrhea, and constipation, Intervention: Notify MD of any abnormal findings. A review of a nurse's notes on Resident #20's clinical record dated [DATE] at 1:20 PM, evidenced the following: "Resident found lying on floor behind bed, is awake and verbal but some confusion, assessed for range of motion to upper and lower extremities, no complaint of pain, small Hemotama noted to back of head, oxygen at 73%, oxygen started, pupils equal and reacting, unable to palpate pulse, blood pressure ,[DATE], attending physician notified and ordered transferred to the local hospital emergency room by emergency medical personnel (911). Responsible Party unable to be contacted by phone and message left to call facility." Review of the local hospital emergency room "Provider Notes" dated [DATE] evidenced the following: Resident presented via emergency medical service (EMS) with altered mental status and [MEDICAL CONDITION]. Per EMS patient's abdomen is "Distended", has alcoholic [MEDICAL CONDITION], oxygen stats in the 70's and the systolic BP was 60 when they arrived. Review of the local hospital emergency room physical examination dated [DATE] evidenced the following: Abdominal: patient exhibits "Distension" and no tenderness Review of the Differential Diagnosis; Clinical Impression; Plan included the following: Patient has marked "abdominal distension" with tympani and suggestions of acute [MEDICAL CONDITION] with patient being intubated. Awaiting chest and abdominal films, cardiac labs, infectious workups and [MEDICATION NAME]. Review of "Provider Notes" dated [DATE] evidenced the following: Patient had CT (computer tomography) scan and findings most consistent with a closed-loop obstruction in a sigmoid volvulus. Review of the "Provider Notes" dated [DATE] evidenced the following: Patient had surgery consult and taken to operating room for exploratory laparotomy and found to have sigmoid volvulus and a portion of the distal ilium and sigmoid colon was removed and [MEDICAL CONDITION] placed. Patient's current problems include septic shock, [MEDICAL CONDITION], acute [MEDICAL CONDITIONS], acute metabolic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Review of the discharged summary dated [DATE] evidenced the following: Resident #20 expired at the local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the EMS documentation evidenced the facility nursing staff only advised the responding personnel of Resident #20's fall but gave no information on the residents abdominal distension or any other complications. Review of the nursing twenty-four hour report sheet from [DATE] to [DATE] evidenced there was no reporting of complications, constipation or abdominal distension on all three nursing shifts for Resident #20. Review of the nursing notes on Resident #20's clinical record from [DATE] to [DATE] evidenced no notes on any observed changes in the resident's condition, physical assessment observations, no vital sign recording, no resident request for pain medications, no daily observations of activities, no input and/or output observations, no dietary observations, no bowel and bladder observations, no observations or assessments during medication pass and/or resident complaints or comments. Resident #20 required extensive assistance with one staff assistance for activities of daily living (ADL's) including eating, toileting, bathing and dressing, and there was no documentation the Certified Nursing Assistance observed and reported there was any significant change with the resident. Review of the Bowel Movement Log for Resident #20 from [DATE] to [DATE] evidenced the Certified Nursing Assistance's were documenting on all three shifts the resident was not experiencing any bowel movements. Due to the lack of documentation regarding Resident #20's it could not be determined when the abdominal distension presented itself nor how long the resident had a change in bowel elimination patterns. During an interview with Certified Nursing Assistant #1 on [DATE] at 11:45 AM, she stated if Resident #20 did not have a bowel movement they would document the Bowel Movement log, enter it into the ADL tracking system as well as report it to the nurses after three days During an interview with the Director of Nursing (DON) on [DATE] at 12:25 noon, she stated after three days if a resident did not have a bowel movement then the nursing staff should start the bowel movement protocol and report the information to the attending physician. The facility staff failed to recognize, document and report to the attending physician a significant change in status including an abdominal distension in a timely thus delaying medical intervention for the care and treatment of [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the attending physician ' s Standing Orders updated on 2008 evidenced the following protocol for Constipation and confirmed by the Director of Nursing (DON) on [DATE] at 12:25 PM as being the current protocol and was as follows: "After three (3) days without bowel movement (BM), start bowel protocol. (1.) Resident may have choice for constipation: MOM 30 cc everyday as needed (may add 5 ml of Cascara) or [MEDICATION NAME] suppository rectally every day as needed or Fleets or soap suds enema per rectum every day as needed. (2.) Stool softener of choice: [MEDICATION NAME] one package in eight ounces of fluid every day or [MEDICATION NAME] 100 mg twice a day or [MEDICATION NAME] 200 mg once a day or Sorbital 70% 30 cc every day or Senna S one twice a day or Senna S two once a day." There was no evidence the facility implemented the bowel protocol or monitored the resident for constipation in accordance with his care plan. 2. The facility staff failed to notify emergency medical services to transport Resident #21 to a local hospital emergency facility in a timely manner upon receiving an order from the attending physician Resident #21 was a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #21's most recent Significant Change MDS (Minimum Data Set Assessment) dated [DATE] coded the resident had being moderately impaired. Resident #21 needed was totally dependence needing 1 staff for all aspects of activities of daily living (ADL's). Review of the clinical record evidenced a Durable Do Not Resuscitate Order (DNR) dated [DATE], signed by the Responsible Party (RP). Review of the clinical record evidenced a nursing note dated [DATE] at 5:30 AM that included the following: Resident #21 condition changes, Non responding verbally. oxygen remains intact, vital signs: T - 102, P - 120, R - 24, B/P - ,[DATE], Turned and positioned for comfort, attending physician notified, Comfort Measures Continue, RP notified of resident status. Review of the clinical record evidenced a nursing note dated [DATE] at 7:30 AM that stated: During rounds resident noted to have labored breathing, Continues on Comfort Care. Review of the clinical record evidenced a nursing note dated [DATE] at 9:35 AM that stated: RP came to the facility to visit. Resident had a status change and code status remains DNR/Comfort measures with no hospitalization s, IV's, or Tube feedings. RP approached this writer and stated she wanted to reverse Resident #21 to full code. RP stated she wanted resident to be sent to the local hospital emergency room . New order received to send to emergency room from attending. Code status reversed to "FULL CODE". Review of the clinical record evidenced a nursing note date [DATE] at 10:15 AM that stated: 911 called, Cardiopulmonary Resuscitation (CPR) initiated, no vital signs, no heart beat, no respirations. Review of the clinical record evidenced a nursing note date [DATE] at 10:17 AM that stated: 911 arrived and was unable to get response from CPR. RP and family in facility and was made aware. resident expired. Attending Physician notified. Family made aftercare arrangement. During an interview with the Director of Nursing (DON), being the writer of the aforementioned nursing notes, she stated the events happen as written. When asked why it took 47 minutes to call 911 after getting the order from the attending physician, she stated she was talking with the family trying to get a for sure decision on what they wanted the resident's code status to be. When advised she had received a new order from the attending physician for FULL CODE status and to call 911, The DON stated she wanted to make sure this was what the family wanted. The facility staff failed to notify emergency medical services to transport Resident #21 to a local hospital emergency facility in a timely manner upon receiving an order from the attending physician. The Administrator and DON were made of the stated findings on [DATE] at 1:40 PM and no additional information was provided to the surveyor. 3. The facility staff failed to notify the attending physician of blood sugars outside of the ordered parameters for Resident #8 Resident #8 was a [AGE] year old readmitted to the facility on [DATE] and an readmitted s of [DATE], and [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE] evidenced Resident #8 was coded as being moderately impaired. Resident #8 was assessed needing extensive assistance with all activities of daily living (ADL's). A review of the clinical record evidenced Resident #8 had the following initial order physician order starting [DATE] and recertified every month: (1.) Sliding scale blood sugars with insulin coverage (2.) Blood sugars less than 70 or greater than 400 notify the attending physician A Review of Resident #8's Care Plan with updates through [DATE] evidenced interventions for diabetes that included: Accuchecks & monitor results as ordered by physician. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Date Time Accuchecks Results ,[DATE] 11:30 AM 474 ,[DATE] 04:00 PM 405 ,[DATE] 04:00 PM 429 ,[DATE] 04:00 PM 425 ,[DATE] 04:00 PM 474 ,[DATE] 06:30 AM 403 ,[DATE] 11:30 AM 448 ,[DATE] 04:00 PM 429 ,[DATE] 11:30 AM 489 ,[DATE] 04:00 PM 442 ,[DATE] 04:00 PM 409 ,[DATE] 04:30 PM 485 ,[DATE] 04:30 PM 430 A review of Resident #8's clinical record evidenced no documentation the attending physician was notified of the out of ordered parameters A review of the clinical record evidenced Resident #8 required sliding scale insulin coverage daily and consistently after blood sugar checks as verified by the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A review of the laboratory results ordered by the attending physician to monitor Resident #8's diabetes and glucose (sugar) levels evidenced only the following recent results: Hemoglobin A1C lab results (monitors body blood glucose/sugar levels over a 3 month period) ? [DATE] - 13.1 (High) - Ranges: 4XXX,[DATE].9 (Normal), Average Glucose - 328 (High) ? [DATE] - 13.5 (High) - Ranges: 4XXX,[DATE].9 (Normal), Average Glucose - 342 (High) Review of the clinical record evidenced Resident #8 had not as of [DATE] experienced any adverse change of condition requiring immediate medical intervention On [DATE] at 10:15 AM, Resident #16 was observed lying in bed, appearing to be sleep. When asked during an interview on [DATE] at 9:15 A.M., the Unit Manager Licensed Practical Nurse (LPN #1), for Nursing Unit #2, she was not able to provide any documentation the attending physician had been notified of the abnormal blood sugars On [DATE] at 2:30 PM during an interview with the Administrator and Director of Nursing (DON), stated we were made aware of this problem and have no additional information to provide at this time." No documentation was presented regarding the blood sugars by the facility prior to the survey end on [DATE]. 4. The facility staff failed to obtain a physician's order for the removal of a Foley catheter for Resident #25. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing notes dated [DATE] at (1940) 7:40 P.M. indicated: "Foley catheter (d/c ed) discontinued with out incident by this (RN)." A review of the clinical records did not indicate a physician's order for the removal of the Foley catheter. A facility policy with a revision date of [DATE] indicated: "Urinary catheters will be removed/inserted in accordance with physician's orders. A physician must provide written justification by diagnosis, or history of the need for catheterization." During an interview on [DATE] at 11:00 A.M. with the Administrator and the Director of Nursing they stated, they were not aware that Resident #25 had a [DIAGNOSES REDACTED]. 5. The facility staff failed to identify and implement individualized, person-centered interventions to understand, prevent, relieve and / or accommodate behavioral expressions of distress during Showers and other Activities of Daily Living (ADL) for a Resident with Dementia for Resident #1. Resident # 1, a [AGE] year old, was admitted to the facility on [DATE] following a Right [MEDICAL CONDITION] with [DIAGNOSES REDACTED]. According to Resident # 1's latest full MDS (Minimum Data Set Assessment), with an ARD (Assessment Reference Date) of [DATE], done as an Annual review, Resident #1 was coded as severely impaired in daily decision-making, rarely, if ever, understanding or being understood and demonstrating both short and long range memory problems. Resident # 1 was coded as not demonstrating any [MEDICAL CONDITION] or behaviors. Resident # 1 was coded as not demonstrating wandering or rejection of care. Bath preference including shower, tub or bed bath were not checked for preference by staff. Resident # 1 was coded as having minimal difficulty hearing and and moderately impaired in vision. Comparison of the current annual MDS (Minimum Data Set), with the previous annual MDS, ARD (Assessment Reference Date) of [DATE], indicated Resident # 1 had declined in two areas from requiring limited assistance in eating to total dependence; and from extensive assistance to total assistance in personal hygiene over the past year. On [DATE] at 11:00 am this surveyor observed Resident # 1 in a high back wheelchair in her room. When spoken to, the resident became very agitated and wanted to know why the surveyor had taken her cloths. The resident stated "when my daughter gets here she is going to call the police". On [DATE] at 8:40 am Resident # 1 was observed in the bedroom being fed by LPN # 2. The LPN was sitting beside the resident in a chair. Resident # 1 was smiling. Review of Nurses Notes from [DATE] through [DATE] included many references to Resident # 1's behavior of yelling, crying and loud screaming related to showering and other Activities of Daily Living. The notes were as follows: * [DATE] at 9:00 pm : "PM care attempted. Resident resisting. Hold (ing) arms tight to chest. Refusing to let CNA (Certified Nursing Assistant)take shirt off. Resident crying and hollering out "no, leave me alone". This writer to room , noted CNA attempting to place resident to standing lift, resident resisting, crying and hollering out. This writer assisted CNA in helping to take cloths off and assisting resident to standing lift. Resident continued to cry and holler out in hallway "I'm going to tell my daughter". CNA assisted this resident to shower room for shower." (an entry at 9:15 pm stated "Out of Shower (?) with CNA, the resident continued to cry "I'm going to tell my daughter". Assisted out of W/C per CNAs x2. Assisted to bed. ...". There was no documentation of consideration of cause of or interventions to address the expression of distress related to having cloths removed or receiving a shower at that time. * [DATE] 12:00 noon "Resident taken to shower room and given shower. After shower resident began to cry uncontrollably and accuse CNA and this nurse of hurting her and "she could not raise her arms" and we were "forcing her to do things she didn't want to do'. This nurse tried to console resident and assure we were only helping her with her cloths on. She finally calmed down and allowed this nurse to assist her." There was no documentation of consideration of cause of or interventions to address the expression of distress related to having cloths removed or receiving a shower at that time. * [DATE] 10:00 am "...Resident began to cry inconsolably during AM care 'stating let me die, please let me die'. Crying continued for 15 to 20 minutes then resident settled down on her own". There was no documentation of consideration of cause of or interventions to address the expression of distress related to AM care. There was no response to the residents statement regarding dying. *[DATE] 10:00 am "Resident extremely tearful during ADLs crying out that CNA was 'killing her' and that 'she wished she could die'. Once ADLs were complete resident ceased crying". There was no documentation of consideration of cause of or interventions to address, the expression of distress related to AM care. There was no response to the residents statement regarding dying. *[DATE] 10:00 am "Resident crying hysterically and combative with staff during ADL care this morning. This nurse attempted to calm (resident) down. Resident eventually calmed herself down and slept". There was no documentation of consideration of cause of or interventions to address, the expression of distress related to ADLS. According to the note Resident # 1 was allowed to "calm herself down". Review of Resident # 1's Current Care Plan with onset of [DATE] identified the following problems related to behaviors: * "(Resident's name) can be resistant to care at times. She makes false accusations toward staff and states that 'I am going to tell my daughter on you". She is frequently tearful and at times is not easily redirected". * "I have bathing, grooming and dressing deficits R/T (related to) decreased mobility secondary to DJD ([MEDICAL CONDITION] joint disease), OP (?) and Cognitive decline. 'I scream at times when I receive a shower by staff' ". Review of the resident's Care Plans from [DATE] through [DATE] did not reflect any individualized identification of cause, approaches or treatment , monitoring or follow-up interventions related to Resident #1's expressions of distress including the tearfulness, yelling or screaming during ADLs particularly showers. Review of Resident # 1's Mental Health Progress Notes from [DATE] to [DATE] did not include any reference to the issue of crying, yelling or screaming related to ADLs and Showers. Review of the resident's clinical record which indicated Resident # 1 suffered from frequent skin tears to the resident's arms during that time period were never investigated to determine if the injuries were associated with or resultant from the significant behaviors. Review of Resident # 1's clinical record, including nurses notes, Mental Health Progress notes and physician notes, from [DATE] through [DATE], did not reveal any assessment of underlying cause of the behaviors during Showers or ADLs, precipitating events or environmental triggers of the demonstrated significant behaviors that included crying, yelling and screaming during showers or other ADL care. There was no indication of assessment of the impact of hearing or vision problems related to the behaviors. On [DATE] 2:15 pm, RN (Registered Nurse) #1, the Manager of Unit 2, stated Resident #1 had crying and tearful episodes and periods of confusion. She stated she did not recall any discussion of the behaviors in the Care Planning meetings or with the daughter to try to identify underlying issues or to prevent recurrence. She stated she was unaware if there was a relationship between the frequent skin tears and the behaviors. Interview with CNA # 3 on [DATE] the CNA stated, when asked about Resident # 1's behaviors, stated "she does cry, and I tell her to calm down" and I come back later when she 'calms down'. We have to get it done". The CNA stated the resident "doesn't want her hair done...She used to be really terrible'. The CNA stated she was not sure if the nurses had talked to her daughter or tried to figure out why she gets upset. On [DATE] at 9:00, CNA #2 stated she gives Resident # 1 a shower several times a month. The CNA stated sometimes she does tense up and resist care. , the CNA stated the resident does cry loud, "hysterically". When asked what she does then, the CNA responds "Then I tell the nurse". On [DATE] at 10:00 am the Activities Director stated sometimes the resident seems confused, that she really doesn't understand what is going on, she is scared. I know she is scared. She cries loud, sometimes very loud. The Director stated the resident goes back in time and talks about her husband and believes she is 'there' by herself and is afraid to leave the room. She described the resident's thoughts as jumbled. The Director stated she was not sure where the behavior comes from. She stated she had not participated in a discussion regarding the behaviors. During an interview with Director of Nursing (DON) [DATE] at 9:15 am , the DON stated the facility does not have a policy / procedure or guidelines on dementia care. She stated she was not aware of any specific education on Dementia Care except in the Silverchair module on care of the aged. She stated she did not believe the Silverchair module covered Catastrophic Care. She stated she was unable to provide the surveyor with a copy of the program. 6. The facility staff failed to obtain a physician's order to crush medications and to mix them in applesauce prior to administering the medications to Resident #6.. Resident #6 was a [AGE] year old with an Original admission date of [DATE] and most recent Readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an Admission/Reentry MDS (minimum data set-an assessment protocol) with an ARD (assessment reference date of [DATE]. The resident's BIMS (brief interview for mental status) score was 15 which indicated the resident was cognitively intact and was able to make daily decisions regarding her care. The resident was further coded as being totally dependent on staff for completion of her ADLs (activities of daily living) except for eating which required set up by staff. The resident was also incontinent of bladder and bowel. A medication administration pass was observed on [DATE] at approximately 8:30 am, for Resident #6 by RN (registered nurse) #2. After RN #2 had poured and verified the medications to be given to the resident she proceeded to crush the medications and place them into applesauce. RN #2 then took the crushed medications mixed in the applesauce and administered them to the resident. After the observation was completed and RN #2 returned to the medication cart she was then asked why the medications were crushed and put into applesauce. She stated, "I think that they are easier for the resident to swallow." When asked if a physician order was obtained to change the form of the medications and to place the crushed medications into applesauce for administration she stated, "No." An interview was conducted on [DATE] at approximately 9:30 am with RN #1-Unit Manager. When the Unit Manager was asked about changing the form of medications prior to administration she stated, "We have to have a doctor's order to do that." The Unit Manager then proceeded to review Resident #6's clinical record. No order to crush the medications could be found. Administration was informed of the findings on [DATE] at approximately 3:15 pm, at a briefing. Administration stated they did not have any additional information to be considered. Complaint Deficiency

Based on observation, staff interview, clinical record review and facility document review, facility staff failed to provide care and treatment to promote the healing of a pressure ulcer for 1 of 24 residents in the survey sample, Resident #9. The findings include: Resident #9 was admitted to the facility on [DATE] and a readmission on 3/15/10 with [DIAGNOSES REDACTED]. The most current admission MDS (Minimum Data Set) dated 3/15/10 coded Resident #1 as having long and short term memory problems and severely impaired in cognitive skills for daily decision making. The resident was also coded as totally dependent for ADLs (activities of daily living) and as having two Stage IV (A full thickness of skin and subcutaneous tissue is lost exposing muscle or bone) pressure ulcers. Review of the 3/10/09 Care Plan updated 11/25/09 and 2/23/10 evidenced problems of at risk for impaired skin integrity R/T (related to) dementia, and decreased mobility secondary [MEDICAL CONDITION](stroke) with interventions that include daily skin inspection during care, weekly body checks, and report changes in skin condition to charge nurse. Review of nursing notes dated 1/26/10 at 9:00PM evidenced, "Area to buttocks app (approximately) 1 cm (centimeter) no (indicated by a line through a zero) drainage or odor noted. Wash (with) NS (normal saline), (with) solosite (a treatment for [REDACTED]. On 1/27/10 the Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 1.5cm x 1cm, no depth, with serous drainage, no odor, red in color with no necrotic tissue, and graded as a Stage II (a partial thickness loss of skin layers that looks like an abrasion, blister or shallow crater). A physician order [REDACTED]. Review of 2/2/10 10:00AM nursing notes evidenced, "Pt (patient) assessed by Tx (treatment) nurse for open area to LT (left) buttock around wound bed edges macerated present with (line above the letter c) LG (large) amt (amount) of exudate...". On 2/4/10 (Thursday) the Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 2.5cm x 3cm, no depth, with serous drainage, no odor, no necrotic tissue, and graded as a Stage II. On 2/8/10 (Monday) the Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 3.2cm x 3.8cm, no depth, with serous drainage, no odor, no necrotic tissue, graded as a Stage IV with a note stating, "In center of wound Stage IV around Stage II". During an interview on 5/7/10 at 2:45PM, LPN #1 stated there was eschar (a slough or piece of dead tissue that is cast off from the surface of the skin) in the center which she graded as a Stage IV and the area surrounding the center was graded as a Stage II. Review of February, 2010 TAR (Treatment Administration Record) evidenced no wound care was provided on Saturday, 2/6/10 or Sunday, 2/7/10. The wound progressed from a Stage II on Friday to a Stage IV on Monday, 2/8/10. Review of 2/9/10 (Tuesday) 10:00AM nursing notes evidenced, "Pt (patient) assessed by Tx (treatment) nurse for LT (left) buttock wound bed has deteriated (sic) in center of bed, soft necrotic tissue, around necrotic tissue has red tissue (with) Lg amt of exudate and slight foul odor...". On 2/9/10 a physician order [REDACTED]. The physician also ordered an Atmos Air 4000 Mattress. Review of the February TAR evidenced no wound care was provided on Thursday, 2/11/10, Friday, 2/12/10, and Tuesday, 2/16/10. The TAR evidenced the 2/9/10 physician order [REDACTED]. On 2/13, 2/14, 2/15, 2/17, 2/18, and 2/19 wound care was only provided once a day instead of twice a day as ordered by the physician. On the February TAR a line was drawn across the number 20 with the word "Rewritten". On another page of the February TAR the physician order [REDACTED]. No wound care was documented on 2/20, 2/21, or 2/22. The 2/15/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 4cm x 3.6cm, 1.5cm depth, with serous drainage, odor, necrotic tissue, and graded as a Stage IV. The 2/22/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 4.2cm x 5.6cm, 1.5cm depth, with serous drainage, odor, necrotic tissue, and graded as a Stage IV. The 3/1/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 4.5cm x 5.3cm, 1.5cm depth, with serous drainage, odor, necrotic tissue, and graded as a Stage IV. The 3/8/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 4.5cm x 5cm, 1.5cm depth, with serous drainage, odor, necrotic tissue, and graded as a Stage IV. Review of the clinical record indicated Resident #9 was transferred to the hospital on [DATE] and was diagnosed with [REDACTED]. When the resident returned to the facility on [DATE], the left buttock was described in the nursing note admission as a Stage IV measuring 6cm long, 4cm width, 2.5cm depth with some necrotic areas and no odor or drainage. The 3/15/10 physician orders [REDACTED].? strength - irrigate and pack sacral decub. q (every) day - apply 4x4 sponge & ABD dressing- unless otherwise contraindicated by Tx (treatment) nurse. Tx nurse to evaluate. " The 3/15/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 4.5cm x 5cm, 1.5cm depth, with serous drainage, odor, necrotic tissue, and graded as a Stage IV. Review of the physician order [REDACTED].? Dakin - New Tx - Clns (cleanse) (with) DWC (Dermal Wound Cleanser) (to) apply Santyl (with) [MEDICATION NAME] & gauze q day " . The 5/3/10 Weekly Skin Condition Progress Report evidenced the left buttock wound was described as 8cm x 5.3cm, 2.2 cm depth, with serous sanguinous drainage, odor, necrotic tissue, and graded as a Stage IV. While observing wound care on 5/6/10 at 10:00AM, the wound was noted to be beefy red with granulating tissue and no underlying structures such as muscle or bone were visible. Tunneling was noted on the side of the wound closest to the coccyx. LPN #1 stated the ulcer was looking much better and was a healing Stage IV. Review of the TARs for 3/15-3/31/10, 4/1-4/30/10, and 5/1-5/6/10 evidenced treatments were documented as ordered by the physician. During an interview on 5/7/10 at 2:45PM with the Administrator, DON (Director of Nursing), and LPN #1, the Administrator stated wound care is provided by the nurses when the wound nurse is off or has another assignment. The administrator also stated since LPN #1 does not work on weekends, the unit nurses are assigned to do wound care on weekends. When the Administrator was asked about no documentation of wound care on February, 2010 TAR for 2/6, 2/7, 2/11, 2/20, 2/21, and 2/22, she stated, "If it is not documented, it is not done".