Every finding on record at Senior Citizens Home

Based on observations and staff interviews, the facility failed to keep food service equipment free of debris and corrosion by failing to clean 2 of 3 HVAC (heating and air conditioning system) filters observed. This practice had the potential to affect food served to the residents who resided in the facility.The findings included:During the tour of the kitchen with the Certified Food Manager on 3/10/26 at 11:56 AM the kitchen preparation table was observed. Two feet above the food preparation table where wrapped silverware was stacked ready for lunch service, 2 of the 3 HVAC vents were observed with dark debris on the metal vents. The air filter system was off at the time. A second observation on 03/11/2026 11:08 AM the kitchen filters were observed in the same condition with dark debris on the metal vents. The air filter system was on and blowing towards the tray line, 6 feet away. The tray line was not in use at the time.In an interview on 3/11/26 at 11:10 AM the Certified Food Manger stated the HVAC filters were not on a kitchen cleaning schedule as Maintenance came in every 1-2 months to clean the vents. The CFM indicated she was not sure when the filters had last been cleaned.In an interview on 3/11/26 at 11:29 AM the Maintenance Director stated they recently switched company ownership, and the reminder to clean the kitchen vents, was no longer in his Tel's report (software program that tracks and assigns work orders). He indicated the filters looked original that had corrosion and was not sure when he last cleaned the kitchen vents. In an interview on 3/11/216 at 11:30 AM the Administrator stated they would get the HVAC filters replaced and cleaned on a regular basis.

Based on record review, and interviews with staff, Director of Nursing, Nurse Practitioner, Pharmacy Technician, and Pharmacist, the facility failed to provide services to ensure the acquiring, dispensing, and administration of medications for 1 of 5 sampled residents whose medications were reviewed (Resident #59). The facility failed to have an anticonvulsant, antipsychotic, and a triple-therapy bronchodilator available for administration to Resident #59.The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included COPD, depression and bipolar disorder.a. Resident #59 had a physician order initiated on 2/5/26 for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligrams(mg) (an anticonvulsant medication sometimes used for mood stabilization)- Give 1000 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/6/25 at 8:34 PM and written by Nurse #1 revealed Divalproex Sodium medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/8/25 at 8:32 PM and written by Nurse #1 revealed Divalproex Sodium medication was on order.b. Resident #59 had a physician order initiated on 2/5/26 for Olanzapine 2.5 mg tablet (an antipsychotic medication)- Give 2.5 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/6/25 at 8:35 PM and written by Nurse #1 revealed Olanzapine medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/7/26 by Nurse #2, with a chart code that referenced the progress notes.A Medication Administration note dated 2/7/26 at 9:37 PM and written by Nurse #2 revealed Olanzapine medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/8/25 at 8:32 PM and written by Nurse #1 revealed Olanzapine medication was on order.c. Resident #59 had a physician order initiated on 2/5/26 for Trelegy Ellipta Inhalation Aerosol powder Breath Activated 200-62.5-25 milligrams per actuation (mg/act) Fluticasone Umeclidinium-Vilanterol- One puff -inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD).Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.Review of a Medication Administration note dated 2/6/26 at 1:29 PM and written by Nurse #1 revealed Trelegy Ellipta medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/7/26 by Nurse #2, with a chart code that referenced the progress notes.A Medication Administration note dated 2/7/26 at 3:06 PM and written by Nurse #2 revealed Trelegy Ellipta was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A health status note dated 2/8/26 at 6:19 PM and written by Nurse #1 revealed the on-call provider was notified that the facility was still awaiting delivery of Resident #58's medication from pharmacy. Nurse #1 documented staff to continue to monitor.A Medication Administration note dated 2/8/26 at 9:45 PM and written by Nurse #1 revealed Trelegy Ellipta medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/9/26 by Nurse #3, with a chart code that referenced the progress notes.Review of the electronic medical record revealed no documentation of a medication administration note written by Nurse #3 on 2/9/26.Nurse #1 was interviewed on 3/10/26 at 2:29 PM. Nurse #1 stated that when a resident was newly admitted to the facility it could take a little while for the residents to receive their medications from the pharmacy. Nurse #1 stated she did not check the pyxis (an automated, secure, and centralized system used in healthcare to manage the storage, dispensing, and tracking of medications) on 2/6/25 to see if medications were available for Resident #59. Nurse #1 stated that when medications were not available the provider was notified and a follow-up phone call was placed to the pharmacy. Nurse #1 stated she placed a call to the on-call provider on 2/8/26 to notify the provider that the facility was still awaiting delivery of Resident #59's medications. Nurse #1 stated in some cases the nurse has reached out to the resident representative to see if the resident had a supply of the medication at home. Nurse #1 denied reaching out to Resident #59's family. Nurse #2 was interviewed on 3/10/26 at 4:26 PM. Nurse #2 stated when Resident #59 was admitted he did not get all his medications delivered from the pharmacy. Nurse #2 stated Resident #59's medications were ordered from the pharmacy when he was admitted by the administrative nurses. Nurse #2 stated the administrative nurses were responsible for entering the physician orders and verifying the orders with the discharge summary and ordering medications from the pharmacy. Nurse #2 stated when medications were not received from the pharmacy the nurse followed up with pharmacy about medication status. Nurse #2 further stated the provider was notified that Resident #59 did not have his Trelegy inhaler on 2/7/26 for further orders and the pharmacy was notified. Nurse #2 stated she was instructed to monitor resident. Nurse #3 who administered Resident #59's medication on 2/9/26 did not respond to a request for interview. An interview was conducted with the Pharmacist Services Technician on 3/10/26 at 2:12 PM. The technician verified that Resident #59's Trelegy Ellipta, Depakote and Olanzapine medication orders were received from the facility on 2/9/26 and the medications were delivered the evening of 2/9/26.An interview was conducted with the Director of Nursing on 3/11/26 at 2:23 PM. The DON stated the previous process was for the physician order to be entered into the electronic medical record and the information was transmitted to the pharmacy electronically. The DON stated the facility had just switched over to a new pharmacy on 2/1/26. The DON stated the facility was not aware that Resident #59's medication orders had not been transmitted electronically to the pharmacy on 2/5/26. The DON stated she was notified by Nurse #3 on 2/9/26 that Resident #59 did not have his Trelegy inhaler. The DON stated once she became aware of the issue on 2/9/26 she faxed the physician orders for Trelegy, Olanzapine and Divalproex Sodium for Resident #59 to the pharmacy. The DON stated she could not recall any education from the pharmacy during the transition training about the transmittal process for orders changing. The DON stated that when a resident missed a medication the nurse was supposed to follow up with the pharmacy and the provider. The DON further stated the nurses had access to the medication pyxis which housed emergency medications and frequently used medications. The DON stated the facility had not been faxing orders to the pharmacy prior to 2/1/26. An interview was conducted with the Pharmacist on 3/12/26 at 11:44 AM. The pharmacist revealed orders were received from the facility for Resident #59 via fax on 2/9/26. The Pharmacist verified orders for Depakote 125mg, Olanzapine 2.5 mg and Trelegy Ellipta were received and the medications were delivered to the facility on the second pharmacy delivery at 7:00 PM on 2/9/26. The Pharmacist revealed the facility had received education from the pharmacy staff on the new pharmacy process prior to the system change on 2/1/26. The Pharmacist stated changes to the process for submitting physician orders which included physician orders that were to be faxed to the pharmacy were included in the in-service education. She further stated that pharmacy staff were at the facility before the pharmacy switch over and during the transition. During an interview with the Administrator on 3/12/26 at 11:32 AM, she stated the facility changed to a new pharmacy on 2/1/26. The Administrator stated that the staff was trying to get acclimated with the new pharmacy. The Administrator stated she was made aware that there was an issue with the integration of the new system. The Administrator stated the facility had no knowledge that there was an issue with the transmission of medication orders until the issue with Resident #59's medications was brought to the nursing staff's attention. The Administrator stated the nursing staff was under the impression that the orders would be transmitted electronically just like the previous system. The Administrator stated when the DON followed up on 2/9/26 with the pharmacy, it was discovered there was an interface problem with the current system communicating to the new pharmacy.

Based on record review, and interviews with staff, Nurse Practitioner, Pharmacist, Assistant Director of Nursing, and Director of Nursing, the facility failed to prevent a significant medication error for 1 of 5 residents whose medications were reviewed (Resident #59). The facility failed to administer prescribed antipsychotic medication, anticonvulsant medication and triple therapy bronchodilator to Resident #59. The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), depression and bipolar disorder. a. Resident #59 had a physician order initiated on 2/5/26 for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligrams(mg) (an anticonvulsant medication sometimes used for mood stabilization) Give 1000 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/6/25 at 8:34 PM and written by Nurse #1 revealed Divalproex Sodium medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Divalproex Sodium was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/8/25 at 8:32 PM and written by Nurse #1 revealed Divalproex Sodium medication was on order.b. Resident #59 had a physician order initiated on 2/5/26 for Olanzapine 2.5 mg tablet (an antipsychotic medication) Give 2.5 mg by mouth at bedtime for bipolar disorder.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/6/25 at 8:35 PM and written by Nurse #1 revealed Olanzapine medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/7/26 by Nurse #2, with a chart code that referenced the progress notes.A Medication Administration note dated 2/7/26 at 9:37 PM and written by Nurse #2 revealed Olanzapine medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Olanzapine was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/8/25 at 8:32 PM and written by Nurse #1 revealed Olanzapine medication was on order.c. Resident #59 had a physician order initiated on 2/5/26 for Trelegy Ellipta Inhalation Aerosol powder Breath Activated 200-62.5-25 milligrams per actuation (mg/act) Fluticasone Umeclidinium-Vilanterol. One puff -inhale orally one time a day for COPD.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/6/26 by Nurse #1, with a chart code that referenced the progress notes.Review of a Medication Administration note dated 2/6/26 at 1:29 PM and written by Nurse #1 revealed Trelegy Ellipta medication was on order.A health status note dated 2/6/26 and written by Nurse #1 revealed Resident #59 was on oxygen at 2 liters per minute via nasal cannula. Resident #59's respirations were even and unlabored.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/7/26 by Nurse #2, with a chart code that referenced the progress notes.A Medication Administration note dated 2/7/26 at 3:06 PM and written by Nurse #2 revealed Trelegy Ellipta was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/8/26 by Nurse #1, with a chart code that referenced the progress notes.A Medication Administration note dated 2/8/26 at 9:45 PM and written by Nurse #1 revealed Trelegy Ellipta medication was on order.Documentation on the February Medication Administration Record (MAR) for Resident #59 revealed that Trelegy Ellipta was not administered on 2/9/26 by Nurse #3, with a chart code that referenced the progress notes.Review of the electronic medical record revealed no documentation of a medication administration note written by Nurse #3 on 2/9/26.During an interview on 3/10/26 at 2:29 PM, Nurse #1stated she had notified the on-call provider on 2/8/26 that the facility was still awaiting delivery of Resident #59's medication from pharmacy. Nurse #1 stated she was given the directive to continue to monitor Resident #59. Nurse #1 confirmed she did not administer Divalproex Sodium, Olanzapine and Trelegy to Resident #59 on 2/6/26 and 2/8/26 because they were not available/on order.During an interview on 3/10/26 at 4:26 PM, Nurse #2 stated Resident #59's medications had not arrived on 2/7/26 and she notified the pharmacy on 2/7/26 when Resident #59's medication had not arrived. Nurse #2 confirmed she did not administer Trelegy and Olanzapine to Resident #59 on 2/7/26 because it was on order. Nurse #3 did not respond to a request for interview.An interview was conducted with Resident #59 on 3/10/26 at 10:12 AM. Resident #59 stated he did not have his inhaler and a couple of other medications when he first got to the facility in February. Resident #59 stated the facility did get all his medications, but it took a few days. Resident #59 denied having any adverse effects from not receiving medications.Documentation in the Nurse Practitioner Progress Note dated 2/9/26 at 8:00 AM revealed Resident #59 was seen for a follow up visit for missing medication. The progress note indicated Resident #59 was admitted on Friday and his medications were not delivered until Saturday night. The note indicated Resident #59 had missed doses of Trelegy, Valproic Acid and Olanzapine. Resident #59 was described as calm and cooperative with care. There were no behaviors reported. Resident #59 had oxygen in place and exhibited no shortness of breath. The plan was to monitor Resident #59 for adverse reactions. An interview was conducted with the Nurse Practitioner on 3/12/26 at 12:10 PM. The Nurse Practitioner explained that interruption of Depakote and Olanzapine could cause mood instability and increased behaviors. She further stated that the omission of Trelegy could cause increased breathing issues. The NP stated Resident #59's medication should have been administered as ordered.A health status note dated 2/9/26 at 8:33 AM and written by the Director of Nursing (DON) revealed the on-call provider was made aware that Resident #59 had missed medications. The provider instructed to monitor Resident #59. The note further revealed the DON contacted the pharmacy to find out about Resident #59's missing medications. The note indicated a medication profile had to be created for Resident #59 and the missing medications would be sent out with the next pharmacy delivery.An interview was conducted with the Director of Nursing on 3/11/26 at 2:23 PM. The DON stated that Resident #59 was expected to receive medications as prescribed. The DON stated the medication orders were entered into the system on 2/5/26 and she thought the pharmacy had received the orders electronically on 2/5/26 when they were entered. The DON reported that when the facility became aware that the orders did not transmit electronically to the pharmacy, Resident #59's orders were faxed over to the pharmacy on 2/9/26. An interview was conducted with the Pharmacist on 3/12/26 at 11:44 AM. The Pharmacist stated that orders were to be faxed to the pharmacy so that a resident profile could be created. The Pharmacist stated delivery of the medications would prevent residents from missing any doses at the scheduled administration times. The Pharmacist confirmed Resident #59's medication orders were faxed to the pharmacy on 2/9/26 and the facility received the medications the night of 2/9/26. During an interview on 3/12/26 at 11:32 AM, the Administrator stated the facility should have made sure that the resident received his medications on time as prescribed. The Administrator further stated communication with the pharmacy may have prevented the medication errors.

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 3 2024). Findings included: Review of the PBJ for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed there were no Registered Nurse (RN) hours for 4/13/24, 4/14/24, 4/27/24, 4/28/24, and 6/15/24. The PBJ report also noted the facility failed to have licensed nursing coverage 24 hours per day for 4/13/24, 4/14/24, 4/28/24, 6/15/24, and 6/16/24. Review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 4/13/24, 4/14/24, 4/27/24, 4/28/24, and 6/15/24 revealed there were RN hours for the 3rd quarter of the fiscal year 2024. The Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and the nursing staff time detail reports for 4/13/24, 4/14/24, 4/28/24, 6/15/24, and 6/16/24 were reviewed and revealed there were 24-hour per day licensed nursing coverage for the 3rd quarter of the fiscal year 2024. An interview was conducted on 12/04/24 at 12:01 pm with the Human Resources Manager who revealed she was responsible for entering all nursing hours into the payroll system and the corporate office submitted the data to CMS for the PBJ reports. The Human Resources Manager stated she did recall that there were times that she submitted the payroll data to corporate without all the licensed nursing staff because she had not yet received the information from agency staff. The Human Resources Manager stated she did update the payroll system with the licensed nursing and RN hours when she received the information from the agency staff and she thought the PBJ reports would be resubmitted and updated once the payroll report was corrected. During an interview on 12/04/24 at 12:04 pm with the Administrator she revealed the PBJ data was submitted based off the information entered by the Human Resources Manager. The Administrator stated the facility had RN hours and licensed nursing staff as required but there must have been an error when the data was reported.

Based on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in developing the Facility Assessment, failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies, and failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, which had the potential to affect 49 of 49 residents. The findings include: Review of the Facility Assessment revealed it was revised 8/13/24 and updated on 9/24/24 and 11/01/24. The persons involved in completing the assessment were listed as the Administrator, the Director of Nursing (DON), the Medical Director, Social Service Director, Food Service Director, Environmental Operations Director, Therapy Director, and a Governing Board Member. There was no indication that direct care staff were involved in completing the assessment or that the facility solicited and considered input from residents, resident representatives and family members. The Facility Assessment did not note if a contract or other agreement was in place related to which provider was responsible for medical supplies, ambulance, or emergency services, and dialysis services for the facility. Further review of the Facility Assessment revealed that the staffing plan listed the number of Nurses (Registered Nurse or Licensed Practical Nurse), and Certified Nursing Assistants (CNAs) noted as the desired number FTE (full-time equivalent, the total number of full-time employees working in an organization) of staff and the professional requirement for those staff members. However, the staffing plan did not address staffing needs for each shift and weekends, or address staffing needs in these areas based on changes to the resident population as required. During an interview with the Administrator on 12/05/24 at 10:57 am she revealed the facility assessment was usually completed as a collaboration of department heads. She stated she was not in the facility when the new process was implemented, and she did not complete the provided facility assessment. The Administrator reported she did update the new management team on the facility assessment when she started at the facility, but she did not update or review any other information.

Based on record review and staff interviews, the facility failed to conduct quarterly reviews of resident care plans for 5 of 23 resident care plans that were reviewed (Resident #23, Resident #6, Resident #9, Resident #8, and Resident #45). The findings included: 1. Resident #23 was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD) and osteoarthritis. A review of Resident #23's care plan revealed the most recent review date of 7/30/24 and no further reviews or updates had been completed. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact. An interview was completed on 12/3/24 at 10:03 am with the Director of Nursing (DON) who revealed she was both the MDS Nurse and the DON for the facility. She stated she was responsible for reviewing resident care plans. The DON verified Resident #23's care plan review was overdue. The DON stated she was aware the resident care plans were behind, and she was working on getting them completed. An interview was completed on 12/5/24 at 11:07 am with the Administrator who revealed she was not aware the resident care plans were not being reviewed. The Administrator stated the MDS Nurse was responsible to review and update resident care plans as required. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease, and stroke. A review of Resident #6's care plan revealed the most recent review date of 5/23/24 and no further reviews or updates had been completed. The MDS quarterly assessment dated [DATE] revealed Resident #6 was cognitively intact. An interview was completed on 12/3/24 at 10:03 am with the Director of Nursing (DON) who revealed she was both the MDS Nurse and the DON for the facility. She stated she was responsible for reviewing resident care plans. The DON verified Resident #6's care plan review was overdue. The DON stated she was aware the resident care plans were behind, and she was working on getting them completed. An interview was completed on 12/5/24 at 11:07 am with the Administrator who revealed she was not aware the resident care plans were not being reviewed. The Administrator stated the MDS Nurse was responsible to review and update resident care plans as required. 45044 3. Resident #9 was admitted to the facility on [DATE] with diagnoses that included heart disease, chronic obstructive pulmonary disease, and atrial fibrillation. A review of Resident #9's care plan list revealed the most recent review date of 7/15/24 and no further reviews or updates had been completed. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. An interview was completed on 12/5/24 at 9:59am with the Director of Nursing (DON). The DON verified Resident #9's care plan review was overdue. The DON stated she was currently working to ensure all resident care plans were reviewed and updated in a timely manner. An interview was completed on 12/5/24 at 11:15am with the facility's Administrator. The Administrator stated it was her expectation residents' care plan were reviewed and updated timely. 4. Resident #8 was admitted to the facility on [DATE] with diagnoses that included dementia and atrial fibrillation. A review of Resident #8's care plan list revealed the most recent review date of 7/22/24 and no further reviews or updates had been completed. A MDS assessment dated [DATE] revealed Resident #8 was severely cognitively impaired. An interview was completed on 12/5/24 at 9:59am with the Director of Nursing (DON). The DON verified Resident #8's care plan review was overdue. The DON stated she was currently working to ensure all resident care plans were reviewed and updated in a timely manner. An interview was completed on 12/5/24 at 11:15am with the facility's Administrator. The Administrator stated it was her expectation residents' care plan were reviewed and updated timely. 5. Resident #45 was admitted to the facility on [DATE] with diagnoses that included diabetes, dementia, and a history of a stroke. A review of Resident #45's care plan list revealed the most recent review date of 7/15/24 and no further reviews or updates had been completed. A MDS assessment dated [DATE] revealed Resident #45 was severely cognitively impaired. An interview was completed on 12/5/24 at 9:59am with the Director of Nursing (DON). The DON verified Resident #45's care plan review was overdue. The DON stated she was currently working to ensure all resident care plans were reviewed and updated in a timely manner. An interview was completed on 12/5/24 at 11:15am with the facility's Administrator. The Administrator stated it was her expectation residents' care plan were reviewed and updated timely.

Based on observations, record reviews, resident interview, and staff interviews the facility failed to correctly code the Minimum Data Set (MDS) assessment in the areas of falls and restraints for 2 of 23 residents whose MDS assessments were reviewed for accuracy (Residents #45 and #23). The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, dementia, and a history of a stroke. An incident report dated 8/5/24 at 5:37pm stated Resident #45 was observed laying on the floor in front of her personal recliner. The note stated Resident #45's lower extremities had normal range of motion and were without pain. The facility Nurse Practitioner (NP) was notified and an order for an x-ray of the Resident's left hip was received. The quarterly MDS dated [DATE] revealed Resident #45 was severely cognitively impaired and was coded no for any falls since admission/entry, reentry, or prior assessment. The review further revealed the questions regarding the number of falls and major injury since admission/entry, reentry or prior assessment sections were disabled. An interview was completed on 12/4/24 at 10:46am with the MDS Nurse. The Nurse stated the MDS assessment was coded inaccurately and should have been coded for 1 fall with a major injury. An interview was completed on 12/5/24 at 10:01am with the Director of Nursing (DON). The DON stated the MDS assessment was coded in error. The DON stated the MDS Nurse had completed a modification to the inaccurate MDS assessment on 12/5/24. An interview was completed on 12/5/24 at 11:09am with the facility's Administrator. The Administrator stated it was her expectation that the MDS assessment be coded correctly and reflect an accurate picture of the Resident. 45045 2. Resident #23 was admitted to the facility on [DATE]. Resident #23 had an active physician order dated 12/31/21 for 1/4 bed rails to be used as assist device for bed mobility only. The care plan last reviewed on 5/27/24 revealed Resident #23 had an activities of daily living self-care performance deficit related to limited mobility with an intervention of 1/4 side rails to assist with bed mobility. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact and was coded for physical restraints noted as bed rails, used daily. An observation and interview were conducted on 12/02/24 at 11:34 am with Resident #23. The bed was noted to have 2 upper side rails in place. Resident #23 stated she used the side rails to move and turn herself when she was in bed. A telephone interview was conducted on 12/04/24 at 8:15 am with MDS Nurse #2 who stated when a resident used side rails for mobility they were not to be coded as a restraint. MDS Nurse #2 stated she must have made an error when she coded Resident #23's side rails as a restraint. During an interview on 12/05/24 at 9:40 am with the Director of Nursing (DON) who revealed Resident #23 used the side rails to allow for turning and repositioning in bed and they should not have been coded as restraints. An interview was conducted with the Administrator on 12/05/24 at 10:44 am who revealed the MDS Nurse was responsible to ensure the resident assessments were coded accurately.

Based on record review and staff interviews, the facility failed to have a physician order for dialysis in the medical record for 1 of 1 resident reviewed for dialysis (Resident #204). Findings included: Resident #204's hospital discharge summary dated 11/21/2024 included instructions that included the name, address and telephone number of the dialysis center and indicated Resident #204's chair time was Monday, Wednesday, and Friday at 12:00 PM. Resident #204 was admitted to the facility on [DATE] with diagnosis including end stage renal disease stage 5. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #204 was coded for dialysis. During an interview with the Unit Manager on 12/3/2024 at 2:51 p.m. she revealed she was responsible for admitting Resident #204 to the facility. She stated she reviewed the hospital discharge summary for Resident #204, and she did not remember how she omitted entering the physician order for dialysis in his medical record. In an interview with Nurse #2 on 12/3/2024 at 2:58 p.m. she revealed she could not locate a physician order for dialysis for Resident #204 but was aware Resident #204 received dialysis. During an interview with the Director of Nursing (DON) on 12/4/2024 at 9:50 a.m. she revealed that it was the responsibility of the admission nurse to ensure the physician orders were entered. The DON stated that the Unit Manager omitted the order for dialysis for Resident #204 in error. During an interview with the Administrator on 12/5/2024 at 8:25 a.m. she revealed it was the responsibility of nursing staff to ensure physician orders were transcribed upon receipt. She further stated that the admitting nurse should have reviewed the hospital discharge summary for Resident #204 and included the order for dialysis.

Based on record review and staff interviews, the facility failed to post accurate licensed nurse staffing data for 18 of 30 days reviewed for sufficient staffing (11/02/24, 11/03/24, 11/05/24, 11/06/24, 11/09/24, 11/10/24, 11/13/24, 11/15/24, 11/16/24, 11/17/24, 11/18/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/27/24, 11/28/24, 11/30/24). The findings included: A review of the posted Daily Nursing Staffing Forms from 11/01/24 through 11/30/24 revealed the following: a. A review of the Daily Nursing Staffing Form for the 7:00 am-3:00 pm shift revealed the licensed nursing staff was not recorded accurately for the following days: 11/02/24-Daily Nursing Staffing Form recorded 3 Licensed Practical Nurses (LPNs); the Daily Staffing Sheet recorded 1 LPN. 11/03/24- Daily Nursing Staffing Form recorded 1 Registered Nurse (RN) and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/09/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/10/24-Daily Nursing Staffing Form recorded 3 LPNs; the Daily Staffing Sheet recorded 1 LPN. 11/16/24-Daily Nursing Staffing Form recorded 3 LPNs; the Daily Staffing Sheet recorded 1 LPN. 11/17/24-Daily Nursing Staffing Form recorded 3 LPNs; the Daily Staffing Sheet recorded 1 LPN. 11/23/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/24/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. 11/28/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 1 LPN. 11/30/24-Daily Nursing Staffing Form recorded 1 RN and 3 LPNs; the Daily Staffing Sheet recorded 0 RN and 2 LPNs. b. A review of the Daily Nursing Staffing Form for the 3:00 pm-11:00 pm shift revealed the licensed nursing staff was not recorded accurately for the following days: 11/02/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/06/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/09/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/10/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/13/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/17/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/23/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/24/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/28/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/30/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. c. A review of the Daily Nursing Staffing Form data sheets for the 11:00 pm-7:00 am shift revealed the licensed nursing staff was not recorded accurately for the following days: 11/05/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/09/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/15/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/17/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/18/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPN; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/22/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/25/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/27/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. 11/30/24-Daily Nursing Staffing Form recorded 0 RN and 2 LPNs; the Daily Staffing Sheet recorded 1 RN and 1 LPN. An interview was conducted on 12/04/24 at 12:37 pm with the Scheduler who revealed she used a staffing template when she completed the Daily Staffing Form, and she tried to make sure the staffing numbers were correct when she completed the form. The Scheduler stated she must have missed the days where the staffing was incorrect when she completed the form. During an interview with the Director of Nursing (DON) on 12/05/24 at 9:42 am who revealed she was new to the facility, and she was not aware the Daily Staffing Form information was being completed incorrectly. The DON stated she had not checked the Daily Staffing Forms for accuracy in the past, but she stated the Scheduler should verify the information was correct before posting the information.

Based on record review, staff interview, Physician Assistant interview, Pharmacy Director interview, Surgical Physician interview and resident interview the facility failed to provide antibiotic, diabetic, hypertension, antiepileptic, and pain medication as ordered resulting in significant errors by omission of high alert medications for one (Resident #1) of one resident reviewed for significant medication errors. Antibiotic medications were delayed after admission to the facility due to a transcription error for Resident #1. Diabetic, hypertension, antiepileptic, and pain medication were omitted initially upon admission due to a delay obtaining required medications from the pharmacy for Resident #1. Findings included: 1.Documentation on a hospital discharge summary dated 10/30/2023 revealed Resident #1 was to be discharged to the facility post operation for an amputation. The problem list on the discharge summary revealed Resident #1 had a diabetic infection of his left foot. The surgical wound was cultured and grew out bacteria. The plan was to continue at least 4 weeks of the antibiotics Levaquin and Flagyl when Resident #1 discharged to the facility as discussed with the infectious disease specialist. Documentation on the same hospital discharge summary revealed physician orders for Levaquin in the form of a 500- milligram (mg) tablet administered by mouth every day and Flagyl in the form of a 500 mg tablet to be administered by mouth twice a day. Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses some of which included diabetes mellitus, status post amputation of left great toe and left forefoot, and diabetic left foot infection. Documentation in the electronic medical record system revealed Nurse #2 entered an order on 10/30/203 for Resident #1 to receive Levaquin in the form of a 500 mg tablet by mouth one time daily for 10 days with a start date of 11/9/2023. Documentation on the Medication Administration Record (MAR) for November of 2023 revealed the first day the antibiotic Levaquin was administered to Resident #1 was 11/9/2023, 10 days from 10/30/2023. Documentation in the electronic medical record system revealed Nurse #2 entered an order on 10/30/2023 for Resident #1 to receive Flagyl in the form of a 500 mg tablet by mouth two times a day for 14 days with a start date of 11/13/2023. At the time of the survey the documentation on the MAR for November 2023 revealed the first day the antibiotic Flagyl was to be administered to Resident #1 was 9:00 PM on 11/13/2023, 14 days from 10/30/2023. An interview was conducted with Nurse #2 on 11/13/2023 at 1:01 PM. Nurse #2 indicated she thought she was putting in the orders for the antibiotic medication Levaquin and Flagyl to be started immediately upon admission of Resident #1 on 10/30/2023. Nurse #2 confirmed she made an error and put the wrong start dates for the antibiotics for Resident #1. An interview was conducted with the Physician Assistant (PA #1) on 11/13/2023 at 1:29 PM. PA #1 confirmed she saw Resident #1 on the morning of 10/31/2023 and reviewed his chart as a new admission. PA #1 confirmed the antibiotics Levaquin and Flagyl, according to the hospital discharge summary, were supposed to continue to be administered when he arrived at the facility. PA #1 noted Resident #1 was on intravenous antibiotics in the hospital but was to switch to administration by mouth at the facility. PA #1 confirmed the antibiotics Levaquin and Flagyl should have been started immediately upon admission because that was what the order was for. PA #1 revealed delaying the provision of antibiotics could have a potential effect or outcome on the healing process and the infection in the left foot of Resident #1 but, he had not shown any signs of a systemic change since admission. Documentation on a Brief Interview for Mental Status dated 10/31/2023 revealed Resident #1 was screened as cognitively intact. Resident #1 was interviewed on 11/11/2023 at 4:13 PM. Resident #1 indicated he did not suffer anything health wise from not having his antibiotics available to him but revealed it was stressful worrying about not having his antibiotics after surgery. The Surgical Physician who performed the amputation procedure on the left foot of Resident #1 was interviewed on 11/15/2023 at 9:08 AM. The Surgical Physician revealed the following information. The Surgical Physician saw Resident #1 during a follow up appointment on 11/14/2023. The open wound looked good, was very much improved, and did not show signs of infection. It was not an ideal situation regarding Resident #1 not continuing with his antibiotics when he was first admitted to the facility but, more importantly the facility provided good wound care with the wound VAC (vacuum-assisted closure). Resident #1 was always at a higher risk for infection because he had diabetes and had always had uncontrolled blood glucose levels. 2. Resident #1 had cumulative diagnoses some of which included Type 2 diabetes, Hypertension, Bipolar disorder, congestive heart failure, anxiety disorder, status post orthopedic surgery, and post-traumatic stress disorder. Documentation in the electronic medical record of Physician orders listed as entered on 10/30/2023 by Nurse #2 at 12:57 PM for Resident #1 included some of the following medications. Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 60 units of insulin to be injected subcutaneously every morning for Type 2 diabetes. 15 units of insulin were to be injected subcutaneously if Resident #1 was not eating breakfast. Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 30 units of insulin were to be injected subcutaneously every evening for Diabetes Mellitus. Empagliflozin in the form of a 10 mg tablet taken by mouth once a day for Diabetes Mellitus. Carvedilol in the form of a 3.125-mg tablet twice daily for Hypertension. Lamotrigine in the form of a 200 mg tablet to be taken by mouth two times a day for coronary artery disease. (Lamotrigine is a medication that requires periodic monitoring of levels of the medication in the blood.) Pregabalin in the form of a 100 mg capsule to be taken by mouth two times a day for pain. Ranolazine extended release in the form of a 1000 mg tablet to be taken by mouth two times a day for Hypertension. Documentation in an admission summary dated 10/30/2023 written by Nurse #1 indicated Resident #1 arrived at the facility at approximately 2:00 PM. Nurse #1 was interviewed on 11/11/2023 at 5:03 PM. Nurse #1 confirmed she worked from 7:00 AM to 11:00 PM on 10/30/2023 and the medications for Resident #1 did not come in on that shift from the pharmacy. Nurse #2 was interviewed on 11/11/2023 at 3:53 PM. Nurse #2 revealed she entered the physician orders for medications from the hospital discharge summary into the electronic medical record system for Resident #1. Nurse #2 stated a second nurse was to confirm the physician orders with the facility physician and then have the orders sent to the pharmacy. Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #1 did not receive any medications on 10/30/2023 after his arrival at 2:00 PM to include his Novolin insulin, Carvedilol, Lamotrigine, Pregabalin, and Ranolazine. Nurse #3 was interviewed on 11/11/2023 at 6:28 PM. Nurse #3 confirmed she worked from 11:00 PM on 10/30/2023 to 7:00 AM on 10/31/2023. Nurse #3 conveyed the following information regarding the medication orders for Resident #1. Nurse #3 was informed at the start of her nursing shift on 10/30/2023 Resident #1 was admitted to the facility that afternoon and did not have any medications in the facility yet. Nurse #3 looked in the electronic record system and compared the discharge summary from the hospital to orders that were entered into the electronic medical record system. Nurse #3 found no discrepancies except for the lack of information on allergies. Nurse #3 completed the allergy information and submitted the orders to the pharmacy. Review of the MAR for October 2023 revealed Resident #1 did not receive his ordered 7:30 AM dose of Novolin insulin nor his 9:00 AM ordered doses of Empagliflozin, Carvedilol, Lamotrigine, Pregabalin, and Ranolazine on 10/31/2023. The Physician Assistant (PA #1) for Resident #1 was interviewed on 11/13/2023 at 1:29 PM. PA #1 stated was made aware on the morning of 10/31/2023 that Resident #1 did not have his medications delivered from the pharmacy at that time as she was reviewing his chart as a new admission. PA #1 stated her specific concern was that insulin was not available for Resident #1. PA #1 revealed she went with Nurse #4 to check the blood sugar of Resident #1 and find insulin by any means necessary if insulin was required. PA #1 revealed she called the pharmacy to order the medications for Resident #1 to be sent as soon as possible. Nurse #4 was interviewed on 11/13/2023 at 12:25 PM, who worked the 7:00 Am to 3:00 PM shift on 10/31/2023. Nurse #4 stated that on the morning of 10/31/2023 Resident #1 still did not have his medications to include insulin. Nurse #4 stated she went to PA #1, who was in the building, and notified her of the lack of medications for Resident #1. Nurse #4 explained she went with PA #1 to check the blood sugar of Resident #1 and it was within normal limits, not requiring insulin administration. Nurse #4 revealed Resident #1 did not require pain medication on the morning of 10/31/2023. Documentation in electronic medication administration notes for Resident #1 on 10/31/2023 revealed the evening dose of Novolin insulin to be administered at 5:00 PM stated, Medication not available from pharmacy. Documentation on the MAR for 10/31/2023 revealed Resident #1 received his evening medication ordered doses of Carvedilol, Lamotrigine, Pregabalin, and Ranolazine extended release. An interview was conducted with the Pharmacy Director for the facility pharmacy on 11/11/2023 at 3:19 PM. The Pharmacy Director was able to convey the following information from the pharmacy records. The first facsimile from the facility regarding the medications for Resident #1 was received by the pharmacy at 5:42 PM on 10/30/2023, after the closing time of 5:30 PM for the pharmacy. At 11:30 PM on 10/30/2023 the facility pharmacy received a lot of physician orders for Resident #1. The orders for Resident #1 were processed when the pharmacy reopened on 10/31/2023. The first delivery of medications was sent with the driver at 1:19 PM on 10/31/2023. The driver delivered the medications for Resident #1 at 8:44 PM on 10/31/2023 to the facility and the medications were signed for by Nurse #3 at that time. The Pharmacy Director had no explanation for why the pharmacy driver delivered the medications for Resident #1 outside of the expected delivery times contracted by the facility. The Pharmacy Director explained that it was the expectation of the pharmacy that if medications were needed after the close of business of the pharmacy, the backup pharmacy needed to be called by the facility so that medications were obtained by morning for the resident. The Pharmacy Director confirmed the facility did not currently have an automated medication dispensing machine that contained significant medications such as insulin as a backup for needed medications. An interview with the Director of Nursing was conducted on 11/11/2023 at 3:04 PM. The facility policy, as explained by the DON, was for a nurse to enter the physician orders into the MAR and once on the MAR, the orders were to be transmitted to the pharmacy. The DON revealed that the facility received two deliveries of medications from the pharmacy, one at approximately 2:00 PM and another at approximately 9:00 PM. The DON further revealed that the pharmacy was a new pharmacy for the facility and the facility had no back up medications onsite in an automated medication dispensing system. The DON indicated the delivery times from the pharmacy needed to change and an automated medication dispensing system for a back-up of medications would need to be obtained from the pharmacy to prevent significant medication errors. Documentation on a Brief Interview for Mental Status dated 10/31/2023 revealed Resident #1 was screened as cognitively intact. Resident #1 was interviewed on 11/11/2023 at 4:13 PM. Resident #1 stated it was a stressful and frustrating 2 days when he was first admitted to the facility as he did not understand why his medications were not available to him. Resident #1 stated he did not suffer anything health wise from not having his medications available to him but reiterated it was stressful worrying about not having his insulin, heart medications, and pain medication after surgery. Resident #1 stated he was able to tolerate the pain while he waited for his medication to arrive at the facility.

Based on record review, staff interview, pharmacy director interview, physician assistant interview, and resident interview the facility failed to provide medications upon admission for 18 hours for 1 (Resident #1) of 3 residents reviewed for provision of medication upon admission. Findings included: Resident #1 had cumulative diagnoses some of which included Type 2 diabetes, Hypertension, Bipolar disorder, congestive heart failure, anxiety disorder, status post orthopedic surgery, and post-traumatic stress disorder. Documentation in the electronic medical record of Physician orders listed as entered on 10/30/2023 by Nurse #2 at 12:57 PM for Resident #1 included the following medications: - Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 60 units of insulin to be injected subcutaneously every morning for Type 2 diabetes. 15 units of insulin were to be injected subcutaneously if Resident #1 was not eating breakfast. - Novolin (Insulin) 70/30 Flex Pen Subcutaneous Suspension Pen 30 units of insulin were to be injected subcutaneously every evening for Diabetes Mellitus. - Aspirin in the form of an 81-milligram (mg) tablet taken by mouth once daily as supplement. - Atorvastatin Calcium in the form of an 80-mg tablet taken by mouth at bedtime for coronary artery disease. - Empagliflozin in the form of a 10 mg tablet taken by mouth once a day for Diabetes Mellitus. - Prasugrel HCL in the form of a 10 mg tablet taken by mouth one time a day as supplement. - Carvedilol in the form of a 3.125-mg tablet twice daily for Hypertension. - Sertraline HCL in the form of two 100 mg tablets taken by mouth one time a day for bipolar disorder. - Buspirone HCL in the form of a 7.5 mg tablet to be taken by mouth one time a day for bipolar disorder. - Icosapent Ethyl in the form of a 2-gram capsule to be taken by mouth two times daily for coronary artery disease. - Lamotrigine in the form of a 200 mg tablet to be taken by mouth two times a day coronary artery disease. - Pregabalin in the form of a 100 mg capsule to be taken by mouth two times a day for pain. - Ranolazine extended release in the form of a 1000 mg tablet to be taken by mouth two times a day for Hypertension. - Probiotic Acidophilius in the form of a capsule to be taken by mouth three times a day as supplement. - Alprazolam in the form of a 0.5 mg table to be taken by mouth every 24 hours as needed for anxiety. - Nitroglycerin Sublingual in the form of a 0.4 mg tablet to be taken sublingually every 5 minutes as needed for chest pain. Repeated every 5 minutes up to 3 0.4 mg tablets maximum. - Levofloxacin in the form of a 500 mg tablet to be administered by mouth one time a day for 10 days for amputation. - Metronidazole in the form of a 500 mg tablet to be administered by mouth two times a day for 14 days for antiinfection. - Oxycodone HCL in the form of a 5 mg tablet to be administered by mouth every 6 hours as needed for pain. Documentation in an admission summary dated 10/30/2023 written by Nurse #1 indicated Resident #1 arrived at the facility at approximately 2:00 PM. Nurse #1 was interviewed on 11/11/2023 at 5:03 PM. Nurse #1 revealed that another nurse entered the medications from the hospital discharge summary for Resident #1 to the electronic medical record system for transmission to the pharmacy on 10/30/2023. Nurse #1 additionally revealed she did not contact the physician or the pharmacy regarding the medications for Resident #1 because she assumed the medications for Resident #1 were already verified by the physician and would come in on the night shift. Nurse #1 confirmed she worked from 7:00 AM to 11:00 PM on 10/30/2023 and the medications for Resident #1 did not come in on that shift from the pharmacy. Nurse #2 was interviewed on 11/11/2023 at 3:53 PM. Nurse #2 revealed she entered the physician orders for medications from the hospital discharge summary into the electronic medical record system for Resident #1. Nurse #2 stated a second nurse was to confirm the physician orders with the facility physician and then have the orders sent to the pharmacy. Review of the Medication Administration Record (MAR) for October 2023 revealed Resident #1 did not receive any medications on 10/30/2023 after his arrival at 2:00 PM. Nurse #3 was interviewed on 11/11/2023 at 6:28 PM. Nurse #3 confirmed she worked from 11:00 PM on 10/30/2023 to 7:00 AM on 10/31/2023. Nurse #3 conveyed the following information regarding the medication orders for Resident #1. Nurse #3 was informed at the start of her nursing shift on 10/30/2023 Resident #1 was admitted to the facility that afternoon and did not have any medications in the facility yet. Nurse #3 looked in the electronic record system and compared the discharge summary from the hospital to orders that were entered into the electronic medical record system. Nurse #3 found no discrepancies except for the lack of information on allergies. Nurse #3 completed the allergy information and submitted the orders to the pharmacy. Review of the MAR for October 2023 revealed Resident #1 received his ordered dose of Aspirin as the only medication received at 9:00 AM on 10/31/2023. The Physician Assistant (PA #1) for Resident #1 was interviewed on 11/13/2023 at 1:29 PM. PA #1 stated was made aware on the morning of 10/31/2023 that Resident #1 did not have his medications delivered from the pharmacy at that time as she was reviewing his chart as a new admission. PA #1 stated her specific concern was that insulin was not available for Resident #1. PA #1 revealed she went with Nurse #4 to check the blood sugar of Resident #1 and find insulin by any means necessary if insulin was required. PA #1 revealed she called the pharmacy to order the medications for Resident #1 to be sent as soon as possible. Nurse #4 was interviewed on 11/13/2023 at 12:25 PM, who worked the 7:00 Am to 3:00 PM shift on 10/31/2023. Nurse #4 stated that on the morning of 10/31/2023 Resident #1 still did not have his medications to include insulin. Nurse #4 stated she went to PA #1, who was in the building, and notified her of the lack of medications for Resident #1. Nurse #4 explained she went with PA #1 to check the blood sugar of Resident #1 and it was within normal limits, not requiring insulin administration. Nurse #4 revealed Resident #1 did not require pain medication on the morning of 10/31/2023. Documentation in electronic medication administration notes for Resident #1 on 10/31/2023 revealed the evening dose of Novolin insulin to be administered at 5:00 PM stated, Medication not available from pharmacy. Documentation on the MAR for 10/31/2023 revealed Resident #1 received his evening medication ordered doses of Atorvastatin, Buspirone, Carvedilol, Icosapent Ethyl, Lamotrigine, Pregabalin, Ranolazine extended release, and Oxycodone. An interview was conducted with Nurse #6 on 11/13/2023 at 2:28 PM. Nurse #6 confirmed she was working on the 7:00 AM to 3:00 PM shift on 11/01/2023 and was assigned to the medication cart on the hall Resident #1 resided. Nurse #6 confirmed the morning medications were available for Resident #1 to include his morning dose of insulin. An interview with the Director of Nursing was conducted on 11/11/2023 at 3:04 PM. The facility policy, as explained by the DON, was for a nurse to enter the physician orders into the MAR and once on the MAR, the orders were to be transmitted to the pharmacy. The DON revealed that the facility received two deliveries of medications from the pharmacy, one at approximately 2:00 PM and another at approximately 9:00 PM. The DON further revealed that the pharmacy was a new pharmacy for the facility and the facility had no back up medications onsite in an automated medication dispensing system. An interview was conducted with the Pharmacy Director for the facility pharmacy on 11/11/2023 at 3:19 PM. The Pharmacy Director was able to convey the following information from the pharmacy records. The first facsimile from the facility regarding the medications for Resident #1 was received by the pharmacy at 5:42 PM on 10/30/2023, after the closing time of 5:30 PM for the pharmacy. At 11:30 PM on 10/30/2023 the facility pharmacy received a lot of physician orders for Resident #1. The orders for Resident #1 were processed when the pharmacy reopened on 10/31/2023. The first delivery of medications was sent with the driver at 1:19 PM on 10/31/2023. The driver delivered the medications for Resident #1 at 8:44 PM on 10/31/2023 to the facility and the medications were signed for by Nurse #3 at that time. The Pharmacy Director had no explanation for why the pharmacy driver delivered the medications for Resident #1 outside of the expected delivery times contracted by the facility. The Pharmacy Director explained that it was the expectation of the pharmacy that if medications were needed after the close of business of the pharmacy, the backup pharmacy needed to be called by the facility so that medications were obtained by morning for the resident. The Pharmacy Director confirmed the facility did not currently have an automated medication dispensing machine that contained insulin as a backup for needed medications. Documentation on a Brief Interview for Mental Status dated 10/31/2023 revealed Resident #1 was screened as cognitively intact. Resident #1 was interviewed on 11/11/2023 at 4:13 PM. Resident #1 stated it was a stressful and frustrating 2 days when he was first admitted to the facility as he did not understand why his medications were not available to him. Resident #1 stated he did not suffer anything health wise from not having his medications available to him but reiterated it was stressful worrying about not having his insulin, blood thinners, antibiotics, and pain medication after surgery. Resident #1 stated he was able to tolerate the pain while he waited for his medication to arrive at the facility.

Based on observations, record review and Physician, resident, Responsible Party (RP), and staff interviews the facility failed to provide a pest free living environment for 1 of 1 resident residing in the facility (Resident #42). The facility's failure contributed to Resident #42 sustaining a rash to her arms and legs due to ant bites resulting in itching and discomfort. The Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive 1-2 staff member assistance with all activities of daily living including bed mobility. Resident #42 was coded as having no limitations in her range of motion, clear speech, and had the ability to understand others. A review of the Pest Control Commercial Services Agreement dated 7/11/23 stated services would be provided weekly specifically targeting roaches, ants, and mice. The specifications of the service provided included treating all common areas, exterior and interior doorways, and exterior of the building for general pests. The pest control service report dated 7/18/23 revealed the perimeter of the facility was treated for black ants and roaches. The report indicated common areas in the facility were spot treated for roaches only. The report did not specify if roaches or ants were observed during the visit. The pest control service report dated 7/25/23 revealed the perimeter of the facility was treated for ants. The report did not specify if ants were observed during the visit. A progress note dated 7/27/23 at 6:55am and written by Nurse #1 stated Resident #42 was moved to room [ROOM NUMBER] due to an ant infestation in her room (room [ROOM NUMBER]). The note indicated ants were observed in her bed and scattered throughout her room. A telephone interview was completed on 9/25/23 at 3:25pm with Nurse #1. The Nurse verified he worked nightshift on 7/26/23. Nurse #1 stated he was unable to recall providing care to Resident #42 or observing any pests in her room. A review of the July 2023 Physician Order Summary revealed an order dated 7/27/23 for Triamcinolone Cream (steroid cream) 0.1% apply to rash 3 times daily for 14 days. A telephone interview was completed on 9/26/23 at 3:56pm with Nurse Aide (NA) #1. The NA indicated she provided care for Resident #42 during the nightshift on 7/26/23. NA #1 stated she did not observe ants on the Resident or in her room during the night. The NA stated she did not see the Resident scratching her arms or legs during the shift. NA #1 stated she was notified by Nurse #6 he observed ants in the Resident's room on the morning of 7/27/23. The NA was unable to recall the exact time of her final check on the Resident. The NA stated she did not recall Resident #42 scratching her arms during any shifts she was assigned to care for her. A telephone interview was completed on 9/27/23 at 9:15am with Nurse #6. The Nurse verified he was assigned to provide care for the Resident during the day shift on 7/27/23. Nurse #6 stated when he arrived at the facility, Resident #42 had already been moved to a new room (22). The Nurse revealed he did not observe any ants on the Resident in the new room (22) and did not go in the Resident's previous room during his shift. Nurse #6 stated he observed red areas scattered on the Resident's arms and legs. The Nurse indicated the Medical Director was notified, assessed the resident, and prescribed Resident #42 a cream for the rash. Nurse #6 stated Nurse #1 informed him of the ant infestation in Resident #42's room during shift report on 7/27/23. Nurse #6 revealed he observed Resident #42 intermittently scratching her arms approximately 2-3 days after sustaining the ant bites, but the prescribed steroid cream decreased the Resident's scratching. The Nurse stated he had not observed ants in any other Resident rooms. A telephone interview was completed on 9/24/23 at 10:20am with Resident #42's RP. The RP revealed she arrived at the facility to visit the Resident at approximately 7:45am on 7/27/23. She was made aware the Resident had just been moved to a different room due to ants being observed in her room. The RP indicated she visited the Resident's previous room (32) on 7/27/23 and only observed small black ants on the Resident's bed. The RP stated she visited Resident #42 and observed a red rash scattered throughout her arms and legs and observed the Resident scratching her arms. The RP revealed the resident's assigned nurse informed her the Physician had been notified and an order was obtained for a steroid cream. The RP stated she had not observed pests in Resident #42's room prior to 7/27/23 and had not observed them since. Undated pictures of Resident #42's room were provided by the RP. The pictures revealed an empty bed with approximately 10-12 small black ants crawling on the bottom sheet. An observation of Resident #42 was completed on 9/24/23 at 11:55am. No rash was observed on the Resident's arms or legs, and no pests were observed in her room. Resident #42 was questioned if she recalled the ants on 7/27/23 and she shook her head no. Observations of the facility's common areas and resident rooms on 9/24/23 at 10:00am yielded no observations of pests. Observations of the facility's common areas and resident rooms on 9/25/23 at 3:35 pm yielded no observations of pests. The pest control service report dated 8/1/23 revealed the perimeter and common areas of the facility were treated for roaches. The report did not specify if roaches were observed during the visit or anything about ants being observed in Resident #42's room on 7/27/23. The pest control service report dated 8/8/23 revealed the perimeter of the facility was treated for roaches. The report did not specify if roaches were observed during the visit. The pest control service report dated 8/15/23 revealed the perimeter of the facility was treated for roaches and ants. The report did not specify if roaches or ants were observed during the visit. The pest control service report dated 8/22/23 revealed the perimeter of the facility was treated for roaches and ants. The report did not specify if roaches or ants were observed during the visit. The pest control service report dated 8/29/23 revealed the perimeter of the facility was treated for roaches. The report did not specify if roaches were observed during the visit. The pest control service report dated 9/5/23 revealed the perimeter of the facility was treated for roaches. The report did not specify if roaches were observed during the visit. A telephone interview was completed on 9/25/23 at 2:23pm with the former Director of Nursing (DON) #1. The DON stated she was made aware of ants in Resident #42's room when she arrived at the facility on 7/27/23. She revealed at the time of her arrival, the Maintenance Director had already been notified, exterminated the ants, and had housekeeping cleaning the room. She further stated staff had already moved the Resident to a clean room and notified the RP and Medical Director. Former DON #1 stated she did not observe ants in the Resident's old room. The DON stated she was unsure of what attracted the ants to Resident #42's room. She revealed housekeeping staff cleaned the room and the Maintenance Director verified all ants were exterminated from the room. An interview was completed on 9/26/23 at 9:30am with the Medical Director. The Medical Director indicated she assessed Resident #42 on 7/27/23. The Medical Director stated she observed a red rash scattered throughout the Resident's arms and legs. She indicated the rash appeared to be ant bites. The Medical Director stated she was unable to recall if the Resident was scratching the rash during her visit. The Medical Director stated she prescribed a steroid cream to treat the rash, and the rash was healed approximately 1 week later. A telephone interview was completed on 9/26/23 at 12:27pm with the Pest Control Technician. The Technician stated his company began providing services in July 2023. He stated he visited weekly to treat the facility for pests, which included ants and roaches. The Technician stated on his first visit, 7/18/23, roaches were observed in common areas throughout the facility. The Technician stated during his visits, he sprayed the perimeter of the building, inspected high probability areas (kitchen, staff breakroom, common areas) and treated as needed. He revealed during each visit he inspected a set number of Resident rooms for pests, and by the end of each month he had inspected all areas of the facility. The Technician stated outside food brought in and eaten in Resident rooms was a contributing factor to pests in rooms. He indicated he had spoken with housekeeping staff and the Administrator regarding residents eating food in their rooms and the importance of eliminating food particles after the resident had eaten. The Technician was unable to recall what rooms were treated during each visit. He revealed he treated the perimeter of the building for ants and roaches on 7/25/23 and did not recall observing ants in the facility. The Technician stated he did not recall being contacted on 7/27/23 regarding ants, and his next service day was 8/1/23. The Technician stated he did not observe ants in the facility on 8/1/23. He stated the observation of pests had decreased dramatically since he started providing services to the facility. The Technician stated it was his opinion the facility was doing everything possible to eliminate any pests that entered the building. An interview was completed on 9/26/23 at 1:34pm with the Maintenance Director. The Director stated the pest control company visited weekly to spray the exterior of the building. He revealed the company inspected the building and spot treated areas during each visit. The Maintenance Director stated when pests were observed in between the pest company's visits, he eliminated them and notified the pest company at their next visit. The Maintenance Director stated he was notified when he arrived the morning (unable to recall time) of 7/27/23 by staff, ants were found in Resident #42's room (32). The Director stated he observed ants around the windowsill and several scattered on the floor (approximately 20). He did not recall seeing ants in the Resident's bed. The Maintenance Director stated vacuumed the ants up, sprayed the areas where ants were observed, and had housekeeping thoroughly clean the room. He indicated he did not contact the pest company because they were scheduled to visit on 8/1/23. The Director stated food in resident rooms attracted the pests but was unable to recall if he observed food or crumbs in Resident #42's room. The Director stated since the new Pest Company began providing services in July 2023 and he had not observed ants in the facility since 7/27/23. An interview was completed on 9/27/23 at 1:02pm with the Interim DON. The DON stated she felt the pest control issue in July 2023 was a result of the failure of the previous facility owners and pest control company to maintain an effective pest control program. The DON stated when the current pest control company began providing services in July 2023 the observation of pests had decreased. An interview was completed on 9/27/23 at 1:21pm with the Administrator. He indicated when the facility identified ongoing observations of pests (roaches only) with the prior pest company, the facility contracted with a new pest control company to begin providing services. The Administrator stated he felt due to the age of the building and the prior pest control company only treating the outside of the building this did not fully eliminate the pests. He revealed he had not observed ants in the facility. The Administrator stated the facility thoroughly sanitized Resident #42's room on 7/27/23 and made the Pest Technician aware of the ants during his visit on 8/1/23. He revealed Resident #42's room (32) was treated for ants prior to being moved back into it. The Administrator stated the new pest control company began providing services on 7/18/23 and had been servicing the facility weekly since that time.

Based on record review, observations, staff, and Physician interview, the facility failed to safely transfer a dependent resident from wheelchair to bed which resulted in the fracture of the right humeral head (shoulder joint) and injury to the toenail of the right great toe with bleeding for 1 of 1 Residents (Resident #27) reviewed for accidents The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke that resulted in right sided weakness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #27 was severely cognitively impaired. The MDS indicated the Resident was dependent on 2 staff members for transfers and was coded as having impairment on 1 side of his upper and lower extremities. A care plan for an activities of daily living (adl) self-care performance deficit was last revised on 3/21/23. The interventions included assistance from 2 staff members and a mechanical lift for transfers, extensive to total assistance from 1-2 staff members for bed mobility, and extensive to total assistance from 1 staff member for dressing. A Care Guide dated 3/21/23 revealed Resident #27 required a 2 staff member mechanical lift transfer. A review of Resident #27's incident report dated 5/16/23 Nurse #5 revealed during a transfer from his wheelchair to his bed, Resident #27's right great toe was injured during a transfer. The report revealed blood was observed on his right sock around the great toe area. The Nurse Manager evaluated the area and found the Resident's right great toe toenail was injured. The area was cleaned, and treatment was provided. A review of Resident #27's May 2023 Physician order summary revealed an order dated 2/10/23 for Norco 5-325mg (pain medication) 1 tablet by mouth twice daily. Review of Nurse Aide (NA) #5's statement dated 5/16/23 at 3:00pm revealed at approximately 2:45pm the NA went to transfer Resident #27 into bed to provide incontinence care. Prior to the transfer, the Resident was pointing at his feet and NA #5 observed blood on his sock, removed the sock, and notified the Nurse Manager who evaluated and treated the area. A telephone interview was completed on 9/26/23 at 12:37pm with NA #5. The NA stated around 2:00pm-2:30pm on 5/16/23 Resident #27 requested assistance back to bed. The NA stated she placed the Resident's arms around her neck, used the waistband of his pants to lift him from his wheelchair to the bed, placed his legs in the bed, and adjusted him to a comfortable position. The NA stated once the Resident was in bed, she observed dried brown blood on his right sock. The NA stated the Resident must have hit his toe prior to the transfer. NA #5 indicated she left the room and notified the Nurse Manager. The NA stated she had worked for the facility via a staffing agency approximately one month prior to providing care for Resident #27. She indicated she was not made aware of where or how to look for a resident's care plan and did not ask another staff member how to access it. NA #5 confirmed she was aware Resident #27 was a 2 staff member mechanical lift transfer. The NA stated she did not request assistance from an additional staff member to transfer Resident #27 or use the mechanical lift. Review of the Activity Assistant's written statement dated 5/18/23 at 2:00pm revealed at approximately 2:30pm (5/16/23) she observed NA #5 exiting Resident #27's room. The NA informed the Activity Assistant the Resident's toenail was bleeding. The Activity Assistant entered the Resident's room, observed him in bed, and the toenail on his right foot bleeding. The statement further revealed she did not observe a mechanical lift in the room or located outside the Resident's room. Review of Nurse #3's written statement dated 5/16/23 revealed at approximately 2:45pm the Nurse Manager notified her Resident #27's toenail was bleeding. The statement revealed the evening shift nurse had arrived on shift and completed the incident report. An interview was completed on 9/26/23 at 11:44am with Nurse #3. The Nurse verified she was assigned to provide care for Resident #27 on 5/16/23. Nurse #3 stated she was completing shift report to the oncoming nurse when she was notified by the Nurse Manager that the Resident had an injury to his right great toe. The Nurse stated the oncoming nurse completed the Incident Report regarding the injury. An interview was completed on 9/26/23 at 11:55am with NA #7. The NA stated she was assigned to provide care for Resident #27 on 5/17/23. NA #7 revealed during the Resident's bath, he was holding his right arm and did not want her touching it during his bath. The NA stated she informed Nurse #3 and the Nurse Manager. The NA confirmed the Resident's care plan which revealed what type of assistance and how the Resident transferred was attached to the back of the closet door. She stated when she was unsure of what extent of care a resident was, she referred to the care plan. An interview was completed on 9/26/23 at 11:50am with Nurse #4. The Nurse revealed she was assigned to care for Resident #27 on 5/17/23. Nurse #4 stated the NA assigned to care for Resident #27 (NA #7) on 5/17/23, notified the Nurse Manager at some point during the morning (was unable to recall the time), that the Resident was experiencing right arm pain. The Nurse stated the Physician evaluated the Resident and ordered him to be transferred to the emergency department for evaluation and treatment. A progress note written by the Nurse Manager and dated 5/17/23 at 11:15am stated the Physician was in the facility that morning, was made aware Resident #27 complained of pain in his right arm and shoulder, the Physician evaluated the Resident, and placed an order to send him to the emergency department for an x-ray and treatment. An interview was completed on 9/26/23 at 9:37am with the Nurse Manager. The Nurse Manager stated upon entering the Resident's room on 5/16/23, she observed bright red blood around Resident 27's right great toenail. The Nurse indicated she provided treatment to Resident #27's right great toe on 5/16/23 following an injury that occurred during a transfer by NA #5. She stated at that time the Resident did not complain of pain in his right arm. The Nurse stated Resident #27 had required 2 staff members and a mechanical lift transfer since admission to the facility due to right sided weakness resulting from a stroke. The Nurse Manager stated it was the facility's protocol to have 2 staff members assist with mechanical lift transfers. The Nurse revealed she observed Resident #27 holding his right arm and grimacing when he touched it. Review of NA #6's written statement dated 5/18/23 at 3:50pm revealed she provided care for Resident #27 on the night of 5/16/23 and he did not complain of pain while care was provided. Multiple attempts made to contact NA #6 were unsuccessful. Review of Nurse #3's second written statement dated 5/18/23 revealed a nursing assistant notified her Resident #27 complained of pain in his right arm on 5/17/23. Nurse #3 stated she observed the Resident unable to move his arm without experiencing pain. The Physician was present in the facility and informed of what occurred during the Resident's transfer into bed on 5/16/23. The Physician evaluated the Resident, and an x-ray of his arm was ordered. An interview was completed on 9/26/23 at 11:44am with Nurse #3. Nurse #3 revealed she provided care for Resident #27 on 5/17/23 also. The Nurse stated she was notified by NA #7 the Resident was holding his right arm and refused for her to wash it during his bath. Nurse #3 stated the Nurse Manager and herself verified the Resident had pain in his right arm and notified the Physician. Review of Resident #27's hospital discharge summary dated 5/17/23 revealed the Resident was diagnosed with a fracture of the right humeral head. The fracture was treated with the application of a sling while awake and until the Orthopedic (bone) Physician discontinued the order. A progress note dated 5/17/23 at 10:32pm stated the Resident returned to the facility at approximately 5:40pm with a diagnosis of a right humeral head fracture. The Resident had no complaints of pain or discomfort. A Report of Consultation note revealed Resident #27 was evaluated by an Orthopedist on 5/19/23. The note revealed there was no right arm swelling or redness observed during the visit. The Physician ordered Resident #27's right arm to remain in a sling for approximately 4 weeks and Norco 5-325mg (pain medication) 1 tablet every 6 hours as needed for pain. A physician's order dated 5/21/23 indicated Resident #27's Norco 3-325mg twice daily was increased to three times daily. A telephone interview was completed on 9/25/23 at 10:58am with the facility's Administrator. The Administrator revealed on 5/16/23 at approximately 2:30pm NA #5 transferred Resident #27 into bed without the assistance of a 2nd staff member and mechanical lift as the care plan indicated. Following the transfer, NA #5 notified the Nurse Manager she observed blood on the Resident's right sock. The Nurse Manager evaluated and provided treatment to the Resident's injured great right toe. The Administrator stated at that time Resident #27 did not complain of right arm pain. During the morning of 5/17/23 it was noted the Resident complained of right arm pain and was sent to the emergency department for evaluation and treatment. During the visit, the Resident was found to have a right arm fracture and was discharged with an order to wear a right arm sling and follow up with an Orthopedist. The Administrator stated NA #5 was removed from the schedule immediately and an investigation was started. The Administrator stated the investigation revealed NA #5 transferred Resident #27 by lifting him from his chair and pivoting him to the bed. He revealed Resident #27 was unable to stand due to right sided deficits due to a stroke and was a 2 staff member mechanical lift transfer. The Administrator revealed during his interview with NA #5, the NA confirmed she was aware Resident #27 was a 2 staff member mechanical lift transfer and completed the transfer by herself. The Administrator stated education on proper transfers of a resident was started on 5/16/23 by the DON and was provided to all nursing staff. An observation of Resident #27 was completed on 9/25/23 at 11:16am. The Resident was sitting up in his wheelchair, when questioned if he had pain in his right arm his shook his head no. An interview was completed on 9/26/23 at 9:20am with the Medical Director. The Medical Director revealed she evaluated Resident #27 on 5/17/23 due to his complaints of right arm pain and injury to his right great toe. The Medical Director indicated she ordered Resident #27 to be transferred to the hospital for an evaluation and treatment. She stated due to the Resident's multiple health diagnoses (iron deficiency anemia, seizure disorder, and Multiple Sclerosis) and anticonvulsant medications; he was at a higher risk for bone fractures. The Medical Director stated Resident #27 had limited range of motion (ROM) in right side due to a previous stroke and a 2 staff member mechanical lift transfer was appropriate. She stated the right humeral head fracture did not decrease the Resident's ROM and placing a sling on the Resident's right arm and Orthopedist follow up visits were appropriate treatment. The Medical Director indicated she reviewed the 5/19/23 Orthopedist consult report and scheduled Resident #27's pain medication because she felt due to his dementia, he would not request medication when he was in pain. The Medical Director stated it was her opinion the fracture was a result of the improper transfer on 5/16/23. She revealed due to the Resident's dementia, it was possible the Resident focused on the injury of his toe on 5/16/23 and was unaware of right arm pain until later. A telephone interview was completed on 9/26/23 at 1:15pm with the Former Director of Nursing (DON) #2. The DON stated all staffing agency employees were educated on where care plans were in a resident's room and how to access it in the resident's electronic medical record. The DON revealed when she interviewed NA #5 regarding the 5/16/23 transfer, the NA verified she was aware Resident #27 was a 2 staff member mechanical lift transfer, did not want to wait for an additional staff member to assist with the transfer, and felt comfortable transferring the Resident the way she completed it. The DON stated Resident #27 complained of right great toe pain on 5/16/23 and on the morning of 5/17/23 complained of right arm pain. A follow-up telephone interview was completed on 9/27/23 at 1:20pm with the Administrator. The Administrator stated it was his expectation all nursing staff refer to a resident's care plan when they were unsure of a resident's level of care.

Based on record review and staff interviews, the facility failed designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. The findings included: During an interview with the Interim Director of Nursing (DON) on 9/24/23 at 11:30 am she revealed the Infection Preventionist (IP) was responsible for the facility's Infection Prevention and Control Program. The DON stated the IP was new to the position and had not completed any of the required training programs for the IP position yet. The DON stated the facility did not have any staff members with specialized training to meet the qualifications for the IP role. An interview was conducted with the IP on 9/25/23 at 11:29 am who revealed she was new to the position and the facility planned for her to attend the next training session to complete the required specialized training. She stated she was shown how to monitor infections in the facility but had not had any other education regarding the Infection Prevention and Control Program. During an interview on 9/26/23 at 11:21 am the Administrator revealed he was aware the IP had not completed the required training for the Infection Preventionist position. The Administrator stated he was aware the IP role required specialized training, but he thought the Interim DON had completed the training and would be responsible until the IP was able to complete the training.

Based on a lunch meal tray line observation, staff interviews and record review the facility failed to provide pureed food items with a smooth consistency. This failure had the potential to affect 7 of 45 residents with diet orders for a pureed diet texture. The findings included: A review of the Diet Order Report dated 9/27/23 revealed 7 residents with diet orders for a pureed diet texture. Review of the menus revealed the facility followed the National Dysphagia Diet (NDD) for residents with diet orders for a pureed diet texture. The NDD recorded a dysphagia pureed diet required all foods pureed and thickened, if necessary, to a pudding-like consistency, lump free, requiring little to no chewing. An observation was conducted on 9/25/23 at 12:46 pm of Resident #27 eating his lunch meal in the dining room. Resident #27's meal ticket indicated he was on a pureed diet. The observation revealed no issues with the consistency of the pureed meal. A continuous observation of the lunch meal tray line on 9/26/23 from 11:45 AM - 12:01 PM revealed the Certified Dietary Manager (CDM) recorded the internal temperature of the food items stored on the tray line intended for the lunch meal service, including pureed green beans and pureed meat sauce, were observed with a lumpy consistency smaller than pea-sized when the food was stirred. The CDM observed the lumpy consistency but did not say anything until the surveyor intervened. Cook #1 was instructed by the CDM to use a standard blender to further puree these foods until a smooth consistency was achieved. The pureed bread was a smooth pureed consistency. An observation was conducted on 9/26/23 at 8:19 am of Resident #27 eating his breakfast meal independently in his room. Resident #27's meal ticket indicated he was on a pureed diet. The observation revealed no issues with the consistency of the pureed meal. Cook #1 was interviewed on 9/26/23 at 11:45 AM. She stated that she had been preparing the pureed foods with chunks for the last 2 months because the new owners would not purchase a new immersion blender. The current immersion blender was broken, and she had to use a standard blender. An interview was conducted with the District Manager on 9/26/23 at 2:52 PM. She stated if the surveyor did not intervene, the pureed green beans and meat sauce with a lumpy consistency would have been served to residents with a puree diet order. She stated that the immersion blender was broken, and a standard blender was provided as a replacement. However, a standard blender would not have been sufficient in an industrial kitchen to produce pureed foods for three meals each day. The District Manager indicated that she notified the interim Director of Nursing (DON) about the broken immersion blender. The CDM stated on 9/26/23 at 2:58 PM that she told the interim DON during the morning meeting on 9/13/23 that the immersion blender was broken. The CDM told the interim DON that the previous owners provided a standard blender. The interim DON told her that a replacement immersion blender was too expensive. The CDM indicated the standard blender provided by the previous owners stopped working on 9/24, and she had to borrow the standard mixed drinks blender from the activities department to puree food for meal service. She stated that the spaghetti noodles would have been pureed further, but if the surveyor had not intervened, she would have served the pureed meat sauce and pureed green beans with lumps. If she had an operational/appropriate blender, then the pureed foods would have been at the correct consistency. The Speech Language Pathologist (SLP) was interviewed on 9/27/23 at 10:55 AM. During the interview, she stated she had worked at the facility for the last 2 weeks. She further stated she fed one resident pureed food and did not find an issue with the consistency at that time. However, if pureed foods had chunks in them, the risks would be choking, aspiration pneumonia or death. The SLP indicated that no concerns about the consistency of pureed foods were brought to her attention. A phone interview with the Registered Dietitian (RD) occurred on 9/27/23 at 10:59 AM. The RD stated he had seen the pureed foods (spaghetti, meat sauce and green beans) on 9/26/23 lunch meal tray line as Dysphagia Advanced mechanical consistency rather than puree. He stated that he noticed puree food items with a lumpy consistency within the past month due to the broken immersion blender, and he and the CDM notified the interim DON multiple times about the broken immersion blender. The Administrator stated in an interview on 9/27/23 at 1:26 PM that he was on Family Medical Leave Act absence since the second week of July 2023. He stated that a new immersion blender was purchased 3-6 months ago, and he was unaware that it was broken. As soon as management staff were notified of a broken immersion blender, it should have been serviced or replaced immediately. Standard blenders were used in the past for emergency purposes until the immersion blender was replaced. The standard blenders needed to blend food for longer to achieve the proper consistency of pureed foods.

Based on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 5/12/22. This was for two deficiencies cited in the areas of food procurement store/prepare/serve sanitation (F812) and infection prevention/control (F880). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. F812: Based on observation and staff interviews, the facility failed to 1) maintain the temperature of potentially hazardous cold foods at 41 degrees Fahrenheit or below (yogurt and milk) prior to delivery 2) label/date, store, and discard perishable foods beyond the use date in one of two kitchen refrigerators and failed to 3) allow plates to air dry prior to assemblage and stacking for one of two observations. These practices had the potential to affect all residents. During the recertification survey that concluded on 5/12/22, the facility failed to maintain kitchen equipment clean, in good repair and in a sanitary manner to prevent cross contamination by failing to remove excessive ice and food debris from 2 of 4 freezers, failed to make repairs to a damaged freezer, failed to clean 1 of 2 ovens, 3 of 3 heating/ventilation/air conditioners (HVAC) filters, 1 of 1 can openers, and clean 1 of 1 nourishment room refrigerators. On 9/26/23 at 10:59 AM, the Administrator was interviewed. He revealed that F812 was a repeat tag due to excessive turnover in the kitchen. He indicated that the Certified Dietary Manager (CDM) had been working unnecessary hours, as well covering open shifts. The Administrator stated that more education/auditing was needed for kitchen staff and follow-up actions to be performed by the management team. 2. F880: Based on observations, record review, and staff interviews, the facility failed to implement their infection control policy and policy for handling soiled linen. Laundry Aide #1 was observed having soiled linens come in contact with her clothing while sorting them into the washing machine and transferring unbagged soiled linens from a soiled linen bin on a resident hall to an open laundry basket to transport the linens to the laundry room for 1 of 2 laundry aides observed (Laundry Aide #1). During the recertification survey that concluded on 5/12/22, the facility failed to implement a Legionella prevention program. This deficient practice had the potential to affect all 44 residents. The Administrator was interviewed on 9/27/23 at 1:40 PM. He revealed that the F880 tag was a repeat due to the turnover of staff and recent change of ownership.

Based on observation and staff interviews, the facility failed to 1) maintain the temperature of potentially hazardous cold foods at 41 degrees Fahrenheit or below (yogurt and milk) prior to delivery 2) label/date, store, and discard perishable foods beyond the use date in one of two kitchen refrigerators and failed to 3) allow plates to air dry prior to assemblage and stacking for one of two observations. These practices had the potential to affect all residents. The findings included: 1. An observation of the lunch meal dining service occurred on 9/26/23 at 12:01 PM. Perishable dairy products for the lunch meal were displayed on a meal tray adjacent to the tray line. The following temperatures were obtained at the request of the surveyor by the District Manager and these foods were ready for service: - single serve yogurt container: 59.8 degrees Fahrenheit - whole milk carton: 49 degrees Fahrenheit As a result, all perishable dairy products were discarded by the District Manager and Certified Dietary Manager (CDM). During an interview with the CDM on 9/26/23 at 2:58 PM, she revealed that if the surveyor did not intervene, the yogurt and milk would have been served at unsafe temperatures. She stated the cold dairy items should have been on ice prior to meal service and not have exceeded 41 degrees Fahrenheit. The Administrator was interviewed on 9/27/23 at 1:26 PM. He revealed that all dairy products used for meal service should come directly from the refrigerator and placed in an ice bath to remain below 41 degrees Fahrenheit. 2. An observation of the kitchen and an interview with the CDM were conducted on 9/24/23 at 10:23 AM. The following food items were found in the refrigerator in front of the ice chest: 1 package of turkey slices not dated or sealed, 1 opened plastic bag of hot dogs dated 9/15, 1 plastic bag of cabbage not sealed and dated 9/8, chunks of ham wrapped in plastic without a date, 1 plastic container labeled beef and dated 9/17, 1 not sealed plastic bag of parmesan cheese dated 9/1, 1 plastic container of baked beans dated 9/9, 1 plastic bag of ham slices dated 9/8, 1 plastic container of greens dated 9/6, 1 plastic container of diced tomatoes dated 9/12, 1 not sealed plastic bag of coleslaw dated 9/19, 1 plastic container of tuna salad dated 9/13, 1 not sealed plastic bag of sliced yellow cheese dated 9/11, 1 bag of shredded yellow cheese wrapped in plastic and not dated. The Dietary Manager stated the shelf life of prepared foods/opened containers was 7 days. She stated she normally went through the refrigerator every Monday and discarded necessary items. An interview was conducted with the Administrator on 9/26/23 at 10:59 AM, and he stated that food should be labeled, dated, and stored properly. 3. An observation of the kitchen and an interview with the CDM were conducted on 9/24/23 at 10:48 AM. Thirty-one out of fifty-eight plates were observed to be stacked wet and ready for use on a shelf underneath the tray line. The CDM stated there was not enough space in the kitchen to air dry the plates. Also, there was only one air drying cart available used for the dome lids. During an interview with the Administrator on 9/27/23 at 1:26 PM, he revealed the plates should have been air dried prior to storage for meal service.

Based on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days week for 8 of 62 days reviewed (7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23). Findings include: The nursing staff schedule and the staff posting was reviewed from 5/1/223 through 9/15/23. The daily staffing sheet indicated a Registered Nurse (RN) was not scheduled for at least eight consecutive hours a day on the following dates: 7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23. In an interview with the Nurse Manager (NM) on 9/25/23 at 8:37 A.M. she stated she was the scheduler for the facility. She revealed the staffing agency was contracted by her facility to assign an RN to the facility on [DATE], 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23 but failed to do so. During an interview with the prior DON on 9/25/2023 2:33 P.M. she stated she was the RN on weekdays. She revealed they relied on an agency for weekend RN coverage, and the agency was unable to provide RN coverage on 7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23. An interview was conducted on 9/25/23 at 8:37 A.M. with the Director of Nursing (DON). She revealed she was aware of no RN coverage on 7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23. She stated they have had difficulty hiring RN's and the agency was not able to provide an RN to assist with the coverage on those dates.

Based on observations, record review, and staff interviews, the facility failed to provide nail care to 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included stroke with hemiplegia (paralysis one side of body) on the right side and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #27 had severe cognitive impairment and required staff assistance for personal hygiene and bathing. Resident #27 was not coded for behaviors and had impaired range of motion on one side for the upper and lower extremities. Resident #27's care plan, last revised on 9/09/23, revealed he had an activities of daily living (ADL) self-care performance deficit related to history of stroke with hemiplegia and was dependent on staff for personal care and bathing. Review of Resident #27's care guide (no date) revealed he was scheduled for showers on Monday and Thursday on the 3:00 pm-11:00 pm shift. Record review of the Resident #27's shower documentation by Nurse Aide (NA) #2 revealed his shower was documented as not applicable (NA) on 9/25/23 on the 3:00 pm-11:00 pm shift. No further documentation regarding why the shower was not completed for Resident #27. An attempt to interview NA #2 on 9/27/23 at 8:41 am, who was assigned to Resident #27 on the 3:00 pm-11:00 pm shift on 9/25/23 (a scheduled shower day) was unsuccessful. An observation on 9/24/23 at 11:12 am of Resident #27 revealed the fingernails of his left hand were trimmed and there was a dark brown substance under all of his nails. A telephone interview was conducted on 9/26/23 at 2:27 pm with Nurse Aide (NA) #3 who was assigned to Resident #27 on 9/24/23 during the 7:00 am-3:00 pm. NA #3 stated she usually tried to do nail care when she gave a bed bath, but she did not give Resident #27 a bed bath or provide nail care when she was assigned to his care on 9/24/23. NA #3 stated the facility was short one NA and everyone was helping provide care to all the residents, so she just did not have enough time to check if Resident #27's fingernails were dirty. An observation was conducted on 9/25/23 at 12:46 pm of Resident #27 revealed the fingernails of his left hand were trimmed and there was a dark brown substance under all of his nails. An interview was conducted on 9/25/23 at 2:56 pm with NA #1 who confirmed she was assigned to provide care to Resident #27 on 9/25/23 during the 7:00 am -3:00 pm shift. She stated nail care was completed as needed and on scheduled shower days. NA #1 reported she provided nail care if she had time if not it would be done on his shower day which was Monday and Thursday on the 3:00 pm to 11:00 pm shift. NA #1 stated she gave Resident #27 a bed bath in the morning, but she did not provide nail care on her shift because she did not have enough time to check Resident #27's nails today to see if nail care was needed. An observation on 9/26/23 at 8:29 am of Resident #27 revealed the fingernails of his left hand were trimmed and there was a dark brown substance under all of his nails. An interview was conducted on 9/26/23 at 3:23 pm with the Nurse Manager who revealed Resident #27's nail care was to be completed daily during ADL care and as needed when nails were observed to be dirty. During an interview with the Interim Director of Nursing on 9/27/23 at 12:33 pm she reported that Resident #27's nail care was to be completed daily if they were dirty.

Based on record review, resident, and staff interviews the facility failed to invite the resident to participate in the development of care planning for 1 of 14 Residents care plans reviewed (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE], and recently readmitted on [DATE] with diagnoses that included Anemia, Type 2 Diabetes Mellitus, Chronic Kidney disease and Hyperlipidemia. A review of Resident #41's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #41's care plan revealed it was updated on 7/23/2023. A review of Resident #41's nursing progress notes revealed there was a care plan meeting on 4/13/23 and 7/19/23. There was no documentation to indicate Resident # 41 was included in her care plan development and/or invited to participate in her care plan meeting. During an interview with Resident #41 on 9/24/2023 at 12:00 P.M. Resident #41 stated she has not participated in any care plan meeting since her admission to the facility. She revealed she never received a verbal or written invitation. She explained further she would be readily available to attend any meeting when invited. An interview on 9/25/2023 at 10:19A.M. with the MDS Nurse revealed she was not sure why she did not involve or invite Resident #41 to her care plan meeting. She stated it was her responsibility to invite Resident #41 to her care plan meeting. An interview was conducted with the Director of Nursing (DON) on 9/26/2023 at 10:58 A.M. She stated it was the responsibility of the MDS nurse to invite Resident #41 to the care plan meeting. During an interview with the Administrator on 9/27/2023 at 1:28 P.M. he stated the MDS Nurse had the responsibility of inviting Resident #41 to the care plan meeting. He stated he was not aware Resident #41 never participated in her care plan meeting.

Based on record review, physician interview, staff interviews, and responsible party interview, the facility neglected to protect a cognitively impaired resident from harm that resulted in multiple bruises to her mid sternum, left arm, left axilla, and left inner thigh on 03/02/18, bruises to her left arm and left axilla on 03/03/18, and multiple bruises under her right breast, right axilla, right sternum, and under her right ribs that extended down to her right hip on 03/19/18 for 1 of 3 residents (Resident # 28). Immediate Jeopardy began on 03/2/18 when Resident # 28 was noted to have bruising to her mid sternum, left arm, left axilla, and left inner thigh. Immediate Jeopardy was removed on 09/28/18 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident # 28 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].) Reviewed Resident # 28's quarterly Minimum Data Set (MDS) dated for 1/31/18. Resident evaluated to have a Brief Interview for Mental Status (BIMS) score of 99 (resident unable to complete the interview.) She was coded to have moderately impaired cognition, requiring extensive assistance with transfers, and with most activities of daily living. She was coded as a zero (behaviors not exhibited) for behaviors. She was coded as a one (behavior of this type occurred 1 to 3 days during evaluation period) for rejecting evaluation or care. Review of Resident # 28's most recent Care Area Assessments (CAA) did not reveal a behavior assessment. Review of Resident's care plan reviewed on 02/09/18 stated that the resident was at risk for behavior problems and resistance to care. The care plan also stated, Monitor/document any patterns to behavior. If resident physically aggressive, make sure resident is in a safe setting and attempt care at later time. The care plan also further stated, Provide assistance with transfers daily. A nurse's note dated 3/2/18 at 10 pm revealed, Resident alert and oriented to self. Out of bed in wheelchair until after dinner. Resident noted to have a large purplish bruise to left breast, sternum (center of chest), and left axilla/arm. Resident also has discoloration on left inner thigh area. Review of an incident report dated 3/2/18 revealed, During resident am care/bath Certified Nursing Assistant (CNA) reported to this nurse to come see resident related to bruise on chest. Resident observed to have dark purple to mid sternum to left arm, left axilla, left inner thigh. Review of a bruise investigation dated 3/2/18 at 09:30 AM revealed, Describe the Bruise: Location- mid sternum 10 centimeters x 4 centimeters to left upper arm and left axilla 6 centimeters x 6 centimeters left inner thigh 4 centimeters x 4 centimeters. Review of an Investigation Follow-up completed for incident on 03/02/18 on 03/13/18 revealed, Resident was observed to have a purple area across the chest. Recommendations/new interventions -- encourage staff to exercise care/caution during activities of daily living (ADL) for care/ transferring/ repositioning. Review of Resident # 28's physician's orders [REDACTED]. Review of a nurses' note dated 3/3/18 at 10:35 AM revealed, Resident resting in bed. Noticed to have a bruise around left breast. She shows no sign of pain or discomfort at this time. Review of an incident report dated 3/3/18 revealed, Resident observed in bed eyes close. Purple bruise on left arm and left axillary. Review of a bruise investigation for incident on 03/03/18 at 07:15 AM revealed, Describe the bruise: Location- left arm and axillary. Size- down left arm and entire underarm. Color - purple. Review of a nurse's note dated 03/4/18 at 03:30 PM revealed, Resident has been up in wheelchair most of the day. Noticed to have a bruise on left arm and under arm now. No signs and symptoms of pain. Review of an investigation follow-up for incident on 03/03/18 was dated 03/23/18 revealed, Description of situation- purple area on left arm and axilla. Summary of investigation- resident was observed to have a purple area left arm and left axilla. Recommendations/new interventions -- encourage resident and staff to be aware of surroundings during transfers/repositioning/ADL care. Review of a nurse's note dated 03/5/18 revealed, Doctor of Medicine (MD) in facility and saw resident. New order wrote for a complete blood count (CBC), comprehensive metabolic panel (Chem12), and a [MEDICATION NAME]/international normalized ration (PT/INR) next blood draw. Review of a physician consult dated 03/06/18 revealed a [DIAGNOSES REDACTED]. Review of a nurses' note dated 3/19/18 at 03:03 PM revealed, At 09:20 called to resident's room by CNA who was giving resident a bed bath, resident noted to have large purple bruising under right axilla, over right breast, and sternum, under right breast, to under right rib area to right hip. Resident denies pain to areas. Zero facial grimacing noted when area assessed. Physician in house at 10:00 and informed. Called and informed resident's responsible party (RP) at 11:20. Review of an Incident report dated 03/19/18 noted, During am bath CNA reported to this nurse that resident had bruising to right side and to come see resident. Review of a Bruise investigation dated 03/19/18 at 09:40 AM noted, Describe the Bruise-- Location- right axilla, under right breast, right sternum, to under right ribs. Review of an Investigation follow-up noted for incident for 03/19/18 revealed, Purple area to right side. Summary of investigation - resident was observed to have a purple area to right side. Recommendations/new interventions-encourage staff to exercise care/caution during ADL care/transferring/repositioning. An interview with the Staff Development Coordinator (SDC) was conducted on 09/26/18 at 11:04 AM. She recalled Resident # 28 having a large area of bruising on her left side. She said it was a very large bruise. She did not know what caused area. She said she does not investigate incidents. She said if she suspected a resident had been abused she would report it to the administrator. Interview on 9/26/18 at 11:43 AM with Resident # 28's physician conducted. Physician recalled resident having bruising in (MONTH) of this year that was significant in size. She said she had thought the bruising had come from a witnessed fall, or some type of trauma. She said the facility had informed her that resident had not had any reports of falls. She went on to say she wanted to get an x-ray of the areas, however; the resident refused. She stated she did order blood work, and resident had an abnormal hemoglobin. She stated had talked to RP about a possible blood transfusion, and after they talked about sending her to get the blood transfusion they decided to not send her out because it would be harder on her to move her somewhere else. She denied resident had any kind of pathological contributing factor. An interview was conducted with the Administrator on 09/26/18 at 11:19 AM. He confirmed that the incident report, bruise investigation, and incident follow-up was all that the facility had completed for the incident reports dated 3/2/18, 3/3/18, and 3/19/18. He said he recalled reports of the bruising, but he did not know what had caused the bruising. He said the facility has a meeting once a week to discuss resident incidents. He said he does not attend those meetings. On 09/26/18 12:02 PM an interview was conducted with NA #25. NA stated that resident #28 is a two person stand and pivot with transfers. She said resident is not combative with care and needs help with her care. An Interview was conducted on 9/26/18 at 12:12 PM with the director of nursing (DON.) DON did not recall Resident # 28 having bruising. She stated she did not come to work for the facility until after the beginning of (MONTH) this year. On 09/26/18 at 01:57 PM Administrator advised that the facility had been in contact with the resident #28's physician, and she had said that the bruising had come from the resident being combative with care. He said he thinks that the resident might have hit herself on her table, and it had caused the bruising. An interview was conducted on 09/26/18 at 02:08 PM with the Social Worker (SW). She said she remembered discussing the bruising, but she did not see the bruising. She said she did not know what caused the bruising. She thinks that they had thought it might have come from a bedside table, but she wasn't sure. She said when they review incidents if something large like a bruise, or there is something unusual about incident she would tell the administrator. She said in hind sight she now questioned that decision to not report the incidents. An interview was conducted on 09/26/18 at 02:20 PM with the MDS coordinator. She said resident # 28 was total care, could tell staff basic things she needs, was childlike, and very sweet. She said incident reports are discussed once a week on Fridays. She said the meetings are attended by herself, DON, SW, and SDC. She said they may might not have the meeting on Fridays if there is something else going on in the facility. She recalled discussing the bruising, but she did not know what had happened to cause the bruising. She said maybe the resident had hit a table. She said the resident has thin skin, and she refused care at times. She said she did not think anyone would purposefully hurt the resident. She said it was our best guess what happened. An interview was conducted with Nurse #50 on 09/27/18 at 01:43 PM. She said she remembered Resident # 28 having bruising in (MONTH) of this year. She said she did not know what caused it. She denied resident was combative with care. An interview was conducted on 09/26/18 at 02:37 PM with Resident # 28's RP. He recalled resident having bruising back in the spring. He did not recall if facility had told him what had caused the bruising. He said resident's physician did not call and discuss the bruising with him. He did recall the physician calling him to discuss the resident's lab work. He also recalled physician advising him that the resident had refused an x-ray. He said the resident often refuses things because she has always had the mind of a child. An interview was conducted with NA # 26 on 09/26/18 at 03:03 PM. She said she gives Resident # 28 her snacks and helps put her to bed. She remembered seeing the resident having bruising in (MONTH) of this year but didn't know what caused it. She said the bruising was very noticeable, and when she touched the side where the resident had the bruising the resident jumped. She said resident leans forward in her wheelchair at times, and she will assist resident to reposition because the resident is unable to reposition herself. She denied resident was resistive or combative with care. She said resident was a stand and pivot with transfers. She said that she was able to transfer her by herself, but other staff had to have two people to transfer her. An interview was conducted on 09/26/18 at 03:08 PM with NA #27. She stated she sets Resident #28 up to eat her meals and puts on her night clothes. She said resident is a stand and pivot 2 person assist. She said she remembers the resident having the large area of bruising. She did not know what caused the bruising or had never heard anyone it happened. She said resident was not combative with care, but she did refuse care at times. Interview was conducted with NA # 28 on 09/26/18 at 03:18 PM. She stated Resident # 28 was somewhat total care. She said she remembered the resident having bruising in (MONTH) of this year. She said she did not know what caused it. She denied resident was combative with care. She said resident verbally argues with her roommate sometimes, but they have never been physical with each other. An interview was conducted with Nurse #51 on 09/26/18 at 04:21 PM. She stated she no longer works at the facility, but she does remember Resident # 28 having bruising earlier this year. She said it was such a large area that extended down the resident's entire side. She said she never knew what caused the bruising. She stated resident required help with her care. She denied resident was combative with care, but resident did refuse care sometimes. She said she had a mind of a child. An interview with NA #29 was conducted on 9/26/18 at 04:17 PM. She stated she no longer works at the facility. She recalled Resident #28 had bruising on both sides of her body. She did not know what happened to cause the bruising. She denied resident was combative with care. An interview was conducted with Nurse #52 on 9/26/18 at 04:49 PM. She stated she no longer works at the facility. She remembers Resident # 28's bruising on both sides of her body. She did not know what caused the bruising. She denied resident was combative with care. An interview was conducted with NA # 30 on 09/26/18 at 05:09 PM. She remembered Resident # 28 having bruising earlier this year. She said had not saw the bruising the night before it had reported, but she had saw it the night after it had been reported when she had removed resident's wet nightgown. She said resident did not try to get out of bed unassisted. She said resident was a stand and pivot with transfers and needed help with all her care. She denied resident was combative with care. An interview was conducted with NA # 31 on 09/26/18 at 05:28 PM. She recalled Resident # 28 having bruising on both sides of her body earlier this year. She said the bruising was everywhere. She said she did not know what caused the bruising. She said resident was not combative with care. An interview was conducted with NA # 32 on 09/26/18 at 08:42 PM. She stated she no longer works at the facility. She recalled that resident had horrible bruising that she reported to the nurse earlier this year. She said she doesn't work there anymore because she did not want to lose her license. She said she reported bruises and skin tears all the time, and no one would do anything about it. On 09/27/18 at 08:56 AM the Administrator, Social Worker, MDS Coordinator, and DON were advised that the facility was in Immediate Jeopardy for Resident # 28. The facility provided credible allegation of compliance for immediate jeopardy as follows: The process that led to this deficiency was the resident being resistant to care at times and staff not handling the resident properly during an episode. The residents care plan was updated on 9/27/18 now shows behavior problems and resistance to care. The Administrator determined the bruising came from the resident being combative or resistant to care. The facility has a policy on unexplained injuries. All staff are in-service annually on abuse and neglect. Nursing staff will do an assessment on all residents to ensure there is no injury of unknown origin. If an injury of unknown origin is found, an investigation will be started immediately. Nursing assessment were performed on 9-27-18. The Staff Developer will in-service nursing staff on 9-27-18 and 9-28-18 about notifying within 2 hours abuse or bruising of unknown origin if there is a serious injury. The administrator will revise the abuse policy and will conduct daily meetings with the Risk Committee. Nursing staff will be trained on the policy of unexplained injuries on 9-27-18 and 9-28-18. All staff will be trained on the policy on upon hiring and on an annual basis. A 24-hour report and 5-day report will be sent to the State Agency. Nursing staff will perform an assessment on all resident to ensure there is no injury of unknown origin. Based on the assessment, the facility will make sure there is an incident report if an injury is found. If an injury of unknown origin is found an investigation will be started immediately. The Nursing staff that are on vacation will be in-serviced when they come back to work on (MONTH) 1st. Starting on 9-27-18, for 90 days the Administrator will monitor to make sure that daily meetings are being conducted to review incident reports. On a weekly basis for 90 days, 5 staff members will be interviewed about the signs of abuse, who they should report it to and when an injury is classified as an injury of unknown source. The audit tool will include that the meeting took place and whether there were any injuries of unknown origin. An audit tool will be created to interview staff to ensure they know the signs of abuse, who to report it to and if an injury is classified as unknown. On a weekly basis, for 90 days, the DON will monitor two staff members to ensure they are properly handing residents that are combative with care. She will use an audit tool to monitor this. Care plans for combative residents are reviewed quarterly and upon any indication of a significant change in behavior. The care plan will be reviewed for new interventions that may be needed. Staff will be in-serviced to report changes in behavior to notify the care plan team. The Administrator is responsible for submitting the plan of correction and implementing the policy on unexplained injuries. The administrator will update the abuse policy and unexplained injury policy. Also, Administrator will send a 24-hour report and 5 day report to the state agency The immediate jeopardy was removed after it was verified on 9/28/18 at 5 PM as evidenced by: Interviews with the nursing staff and non-nursing staff revealed they had received education on unexplained injuries, who to report injuries and time frames of reporting. The interviews also confirmed the staff had received training regarding new changes on who to report those injuries. Interviews with nursing administration revealed that they were aware of the daily meeting schedule to review incident reports. The interviews also revealed that they would identify any unknown injuries to ensure that it will be reported promptly and thoroughly investigated.

Based on observations, staff interviews, and record review, the facility failed to assess and meet the nutritional needs of a resident receiving a gastrostomy tube feeding, resulting in weight loss for 1 of 4 sampled residents (Resident #69) reviewed for Nutrition. The findings included: Resident #69 was admitted to the facility from a hospital on [DATE] with a cumulative [DIAGNOSES REDACTED]. Resident #69 ' s admission medication orders dated 10/29/15 included 20 milligrams (mg) [MEDICATION NAME] to be given per gastrostomy tube once daily; [MEDICATION NAME]to be given on a sliding scale basis; and 8 mg glimepiride (an antidiabetic agent) given by gastrostomy tube once daily. Resident #69 ' s admission orders [REDACTED]. Diabetisource is a tube feeding formulation designed for people with diabetes and stress induced high blood sugar levels. On 10/30/15 at 11:50 AM, a Physician ' s Telephone Order was received to change Resident #69 ' s gastrostomy feeding to Boost Glucose Control formula, given as one can (237 ml) every 6 hours. Boost Glucose Control is a nutritional formulation designed for people with diabetes; it is intended for use as an oral supplement. According to the manufacturer ' s product information, Boost Glucose Control is not intended as a tube feeding formulation. However, if a healthcare provider selected this product for a tube feeding, 5 cans (1185 ml) were required to meet 100 percent of the Recommended Daily Intake (RDI) for essential nutrients. Four cans of Boost Glucose Control provided every 24 hours, as ordered, yielded 1000 calories with 56 grams of protein and 792 ml of free water daily (exclusive of the water flushes). Resident #69 did not receive any nutrition or fluids by mouth. The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Admission Nursing Assessment & Review dated 10/29/15 revealed the resident was 61 inches tall and weighed 125 pounds (#). No skin breakdown or pressure ulcers were reported. No notes of [MEDICAL CONDITION] (fluid retention) were made. The resident ' s admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 had severely impaired cognitive skills for daily decision making. The resident was totally dependent on staff for all of her activities of daily living (ADLs). A review of Resident #69 ' s Care Area Assessment (CAA) Summary dated 11/3/15 addressed the use of a feeding tube. The summary read: Feeding Tube: Triggered by Resident has a feeding tube present. Resident factor to consider: she has dx (diagnosis) of [MEDICAL CONDITIONS], a-fib [MEDICAL CONDITIONS], DM (diabetes), advanced dementia,[MEDICAL CONDITION](hypertension) and others. She is NPO (nothing by mouth) and all fluids and nutrition are via feeding tube. Tube was present upon admission to SNF (Skilled Nursing Facility). She does not attempt to remove the tube. She does not move often. She is non-communicative. No noted abdominal distention. Current weight is 125 pounds. No referrals, will proceed with care plan to maintain tube and weight. The CAA Summary did not include an analysis of the current weight compared to her usual body weight. The CAA did not address an assessment of the nutritional needs of this resident nor did it address an analysis of the current tube feeding orders and whether the current tube feeding met her nutritional requirements. The CAA did not include information provided by the facility ' s consultant dietitian; it indicated no referrals were planned. A review of Resident #69 ' s Care Plan dated 11/3/15 included the following area of focus: Alteration in nutrition related to use of a feeding tube. There were no Interventions/Approaches which addressed Resident #69 ' s weight in the care plan. Additionally, no Interventions/Approaches addressed an assessment of the resident ' s nutritional needs or an analysis of the adequacy of her tube feeding in meeting these needs. The care plan Interventions/Approaches did not indicate a referral would be made to the consultant dietitian, either initially or on an as needed basis. A review of Resident #69 ' s medical record included the following laboratory results dated [DATE]: total protein = 5.0 (normal range = 6.5-8.0), and [MEDICATION NAME] = 2.4 (normal range = 3.0-5.5). [MEDICATION NAME] is the most abundant protein in human blood plasma and is frequently used in blood test panels for general health screening. An [MEDICATION NAME] level of 2.4 may be indicative of moderate to severe visceral protein depletion. A review of Resident #69 ' s Weight Records included the following: 11/4/15 Weight = 118 pounds. A Nurse ' s Note dated 11/4/15 noted the resident had non-[MEDICAL CONDITION] to her right upper extremity. No other notations of [MEDICAL CONDITION] were reported. Further review of Resident #69 ' s Weight Records included the following: 11/11/15 Weight = 111 pounds; 11/18/15 Weight = 105 pounds; 11/25/15 No weight was noted; and, 12/2/15 No weight was noted. A review of the Physician ' s Progress Notes included a notation written on 12/2/15 which read, in part: Objective (O): Weight decrease gradual from 12 on 10/29 to 105 on 11/21. Assessment/Plan (A/P): Weight loss: increase 320 ml every 6 hours from 240 . A Physician ' s Telephone Order was written on 12/2/15 for weekly weights due to continuous weight loss (per weight committee). Resident #69 ' s dose of glimepiride was decreased from 8 mg to 4 mg once daily; her tube feeding was increased to 320 ml every 6 hours. 320 ml of Boost Glucose Control given every 6 hours yielded approximately 1349 calories with 75.6 grams of protein and 1069 ml of free water daily (exclusive of the water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Weight Record included the following: 12/9/15 Weight = 96 pounds; A Physician ' s Progress Note dated 12/14/15 indicated, .Patient has been comfortable and stable. A review of Resident #69 ' s Weight Records included the following: 12/16/15 Weight = 98 pounds. On 12/16/15 at 4:30 PM, a Physician ' s Telephone Order was written to discontinue Resident #69 ' s [MEDICATION NAME]. Further review of Resident #69 ' s Weight Records included the following: 12/23/15 Weight = 97 pounds; and, 12/30/15 Weight = 96 pounds. On 12/30/15 at 2:00 PM, the Nurse ' s Notes revealed a Stage 2 pressure area was found on Resident #69 ' s sacrum. A Physician ' s Telephone Order was written to initiate a multivitamin given once daily, 220 mg zinc to be given once daily, 500 mg vitamin C given once daily, and 1 pack of [MEDICATION NAME] (an amino acid supplement used to promote wound healing) to be given twice daily until the area was healed (or for 90 days). On 12/31/15, a Physician ' s Telephone Order was written to change the tube feeding formulation to Diabetisource and to initiate this feeding at 55 milliliters per hour (ml/hr) continuous feeding (versus the previously ordered bolus feeding schedule). Diabetisource provided at 55 ml/hr via continuous feed yielded 1584 calories with 79.2 grams of protein and 1080 ml of free water daily (exclusive of the tube feeding water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Weight Records included the following: 1/6/16 Weight = 102# pounds. A review of Resident #69 ' s Medical Record revealed there were no Nutrition Progress Notes completed for this resident. A nutritional assessment was not available to estimate her calorie, protein, and/or fluid needs; nor was there an approximation of the calories, protein, and/or free water provided by the tube feeding ordered for the resident since her admission to the facility on [DATE]. An interview was conducted on 1/6/16 at 3:14 PM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported residents ' weights were followed weekly by the facility ' s Weight Committee. The Committee consisted of the DON, the Social Worker, the MDS Nurse, and the Staff Development Coordinator. The DON reported this Committee would decide if someone needed to be on a weekly weight and if so, she would write the order per facility protocol and let the resident ' s MD know of the concerns. At that point, the DON reported the MD would decide if a nutritional supplement should be ordered for the resident. The DON acknowledged Resident #69 ' s continuing weight loss was identified by the Committee and she was weighed weekly to follow the weights. No other interventions were reported. A telephone interview was conducted on 1/6/16 at 3:44 PM with the facility ' s consultant Registered Dietitian (RD). During the interview, the consultant RD reported she typically tried to come to the facility on ce a month. However, the RD noted she hadn ' t been in the facility the past month. Upon further questioning, the RD reported her last nutrition consultation visit to the facility was approximately 10 weeks ago and prior to Resident #69 ' s admission date of [DATE]. She reported the Dietary Manager for the facility did not have any clinical responsibilities whatsoever. When asked, the RD stated she usually checked on residents receiving a tube feeding when he/she was first admitted to the facility and when due for a quarterly assessment. She indicated residents with a tube feeding were also reviewed if he/she was losing weight or had another problem prior to the scheduled assessment date. The RD reported staff at the facility were able to contact her for a consultation as needed, but acknowledged no such request had been made since her last visit to the facility. Upon briefly reviewing Resident #69 ' s tube feeding orders, laboratory results and history of weight loss, the RD stated, Yeah, that ' s something that should have been addressed. A telephone interview was conducted on 1/7/16 at 10:58 AM with Resident #69 ' s family member. Upon inquiry, the family member reported the resident ' s usual adult weight was, in the 120 ' s. Additionally, the family member reported during the months prior to and during her admission to the hospital and facility, the resident did not experience any problems with fluid retention. A telephone interview was conducted on 1/7/16 at 2:33 PM with the resident ' s Medical Doctor (MD). When asked how he decided on the initial choice of the tube feeding formulation and volume provided, the MD indicated he would typically continue with the hospital regimen upon discharge but may have went with the formulation the facility had available (referring to Boost Glucose Control). The physician reported Resident #69 had heart failure and required a fluid restriction. When asked if he had considered more nutrient-dense formulations intended for fluid-restricted patients, the MD indicated he did not. The MD reported his intention was maintenance and he wanted to increase the tube feeding calories provided to Resident #69, judiciously. He estimated the resident needed approximately 1000 calories a day and less than 1000 ml fluid daily to achieve this goal. A follow-up interview was conducted on 1/7/16 at 1:33 PM with the facility ' s DON. The DON reported the facility ' s consultant RD normally reviewed the residents receiving a tube feeding to ensure the formulation and volume provided met his/her nutritional needs. However, the DON indicated she had not seen the RD in the building for quite a while. When asked if she would have expected the RD to have reviewed Resident #69 ' s tube feeding regimen to ensure she was getting enough calories to prevent weight loss, she stated, Yes. Upon inquiry as to who was responsible to ensure the resident was meeting her protein needs, the DON stated, the doctor and the dietitian.

Based on observations, staff interviews, and record review, the facility failed to assess and meet the nutritional needs of a resident for 1 of 3 sampled residents (Resident #69) who was at a high risk for the potential development of pressure ulcers. The findings included: Resident #69 was admitted to the facility from a hospital on [DATE] with a cumulative [DIAGNOSES REDACTED]. Resident #69 ' s admission orders [REDACTED]. Diabetisource is a tube feeding formulation designed for people with diabetes and stress induced high blood sugar levels. On 10/30/15 at 11:50 AM, a Physician ' s Telephone Order was received to change Resident #69 ' s gastrostomy feeding to Boost Glucose Control formula, given as one can (237 ml) every 6 hours. Boost Glucose Control is a nutritional formulation designed for people with diabetes; it is intended for use as an oral supplement. According to the manufacturer ' s product information, Boost Glucose Control is not intended as a tube feeding formulation. However, if a healthcare provider selected this product for a tube feeding, 5 cans (1185 ml) were required to meet 100 percent of the Recommended Daily Intake (RDI) for essential nutrients. Four cans of Boost Glucose Control provided every 24 hours, as ordered, yielded 1000 calories with 56 grams of protein and 792 ml of free water daily (exclusive of the water flushes). Resident #69 did not receive any nutrition or fluids by mouth. The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Admission Nursing Assessment & Review dated 10/29/15 revealed the resident was 61 inches tall and weighed 125 pounds (#). No skin breakdown or pressure ulcers were reported. No notes of [MEDICAL CONDITION] (fluid retention) were made. Resident #69 ' s assessment of pressure ulcer potential using the Norton Pressure Ulcer Scale was also completed on 10/29/15. The resident ' s total Norton scale was 6 on a scale of 5 to 20. Based on the total Norton scale, Resident #69 was at a high risk for the potential development of pressure ulcers. The resident ' s admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 had severely impaired cognitive skills for daily decision making. The resident was totally dependent on staff for all of her activities of daily living (ADLs). She was incontinent of bladder and bowel. No pressure ulcers were reported. A review of Resident #69 ' s Care Area Assessment Summary dated 11/3/15 addressed her risk for the development of pressure ulcers. The narrative read, in part: Triggered by Resident is dependent in bed mobility and incontinent of bowel and bladder and at risk for developing pressure ulcers .She has no pressure ulcers at this time. No skin breakdown and no treatments .She has an anti-pressure mattress on her bed. She is turn(ed) and repositioned every 2 hours and as needed .No referrals, will proceed with care plan to prevent pressure ulcers. A review of Resident #69 ' s Care Plan dated 11/3/15 included the following area of focus: Pressure Ulcer-Resident is at risk for skin breakdown related to decreased mobility and incontinence. The interventions included, in part: All nutrition and fluids via feeding tube as ordered. The interventions did not include a referral to the facility ' s consultant dietitian for an assessment of the resident ' s nutritional needs (either initially or on an as needed basis). A review of Resident #69 ' s medical record included the following laboratory results dated [DATE]: total protein = 5.0 (normal range = 6.5-8.0), and [MEDICATION NAME] = 2.4 (normal range = 3.0-5.5). [MEDICATION NAME] is the most abundant protein in human blood plasma and is frequently used in blood test panels for general health screening. An [MEDICATION NAME] level of 2.4 may be indicative of moderate to severe visceral protein depletion. A review of Resident #69 ' s Weight Records included the following: 11/4/15 Weight = 118 pounds. Further review of Resident #69 ' s Weight Records included the following: 11/11/15 Weight = 111 pounds; 11/18/15 Weight = 105 pounds; 11/25/15 No weight was noted; and, 12/2/15 No weight was noted. A review of the Physician ' s Progress Notes included a notation written on 12/2/15 which read, in part: Objective (O): Weight decrease gradual from 12 on 10/29 to 105 on 11/21. Assessment/Plan (A/P): Weight loss: increase 320 ml every 6 hours from 240 . A Physician ' s Telephone Order was written on 12/2/15 for weekly weights due to continuous weight loss (per weight committee). Resident #69 ' s tube feeding was increased to 320 ml every 6 hours. 320 ml of Boost Glucose Control given every 6 hours yielded approximately 1349 calories with 75.6 grams of protein and 1069 ml of free water daily (exclusive of the water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Weight Record included the following: 12/9/15 Weight = 96 pounds; 12/16/15 Weight = 98 pounds. 12/23/15 Weight = 97 pounds; and, 12/30/15 Weight = 96 pounds. On 12/30/15 at 2:00 PM, the Nurse ' s Notes revealed a Stage 2 pressure area was found on Resident #69 ' s sacrum. Wound Records dated 12/30/15 revealed the pressure ulcer measured 1.4 x 1 x 0 centimeter (cm) with granulation tissue present. The date of the wound origin was noted as 12/30/15. On 12/30/15, a Physician ' s Telephone Order was written for the following: Clean sacrum area with normal saline; apply [MEDICATION NAME] and Medseptic every shift until healed. The order also initiated a multivitamin given once daily, 220 mg zinc given once daily, 500 mg vitamin C given once daily, and 1 pack of [MEDICATION NAME] (an amino acid supplement intended to promote wound healing) to be given twice daily until the area was healed (or for 90 days). On 12/31/15, a Physician ' s Telephone Order was written to change the tube feeding formulation to Diabetisource and to initiate this feeding at 55 milliliters per hour (ml/hr) continuous feeding (versus the previously ordered bolus feeding schedule). Diabetisource provided at 55 ml/hr via continuous feed yielded 1584 calories with 79.2 grams of protein and 1080 ml of free water daily (exclusive of the tube feeding water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. Wound Records dated 1/4/16 revealed Resident #69 ' s sacral pressure ulcer measured 1.5 x 1 x 0 centimeter (cm) with granulation tissue present. A review of Resident #69 ' s Weight Records included the following: 1/6/16 Weight = 102# pounds. On 1/7/16, Physician ' s Telephone Orders were written to clean the resident ' s Stage 2 pressure ulcer with normal saline; apply Hydrogel and cover with Opsite; and, check the resident ' s total protein and [MEDICATION NAME] via laboratory blood tests on the next lab day. An observation was made of the resident ' s sacral pressure ulcer and treatment on 1/7/16 at 9:37 AM. The wound bed was pale with no drainage or odor noted. The wound measured 2 x 1 x 0.2 cm. A review of Resident #69 ' s Medical Record revealed there were no Nutrition Progress Notes completed for this resident. A nutritional assessment was not available to estimate her calorie, protein, and/or fluid needs; nor was there an approximation of the calories, protein, and/or free water provided by the tube feeding ordered for the resident since her admission to the facility on [DATE]. An interview was conducted on 1/6/16 at 3:14 PM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported residents ' weights were followed weekly by the facility ' s Weight Committee. The DON acknowledged Resident #69 ' s continuing weight loss was identified and the resident was weighed weekly to follow the weights. No other interventions were reported. A telephone interview was conducted on 1/6/16 at 3:44 PM with the facility ' s consultant Registered Dietitian (RD). During the interview, the consultant RD reported her last nutrition consultation visit to the facility was prior to Resident #69 ' s admission date of [DATE]. When asked, the RD stated she usually checked on residents receiving a tube feeding when he/she was first admitted to the facility and when due for a quarterly assessment. She indicated residents with a tube feeding were also reviewed if he/she was losing weight or had another problem prior to the scheduled assessment date. The RD reported staff at the facility were able to contact her for a consultation as needed, but acknowledged no such request had been made since her last visit to the facility. Upon briefly reviewing Resident #69 ' s tube feeding orders, laboratory results, weight loss, and pressure ulcer development, the RD stated, Yeah, that ' s something that should have been addressed. A telephone interview was conducted on 1/7/16 at 2:33 PM with the resident ' s Medical Doctor (MD). When asked how he decided on the initial choice of the tube feeding formulation and volume provided, the MD indicated he would typically continue with the hospital regimen upon discharge but may have went with the formulation the facility had available (referring to Boost Glucose Control). The physician reported Resident #69 had heart failure and required a fluid restriction. The MD reported his intention was maintenance and he wanted to increase the tube feeding calories provided to Resident #69, judiciously. He estimated the resident needed approximately 1000 calories a day and less than 1000 ml fluid daily to achieve this goal. A follow-up interview was conducted on 1/7/16 at 1:33 PM with the facility ' s DON. The DON reported the facility ' s consultant RD normally reviewed the residents receiving a tube feeding to ensure the nutrition formulation and volume provided met his/her nutritional needs. When asked if she would have expected the RD to have reviewed Resident #69 ' s tube feeding regimen to ensure the resident was getting enough calories, protein, and fluid, she stated, Yes. When asked if she thought the resident ' s pressure ulcer was preventable and could have been avoided, the DON replied, honestly, yes.

Based on record review and staff interviews, the facility failed to comprehensively assess the needs of a resident receiving a gastrostomy tube feeding for 1 of 4 residents (Resident #69) reviewed for Nutrition. The findings included: Resident #69 was admitted to the facility from a hospital on [DATE] with a cumulative [DIAGNOSES REDACTED]. Resident #69 ' s admission orders [REDACTED]. Diabetisource is a tube feeding formulation designed for people with diabetes and stress induced high blood sugar levels. On 10/30/15 at 11:50 AM, a Physician ' s Telephone Order was received to change Resident #69 ' s gastrostomy feeding to Boost Glucose Control formula, given as one can (237 ml) every 6 hours. Boost Glucose Control is a nutritional formulation designed for people with diabetes; it is intended for use as an oral supplement. According to the manufacturer ' s product information, Boost Glucose Control is not intended as a tube feeding formulation. However, if a healthcare provider selected this product for a tube feeding, 5 cans (1185 ml) were required to meet 100 percent of the Recommended Daily Intake (RDI) for essential nutrients. Four cans of Boost Glucose Control provided every 24 hours, as ordered, yielded 1000 calories with 56 grams of protein and 792 ml of free water daily (exclusive of the water flushes). Resident #69 did not receive any nutrition or fluids by mouth. The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. The resident ' s admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 had severely impaired cognitive skills for daily decision making. The resident was totally dependent on staff for all of her activities of daily living (ADLs). Resident #69 was reported to be 61 inches tall and weighed 125 pounds. The MDS assessment indicated she received 51% or more of her calories and 501 milliliters or more via a tube feeding. A review of Resident #69 ' s Care Area Assessment (CAA) Summary dated 11/3/15 addressed the use of a feeding tube. The summary read: Feeding Tube: Triggered by Resident has a feeding tube present. Resident factor to consider: she has dx (diagnosis) of [MEDICAL CONDITIONS], a-fib [MEDICAL CONDITIONS], DM (diabetes), advanced dementia,[MEDICAL CONDITION](hypertension) and others. She is NPO (nothing by mouth) and all fluids and nutrition are via feeding tube. Tube was present upon admission to SNF (Skilled Nursing Facility). She does not attempt to remove the tube. She does not move often. She is non-communicative. No noted abdominal distention. Current weight is 125 pounds. No referrals, will proceed with care plan to maintain tube and weight. The CAA Summary did not include an analysis of the current weight compared to her usual body weight. The CAA did not address an assessment of the nutritional needs of this resident nor did it address an analysis of the current tube feeding orders and whether the current tube feeding met her nutritional requirements. The CAA did not include information provided by the facility ' s consultant dietitian; it indicated no referrals were planned. A review of Resident #69 ' s Weight Records included the following: 11/4/15 Weight = 118 pounds. 11/11/15 Weight = 111 pounds; 11/18/15 Weight = 105 pounds; 11/25/15 No weight was noted; and, 12/2/15 No weight was noted. A Physician ' s Telephone Order was written on 12/2/15 for weekly weights due to continuous weight loss (per weight committee). Resident #69 ' s tube feeding was increased to 320 ml every 6 hours. 320 ml of Boost Glucose Control given every 6 hours yielded approximately 1349 calories with 75.6 grams of protein and 1069 ml of free water daily (exclusive of the water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Weight Record included the following: 12/9/15 Weight = 96 pounds; 12/16/15 Weight = 98 pounds. 12/23/15 Weight = 97 pounds; and, 12/30/15 Weight = 96 pounds. On 12/30/15 at 2:00 PM, the Nurse ' s Notes revealed a Stage 2 pressure area was found on Resident #69 ' s sacrum. On 12/31/15, a Physician ' s Telephone Order was written to change the tube feeding formulation to Diabetisource and to initiate this feeding at 55 milliliters per hour (ml/hr) continuous feeding (versus the previously ordered bolus feeding schedule). Diabetisource provided at 55 ml/hr via continuous feed yielded 1584 calories with 79.2 grams of protein and 1080 ml of free water daily (exclusive of the tube feeding water flushes). The resident ' s medical record did not include an assessment of her nutritional needs or an approximation of the nutritional content of the tube feeding ordered. A review of Resident #69 ' s Weight Records included the following: 1/6/16 Weight = 102# pounds. A review of Resident #69 ' s Medical Record revealed there were no Nutrition Progress Notes completed for this resident. A nutritional assessment was not available to estimate her calorie, protein, and/or fluid needs; nor was there an approximation of the calories, protein, and/or free water provided by the tube feeding ordered for the resident since her admission to the facility on [DATE]. An interview was conducted on 1/6/16 at 3:14 PM with the facility ' s Director of Nursing (DON). Upon inquiry, the DON reported residents ' weights were followed weekly by the facility ' s Weight Committee. The DON acknowledged Resident #69 ' s continuing weight loss was identified by the Committee and she was weighed weekly to follow the weights. No other assessments or interventions were reported. A telephone interview was conducted on 1/6/16 at 3:44 PM with the facility ' s consultant Registered Dietitian (RD). During the interview, the consultant RD reported she typically tried to come to the facility on ce a month. However, the RD noted she hadn ' t been in the facility the past month. Upon further questioning, the RD reported her last nutrition consultation visit to the facility was approximately 10 weeks ago and prior to Resident #69 ' s admission date of [DATE]. She reported the Dietary Manager for the facility did not have any clinical responsibilities whatsoever. When asked, the RD stated she usually checked on residents receiving a tube feeding when he/she was first admitted to the facility and when due for a quarterly assessment. She indicated residents with a tube feeding were also reviewed if he/she was losing weight or had another problem prior to the scheduled assessment date. The RD reported staff at the facility were able to contact her for a consultation as needed, but acknowledged no such request had been made since her last visit to the facility. Upon briefly reviewing Resident #69 ' s tube feeding orders, laboratory results and history of weight loss, the RD stated, Yeah, that ' s something that should have been addressed. A telephone interview was conducted on 1/7/16 at 9:56 AM with the facility ' s MDS Nurse. During the interview, the MDS nurse reported she participated in the weekly Weight Committee meetings. However, she was unable to provide details related to any concerns identified for Resident #69. An interview was conducted on 1/7/16 at 1:33 PM with the facility ' s DON. The DON reported the facility ' s consultant RD normally reviewed the residents receiving a tube feeding to ensure the formulation and volume provided met his/her nutritional needs. However, the DON indicated she had not seen the RD in the building for quite a while. When asked if she would have expected the RD to have reviewed Resident #69 ' s tube feeding regimen to ensure she was getting enough calories to prevent weight loss, she stated, Yes. Upon inquiry as to who was responsible to ensure the resident was meeting her protein needs, the DON stated, the doctor and the dietitian.