Every finding on record at Rocky Mountain Care - Logan

Based on interview and record review, the facility did not ensure that a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 46 sampled residents, a resident was admitted to the facility with surgical wounds and Moisture Associated Skin Damage (MASD) and was discharged with a stage 4 pressure ulcer. This example will be cited at a harm level. Resident identifier: 89. Findings included: Resident 89 was admitted to the facility on [DATE] and discharged on 7/24/24 with diagnoses which included infection and inflammatory reaction due to internal left knee prosthesis, Methicillin resistant Staphylococcus aureus infection, and osteomyelitis. A form titled Clinical admission Documentation dated 3/28/24, revealed resident 89's skin was clean/dry/intact with surgical wounds. The wounds were breakdown on proximal posterior left lower extremity r/t [related to] brace, breakdown on coccyx r/t MASD. It should be noted there was no other information regarding the wounds above. There were no measurements or descriptions of the wounds. A physician's order dated 3/28/24 until 5/3/24, revealed that resident 89 had a knee immobilizer and the frequency was twice daily. There was no information on what was to be done with the knee immobilizer twice daily. It was signed off by a nurse twice daily on the Medication Administration Record. A nurses note dated 3/28/24, revealed Pt [patient] has some breakdown r/t friction from leg brace, pillowcase barrier applied. Pt also has MASD on coccyx, barrier cream applied. Pt has 2 wound vac's to LLE [left lower extremity] r/t surgical wounds and infection. Care plans initiated on 3/29/24, revealed resident 89 had skin impairment of surgical wound to left hip/upper thigh. Another care plan revealed [Resident 89] will have no unaddressed alteration to skin integrity, through next review. A Braden Scale for Predicting Pressure Sore Risk dated 3/29/24, revealed resident 89 was at high risk for developing pressure sores. A physician's order dated 3/29/24 until 7/24/24, revealed barrier cream to buttocks/peri-area as needed and apply with each incontinent episode until discharge. There were no signatures on the Treatment Administration Record that the treatment was done. Care plans further revealed on 4/11/24, resident 89 had skin impairment to the sacrum. A nursing note dated 4/12/24, revealed that resident 89 had wound care rounds completed for surgical wounds and the patient was wearing a brace to his left lower extremity. A physician's order dated 4/12/24, revealed treatment to his Gluteal cleft cleanse wound and apply medihoney to wound bed and secure with dressing three times a week. A daily skilled charting dated 4/14/24, revealed resident 89 had a surgical wound with no other skin issues documented. A care plan dated 4/22/24, revealed left inner thigh skin impairment and over the counter powder was ordered to be applied. A physician's order dated 4/29/24, revealed the left great toe was to be cleansed and skin prep applied twice daily. A physician's order dated 4/30/25, revealed for the Sacrum to remove the old dressing. Cleanse wound with wound cleanser or normal saline. Apply medihoney to wound bed. Secure with cover dressing. Complete 3 times weekly and as needed if soiled or dislodged. There was no documentation regarding the wound. A care plan dated 5/2/24, revealed resident 89 had actual skin impairment to his left great toe and left posterior calf. A nurses note dated 5/2/24, revealed the wound care provider documented a new wound to the left posterior calf noted by an aide post shower this morning. There was also a great toe wound noted. There were no wound measurements or description of the wound. Physician orders for wound treatment to the left posterior calf started on 5/4/24, until discharge. A nurse's note dated 5/13/24, revealed a wound to the left posterior calf. The area was still black and the surrounding skin was pink and intact. A nurse's note dated 5/18/24, revealed wound to left toe cleaned and wound was showing improvement. It should be noted that no objective data was documented to show the wound improvement. A nurse's note dated 5/19/24, revealed a wound was cleansed, betadine applied, left open to air. It should be noted that the note was not specific to which wound. A nurses note dated 5/20/24, revealed hip surgery was canceled due to a wound on the back of leg. A nurse's note dated 5/22/24, revealed a wound to the left great toe was open to air. A nursing note dated 5/26/24, revealed Wound to calf is open with yellow slough on top, moderate yellow drainage et [and] foul ordor [sic]. Surrounding tissue is intack [sic] et pink. A daily skilled charting dated 6/11/24 revealed resident 89 had other for skin integrity. There was no other information. The first weekly skin assessment was dated 6/19/24, new onset left calf skin impairment. A physician's note dated 6/23/24, revealed stage 4 ulcer of left shin. It should be noted that prior documentation had the wound located on the calf and not the shin. The documentation made it unable to determine if two wounds were located with one the left calf and one on the left shin. Weekly skin assessments dated 6/26/24, 7/3/24, and 7/12/24, revealed skin was pink, dry, warm, intact. The locations listed on the assessments were left calf and ankle posterior. A nurse note dated 6/27/24, revealed that resident 89 had surgical site on left anterior thigh reopen and left posterior calf was progressing well. A physician's note dated 7/1/24, and 7/4/24, revealed resident 89 had a stage 4 ulcer of left shin which was managed by wound care. A physician's note dated 7/11/24, revealed resident 89 had a Stage 4 ulcer on Left hip treated with calcium alginate dressings. It should be noted this was another skin breakdown area. It should be noted that this was the first documentation of a stage 4 PU on the left hip. Prior documentation described the left anterior thigh as a surgical site only. A physician's note dated 7/21/24, revealed resident 89 was seen for wound debridement. The treatment plan revealed a pressure ulcer of right hip stage 4. There were no wound treatments for the right or left hip in the Medication Administration Record. A physician's note dated 7/23/24, revealed . He [resident 89] has been receiving wound care for a Stage 4 pressure ulcer on the posterior left lower leg. It should be noted that resident 89 was admitted with breakdown on proximal posterior left lower extremity r/t brace and breakdown on coccyx. Resident 89 further developed wounds and there was no documentation of interventions used to prevent skin breakdown. Resident 89 was admitted with a knee immobilizer and developed a stage 4 pressure ulcer on his calf that the immobilizer was on. Additionally, resident 89's left hip surgical site degraded and was classified as a stage 4 pressure ulcer and there were no interventions to prevent further skin breakdown. Resident 89 developed skin breakdown to his toe and there were no interventions to prevent the skin breakdown. In addition, there was no documentation of when resident 89 developed skin breakdown to his sacrum area. On 2/11/26 at 3:10 PM, the Administrator was asked for additional information regarding what the facility was doing to prevent skin breakdown. The Administrator stated she did not have documentation beyond what was in the resident's medical record. The Administrator was unable to provide additional information.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 3 out of 46 sampled residents, a resident experienced a change in condition after a fall, was not provided treatment for 2.5 hours, and ended up passing away. Another resident complained of hip pain after a fall and was not sent to the hospital for 10 hours. These examples will be cited at harm. In addition, a resident was not provided treatment when he was experiencing low oxygen saturation levels. Resident identifiers: 74, 86, and 90. Findings included:HARM1. Resident 90 was admitted to the facility on [DATE] with diagnoses which included, paroxysmal atrial fibrillation, difficulty in walking, and muscle weakness.The facility reported to the State Survey Agency (SSA) on 6/12/24, that resident 90 was found on the floor in her bathroom at 1:30 PM, and she stated she did not hit her head. Neurological checks were initiated and no changes or abnormal vitals were identified until 8:30 PM. Resident 90 was sent to the Emergency Department due to nausea, vomiting, and confusion where she subsequently passed away.A review of resident 90's medical record revealed the following:a. On 6/11/24 at 1:32 PM, a nursing note documented, pt. [patient] calling for help from bathroom. pt. found on floor next to soilet [sic] in soiled clothing. pt immediately assisted back onto toilet, changed into clean clothing, neuros [neurologicals] started, and vitals. vitals and neuros are baseline for pt. pt. denies hitting head and no signs of injury present. pt. has a current UTI [urinary tract infection], poor lighting in bathroom, and no grippy socks were on. maintenance informed of the poor lighting, grippy socks placed, call light clipped to pt. with education to use that when needing to transfer, and pt. placed back into chair.b. On 6/11/24, neuro checks began at 1:15 PM. At 8:00 PM, the neuro sheet documented resident 90's blood pressure as 171/80 and heart rate was 106. At an unknown time the neuro sheet documented resident 90's level of consciousness as lethargic-slow to respond to verbal stimuli, hand grasps as weakness, and speech as slurred. c. On 6/12/24 at 1:40 AM, a nursing note documented, At 2030 [8:30 PM] pt started c/o [complaining of] HA [headache] and reported that she did hit her head at the time of the fall-bp [blood pressure] 123/59. 2100 [9:00 PM] neuros again checked 145/77. She was c/o nausea, vomiting, and was not following simple cues. 2130 [9:30 PM] BP assessed again 171/80. pthad [sic] left sided weakness for grip strength. Nurse contacted PA [physician assistant] and he reported that since her focal point has deficits et [and] that she has weakness, that needed [sic] to send her out. Called pt son et reported finding et he reported to send to ER [emergency room] for CT [computed tomography] Scan. EMTS [emergency medical technicians] called and pt was sent out at 2230 [10:30 PM] .A review of resident 90's Facility Reported Investigation interviews revealed the following:a. Registered Nurse (RN) 4's interview documented, I first saw [resident 90] for her 1900 [7:00 PM] neuro check. All checks and vitals were WNL [within normal limits]. At about 2000 [8:00 PM] the CNA [Certified Nursing Assistant] notified me she was complaining of a headache. I notified [name redacted] the wing nurse of the headache concerned [sic] due to her fall earlier in the day. [Name redacted] stated that she got in report that [resident 90] did not hit her head when she fell earlier in the day. I prepared her 2000 meds [medications] adding Tylenol for the headache. I then administered her meds and did the 2000 nuero [sic] checks. They were all WNL, but her blood pressure was starting to elevate. She conversed with me appropriately. I spent several minutes with her at the time administering her breathing treatment. I asked the CNAs to get her an ice pack to see if it helped her headache. At about 2100 [9:00 PM] the CNA notified me that [resident 90] had vomited. I immediately went in and assessed her. Her LOC [level of consciousness] had changed concerningly although she would still respond to me. She would not open her eyes. She followed commands to grip my hands. Right hand was strong, no grip at all with the left. I immediately notified [name redacted] the wing nurse and she started the notification process of all appropriate parties. I instructed the CNAs to clean [resident 90] up. She vomited once more right before the EMTs arrived.b. RN 5's interview documented, As I was receiving report for shift change, I was informed that pt [resident 90] had taken a fall earlier in the day and was on neuros. I asked many questions to see where they fell, if head was hit and behavior change from normal. Med nurse and swing aides gave answers, fell in bathroom and hit head and was recently complaining of headache. Once report was finished, I entered the room to immediately check on pt. Pt name was called many times and arm stimulation was used before pt responded. Pt kept saying yes to all questions and requests regardless of questions or tasks asked. Pt was unable to open eyes or respond as normal. Med nurse was notified who informed me to notify and give all information to the charge nurse. Charge nurse was notified and call Non-emergency line and requested transportation for pt. Med nurse called on radio that pt was throwing up and needs immediately [sic] attention. Swing aide and I rushed to the room to assist pt. As assisting EMTs arrived and took over. Charge nurse, swing aide and I stayed in room to assist and comfort roommate. EMT's stated BP was out of range and no response of puplies [sic]. Pt was assisted on stretcher and EMTs transported to hospital.A review of resident 90's hospital CT scan records revealed, Head CT: This examination is abnormal. There is a very large holohemispheric right cerebral convexity subdural hematoma, most pronounced along the right frontal lobe and subinsular cortex. This subdural hematoma measures 3.2 cm [centimeters] in maximum thickness. There is an additional right parafalcine subdural hematoma measuring up to 16mm [millimeters] in thickness-posteriorly. There is effacement on the right lateral ventricle. There is a leftward shift of the septum by approximately 21 mm. There is developing moderate right and left uncal and subfalcine herniation. [It should be noted that resident 90 was on anticoagulant medication and her International Normalized Ratio level was 3.5 on 6/11/24 at 10:51 PM.]On 2/5/26 at 10:58 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she expected staff to reach out to the Director of Nursing or herself about any changes in condition that residents may have. The ADON stated that the medical provider made the decisions on when to send a resident to the hospital. On 2/6/26 at 5:02 PM, the facility provided additional information regarding resident 90. It should be noted that the additional information did not include why there was a 2.5 hour delay in sending resident 90 to the hospital once she began experiencing a change in condition. Resident 90 passed away on 6/12/24 at 1:48 AM. 2. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinsonism, muscle weakness, difficulty walking and sepsis. The facility reported to the SSA that resident 86 was found on the floor on 6/8/25, complaining of pain and an x-ray confirmed there was a fracture. A nursing progress note revealed resident 86 had a fall on 6/5/25. Resident 86 was moved closer to the nurses station. A nursing progress note from Licensed Practical Nurse (LPN) 1 dated 6/8/25 at 9:26 AM, revealed, Pt had fall this morning at approximatly [sic] 0645 [6:45 AM]. Pt found lying flat on ground next to bed and stated she had L [left] hip pain. Pt assessed no new bruising or redness noted at the time of fall. Pt unable to tell nurse where she was trying to go or what she needed. Pt at baseline. Nuro [sic] and vital check started. Pain medication administered and family Management and MD [medical doctor] notfified [sic]. Order placed for L hip xray. On 6/8/25 at 9:37 AM, a nursing progress note revealed Pt bed placed at lowest position, replaced personal socks with non slip socks, personal items and call light placed in reach. On 6/8/25 at 10:55 AM, a nursing progress note revealed, Pt stated the cna hit her while nurse and cna were moving her up in bed. Pt was not hit by CNA the movement in bed using the draw sheet made her uncomfortable. On 6/8/25 at 7:04 AM, oxycodone 5 milligrams was administered with a pain level of 5. On 6/8/25 at 1:06 PM, oxycodone 5 milligrams was administered for left hip pain. The medication was documented as being ineffective with pain relief. On 6/8/25 at 4:59 PM, a nursing progress note revealed Pt discharged to [local] hospital via ambulance, due to left femoral neck fracture at 6/8/2025 1650 (4:50 PM). MD, family and unit manager notified. Copy of POLST [physician order for life sustaining treatment] Emergent discharge and Quality imaging results sent with ambulance staff. Pt or family unable to sign paperwork copy to be faxed to hospital. Nurse to Nurse report Hospital ER called and updated on PT info condition, baseline, vitals and arival [sic] with left femoral neck fracture. On 6/8/25 at 9:06 PM, a nursing progress note revealed 6/8 Unwitnessed Fall: Patient was found lying supine on the floor adjacent to her bed following an unwitnessed fall. She reported pain localized primarily to the left hip but was unable to confirm any head impact. A comprehensive head-to-toe assessment revealed no visible bruises, lacerations, or hematomas on the head. Neurological examination indicated pupils equal, round, and reactive to light, with bilateral hand-grip strength consistent with her baseline. Examination of the left hip showed mild erythema without evidence of bruising, swelling, or deformity. No additional abnormalities were noted on supporting extremities. Vital signs were within normal limits. The patient received her prescribed analgesic in conjunction with her scheduled morning medications. The attending physician, nursing management, and the patient's daughter . were promptly notified. A STAT [immediately] X-ray of the left hip was ordered per their direction. At the time of the fall, the patient was not wearing non-slip socks; her personal socks were immediately replaced with non-slip footwear. The orthopedic boot had been removed for comfort while resting and had not yet been reapplied. The room was free of clutter, with personal items and the call light within reach, and the bed was in its lowest position. The patient had been assisted with toileting less than 30 minutes prior to the incident. Post-fall, the patient was educated on the importance of using her orthopedic boot for ankle support and instructed to use the call light for assistance before mobilizing. Fall-risk assessment and care plan will be reviewed and updated to reflect this event. Resident 86 was readmitted to the facility with hospice services and passed away on 6/15/25. On 2/4/26 at 12:13 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated she started on 6/16/25, and was unable to find additional information for resident 86's fall and change in condition. On 2/11/26 at 1:18 AM, a phone interview was conducted with LPN 1. LPN 1 stated after a fall he completed an initial assessment which included evaluating for a major injury and then neuro checks and vital signs were done for 72 hours. LPN 1 stated if a resident was on blood thinner, then a CT scan would be needed. LPN 1 stated resident 86 sustained a fall and complained of more pain in her hip and an x-ray was ordered. LPN 1 stated initially resident 86 complained of pain but not a significant amount of pain. LPN 1 stated he could not remember if the x-ray was ordered stat and if it was done at the facility or the hospital. LPN 1 stated he did not know why resident 86 was not sent to the emergency room for 10 hours after complaining of pain to the hip, but it was probably because he did not have a physician's order to send resident 86 to the hospital. LPN 1 stated he wanted to see if the resident's pain could be controlled at the facility. LPN 1 stated resident 86 had severe pain only with movement like rolling in bed or moving. LPN 1 stated he remembered her being in pain but did not remember any concerns of a CNA hitting her when repositioning her in bed. POTENTIAL FOR HARM 3. Resident 74 was admitted to the facility on [DATE] with diagnoses which included muscular dystrophy, obstructive sleep apnea, and dysphagia. The facility reported to the SSA on 12/28/25, that a nurse was not attending to resident 74 when his oxygen saturations (sats) were at 35% and a heart rate in the 100s. Resident 74 appeared gray-blue in color with an ashen appearance. A nurse reported to administration that resident 74's nurse had neglected him by not treating the low sats. A CNA had told the nurse that earlier in the evening resident 74's sats were in the 40s and 50s. After resident 74 did a cough assist and was placed on oxygen, his sats improved to 93%. Resident 74's medical record was reviewed 2/4/26 through 2/12/26. Resident 74's sats from 10/2/25 through 11/30/25, were above 90% on room air. A physician's order dated 10/27/25, and discontinued on 12/21/25, revealed to offer cough assist treatment every shift for airway management. On 12/1/25 at 6:17 AM, resident 74's sats were 80%. At 10:38 AM, a secured conversation via text message between facility staff and the provider revealed that the provider would like the facility to obtain a chest x-ray and a laboratory value for the resident. There was no documentation of treatment provided for low sats until 4 hours later. The next sats documented were on 12/5/25. A physician's order dated 10/2/24, revealed Bilevel Positive Airway Pressure (BIPAP) to be applied every night when sleeping but to hold from 12/1/25 through 12/28/25. It should be noted that there was no documentation located to indicate why the BIPAP order was to be held during this time frame. On 12/2/25 at 8:35 AM, the x-ray results revealed possible bronchitis and continue to offer cough assist. A nursing progress note dated 12/3/25 at 2:03 AM, revealed Alert Charting- Resident on alert charting related to a Change of Condition Hypoxia. every shift for change of condition for 3 Days Document in progress note how the resident is doing post their change of condition for 72 hours after no hypoxia concerns this shift. A physician's order dated 12/3/25, revealed cough assist treatment. Cough assist present on home setting. Registered Nurse (RN) to hold mask in place for patient to complete 4 coughs. The frequency was every shift for airway management. A secure conversation via text message between a nurse and physician on 12/4/25 at 5:36 PM, revealed resident 74 had called the nurses station 10 times. The nurse talked to resident 74 about that behavior and not getting consistent and solid sleep and that would affect his health in a negative way. The nurse asked resident 74 about a medication for sleep aide and resident 74 was agreeable. The physician ordered melatonin 3 milligrams (mg) every night. It should be noted there were no sats documented that night. On 12/6/25 at 3:21 AM, sats were 88% and at 5:37 AM, sats were 76%. There were no follow up sats. On 12/7/25 at 4:00 AM, sats were 86%, at 5:00 AM sats were 86%, at 6:34 AM sats were 75%, and at 3:54 PM sats were 90% on room air. Resident 74 refused cough assist and told the nurse it was as needed according to the orders-administration note. On 12/10/25 at 5:00 AM, sats were 85%. There were no follow up sats. On 12/17/25 at 5:38 AM, sats were 85%. There were no follow up sats. On 12/19/25 at 5:51 AM, sats were 65% and at 6:16 AM, sats were 65%. There were no follow up sats. On 12/26/25 at 5:52 AM, sats were 51%. There were no follow up sats. Cough assist was done at 12:58 PM. There was no follow up documentation after resident 74 had sats at 51%. On 12/27/25 at 5:40 AM, sats were 48%, at 6:26 AM, sats were 94%. On 12/28/25 at 4:32 AM, a nursing progress note revealed, resident has not slept for any length of time that would be considered restful despite being given a dose of melatonin at HS [hours of sleep]; has been highly [sic] using his phone to call for assistance in repositioning in bed only to call again within minutes to be repositioned again; offered oral pain med multiple times this shift with resident declining offered med; has also been noted to be randomly talking in jibberish [sic] as if there is someone present in the room that in reality is not there; will continue to monitor sleep and behaviors On 12/28/25 at 5:00 AM, sats were 47% and at 5:59 AM sats were 93%. Cough assist treatment was completed at 1:35 AM. On 12/28/25 at 7:32 AM, a secure conversation via text message between facility staff and a medical provider revealed resident 74 was requiring 4 liters of oxygen after being found at 47% oxygen sats on room air. Resident 74 was very pale and cyanotic in lips, according to the message. A nurses note dated 12/28/25 at 5:31 PM, revealed, . Family looking for Bi pap and will bring it in if they find it. On 12/28/25, resident 74 was started on Amoxicillin-Pot Clavulante tablet 875-125 MG every 12 hours until 1/5/26, for bacterial infection/pneumonia. On 12/30/25, a physician's note revealed resident 74 had aspiration pneumonia. On 2/4/26 at 9:22 AM, an interview was conducted with resident 74. Resident 74 stated he used oxygen and staff monitored his oxygen levels. Resident 74 was observed to have oxygen being administered via a nasal cannula. On 2/9/26 at 1:48 PM, a phone interview was conducted with CNA 9. CNA 9 stated sats were checked every morning at 5:00 AM, for residents. CNA 9 stated resident 74 refused oxygen when he was first admitted to the facility. CNA 9 stated resident 74 was normally in the 70s and 80s for sats during the night. CNA 9 stated one night resident 74 was hot and cold, calling for help every 15 minutes throughout the 8 hour shift. CNA 9 stated he was calling to get adjusted like blanket on, blanket off, and then he said it was hard for him to breathe. CNA 9 stated resident 74's oxygen was in the 40s so she sat down with him and discussed using respiratory therapy to help him get his oxygen up. CNA 9 stated resident 74 was blue in the face and pale, so CNA 9 told him that he would die if he did not use oxygen. CNA 9 stated the resident agreed to oxygen that night. CNA 9 stated when she noticed resident 74 turning blue she was in the middle of helping the resident use the urinal, so she finished helping him and then took the garbage in his room out. CNA 9 stated she then informed the nurse that his sats were low and he was blue. CNA 9 stated she was told by the nurse to get an oxygen concentrator, so she did and his sats increased to above 90%. On 2/4/26 at 1:53 PM, an interview was conducted with RN 6. RN 6 stated sats were taken daily between 3:00 PM and 5:00 PM, by the CNA's. RN 6 stated it was not standard to have sats checked during the night shift. RN 6 stated if a resident had low sats, it was standard to provide oxygen and then recheck saturations. RN 6 stated resident 74 dropped in sats and another nurse and CNA were checking on him. RN 6 stated resident 74 had pneumonia. RN 6 stated that the monitor to check sats did not work on all of resident 74's fingers. RN 6 stated resident 74 did not wear oxygen until after he was diagnosed with pneumonia. RN 6 stated a CNA reported that the resident's sats were at 47% sats oxygen was started. RN 6 stated if a resident's oxygen saturations were below 80% she would provide oxygen and report it to the DON, physician, and family. On 2/4/26 at 9:28 AM, an interview was conducted with the ADM and Director of Nursing (DON). The DON stated she received a phone call from a nurse on 12/28/25 that resident 74 was having oxygen issues and his nurse did not act fast enough. The DON stated there was an investigation started. The ADM stated she was unable to determine if there was neglect. The ADM stated she did not look at previous oxygen levels.

Based on observation, interview, and record review, the facility did not ensure that the environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 46 sampled residents, a resident sustained a fall with a head injury while left unsupervised in the shower. This will be cited at a harm level. Additionally, a resident was involved in a motor vehicle accident that resulted in injuries while being transported in the facility vehicle, and the facility hot water temperatures registered as high as 130 degrees inside resident rooms. Resident identifiers: 32 and 44. Findings included: HARM 1. Resident 44 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the large intestine and rectum, muscle weakness, orthostatic hypotension, and moderate protein-calorie malnutrition. On 2/11/26 at 2:55 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 44 just had a fall in the shower room and sustained a head laceration. RN 1 stated that the wound did not need sutures or steri strips to close and they were applying pressure. RN 1 stated that resident 44 was left unattended in the shower room. RN 1 stated that resident 44 used to be a set up assist for showers, but had recently had a decline and change in condition. RN 1 stated that the aides were not aware of the change in condition and decline and that resident 44 needed assistance with showering. RN 1 stated that she provided education to the aides and informed them that resident 44 was not to be left alone in the shower room, especially since it was so slippery in there. Resident 44's medical records were reviewed. On 2/11/26 at 3:16 PM, resident 44's Nurses Note documented, Pt [patient] walked out of shower room and stated he fell. Fall was unwitnessed. Pt was lethargic and walked with cane. Pt fully dressed but had no footwear. Pt was assisted to nearby chair. Pt stated he slipped on water and hit his head. Pt stating his R [right] side is also hurting but was hurting prior to fall as well. Pt was assessed fully. VS [vital signs] WNL [within normal limits]. Neuro [neurological] checks initiated. Cut present to back of head, wound care completed. No bruising noted anywhere on body. Hospice team, PA [Physician Assistant], ADON [Assistant Director of Nursing], and EC [emergency contact] were notified. AC [alert charting] completed and wound care orders in place. CNA [Certified Nursing Assistant] educated not to leave resident unattended in shower room and increased rounding to be done on pt. On 2/11/26 at 3:32 PM, resident 44's Nurses Note documented, Morphine changed to Q4h [every 4 hours] per hospice. Resident 44's bathing task for the last 30 days revealed that the staff identified on 1/15/26, that the resident required supervision or touching assistance with bathing, and on 1/31/26, that the resident required partial to moderate assistance with bathing. Resident 44's First Responder Report documented that the resident reported pain to the right side of his head after his fall. The resident reported that the wet surface contributed to the fall. The report documented that the resident was placed in shower at 2:20 PM, and was last checked on at 2:40 PM. The report documented contributing factors to the fall was left alone in the shower, no supervision, and no use of the call light. The report documented that the resident had previous falls and the author was unsure if there were any fall interventions in place prior to the fall. It should be noted that the author of the report was the resident's nurse. On 2/11/26 at 2:45 PM, the neurological assessment was initiated. The assessment did not contain documentation for level of consciousness, movement, hand grasps, pupil size and reaction, and speech for the 4:00 PM, 4:30 PM, 5:00 PM, and 5:30 PM, time slots. Resident 44's care plan had a focus area for at risk for falls secondary to advanced age and weakness that was initiated on 9/9/25. Interventions identified on the care plan prior to the fall on 2/11/26, were to encourage the use of the call light, encourage the resident to keep the bed in the lowest position, and to keep the room free of clutter and tripping hazards. On 2/12/26 at 9:02 AM, an interview was conducted with resident 44. Resident 44 stated that he slipped while taking a shower and the CNA was not in the room with him. Resident 44 stated that he did not usually need one CNA and he was very confident. Resident 44 stated that it hurt his right side and he hit his head. The resident was observed with a bandage on his head. Resident 44 stated that he normally showered on his own. Resident 44 stated that he had recently started using a cane for ambulation. Resident 44 was observed grunting in pain and reported a pain of 3/10 that was located on his right side where he fell. Resident 44 stated that he had not used a shower chair before and he did not use the cane in the shower room. Resident 44 stated that the CNAs set up the shower room for him but they did not stay with him. They never had to. On 2/12/26 at 9:11 AM, an interview was conducted with CNA 2 and CNA 3. CNA 3 stated that the alerts on the kardex would tell them if a resident had a change of condition and it was also passed off in change of shift report. CNA 3 stated that resident 44 required supervision for ambulation and he used a cane. CNA 3 stated that resident 44 was currently not feeling well and needed a little extra help. CNA 3 stated that resident 44 required stand by assistance for showers and he had always been that way. CNA 3 stated that they did not leave resident 44 alone in the shower room and they were to stay with him at all times. CNA 3 stated that this had always been resident 44's assistive needs for a shower. On 2/12/26 at 9:41 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that any resident change in condition should be communicated by the nurse to the aides, and then in report. The ADON stated that the resident assistance needs should also be communicated the same way. The ADON stated that neurological checks were initiated for an unwitnessed fall or a fall with a hit to the head. The ADON stated that the licensed nurse would do the actual neuro check and the CNA would take the vital signs. The ADON stated that the nurses were assessing for any change from baseline and any indication of complications with a strike to the head such as brain bleed or a concussion. The ADON stated she was not sure why resident 44's neuro assessment was incomplete. The ADON stated that resident 44 was taken to the shower room and left unattended and had an unwitnessed fall. The ADON stated that that staff should have stayed with the resident in the shower room. POTENTIAL FOR HARM 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included paraplegia, unspecified injury of Thoracic (T)7-T10, and post traumatic stress disorder. On 2/10/26 at 11:43 AM, an interview was conducted with resident 32. Resident 32 stated that she had an accident in the facility van. Resident 32 stated that the Transportation Driver (TD) was late to pick her up for the scheduled appointment. Resident 32 stated that while driving to the appointment the TD went off the road and through a fence. Resident 32 stated that she was thrown from her wheelchair and her seatbelt was not secured properly. Resident 32 stated that she hit the armrest and sustained bruising to her ribs and then landed on the floor of the van. Resident 32 stated that the TD was drowsy while driving. Resident 32's progress notes revealed the following: a. On 11/7/24 at 11:09 AM, the note documented, ED [emergency department] Note: Note reviewed, resident evaluated following MVA [motor vehicle accident]. X-rays and CT [computed tomography] scans completed. No new orders, recommend to follow-up with a trauma orthopedist. b. On 11/7/24 at 2:29 PM, the note documented, New orders for norco 5/325 1 tab [tablet] Q [every] 6 hours PRN [as needed], Chest, bilat [bilateral] lower extremities, Hip and Right shoulder X-ray. Per house MD [Medical Doctor]. c. On 11/7/24 at 3:08 PM, the note documented, Patient involved in car accident on 11/7, assessment performed once returned to facility. Neuro: . -headache generalized and rated 7/10 Skin/Integumentary. -bruising/redness to right forehead -bruising/redness to right cheek -redness and irritation to right shoulder -redness/bruising to right knee Musculoskeletal/ROM [range of motion]: . -bilateral upper extremities ROM limited due to pain -pain in right shoulder worse than left -neck movement limited due to pain Abdomen: . -pain in all four quadrants -increase in pain in upper quadrants around ribs Respiratory: . -tachypnea/shallow respirations due to rib/abd pain -educated on breathing techniques to assist with pain -lung sound present but slightly diminished in right upper lobe -oxygen levels >92% RA [room air] Psychological/Emotional: . -patient distraught upon arrival back to facility -she states she feels like crying at any moment -feelings of emotions arising from past car accident that left her paralyzed Pt states when the car crash took place she did not want to be taken by ambulance to the hospital, patient states she requested to be brought back to [facility] for assessment and if her health requires it she will agree to go to the hospital via ambulance. Xrays ordered for bilateral lower extremities, patient is concerned that she may have broken something in her lower extremities but is unable to feel it. Xrays to bilateral ribs (all views), Xray to right upper shoulder due to decreased ROM and severe pain. d. On 11/7/24 at 4:14 PM, the note documented, Since pain medication administered, patient has continued to have an increase in pain and her headache has gone from a 7/10 to 10/10. Patient being transferred to emergency room for further diagnostic testing and evaluation. e. On 11/9/24 at 10:14 PM, the note documented, Pt. stated that she is having increased pain to her R ribs/side due to that being the side that took the brunt of impact during the accident. f. On 11/14/24 at 4:39 AM, the note documented, at bedtime resident was reporting increased pain to rib and flank area at bedtime-pain improved after Norco, Ibuprofen, Tylenol and topical pain relieving cream; was crying and anxious at bedtime as well but that improved after HS [bedtime] meds as scheduled; does have some bruising to flank/hip area that appears to be fading that occurred with MVA she was in last week. On 11/7/24, the hospital discharge handout documented the diagnoses from the visit were motor vehicle collision, multiple contusions, shoulder contusion, elbow contusion, wrist contusion, and femur fracture. It should be noted that the femur fracture was evaluated and determined to be an incomplete healed fracture. Resident 32 was referred to a trauma orthopedist for a follow up of the unhealed fracture. The facility Incident report Physical Asset Dodge Caravan documented that the TD could not explain what happened. I was getting off and the next thing I know there were branches and trees and I was in a sand bank of some sort. The report documented that resident 32 was evaluated by Emergency Medical Services and was found out of her chair during the assessment. The report documented that the TD was taken for a drug screening per policy and then suspended from all driving privileges. On 11/13/24, the After Action Accident Report documented that the TD was permanently removed from driving privileges. On 12/11/24, the After Action Accident Report documented that the vehicle was determined to be a total loss. On 1/9/25, the After Action Accident Report documented that Human Resource and the Administrator terminated the TD's employment due to the MVA. The transportation logs were reviewed from November 2024 through January 2025. The logs documented the residents that were transported during that time period but did not document who the transportation driver was for each resident transported. The personnel file for the TD was reviewed. No documentation could be found for any training that was provided to the TD related to safely securing a resident during transportation or education on transporting residents. The date of hire for the TD was 4/13/23, and date of termination was 1/9/25. On 2/11/26 at 10:38 AM, an interview was conducted with the Administrator (ADM). The ADM stated that they had been using a sister company for resident transportation since June 2025. The ADM stated that the transportation van was housed at the facility for resident transfers. The ADM stated that some facility staff still provided occasional resident transportation when the other service provider was not available. The ADM stated that the Director of Nursing and the Patient Care Coordinator (PCC) were the two facility staff members that still provided resident transportation. The ADM stated that the driver training was provided by the corporate office and included defensive driving tactics, a ride a long, and a competency assessment. The ADM stated that this Included demonstrating how to safely secure a resident in the van that was transported in a wheelchair or a stretcher, how to safely load and unload a resident in the van, and safe driving practices. On 2/11/26 at 10:47 AM, an interview was conducted with the PCC. The PCC stated that he was still on the facility car insurance and he transported a resident last Saturday. The PCC stated that the previous TD handled all resident transportation. The PCC stated that the TD was terminated after he had an accident in the van. The PCC stated that the TD was exiting the freeway and lost control of the vehicle. The PCC stated that the TD later reported that he had fallen asleep while driving. On 2/12/26 at 10:48 AM, a follow-up interview was conducted with the ADM. The ADM stated that the TD had not received any education for driving the facility van. On 2/12/26 at 1:45 PM, the ADM stated that all drivers were provided training on transportation in June 2025 and this was after the TD's termination. The ADM stated that the TD could have transported residents prior to his termination. The ADM stated that she was not aware of any education that was provided to staff after the accident with resident 32. The ADM stated that she could not confirm if the TD transported residents after the accident or if education was provided to staff after the accident on how to safely transport and secure residents in a wheelchair. The ADM stated that the TD was the only driver employed with the building at the time and he was most likely still driving residents after the accident. 3. WATER TEMPERATURES It should be noted that all temperatures were in degrees Fahrenheit and were obtained using a digital probe thermometer. The surveyors' thermometers were calibrated in ice water on 2/9/26 at 9:00 AM. On 2/9/26 at 9:23 AM, room [ROOM NUMBER], occupied by two residents, had a sink in the room with a water temperature of 130.2. On 2/9/26 at 9:46 AM, room134, occupied by two residents, had a sink in the room with a water temperature of 119.4. On 2/9/26 at 9:50 AM, room [ROOM NUMBER], occupied by two residents, had a sink in the room with a water temperature of 129. On 2/9/26 at 10:10 AM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 127.4. On 2/9/26 at 10:18 AM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 123. On 2/9/26 at 10:25 AM, room [ROOM NUMBER], had a sink in the room with a water temperature of 126.6. The resident stated the water would get hot quickly. On 2/9/26 at 10:35 AM, room [ROOM NUMBER], had a sink in the room with a water temperature of 128 degrees. On 2/9/26 at 11:01 AM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 118.2. On 2/9/26 at 12:04 PM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 123.9. On 2/9/26 at 2:29 PM, room [ROOM NUMBER], had a sink in the room with a water temperature of 125.2. The resident stated that sometimes the water was too hot in the shower room and she would have to tell the staff to turn down the hot water. On 2/10/26 at 8:46 AM, room [ROOM NUMBER], had a sink in the room with a water temperature of 126.6. On 2/10/26 at 8:46 AM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 125.2. On 2/10/26 at 9:07 AM, public restroom [ROOM NUMBER], had a sink in the restroom with a water temperature of 123. On 2/10/26 at 9:24 AM, room [ROOM NUMBER], occupied by one resident, had a sink in the room with a water temperature of 118.9. On 2/12/26 at 10:08 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he used a digital thermometer to test water temperatures weekly. The Maintenance Director stated that the building was broken down by four quadrants and each quadrant was tested weekly. The Maintenance Director stated that he would test every area a resident could put their hands in. The Maintenance Director stated that he would test the resident sinks, dining room sink, therapy gym sink, the front two bathrooms, the showers, the salon, and the activities room. The Maintenance Director stated the water heaters were set slightly above 120 so the hot water was able to reach the end of the building. The Maintenance Director stated when the staff started running the water in the shower rooms the resident room water temperatures would fluctuate. The Maintenance Director stated he had a few rooms that were running high so he had a mixing valve on order. The Maintenance Director stated that the dining room sink had a mixing valve. An observation of water temperatures was conducted with the Maintenance Director. On 2/12/26 at 10:19 AM, room [ROOM NUMBER] had a sink water temperature of 131. The North water heater was observed to be set at 130. The Maintenance Director stated that the North water heater did not have a mixing valve. On 2/12/26 at 10:25 AM, room [ROOM NUMBER] had a sink water temperature of 120.7. The South water heater operating set point was observed to be set at 125 and the tank was reading 122. The Maintenance Director stated the South water heater did not have a mixing valve. The Maintenance Director stated he was getting mixing valves for all the sinks that were running high temperatures.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was undated food in the refrigerator and freezer, expired items in dry storage, expired items in the resident refrigerator, and the sanitizer bucket was not testing at the required sanitation levels. Findings included:1. On 2/9/26 at 8:21 AM, an initial tour of the kitchen was conducted. The following observations were made:a. Multiple cups with different liquids with lids were undated in the refrigerator.b. An opened bag of frozen vegetables that was undated in the freezer. c. An opened bag of buns was undated in the freezer.d. An opened bag of corndogs with an opened date of 12/5/25, was open to air.e. Cans of evaporated milk with an expiration date of 1/26/26, were located in dry storage.f. Three sandwiches with a use by date of 2/6/26, were located in the resident refrigerator.g. A pepperoni and cheese snack pack with an expiration date of 2/4/26, was located in the resident refrigerator.On 2/9/26 at 8:49 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the drinks in the refrigerator should be dated. The DM stated that the frozen vegetables were thrown in a box and staff had forgotten to date the bag. The DM stated that the bag of corn dogs should be closed and not open to air. The DM stated that the cans of evaporated milk should be discarded because they were expired. The DM stated that kitchen staff were responsible for the resident refrigerator and all expired items should be thrown out. 2. On 2/11/26 at 11:24 AM, a follow-up tour of the kitchen was conducted. The following was observed:a. The sanitation bucket was tested and resulted at 75 parts per million (PPM). The DM stated that the level should be at 100 PPM. The DM stated that the sanitation bucket must not have been changed prior to the start of lunch and that she would talk with her staff about this. The DM stated that at 75 PPM surfaces were not being sanitized correctly.b. Fresh vegetables, potato salad, and ranch cups were not dated inside of the refrigerator.On 2/11/26 at 11:30 AM, a follow-up interview was conducted with the DM. The DM stated that the vegetables, potato salad, and ranch cups should all be dated and that she again would talk with her staff about dating items.

Based on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence of a thorough investigation. Specifically, for 9 out of 46 sampled residents, residents with fractures, a motor vehicle accident involving a resident, allegations against staff regarding care and abuse, a resident that self harmed, and an allegation against a spouse of abuse were not thoroughly investigated to determine if there was abuse or neglect. Resident identifiers: 32, 38, 86, 87, 88, 91, 92, 93, and 95. Findings included:1. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, major depressive disorder, epilepsy, and unsteadiness on feet. The facility reported to the State Survey Agency (SSA) on 6/8/25, that resident 86 sustained a fall and complained of pain. There was an x-ray done and resident 86 sustained a fracture. Resident 86 had poor cognition and safety awareness. There was no investigation provided by the facility to determine if there was abuse or neglect. On 2/4/26 at 12:13 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated she was unable to find an investigation into resident 86. ADM 1 stated she started as the Administrator on 6/16/25. At 12:54 PM, ADM 1 was interviewed and stated she found stacks of paper on her desk when she started and found abuse investigation paperwork. ADM 1 stated since June 2025, all abuse investigations should be in the medical record. 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included paraplegia, unspecified injury of Thoracic (T)7-T10, and post traumatic stress disorder. On 2/10/26 at 11:43 AM, an interview was conducted with resident 32. Resident 32 stated that she had an accident in the facility van. Resident 32 stated that while driving to the appointment the Transportation Driver (TD) went off the road and through a fence. Resident 32 stated that she was thrown from her wheelchair and her seatbelt was not secured properly. Resident 32 stated that she hit the armrest and sustained bruising to her ribs and then landed on the floor of the van. Resident 32 stated that the TD was drowsy while driving. Review of the facility abuse investigations revealed no documentation of the incident. On 2/11/26 at 11:07 AM, an interview was conducted with the [NAME] President of Physical Assets (VPPA). The VPPA stated that she did an investigation into the accident and sent over an incident report of the Physical Asset Dodge Caravan. It should be noted that none of the information contained in the incident report was specific to abuse or neglect. On 2/12/26 at 10:48 AM, an interview was conducted with the ADM 1. ADM 1 stated that she only had the physical asset investigation that was sent over by the VPPA. ADM 1 stated that was the only documentation on the incident. ADM 1 stated that she had no additional investigation documentation for this incident. 3. Resident 38 was admitted to the facility on [DATE] with diagnoses which included, fibromyalgia, paraplegia, muscle weakness, and spinal stenosis. The facility reported to the SSA on 1/7/25, that resident 38 reported to the Director of Nursing that their brief was not being changed when asked. There was no investigation provided by the facility to determine if there was abuse or neglect. 4. Resident 87 was admitted to the facility on [DATE] with diagnoses which included, fracture of head of right femur, cellulitis of right lower limb, and difficulty walking. The facility reported to the SSA on 12/23/24, that resident 87 reported that Certified Nursing Assistant (CNA) 4 was moving blankets around resident 87's leg and that CNA 4 hit resident 87 in the calf. Resident 87 also stated that CNA 4 tossed a remote control at her. There was no investigation provided by the facility to determine if there was abuse or neglect. 5. Resident 88 was admitted to the facility on [DATE] with diagnoses which included, left hip osteoarthritis, and acute pain. The facility reported to the SSA on 11/12/24, that resident 88 reported that during a brief change that CNA 4 hit her hand away. There was no investigation provided by the facility to determine if there was abuse or neglect. 6. Resident 91 was admitted to the facility on [DATE] with diagnoses which included paraplegia, lymphocytic leukemia, and neuromuscular dysfunction of bladder. The facility reported to the SSA on 2/12/25, that resident 91's daughter stated that resident 91's wound was not being cared for in line with doctors orders. There was no investigation provided by the facility to determine if there was abuse or neglect. 7. Resident 92 was admitted to the facility on [DATE] with diagnoses which included hydrocephalus, lymphedema, chronic pain syndrome, and generalized anxiety disorder. The facility reported to the SSA on 12/16/24, that resident 92 reported that a CNA asked resident 92 inappropriate questions while providing peri-care. There was no investigation provided by the facility to determine if there was abuse or neglect. 8. Resident 93 was admitted to the facility on [DATE] with diagnoses which included paraplegia, wedge compression fracture of T11-T12 vertebra, major depressive disorder, and suicide attempt sequela. The facility reported to the SSA on 8/1/24, that blood was observed on resident 93's sheets, with the resident stating he had intentionally cut himself. There was no investigation provided by the facility to determine if there was abuse or neglect. 9. Resident 95 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, dementia, and cerebral infarction. The facility reported to the SSA on 5/1/24, that resident 95 said her husband hit her arm during an argument while he was visiting. There was no investigation provided by the facility to determine if there was abuse or neglect. On 2/4/26 at 12:33 PM, an interview was conducted with ADM 2. ADM 2 stated there was a new system in place for all facility reported incidents (FRI). ADM 2 stated the ADM entered the FRI information into a company system where multiple people were able to look at it and provide feedback on how to investigate the allegation. ADM 2 stated he was unable to find the investigations for residents 38, 86, 87, 88, 91, 92, 93, and 95. On 2/10/26 at 11:49 AM, an additional interview was conducted with ADM 1, who stated that the facility had begun using a resource titled Investigation Timeline Tool in November 2025, which helped guide all investigations into allegations of abuse or neglect. ADM 1 outlined the standard procedure following an allegation, stating she immediately took steps to ensure resident safety, started gathering information and witness statements from all involved, and reported the incident to the SSA and other appropriate agencies within two hours. ADM 1 also detailed the protocol for staff-involved allegations, stating the staff member was immediately removed from resident care and placed on leave until the investigation was completed; and the staff member was not permitted to resume working at the facility if the allegation was substantiated. ADM 1 stated that the facility implemented interventions based on the investigation's findings and developed a follow-up plan to ensure the interventions were implemented effectively. ADM 1 stated that the corporate team reviewed the facility investigations for thoroughness, and the facility was required to submit a review of its findings to the SSA by Day 5.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, for 3 out of 46 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for a resident with a feeding tube, a resident did not have EBP signage or supplies in their room, and cross contamination occurred during lunch when staff fed a resident a sandwich with their bare hands. Resident identifiers: 1, 9, and 47. Findings included: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses which included aphasia following cerebrovascular disease, cerebral infarction, and chronic obstructive pulmonary disease. The following observations were made of resident 47: a. On 2/9/26 at 9:43 AM, resident 47 was not connected to her feeding tube. The end of the tube was not capped and was hanging around the intravenous (IV) pole. b. On 2/10/26 at 8:46 AM, Certified Nursing Assistant (CNA) 5 disconnected the feeding tube from resident 47 and hung it around the pump. CNA 5 was observed to be wearing gloves and did not place a cap on the end of the feeding tube. CNA 5 was not observed to be wearing a gown. c. On 2/10/26 at 8:53 AM, CNA 5 put on gloves and went into the bathroom and brought resident 47 to her bedside. CNA 5 was observed to pick up the feeding tube and connect resident 47 to the tube feeding. CNA 5 was not observed to be wearing a gown. d. On 2/11/26 at 9:51 AM, resident 47's feeding tube was hanging on the IV pole around the pump and was not capped. e. On 2/11/26 at 9:54 AM, resident 47 was assisted from the bathroom by the Restorative Therapy Aide (RTA). The RTA was observed to put on gloves and connect resident 47 to her feeding tube. The RTA was not observed to be wearing a gown. On 2/11/26 at 9:55 AM, an interview was conducted with the RTA. The RTA stated that she helped resident 47 back into bed and connected her feeding tube. The RTA stated that she restarted the feeding tube pump. The RTA stated that she only needed to wear gloves when assisting resident 47. On 2/11/26 at 11:16 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that she only wore gloves when she handled resident 47's feeding tube in any way. RN 3 stated that with EBP precautions she only had to wear gloves. On 2/12/26 at 9:22 AM, an interview was conducted with CNA 6. CNA 6 stated that gowns only needed to be worn for residents that had droplet precautions. CNA 6 stated that she only wore gloves when she assisted residents with tube feeds. CNA 6 stated that when she showered residents with tube feeds she just wore gloves and not a gown because she did not have to worry about being sprayed by the tube feed because it was not running. On 2/12/26 at 9:49 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that any time staff handled a tube feed they should be wearing gloves. The ADON stated that she was the Infection Preventionist at the facility and as far as she knew only gloves were required. The ADON stated that EBP signs were placed on resident doors to notify staff about what protective equipment they needed to use. The ADON stated that feeding tubes required additional protective equipment but could not recall what was needed. The ADON stated that feeding tubes should have a cap on the end when they were not in use. 2. Resident 1 was admitted to the facility on [DATE] with diagnoses which included anorexia, gastrointestinal hemorrhage, abscess of lung with pneumonia, severe sepsis, and stage three pressure ulcer of sacral region. On 2/9/26 at 9:39 AM, an observation was made of resident 1's urinary catheter. No EBP sign or supplies were observed inside or outside of resident 1's room. On 1/3/26, orders were initiated to ensure EBP were implemented every shift for resident 1's catheter and wounds. An additional observation on 2/12/26 at 9:49 AM, noted no EBP signs or supplies inside or outside of Resident 1's room. On 2/12/26 at 10:00 AM, an interview was conducted with RN 7. RN 7 stated that a resident was to be placed on EBP for an exposed line, a wound, or an infection, noting that EBP provided an extra layer of protection for both residents and staff. RN 7 stated that staff were to wear a gown and gloves if the resident's reason for EBP was exposed, and that EBP policy required a sign on the door and supplies placed in a hanging caddy within the room. An observation of resident 1's room, conducted with RN 7, revealed no EBP sign or supplies present. RN 7 stated that resident 1 should be on EBP due to his catheter. On 2/12/26 at 10:13 AM, an additional interview was conducted with RN 7. RN 7 stated that a EBP sign had been posted on resident 1's door, and the necessary supplies had been placed in his room. RN 7 stated that resident 1 had always been on EBP for his wounds, but she was unsure what had happened to the sign and supplies. 3. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of multiple sclerosis, paraplegia, dysphagia, and unspecified tremor. On 2/9/26 at 12:25 PM, an observation was made of the meal service in the main dining room. CNA 7 was observed to assist resident 9 with their lunch meal. CNA 7 picked up resident 9's French Dip sandwich and handed it to the resident. CNA 7 was observed to touch resident 9's food bare handed. CNA 7 then obtained a ham and cheese sandwich from the kitchen. CNA 7 touched resident 9's plate and lid and then touched resident 9's wheelchair armrest. CNA 7 removed half of the sandwich from a zip loc bag and handed it to resident 9. CNA 7 was observed to also touch resident 9's ham and cheese sandwich bare handed. On 2/11/26 at 12:33 PM, an interview was conducted with CNA 8. CNA 8 stated that she should never touch the resident's food barehanded and serve it to the resident. On 2/12/26 at 9:58 AM, an interview was conducted with the ADON. The ADON stated that staff should not be touching resident food items barehanded. The ADON stated that they should use utensils instead of touching the food items.

Based on observation, interview, and record review, the facility did not ensure that the resident was allowed to call for staff assistance through the call system from the resident's bed. Specifically, for 1 out of 46 sampled residents, a resident's call light was not accessible to the resident while they were in their bed. Resident identifier: 39. Findings included:Resident 39 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. On 2/10/26 at 8:48 AM, an observation was made of resident 39 in her bed. Resident 39's call light was clipped to the top of the bedsheet on the left side, out of reach of the resident's right hand. Resident 39 stated that staff were supposed to clip the call light to her shirt on the left side so she could reach it. Resident 39 stated that she had left sided paralysis. Resident 39 then pointed out the signs that were posted in her room that stated to clip the call light to her left chest. A sign was observed on the wall above the resident's head of bed and next to the sink. A grievance form dated 3/13/25, documented that resident 39's spouse called and reported that when he visited the resident on 3/5/25, the resident's call light was out of reach. The corrective actions taken were to place signs above resident 39's bed to remind staff to place the call light and phone on the resident's right side within reach. A grievance form dated 6/5/25, documented that resident 39's husband visited on 6/4/25, and resident 39's call light was out of reach. The corrective action was to replace the signs to remind staff to place the call light clipped to resident 39's left chest. On 3/28/25, resident 39 had a care plan focus area initiated for alterations in Activities of Daily Living (ADL) function secondary to cerebral vascular accident with left sided weakness. On 3/28/25, an intervention was initiated to encourage the resident to use the call light when ADL assistance was needed. On 2/12/26 at 12:36 PM, an interview was conducted with the Social Service Director (SSD). The SSD stated that there had been times that resident 39's husband had come in and found the call light not within reach and not clipped to her left shirt front. The SSD stated that when she investigated the grievance she had also found times when the call light was not within resident 39's reach. The SSD stated that she then followed up with the staff on the floor who placed the call light and nursing management then provided education on the situation. On 2/12/26 at 1:23 PM, an interview was conducted with Certified Nurse Assistant (CNA) 7. CNA 7 stated that resident 39 needed her call light to be clipped to her gown to ensure that she could reach it with her right hand. CNA 7 stated that it would not be okay to have the call light clipped to the top of the bed because resident 39 could not see it or reach it. On 2/12/26 at 1:25 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 39's call light should be within reach. The ADON stated that resident 39 had paralysis to her left side so it needed to be within reach of her right arm.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications of use; or in the presence of adverse consequences. Specifically, for 1 out of 46 sampled residents, a resident's medication was administered when it should have been held per the physician ordered parameters. Resident identifier: 2. Findings included:Resident 2 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral vascular accident, acute kidney failure, and idiopathic hypotension. Resident 2 had a physician order for furosemide Oral Tablet 20 milligram, Give 1 tablet by mouth one time a day. Hold for Systolic Blood Pressure (SBP) less than 110 or Diastolic Blood Pressure (DBP) less than 60. Resident 2's Medication Administration Record (MAR) documented that the furosemide was administered when it should have been held for low blood pressures (BP) on the following dates: 1/4/26 (BP 96/64), 1/5/26 (BP 105/65), 1/7/26 (BP 106/68), 1/8/26 (BP 94/58), 1/15/26 (BP 109/85), 1/16/26 (BP 105/70), 1/17/26 (BP 92/60), 1/20/26 (BP 100/69), 1/23/26 (BP 107/68), and 1/20/26 (BP 106/68). On 2/10/26 at 2:10 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 2's furosemide had parameters to hold if SBP was less than 110 and DBP less than 60. RN 1 stated that for any BP outside of those ranges she would hold the medication. On 2/11/26 at 10:22 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that nurses should hold medications based on the parameters, and the best practice would be to check the blood pressure again. The ADON stated that all hold parameters were documented in the MAR.

Based on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 1 out of 46 sampled residents, a resident's percutaneous endoscopic gastrostomy tube did not have the formula bag labeled with the date and time of the formula preparation, or the nurse's initials who initiated the infusion. Additionally, untrained staff were observed to stop and start the tube feeding and connect and disconnect the tube feeding. Resident identifier: 47. Findings included:Resident 47 was admitted to the facility on [DATE] with diagnoses which included aphasia following cerebrovascular disease, cerebral infarction, and chronic obstructive pulmonary disease. The following observations were made of resident 47: a. On 2/10/26 at 8:46 AM, Certified Nursing Assistant (CNA) 5 stopped resident 47's tube feeding, disconnected the tube from resident 47, and took resident 47 to the bathroom. b. On 2/10/26 at 8:53 AM, CNA 5 brought resident 47 out of the bathroom and wheeled her to the side of the bed. CNA 5 picked up the feeding tube and connected resident 47 to the feeding tube and restarted the tube feeding pump. c. On 2/10/26 at 9:00 AM, resident 47's tube feed was labeled with 2/10. d. On 2/11/26 at 9:28 AM, resident 47's tube feed was labeled with 2/10 @ [at] 1320 [1:20 PM]. e. On 2/11/26 at 9:54 AM, resident 47 was assisted into bed by the Restorative Therapist Assistant (RTA). The RTA connected resident 47's feeding tube and restarted the tube feed. On 2/11/26 at 9:55 AM, an interview was conducted with the RTA. The RTA stated that she helped resident 47 back into bed and connected her feeding tube. The RTA stated that she restarted the feeding tube pump. On 2/11/26 at 11:01 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that nurses were the only staff in the facility that were allowed to stop or start a tube feeding and to connect or disconnect a tube from a resident. RN 2 stated that tube feeds should be labeled with the date, time of administration of the tube feed, and initials of the nurse that started the tube feed. On 2/11/26 at 11:16 AM, an interview was conducted with RN 3. RN 3 stated that only nurses should be stopping or starting the feeding tube pump and connecting or disconnecting tube feeds. RN 3 stated that labels usually came with the tube feed, but she could not find them and so she labeled it with the date only. On 2/12/26 at 8:37 AM, an interview was conducted with CNA 2. CNA 2 stated that CNAs were not supposed to be touching the tube feeds or the pump. CNA 2 stated that if a resident needed to be disconnected for any reason then she would tell a nurse. On 2/12/26 at 9:03 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that CNAs should not be handling the tube feed or starting and stopping the tube feed because it was out of their scope of practice. On 2/12/26 at 9:49 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that licensed nursing staff should only be handling tube feeds and that no other staff have been trained to handle the tube feeds. The ADON stated that tube feeds should be labeled when it was opened. The ADON stated that she was unsure of what additional information was required when labeling the tube feed formula. The ADON stated that tube feed formulas should be labeled correctly to prevent errors and to ensure staff were administering at the correct time. The ADON stated that she would find out what information was required when labeling tube feed formula. Review of the Lippincott Nursing Procedures documented under Enteral Gastric, Duodenal, and Jejunal Tube Feeding for implementation to Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of who prepared, hung and checked the enteral formula against the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY-NOT FOR IV USE. Wolters Kluwer. Lippincott Nursing Procedure. Ninth Edition. Philadelphia, PA. (2023), pp 296.

Based on interview and record review, the facility did not permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the health or safety of an individual in the facility was endangered; the licensee ceases to operate the facility; the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; the transfer or discharge was appropriate because the resident's health has improved sufficiently so the resident no longer needed the services provided by the facility; or the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility. The facility did not ensure that discharged residents' medical records included documentation of the specific resident needs that could not be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs. In addition, the facility did not complete a discharge summary that included a post-discharge plan of care. Specifically, for 2 out of 46 sampled residents, a resident was discharged to an ex-spouses house after the physician had documented the resident had potential decline, the hospice nurse was unaware of the discharge, and there was no new discharge summary for the resident. In addition, there was no documentation regarding why a resident was discharged , why the facility was unable to meet her needs, and why she was not readmitted to the facility after being discharged . Resident identifiers: 83 and 94. Findings included: 1. Resident 94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included liver cell carcinoma, heart failure, and developmental disorder of scholastic skills. On 1/12/24 at 7:04 AM, a provider note stated resident 94 was recently diagnosed with liver cancer, and the oncologist told the patient he had '6-9 months to live, but closer to 6 months' according to the patient. He was admitted to hospice. He does not have a permanent place to live. He now comes to us for comfort management. On 4/11/24 at 6:15 PM, a social services note revealed resident 94's discharge plan was to continue receiving long term care at the facility and that he continues to need skilled nursing and hospice due to end of life diagnosis. On 4/28/24, an active problem titled [resident 94] current status/function requires Long Term Nursing level of care at this time was started on resident 94's care plan. The category was Discharge Plan - Long Term Care Stay. The next care conference date was 7/10/24. It should be noted that no additional information about facility discharge planning could be located in resident 94's medical record. On 5/7/24 at 10:51 AM, a provider note documented evidence of resident 94's potential decline. The note stated resident 94 reports experiencing frequent dizziness, describing it as a spinning sensation that goes from right to left. He states that he usually sits down to avoid falling when the dizziness occurs. Patient also mentions a significant loss of appetite, which he attributes to his liver cancer. Additionally, the patient complains of stomach discomfort and believes he may be experiencing acid reflux. It should be noted that this provider note did not include any reference to an upcoming facility discharge. On 5/8/24 at 9:14 AM, a hospice skilled nursing visit note showed further evidence of resident 94's potential decline. Patient reports he has only eaten one sausage patty in 2 days because he has no appetite and food makes him sick. He reports the right side of his abdomen has been hurting so bad it brings tears to his eyes and he rated that pain at an 8/10. That is new as of this week. He reports feeling so weak he doesn't feel safe going on walks around the building anymore like he used to. It should be noted that this hospice note did not include any reference to an upcoming facility discharge. On 5/15/24 at 9:04 AM, a hospice skilled nursing visit note documented additional evidence of resident 94's potential decline. Decline noted as evidenced by increasing pain and weakness. Patient was ambulating down the hall with a cane today. He normally doesn't use any DME [Durable Medical Equipment] to ambulate but he said he's been feeling weaker and more unsteady lately. He reports the headaches are at a 10/10 intermittently throughout the day and night. Staff report he's asking for morphine every hour as well. Nurse palpated his upper abdomen today and right side is firm and abdomen distended. Nurse observed face and eyes were mildly jaundiced today. Patient reports having more nausea and he's thrown up at least once daily for the past week. He isn't eating more than 25% of 1 meal daily now when he used to eat 100% of 3 meals. It should be noted that this was the morning that resident 94 was discharged from the facility, and that this hospice note did not include any reference to an upcoming facility discharge. On 5/15/24 at 11:21 AM, a hospice chaplain visit note revealed the first mention in resident 94's medical record that the facility initiated his discharge. [Resident 94] said he's being asked to leave the facility but doesn't know where he is going yet. I listened and gave emotional support. I spoke with hospice director and she said living arrangements are being made for him. On 5/15/24 at 3:57 PM, a document titled Transition of Care/Discharge Summary was printed. The discharge summary provided an admit date of 1/12/24, and a discharge date of 5/12/23. [Note: the discharge date for resident 94's 1/12/24 admission was 5/15/24.] The document stated that resident 94's discharge destination was his Recreational Vehicle (RV) with home health services. The discharge goal was resident 94 would continue to get stronger with the home health services. All wet ink signatures on the discharge summary were dated on 5/15/24 at 4:45 PM. The document did not contain information about hospice services. On 5/15/24 at 5:18 PM, a nursing progress note documented [Resident 94] had discharge teaching done and all questions answered. [Resident 94] left in private vehicle with personal belongings. [Resident 94] also had 3 days supply of medications sent with him. On 5/17/24 at 9:53 AM, a hospice communication note documented Nurse was notified this morning that patient is on LOA [leave of absence] and staying at his ex-wife's home currently. On 2/5/26 at 11:45 AM, an interview was conducted with the Social Services Director (SSD). The SSD stated a welcome meeting is held upon a resident's admission to the facility, during which work on the discharge plan begins. The SSD stated she would evaluate whether a resident needs long-term care, assisted living, or independent living, along with any concerns about returning to the community. The SSD stated that she requested a day or two of notice to set up home health or DME, arrange transport, and ensure the team had verified there were no factors that would keep the resident at the facility. The SSD stated that after arrangements had been made she would e-mail nursing so they could prepare for the day of discharge, such as sending prescriptions to the pharmacy, and confirming home health was set up. According to the SSD, resident 94 was very independent, had a terminal diagnosis, and had become threatening to staff and residents, but stated she did not know the specifics, other than he disliked his roommate and let staff know. The SSD stated resident 94 was not given a 30 day discharge notice, and she was not sure why a resident who was documented as declining would be discharged . It should be noted that following the social services note from 4/11/24, referenced prior, which indicated resident 94 was to continue receiving long-term care at the facility, five progress notes documented aggressive behaviors towards staff or residents from resident 94 on 4/27/24, 5/12/24, 5/13/24, and 5/14/24. A review of resident 94's care plan revealed no active problems or interventions related to aggressive behaviors. The provider note from 5/7/24, referenced prior, did not document any concerns regarding aggressive behaviors. A review of resident 94's medical record from 4/11/24 to 5/15/24, revealed no documentation of the hospice provider being contacted regarding behavioral concerns, no medication adjustments to manage those concerns, and no room changes during this time. On 2/9/26 at 1:49 PM, an interview was conducted with the Hospice Director. The Hospice Director stated that resident 94's hospice medical record did not have any information of a planned facility discharge prior to the hospice chaplain note on 5/15/24. On 2/12/26 at 1:05 PM, an additional interview was conducted with the SSD, who stated hospice records indicate resident 94 was discharged to his ex-wife's home. The SSD stated she did not complete the Transition of Care/Discharge Summary document and was unsure why the discharge destination was his RV. The SSD stated that resident 94's original care plan was to remain in the facility and receive long term care. The SSD stated that she was not involved in the process of discharging resident 94, and that it was not normal for her to be uninvolved. The SSD stated that if a resident leaves Against Medical Advice (AMA) the nurses educate the resident about safety risks, have the resident sign paperwork, and if possible notify the SSD so she can set up the appropriate community services. The SSD stated she was unsure if resident 94 left AMA. On 2/12/26 at 1:32 PM, an interview with Administrator (ADM) 1. ADM1 stated that she was not employed at the facility during the time of resident 94's discharge. ADM 1 stated that resident 94's ex-wife informed ADM 1 that following Resident 94's discharge from the facility, he resided at the ex-wife's home for approximately one month before moving to his sibling's home, where he subsequently passed away. On 2/12/26 at 1:51 PM, an interview was conducted with the Regional Social Work Director (RSWD), who stated that after record review she determined that resident 94 had a previous discharge on [DATE], when he was discharged to his RV with home health services. RSWD stated that staff failed to follow the discharge process for Resident 94's 5/15/24 discharge because they used the discharge summary from 5/12/23. The RSWD stated that because the discharge process was not followed the facility did not coordinate the discharge with the hospice nurse and a new discharge summary was not created to indicate an accurate location of where the resident planned to reside. 2. Resident 83 was admitted to the facility on [DATE], discharged to the hospital and readmitted on [DATE] and discharged on 8/27/25 with diagnoses which included diffuse traumatic brain injury (TBI) with loss of consciousness, spastic hemiplegia, major depressive disorder, paraplegia, antisocial personality disorder and suicidal ideations. Resident 83's medical record was reviewed 2/4/26. A nursing progress note dated 8/27/25 at 1:49 PM revealed, Pt [patient] was outside of another pt's room and was using vulgar language towards other pt. Nurse removed pt from situation and discussed taking space from neighbor. Pt was visibly upset about situation but verbalized understanding. Within 2 minutes pt was back outside of neighbors door, this time with an elevated voice. Nurse removed pt from doorway and pt proceeded to kick her chair backwards towards nurse. Pt began to hit nurse with plastic gum packet in her hand. Nurse assisted pt outside to allow her some fresh air and remove her from potential triggers. Pt and nurse had a conversation outside and pt calmed down. Pt expressed her frustrations and stated she would stay away but she needed to go to the bathroom. Nurse brought pt back in building and immediately pt began using vulgar language again and calling all the staff 'fucking bitches.' Pt began to hit staff repeatedly and attempted to tip her wheelchair back. Pt threw plastic gum package at different nurse. DON [Director of Nursing] arrived and pt agreed to go talk privately with her. A Discharge summary dated [DATE] revealed that resident had physical aggression, verbal aggression, unable to manage by staff, history of suicidal ideation. There was no documentation from resident 83's physician regarding why the facility was unable to care for the resident and what interventions were tried. On 2/5/26 at 9:38 AM, an interview was conducted with the Restorative Therapy Aide (RTA). The RTA stated resident 83 was agitated and aggressive with staff. The RTA stated resident 83 was sent to the hospital because she hurt staff, threw glass dishes at staff, and punched staff. The RTA stated staff were afraid to work with resident 83. On 2/5/26 at 11:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 83 was blue sheeted (involuntarily committed) to a local hospital because she was very aggressive and hit a Certified Nursing Assistant in the face. The ADON stated the DON and psychiatric nurse took the resident into the parking lot and worked on deescalating her but were unable to. The ADON stated the facility did not feel residents or staff were safe if resident 83 returned to the facility. On 2/5/26 at 11:45 AM, an interview was conducted with the SSD. The SSD stated prior to a resident being admitted to the facility, central intake will review all the information to determine if the resident is the right fit for the facility. The SSD stated resident 83 was blue sheeted to a local hospital because of physical aggression to staff and hurting staff. The SSD stated the mobile crisis unit was unable to deescalate resident 83.The SSD stated resident 83 was wrapping things around her neck really tightly in an attempt to commit suicide. The SSD stated resident 83 had been sent to the hospital for aggression and was readmitted to the facility but continued to have outbursts. The SSD stated police were called and the physician was involved with the discharge. The SSD stated resident 83 was not safe to readmit to the facility and it would have put staff and residents in harm's way. On 2/5/26 at 12:21 PM, an interview was conducted with ADM 1. ADM 1 stated resident 83 had a TBI and would get belligerent with her words. ADM 1 stated resident 83 was very aggressive to staff and made a suicide attempt when she was blue sheeted to the hospital. ADM 1 stated she had been readmitted to the facility after a hospital stay, but was blue sheeted again because she was aggressive, hitting staff, throwing things, trying to wrap things around her neck, and yelling. ADM 1 stated the facility chose not to take her back because she was a danger to herself and staff. ADM 1 was unable to provide documentation from the physician on why the resident was discharged , why the facility was unable to meet her needs, what interventions were tried, and why she was not readmitted to the facility after being discharged .

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately to the State Survey Agency (SSA). Specifically, for 1 out of 46 sampled residents, a resident was involved in a motor vehicle accident that resulted in injuries while being transported in the facility vehicle and the incident was not reported to the SSA. Resident identifier: 32.Findings included: Resident 32 was admitted to the facility on [DATE] with diagnoses which included paraplegia, unspecified injury of Thoracic (T)7-T10, and post traumatic stress disorder. On 2/10/26 at 11:43 AM, an interview was conducted with resident 32. Resident 32 stated that she had an accident in the facility van. Resident 32 stated that the Transportation Driver (TD) was late to pick her up for the scheduled appointment. Resident 32 stated that while driving to the appointment the TD went off the road and through a fence. Resident 32 stated that she was thrown from her wheelchair and her seatbelt was not secured properly. Resident 32 stated that she hit the armrest and sustained bruising to her ribs and then landed on the floor of the van. Resident 32 stated that the TD was drowsy while driving. Review of the facility abuse investigations revealed no documentation of the incident, and no documentation could be found that the incident was reported to the SSA. On 2/11/26 at 11:07 AM, an interview was conducted with the [NAME] President of Physical Assets (VPPA). The VPPA stated that she did an investigation into the accident. The VPPA stated that she did not report the incident to the SSA and she was not sure if the Director of Nursing or the Administrator had reported it. On 2/12/26 at 10:48 AM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated that she only had the physical asset investigation that was sent over by the VPPA. ADM 1 stated that was the only documentation on the incident. ADM 1 stated that she had no additional investigation documentation for this incident and it did not appear that it was reported to the SSA. [Cross-refer F689]

Based on observation, interview, and record review, the facility did not ensure that medication error rates were not five percent or greater. Observations of 25 medication opportunities on 5/8/24, revealed four medication errors which resulted in a 16% medication error rate. Specifically, for 4 out of 28 sampled residents, medications that were supposed to be taken at least 30 minutes before meals were given to the residents after they had consumed a meal. Resident identifiers: 23, 33, 51, and 69. Findings included: 1. On 5/8/24 at 8:36 AM, an observation was made of Registered Nurse (RN) 3 during morning medication administration on the north west hallway. RN 3 was observed to give pantoprazole 40 milligrams (mg) to resident 23 after he had eaten breakfast. On 5/8/24 at 8:38 AM, an interview was conducted with RN 3. RN 3 stated that resident 23 preferred to take his medications after breakfast. RN 3 stated that she did not know if resident 23's preference for taking medications after meals was known by others or written in the medical record. RN 3 stated that she knew resident 23's medication preference because she had been his nurse before. RN 3 stated that the doctor's order was to take the pantoprazole on an empty stomach at least 30 minutes before meals. 2. On 5/8/24 at 8:40 AM, an observation was made of RN 3 during morning medication administration on the north west hallway. RN 3 was observed to give gabapentin 600 mg to resident 51 after she had eaten breakfast. The medication directions stated to give before meals and at bedtime. On 5/8/24 at 8:41 AM, an interview was conducted with RN 3. RN 3 stated that resident 51 was often times hard to find in the morning. RN 3 stated that the order for gabapentin was to be given before meals and at bedtime. RN 3 stated that she tried to give the gabapentin before breakfast, but could not locate the resident in the mornings a lot of the time and gave the medication to resident 51 when she located her even if the resident had eaten a meal. 3. On 5/8/24 at 8:50 AM, an observation was made of RN 3 during morning medication administration on the north west hallway. RN 3 was observed to give metoclopramide 5 mg to resident 33 after the resident had eaten breakfast. On 5/8/24 at 8:53 AM, an interview was conducted with RN. RN 3 stated that the order for the metoclopramide was that it should be given before meals. RN 3 stated that she should have given metoclopramide before resident 33 ate breakfast. 4. On 5/8/24 at 9:08 AM, an observation was made of RN 3 during morning medication administration on the south east hallway. RN 3 was observed to give omeprazole 20 mg to resident 69 after the resident had eaten breakfast. On 5/8/24 at 9:10 AM, an interview was conducted with RN 3. RN 3 stated that all medications that have orders to be given before meals must be given to residents before they eat. On 5/8/24 at 11:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was nothing charted in the medical record that showed a resident's preferred schedule regarding medications and when the resident received them. The DON stated that all nurses need to follow what the doctor's orders were for giving medications. The DON stated that medications that were supposed to be taken before meals, need to be given to residents before meals. The DON stated if medications that need to be given prior to meals were routinely given after residents have eaten a meal, then the doctor's orders need to be updated to reflect this.

Based on observation, interview, and record review, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 3 out of 28 sampled residents, resident rooms had cracked and broken drywall, peeling paint, a door handle that sticks, and a loose toilet. Resident identifiers: 18, 24, and 37. Findings included: On 5/6/24 at 10:17 AM, an interview was conducted with resident 37. Resident 37 stated that he had to tape a large hole in his wall to close the hole. Resident 37 stated that the toilet in the bathroom was wobbly and moved around when he tried to use it. Resident 37 stated that the door handle in his room would get stuck and it was hard to open the door. Resident 37 stated that he had spoken with the Maintenance Director about the issues in the room, but nothing was ever fixed. Resident 37 stated that he believed the Maintenance Director did not want to fix anything in his room because the Maintenance Director did not like the resident. On 5/6/24 at 10:20 AM, an observation was made of resident 37's room. Resident 37's room had a large hole in the wall near the bed that was taped with blue tape, paint chipped on multiple walls, the toilet was loose and moved easily from side to side, and the door handle was difficult to use. On 5/6/24 at 10:54 AM, an observation was made of resident 24's room. Resident 24's room had paint and drywall that was chipped and peeling near the bathroom door. On 5/6/24 at 11:43 AM, an interview was conducted with resident 18. Resident 18 stated the walls and cabinets in the room were beat up. Resident 18 stated the Formica on the door entering the room was torn off in places. Resident 18 stated that his roommate did that to the wall, the door, and the cabinet. Resident 18 stated his roommate was always in a hurry and not happy. An observation was made of resident 18's room. Resident 18's room had paint and drywall peeling from the walls near the sink and bathroom. The main door was missing pieces of Formica and the cabinets were chipped. On 5/8/24 at 10:26 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that in most situations he was notified of maintenance issues through the work order lists that were hung near the lobby. The Maintenance Director stated that in some circumstances he found out about maintenance issues through audits of the resident rooms whenever he was in rooms of residents. The Maintenance Director stated that for resident 18's room, he needed to provide a cover for the nightlight that needed to be secured. The Maintenance Director stated that the call light cord needed to be secured to the wall. The Maintenance Director stated that the room required patches to the drywall, paint to the walls, and possibly a guard to the area that had been run into a lot by wheelchairs. The Maintenance Director stated that he was unsure about the time frame as to when these items would be repaired as he was still figuring out what products were required to fix them. The Maintenance Director stated that he had known about resident 37's maintenance needs for about a month and that resident 37 could be difficult to work with. The Maintenance Director stated that the hole in the wall needed to be patched and could be a quick repair. The Maintenance Director stated that the hole in the wall and the door latch would probably take about a week to repair. The Maintenance Director stated resident 37's toilet closet flange was rusted completely out and needed to be replaced. The Maintenance Director stated the toilet was secured to the ground, but did move around. The Maintenance Director stated that he was unsure of the timeframe that he would begin to work on the repairs due to the clutter in resident 37's room. On 5/8/24 at 10:59 AM, an interview was conducted with the Administrator (Admin). The Admin stated that he had not heard that resident 37's room needed multiple repairs. The Admin stated that there was not a specific time frame for maintenance items to be completed unless it was an emergent electrical or water issue that would jeopardize resident safety. The Admin stated that there was a work order log near the lobby where items that needed to be addressed were submitted. The Admin stated that if the repairs were related to fixing or painting walls, that this could take up to a week to be completed. The Admin stated that nothing should take over a month to be addressed and fixed by maintenance. 33215

Based on observation, interview, and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 28 sampled residents, a resident was not administered their supplement for wound healing and increased protein needs as ordered by the physician due to the supplement not being available. Resident Identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, infection and inflammatory reaction due to internal left knee prosthesis, acute embolism and thrombosis of deep veins of lower extremity, type 2 diabetes mellitus without complications, muscle weakness, endocarditis, paroxysmal atrial fibrillation, and peripheral vascular disease. Resident 18's medical record was reviewed on 5/9/24. On 4/4/24 at 7:35 AM, a Dietary progress note documented . Will recommend medpass 1.7 60ml [milliliters] TID [three times a day] or liquacel 30ml BID [two times a day] per res [resident] desire. Will contiue [sic] to monitor via monthly weights. On 4/4/24 at 3:47 PM, a Dietary progress note documented Spoke w [with] pt [patient] about increasing protein consumption. Pt is pleased with cottage cheese and Greek yogurt and would like to continue. Dietitian asked Dietary Director to ask pt about med pass or liquacel for additional protein supplement. Dietary Director gave pt samples of both and pt decided he wanted liquacel. Dietary Director informed pt he would get it 2x [times] a day. Pt seemed pleased with outcome and would also like the in house milkshakes on occasion. Dietitian/nursing to follow up on orders. On 4/17/24 at 8:31 AM, a Nursing progress note documented New order per NAR [Nutrition At Risk]. Liquacel 30 mL daily for supplement. [Note: The recommendation per the Dietary progress note dated 4/4/24 at 7:35 AM, was Liquacel 30 ml BID.] The April and May 2024 Medication Administration Record were reviewed. The following order dated 4/18/24, documented Liquacel (amino acids-protein hydrolys) liquid; 16-100 gram-kcal [kilocalorie] /30 mL; Amount to Administer: 30 mL; oral once a day. The following were documented regarding the Liquacel. a. On 4/25/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. b. On 5/5/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. c. On 5/6/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable Comment: pharmacy notified. d. On 5/7/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. On 5/9/24 at 11:09 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated when there were five or six pills left for the resident she would first double check that there were not some already stocked at the facility. RN 4 stated she would then pull the tab on the medication card, add it to the refill order form, and fax the form to the pharmacy. RN 4 stated if there was not a tab on the medication card she would make a note and call the pharmacy for the refill. RN 4 stated that sometimes it was hard to get certain medications from the pharmacy timely but it was usually an insurance issue. RN 4 stated the pharmacy was usually good at delivering. RN 4 stated there was a different pharmacy for hospice residents and they were really good. RN 4 stated the Liquacel was ordered with the over the counter (OTC) medications, Central Supply ordered the Liquacel, and the Liquacel was stored in the medication room. RN 4 stated that the Transportation staff member ordered the Liquacel. RN 4 stated when the staff were low on the Liquacel she would fill out a form and add the item to the list for Central Supply to order. RN 4 stated if the staff were out of the Liquacel and they needed it, Central Supply would just go and grab it. An observation was conducted of the medication room with RN 4. There was no Liquacel observed in the medication room. Liquacel was observed on the list to be ordered. On 5/9/24 at 11:22 AM, an interview was conducted with the Transportation Director (TD). The TD stated that she was the staff member that ordered OTC medications and she had just started working central supply. The TD stated there was a paper in the medication room where staff could write down the OTC medications that were out. The TD stated that every Friday she would review the list and the list would be sent out on Monday by noon. The TD stated she would keep the past order and ask the Director of Nursing (DON) if there were any extra supplies that needed to be ordered. The TD stated she would also ask the Certified Nursing Assistants and the nurses if she was missing anything that needed to be ordered or if she needed to order more of something. The TD further stated if the staff saw her in the hallway they could inform her of items they needed and she would write it on the list. The TD stated the Liquacel was something that she ordered OTC but she had not had to order the Liquacel as of yet. The TD stated if she had problems getting items she would call the representative with the supply company to see if they could get the item sooner or a replacement. The TD stated the items ordered on Monday would be at the facility on Tuesday. The TD stated that sometimes there was a delay on some items. The TD stated the supply company would let her know if items were delayed and sometimes the representative would get the item to her as soon as possible and would overnight items if needed. On 5/9/24 at 12:57 PM, an interview was conducted with the Registered Dietician (RD) and the Dietary Director (DD). The RD stated that resident 18 was started on the Liquacel for wound healing. The RD stated she wanted to make sure resident 18 was getting adequate protein for wound healing. The DD stated that the Liquacel was ordered through a supply company as an OTC product. The RD clarified that the Liquacel order should have been BID. The RD stated she would go through the NAR meeting notes, she would list the dietary recommendations for the team, and then she would email the recommendations to the team. The RD stated that the DON, Unit Manager, DD, and the Administrator attended the NAR meetings. The RD stated that after the NAR meeting on 4/4/24, the DD spoke with resident 18 regarding the supplement. The RD stated that her recommendation for the supplement on 4/4/24, was an order pending because she gave resident 18 the choice of Med Pass or Liquacel. On 5/9/24 at 1:10 PM, an interview was conducted with the DON. The DON stated that in order to refill a medication the staff were to pull the tag off the medication card and put it on the refill list, check to ensure the medication was not somewhere in the facility, and fax the refill list to the pharmacy. The DON stated if the medication was out the facility had an emergency medication system. The DON stated if the medication needed was not in the emergency medication system the staff were to call the pharmacy to see when the medication would be delivered. The DON stated that she had access to the orders and she could see if the medication was actually delivered. The DON stated that Liquacel was OTC and Central Supply ordered the Liquacel. The DON stated if the staff were running low the staff would write it on the list and Central Supply ordered weekly. The DON stated that Liquacel came in a case of eight bottles. The DON stated that dietary recommendations were passed on verbally in the NAR meeting and discussed with the Physicians Assistant. The DON stated that the Unit Manager would input the orders. On 5/9/24 at approximately 1:10 PM, a follow up interview was conducted with RN 4. RN 4 stated that resident 18 was taking the Liquacel and then two days in a row resident 18 had refused the Liquacel because of diarrhea. RN 4 stated the facility did not have Liquacel on Monday, but she gave resident 18 Metamucil instead.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 28 sampled residents, a resident with a respiratory illness experienced a delay in getting their illness treated timely. Resident Identifier: 43. Findings Included: Resident 43 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, dementia, gastro-esophageal reflux disease without esophagitis, major depressive disorder, morbid severe obesity due to excess calories, and asthma. On 5/6/24 at 2:12 PM, an interview was conducted with resident 43's Family Member (FM). The FM stated resident 43 had not been feeling well since Friday. The FM stated the doctor should have been made aware of resident 43's condition a lot sooner than today. The FM stated the Director of Nursing (DON) had been made aware of resident 43's condition over the weekend. The FM stated when the DON had come in to evaluate resident 43 today, they had been unaware of how bad resident 43 was doing. The FM stated over the weekend resident 43 had only been given nasal spray and Mucinex to help with their symptoms. The FM stated once the doctor had seen resident 43, they had ordered a chest x-ray, a breathing treatment, and they had put resident 43 on oxygen. The FM stated resident 43 should have been treated sooner. Resident 43's medical record was reviewed on 5/7/24. On 4/8/24, an annual Minimum Data Set assessment documented resident 43 had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. An as needed physician order with a start date of 1/29/23, documented as followed, albuterol sulfate HFA [hydrofluoroalkane] aerosol inhaler; 90 mcg [micrograms]/actuation; amt [amount]: 2 puffs; inhalation. This was ordered for wheezing or shortness of breath. An as needed physician order with a start date of 1/29/2023, documented as followed, fluticasone propionate [OTC] [over the counter] spray, suspension; 50 mcg/actuation; amt: 1 spray; nasal. This was ordered for nasal congestion. Resident 43's May 2024 Medication Administration Record (MAR) was reviewed and documented that the following as needed medications were given: a. On 5/3/24 at 4:20 PM, fluticasone nasal spray due to congestion. b. On 5/4/24 at 7:13 AM, fluticasone nasal spray and the albuterol inhaler due to congestion. c. On 5/5/24 at 11:23 PM, albuterol inhaler due to cough. On 5/4/24, A Long-Term Weekly Assessment documented that resident 43's respiratory assessment was within normal limits, on room air, and no shortness of breath was noted. On 5/5/24 at 3:39 PM, resident 43's oxygen saturation was documented to be 89%. [Note: No documentation was located to indicate any interventions were put in place to help with resident 43's low oxygen level.] On 5/6/24 at 10:34 AM, a nurses note documented, pt. [patient] was experiencing labored breathing with c/o [complaint of] SOB [shortness of breath]. O2 [oxygen] sats [saturations] were taken and pt. was at 80% on RA [room air]. PA [Physician Assistant], DON, UM [Unit Manager], and family notified of this change in condition. new orders for albuterol nebulizer q6h [every 6 hours] x [for] 10 days, cbc [complete blood count], cmp [complete metabolic panel], and chest XR [x-ray]. pt. is now on 3L [liters] of O2 and is maintaining > [greater than] 90%. nebulizer tx [treatment] was effective and pt. reported that they were able to breathe better. On 5/7/24 at 4:54 AM, a nurses note documented, Resident continues to receive scheduled nebulizer treatments during the night with an occasional cough present. SOB observed with pt having to be reminded to keep oxygen 3L NC [nasal cannula] in place and HOB [head of bed] elevated multiple times. Pt has been alert and able to make needs known. Chest x-ray still waiting to be taken. Fluids encouraged and call light within reach. On 5/7/24 at 2:02 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 43 had come down with something pretty fast in the last few days. LPN 1 stated they believed resident 43 started to feel unwell on Saturday and that they were fighting a cold. LPN 1 stated something was going on with resident 43's lungs right now. LPN 1 stated they believed the physician assistant had come in yesterday. LPN 1 stated the PA had ordered labs and a chest x-ray. LPN 1 stated that resident 43 had been complaining of a stuffy nose and chest tightness for a couple of days. LPN 1 stated they had given resident 43 an inhaler over the weekend and stated resident 43 indicated the inhaler had helped their symptoms. LPN 1 stated that resident 43's vitals had remained within limits and there was nothing to indicate it was anything more than a cold. On 5/7/24 at 2:21 PM, an interview was conducted with the DON. The DON stated there was a phone call they had received around midnight on Saturday night. The DON stated the nurse called them because they were concerned about a few residents due to cold symptoms. The DON stated they remembered the nurse mentioning a few resident names and they were unsure if resident 43's name was mentioned. The DON stated when staff called the on call person, the purpose of the phone was to help guide the nurse on the next steps they needed to take. The DON stated there were standing orders the nurses were able to use. The DON stated they were never called again so they assumed everything was fine. The DON stated when they came in on Monday, they saw resident 43 and notified the physician assistant that resident 43 sounded like crap. The DON stated the physician assistant did their assessment and put orders in place after seeing how resident 43 was doing. On 5/8/24 at 1:17 PM, a telephone interview was conducted with LPN 2. LPN 2 stated resident 43 had a cough on Sunday. LPN 2 stated resident 43 presented the same as any other day they had taken care of them. LPN 2 stated vitals were obtained twice a day unless they needed to get more. LPN 2 stated nurses reviewed vitals once the Certified Nursing Assistants had obtained them and if any vitals were outside of parameters the nurse personally rechecked them. LPN 2 stated a doctor's order was needed before a resident was put on oxygen since it was considered a medication. LPN 2 stated they had not been made aware of resident 43's oxygen level being at 89%. LPN 2 stated resident 43's oxygen baseline was in the 90's. LPN 2 stated if a resident was not at their baseline, then check on the resident and assess if they were feeling okay. On 5/8/24 at 2:56 PM, a telephone interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 43 had complained of having a cold and a sore throat and told them they need to talk to the provider because they felt like they were going to die. RN 2 stated they had done an assessment on resident 43 and every thing had checked out fine. RN 2 stated they had assured resident 43 there were no signs of immediate death. RN 2 stated they told resident 43, the provider would be in on Monday to see them. RN 2 stated they had called the DON at around 11:30 PM, on Saturday night and informed the DON about their concern about a few residents having cold symptoms such as coughs and sore throats. RN 2 stated they had mentioned resident 43's name to the DON and notified the DON that they were not feeling well. RN 2 stated they were concerned about a Coronavirus Disease 2019 outbreak and needed guidance on what to do for those residents. RN 2 stated vitals were obtained about twice a day, once during the day and once at night. RN 2 stated when vitals were outside of parameters such as a low oxygen saturation, first they tried nonpharmacological interventions such as deep breathing exercises and repositioning in bed and then they rechecked the oxygen saturation. RN 2 stated if the oxygen saturations were still low, then they notified the provider. RN 2 stated resident 43's vitals were within normal limits on Saturday. RN 2 stated resident 43 had sounded nasally but their lungs and heart sounded fine. On 5/9/24 at 7:52 AM, a follow up interview was conducted with the DON. The DON stated the nurses reviewed all the vitals once they were obtained by the certified nursing assistants. The DON stated if a vital was outside of parameters, they expected staff to check on the resident and re-take the vitals. The DON stated if a resident's oxygen was below 90%, there was a standing order in place for oxygen. The DON stated if a resident was put on oxygen then staff needed to make the physician and the DON aware and it was considered a change of condition. The DON stated looking at resident 43's oxygen saturation on Sunday afternoon, it appeared they had done nothing about resident 43's low oxygen saturation. The DON was unable to locate any documentation to indicate any interventions had been put in place to help with resident 43's low oxygen saturation.

Based on observation, interview, and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 28 sampled residents, a resident that had a recommendation for Liquacel twice a day (BID) for wound healing and increased protein needs had the Liquacel order implemented daily and the Liquacel was unavailable for four administrations. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, infection and inflammatory reaction due to internal left knee prosthesis, acute embolism and thrombosis of deep veins of lower extremity, type 2 diabetes mellitus (T2DM) without complications, muscle weakness, endocarditis, paroxysmal atrial fibrillation, and peripheral vascular disease. Resident 18's medical record was reviewed on 5/9/24. A care plan problem with a start date on 1/26/24, documented Category: Nutritional Status [resident 18] is at risk for nutritional deficits r/t [related to] increased energy needs for healing. The goal included, [Resident 18] will not experience any untreated weight variances through next review. The interventions included: a. Offer supplements and double portions. b. Dietitian/Nutritional assessment or evaluation, as needed. c. Honor food preferences. d. Provide assistance with meals, as needed. e. Provide diet and snacks as prescribed. f. Weight monitoring as prescribed. On 2/2/24 at 7:19 PM, a Dietary progress note documented Res [resident] admitted with surgical wound to knee and on ABX [antibiotic] for MRSA [Methicillin-resistant Staphylococcus aureus]. Hx [history] of depression. homeless, meth use, T2DM, knee infection. Admit wt [weight] of 296# [pounds] with BMI [body mass index] of 31-obese. BG [blood glucose] ~150mg/dL [milligrams per deciliter] and A1C [blood test to diagnosis diabetes] of 7.8H [high]. Res is able to make needs known no issues chewing/swallowing. He desires to eat in his own room. Skin is intact. Res with increased energy needs for healing and IBW [ideal body weight] is 208-285# ~3000kcals [kilocalorie] and ~150g [grams] protein daily. Res is eating well and has requested large portions. Res not available to speak to today. RD [Registered Dietician] to offer additonal [sic] protien [sic] food sources or offer house supplement. Will attempt again x 7 days. diet order: CCHO [consistent carbohydrate diet] with ~88% PO [by mouth]. Diet order is appropriate and with increased energy needs PO is possibly not meeting estimated energy needs. Will order supplement if res consents. Kitchen to serve double portions. Will follow per weekly wts [weights] and discuss in NAR [Nutrition at Risk] Res at moderate risk for malnutrition r/t PMH [poor medical history], poor mobility, inadquate [sic] oral intake. Supplement order pending. On 2/23/24 at 6:51 AM, a Physicians Assistant (PA) progress note documented . Patient also states he wonders if he is getting enough protein. He states supplementation has been considered, but he feels he is 'nearly 300 pounds' and may not be getting enough protein. Appreciate dietary recommendations for appropriate protein intake. On 4/4/24 at 7:35 AM, a Dietary progress note documented Monthly High Risk Nutritional Assessment Pertinent Diagnosis: T2DM, chronic wound Current wt/BMI: 282# / 30 Admit wt: 292# UBW [usual body weight]: ~290# Wt trends: wt trending down slightly but no significant wt changes x 4 months . Supplement/MVI [multi vitamin]: MVI Allergies: none Medication with nutritional implications: metformin, vitamin C Pertinent labs: BG ~110mg/dL Skin integrity: diabetic ulcer UST [unstageable] on heel . Estimated energy needs: 3182-3818 kcals // 165g protein // 3818 ml [milliliters] fluid Intervention/discussion: Res with wt trending down slightly and very elevated kcal/protein needs. Res has been eating well and wound is stable but current energy needs are likely not met for wound healing. Will recommend medpass 1.7 60ml TID [three times a day] or liquacel 30ml BID per res desire. Will contiue [sic] to monitor via monthly weights. On 4/4/24 at 3:47 PM, a Dietary progress note documented Spoke w [with] pt [patient] about increasing protein consumption. Pt is pleased with cottage cheese and Greek yogurt and would like to continue. Dietitian asked Dietary Director to ask pt about med pass or liquacel for additional protein supplement. Dietary Director gave pt samples of both and pt decided he wanted liquacel. Dietary Director informed pt he would get it 2x a day. Pt seemed pleased with outcome and would also like the in house milkshakes on occasion. Dietitian/nursing to follow up on orders. On 4/12/24 at 7:35 AM, a PA progress note documented . Patient expressed to me several frustrations today. He is worried about numbness/tingling in this pinky fingers and part of ring fingers bilaterally. He is worried this is peripheral neuropathy and it indicates his diabetes is not under control. He is concerned about his diet, that it is not 'diabetic' and he is not getting enough protein. He understands he can't have it exactly like he had it at home, but seems very anxious about his upcoming surgery and having the best outcome. He feels frustrated that it feels to him when he has an issue, it is fixed for 'a few days, then it goes back to the way it was.' He does feel like he is concerned we can't 'meet his needs' here, and is thinking he wants to go to another facility. He states his upcoming surgery is scheduled on 5/20 [24]. On 4/17/24 at 8:31 AM, a Nursing progress note documented New order per NAR [Nutrition At Risk]. Liquacel 30 mL daily for supplement. [Note: The recommendation per the Dietary progress note dated 4/4/24 at 7:35 AM, was Liquacel 30 ml BID.] On 5/7/24 at 8:55 AM, a Dietary progress note documented NAR meeting; wound status Pertinent Diagnosis: T2DM, chronic wound Current wt/BMI: 282# / 30 Admit wt: 292# UBW: ~290# Wt trends: -6.8% x 3 months (not significant) . Pertinent labs: BG ~125mg/dL Skin integrity: multiple diabetic ulcers to LE [lower extremity] x4; chronic . Estimated energy needs: 3182-3818 kcals // 165g protein // 3818 ml fluid Intervention/discussion: liquacel started BID to provide ~30g protein daily. PO is ~88% with cottage cheese and greek yogurt offered daily for additional protein as well. Res has refused Liquacel a few times. Will speak with res on 5/9/24 to update diet/supplement preferences. Current PO and supplement is likely meeting estimated energy needs. Will continue to follow per monthly weights. The April and May 2024 Medication Administration Record were reviewed. The following physician's order dated 4/18/24, documented Liquacel (amino acids-protein hydrolys) liquid; 16-100 gram-kcal/30 mL; Amount to Administer: 30 mL; oral once a day. The following were documented regarding the Liquacel. a. On 4/25/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. b. On 5/5/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. c. On 5/6/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable Comment: pharmacy notified. d. On 5/7/24 at 6:00 AM to 10:00 AM, Not Administered: Drug/Item Unavailable. On 5/9/24 at 11:09 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated when there were five or six pills left for the resident she would first double check that there were not some already stocked at the facility. RN 4 stated she would then pull the tab on the medication card and add it to the refill order form and fax the form to the pharmacy. RN 4 stated if there was not a tab on the medication card she would make a note and call the pharmacy for the refill. RN 4 stated that sometimes it was hard to get certain medications from the pharmacy timely but it was usually an insurance issue. RN 4 stated the pharmacy was usually good at delivering. RN 4 stated there was a different pharmacy for hospice residents and they were really good. RN 4 stated the Liquacel was ordered with the over the counter (OTC) medications, Central Supply ordered the Liquacel, and the Liquacel was stored in the medication room. RN 4 stated that the Transportation staff member ordered the Liquacel. RN 4 stated when the staff were low on the Liquacel she would fill out a form and add the item to the list for Central Supply to order. RN 4 stated if the staff were out of the Liquacel and they needed it, Central Supply would just go and grab it. An observation was conducted of the medication room with RN 4. There was no Liquacel observed in the medication room. Liquacel was observed on the list to be ordered. On 5/9/24 at 11:22 AM, an interview was conducted with the Transportation Director (TD). The TD stated that she was the staff member that ordered OTC medications and she had just started working central supply. The TD stated there was a paper in the medication room where staff could write down the OTC medications that were out. The TD stated that every Friday she would review the list and the list would be sent out on Monday by noon. The TD stated she would keep the past order and ask the Director of Nursing (DON) if there were any extra supplies that needed to be ordered. The TD stated she would also ask the Certified Nursing Assistants and the nurses if she was missing anything that needed to be ordered or if she needed to order more of something. The TD further stated if the staff saw her in the hallway they could inform her of items they needed and she would write it on the list. The TD stated the Liquacel was something that she ordered OTC but she had not had to order the Liquacel as of yet. The TD stated if she had problems getting items she would call the representative with the supply company and see if they could get the item sooner or a replacement. The TD stated the items ordered on Monday would be at the facility on Tuesday. The TD stated that sometimes there was a delay on some items. The TD stated the supply company would let her know if items were delayed and sometimes the representative would get the item to her as soon as possible and would overnight items if needed. On 5/9/24 at 12:57 PM, an interview was conducted with the Registered Dietician (RD) and the Dietary Director (DD). The RD stated that resident 18 was started on the Liquacel for wound healing. The RD stated she wanted to make sure resident 18 was getting adequate protein for wound healing. The DD stated that the Liquacel was ordered through a supply company as an OTC product. The RD clarified that the Liquacel order should have been BID. The RD stated she would go through the NAR meeting notes, she would list the dietary recommendations for the team, and then she would email the recommendations to the team. The RD stated that the DON, Unit Manager, DD, and the Administrator attended the NAR meetings. The RD stated that after the NAR meeting on 4/4/24, the DD spoke with resident 18 regarding the supplement. The RD stated that her recommendation for the supplement on 4/4/24, was an order pending because she gave resident 18 the choice of Med Pass or Liquacel. On 5/9/24 at 1:10 PM, an interview was conducted with the DON. The DON stated that in order to refill a medication the staff were to pull the tag off the medication card and put it on the refill list, check to ensure the medication was not somewhere in the facility, and fax the refill list to the pharmacy. The DON stated if the medication was out the facility had an emergency medication system. The DON stated if the medication needed was not in the emergency medication system the staff were to call the pharmacy to see when the medication would be delivered. The DON stated that she had access to the orders and she could see if the medication was actually delivered. The DON stated that Liquacel was OTC and Central Supply ordered the Liquacel. The DON stated if the staff were running low the staff would write it on the list and Central Supply ordered weekly. The DON stated that Liquacel came in a case of eight bottles. The DON stated that dietary recommendations were passed on verbally in the NAR meeting and discussed with the PA. The DON stated that the Unit Manager would input the orders. On 5/9/24 at approximately 1:10 PM, a follow up interview was conducted with RN 4. RN 4 stated that resident 18 was taking the Liquacel and then two days in a row resident 18 had refused the Liquacel because of diarrhea. RN 4 stated the facility did not have Liquacel on Monday, but she gave resident 18 Metamucil instead.

Based on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. Specifically, for 1 out of 28 sampled residents, a pharmacy recommendation to discontinue a statin medication that may cause myopathy and rhabdomyolysis if administered concomitantly with daptomycin was not acted upon timely when the physician agreed to the recommendation. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, infection and inflammatory reaction due to internal left knee prosthesis, acute embolism and thrombosis of deep veins of lower extremity, type 2 diabetes mellitus without complications, muscle weakness, endocarditis, paroxysmal atrial fibrillation, and peripheral vascular disease. Resident 18's medical record was reviewed on 5/9/24. A pharmacy Consultation Report dated 3/14/24, recommended to consider discontinuing atorvastatin calcium during daptomycin therapy. The recommendation was accepted and signed by the Physician Assistant (PA) on 3/15/24. A physician's order dated 1/27/24, documented atorvastatin tablet; 40 mg [milligrams]; Amount to Administer: 40 mg; oral at Bedtime. The physician's order was open ended. A physician's order dated 2/29/24, documented daptomycin recon [reconstitution] soln [solution]; 500 mg; Amount to Administer: 1gram; intravenous Once A Day. The physician's order was discontinued on 4/2/24. On 3/15/24 at 6:51 AM, a PA progress note documented . 3/15/2024 Pharmacy recommendations were to hold the atorvastatin while patient was on daptomycin. Discussed this with the patient, and it will be held. On 4/4/24 at 12:55 PM, a Nursing progress note documented Atorvastatin 40 mg hold d/c'd [discontinued] d/t [due to] Abx [antibiotic] daptomycin completed on 4/2/24 per PA. The March and April 2024 Medication Administration Record (MAR) were reviewed. The atorvastatin was administered daily in March 2024, concomitantly with the daptomycin. The atorvastatin was held on 4/2/24 and 4/3/24, according to the April 2024 MAR. On 5/8/24 at 12:52 PM, an interview was conducted with the DON. The DON stated the pharmacist reviewed the resident's monthly and would get the reports to her within 24 hours after the psychotropic meeting. The DON stated the reports always came on a Friday. The DON stated that the following Monday the MD would review the pharmacist recommendations. The DON stated if the recommendation was discussed in the psychotropic meeting she already had the order and could sign it off. The DON stated that the other stuff not discussed would go to the PA and he would look over the recommendations and sometimes the PA would hand them off to the MD. The DON stated that depending on the resident's insurance the recommendations may go to the Nurse Practitioner. The DON stated that after the recommendations were signed she would get them back usually within 24 hours. The DON stated that within 24 to 48 hours she would get the orders updated and noted. The DON stated that she was on vacation right after psychotropic meeting in March 2024, and that probably contributed to the recommendation not being implemented. The DON stated that the PA probably gave the recommendations back to her knowing that she managed those and she was on a 10 day vacation until 3/25/24.

Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had evaluated and determined that the resident's right to self-administer medications was clinically appropriate. Specifically, for 1 out of 28 sampled residents, medications were found at a resident's bedside and the resident had not been evaluated to self-administer their medications. Resident identifier: 43. Findings Included: Resident 43 was admitted to the facility on [DATE] with the following diagnoses of polyneuropathy, dementia, gastro-esophageal reflux disease without esophagitis, major depressive disorder, morbid severe obesity due to excess calories, and asthma. On 5/6/24 at 2:12 PM, an interview was conducted with resident 43's family member. An observation was made of two medications inside of a medicine cup located on top of resident 43's bedside table. The family member stated the medications were Tums, which resident 43 took when they needed them. Resident 43's medical record was reviewed on 5/7/24. On 1/30/23, a self-administration of medication assessment documented resident 43 did not want to self-administer their own medication. On 4/8/24, an annual Minimum Data Set assessment documented that resident 43 had a Brief Interview for Mental Status score of 7, which indicated a cognitive status of severe impairment. On 5/7/24 at 1:58 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they normally did not leave medications at the bedside and if they did, it required a physician's order. LPN 1 stated they gave residents their medications and watched them swallow the pills. LPN 1 stated they were unaware of any residents that were allowed to have pills at the bedside. LPN 1 stated resident 43 liked to take their Tums one at a time and saved the other ones for later. On 5/7/24 at 2:13 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated residents were not allowed to have pills at the bedside until they were assessed to be safe for self-administration and then the doctors were consulted about the matter. RN 1 stated a self-administration care plan was added to the resident's plan of care. RN 1 stated a self-administration assessment was initially done when a resident was admitted to the facility. On 5/7/24 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated residents were not allowed to have medications at the bedside unless a self-administration assessment had been completed and there was a physician's order for medication self-administration. The DON stated the purpose of the assessment was to determine if a resident was safe to administer their own medication. The DON stated there was only one resident they were aware of that was allowed to have pills at the bedside and resident 43 was not that resident.

Based on interview and record review, the facility did not ensure that each resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 1 out of 28 sampled residents, a resident with limited range of motion was not given restorative nursing services that was recommended by physical therapy (PT) to prevent further decrease in range of motion. Resident Identifier: 37. Findings included: Resident 37 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included, but not limited to, chronic inflammatory demyelinating polyneuritis, diabetes mellitus with hyperglycemia, difficulty walking, hypertension, chronic pain syndrome, and muscle weakness. On 5/6/24 at 10:30 AM, an interview was conducted with resident 37. Resident 37 stated that he would like to do physical therapy and/or occupational therapy because he felt that he had lost mobility and range of motion in both upper and lower extremities. Resident 37 stated that he had been informed that his insurance would not cover any type of therapy services and he had not been offered any alternative therapies or exercises by the facility. Resident 37's medical record was reviewed on 5/7/24. A care plan initiated on 9/23/23, documented that the resident is at risk for altered ADL [activities of daily living] function. with interventions that include encourage PT/OT [occupational therapy] services as prescribed and assist with completing ADL tasks each day. On 10/3/23, an orthopedic note documented, . will give him a prescription for physical therapy to work on range of motion and functional rehab. On 10/3/23, a nursing note documented, Rt [resident] seen by MD [Medical Doctor]. New order given- PT right knee. F/U [follow up] 10/31/23. On 10/11/23, a physical therapy evaluation was performed on resident 37 which recommended that resident 37 participate in the restorative nursing program for upper and lower extremity range of motion. On 5/7/24 at 1:16 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that he was unaware of any therapy needed for resident 37, but would check the notes to confirm this. On 5/7/24 at 2:04 PM, an interview was conducted with the DOR. The DOR stated that resident 37 had a physical therapy evaluation on 10/11/23, and it was determined that resident 37 would benefit from the restorative nursing program and was referred to this program. On 5/7/24 at 2:10 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that when she received a referral for the restorative nursing program she reviewed it and subsequently inputted the referral into the medical record if she felt the certified nursing assistants could assist the resident. The MDS Coordinator stated that she could not locate a referral for resident 37. The MDS Coordinator stated that she would talk with resident 37 regarding the restorative nursing program to see if it was something that resident 37 wanted to participate in. On 5/8/24 at 11:07 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 37 continued to have ROM problems with his lower extremities that was present when he admitted into the facility. The DON stated that resident 37 was diagnosed with bursitis a few months ago and this had caused a worsening in ROM with his upper extremities. The DON stated that she was unsure if resident 37's lower extremity ROM had worsened since being admitted to the facility. On 5/8/24 at 11:10 AM, an interview was conducted with the Administrator (Admin). The Admin stated that he had not heard of resident 37 wanting to participate in therapy services. The Admin stated that he had, in the past, discussed with resident 37 that the resident would have to personally pay for therapy services and resident 37 did not want to pay for these services. The Admin stated that he believed resident 37 had been receiving restorative nursing assistance and was part of the restorative nursing program.

Based on record review and interview, the facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for 1 out of 28 sampled residents, the facility coded a resident as having received insulin during the seven day Minimum Data Set (MDS) observation period when the resident had not received any insulin. Resident Identifier: 14. Findings Included: Resident 14 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis subsequent encounter, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus without complications. Resident 14's medical record was reviewed from 5/6/24 through 5/9/24. Resident 14's admission MDS assessment dated [DATE], was reviewed. The MDS assessment documented that Resident 14 received insulin on one of seven days of the seven day lookback observation period. Resident 14's order history was reviewed. There were no orders for insulin since the admission to the facility on [DATE]. Resident 14's Medication Administration Record was reviewed. There was no documentation that Resident 14 had received any insulin since the admission to the facility on [DATE]. On 5/9/24 at 10:11 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the MDS assessment had been miscoded and that Resident 14 had not received any insulin during the seven day look back period.

Based on interview and record review, it was determined for 2 of 6 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, one resident received a burn from a non-approved heat pack. Additionally, one resident received a skin tear and had no documentation of Medical Doctor (MD) notification or physician ordered treatments. Resident identifiers: 1 and 5. Findings include: 1. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 7/11/19. An incident report dated 2/22/19 at 2:00 PM, revealed that a burn was identified to resident 5's posterior right shoulder, the facility description revealed nurse noticed sore on back below R (right) shoulder blade during shower. Upon investigating: Resident states it wasn't there a week ago as CNA (certified nursing assistant) (CNA 1) scrubbed his back in shower. CNA (CNA 1) confirmed there was no sore there a few days ago. Resident asked if heat pack was used recently, resident confirmed a nurse (RN (registered nurse) 1) made hot pack for him & it was placed on that area of his back. A nurse's note dated 2/22/19 at 3:39 PM, revealed pt (patient) noted to have wound on back between scapula. wound has macerated edges with pink skin. dark unstageable tissue noted at center of wound. contacted (MD 1) and received orders to send to (name of local wound clinic) wound clinic for evaluation and tx. (treatment) silicone foam dressing placed on wound. On 7/11/19 at 1:00 PM, resident 5 was interviewed. Resident 5 stated that RN 1 placed the heat pack on resident 5's back because he was experiencing pain. Resident 5 stated that he was in bed asleep with the heat pack underneath his right shoulder. Resident 5 stated that he could not feel that the heat pack was too hot because he had had multiple back surgeries that had left the skin numb. Resident 5 stated that the facility staff found the burn a couple of days later. A Minimum (MDS) data set [DATE] revealed that resident 5 had a Brief Interview for Mental Status score of 15. Which indicated that resident 5 was cognitively intact. A note from the wound care clinic dated 2/26/19, revealed Burn to Left upper Back. Eschar present (with) dried skin around perimeter (about) 7 cm (centimeters) Across. Debrided eschar & dried skin: minor bleeding noted. Burn is almost through Dermis - very deep 2nd or early 3rd degree. (Note: Resident 5 was seen by the wound clinic weekly, for debridement of his burn, until 5/28/19.) A wound clinic note dated 5/28/19, stated (resident 5's) burn is fragilely healed today. I removed some dried epidermis around the area. No open area remains. Dressed with Mupirocin ointment & a [MEDICATION NAME] foam dressing. Needs covered x 1 week for protection, then is okay to leave open to air. discharged from our care. The facility Wound Rounds log showed that the facility monitored resident 5's wound for size, appearance, pain level, and treatment orders from 2/25/19 to 6/9/19. On 7/11/19 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that prior to the incident the facility did not have a policy which pertained to the use of heat packs on residents, but that the facility staff had made known that heat packs were to be only applied by the rehab therapy department. The DON stated that he believed RN 1 heated up a wet washcloth in the microwave, and then placed it in a garbage bag and pillowcase. The DON stated that he did not know if RN 1 had monitored the heat pack. The DON stated that RN 1 had been a nurse for [AGE] years. The DON stated that employee education was sent out to the staff's personal e-mails on 2/25/19, which addressed heat packs. A copy of the e-mail education was obtained on 7/11/19 from the DON, and stated NO HOME MADE HEAT PACKS/HOT PACKS!!! (Wound Care Nurse) is ordering some hot/cold packs that have a more consistent heat output. And if you place one of these on a patient, you need to monitor them constantly, assessing their skin, etc. Please Do Not use the wet towel in the Microwave trick anymore. These hot packs can and have burned patient's skin. (Note: There was no way to verify which staff members saw and read the e-mail.) On 7/11/19 at 2:41 PM, an interview was conducted with RN 1. RN 1 stated that the burn on resident 5's shoulder was his fault. RN 1 stated that he made the heat pack and placed it on resident 5's back. RN 1 stated that he had not realized that resident 5 had no feeling to the skin on his back, and that resident 5 would be unable to identify if the heat pack had burned him or not. RN 1 stated that he heated up a wet towel in the microwave and then wrapped it in other layers prior to applying it to resident 5's back. RN 1 stated that he did not remember how long he left the heat pack on resident 5. RN 1 stated that he had made those kinds of heat packs for years and thought it was safe. RN 1 stated that he was not sure what the facility policy was regarding heat packs prior to the incident. On 7/11/19 at 3:55 PM, a follow up interview was conducted with resident 5. Resident 5 stated that he did not feel any pain during debridement at his wound clinic appointments because his skin was numb from multiple surgeries. Resident 5 stated that the only issue he had was that he had to pay for the wound clinic appointments, even though it was one of the facility staff that caused the burn. On 7/11/19 at 3:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she did not apply heat packs to residents and that she did not know of any nurses that did apply heat packs. LPN 1 stated that only therapy staff applied heat packs. On 7/11/19 at 3:51 PM, an interview was conducted with RN 2. RN 2 stated that nursing was not to apply heat pack, heating pads, or rice packs to residents. RN 2 stated that therapy had some heat packs that only the therapy department applied. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/11/19 at 2:13 PM, a phone interview was conducted with resident 1's family member. Resident 1's family member stated that resident 1 was at the facility for a 5 day respite stay. Resident 1's family member stated that she had been called by facility staff and told that resident 1 sustained a fall. Resident 1's family member stated that she went to the facility on [DATE] and found resident 1 with a black eye and skin tear to the left forearm. Resident 1's family member stated that facility staff did not inform her that resident 1 had a skin tear and a back eye. Resident 1's family member stated that the skin tear on resident 1's forearm was large. Resident 1's family member stated that resident 1 had passed away after her respite stay at the facility. Resident 1's medical record was reviewed on 7/11/19. A nursing progress note dated 3/17/19 at 4:27 PM revealed that resident 1 sustained a fall in her room. The note further revealed that resident 1 was found on the floor in front of her recliner that was in the highest position. The note revealed that neuro checks were initiated and resident 1 .had a hematoma to her left forehead and redness under her left eye. There were no other injuries noted in the progress note. An incident report dated 3/17/19 at 3:20 PM revealed that resident 1 sustained a fall. The injury that was documented was L (left) Forehead Hematoma. There was no information about other injuries. Resident 1 did not have any other incident reports completed during her stay at the facility. A hospice progress note dated 3/17/19 at 7:24 PM revealed that nursing staff called to report resident 1 had sustained a fall at approximately 3:20 PM. The hospice note revealed that resident 1 had a bruise/hematoma to the left forehead and she had an abrasion which was not assessed because there was a dressing on the wound. There was no information about where the wound was on resident 1. There was no information regarding the type or size of the dressing on the abrasion. A nursing progress note from RN 4 dated 3/18/19 at 7:00 AM revealed that resident 1 had c/o (complained of) discomfort r/t (related to) a recent fall to head and Tylenol ordered prn (as needed). There was no documentation that resident 1 was administered pain medication. The progress note revealed that resident 1 had a welt/bruise to her forehead and a Band-Aid was applied. The nurse documented that a skin tear to her left forearm was cleaned and a dressing was applied. There was no information regarding what type of dressing was applied and if the physician had been notified and what treatments were ordered. Resident 1's Medication Administration Record (MAR) for (MONTH) 2019 was reviewed, there was no documentation regarding resident 1 receiving Tylenol on 3/18/19 when she complained of discomfort. Resident 1's Treatment Administration Record (TAR) for (MONTH) 2019 was reviewed, there was no documentation regarding a treatment for [REDACTED]. On 7/11/19 at 3:00 PM, an interview was conducted with RN 4. RN 4 stated that he could not remember resident 1. RN 4 stated if a resident was admitted for less than 30 days he was unable to remember them. RN 4 stated that he dis not remember what type of bandage was used or how big the skin tear was. RN 4 stated that he was not sure if he administered Tylenol for pain. RN 4 stated that if he administered medication it would be documented on the MAR. RN 4 stated that if there were no medications signed out on 3/18/19 then resident 1 was not administered the medication. RN 4 stated that when a resident sustained [REDACTED]. RN 4 stated that he may have asked the next nurse to call the physician but he could not remember. RN 4 stated that all falls and skin tears were to be documented on an incident report. RN 4 stated he did not know if resident 1 sustained the skin tear from the fall or if it was another incident. On 7/11/19 at 3:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after a resident sustained [REDACTED]. The DON stated that if a resident sustained [REDACTED]. The DON stated that resident 1 sustained a fall from her recliner on 3/17/19. The DON stated he did not remember if resident 1 sustained any injuries from the fall. The DON stated that he was not aware if resident 1 had sustained a skin tear but thought she had a hematoma to her forehead. The DON stated that it was possible that the nurse did not see the skin tear after the fall so it was not documented until the next day. The DON confirmed there were no treatments for resident 1's skin tear and no pain medication documented as administered on 3/18/19 when resident 1 complained of discomfort. The DON stated that it was possible that the nurse administered pain medication but did not document it on the MAR. The DON stated that he did not have additional information regarding the skin tear to resident 1's left forearm.

Based on interview, observation and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 6 of 55 sample residents. Specifically, three residents experienced a change in condition without timely intervention by the facility. These examples were cited at a harm level. In addition, one resident was inappropriately respositioned after a fall with a fracture. This example was also cited at a harm level. Also, medications were not properly monitored, and facility staff did not have access to appropriate portions of the medical record. Resident identfiers: 4, 40, 43, 56, 137, and 140. Findings include: HARM: 1. Resident 140 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/2/16 resident 140's medical record was reviewed. A nurses progress note dated 7/3/16 at 11:19 AM revealed the following: Resident became unresponsibe (sic) at about 9 AM. Vital signs were stable at P (pulse) 68, T: (temperature) 98.9, R: (respirations) 20, BP: (blood pressure) 120/58, O2 (oxygen saturation) 96 (percent), unable to reach his wife at this time. We continued to monitor him. His breathing changed at 1050 (10:50 AM) to shallow fast respirations in his stomach. Vitals were checked and a significant change was noted. BP: 104/66, T: 103.0, R: 24, P 134. Lungs are clear with shallow breaths. [MEDICAL CONDITION]. Wife (name of wife) was finally contacted and resuested (sic) him sent immediatly (sic) to (name of acute care hospital). (Name of physician) notified and gave order to send by ambulance to ER (emergency room ). Dispatch contacted at 1100 (11:00 AM). ambulance arrived at 1105 (11:05 AM). Report was given to paramedics and resident was transported out of facility by ambulance at 1120 (11:20 AM). The note was signed by Registered Nurse (RN) 2. A nurses progress note dated 7/3/16 at 2:34 PM revealed the following: Received report from (name of acute care hospital) ER that resident was life flighted to (name of another acute care hospital) for further eval (evaluation) and treatment. Dx: (diagnosis) [MEDICAL CONDITION]. (Note: Client was readmitted to the facility on [DATE] after spending 8 days in the acute care hospital.) On 8/10/16 at 11:00 AM, an interview was conducted with Registered Nurse (RN) 2, who had written the note regarding resident 140's change of condition on 7/3/16. RN 2 stated that resident 140 had been unresponsive to painful stimuli on the morning of 7/3/16, and that she had performed a sternal rub with no response from the resident. RN 2 stated that she had not contacted resident 140's physician with this information because the resident had been unresponsive for 3 days and the physician was aware. RN 2 stated that because of his [DIAGNOSES REDACTED]. He did it every day or so. RN 2 stated that she just let the wife make the decision about whether or not to send residsent 140 to the hospital for the change in condition. RN 2 confirmed that she had not contacted the physician about resident 140's change in condition for at least 2 hours until after she had contacted resident 140's wife. RN 2 stated that when residents who were Do Not Resucitate status had a change in condition, the nurse would first contact the family to determine how the facility staff should handle the situation. On 8/10/16 at 4:00 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that RN 2 should have contacted the physician immediately upon discovering resident 140's change in condition, and not waited for the family member to make the decision regarding sending the resident to the hospital. The DON stated he was unaware of the facility had a policy and procedure in place for resident changes in condition. The facility DON later provided the surveyors with the facility's policy on Change in a Resident's Condition or Status. The policy was subsequently reviewed. The facility policy listed a significant change as a decline or improvement in the resident's status that . will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 56's nursing notes were reviewed and revealed the following entries: a. On 5/26/16 at 3:53 AM, Heard front doorbell going off, when CNA went down to see what was going on, found resident sitting in front of door, she stated that she had gone out to smoke and couldn't get back in, so she tripped on chair and scooted butt over to ring doorbel (sic). Resident did not hit head, she mainly was sitting on floor, denies increased pain or hitting head, resident has no ams (sic). Resident has a scratch on left elbow, looks like road rash, Resident was told to let staff know when she was going outside to smoke and to try and be back by 10. (Note: Per the incident report, the resident's physician was not notified of the resident's fall until 5/27/16.) b. On 6/1/16 at 7:11 PM, Called to pt (patients) room. Pt states she has had an increase in L (left) hip pain since fall, however today her L shin has been bothering her immensly (sic). Voices she is concerned she may need an x-ray. Call placed to (name of resident 56's physician) to request order. No reply. Pt shows no increase in pain or discomfort with palpitation. No internal or external fix (sic) or rotation noted. No redness swelling or bruising ot (sic) note. Pain is voiced to be increased with foot flextion (sic). Sounds more like shin splints. Therapist treated with Biofreeze to ease pain with moderate relief. Will have day nurse f/u (follow up) in AM (morning). c. On 6/2/16 at 3:48 PM, Resident was complaining of Left hip pain that has been increasing over the last week. (Resident 56's physician) was notified and ordered a 3 view Left hip X-ray. Dx (diagnosis): hip pain. A form titled, Incident Report dated 5/25/16 revealed, Heard front doorbell when I went down to see what was going on found resident sitting in front of door she stated 'couldn't get back after smoking in (sic) so tripped on chair and scooted butt over to ring doorbell'. She said she was fine. Resident has no AIMS (abnomal involuntary movment scale), denies hitting head or increased pain. Facility nursing staff documented the following pain scores for resident 56: (Note: The numeric pain scale was used. The scores indicated that 0 was no pain and 10 was the worst pain.) a. On 5/26/16, there was a pain score of 6 documented at 5:00 PM. (Note: There were no other pain scores recorded on 5/26/16.) b. On 5/27/16, there were no documented pain scores. c. On 5/28/16, there were no documented pain scores. d. On 5/29/16, the pain scores documented were 5 at 9:00 AM, 6 at 1:10 PM, 5 at 3:10 PM, 6 at 4:55 PM, and 6 at 9:00 PM. e. On 5/30/15, the pain scores documented were 4 at 8:50 AM, 4 at 1:02 PM, 5 at 5:03 PM. f. On 5/31/16, there were no pain scores documented. g. On 6/1/16, there were no pain scores documented. h. On 6/2/16, the pain scores documented were 5 at 9:00 AM, 6 at 1:05 PM i. On 6/3/16, there were no pain scores documented. (Note: A physician's orders [REDACTED]. However, the physician orders [REDACTED].) A physicians telephone order dated 6/2/16 at 3:48 PM revealed, L hip 3 view x-ray Dx (diagnosis) - hip pain. A Final Report for the hip x-ray dated 6/3/16 revealed, IMPRESSIONS: [MEDICAL CONDITION] trochanter proximally along the proximal aspect of the femoral component, not present on the prior exam. On 8/11/16 at 12:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she did not know why there was a one day delay after the telephone order was obtained for the xray before the x ray was done. In addition, the ADON stated she did not know why there was a 3 day delay from the nurses note when resident 56 requested an x-ray to be done and it was done. The ADON stated she did not know why there were were not consistent documented pain scores. The ADON stated she did not have additional information regarding resident 56's pain between 5/25/16 until the x-ray was obtained on 6/3/16 to determine if resident 56 had increased pain. 3. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/2/16 through 8/11/16 resident 4's medical record was reviewed. Resident 4's nurses notes revealed the following entries: a. On 7/17/16 at 6:18 PM, Resident experiencing cough, wheezing and shortness of breath this morning. No orders for neb (nebulizer) treatment. Temp (temperature) and vitals taken at 0940 (9:40 AM): BP 148/82, R 36, 77 HR, 93 O2, 97.9 T. In and out of sleep throught (sic) the day, cough subsided. Temp taken an hours (sic) ago 1715 (5:15 PM) was 100.4. Tylenol was given PRN (as needed). Will continue to monitor temp and oxygen throught (sic) the night and call pcp (primary care physician) in the morning to discuss poss (possible) pneumonia. b. On 7/18/16 at 2:41 AM, .Temp slightly elevated at 100.4 F (degrees Fahrenheit). Tylenol given to provide relief. No signs of distress or discomfort observed. At 0230 (2:30 AM) temp re-check and noted at 98.3 F. VS (vital signs) sats (saturations) 99% 2L (liters) NC (nasal canulas) T 100.4 F (Fahrenheit) P 97 R 12 BP 117/74. Will continue to monitor. c. On 7/18/16 at 10:00 AM, Resident is sitting up in her recliner in her room. She is awake and alert. no s/o (signs of) discomfort at this time. No observed SOB (Shortness of Breath). Res (respirations) are not labored at this time. She ate very poorly at breakfast. She has a hard time swallowing food, meds (medications), liquids. She has no c/o pain with movment (sic). She was able to transfer without c/o (complaints of) pain or difficulty. Skin is pale and warm. 99.7, 90, 18, 124/85, O2 96 on 2.5. d. On 7/18/16 at 7:06 PM, (Resident 4's physician) nurse called back and stated that (resident 4's physician) is aware of resident difficulty with swallowing. Informed of resident SOB yesterday and her temp of 99.8, resident is not talking a lot (sic) or eating and drinking well. He stated foor (sic) us to monitor and call back for any further SOB or any further changes. She could come in for a chest x-ray. Will monitor and call if needed. e. On 7/19/16 at 5:13 AM, .SOB observed by nurse.Pt notified nurse that she was thirsty and hurt 'everywhere' and very thirsty. Tylenol and water given to provide relief. Vitals taken with temp 99.8 F, P 88, R 12 and BP 148/98. Daughter in to visit pt (patient) with anxiety and agitation observed by nurse. Daughter was very verbally aggressive with staff and wanted to know what was being done about her mothers declining condition. Daughter was informed that day shift nurse had contacted doctor (name of physician) and notified him of recent vitals and SOB. Daughter has requested that her mother be put on more [MEDICATION NAME] to remove water in lungs and [MEDICAL CONDITION] in legs. Will notify day nurse in AM (morning). At 0100 (1:00 AM) pt had episode of diarrhea. CNA's (Certified Nursing Assistant) cleaned pt up and then repositioned pt in bed with head slightly elevated. Sats (saturations) re-checked and noted at 98% on 2L NC and T at 97.7 F. Pt is currently asleep in bed with no signs of distress or discomfort noted. Will continue to monitor. f. On 7/20/16 at 6:58 AM, . SOB and abdominal retractions present. Pt able to speak but appears weak and lethargic. Daughter in to visit pt. Nurse discussed updates with resident and informed her that we are still waiting for a call back from doctor.At 0400 (4:00 AM) rounds scant amount of bloody sputum present on pt's gown. Will continue to monitor. g. On 7/20/16 at 5:15 PM, . T99.5.Lungs moist with Ronchi. SOB weakness and Lethergy (sic). Not eating well Aide in room assisting Res (resident) to eat meals condition worsens res respirations increase cough increases vomiting and having blood tinged sputum MD (medical doctor) (name of physician) called and apprised of situation. (Name of hospice company) came at request of family. Later we were told some of the family members were considering Hospice agency to use Res continuing to decline V/S O2 94 4L T 99.5 P 85 R 35 B/P 95/53. No response from family or MD. Daughter finally called and requested to have her sent to (name of local hospital) to be evaluated at 3:30 PM. There were no x-ray results in resident 4's medical record. The facility staff provided an x-ray report dated 7/20/16 at 3:40 PM which revealed, Bilateral pneumonia right significantly greater than left with associated right parapneumonic effusion. (Note: The x-ray was obtained at the hospital. A nurses note revealed that resident 4's physician wanted resident 4 to have an x-ray done on 7/18/16 if SOB continued.) An Emergency Provider Report from the local hospital dated 7/20/16 at 3:08 PM was reviewed. The report revealed, Allegedly this symptom of worsening over the past 2-3 days. The impression revealed, 1. Bilateral pneumonia right significantly greater than left with associated right parapneumonic effusion. On 8/11/16 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 4 needed to be sent out to the hospital even if the family was unavailable. The DON stated that family members needed to be notified but the family did not decide whether to send a resident to the hospital. The DON stated that resident 4 should have been sent to the hospital after the blood sputum was observed at 4:00 AM. The DON stated that waiting until 3:30 PM, 11 and half hours later, was too long. The DON stated that he did not know why the x-ray was not obtained until 2 days later at the emergency room . 4. Resident 43 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 43 also had a language barrier as she did not speak any English. On 8/3/16 resident 43's medical record was reviewed. An incident report dated 4/15/16 at 14:55 (2:55 PM) revealed that resident 43 fell on to her R (right) hip in the activity room. CNA witnessed fall, CNA stated that pt (patient) was getting up from her chair using her walker, the walker got caught on another pt's (patients) wheelchair. The CNA stated she tried moving the pt in the wheelchair, pt who fell kept ambulating and started to fall, CNA tried to catch pt, pt fell on her R hip. The Report of Injuries or Nurses Assessment section of the incident report revealed that RN (Registered Nurse) assessed. No head injuries, pt was c/o (complaining of) R hip/leg pain. Pt refused to stand/ambulate until after activity. Pt limped on her R leg. A nurses note dated 4/15/16 revealed, Pt fell today at 14:55 (2:55 PM), RN called pt's PCP (primary care physician) to inform of pt fall and to suggest pt be seen at the ER to have an x-ray done. PCP instructed nurse to call pt's daughter and to ask the pt's daughter what she would like the pt to do. Pt's daughter informed nurse to wait until she arrived to facility to make a decision to either keep pt at facility or to have her transported to the ER to have an x-ray taken. Pt's daughter reported not being able to make it into the facility until later due to being out of town traveling back. RN and staff helped wheelchair pt into her room to be placed into her recliner chair. Pt was given her call light and a drink. Pt's daughter arrived to facility (sic) around 1800 (8:00 PM). Daughter spoke with pt, who only speaks Russian, and made the decision to take her to the ER. Pt was transported to ER 18:30 (8:30 PM) by facility transportation with pt's daughter. A nurses note dated 4/16/16 revealed Talked with (name) at (name of local hospital) ER, she stated that resident was admitted to Surgical floor with rt. Femoral neck fracture. DON (Director of Nursing) was notified. No documentation could be located in the medical record that pain levels were being monitored by the staff nor was there any documentation that resident 43 had signs of pain including facial grimacing or moaning. In addition, no vital sign monitoring beyond the original vital signs at the time of her fall could be located in the medical record to indicate that resident 43 would have had an increase in pain. A review of resident 43's physician orders [REDACTED]. No other pain medication had been ordered for resident 43. A review of resident 43's MAR (Medication Administration Record) revealed that resident 43 never received a Tylenol 500 mg on 4/15/16. On 8/4/16 at 2:15 PM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON stated that the facility process for getting a resident into bed after a fall and possible fracture was to get four people and lift the resident very carefully and carry them to bed. When asked if they would lift by the extremities, the ADON stated, yes, very carefully. The ADON stated that possibly a hoyer lift, no, that would not work. The ADON further stated that she did not know why resident 43 stood up after her fall in April and was allowed to limp on it regarding the fractured femoral neck. On 8/11/16 at 9:15 AM, an interview was conducted with CNA 8. CNA 8 stated that she was walking resident 43 into the activity room the day that she fell and that resident 43's walker got stuck on another residents wheelchair and she fell on her right hip. CNA 8 stated that resident 43 had immediate pain in her hip. CNA 8 stated that the RN was called to the room and assessed resident 43 by feeling her leg. CNA 8 stated that she took both of her hands and felt along resident 43's thigh to make sure that she was ok. CNA 8 stated we picked her up and then stated, well, I don't remember that part. CNA 8 then stated that resident 43 was picked up under each arm to a standing position and placed into a regular chair in the activity. CNA 8 stated to talk to the Activity Director because she was there and would remember. On 8/11/16 at 9:30 AM, an interview was conducted with the Activity Director (AD). The AD stated that she remembered the day that resident 43 fell and that she was assessed by the nurse by feeling up and down her leg. The AD stated that resident 43 was picked up under both arms by her nurse and a CNA to a standing position, limped on her leg and then was helped to the chair in the activity room. The AD stated that she sat in the chair for the entire activity which was so not like her. The AD stated that because she sat the entire activity that she was worried about her and informed the nurse that she thought something was wrong. The AD stated that the resident was again assessed and assisted by the nurse and a CNA to a standing position, limped on her leg and was transferred to a wheelchair. The AD stated that she believed that resident 43 sat in her wheelchair until she went to the ER and that the limping on her leg was with both of the transfers to the chair and again to the wheelchair. The AD further stated that she believed that resident 43 was not getting up like she normally would because she was in pain. (NOTE: The incident report dated 4/15/16 revealed that resident 43 was transferred a third time from the wheelchair to her recliner in her room, assisted to a standing position, limped on her leg and sat in her recliner. Resident 43 was given her call light and a drink.) On 8/8/16 at 4:08 PM, an interview was conducted with the facility DON. The DON stated that if a resident had a fall to the floor and was suspected to have a fracture, the protocol would be to gather as many staff as possible to carry the resident to bed. The DON stated that they would not hold onto the fractured extremity but would use a gait belt to assist them back into bed. The DON stated that they would call the resident's physician and try to keep them comfortable until they could be transported to the hospital. (NOTE: Resident 43 was transferred three times to different chairs and allowed to stand/limp on her leg with each transfer after her fall. Resident 43 was not assessed for pain, given any pain medication or had vital signs monitored after her fall. Resident 43 was not sent to the ER for more than 3 ½ hours after the fall.) NOT- HARM: 5. Resident 137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/11/16, resident 137's medical record was reviewed. A nurses note dated 8/10/16 at 14:43 (2:43 PM) revealed Patient blood pressure noted to be high this AM at 184/92, rechecked at (sic) it was 200/100. Blood pressures reviwed (sic) with (Physician's name) office and a slow increase noted, resident is currently not on any blood pressure (sic). Per (Physician's name) patient to start [MEDICATION NAME] 20 milligrams (mg) STAT (short turn around time) and repeat blood pressure throughout the day, if resident blood pressure continues to increase or become symtomatic (sic) patient needs to go to the ER (emergency room ), if no sx (symptoms) and blood pressure decreases then we can continue to monitor and follow up as needed, pharmacy notified and charted on MAR (Medication Administration Record). An addendum added to the nurses note at 16:41 (4:41 PM) revealed Blood pressure continues to be high at 204/84 patient denies headache, visual disturbanced (sic) blood pressure medication has been administer (sic) will continue to watch it and patient will notify us with any changes. The Blood Pressure Monitoring Flowsheet revealed the following recorded blood pressures: a. 8/10/16 at 7:00 AM, 184/92. b. 8/10/16 at 11:00 AM, 200/100. c. 8/10/16 at 15:00 (3:00 PM), 204/84. d. 8/10/16 at 21:04 (9:04 PM), 160/88. e. 8/10/16 at 21:34 (9:34 PM), 160/88. The MAR for resident 137 revealed that the [MEDICATION NAME] 20 mg was not administered until 15:21 (3:21 PM), approximately 38 minutes after the documentation in the nurses notes of the STAT order. Additionally, resident 137's blood pressure was not monitored for 6 hours and 4 minutes between 3:00 PM and 9:04 PM and the follow up blood pressures that remained high were not called into resident 137's physician. 6. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/10/16 resident 40's medical record was reviewed. A review of resident 40's vital signs revealed that resident 40 had a blood pressure of 204/101 on 8/9/16. physician's orders [REDACTED].> (greater than)185 or DBP (diastolic blood pressure) > 100. The MAR for resident 40 revealed that the Losartan and the [MEDICATION NAME] had been given per physician orders, but, that the [MEDICATION NAME] had not been administered to resident 40. On 8/10/16 at 9:00 AM, an interview was conducted with RN 1. RN 1 stated that if she had a resident with an extremely high BP, she would give the resident's ordered medications and recheck the BP to see if it had decreased. RN 1 stated that if the BP had not decreased enough she would call the resident's physician. On 8/10/16 at 9:15 AM, an interview was conducted with the DON. The DON stated that the [MEDICATION NAME] 0.1 mg should have been administered to resident 40 per the physician's orders [REDACTED]. A nurses note dated 8/10/16 at 9:29 AM was brought to this surveyor after interviewing the facility staff by the DON. The nurses note revealed Late entry for 8/9/16. Residents blood pressure 204/101 in the AM. Blood pressure noted to be high. AM blood pressure medication administered and blood pressure check was followed up a few hours later and blood pressure noted to be 160/90. No documentation could be located in the medical record that resident 40's BP had decreased to 160/90 nor was there any documentation that resident 40's physician had been notified of the BP of 204/101. Documentation of resident 40's BP on 8/10/16 at 8:00 AM was 178/92 and at 12:00 PM was 160/90. On 8/10/16 at 9:40 AM, an interview was again conducted with RN 1. RN 1 stated that she could not locate the paperwork from yesterday that showed that resident 40's blood pressure had dropped to 160/90 and did not know why she did not record the blood pressure in the medical record. RN 1 stated that she just remembered that the blood pressure had dropped to 160/90. RN 1 further stated that she was not aware of resident 40's [MEDICATION NAME] until just now. RN 1 read the physician's orders [REDACTED]. When RN 1 was asked why she had not called resident 40's physician regarding the blood pressure of 204/101, RN 1 stated, I know, right? 7. On 8/4/16 at 1:15 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he was not aware he had access to resident care plans in the electronic medical record. LPN 1 then stated I only learned how to access the care plans yesterday. In addition, LPN 1 stated that he could not access any information in the electronic medical record older than one month. When asked how staff knew what interventions were supposed to be in place, LPN 1 stated that facility staff communicated the interventions on each shift change. LPN 1 also stated that there was a second electronic medical record used at the facility that was used to track resident behaviors. LPN 1 stated that he did not have access to a second electronic medical record in which resident behaviors were tracked. On 8/4/16 at 1:20 PM, an interview was conducted with CNA 10. CNA 10 stated that she did not have access to the electronic medical record or resident care plans. At approximately 1:30 PM, LPN 1 was observed to ask a CNA to log in to the second electronic medical record. The CNA was observed to log in using her credentials, and then LPN 1 was observed to enter in resident information that he had observed, using the CNA's credentials. On 8/11/16 at 10:55 AM, an interview was conducted with the facility DON. The DON stated that he was unaware the CNAs were usiing their credentials to log the nurses in to the second electronic medical record. The DON stated that all staff members should have their own login credentials to each medical record. The DON stated that he was unsure why facility nurses were unaware they had access to resident care plans or why the CNAs did not have access. (Cross refer to F333, F329, F507, F508, F498, F323, and F157)

Based on observation, interview and record review, it was determined for 7 of 55 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, interventions were not put in place to prevent falling, one resident was transferred three times while limping on a fractured hip, one resident with Parkinson's was left alone in activities with a pair of scissors and sustained a cut to his thumb, one resident was transferred by a CNA (Certified Nursing Assistant) without having the proper training for transferring amputees, the steam table was left in the hallway near resident rooms unattended, and the ladder was left multiple times in the hallway near resident room unattended. Resident identifiers: 4, 33, 40, 43, 100, 121 and 140. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/10/16 resident 40's medical record was reviewed. A nurses note dated 5/7/16 revealed, Rt (resident) found on floor in her room lying on her left side, by recliner on floor. Rt was tring (sic) to reach her walker to go to the bathroom. Rt c/o (complained of) pain to left cheek and states she hit her head. rt was very upset that she had a family party and was going to miss it. Rt assessed by nurse, ROM (range of motion) WNL (within normal limits) for resident, neuro checks WNL. Rt was assisted to recliner. Vitals done by aides. Rt comforted about family party and appeared to calm down. Dr. (Resident 40's physician) in the building and he went in and assessed Rt. Dr. (Resident 40's physician) gave orders to apply ice pack and she could go with family. If family wishes at anytime she can go to the ER (emergency room ) to eval (evaluate) and treat. Ice pack applied and Rt given a prn (as needed) pain med (medication). Family in to pick up Rt and family made aware of fall. Family counseled on what to watch for while Rt was out. Family did not wish for Rt to go to the ER. Rt out with family, upon return, Rt tolerated well and had no new c/o pain or discomfort. Family does not want Rt to go to the ER at this time. No concerns at this time. DON (Director of Nursing) notified. An incident report dated 5/7/16 at 11:45 AM, revealed This nurse heard 'moaning' from down hall. Nurse found resident lying on left side by chair on floor. Rt c/o hitting head and pain to L (left) cheek. No other c/o. Rt very emotional that she was going out with family and 'ruined' the party. The Report of Injuries or Nurses Assessment section of the incident report revealed, Rt neurochecks WNL. ROM WNL for rt. Resident assisted back to chair and reassured about family plans. The Corrective Action Taken by Nurse on Duty section of the incident report revealed, Rt counseled on use of call light for assist. Safety precautions implemented were, educate resident to use call light when transfering (sic). A nurses note dated 5/15/16 revealed, CNA (Certified Nursing Assistant) reported helping pt (patient) up off the toilet, pt slipped and sat back down onto the toilet and sat crooked. Pt c/o pain in her left hip area afterwards. RN (Registered Nurse) assessed area of reported injury. Pt was able to lift leg and place pressure on it. RN discussed situation with pt and pt reported only wanting to speak to PT/OT (physical therapy/occupational therapy) about her leg in the morning and then go from there as needed for her care. An incident report dated 5/15/16 at 19:50 (5:50 PM) revealed, CNA reported helping pt up off the toilet, pt slipped and sat back down onto the toilet and sat crooked. Pt c/o pain in her L hip area afterwards. The Report of Injuries or Nurses Assessment section of the incident report revealed, RN assessed area of reported injury. Pt was able to lift leg and place pressure on it. The Corrective Action Taken by Nurse on Duty section of the incident report revealed, RN discussed situation with pt and pt reported only wanting to speak to PT/OT about her leg in the morning and then go from there as needed for her care. Safety precautions implemented were, Check for UTI (urinary tract infection) d/t recent multiple falls. An incident report dated 6/7/16 at 17:20 (5:20 PM) revealed, Resident was ambulating by herself c her walker. States she felt weak, fell down onto her butt then fell backwards and hit her head. She states she felt sleepy but wanted a drink and to go to the bathroom. She cannot remember if she thought to use her call light. The Report of Injuries or Nurses Assessment section of the incident report revealed, R elbow skin tear. R hip pain. Lumbar pain. Weakness. Increased confusion. No neuro defecits (sic). No other hematoma/abrasions noted at this time. The Corrective Action Taken by Nurse on Duty section of the incident report revealed, Pt educated on her current condition of increased weakness and need for assistance anytime she is up. Discussed pain and option of going to get x-rays. Safety precautions implemented were, f/u (follow up) UA (urinalysis) to check for UTI and clip call light to shirt for reminder. A nurses note dated 6/8/16 revealed, Resident has been complaining more frequently todsy (sic) about pain from her fall. Dr. (Resident 40's physician) was called about pain medication and ststed (sic) that we can give her hydrocodone every 4 hrs (hours) instead of 6 hr. A nurses note dated 6/8/16 revealed, Called Dr. (ER physician) to clarify WB (weight bearing) status. Pt to be non weight bearing until further orders. A nurses note dated 6/11/16 revealed, Late entry note on fall from 6/7/16, res (resident) was self ambulating c (with) walker, she states she does not remember why she did not use her call light and that weakness was the cause of her fall, she wanted to go to the bathroom and to get a drink, CNA witnessed res fall as she walked by the room, res fell on to her bottom then fell back and hit her head, res helped back to her chair where she was uncomfortable and was then transferred to the bed, res emotionally distraught d/t (due to) frequent recent falls, res c/o increased pain to R (right) hip and lumbar spine, no other concerns, RN contacted famiy (sic) and PCP (primary care physician), res sent to ER for assessment, concerns of re injury of pelvis or fx (fracture) of back, skin tear to R elbow dressed by RN, no other marks noted at this time, no neuro defecits (sic). Resident 40's MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 40 required extensive two person assist for bed mobility, transfers and ambulation in her room. The MDS revealed that resident 40 required extensive one person assist for ambulation outside of her room. Resident 40's Fall Care Plan revealed the following: -Will be free from injury post fall (GOAL) (Activated) Last Evaluated 7/6/16 (Not Met) -Description of fall activity (Activated) -Additional Intervention to Prevent Future Fall (Activated) -High Risk for falls and injuries (GOAL) (Activated) Las Evaluated 7/6/16 (Met) -History of osteoporosis (GOAL) Last Evaluated 7/6/16 (Met) Interventions on the Fall Care Plan included the following: -Morse Fall Risk Standard Precautions -Eval for Orthostatic Hypotension, Slower Position Transition -Ensure Glasses Worn and Lighting Optimal -Intervene for Unsafe Behaviors Effecting (sic) Fall Risk -Adjust Medications if Sedation Affects Mobility -Continue Vitamin D3 as ordered -Evaluate Room for Clutter, Blocked Pathways and Intervene -Evaluate Assistive Devices for Strength and Safety -Evaluate routine and Patterns to Assist at Times Needed -Falling Star Program per Protocol (NOTE: All of the above interventions were last evaluated on 7/6/16 and documented that the interventions had been met.) Two additional interventions added to the care plan included the following: -May TTWB (toe touch weight bearing) right leg and progress to WBAT (weight bearing as tolerated) RLE (right lower extremity) w (with)/P.T. (physical therapy). -Ensure call light in reach, clip to shirt, chair or bed and reimind (sic) to use. (Note: The above interventions were documented as activated although there was no date or time as to when they were activated. Additionally, no orders could be located in the medical record showing that resident 40's weight bearing status on the right leg had increased from non weight bearing to toe touch weight bearing status.) A final report from the local emergency room dated 6/8/16 revealed that resident 40's final [DIAGNOSES REDACTED]. On 8/9/16 at 1:45 PM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON confirmed that resident 40 had a cognitive deficit and could not remember to use her call light. The ADON stated that she did not know why specific interventions had not been activated after two falls for resident 40 since she was a known fall risk. The ADON further stated that she did not know what other interventions could have been activated for resident 40 to keep her safe and that they try to keep her safe. 2. Resident 43 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 43 also had a language barrier as she did not speak any English. On 8/3/16 resident 43's medical record was reviewed. An incident report dated 4/15/16 at 14:55 (2:55 PM) revealed that resident 43 fell on to her R (right) hip in the activity room. CNA witnessed fall, CNA stated that pt (patient) was getting up from her chair using her walker, the walker got caught on another pt's (patients) wheelchair. The CNA stated she tried moving the pt in the wheelchair, pt who fell kept ambulating and started to fall, CNA tried to catch pt, pt fell on her R hip. The Report of Injuries or Nurses Assessment section of the incident report revealed that RN (Registered Nurse) assessed. No head injuries, pt was c/o (complaining of) R hip/leg pain. Pt refused to stand/ambulate until after activity. Pt limped on her R leg. A nurses note dated 4/15/16 revealed, Pt fell today at 14:55, RN called pt's PCP (primary care physician) to inform of pt fall and to suggest pt be seen at the ER to have an x-ray done. PCP instructed nurse to call pt's daughter and to ask the pt's daughter what she would like the pt to do. Pt's daughter informed nurse to wait until she arrived to facility to make a decision to either keep pt at facility or to have her transported to the ER to have an x-ray taken. Pt's daughter reported not being able to make it into the facility until later due to being out of town traveling back. RN and staff helped wheelchair pt into her room to be placed into her recliner chair. Pt was given her call light and a drink. Pt's daughter arrived to facility (sic) around 1800 (8:00 PM). Daughter spoke with pt, who only speaks Russian, and made the decision to take her to the ER. Pt was transported to ER 18:30 (8:30 PM) by facility transportation with pt's daughter. A nurses note dated 4/16/16 revealed Talked with (name) at (name of local hospital) ER, she stated that resident was admitted to Surgical floor with rt. Femoral neck fracture. DON (Director of Nursing) was notified. On 8/4/16 at 2:15 PM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON stated that the facility process for getting a resident into bed after a fall and possible fracture was to get four people and lift the resident very carefully and carry them to bed. When asked if they would lift by the extremities, the ADON stated, yes, very carefully. The ADON stated that possibly a hoyer lift, no, that would not work. The ADON further stated that she did not know why resident 43 stood up after her fall in April and was allowed to limp on it regarding the fractured femoral neck. On 8/11/16 at 9:15 AM, an interview was conducted with CNA 8. CNA 8 stated that she was walking resident 43 into the activity room the day that she fell and that resident 43's walker got stuck on another residents wheelchair and she fell on her right hip. CNA 8 stated that resident 43 had immediate pain in her hip. CNA 8 stated that the RN was called to the room and assessed resident 43 by feeling her leg. CNA 8 stated that she took both of her hands and felt along resident 43's thigh to make sure that she was ok. CNA 8 stated we picked her up and then stated, well, I don't remember that part. CNA 8 then stated that resident 43 was picked up under each arm to a standing position and placed into a regular chair in the activity. CNA 8 stated to talk to the Activity Director because she was there and would remember. On 8/11/16 at 9:30 AM, an interview was conducted with the Activity Director (AD). The AD stated that she remembered the day that resident 43 fell and that she was assessed by the nurse by feeling up and down her leg. The AD stated that resident 43 was picked up under both arms by her nurse and a CNA to a standing position, limped on her leg and then helped her to the chair in the activity room. The AD stated that she sat in the chair for the entire activity which was so not like her. The AD stated that because she sat the entire activity that she was worried about her and informed the nurse that she thought something was wrong. The AD stated that she was again assessed and assisted by the nurse and a CNA to a standing position, limped on her leg and transferred to a wheelchair. The AD stated that she believed that resident 43 sat in her wheelchair until she went to the ER and that the limping on her leg was with both of the transfers to the chair and again to the wheelchair. The AD further stated that she believed that resident 43 was not getting up like she normally would because she was in pain. (NOTE: The incident report dated 4/15/16 revealed that resident 43 was transferred a third time from the wheelchair to her recliner in her room, assisted to a standing position, limped on her leg and sat in her recliner. Resident 43 was given her call light and a drink.) On 8/8/16 at 4:08 PM, an interview was conducted with the facility DON (Director of Nursing). The DON stated that if a resident had a fall to the floor and was suspected to have a fracture, the protocol would be to gather as many staff as possible to carry the resident to bed. The DON stated that they would not hold onto the fractured extremity but would use a gait belt to assist them back into bed. The DON stated that they would call the resident's physician and try to keep them comfortable until they could be transported to the hospital. 3. Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/2/16 at 8:36 AM, an interview was conducted with resident 100. Resident 100 stated I had a nurse who was helping me to bed, grabbed my arm and was just squeezing. I complained to her several times that she was hurting me and to please stop squeezing. She threw me on the bed and told me that she wasn't hurting me. On 8/10/16, resident 100's medical record was reviewed. The facility incident report dated 7/12/16 was completed by LPN (Licensed Practical Nurse) 2 and revealed the following: was called into (sic) see residents L (left) arm @ (at) 2:30 AM to see some bruises. Upon going in to see resident and help her out of the bathroom, I noticed a few bruises that went down her left bicep. Resident stated 'when they put me to bed they grabbed my arm to help me stand up and put me to bed and they kinda (sic) pinched it.' Resident stated she didn't know who the aide was but she hasn't seen her much before. A note dated 7/14/16 revealed the following: (Resident 100) bruise to left upper arm investigation. (CNA 5) stated (to Administrator and Director of Nursing) that she had difficulty transferring (resident 100) on previous occasions and received assistance during those instances. (CNA 5) stated that she transferred (resident 100) to bed on the night of 7/12/16 some time after 8 PM by herself and probably held onto (resident 100's) arm too tightly because she didn't want her to fall. (CNA 5) later reported a bruise on (resident 100's) left upper/outer arm to (LPN 2), the nurse on duty. (CNA 5) stated that the bruise probably resulted when she was transferring (resident 100) to bed. A facility administrator write up of the interview which was not dated, revealed the following: The aid (sic) was identified as a (CNA 5), a new aid (sic) at RMC (Rocky Mountain Care). I spoke to (CNA 5) and she said she had an awkward/difficult transfer with (resident 100) and she said she griped (sic) her arm. I asked (CNA 5) if (resident 100) said she was hurting and (CNA 5) said (resident 100) only mentioned to put her in bed faster because she was hurting her arm. I asked what her reply to (resident 100's) comments was and she said she just said 'okay'. I asked (CNA 5) if she has transferred (resident 100) alone before and she said that was her first time transferring an amputee. On 8/12/16 the facility administrator was interviewed. The facility administrator stated that when he had interviewed resident 100, resident 100 had told him that CNA 5 had squeezed her arm too tightly because she did not know how to transfer resident 100 properly. The Report or Nurses Assessment section of the incident report revealed that resident 100 was bruised down L (left) bicep. The Corrective Action Taken by Nurse on Duty section of the incident report revealed that the incident had been reported to administration for further evaluation. After the investigation of the bruising, the result written on the facility incident report revealed, CNA (Certified Nursing Assistant) 5 involved will have inservice from Physical Therapy for proper transfering (sic) of patients. 4. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 810/16 resident 33's medical record was reviewed. An incident report dated 10/26/15 at 4:45 PM written by the activities assistant, revealed, (Resident 33) was in the activities room opening up a pocket knife. I stepped out in the hall. When I returned there was blood on the floor. (Resident 33) was standing at sink with his thumb under the water. He cut his left thumb. I went to get the nurse to look at cut. The Report of Injuries or Nurses Assessment section of the incident report revealed, L (left) finger thumb (sic) 1 (inch) cut bled for 30 minutes c (with) pressure and ice. The Corrective Adction Taken by Nurse on Duty section of the incident report revealed, Took knife away, put in safe. Education to activity staff regarding safety with knives. On 8/10/16 at 3:00 PM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON stated that she was not sure why he was given a knife to carve a pumpkin even though he had Parkinson's Disease or why he was left alone in the activity room. On 8/10/16 at 3:30 PM, the ADON came to talk with this surveyor. The ADON stated that she had talked with the Therapeutic Recreation Technician (TRT). The ADON stated that resident 33 was the only resident in the activities room and the TRT had stepped out of the activity room while he was there. Resident 33 had a pocket knife that was in a plastic case and had obtained a pair of scissors from the activity room to cut the pocket knife casing to get it out and cut his finger with the scissors. The ADON stated that resident 33 should not have been left alone in the activity room. 5. Resident 140 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/1/16 at approximately 9:30 AM, a tour was conducted of the facility. During that tour, resident 140 was observed in his room. Resident 140 was laying flat in bed, with a nasogastric tube with formula running. On 8/3/16 at 8:25 AM, an observation was made of resident 140 in his room. Resident 140 was observed to be laying in bed with a nasogastric tube with formula running. The head of resident 140's bed had been elevated to approximately a 15 degree angle. On 8/11/16 at 11:21 AM, an observation was made of resident 140. Resident 140 was observed be laying in bed with a nasogastric tube with formula running. Resident 140 was observed to be laying in bed with the head of the bed elevated to approximately a 15 degree angle. On 8/2/16 resident 140's medical record was reviewed. No physician orders regarding resident 140's position in bed while the tube feeding was running were located. A care plan dated 7/12/16 indicated that resident 140 was to have the head of his bed positioned to prevent aspiration. However, the care plan did not give specific parameters as to what the bed position should be. 6. Resident 121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/16 at 9:15 AM, an observation was made of resident 121. Resident 121 was observed to be laying in bed with a nasogastric tube with formula running. Resident 121 was observed to be laying in bed with the head of the bed elevated to a 15 degree angle. On 8/2/16 at 7:43 AM, an observation was made of resident 121. Resident 121 was observed to be laying in bed with a nasogastric tube with formula running. Resident 121 was observed to be laying in bed with the head of the bed elevated to a 15 degree angle. An interview was conducted with resident 121. Resident 121 stated her head of bed was positioned lower than the current angle observed. Resident 121's tube feeding formula was labeled, 8/1/16 Fibersource 75mls/hr (milliliters per hour). The tube feeding pump was observed to infuse at 75 ml per hour and flushing 50 ml per hour of water. On 8/3/16 at 8:25 AM, an observation was made of resident 121. Resident 121 was observed to be laying in bed with a nasogastric tube with formula running. Resident 121 was observed to be laying in bed with the head of the bed elevated to a 15 degree angle. On 8/11/16 at 11:21 AM, an observation was made of resident 121. Resident 121 was observed be laying in bed with a nasogastric tube with formula running. Resident 121 was observed to be laying in bed with the head of the bed elevated to a 15 degree angle. 7. On 8/1/16 at 12:26 until 12:28 PM, an observation was made of the steam table being unattended in the south hallway. On 8/9/16 at 8:35 AM, an interview was conducted with Cook 1. Cook 1 stated that if he needed to go to the kitchen, the steam table could be left unattended with the food covered. Cook 1 stated that he changed his gloves when he returned to the steam table. 8. On 8/1/16 and 8/2/16 throughout the day, observations were made of a ladder in the hallway. The ladder was observed to be unattended throughout the day. On 8/3/16 at 8:20 AM, an observation was made of a ladder in the hallway. The ladder was observed to be unattended for 30 minutes. On 8/9/16 at 2:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the steam table should not be left unattended in the hallway. The DON stated that usually ladders are not left unattended in the hallway. The DON stated that was a problem and both should not be left unattended. 9. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed 8/2/16 through 8/11/16. An Incident and Accidents log provided by the Director of Nursing (DON) revealed that resident 4 experienced the following falls: a. 6/3/16, Trying to get her shoes. fell back on chair then to floor. Send in for U.A. (urine analysis) for possible U.T.I. (urinary tract infection). Resident 4's Incident Report was reviewed and revealed the following: a. 6/2/16 at 3:00 PM, Resident was trying to stand up and got her shoes before standing she slide on the floor and sat on her recliner and went to the floor. No injuries or bruising could be found. The floor was dry at the time. One of the PT (Physical Therapists) had just helped her sit down a few minutes earlier. Resident has had some confusion throught (sic) the day. The documented Corrective action taken by nurse on duty was Resident encouraged to call for help anytime she needs it. She was encouraged to report any new injuries if necessary. It was futher documented, Will check for UTI to r/o (rule out) underlying medical conditions. b. 6/3/16 at 4:25 AM, Found (resident 4) by sink on floor, alert.no apparent injuries, No change in LOC (loss of consiousness). Resident stated was trying to wash hands and lost her balance. Resident reminded to use call light throughout shift. Resident back to chair, no complaints. The nurse documented, Corrective action taken by nurse on duty: Pressure alarm on and in place. Call light within reach, frequent checks. U/A ordered (and) labs. Resident 4's nurses notes revealed the following entries: a. On 6/2/16 at 4:31 PM, Resident was found on the floor in fromt (sic) of her chair she stated that she was trying to put on her shoes. She slide (sic) on the floor and landed back on the chair then slide to the floor (sic). She was evaluated and was helped to the chair. (Note: There were no documented interventions.) b. On 6/3/16 at 4:45 AM, Resident found on floor by sink and bathroom, not witnessed, resident did not lose consciousness, alert, but seems more confused this shift. No apparent injuries, or change in LOC.new orderd (sic) for BMP (basic metabolic panel) and U/A for this AM. Resident pressure alarm on and in place, call light within reach, frequent check. A fall care plan dated 4/12/16 revealed the follwoing outcomes, will be free from injury post fall. Activity program developed per needs or adequate lighting or ambulation/mobility scheduled or assistive device evaluated for safety or attended while in bathroom or bed alarm or bedside commode leg ti(sic). Interventions developed were, ensure glasses worn and lighting optimal, consult physician for PT (Physical Therapy) or (Occupational Therapy), intervene for unsafe behaviors effecting fall, adjust mediations if sedation affects mobility, evaluate room for clutter, blocked pathways and intervene, evaluate assistive devices for strength and safety, evaluate routine and patterns to assist at times needed. Resident 4's physician's orders dated 6/3/16 at 4:45 AM revealed, Draw BMP this am (morning), get U/A this AM 6-3-16 for increased confusion. (Note: The intervention for the fall on 6/2/16 was to obtain a U/A. The U/A was not obtained until 6/3/16 after the second fall.) On 8/9/16 at 10:00 AM, an interview was conducted with the DON. The DON stated that Interdiscipnary Team (IDT)'s intervention was to get a UA to rule out a UTI after the fall on 6/2/16. The DON stated that was the same intervention for the falls on 6/2/16 and 6/3/16. On 8/9/16 at 12:36 PM, an interview was conducted with the ADON. The ADON stated that after admission a morse code was completed to determine if a resident was a fall risk. The ADON stated that resident 4's score was 80 which revealed she was a high risk.

Based on record review and interview, it was determined that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 34 sample residents. Specifically, one resident did not receive appropriate care and treatment when he presented with [DIAGNOSES REDACTED] and one resident did not receive the appropriate care and assistance after sustaining a fracture. Resident identifiers: 56 and 68. Findings include: 1. Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/28/15, resident 68's medical record was reviewed. Review of nursing notes revealed the following entries: a. 4/27/15 11:42 AM: "resident has continued to be less responsive since insulin administration this am (morning), checked BS (blood sugar) at breakfast and was 75, then again at 10 and it was 61 upon last BS check pt (patient) was extreamely (sic) diaphoretic and unresponsive. Called physicaian (sic) and received order for [MEDICATION NAME], administered as ordered. Order for [MEDICATION NAME] was for PRN (as needed) low BS. Will continue to monitor." b. 4/27/15 4:11 PM: "after [MEDICATION NAME] administration bs remained low. Additional dose given, with little result. Called family and daughter stated that she wanted to send him to the ER (emergency room ). Called dispatch for transport, upon arrival bs checked again and was 30 d50 (50 percent [MEDICATION NAME]) given through periferal (sic). Report called to ED to (nurse) RN (Registered Nurse). " c. 4/27/15 4:15 PM: "Called ER to follow up with status of pt. Receved (sic) report from (nurse) RN (registered nurse) that they will be admitting to the floor." A review of the April 2015 physician recertification orders revealed an order dated 3/20/15 for "Humalog insulin 100 units/mL (milliliters) 1-10 units AM/morning, Lunch, Afternoon, sliding scale: 125-150: 1 unit 151-175: 2 units 176-200: 3 units 201-225: 4 units 226-250: 5 units 251-275: 6 units 276-300: 7 units 301-325: 8 units 326-350: 9 units 351-375: 10 units". A review of the Medication Administration Record [REDACTED]. On 4/28/15 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that resident 68 was admitted to the hospital the day before because he had a low blood glucose. LPN 4 stated that if a resident had a low blood glucose, she would give the resident orange juice and recheck the blood glucose in 15 minutes. If the blood glucose was still low then she would call the physician to ask for more instructions on the resident's care. LPN 4 stated that she would also call the resident's family. On 4/28/15 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident should have received only 8 units of insulin for a blood glucose of 320. The DON didn't know if the the extra two unit of insulin would have dropped the resident blood glucose that low. The DON stated that the resident had been admitted to the hospital [MEDICAL CONDITION] and pneumonia. On 4/29/15 the emergency room Final Report was reviewed. The report included the following dated 4/27/15 2:05 PM: "...this patient was admitted to the intensive care unit... in stable condition...for further evaluation and treatment of [REDACTED]." On 4/29/15 the facility policy for "Nursing Care of the Resident with Diabetes Mellitus" was reviewed. The policy indicated that for a resident with [DIAGNOSES REDACTED] that was symptomatic but responsive and the resident was able to swallow the nurse was to "immediately give the resident an oral form of rapidly absorbed glucose (4 ounces of juice or 5-6 ounces of soda), recheck the blood glucose in 15 minutes and repeat if indicated...If no improvement notify physician for further orders". For a resident that is unable to swallow: "immediately administer oral glucose paste to [MEDICATION NAME] muscosa, intramuscular [MEDICATION NAME] or IV 50% [MEDICATION NAME] per facility protocol, recheck blood glucose in 15 minutes and repeat if indicated. Remain with resident..." On 4/29/15 at 12:15 PM, an interview was conducted with LPN 2. LPN 2 stated that he was the nurse providing care to resident 68 on 4/27/15. LPN 2 stated that he had checked resident 68's blood glucose at 730 and administered 10 units of insulin for a blood glucose of 320. LPN 2 stated that at 8:00 AM a CNA (Certified Nursing Assistant) told him that resident 68 wasn't doing so well. LPN 2 stated that resident 68 was pale and lethargic. LPN 2 stated he re-checked the resident 68's blood glucose, which was 75 at that time. LPN 2 stated that he encouraged resident 68 to drink his juice then he texted the physician and continued to administer medications to the other residents. LPN 2 stated that he rechecked resident 68's blood glucose level around 10 am with a result of 61. LPN 2 stated he called the physician on his cell phone and left a message when the physician did not answer. LPN 2 stated that he rechecked the blood glucose and the level was continuing to decrease so he called the physician's office and talked to the physician who ordered [MEDICATION NAME] to be given to wait an hour and give another dose if indicated. LPN 2 stated that after the second dose of [MEDICATION NAME] had been administered, the blood glucose level remained low at 56. He then called the family and asked what they would like to do and the family requested the resident to be sent to the hospital. A review of the physician telephone orders was completed. An order dated 4/27/15 at 11:42 AM for "[MEDICATION NAME] PRN (as needed) low blood sugar" was noted. Resident 68 was transferred to the hospital at approximately 1:30 PM on 4/27/15. (Note: There was an extended delay in treatment of [REDACTED].) 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 56's medical record was reviewed on 4/28/15. On 3/22/15, a licensed staff member documented the following in a "Nursing Note:" a. 3/22/15 at 12:49 PM: "Resident transported to ER (emergency room ) via ambulance after complaints of chest pain starting in LLE (Left Lower Extremity). Resident states the pain has been persistent for past three days but is worse today. Pain is worse with movement and clutches chest as she coughs. Oxygen saturation at 85% on RA (Room Air) and 90% on 2 L (liters) and slightly propped up in bed. Son, (name redacted) was contacted and gave permission to send her to the ER unless it subsides. Full set of vitals taken and hard copy of MAR (Medication Administration Record) and cover sheet sent with the resident to ER." b. 3/22/15 2:38 PM: "Chest x-ray and ultrasound of left lower extremity being done now at (local hospital) to rule out [MEDICAL CONDITIONS]. Will call back to find out if she has been admitted ." c. 3/22/15 at 4:56 PM: "Received report from (local hospital) ER, chest x-ray and ultrasound came back negative for [MEDICAL CONDITION]. Resident has fracture of Lateral LT (left) patella from unknown origin. Son, (name redacted) arrived shortly after she came back from ER, and was updated and notified of all events. He claims he has been in the facility lately and she has not complained of pain or mentioned any falls." On 3/27/15, resident 56 was seen by an orthopedic specialist. The orthopedic specialist documented: "Chief Complaint: Lt (left) Patella fx (fracture) - fell . ...History of Present Illness: Patient presents to clinic today with complaints of a left patella fracture patient was seen in the ER (emergency room ) complaining of an x-ray showed possible bipartite patella or possible patella fracture in the plane of motion. Patient is here for follow-up. ...Assessment/Plan: Injury of patella. Patient will be restricted as far as weightbearing (sic) and transfer only with help. We'll have the patient return in 3 weeks with repeat 3 view of the left knee. Patient is to have protected weightbearing (sic). ..." On 3/27/15, a telephone order was received from the orthopedic specialist which documented, "NON WEIGHTBEARING (sic) FOR 3 WKS (weeks). RETURN IN 3 WEEKS FOR X-RAY. NO BRACE NEEDED AT THIS TIME - PATELLAR FX (FRACTURE)." On 4/17/15, the left knee was again x-rayed. The primary care physician documented, "(Assessment: {Patella} fx (fracture) well healing. (Plan) Will {continue with current restriction. Restrictions for activity given for another 4-6 weeks to protect fx (fracture) site. Written referral to physical/occupation therapy...}" On 4/28/15 at 1:30 PM, Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated that resident 56 was "partial weight bearing" with a two person assist for all transfers. On 4/28/15 at approximately 1:40 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she did not know what resident 56's weight bearing status was. On 4/28/15 at 1:50 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that resident 56 was non-weight bearing related to the left patellar fracture. On 4/28/15 at 2:10 PM, the facility Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 56 should be non-weight bearing. On 4/28/15 at approximately 2:40 PM, RN 1 and CNA 1 were observed while assisting resident 56 to a standing position. RN 1 and CNA 1 had resident stand, while bearing weight on both lower extremities. On 4/28/15 at 2:45 PM, RN 1 was again interviewed related to resident 56's non-weight bearing status. RN 1 stated "we try" to maintain the non-weight bearing status. On 4/28/15 at approximately 3:00 PM, RN 1 and CNA 3, who also functioned as the facility restorative aide, were observed while transferring resident 56 from her wheelchair to the scale. Resident 56 was bearing weight on her left lower extremity while walking forward and turning around. On 4/28/15 at approximately 3:14 PM, the Director of Therapy (DOT) services was interviewed. The DOT stated that resident 56 was ambulated with a platform walker. The DOT stated that he "thought it was (resident 56's) elbow that was broken not her knee" and that he "didn't clearly understand" where the fracture was and was not aware of resident 56's non-weight bearing status.

Based on observation, interview, and record review it was determined, for 1 of 26 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, facility staff did not place the physician ordered seat belt on a resident while transporting her in her wheel chair. Consequently, the resident fell forward out of the wheelchair and sustained a scalp laceration and subdural hematoma. Additionally, a housekeeping cart was observed to be unlocked and unattended. Resident identifier: 32. Findings include: 1. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/18/14 resident 32's medical record was reviewed. Review of the medical record revealed a "Fall Risk Assessment" completed on 2/24/14. According to the "Fall Risk Assessment", resident 32 received a score of 10. The score of 10 indicated that resident 32 was at a "High Risk" for falls. Review of physician's orders [REDACTED]." Review of resident 32's plan of care revealed the following care plan: "Care Plan Type: Falls Problem: At Risk for Injuries From Falls Due To Recent History of Falls Additional Problems: Related to: (Resident 32) has a history of falls without serious injuries and Dementia and Parkinson's Manifested by: (Resident 32) has history of agitation, poor trunk and muscle control d/t (due to) Parkinson's, and is dependant on staff for mobility (Resident 32) requires enablers (seat belt in chair and low bed in bed) to help prevent injuries and falls due to Parkinson's." The goals of the care plan were: "(Resident 32) is to have no falls unreported to MD (Medical Doctor) during stay." "Staff to practice injury prevention measures TNR (Through Next Review)." Review of the medical record revealed the following nursing entries: a) "03/08/2014 3:12AM Nursing rt (resident) wanted to get up and be in her WC (wheelchair) for a bit. rt was sitting in WC by nurses station and then wanted to lay back down in bed after about 10 minutes of being up. at 0225 (2:25 AM) aid (sic) was wheeling pt to room and had just entered pt's (patient) room when pt started to tip farther forward than normal. aid tried to catch rt to keep her in the WC but only caught the brief which ripped. pt head dove out of chair and landed on her head on the front side. aid came and got this nse (nurse). this nse went into room et (and) found rt laying on floor on left side, head facing the bed. rt crying loudly. this nse noticed large puddle of blood on floor et large laceration on left side of forehead et bone was visible. this nse called another nse, (initials of a facility nurse), in to help. asked rt what hurt and she stated her head and hips. this nse controlled bleeding while (initials of facility nurse) placed steristrips on laceration. (Initials of facility nurse) and aid remained in room while this nse called non-emergent transport at 0230 (2:30 AM), called (name of local acute care emergency room ) at 0240 (2:40 AM) et gave report to (name), called (name), son, at 0245 (2:45 AM) et notified him of the situation. (Name of Son) stated he was in Ogden and couldn't meet his mom at the hospital, et requested I call his brother, (name). Attempted to call (name) but got no answer. Called (Name of Son) back et told him I couldn't get a hold of (name). Asked (name) if the ER (emergency room ) had questions for him if they could call him; he agreed. morphine 1 ml (milliliter) (20mg (milligram)) given by (initials of nurse) for pain control at 0240 (2:40 AM). Non-emergent positioned pt on backboard, applied c-collar (cervical) on pt, et left at 0300 (3:00 AM) to (name of local acute care emergency room ). notified DON (Director of Nursing) via text at 0311 (3:11 AM)." b) "03/08/2014 4:44AM Nursing staff at (name of local acute care emergency room ) called. pt has subdural hematoma. staff at hospital wanted to know about treatment since pt is a DNR (Do Not Resuscitate). told staff to call pt's responsible party, (name). current phone number given to staff. ER fall update (sic)." On 3/18/14 at 1:15 PM, Certified Nursing Assistant (CNA) 2 was interviewed via telephone. CNA 2 stated that she was the CNA on duty the night that resident 32 fell . CNA 2 stated that resident 32 was moaning out that night and wanted to get out of bed. CNA 2 stated that she assisted resident 32 to get out of bed and then wheeled resident 32 to the nurses' station. CNA 2 stated that after sitting at the nurses' station for about 10 or 15 minutes, resident 32 wanted to go back to bed. CNA 2 stated that she was wheeling resident 32 back to her room when resident 32 began leaning forward in the wheelchair. CNA 2 further stated that resident 2 was falling out of the wheelchair and she (the CNA) attempted to grab resident 32 by the incontinence brief to keep her from falling. CNA 2 stated that the brief tore and resident 32 fell out of the wheelchair and onto the floor. CNA 2 stated that resident 32 had had a similar fall like this before. CNA 2 stated that resident 32 was supposed to have the seat belt on while in the wheelchair because of the previous fall. CNA 2 stated that she had not placed the seat belt on resident 32 when she placed her in the wheelchair. CNA 2 further stated that she (the CNA) had been told by another employee that the seat belt for resident 32's wheelchair was broken. CNA 2 stated "I didn't even check the seat belt. I was told that it was broken so I just put her in the wheelchair and did not put the seat belt on her." On 3/18/14 at 2:00 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that resident 32 used the seat belt in the wheelchair because resident 32 would lean forward in her wheelchair and fall out. On 3/18/14 at 1:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that resident 32 used the seat belt in the wheelchair because resident 32 would lean forward in the wheelchair and fall out. The DON stated that resident 32's family was upset with resident 32's fall. 2. On 3/17/14 at 9:15 AM, an observation was made of a housekeeping cart in the 100 hallway near the main dining room that was unlocked and unattended. The following chemicals were observed to be inside the unlocked housekeeping cart: a. Lemon Furniture Polish with a warning to "remove contaminated clothing" and to "move into fresh air and resuscitate if necessary." b. Carpet cleaner with a warning to "keep out of reach of children." c. Comet Cleaner with a warning to "call poison control center if ingested." d. Sublime cleaner with a warning to "keep out of reach of children" and that "harmful if swallowed." Also inside the unlocked and unattended housekeeping cart was a pair of scissors. On 3/17/14 at 9:20 AM, an interview was conducted with the housekeeper. The housekeeper stated that she should not have left the housekeeping cart unlocked and unattended and that it was "usually closed and locked."

Based on interview, record review, and observation, the facility did not ensure that 3 of 51 residents who entered the facility without a pressure sore did not develop pressure sores. Specifically, three residents developed a pressure sore, one of whom required an amputation. Resident identifiers: 10, 97, and 98. Findings include: 1. Resident 97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/12 resident 97's medical record was reviewed. Resident 97's "Progress Note" from a local clinic dated 7/5/12 documented that resident 97 had experienced a fall at home approximately two weeks prior, that resulted in an ankle fracture. The physician examined resident 97's foot at that time and noted no concerns with resident 97's skin condition. The progress notes also revealed that resident 97 had an "ankle/walking cast applied" with instructions to return in five weeks for removal of the cast. Resident 97's medical record revealed the following as documented by facility staff: a) On 8/2/12, a Pressure Sore Risk assessment revealed that resident 97 was at "high risk" of developing a pressure sore. It should be noted that facility staff documented that resident 97 did not have any sensory impairment even though she had a [DIAGNOSES REDACTED]. b) On 8/8/12, the Weekly Skin Assessment revealed there was a cast on resident 97's left ankle. c) On 8/13/12, a "Progress Note" dated 8/13/12 revealed that resident 97's cast was removed. d) On 8/13/12, a physician's telephone order revealed that resident 97 was to wear a "unaboot for healing fx (fracture)". (Note: No orders could be found to indicate how resident 97's boot was to be monitored, or when resident 97 could have the boot removed, i.e. for showers, etc.) e) On 8/17/12, the Weekly Skin Assessment revealed that resident 97's skin was clean, dry, and intact. f) On 8/20/12, a physician's telephone order revealed that resident 97 was to wear a "hard boot" for her left ankle fracture to "protect ankle - not unaboot". g) On 8/24/12, the Weekly Skin Assessment revealed that there was a "special boot" on resident 97's left foot due to her fracture. Staff did not document if they removed the boot to assess resident 97's skin at that time. h) On 8/31/12, the Weekly Skin Assessment revealed that there was a "brace" or "boot" applied to resident 97's left foot. Staff did not document if they removed the boot to assess resident 97's skin at that time. i) On 9/7/12, the Weekly Skin Assessment revealed that there was a "special boot" applied to resident 97's right foot. Staff did not document if they removed the boot to assess resident 97's skin at that time. j) On 9/11/12, a "Progress Note" revealed that the physician noted that resident 97 was "barely able twinge muscles in LE's (lower extremities). Sensation decreased to knees, mostly gone in lower legs." The physician discontinued the left foot boot at that time as the ankle fracture was healed. k) On 9/14/12, the Weekly Skin Assessment revealed that there was a left "heel stage II pressure ulcer 2" (inches) x (by) 2" small amount of yellow drainage. No odor." Resident 97's "Pink Sheet", a tool used for wound tracking, was reviewed. Review of the pink sheet revealed that as of 9/14/12, facility staff began tracking a "2 (inch) x 2 (inch) white pressure sore to L (left) heel scant serous drainage not open yet small leakage from tiny hole (no) odor." The pink sheet revealed that no measurements of the wound had been taken of resident 97's pressure sore after the initial assessment on 9/14/12. The pink sheet also revealed that the sore on resident 97's left heel was "black" as of 9/28/12, and was "odorous" by 10/2/12. The pink sheet also indicated that on 10/3/12 resident 97 was taken to the local wound clinic. The "Patient Evaluation Report" from the wound clinic dated 10/3/12 was reviewed. The report documented that resident 97's heel wound was now 2.68 inches by 2.99 inches and was now "unstageable" with 80% of the wound listed as "black". The report documented that the wound "appears to be infected and deeply engrossed into the foot." The report also documented that resident 97 was "sent to floor to be admitted for antibiotics and possible surgical intervention." Resident 97's hospital records were obtained. The records documented that on 10/3/12, after being seen in the wound clinic, resident 97 was admitted to the hospital with [REDACTED]. On 11/28/12 at 3:30 PM, an interview was conducted with Medical Doctor (MD) 1 regarding resident 97. MD 1 stated that he visited resident 97 on 10/3/12 when she was seen at the wound clinic. MD 1 stated that this occasion was the first time he had seen resident 97's wound. MD 1 then stated that when he saw resident 97's wound "it was clear that it (the left foot) was going to have to be amputated. MD 1 stated that he was the physician who admitted resident 97 from the wound clinic." MD 1 then stated that the facility staff had to have been "ignoring" the wound for it to have progressed to a "necrotic" state. MD 1 stated that when the surgeon was called in to look at the heel "he took one look at it and said it would have to be amputated." MD 1 stated that resident 97 was "somewhat mentally handicapped so she can't tell you what's going on." MD 1 further stated that resident 97 had "[MEDICAL CONDITION] - of that there was no doubt." When asked about the progression of a wound in a resident with a [DIAGNOSES REDACTED]." MD 1 then stated that he was "angry" about resident 97's pressure sore and that "the wound clinic was too . . . it was clear that it was negligence on the facility's part." MD 1 then stated that the pressure sore was "definitely their (the facility's) fault". MD 1 further stated that after this incident he did not allow the facility staff to treat residents' wounds in the facility, but instead had them sent to the wound clinic to be taken care of. MD 1 then stated that there had been several residents who had acquired avoidable pressure sores at the facility recently, including resident 98. On 11/28/12 at 3:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding resident 97. The ADON stated that when resident 97 first admitted to the facility, she had a cast in place on her left ankle. The ADON stated that the cast was eventually removed and a hard boot was put into place. The ADON stated that when resident 97's pressure sore was first observed by facility staff the wound was "not open" but interventions were put into place. The ADON stated that after residents 10 (see below) and 97 acquired pressure sores in the facility, there were some "revisions" made to the wound program in the facility. On 11/28/12 at 11:20 AM, an interview was conducted with the facility Director of Nursing (DON) regarding resident 97. The DON confirmed that no orders were in place regarding the intermittent removal of resident 97's hard boot., i.e. for showers. The DON stated that after resident 97 was admitted to the hospital and had an amputation, she had investigated the concern to determine if the facility could have prevented the pressure sore. The DON provided a copy of her investigation, which included a statement that resident 97 had multiple risk factors and "I think our charting is in place and I think we should meet with (MD 1) to resolve his concerns." The DON stated that MD 1 was "upset about it" but that resident 97 had severe [MEDICAL CONDITION]. The DON stated that she felt the facility could not have prevented the pressure sore, but that resident 97's surgery the facility put a "wound team" together. When asked about the wound team, the DON stated that it consisted of the ADON and three other nurses. The DON also stated that they had not changed their wound care policies or protocols, but that the wound team "was mainly just put into place for consistency in nurses" who did the dressing changes. 2. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/27/12 at 12:30 PM, resident 10 was observed while sitting in her wheelchair next to the nurse's station. Resident 10 was observed to have a quilted bootie on her left left and a egg crate splint to the right lower extremity. Resident 10's medical record was reviewed on 11/27/12. On 5/30/12, the facility staff completed a significant change MDS assessment for resident 10. The facility staff assessed resident 10 as not being alert and oriented and requiring extensive assistance of one person with bed mobility, dressing, and personal hygiene. The facility staff assessed resident 10 as requiring extensive assistance of two people for transfers and toileting. Resident 10 was further assessed as having impairments on both sides of her lower extremities, and was at high risk for developing pressure sores but had no healed or unhealed pressure sores. A Care Area Assessment (CAA) triggered for pressure ulcers. The facility staff documented that the CAA would be addressed in a care plan. On 9/26/12, the facility staff completed a quarterly MDS assessment for resident 10. The facility staff assessed resident 10 as not being alert and oriented and as requiring extensive assistance of one person for eating. The facility staff assessed resident 10 as requiring extensive assistance of two people for bed mobility and dressing. Resident 10 was further assessed as requiring total assistance of two people for transfers and toileting. Resident 10 was assessed as having impairments on both sides of her lower extremities, was at high risk for pressure ulcers, and had two (2) Stage 2 pressure sores. The care plans developed by the facility staff for resident 10 were reviewed. The facility staff developed a "Risk for Alteration in Skin Integrity" care plan related to: 1. Decreased mobility; 2. Incontinence; 3. Problems with performing own self care; 4. Generalized debility resident on hospice cares; and 5. Weight loss "The facility staff documented the "Risk for Alteration in Skin Integrity" care plan as "exhibited by: 1. Resident has Braden scale of 12 showing high risk for skin breakdown; 2. History of multiple skin tears due to falls - fragile skin; 3. Stage 2 pressure ulcer to left heel; and 4. Stage 2 pressure ulcer to coccyx". The facility staff developed the following goals: "1. Resident/staff will demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing TNR (To Next Review) 2. No signs/symptoms of skin breakdown will occur. If signs and symptoms do occur they will be promptly recognized and treated appropriately X 90 days". The interventions developed by the facility staff to achieve the above goals included: "1. Reposition resident q2 (every 2 hours) hours in bed or chair - grab bars in place on bed to assist (REPOSITION MORE FREQUENTLY IF RESIDENT WILL ALLOW); 2. Weekly skin assessment; 3. Provide measures to decrease pressure/irritation to skin: Pressure relieving device on bed, gel pad to wheelchair and heel boots at all times; 4. Change incontinent pad ASAP (As Soon As Possible) after voiding/defecating; 5. Monitor for signs and symptoms of impaired circulation; 6. Examine feet/nails routinely and provide foot and nail care as indicated; 7. Inspect skin surface;folds and bony prominences routinely; 8. Keep sheets and bedding clean, dry and free wrinkles, crumbs and other irritating material; 9. Maintain strict skin hygiene, using mild soap, drying gently and thoroughly, and lubricating with lotion PRN (as needed) - moisture barrier cream to buttocks and use with each change; 10. Notify MD, Hospice, and family of any changes regarding skin integrity PRN; 11. Evaluate q monthly summary and q resident IDT (interdisciplinary team); 12. Resident may see (name removed) wound clinic for left heel wound treatment and dressing changes; 13. Multivitamin, Zinc and vitamin C and increased protine (sic) for wound healing; 14. Sterile dressing to toe until seen by wound clinic; 15. left heel dressing - [MEDICATION NAME], cotton and covain (sic); 16. Tubi grip socks to bothe (sic) LE (lower extremities)". (Note: The care plan was signed by the facility DON on 11/27/12 and printed on 11/27/12. ) Review of the physician's orders [REDACTED]. 1. 7/27/12: The hospice company received an order for [REDACTED]. Cleanse with normal saline or wound cleanser. 2. apply skin prep to surround. 3. apply [MEDICATION NAME] or similar foam bordered dressing. Change q 3-5 days or PRN for drainage or becomes wet". 2. 7/30/12: "CBC (complete blood count), CMP (complete metabolic profile), A1C (hemoglobin A1C), Lipid. Check L heel wound BID (twice a day) - apply [MEDICATION NAME] daily". 3. 8/17/12: The hospice company received an order for [REDACTED]. 4. 8/17/12: "...Pt. to see (local wound clinic) for left heel wound tx (treatment) and orders for drsg (dressing) (changes)". 5. 8/24/12: "Bactrim DS (double strength) PO (by mouth) BID X 10 days for wound infection. Keflex 250 mg (milligrams) PO QID (four times a day) X 10 days for wound infection". 6. 8/30/12: "Zinc 220 mg PO QD (every day), Vit (Vitamin) C 500 mg PO BID, MV (Multivitamin) PO daily, high protein milk". 7. 9/24/12: "Need to re-send to wound clinic for re-eval of heel sores. ...Report back on potential wound on buttocks". 8. 11/20/12: "Labs - CBC, CMP, Lipid, A1C, UA (urinalysis). L 1st toe contusion concern for [MEDICAL CONDITION]. Start Keflex 250 mg TID (three times a day) X 10 days. F/U (follow up) wound clinic - send pictures of her heels". Review of the facility "Nurse's Notes" revealed that the facility licensed nurses and the hospice licensed nursing staff documented the following entries: 1. 7/23/12: "Reported to nurse that resident has a lg (large) blister on her L heel, 4 cm around. Skin is intact, protective barrier applied. No redness or drainage. Reported to hospice nurse". 2. 7/23/12: "(Hospice nurse) in for routine cares visit. ...Large blister on L foot on inside of heel. No s/s of infection. Padding in place. Cares discussed (with) SNF (skilled nursing facility) staff. Will continue as outlined". 3. 7/23/12 noc (night): "Blister still intact (without) drainage. Heel protector in place throughout shift". 4. 7/27/12 at 1:51 PM: "Open blister found on L medial heel. (Physician) office called for wound orders. Hospice office called about wound. They wanted us to call (physician)". 5. 7/27/12: (Hospice) RN (registered nurse) in for routine hospice visit. ...Blister on medial side of left heel 5 cm X 5.5 cm. Slight drainage from outer edge. SNF nurse applied [MEDICATION NAME] drsg. Awaiting orders from (physician). Verbal order faxed from (hospice): cleanse with normal saline or wound cleanser; apply skin prep to surrounding area; apply [MEDICATION NAME] or similar foam bordered dressing. Change q 3-5 days or PRN for drainage or becomes wet. ..." 6. 7/30/12: "Resident went to see physician and got an order to draw CBC, CMP, AC1 (sic), lipid and to check L heel wound BID - apply [MEDICATION NAME] daily, ..." (Note: On 7/30/12, resident 10 was seen by her PCP (primary care physician). The PCP documented "EXTREMITIES: There is 2+ [MEDICAL CONDITION] that is equal bilaterally. There is also an abrasion on the medial calcaneal of the left foot. Apparently, this has been present since last Thursday. She does have an adhesive gauze dressing in the area. ...Assessment and Plan: ...Open wound of the left foot. ...P. ...Instructions were sent to the nursing home as well to make sure that this wound is checked twice a day and that the use of [MEDICATION NAME] should be considered for this wound. If the wound does not appear to be healing within the next several days to weeks, she is to return to the clinic, and we may need to consider referral to Wound Care to follow this wound. Fortunately, the wound does appear quite superficial and is more of an abrasion than an ulcer at this time". ) 7. 8/2/12: "(Hospice Nurse) in for routine hospice. Pt. slept throughout visit. Wound on R heal (sic) dressing (changed), applied skin prep & (and) 4X4 mepiplex (sic) dressing. ...(Facility) staff will (check) wound regularly, cares will continue as outlined". (Note: On 7/30/12, resident 10's physician wrote new orders for the nurses to place an adaptive dressing, not [MEDICATION NAME]. Additionally, the wound was on resident 10's left heel, not right heel.) 8. 8/2/12 at 12:00 PM: "Call was placed to (physician). Reported labs, stated all labs look O.K. No new orders. Dressing was changed to L heel, old dressing had some yellow and bloody drainage area is darker pink. 4 cm around. Resident has been lethargic and did not take meds or eat meals. Hospice CNA (certified nurse assistant) in to visit". 9. 8/6/12: "(Resident 10) in her WC (wheelchair) by nurses desk. HSN (Hospice Skilled Nurse) took her to her room and changed lft heel blister. dresing (with) [MEDICATION NAME] dressing per MD orders. Scabbed over 2 X 1 cm area. Surrounding skin pink/white. ...HSN notified family/MD of recert et (and) wound". (Note: The physician's orders [REDACTED].) 10. 8/13/12: "(Resident 10) was in dining room. She complained of pain in her left heel. HSN removed Vaseline gauze, gauze, coban and ace bandage. Cleansed (with) wound cleanser applied barrier film and applied [MEDICATION NAME] absorbant. Wound moist (with) mod (moderate) serosang (serosanguineous) drainage. Slight odor present upon dressing removal. No s/s (signs of symptoms) of infection. ..." 11. 8/16/12: "...Wound care performed. Wound bed unstageable d/t (due to) eschar 4.5 cm X 3.5 cm. Odor present upon dressing removal. HSN applied skin prep around wound and placed [MEDICATION NAME] (with) border over wound. Placed heel protector over dressing. HSN left [MEDICATION NAME] in room for future changes. (Facility) to change [MEDICATION NAME] q day until (physician) returns HSN call about wound and whether or not to change orders. Status update message left on (name removed) machine. HSN to return Monday for dressing (change) and assessment or before Mon (Monday) if the need arises". 12. 8/17/12 noc (night shift): "...Pt. to see (wound clinic) for left heel wound treatment and orders for drsg (changes)". 13. 8/20/12: "(Resident 10) was resting in her bed (with) her heels elevated. HSN changed [MEDICATION NAME] dressing. Wound clinic appt (appointment) to be made today by transportation. ..." 14. 8/23/12: "...HSN changed dressing L heel. No changes to area. ..." 15. 8/24/12: (Note: Resident 10 was seen by a local wound clinic. The wound clinic documented "skilled nurse to change dressing Mondays, Wednesdays and Fridays and PRN. Apply [MEDICATION NAME] with cast padding/coban followed by off loading boot. Please keep boot on at all times, and heel offloaded. Keep dressing dry at all times - change if it gets wet. Please refer to patient's primary care for pain management. Pt. will return to clinic in one week". 16. 8/25/12 at 12:00 PM: "Resident is on antibiotic for wound. Dressing is intact. Talked (with) hospice nurse about treatment orders". 17. 8/25/12 noc: "Res continues on abx (antibiotic) therapy for wound care. ..." 18. 8/26/12 noc: "Res continues abx therapy (with) adverse effect. ..." 19. 8/27/12: "(Resident 10) resident in bed. She denies any pain at this time. She fell asleep and slept deeply throughout heel dressing change. ...HSN reviewed orders (with facility) nurse and left (wound clinic) orders sheet. (Facility) to change dressing M et F". 20. 8/27/12 Day: "Received wound orders by way of Hospice nurse. Please see extensive orders in RX (physician) orders". 21. 8/27/12 NOC: "...resident continues on abx therapy (without) adverse rxn (reaction)". 22. 8/28/12 at 3:00 PM: "...Res cont. on abx therapy for her heel injury (without) adverse effects. Will cont to monitor res for adverse effects". 23. 8/28/12 Noc: "..."...Res. tolerates abx for heel wound (with out) any adverse effects. ..." 24. 8/29/12 at 11:25 AM: "...No s/s of adverse reaction r/t abx therapy". 25. 8/29/12 NOC: "...Res. cont. on ABX for sore on heel. Drsg clean, dry, et intact (without) adverse reactions to ABX tx. Res. sleep well t/o (through out) the evening". 26. 8/30/12 at 10:00 AM: "HSN assessment and vitals. ...(Resident 10) resting in her recliner. quickly returns to sleep after answering HSN questions. she complains of pain on her bottom. HSN et CNA's stood her up and placed [MEDICATION NAME] over area to protect. Large red area that blanches well. HSN placed barrier cream over area. Repositioned pt. in recliner and placed pillow under legs to prevent pressure". 27. 8/30/12 at 3:15 PM: "Resident went out to wound clinic. Continue dressings as ordered. Resident is awake et alert @ (at) this time. Call was placed to (physician) for order for vit C, MV, Zinc, Protein powder. 1800 (6:00 PM) TO (telephone order) from (physician's) nurse returned call. see order for supplement". (Note: Resident 10 was seen by a local wound clinic on 8/30/12. The wound clinic physician documented "...referred to the skin and wound care department with the chief complaint, blister on left heel for past 2-3 weeks. Condition Summary: ...Family is concerned about level of care that is being given at the Rehab facility and would like a second opinion about dressing regiments. ...Wound Location: Medial Aspect of the Left Heel. Classification - Pressure Ulcer. Size: L (length) 4.2 cm; W (width) 6.0 cm. Type - Unstageable. Tissue Type - Eschar... Color - red 20%; Black 80%. Subcutaneous tissue exposed". The wound clinic provided new orders which included: "Continue with dressing changes as ordered 8/24/12. Please place piece of foam on top of foot after a couple of layers of cast padding to protect reddened area. You may re-use foam (with) drsg changes. We are also sending an extra piece . Dress the foot further toward toes to help control swelling/[MEDICAL CONDITION] in the foot. ...") 28. 8/30/12 NOC: "...Res cont. on ABX tx d/t wound on L heel. (No) adverse effects r/t ABX tx reported by staff or res (resident). Will cont to monitor res. for adverse effects". 29. 8/31/12 NOC: "Res. continues abx therapy (without) adverse reaction. (No) c/o (complaints of) NVD (nausea, vomiting or diarrhea) or pain noted. She did appear to be a little anxious this evening..." 30. 9/1/12 at 12:00 PM: "...continue on abx for wond (sic) infection. No adverse reactions seen by this nse (nurse). wond (sic) dsg (changed). foot padding applied. elevated L leg (with) pillow". 31. 9/2/12 day: "...continuing on abx therapy for wond (sic) infection (with out) adverse effect noted". 32. 9/2/12 NOC: "Res. continues abx therapy for wound care (without) adverse effect". 33. 9/3/12 at 12:00 PM: "Antibiotic was given for wound infection. No C/O nausea, no observed rash. Resident denies pain @ site. Foot padding is on. Dressing is intact. ..." 34. 9/3/12 NOC: "...Res completed ABX treatment today (with out) adverse effects reported by staff or res. Res family was in to spend the day (with) res. Res. in great spirits while family was here. Her mental affect is improved when family is her (sic). Res. able to speak clear in full sentences today during cares. Res was physically exhausted in evening et fell asleep as soon as family members left. This nurse informed family members of improvement in res. spirit et mental affect when they visit". 35. 9/4/12: "Hospice nurse in for routine visit. (Resident 10) c/o pain in coccyx area. this nurse and aide toileted resident, then repositioned onto R side. Nurse notified of report of pain and she will continue to monitor. Res. now resting comfortably and currently sleeping. Drsg on L heel intact. Pt. wearing pressure reducing boot on L foot. ..." (Note: On 8/24/12, the wound clinic physician gave orders for the resident to have "off loading boots" on at all times, not a pressure reducing boot.) 36. 9/6/12: "(Resident 10) deep asleep in her bed. She slept through the whole assessment. Vitals and skin check. Rt (right) blister forming. HSN communicated this with (facility) et requested a heel protector. ..." (Note: The HSN or the facility licensed nurses did not document that the physician was notified of the right heel blister). 37. 9/10/12: "(Resident 10) in bed, not responsive to voice but opened her eyes briefly to touch. HSN changed lt heel dressing per MD orders, placed [MEDICATION NAME] on lt ant (anterior) ankle to prevent redness. Rt heel small area hardened and dark. HSN placed [MEDICATION NAME] over area to protect along (with) bilat (bilateral) heel/foot protectors. No signs of pain noted at this time. ..." (Note: The order was for resident 10 to have off loading boots on at all times, not bilateral heel protectors). 38. 9/13/12: "(Resident 10) is sleeping in her bed. her senior companion is here to visit pt. She is confused and disoriented. CNA X 2 assisted pt. to the bathroom per pt. request. L heel dressing c/d/i (clean/dry/intact). R heel dressed (with) [MEDICATION NAME], wrapped in cast padding and heel protector replaced". 39. 9/17/12 at 3:00 PM: "HSN for routine assessment & vitals. ...(Resident 10) resting/sleeping in her chair through entire visit. Pt. woke up for brief moments (with) drsg (change) on R & L heel. R heel has small black blister - blister closed. Wrapped R heel (with) padding & placed heel protector on. L heel cleansed (with) wound cleanser. [MEDICATION NAME] placed over ulcer - ulcer hard & black. L heel wrapped (with) cast padding & heel protector/boot replaced. Pt. woke up (with) nonverbal cues of pain (with) drsg (change) - grimace/movement & c/o pain "all over". (LPN) at (facility) notified of pain. ...LPN states (no) other changes @ this time. [MEDICAL CONDITION] noted 3+ in L foot and 2+ in R foot. Ft (feet) elevated in recliner. will continue to provide cares & to monitor". 40. 9/20/12 "(Resident 10) was resting in bed after eating lunch. she awoke to voice and touch but quickly returned to sleep. HSN removed dressing on rt heel. assessed and wrapped (with) [MEDICATION NAME], cast padding, ace bandage and heel protector. ..." 41. 9/24/12: "(Resident 10) was in her recliner and kept yelling out "(name removed)". She said it was her brother. HSN changed her L heel dressing. 4 X 6 cm black, (no) drainage or s/s of infection. Placed [MEDICATION NAME] over L ankle redness and R heel dry/hard area. Wrapped (with) cast padding and ace bandage. [MEDICATION NAME] placed on L heel after cleansing. ..." Note: On 9/24/12, resident 10 was seen by her PCP. The PCP documented "...They (the son and daughter-in-law) are concerned about a sore on her left heel. ...There is a concern that the right heel is now developing a sore as well. ...There is +3 [MEDICAL CONDITION] noted on her feet bilaterally. the left calcaneal area reveals a large decubitus ulcer that is black. There is questionable tenderness to palpation as the patient responds minimally to communication. The lateral aspect of the right heel also has an area that looks like it is a potential concern. This area has [DIAGNOSES REDACTED]. No [MEDICAL CONDITION] is present. It is mildly tender to palpation and appears to be from pressure as well. ...P (Plan). ...continue with cautious wound care. A note was sent to the facility to make sure that they are checking this wound at least daily and changing the dressings as directed by the wound specialist. ...She may need to return follow up with (wound care physician) to assess not only her left heel but also the right heel as this is becoming an issue. The biggest concern is that pressure is the cause of this and she is not being moved sufficiently or not having the proper support to alleviate pressure from some of these areas. ..." 42. 9/25/12 Day: "Resident out to see (physician), order are 1. Need to resend pt. to wound clinic for re-eval of heel sore. 2. ensure hearing aides are removed q night. 3. report back on potential wound on buttocks. Transportation was notify (sic) and will call to set up a date for resident to go back". 43. 9/25/12 Day: "Return from wound clinic. Order are 1. continue L heel dsg as previously ordered (with) [MEDICATION NAME], cotton et coban. 2. No dsg to R heel other than cotton et coban PRN. 3. Off loading to heels (with) boots at all times. 4. No pressure to heel when in chair. 5. Reposition as often as possible. 6. Offloading cushion to wc et chairs. 7. Increase time in bed to offload heels. 8. Moisture barrier cream to buttocks et crease (with) each diaper (change). 9. [MEDICATION NAME] (with) adhesive foam to L antior ankle ulcers. 10. 1 layer of [MEDICATION NAME] size E to both LE (lower extremities)". 44. 9/27/12: "(Resident 10) resting in her bed after lunch. Dressing clean and intact. HSN reviewed new wound care orders. Hospice to perform wound care dressings Mondays". 45. 9/26/12: Resident 10 was seen at a local wound clinic. The wound clinic documented the following: "1. Cont (continue) L heel dressing as previously ordered with [MEDICATION NAME], cotton, coban. 2. No dressing to R heal (sic) other than cotton and coban (if needed). 3. Off loading - heals (sic) with boots at all times. 4. Please try to arrange no pressure to heels when in chair. 5. Please reposition as often as possible. 6. Off loading cushion to wheelchair and chairs. Dx: Pressure ulcer to buttocks Stage II. 7. Increase time in bed to off load heals (sic). 8. Moisture barrier cream to buttocks and cream with each diaper change. 9. [MEDICATION NAME] with adhesive foam to L anterior ankle ulcers. 10. 1 layer of [MEDICATION NAME] size E to both LE (lower extremities)". 46. 10/1/12: "HSN changed L heel dressings per wound clinic orders. Antior (anterior) wounds healing, posterior wound unchanged (with) s/s of infection. she is confused and continues to call out. [MEDICATION NAME] intact coccyx. (Note: The wound clinic order for the coccyx wound was a moisture barrier cream, not [MEDICATION NAME]). 47. 10/5/12: "(Resident 10) sleeping in recliner. (Facility) nurse reports she has been sleeping most of the day. Dressings changed today by (facility). Hospice recert today d/t pt. continues to decline. 5-15 sec (seconds) apnea. R (respirations) 10, P (pulse) 76, BP (blood pressure) 94/50, O2 (oxygen) 94% on RA (room air). Apnea reports to (physician) and (facility) nurse. Will continue to assess". 48. 10/8/12: "(Resident 10) finished with lunch. HSN took her back to her room, assisted ((with) CNA) pt into recliner. HSN changed her L heel dressing. R heel dry skin removed leaving pink fresh skin. [MEDICATION NAME] bilat. L (with) heel protectors. Coccyx dressing changed with [MEDICATION NAME] (sic) absorbant. ...". (Note: The wound clinic order for the coccyx wound was a moisture barrier cream, not [MEDICATION NAME]). 49. 10/11/12: "(Resident 10) was in her wc after having a bath. HSN changed her L foot wounds per wound care orders - tolerated well. ..." 50. 10/18/12: "(Resident 10) was sleeping in bed and did not wake up during the visit. (Facility) states she hardly slept last night. ...all dressings CDI. Continue hospice". 51. 10/21/12 at 2:30 AM: "CNA helped res to restroom, dressing to coccyx appeared to be soild (sic). This nurse (changed) dressing - res laying in bed, and is on her right side, foam boots to blth(sic) heals (sic). ..." (Note: The wound clinic order for the coccyx wound was a moisture barrier cream, not a dressing). 52. 10/21/12 at 3:30 PM: "...message left for hospice regarding skin tear et wond (sic) on coccyx is not improving". 53. 10/21/12 at 4:05 PM: "(H

Based on observation, interview, and medical record review it was determined for two sample residents that the facility did not ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, one residents developed a pressure sore that was avoidable. A second resident developed a pressure sore with no physician's orders to treat the pressure sore until 47 days after the pressure sore developed. Resident identifiers: 23 and 25. 1. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. included diabetes mellitus type II, [MEDICAL CONDITION], spinal stenosis, [MEDICAL CONDITION], obesity, anxiety and depression. On 4/14/11 resident 25's medical record was reviewed. Review of the admission MDS (Minimum Data Set) dated 12/8/10 revealed that facility staff assessed resident 25 as requiring extensive assistance with a one to two person physical assist with bed mobility, dressing, toilet use, and personal hygiene. Facility staff assessed resident 25 as always being incontinent of bowel and bladder with a toileting program in place to manage her bowel incontinence and as being at risk for developing a pressure ulcer. On 12/1/10 facility staff completed a Braden Scale Assessment for Predicting Pressure Sore Risk. Resident 25 received a score of 13. According to the Braden Scale assessment used by the facility, a score of 12 or less indicated the resident was at a high risk for developing a pressure ulcer, a score of 13-14 indicated that the resident was at moderate risk for developing a pressure ulcer. Review of "Weekly Nursing Assessments" completed by facility staff on 1/5/11, 1/27/11, 3/2/11, and 4/6/11 revealed that facility staff assessed resident 25 as being alert with her short and long term memory intact. Facility staff assessed resident 25 on 1/27/11, 3/2/11, and 4/6/11 as having no indicators of [MEDICAL CONDITION] in the last 7 days. Review of the "Weekly Nursing Assessments" completed by facility staff revealed no documentation of skin issues for resident 25 on 4/6/11, 3/2/11, 1/27/11, nor 1/5/11. An undated skin assessment located between 1/5/11 and 1/27/11 indicated that resident 25 had some redness to her coccyx. Review of Physician's orders revealed a physician order dated 3/17/11. The order was for resident 25 to receive zinc, multivitamin, and vitamin C due to an open sore on "bottom". Review of the admission nursing assessment dated [DATE] revealed facility staff documented that resident 25 had no skin issues upon admit to the facility. Review of daily nurse charting notes dated 12/30/10 to 1/19/11 revealed no documentation that resident 25 had any skin breakdown or concerns. On 1/20/11 it was documented on a "Daily Physical Assessment" that resident 25 had a "slightly" red coccyx and barrier cream was applied. Review of the daily nurse charting from 1/21/11 to 3/10/11 revealed no further entries or documentation regarding resident 25's red coccyx nor any skin breakdown or conditions. Review of facility nurses notes revealed an entry dated 3/17/11. It was documented in the nurses notes by a facility nurse that, "Res. (resident) needs to receive supplements to help heal sores, suggested to use Zinc, Multivitamins, Vit C (vitamin C) until healed. Dr. Nash notified." No further documentation could be found regarding the condition of resident 25's skin. Review of "Nutrition Intervention Progress Notes" revealed an entry dated 3/15/11. It was documented by facility staff that resdient 25 had a "wound on her coccyx, sits in wheelchair quite a bit, has a gel pad, not taking a multivitamin... add zinc, vitamin c, and multivitamin" Review of wound records revealed that resident 25 had a red area on coccyx in February 2011. Facility staff documented on a wound form that resident 25 had redness on her coccyx from 2/2/11 through 2/24/11. On 2/24/11 it was documented that resident 25's redness on her coccyx was healed. Review of the facility care plan for resident 25 revealed a care plan dated 12/13/10 for Risk for Alteration in Skin Integrity. No current updates could be found on the care plan. Facility staff documented on the care plan that resident 25 was at risk for alteration in skin integrity related to decreased mobility, decreased sensation, [MEDICAL CONDITION], incontinence, and problems with performing own self care. Facility staff documented that the goals of the care plan were for resident 25 to maintain intact skin TNR (through next review), skin will be clean and dry Q (every) shift X (times) 90 days, resident/staff will demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing TNR, any existing skin problems will be healed and no complications will arise TNR, and no signs/symptoms of skin breakdown will occur. If signs and symptoms do occur they will be promptly recognized and treated appropriately X 90 days. Facility staff documented the following interventions to aide resident 25 in achieving the stated goals: "reposition resident Q 2 hours, weekly skin assessment, provide measures to decrease pressure/irritation to skin: heel protectors, elbow protectors, pressure relieving device on chair, pressure relieving device on bed ... administer skin txs/ointments (treatments) per MD (medical doctor) orders ..."` Review of physical therapy notes revealed no documentaion about dressing changes. On 4/14/11 at 9:20 AM, Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated that resident 25 was continent of bowel and could be both incontinent and continent of urine but that resident 25 was usually incontinent of urine in the brief. CNA 3 stated that resident 25 was not resisitive to cares. CNA 3 further stated that she was not aware of resident 25 having any current skin issues. On 4/14/11 at 9:30 AM, CNA 1 was interviewed. CNA 1 stated that resident 25 required assistance with all of the ADLs (Activities of Daily Living) including turning and repositioning. CNA 1 stated that resident 25 required assistance with toileting. CNA 1 further stated that resident 25 was not in bed much and spent most of the day in activities. On 4/14/11, Licensed Practical Nurse (LPN) 3 was interviewed. LPN 3 stated that resident 25 had a pressure sore in February 2011 that had healed a couple of weeks ago. LPN 3 stated that the sore was 3/4 inch long and was a stage II pressure ulcer. On 4/14/11 at 9:35 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 25 had a sore on her bottom back in February. The DON confirmed that she did not know if resident 25 had a pressure ulcer in March 2011 because of the lack of documentation. The DON stated that she thought that the interventions put into place in March ( vitamin c, zinc, multivitamin) were for the pressure sore resident 25 had in February. The DON confirmed that she did not know if resident 25 has a pressure sore in March. On 4/14/11 observations of resident 25 revealed that resident 25's coccyx was red and blanchable with no open areas. Observations also revealed that resident 25's buttocks were red with no current breakdown. On 4/14/11 resident 25 was interviewed. Resident 25 stated that she could not turn herself in bed and had to rely on staff to assist her with turning. Resident 25 further stated that staff did not come into her room and help her turn. Resident 25 stated that she just lays in bed in one place. On 4/12, 4/13, 4/14, and 4/18/11 resident 25 was observed sitting in her wheel chair with no pressure relieving device in place. On 4/14/11, resident 25 was observed to have an area of breakdown on her left lower calf area. Facility staff and resident 25 both stated that the area of breakdown on her left leg was caused from the new wheel chair. Facility staff and resident 25 further stated that the area of breakdown was from resident 25's leg resting on the leg rest of the wheel chair. 2. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/14/11 at 8:21 AM, the physical therapy manager (PTM) was observed doing a dressing change on the stage II coccyx pressure ulcer of resident 23. The stage II pressure ulcer was approximately 2 centimeters wide and 1.5 centimeters long. The PTM cleansed the wound with and applied a wound gel onto an Allevyn dressing and applied it to the wound. As the PTM changed the dressing he discussed the history of resident 23's pressure ulcer. The PTM stated he started treating the pressure ulcer on resident 23's coccyx two years ago. The PTM stated they had used a wound vac, however, the wound had been like it was for the last year. The PTM stated it would get almost closed then something would happen at night or over the weekend, or someone rolled her wrong and the pressure sore would open. The PTM stated resident 23 needed to be moved with a draw sheet so the ulcer would not open again. The PTM stated the wound had been closed at one time. He stated he documented the healing and measurements of the wound in the physical therapy notes. The PTM stated he had not documented anything on the wound for the last month because he had been "busy". The PTM stated that nothing had changed in the pressure ulcer for the last month. The PTM stated he changed resident 23's dressing during the week and the nurses changed it during the weekends. The facility policy for Wound Care was reviewed. The policy indicated the physician would be notified and wound care orders would be obtained. The healing program indicated that preventative measure would be implemented and the following list would be used as a guide. A stage II pressure ulcer would use a [MEDICATION NAME] dressing. A stage III and IV pressure ulcer would use Allevyn or gauze dressing. The Allevyn dressing should only be changed when saturated. Resident 23's medical record was reviewed on 4/13/11. Resident 23's Minimum Data Set (MDS), dated [DATE] and 1/12/11, indicated resident 23 had one stage II pressure ulcer on a prior MDS. Physician recertification orders dated 4/1/11 indicated: "Change coccyx dressing to steri strips and cover with wound vac adhesive per (PTM)), he will change the dressing". The order was originally written 7/6/10. physician progress notes [REDACTED]. The care plan for Potential for Alteration in Skin Integrity was reviewed. The care plan was dated 4/23/08 and handwritten dates were listed on the bottom of the page every three months until 1/11/11. The problem was related to decreased mobility, [MEDICAL CONDITION] and incontinence all the time. This was exhibited by: "no impairment in sensory perception, nutrition maintained with meal intakes, friction and shear no apparent problem and skin occasionally moist, mobility somewhat limited and history of skin breakdown coccyx, heels. The interventions included repositioning, weekly skin assessment, pressure relieving device, ambulate as tolerated and notify physician and family regarding any changes regarding skin integrity. On 4/14/11 at 10:25 AM, the DON was shown the current recertification physician orders for resident 23's stage II pressure ulcer. The DON stated, "this is really old, we are not using a wound vac." The DON provided an order dated 6/29/10 to continue present wound care, with daily change with a small foam dressing. The DON was shown the care plan for wound for resident 23. The DON stated, "the care plans are very general and not specific to the resident." The DON was asked for documentation of resident 23's pressure ulcer care. A wound form dated 11/11/10 through 1/2/11 indicated the wound was pink, there were no changes and there was drainage in December 2010. The notes dated 12/26/10 described a black quarter sized spot to resident 23's left heel and heel protectors were placed on resident 23. A Wound Form dated 1/2/11 through 4/14/11 indicated at times the ulcer was a stage II and that the dressing was changed by the PTM using an Allevyen dressing. The form did not indicate if it was the coccyx ulcer or the heel ulcer. Physical Therapy notes in the current medical record were dated 1/21/11 through 2/25/11. The Physical Therapist Manager provided notes dated 3/4/11 through 4/8/11 on 4/14/11 at 3:30 PM. Physical Therapy Evaluation Form/Progress Notes dated 9/3/10 through 4/8/11 were reviewed. The notes dated 9/2/10 indicated: "ulcer is closed but patient has a severe case of diarrhea and I am very concerned that it will re-open when CNAs roll patient to clean her up it is very difficult to move her and skin is very fragile" On 9/17/10 the ulcer measured 1.5 centimeters by 0.25 centimeters. The 10/22/10 noted: ". . . keeps splitting open when patient is rolled side to side. Trying to use a draw sheet and working with aides to be more careful." The notes indicated that the PTM was working with staff to move resident 23 with a draw sheet and the foam overlay was removed. The 11/25/10 note indicated the ulcer was 1.25 by 0.5 centimeters. On 12/7/10 the note indicated: "ulcer is clean and seems to be closing. Ulcer is 0.2 x 0.3 x 0.2 centimeters. Closed in between 2 smaller openings. Hopefully ulcer will close this next week." On 12/24/10 the note indicated: "ulcer has reopened to 1.5 centimeters long and 0.4 centimeters wide. Seems to be split open, probably while rolling patient. . . . New pressure sore on heel." The heel pressure ulcer was not described. The notes indicated the ulcer was staying the same, however, due to moisture it was becoming macerated. A Foley was put in to drain urine. The 2/25/11 note indicated: "ulcer has closed slightly. Continue to be 1.5 centimeters long but 0.3 centimeters wide . . . will continue to try keeping ulcer dryer and encourage all to turn carefully." The note dated 3/11/11, given to the surveyor on 3/14/11 by the PTM indicated: "ulcer has become longer this past week. Ulcer is 2.25 centimeters long and 0.5 centimeters wide. . . " The 4/8/11 note indicated: "CNAs continue to use a draw sheet and try to position patient carefully. Noted slight bleeding early in the week, but ulcer has good signs of granulation tissue. Ulcer is 1.5 centimeters x 0.3 centimeters." The care plan for nutrition did not include the pressure ulcer. The care plan was dated 4/8/08 and handwritten dates on the bottom of the page indicated review dates every three months to 1/11/11. The Quarterly Nutritional Reassessment dated [DATE], 10/13/10 and 1/12/11 indicated: "has issue with skin". On 4/14/11 at 8:34 AM, resident 23 was asked how she was moved in bed. Resident 23 stated: "they grab hold of my arm and my side and move me roughly. I told them, but to the young aides it doesn't seem to matter." On 4/14/11 at 10:51 AM, LPN 5 was interviewed concerning resident 23. LPN 5 stated she did not know if resident 23 had any special requirements to move her. LPN 5 asked another nurse and the other nurse explained that resident 23 was moved using a draw sheet. LPN 5 stated she now had orders to use a foam dressing on resident 23's coccyx. LPN 5 was asked about the PTM using an Allevyn dressing on resident 23. LPN 5 stated: "if we don't have Allevyn, we would use a foam dressing."

Based on interview and record review the facility did not ensure that two sample residents maintained acceptable parameters of nutritional status. Specifically two residents were noted to have weight loss with little to no timely interventions. Resident identifiers: 83 and 110. Findings include: 1. Resident 83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/13/11 resident 83's medical record was reviewed. Review of resident 83's medical record revealed that on admission to the facility on [DATE] resident 83's weight was 112 lbs (pounds). Review of current facility weight records revealed the following weights for resident 83: 8/21/10: 109 lbs. 8/22/10: 109 lbs. 8/27/10: 105 lbs. 9/01/10: 105 lbs. 9/03/10: 105 lbs. 9/10/10: 105 lbs. 9/17/10: 106 lbs. 9/24/10: 100 lbs. 10/01/10: 99 lbs. 11/01/10: 100 lbs. 12/01/10: 101 lbs. 01/03/11: 100 lbs. 02/01/11: 100 lbs. 03/01/11: 97 lbs. 04/02/11: 88 lbs. Review of the facility policy and procedure for "Preventing Unintended Weight Loss" revealed the following policy: "It is the goal of this facility to use methods to help prevent weight loss and increase nutrition in our residents. This is to help decrease risk for pressure ulcers and general decline in health and well-being." The procedure used by the facility to ensure that the facility adhered to the policy was as follows: "Nurses and CNAs (Certified Nursing Assistants) will be able to recognize and report to MD (Medical Doctor) and NIT (Nutrition Intervention Team) residents who are at risk for weight loss and interventions will be used to help maintain wight for resident or increase nutrition to promote healing and prevent skin breakdown. Nurses and/or CNAs will: 1. Be aware of, and report, changes in intake of food and fluids. 2. Make sure resident is getting the type of diet that is ordered for that resident. 3. Does the resident need specialized utensils (make sure these are provided for resident) ... 4. Prepare food for residents as you serve them, ie; cut things up, butter bread, remove packaging, etc. 5. Don't rush through the meal, or end meal early. 6. Offer to warm food up if not eaten within 30 minutes. 7. Offer the alternate meal if resident does not eat greater than 50 % of the meal. Offer supplement if resident eats less than 50 % of meal and refuses the alternate. 8. Document accurately, and report special concerns for the nurse to document. 9. Residents with weight loss or pressure ulcers will be reviewed monthly in NIT meeting to make sure all needed interventions are in place." Review of resident 83's care plan revealed an "At nutritional risk related to weakness, skin precaution/Fragile skin, Hip Fx (fracture), Limited Mobility [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease)" dated 8/31/10. Facility staff documented the goals of the care plan to be: Resident will eat at least 75 % of meals TNR (through next review), Resident will remain Hydrated TNR, and Stabilize weight, Admit weight 109 ( + or -) 5 lbs TNR. The following interventions were documented to help resident 83 achieve the above listed goals: Diet as ordered, Sit up for meals, Encourage fluids and offer with meals, Offer high fiber food choices daily, Assist as needed/set up tray, Supervise eating, Monitor weight, intake and labs monthly, Protein.> 1.0 -1.5 gm/kg (grams per kilogram), Steady diet, and No Grapefruit juice. No other documentation or intervention could be found on the care plan to show facility staff assessed resident 83's weight loss or implemented interventions to help resident 83 maintain her admission weight. Review of the physician's orders revealed a physician's order dated 4/13/11 for resident 83 to receive ensure TID (three times daily). Review of physician's orders revealed that resident was currently receiving a regular soft diet. No orders could be found, prior to 4/13/11, for resident 83 to receive supplements with medication pass. Review of the "Dietary History and Food/Beverage Preference" dated 8/20/10 revealed an entry dated 8/26/10 to add enrichment to resident 83's current diet. Review of the "Nutrition Screening and Assessement" dated 8/23/10 revealed an entry dated 9/1/10. Facility staff documented that on 9/1/10 staff were to discontinue resident 83 eating in her room and resident 83 was now eating in the Dining Room at the Restorative Nursing Assistant table (RNA). (Note: According to facility staff the RNA table is where the staff place residents who need assistance with feeding themselves, in order to attain independence and be moved to a table that does not require assistance from staff). Review of dietary notes revealed Nutrition Intervention Progress Notes. On 11/18/10 it was documented by facility staff on the Nurtrition Intervention Progress Notes that resident 83 had lost 6 lbs and currently weighed 99 lbs, resident 83 had dementia, a flat affect and ate at the RNA table. Facility staff documented that resident 83, "eats what she wants and refuses what she wants. Is at RNA table - now fairly stable, intakes 60% most meals, May have Sundowners - Nursing trying to give her (name of supplement drink) now." On 3/15/11 it was documented by facility staff on the Nutrition Intervention Progress Notes that resident 83 was, "receiving an [MEDICATION NAME] diet, had no skin breakdown, had Alzheimer's, not active in physical activities. 40, 55, 40 % and supplement. Moved to feeding dining room May see improvement." On 4/12/11 it was documented on the Nutrition Intervention Progress Notes that resident 83 was, "receiving a regular soft diet, had continued loss inspite of feeding. now in restorative, 40, 55, 40 % intake, check to make sure she is on [MEDICATION NAME] diet and SF (supplements) TID (three times daily)". No documentation could be found in resident 83's medical record to show the Registered Dietitian (RD) calculated resident 83's protein needs. No documentation could be found in resident 83's medical record to show facility staff implemented additional interventions for resident 83's 24 lb weight loss in a 7 1/2 month period, 12 lbs. in the first 30 days after admission and 9 lbs between March and April 2011. On 4/18/11 at 9:18 AM, the Dietary Manger (DM) was interviewed. The Dietary manager stated that the ADON (Assistant Director of Nursing) identified the weight loss of residents. The DM stated that on the second Tuesday of every month the DM, DON (Director of Nursing), ADON, and RD met to go over the comments that the ADON had made and then the RD made her recommendations. (Note: This is the facility NIT meeting held monthly.) The DM stated that if interventions were put into place the interventions would be in the chart on the Summary form. The DM stated that resident 83 is very forgetful and just forgets to eat. The DM stated that resident 83 was on an [MEDICATION NAME] diet with supplements. The DM further stated that the [MEDICATION NAME] diet for resident 83 started in March. The DM stated resident 83 received house supplement three times a day with medication pass. The DM stated that resident 83 was moved to the Restorative table in February or March. The DM further stated that resident 83 was moved to restorative in November and was given a supplement by nursing. The DM confirmed that no other interventions had been put into place for resident 83's weight loss other than the [MEDICATION NAME] diet and supplements. The DM stated that resident 83 did not "trigger" for weight loss until March 2011. The DM stated that the RNA table consisted of 1 RNA (Restorative Nursing Aide) per RNA table. The DM further stated that the RNAs are at the table to assist residents in learning to feed themselves, so the residents may move to a table that required no assistance. On 4/18/11 at 9:42 AM, the ADON was interviewed. The ADON stated that he did the NIT meeting and kept the NIT meeting notes. The ADON stated that he determined who triggered for the meeting based on the computer program that he used. The ADON further stated the computer program went off of which residents gained or lost weight. He stated that the resident will trigger if they have had a 2.5 % gain or loss in one month. The ADON stated that residents who weigh 100 lbs go on weekly weights. The ADON further stated that if the 100 lb residents lose even one pound then the program will trigger the resident to be reviewed in the NIT meeting. The ADON stated that the 100 lb residents and below 100 lbs are weighed weekly and the results are given to him to review. The ADON stated that he monitored the weights and then would talk with the DM about any weight loss. The ADON stated that he would document all interventions implemented on his spreadsheet and not in the resident medical record. The ADON stated that he did not have any interventions documented on his spreadsheet for the last three months. The ADON stated that resident 83 had had "quite a bit of weight loss." The ADON stated he did not know if resident 83 was being weighed weekly. The ADON stated that resident 83 was placed on an [MEDICATION NAME] diet on 4/12/11 and on 4/12/11 a physician's order had been written for resident 83 to receive supplements three times daily with meals. The ADON confirmed that there were no physician's orders for resident 83 to receive an [MEDICATION NAME] diet. The ADON stated that resident 83's previous weight loss had either not triggered in his computer program or he had not monitored it closely and "caught the weight loss." The ADON stated that resident 83 had had a definite change in status and was not eating well. The ADON stated that the interventions that are put into place during the NIT meeting are evaluated for effectiveness during the next month's meeting. The ADON confirmed that the interventions put into place for resident 83 on 4/12/11 should have started sooner. 2. Resident was admitted to the facility on [DATE] wtih [DIAGNOSES REDACTED]. Resident 110's medical record was reviewed on 4/11/11. Resident 110's physician admission orders [REDACTED]. The admission orders [REDACTED]. According to the 2011 Nursing Drug Handbook by Lippincott, Williams and Wilkins, 12.5 to 50 mg of HCTZ once daily is used to treat hypertension; 25 to 100 mg daily or intermittently is used to treat [MEDICAL CONDITION]. Resident 110's physician admission orders [REDACTED]. Resident 110's care plan was reviewed. On 3/17/11 a care plan related to "altered patterns of urinary elimination" was developed. The care plan documented that resident 110 had a catheter that had been discontinued 3/6/11 related to "urine retention after surgery". Resident 110's care plan for nutrition dated 3/7/11 documented that resident 110 was at nutritional risk related to advanced age, [MEDICAL CONDITION], fragile skin and limited mobility. One of the goals listed was to "stabilize weight" so that resident 110 was plus or minus 5 pounds of her admission weight of 105 pounds. Resident 110's "Nutrition Screening and Assessment" dated 3/7/11 documented that resident 110's usual body weight was 105 pounds, and that she had not experienced a weight change recently. The RD documented that resident 110 was at risk for a drug interaction regarding [MEDICATION NAME] therapy, but did not identify the HCTZ as a potential concern. The RD recommended that resident 110 should have her weights monitored. Resident 110's daily weights were reviewed and were listed as follows: 3/5/11 105.6 pounds. 3/6/11 105 pounds. 3/8/11 102 pounds. 3/9/11 102 pounds. 3/10/11 103 pounds. 3/11/11 101 pounds. 3/12/11 100 pounds. 3/13/11 101 pounds. 3/14/11 102 pounds. 3/15/11 100 pounds. 3/16/11 98 pounds. 3/17/11 98 pounds. 3/18/11 98 pounds. 3/19/11 97 pounds. 3/20/11 98 pounds. 3/21/11 95 pounds. 3/22/11 96 pounds. 3/23/11 97 pounds. 3/24/11 95 pounds. 3/25/11 96 pounds. 3/26/11 95 pounds 3/27/11 95 pounds. 3/28 /11 95 pounds. 3/29/11 94 pounds. Resident 110 was discharged on [DATE]. No NIT meeting notes regarding resident 110 could be located. In a document entitled "Care Plan Conference Summary" dated 3/16/11, facility staff documented that resident 110's diagnosis, nursing care activities and social services had been discussed. The section about Dietary care had been left blank, indicating that resident 110's nutrition concerns had not been discussed by the interdisciplinary team. Resident 110's nursing notes were reviewed. No evidence was found that indicated resident 110's physician had been contacted regarding her weight loss. On 4/14/11 an interview was conducted with the facility RD regarding the NIT meetings and resident 110. The RD stated that residents at risk for, or who had experienced, weight loss were identified by the ADON and discussed in the next month's meeting. The RD stated that residents who had lost one or two pounds were discussed as well as residents who were at or below 100 pounds, even if they hadn't experienced any weight loss. The RD stated that the NIT meetings were held monthly and that facility staff "do the nutrition interventions and then they let me know what they did." When asked about resident 110, the RD stated that although resident 110 had her weight checked daily "I'm not looking at the daily weights. The nurses look at that. I don't always know what's going on there." The RD stated that she had not been made aware of resident 110's weight loss. On 4/18/11 an interview was conducted with the facility ADON. The ADON stated that he was responsible for determining who "triggers" to be discussed in the NIT meeting. The ADON stated that any residents who weighed less than 100 pounds were weighed weekly, and the weights were passed on to him. The ADON stated that he "monitored" the weekly weights and then discussed the weight loss with the DM. The ADON stated that he did not have any notes for resident 110, that resident 110's weight loss "did not trigger," and that he was unaware of resident 110's weight loss. 3. Resident 54 was admitted to the facility on [DATE] and discharged [DATE] to the hospital then readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 54's medical record was reviewed on 4/11/11. A review of resident 54 weight record revealed that on admission on 10/6/10 resident 54's weight was 125 lbs. On 11/9/10 resident 54's weight was 114 lbs. On 3/1/11 resident 54 was 115 lbs. Resident 54's physician orders dated 3/10/11, indicated resident 54 was to receive a supplement three times a day with meals. The supplement was originally ordered 10/6/10. The order did not specify what kind of supplement resident 54 was to receive. The Dietary History and Food/Beverage Preference dated 8/26/10 listed the diet order as regular and [MEDICATION NAME]. Under comments or special requests it listed: "really likes pudding, especially rice." A Nutrition Screening and Assessment form dated 8/26/10 indicated resident 54 weighed 142 lbs, needed partial assist with meals and should receive a regular [MEDICATION NAME] diet. The next dietary note was dated 11/18/10. It indicated resident 54 was ate small portions, ate 30% for breakfast, 40% for lunch, and 25% for dinner. It indicated resident 54 would "most likely continue to lose weight." The note indicated: "May move to RNA?" Another dietary note could not be located in the medical record, however, the facility provided a Quarterly Nutritional Reassessment later. The assessment indicated resident 54 was 142 lbs. in August, 2010, 136 lbs. in September, 2010, 119 lbs. in October, 2010, 115 lbs. in November, 2010, 116 lbs. in December, 2010, 114 lbs in January, 2011 and 115 lbs. in February, March and April, 2011. The quarter dated 1/12/11 indicated resident 54 was eating a regular [MEDICATION NAME], small portion diet with 40% for breakfast, 30% for lunch and 40% for dinner. The assessment indicated resident 54 had a supplement with meals, ate in her room, and fed herself. Resident 54's compliance with her diet was good. The care plan flow sheets for November, December, 2010, were reviewed. They indicated resident 54 ate approximately 30% of her breakfast, 67% of her lunch, and 50% of her dinner. The January 2011 flow sheet was reviewed and indicated resident 54 ate 22% of her breakfast, 29% of her lunch and 42% of her dinner. The supplement was included in the fluid intake totals and did not indicate how much supplement resident 54 took. The quarterly nutritional reassessment dated [DATE] indicated resident 54 ate 40% of her meals and received a supplement. The April, 2011 care plan flow sheet was reviewed and indicated resident 54 ate 39% of her breakfast, 23% of her lunch and 28% of her dinner. On 4/13/11 the Director of Nursing (DON) was asked for the care plan. The DON confirmed the care plan was not in the active medical record and later provided the care plan from the resident's previous stay. The closed medical record for resident 54 was reviewed. The care plan for nutrition was dated 8/31/10. The care plan had a space to record weights, however, no weights were recorded. An ADL (activity of daily living) care plan dated 10/28/10 and reviewed on 1/12/11 indicated resident 54 ate in the dining room and only needed a tray set up. Monthly Care Plan Review forms were reviewed for January, February, and March 2011. The review forms did not include nutrition or weight loss. On 3/13/11 at 11:44 AM, resident 54 was observed in her room sitting in her recliner. Resident 54 had a milk and a supplement shake. Resident 54 drank half of the milk and 25% of the shake. At 12:26 PM, resident 54 had consumed 75% of the milk and 50% of the shake, then the milk and shake were removed when lunch was served. At 12:56 PM, resident 54 was observed eating lunch in her room in her recliner. Resident 54 was observed until her tray was removed. Resident 54 did not receive assistance with eating. Resident 54 did not receive any cueing or reminders to eat. On 4/13/11 at 3:41 PM, resident 54 was interviewed. Resident 54 was asked if she received a supplement. Resident 54 stated: "I don't like it. I've only had it once or twice. I drink a little of it." On 3/13/11 at 12:27 PM, Registered Nurse (RN) 2 was interviewed. RN 2 was asked if resident 54 received a supplement. RN 2 stated resident 54 received a supplement with every meal. RN 2 stated she had given resident 54 a supplement that morning and would be giving another one after lunch. The shake that was observed in resident 54's room was from the morning. RN 2 stated resident 54 would drink the whole thing, it just took her awhile. RN 2 reported resident 54 did not eat breakfast because she had never been a breakfast person. On 4/13/11 at 2:50 PM, CNA 6 was interviewed. CNA 6 stated resident 54 was not a big eater and never ate more than 40% of her meal. CNA 6 stated resident 54 was given a supplement but only took a drink out of it, but no more. CNA 6 reported that resident 54 was always saying she was full. CNA 6 stated resident 54 had not had weight loss. When asked if she recorded how much supplement resident 54 consumed, CNA 6 indicated it was included in the total with all the other fluids resident 54 consumed. On 4/14/11 at 9:54 AM, the dietary manager was interviewed. The dietary manager indicated resident 54 received whole milk, super cereal each meal and one teaspoon extra oil on one lunch and dinner item. Resident 54's dietary tray card was reviewed with the dietary manager. The tray card indicated resident 54 was to receive an [MEDICATION NAME] regular diet with small portions and milk and juice for breakfast and milk and water for lunch and dinner. On 4/13/11 at 4:17 PM, the ADON and DON were interviewed concerning resident 54's weight loss. They agreed that between the supplement and eating chocolate resident 54 was maintaining her weight. The DON stated resident 54 liked the supplement and drank all of it. The DON stated resident 54 ate 30, 40, and 50 percent of her meals and that was why they were supplementing her. The DON stated facility staff only documented that the supplement was given and not how much.