Every finding on record at Stonehenge of American Fork

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the staff wore hairnets incorrectly, cell phones were in the food preparation area, a dirty rag was used to clean a plate that was used for a resident's lunch, a spoon was repeatedly touched with dirty gloves then placed on the food. Findings included:On 7/23/25 at 12:18 PM, the following were observed during lunch service: At 12:03 PM, an observation was made of the Cook. The cook wore a hat with a hairnet over the top of it that was not covering her hair. The cook's hair had fallen out of the hat and was not covered by the hairnet.At 12:05 PM, an observation was made of a kitchen aide who had her hair clipped up in the back. The hair net was observed to only be covering the hair in the hair clip not on her scalp.At 12:07 PM, the cook was observed to touch the face of the plates with gloved hands that had touched her face and hair. At 12:08 PM, the dietary manager was observed to enter the cooking area with no hair net in place. At 12:11 PM, a cell phone was observed to be in the cooking area, near the plate warmers. At 12:12 PM, the tongs that had been used in the cheese container were laid on the counter then placed back into the shredded cheese container. At 12:16 PM, the cook was observed to touch the food on the plate with dirty gloves.At 12:19 PM, the spoon that was used to serve the parmesan cheese was touched by dirty gloves then fell back into the cheese. At 12:27 PM, a rag that had been used to wipe the counter and open the oven door was observed to be used to wipe away excessive food on a plate that was given to a resident.On 1/23/25 at 2:58 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all of the staff should have hair coverings that cover all of the hair. The females should have their hair up in their hats, not strands hanging down. The DM stated that the staff should not have a cell phone anywhere in the food area. The DM stated the staff should not be wiping the face of the plates with a dirty rag or touching the face of the plates with dirty gloves. The DM stated that a utensil should not touch dirty gloves or other surfaces and then be placed back into the food for use.

Based on interview and record review, the facility did not ensure that residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident. Specifically, 1 out of 37 sampled residents, a resident was not administered medications timely. Findings included:Resident 18 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic congestive heart failure, morbid obesity, major depressive disorder, weakness, acquired absence of left leg above knee, and essential hypertension.On 7/21/25 at 11:14 AM, an interview was completed with resident 18. Resident 18 stated that she did not receive her nighttime medications until around 11:00 PM, and that was just too late to get them. Resident 18 stated the staff had woken her up last night to administer the medications and it was close to or after midnight. Resident 18 stated that it did not happen with every nurse but it did happen quite a bit. Resident 18 stated she did not want to be woken up to get her medications when they were supposed to be given at a certain time before bedtime. Resident 18 stated it happened during the day and that was also bothersome. Resident 18 stated that they should be able to get their medications on time.Resident 18's medical record was reviewed on 7/21/25 through 7/23/25.The June and July 2025 Medication Administration Record was reviewed and revealed the following dates and times that medications were administered late.a. Gabapentin 300 milligrams (mg) was ordered to be given three times daily.On 6/3/25, due at 2:00 PM given at 5:00 PM.On 6/9/25, due at 7:00 AM given at 11:06 AM.On 6/12/25, due at 2:00 PM given at 5:12 PM.On 6/14/25, due at 7:00 AM given at 12:15 PM.On 6/14/25, due at 2:00 PM given at 4:14 PM.On 6/21/5, due at 7:00 AM given at 11:45 AM.On 6/21/25, due at 7:00 PM given at 11:25 PM.On 6/27/25, due at 7:00 AM given at 11:42 AM.On 7/8/25 due at 2:00 PM and given at 4:07 PM.On 7/10/25 due at 7:00 AM and given at 11:00 AM and administered again at 2:43 PM. It should be noted that this dose was given with only three hours in between the doses.On 7/12/25, due at 7:00 PM and given at 11:01 PM.On 7/16/25, due at 7:00 AM and given at 11:31 AM.On 7/16/25, due at 2:00 PM and given at 3:23 PM.On 7/17/25, due at 7:00 AM and given at 11:21 AM. On 7/17/25, due at 7:00 PM and given at 10:47 PM.On 7/19/25, due at 7:00 AM and given at 12:42 PM.On 7/19/25, due at 2:00 PM and given at 3:23 PM.On 7/20/25, due at 7:00 AM and given at 11:06 AM.B. Lidocaine external patch 4% was ordered to be administered to the left thigh topically two times a day for pain.On 7/20/25, due at 7:00 PM and given at 11:04 PM.C. Trazadone 50 mg by mouth at bedtime.On 7/20/25, due at 7:00 PM and given at 11:04 PM.On 7/22/24 at 2:00 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that medications that were due at 7:00 AM, could be administered to the residents between 6:00 and 8:00 AM. RN 2 stated if a medication was not administered during the time frame the doctor should be contacted for further instruction. RN 2 stated that gabapentin should not be given any closer than every eight hours as it could cause problems for the resident. RN 2 stated the doctor should be contacted if the medication was not administered within the appropriate time frame. On 7/22/25 at 2:03 PM, an interview was conducted with the South Unit Manager (SUM). The SUM stated the staff could administer a medication at the time it was due or within an hour of that time. The SUM stated if the administration was to go past when the medication was due the staff should contact the doctor. The SUM stated if gabapentin had been given at 12:00 PM and then again around 2:00 PM that was too close and the staff should have contacted the doctor. The SUM stated a medication could cause harm to the resident if given too close. On 7/22/25 at 2:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff have a flex time for the administration of medications, flex time means they have a time frame in which the medications could be administered. The DON stated they expected the staff to make the provider aware if the medications were to be administered late. The DON stated it was not appropriate to administer gabapentin at noon and then again around 2:00 PM. The DON stated she expected the staff to perform the same no matter what shift they were working on and ensure that there was enough time in between the ordered doses.

Based on interview and record review, the facility failed to inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 1 out of 3 sampled residents, a resident did not receive a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) when the beneficiary intended to continue services that might not have been covered under Medicare. Resident identifier: 14.Findings included:A SNF Beneficiary Notification Review, completed by the Social Services Director (SSD) for resident 14, dated 7/23/25, indicated, Medicare Part A Skilled Services Episode Start Date: 01/31/25. Last covered day of Part A Service: 04/19/25. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. It further indicated, 1. Was a SNF ABN, Form CMS [Centers for Medicare & Medicaid Services] 10055 provided to the resident? . No . Discussed with daughter via phone call, due to pt's [patient's] cognition. On 7/23/25 at 1:05 PM, an interview was conducted with the SSD. The SSD stated that the SNF ABN was discussed with resident 14's daughter, who was the resident representative, but it was not documented because it was done over the phone. The SSD stated resident 14's daughter came into the facility often and should have received the SNF ABN.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, for 1 out of 37 sampled residents, a resident's heels were observed to not be floated while in bed when it was indicated as needed on the care plan. Resident identifier: 88.Findings included:Resident 88 was admitted to the facility on [DATE] with diagnoses which included a second degree atrioventricular block, dementia, weakness, and hypertension.On 7/22/25 at 1:45 PM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.Resident 88's medical record was reviewed on 7/21/25 through 7/23/25.An admission Nursing Comprehensive assessment dated [DATE] at 3:37 PM, indicated, right hip, open area red area to coccyx left elbow skin tear with dsg [dressing] on and two fingers on left hand taped together r/t [related to] recent fall with hairline fx [fracture] in fingers. It further indicated resident 88 required staff assistance for bed mobility, transfers, and walking and totally dependent on staff for locomotion.An admission Braden Scale assessment on 7/9/25 at 3:55 PM, indicated resident 88 was at risk of developing a pressure ulcer.A Weekly Skin Check dated 7/11/25 at 4:49 PM, indicated resident 88 had a left heel wound.A care plan Focus of I have impaired skin integrity and/or I am at risk for impaired skin integrity: Always incontinent of bowel, I require assistance with bed mobility.Date Initiated: 07/07/2025. It indicated a Goal of I will remain free from new areas of impaired skin throughout my stay Date Initiated: 07/09/2025 Target Date: 10/07/2025. It further indicated Interventions included:a. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 7/9/25;b. Assist me with turning and repositioning every two hours. Date Initiated: 7/9/25;c. Educate me as to causes of skin breakdown; including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 7/9/25;d. Float heels when in bed. Date Initiated: 7/9/25;e. Inform me of any new area of skin breakdown. Date Initiated: 7/9/25;f. Provide pressure relieving/reducing device as ordered. Date Initiated: 7/9/25; andg. Remind me to turn and reposition as needed. Date Initiated: 7/9/25.On 7/22/25 at 1:47 PM, a skin check of resident 88 was observed with Registered Nurse (RN) 1. RN 1 stated he was not aware of a wound on resident 88's heel. RN 1 asked resident 88 if he could look at his heels, resident 88 stated he had a wound on his left heel. RN 1 assessed resident 88's left heel, redness was observed on the skin that was blanchable but slow to return to color after pressure was applied. RN 1 stated he would call that, blanching redness. RN 1 told Certified Nursing Assistant (CNA) 1 to float his heels and that he was going to put in an order to float his heels and to apply a skin prep. CNA 1 was observed to put a pillow under resident 88's ankles to float his heels. RN 1 stated if the skin was not blanchable or if it was opened he would talk to the wound specialist.On 7/22/25 at 1:55 PM, an interview was conducted with CNA 1. CNA 1 stated resident 88 had to have his heels floated and that she had been floating his heels on her previous shifts this week.On 7/23/25 at 7:22 AM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.On 7/23/25 at 12:28 PM, an interview was conducted with CNA 2. CNA 2 stated resident 88 had to have his heels floated but did not know why he had to have his heels floated. CNA 2 stated floating heels could help with comfort or leg swelling and was standard for most residents.On 7/23/25 at 1:08 PM, a follow-up interview was conducted with RN 1. RN 1 stated staff were supposed to notify him if a wound was identified and he would go assess it. RN 1 stated nobody notified him of a wound to resident 88's heal. RN 1 stated blanching redness would not indicate the need to see a wound specialist but a dressing or skin prep would be ordered to protect the skin from breaking down more. RN 1 stated if a resident had low mobility staff would float the heels when the resident was in bed. RN 1 stated he updated the care plans and that any time a care plan was updated it would put the intervention into the Kardex so CNA's would know of the changes and the nurses were also expected to tell the CNA's.

Based on observation, interview, and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and would not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 37 sampled residents, a resident who had blanchable redness on the left heel was observed to not have their heels floated when in bed. Resident identifier: 88.Findings included:Resident 88 was admitted to the facility on [DATE] with diagnoses which included a second degree atrioventricular block, dementia, weakness, and hypertension.On 7/22/25 at 1:45 PM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.Resident 88's medical record was reviewed on 7/21/25 through 7/23/25.A physician's order dated 7/9/25 at 12:18 PM, indicated, Float Heels for protection of skin integrity .An admission Nursing Comprehensive assessment dated [DATE] at 3:37 PM, indicated, right hip, open area red area to coccyx left elbow skin tear with dsg [dressing] on and two fingers on left hand taped together r/t [related to] recent fall with hairline fx [fracture] in fingers. It further indicated resident 88 required staff assistance for bed mobility, transfers, and walking and totally dependent on staff for locomotion.An admission Braden Scale assessment on 7/9/25 at 3:55 PM, indicated resident 88 was at risk of developing a pressure ulcer.A Weekly Skin Check dated 7/11/25 at 4:49 PM, indicated resident 88 had a left heel wound.A care plan Focus of I have impaired skin integrity and/or I am at risk for impaired skin integrity: Always incontinent of bowel, I require assistance with bed mobility.Date Initiated: 07/07/2025. It indicated a Goal of I will remain free from new areas of impaired skin throughout my stay Date Initiated: 07/09/2025 Target Date: 10/07/2025. It further indicated Interventions included:a. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 7/9/25;b. Assist me with turning and repositioning every 2 hours. Date Initiated: 7/9/25;c. Educate me as to causes of skin breakdown; including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 7/9/25;d. Float heels when in bed. Date Initiated: 7/9/25;e. Inform me of any new area of skin breakdown Date Initiated: 7/9/25;f. Provide pressure relieving/reducing device as ordered. Date Initiated: 7/9/25; andg. Remind me to turn and reposition as needed. Date Initiated: 7/9/25.On 7/22/25 at 1:47 PM, a skin check of resident 88 was observed with Registered Nurse (RN) 1. RN 1 stated he was not aware of a wound on resident 88's heel. RN 1 asked resident 88 if he could look at his heels, resident 88 stated he had a wound on his left heel. RN 1 assessed resident 88's left heel, redness was observed on the skin that was blanchable but slow to return to color after pressure was applied. RN 1 stated he would call that, blanching redness. RN 1 told Certified Nursing Assistant (CNA) 1 to float his heels and that he was going to put in an order to float his heels and to apply a skin prep. CNA 1 was observed to put a pillow under resident 88's ankles to float his heels. RN 1 stated if the skin was not blanchable or if it was opened he would talk to the wound specialist.On 7/22/25 at 2:00 PM, a progress note indicated, Assessed L [left] heel with no open area noted at this time and blanching redness. Order in place for floating heels while in bed and skin prep OTA [open to air] bid [twice a day] to heel for blanching redness.On 7/22/25 at 2:07 PM, a new order note indicated, Skin prep to Blanching redness to L heel and leave OTA, apply bid until resolved. every day and night shift for Blanching redness notify wound team of any decline in heel tissue Start Date: 7/22/2025.On 7/23/25 at 7:22 AM, an observation was made of resident 88 laying in bed on his back, his heels were not floated.On 7/23/25 at 1:08 PM, a concurrent interview was conducted with RN 1 and the Director of Nursing (DON). RN 1 stated staff were supposed to notify him if a wound was identified and he would go assess it. RN 1 stated nobody notified him of a wound of resident 88's heel. RN 1 stated blanching redness would not indicate the need to see a wound specialist but a dressing or skin prep would be ordered to protect the skin from breaking down more. RN 1 stated if a resident had low mobility, staff would float the heels when the resident was in bed. The DON stated a head to toe assessment was supposed to be completed weekly and if any wound was found they were supposed to notify RN 1 and the house physician.

Based on observation, interview and record review it was determined, for 2 out of 31 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring which resulted in a fracture and care planned interventions were not implemented, adequate, or timely. Additionally, the facility did not provide adequate supervision or assistance during incontinence care which resulted in a dislocation of the resident's knee. The identified deficiencies were determined to have occurred at a harm level. Resident identifiers: 66 and 73. Findings included: HARM 1. Resident 66 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral vascular accident, insomnia, type 2 diabetes mellitus, malignant neoplasm of rectosigmoid junction, major depressive disorder, anxiety disorder, hypothyroidism, obstructive sleep apnea, hyperlipidemia, hypertension, dependence on supplemental oxygen, obesity, history of falling, dysthymic disorder, vascular dementia, mood affective disorder, and osteoarthritis. On 10/03/23 at 10:33 AM, an interview was conducted with resident 66. Resident 66 stated that she broke her ankle, but did not recall how she broke it. An observation was made of resident 66's foot brace/boot placed in a wheelchair at the bedside. Resident 66 was observed on a air mattress, the bed was at hip height, and no fall mats were located at the bedside. It should be noted that resident 66's room was the last room on the hallway and furthest away from the nurse's station. Resident 66's physician orders revealed the following: a. Non-weight bearing on left lower extremity related to fibula fracture. May wear boot for comfort/support. After September 30, 2023, patient may advance to weight bearing in boot. The order was initiated on 9/20/23. b. Keep bed in lowest position every shift for fall risk. The order was initiated on 3/4/2023. On 8/27/23, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) of 8/15, which would indicate a moderate cognitive impairment. The assessment documented resident 66's functional status as a one person extensive assist for bed mobility, dressing, and toilet use; limited one person assist for eating; and one person physical assist for ambulation in room and corridor. Resident 66's progress notes revealed: a. On 3/4/23 at 12:41 PM, the note documented, Per On-call [name omitted], X-Ray 2V [views] of R [right] knee to r/o [rule out] fracture r/t [related to] unwitnessed fall. b. On 3/4/23 at 7:31 PM, the note documented, X-ray result received. No acute injury of R knee noted. Per on-call NP [Nurse Practitioner] request, on-call NP notified. Per NP, no new orders. Family notified. c. On 3/6/23 at 7:20 PM, the note documented, 3/4 - 3/7 unwitnessed fall. Xray of R knee completed. No new orders. Took meds [medication]. Tolerated well. No adverse effects noted. No new injuries noted from fall. Will continue to monitor. d. On 9/10/23 at 5:02 PM, the note documented, Upon walking into resident room CNA [certified nurse assistant] noted patient with buttocks on floor back against back of bed. This nurse was in hallway outside room notified of fall, went into room to assist patient. Patient stated she needed to go to the bathroom when she got up and feet slipped from underneath her. Patient checked for injuries, assisted x3 [times 3] staff up from floor to bed, 2 staff assisting upper body while one staff holding lower extremities. Patient obtained a abrasion on base of big toe to left foot which she stated she stubbed her foot on table. Initially no other injuries noted. She did complain of pain to her toe initially. Gave her PRN [as needed]tramadol and tylenol to assist with pain. Notified all appropriate persons- [family member name omitted], on call MD [Medical Doctor] and administrator in building. e. On 9/10/23 at 5:12 PM, the note documented, Within about 30 minutes after fall patient started complaining about increased pain to left ankle and leg. Even attempts to pull patient up in bed or turning had become difficult. Called spoke with on call physician asked for orders for Xray of entire left leg due to patients inability to tell me exactly where the pain is. Received orders for 2 view xrays of entire L [left] leg, knee, foot and hip. Also increase in Tramadol to 100 Q8H [every 8 hours] per [name of Nurse Practitioner omitted]. f. On 9/10/23 at 5:29 PM, the note documented, Radiologist came to do xray of patient leg. After xrays were done he notified this nurse that patient had a positive left ankle fracture with a probable left fibula fracture. Family was in in [sic] room with patient, spoke with family. On call physician when speaking earlier had stated to send patient out if xrays showed any kind of abnormalities or fracture. Family stated they would like her sent to hospital. CD made of xrays taken to send to hospital. Called non-emergent for transport. All paperwork sent to hospital with emergency staff. Patient was sent to [name of hospital omitted] per family request. Report called to [name omitted] at ER [emergency room ]. Patient was administered 100mg [milligrams] of Tramadol along with 1000mg of Tylenol less than 30 mins [minutes] before transport got to pick her up. Emergency staff had to administer 100 mg of Fentalyl [sic] to attempt to transfer patient to stretcher. Patient was screaming out in pain, even with entire leg placed in air boot and supported. Family meeting patient at hospital. g. On 9/10/23 at 5:36 PM, the note documented, Received xray results back showing arthritis of left hip, minimal arthritic and chondromalacia changes of left knee, normal left lower extremity and a small posterior cancaneal spur of left foot. This is contraindicating from results verbally given while technician was in building. CD of xrays was sent to emergency room . Will wait for their radiologist to read, patient is currently in ER awaiting treatment. h. On 9/10/23 at 10:25 PM, the note documented, Res [resident] returned to facility at 2200 [10:00 PM]. Report rec'd [received] from daughter. No report from hospital and hospital called EMS [emergency medical services] for transport w/o [without] checking with facility for transportation options. Per daughter, res rec'd Oxycodone at 2130 [9:30 PM] for pain. Fracture boot to left leg/ankle. Script for Oxycodone 5mg PRN Q6 [every 6] hours for pain. Script faxed to pharmacy. Will Monitor. i. On 9/11/23 at 4:00 PM, the note documented, Pt [patient] had fall 9/10/23 with fracture of left ankle and pulled ligaments in left knee. She has been in bed today. Pain medication administered as needed as patient showed s/s [signs and symptoms] or verbalized pain. Boot in place on left lower extremity. No adverse reaction to increase in Tramadol or use of Oxycodone. Nurse Practicioner was notified of patient status and addressed issues. Appointment for Orthopedist has been scheduled today. Continue to watch patient closely and keep patient out of pain and comfortable as possible. Resident 66's incident reports revealed: a. On 3/3/23 at 6:40 PM, the report documented, Pt found on laying on the floor on the left side of the bed. Her head was facing towards the foot of her bed. She was laying on her right side. Pt did not use her call bell to get assistance. Pt was assessed for any injuries. Pt had her socks on her feet. Pt stated she got up to go to the bathroom. The report documented no injuries were noted. Pt denied hitting her head and denied any pain. Notifications made to PA [Physician Assistant] and DON [Director of Nursing}. Fall precautions started. Intervention: Bed in lowest position. The report documented predisposing factors were confusion, incontinence, impaired memory, weakness, and ambulating without assist. It should be noted that the intervention of bed in the lowest position was not a new intervention but was initiated in the care plan for at risk for fall on 11/29/22. b. On 3/4/23 at 11:30 AM, the report documented, Pt found on floor. Pt's head was facing ceiling, pointing toward wall of entrance. Pt's feet were pointing towards her dresser. Pt stated she was trying to get up to go to the restroom. The report documented that the resident did not want to bend her right knee and rated pain at 2/10. The NP was notified and ordered an x-ray to rule out a fracture. It should be noted that no new interventions were identified and initiated on the care plan after the fall on 3/4/23. c. On 9/10/23 at 6:50 AM, the report documented, Upon walking into resident room CNA noted patient with buttocks on floor back against back of bed. This nurse was in hallway outside room notified of fall, went into room to assist patient. Patient stated she needed to go to the bathroom when she got up and feet slipped from underneath her. The report documented that 3 staff assisted the resident up off the floor with 2 on the torso and 1 holding the bilateral lower extremities. An injury of an abrasion to the left toe, an a fracture of the left lower leg, and a fracture of the left ankle was documented, with a pain score of 3/10 reported. The report documented that the radiologist came to perform the xrays and showed an obvious fracture of left ankle and probable fracture of head of left fibula. The report documented that the resident had increasing complaints of pain in left ankle and leg, even with attempts to reposition in bed. Provider ordered x-rays, Tramadol was increased to 100 mg every 8 hours, and the resident was sent to the hospital for further evaluation. It should be noted that no new interventions were identified and initiated on the care plan after the fall on 9/10/23. Review of resident 66's care plan revealed the following: a. On 11/29/22, a care plan for at risk for falls Gait and balance problems, Paralysis was initiated. The goal of the care plan was that resident 66 would be free from falls during her stay at the facility. Interventions identified on the care plan were anticipate and meet the resident's needs; ensure the call light was within reach and encourage to use it for assistance as needed; prompt response to all requests for assistance; bed was to be locked and in its lowest position; educate the resident about safety reminders and what to do if a fall occurs; ensure the resident was wearing appropriate footwear when ambulating; keep pathways free of clutter; keep needed items within reach; provide assistive devices for mobility as needed; and Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat as ordered. It should be noted that all interventions were initiated on 11/29/22. b. On 3/6/23, a care plan for the resident has had an actual fall related to poor balance was initiated. Interventions identified on the care plan were to continue interventions on the at-risk plan; determine and address causative factors of the fall; bed in lowest setting; educate resident to use call light for assistance; x-ray to rule out fracture; administer pain medication; send resident to ER for evaluation and treatment; monitor/document/report to MD any signs or symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture and agitation; and neurological assessment per the facility protocol. It should be noted that all interventions were initiated on 3/6/23. On 9/10/23, the x-ray of resident 66's left foot documented, small posterior calcaneal spur. The report had a hand written note that stated, called to have re-read due to verbal discrepancies with the ED [emergency department]. On 9/10/23, the Computed Tomography (CT) of the left ankle without contrast documented the findings as There is an obliquely oriented, slightly comminuted fracture of the distal fibula, . The impression of the report was a compression mildly comminuted fracture of the distal fibula (lateral malleolus). On 9/10/23, the Hospital History and Physical (H & P) documented that the resident presented to the emergency department status post fall and the history was provided by the family member as resident 66 could not recall the details of the fall. The family member reported that the resident used her wheelchair for mobility but believed today the resident attempted to stand up from the wheelchair without assistance. Patient is able to ambulate a little bit with assistance but can not walk independently. The CT of ankle showed an isolated distal fibula fracture. The treatment was to place the resident in a cam boot for the fracture but not place her in a knee immobilizer. The plan was to have the resident follow-up with orthopedics in one week. Review of the facility Falls Packet Checklist documented the steps for the licensed nurse to take after a resident sustained a fall. Instructions included: to obtain the fall details; indicate the location of injury; indicate any factors present that might have influenced the fall; indicate interventions used and initiate something new and relevant to the current fall; frequent checks initiated for all falls and given to aides, follow-up to ensure completion; and post fall care plan completed and updated with a new intervention. Ideas for post fall interventions (We must have at least one new intervention for each fall) included: patient education (only if patient was alert and oriented times 4 to person, place, time and situation; staff education; bed in lowest position (NOT low bed); toilet every 2 hours (communicate to aides and start in plan of care); room change closer to the nurse's station; wheelchair/walker moved away from the patient; medication review by pharmacy; Call don't fall sign; and frequent checks were required for all falls and DO NOT count as a new intervention. On 12/5/22, resident 66's restorative care plan documented tasks for Active Range of Motion (AROM)/Passive Range of Motion (PROM) and bed mobility for 3-6 times a week. The goal was for resident 66 to perform AROM/PROM and therapeutic exercises for the bilateral upper extremities (BUE) and bilateral lower extremities (BLE) in order to perform functional mobility and Activities of Daily Living (ADL) tasks with decreased need for assistance. The goal stated that resident 66 would get out of bed daily with a hoyer lift and spend at least an hour out of bed to participate in meals and activities. On 10/05/23 at 8:08 AM, an observation was made of resident 66 lying in bed. The resident's bed was at hip level and the call light was positioned on the resident's torso. On 10/5/23 at approximately 8:10 AM, an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated that resident 66 was not able to ambulate, and she was not sure if the resident could bear weight on her legs. CNA 2 stated that resident 66 did not wear her boot anymore and that her leg was previously broken. CNA 2 stated that resident 66 was a 2 person physical assist for transfers and was able to pivot transfer. CNA 2 stated that she made sure to position resident 66 in the center of the bed, because she had a tendency to move to the side when turning. CNA 2 stated that when resident 66 was out of bed in her wheelchair they kept an eye on her. CNA 2 stated that resident 66 was only able to tolerate being in her wheelchair for a few hours before she started complaining of pain. CNA 2 stated that she was not sure if resident 66 had had any falls, and she was not sure how resident 66 fractured her leg. CNA 2 stated that she had not been provided any specific instructions to prevent falls for resident 66. CNA 2 stated that when her leg was broken they were doing a 2 person physical assist for incontinence care to have one staff member located on each side of the resident's bed. CNA 2 stated that resident 66 was no longer a 2 person assist for incontinence care and was able to roll independently with cueing. CNA 2 stated that fall precautions depended on each resident but included bed low to ground, fall mat next to bed, keeping the door open, check on the resident frequently, and ask them to call if they needed anything. On 10/10/23 at 9:08 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 66 was a fall risk and would try to stand independently. CNA 4 stated that interventions to prevent falls for resident 66 were to keep her bed lowered to ground, check on her frequently, and make sure she was positioned in the middle of the bed. CNA 4 stated that resident 66 would scoot to the edge of the bed, throw her legs over the edge, and try to slide out. CNA 4 stated that she broke her ankle on her last fall. CNA 4 stated that resident 66 had multiple falls since being admitted . CNA 4 stated that resident 66 forgets and tried to get up and walk. On 10/10/23 at 9:24 AM, an interview was conducted with CNA 5. CNA 5 stated resident 66 was a fall risk. CNA 5 stated that she had not worked with resident 66 that much, but she was sure she was a fall risk. CNA 5 stated that she made sure she had 2 person physical assist for transfers, and reminded resident 66 to call for assistance. CNA 5 stated resident 66 did not call for assistance a lot, and they would have to round more frequently to check on the resident. On 10/10/23 at 9:34 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that all residents were assessed on admission for a fall risk. RN 3 stated that that interventions for residents identified at risk for falls were fall mats at the bedside, educate the resident to use the call light, and check on them frequently. RN 3 stated that after a resident sustained a fall they check for injuries, obtain vital signs, and conduct the neurological assessment according to the schedule on the form. RN 3 stated that they also notified the resident's family and the provider. RN 3 stated that after a fall interventions could include to remind the resident to use the call light if they were alert and oriented, or to use a fall mat and check the resident more frequently if they had any cognitive deficits. RN 3 stated that the provider would also re-evaluate the residents medication to determine if it contributed to the fall. RN 3 stated they had a fall checklist for the nurses to follow and at the bottom it showed possible interventions that the nurse could implement after a fall. On 10/10/23 at 11:28 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that resident 66 had never been evaluated for and treated with therapy services and had been receiving services from the Restorative Nurse Aide (RNA). PT 1 stated that he made recommendations for restorative care and provided them to the RNA. It should be noted that resident 66's care plan documented an intervention of PT to evaluate and treat as ordered. On 10/10/23 at 1:01 PM, an interview was conducted with RNA 1 and RNA 2. RNA 2 stated that resident 66 had a contracture on her right hand and they rolled a wash cloth and placed it inside her palm. RNA 1 stated they assisted resident 66 with AROM/PROM, bed mobility, dressing and grooming three times a week. RNA 1 stated that resident 66 was a limited assist for AROM with the bilateral lower extremities and the bilateral upper extremity exercises the resident was able to perform independently. RNA 2 stated that they performed exercises with therabands, dumb bells and a hand clip on the left hand. RNA 2 stated that resident 66 was able to stand and bear weight in the past, but had since had an injury to her left foot. RNA 2 stated that interventions to prevent falls were having the bed low to ground and frequent checks for safety and toileting. RNA 2 stated that every time they walked by the room they checked for safety and attempted to toilet the resident every 2 hours if possible. RNA 2 stated that for fall prevention they tried to move any residents at risk for falls closer to the nurse's station. RNA 2 stated that since resident 66 fall, no other rooms had been available near the nurse's station. It should be noted that resident 66's first fall was in March 2023. RNA 2 stated that she was not aware of any other falls other than the fall in September 2023 that resulted in resident 66's fractured ankle. On 10/10/23 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they had a fall protocol checklist that they followed. The DON stated that based on the fall the licensed nurse should implement interventions, notify the DON, family and MD. The DON stated that fall prevention included assessing the resident upon admission for their fall risk. The DON stated that after a fall the staff should implement a new intervention. The DON stated that they would try to plan for a room change closer to the nurse's station, have the resident's bed in a low position and have fall mats placed next to the bed. The DON stated that new interventions implemented after a fall should be something other than what was already listed on the care plan. The DON stated that they tried to determine the cause of the fall after each fall. The DON stated that they identified that resident 66 was attempting to go to the bathroom after each fall. The DON stated that staff should be monitoring resident 66's needs and checking on her frequently. The DON stated that they did discuss a room change for resident 66 as a team, but she was not moved closer to the nurse's station due to not being able to find a roommate that would be suitable for her. The DON stated that she did not recall what was determined about a room change for resident 66 during the Interdisciplinary Team (IDT) meeting. The DON stated she did not recall if a room change was discussed after resident 66's first and second fall in March 2023. The DON stated that staff should be positioning resident 66's bed at the lowest possible level. 43212 2. Resident 73 was admitted to the facility on [DATE] with diagnoses that included osteoporosis with pathological fracture, sarcoidosis, repeated falls, patellofemoral disorders of left knee, weakness, myelopathy, anxiety disorder, and depression. On 10/2/23 at 10:46 AM, an interview was conducted with resident 73. Resident 73 was observed to be sitting in a wheelchair in her room at the time of the interview. Resident 73 stated that shortly after she was admitted , a Certified Nursing Assistant (CNA) and a trainee wanted to do a brief change before the end of the shift. Resident 73 stated she tried to tell the CNA that she did not need a brief change, but the CNA insisted. Resident 73 stated the CNA was unable to do a brief change while she was in her recliner so the CNA attempted to change her brief while standing and her right knee began to hurt. Resident 73 stated she heard a pop and she experienced significant pain. Resident 73 stated the nurse assessed her and she was sent to the hospital for care. Resident 73's records were reviewed between 10/2/23 and 10/10/23. Discharge documentation from the [hospital], dated 9/6/23, revealed: a. Physician notes stating, Reduced R (right) knee subluxation-Continue splint when doing PT (physical therapy) or walking. Per Ortho (Orthopedic) 8/23-keep right knee immobilized. Goal is to create some scar tissue to prevent future dislocations. b. Occupational therapy notes dated 9/6/23 included RLE (right lower extremity): Knee immobilizer, WBAT (weight bearing as tolerated). c. Physical therapy notes dated 9/6/23 included RLE: Knee immobilizer, WBAT. A review of resident 73's Admission Minimum Data Set (MDS) dated [DATE] revealed that resident 73 required two + person extensive assistance with transferring. When moving from a seated to a standing position, the MDS revealed that resident 73 was not steady and was only able to stabilize with staff assistance. Walking activities did not occur, and resident 73 used a wheelchair for mobility. Resident 73's Brief Interview for Mental Status (BIMS) revealed a score of 15, indicating the resident was cognitively intact. Resident 73's care plan dated 9/7/23 revealed that assistance required on admission was 2 person supportive assistance. No documentation related to knee immobilization or that the resident had a knee immobilizer was found. Resident 73's progress notes revealed: a. On 9/7/23 at 12:53 PM, an admission summary note documented, new admit expected [AGE] year,with dx (diagnosis): narcosarcoidosis (sic), vertebral fx(fractures), pmh(past medical history): osteoporosis, anxiety, adhd [attention deficit hyperactivity disorder], anemia. axox(alert and oriented times) 4, dev (developmental) delay. reg (regular) diet, skin reported to be but not seen yet, redness to buttock, teds for edema, r (right) leg immobilizer, old surgical site to buttock. incant (incontinent) b/b(bowel and bladder), last bm (bowel movement) 9/7, takes oxy (Oxycodone) 5mgm [milligram], ibuprofen and [NAME] (Tylenol) for pain. reg (regular) diet, reg text, thin liquids, [NAME] (sic.) transfer, 2 ext (extensive) asst (assistance), cbc (complete blood count) cmp (complete metabolic panel) for tomorrow. exp (expect) arrival 1 ish. b. On 9/7/23 at 2:39 PM, an additional admission summary note documented that resident 73 was admitted and settled into her room. The note stated that resident 73 required a Hoyer transfer. c. On 9/8/23 at 10:25 AM, a skilled progress note documented that resident 73 bears no weight to right leg or to left leg. Pt has unsteady gait requiring supervision. Patient has impaired balance. Weakness present. The note also documented that a Hoyer lift was required for all transfers, and bed mobility and transfers required two+ person physical assistance. patient does not verbalize pain, rates pain 0 on a scale of 0-10. d. On 9/8/23 at 1:15 PM, a physician progress note documented that resident 73 had an extension brace on the right knee. The note also included, She recently had a fall at home and dislocated R knee. Her goals are to get knee brace off and goal to gain a little more mobility to get home. e. On 9/9/23 at 6:38 PM, progress notes documented that resident 73 was administered 5 mg of Oxycodone for pain. The note also stated, pt reporting high levels of pain following an incident with staff. See Progress note. f. On 9/9/23 at 6:52 PM, a progress note revealed that the medication administration was ineffective. The follow-up pain scale was 7. g. On 9/9/23 at 10:41 PM, a nurses note documented, RN [registered nurse] called into pt's [patient's] room at shift change. Pt was sobbing and telling RN that she was hurt by CNA's who had just changed her brief. Pt was asked to tell RN what happened and reported that CNA's came in and told pt that they needed to change her brief. Pt states that she responded by telling CNA that she was dry and did not need her brief changed. CNA insisted that it be changed prior to shift change and pt was told that they would be moving her into the bed to change her brief. Pt told CNA that she was not ready to be put into the bed. CNA proceeded to change resident in chair but was having difficulty. It was then that pt reports that she was made to stand. Pt states that she protested and told CNA that she was non weight bearing and that she was not supposed to be standing and that it was hurting her. Pt then told CNA that her ankles were going numb and her R knee was in significant pain. Pt reports having the CNA respond with 'you'll be fine.' Pt's R knee then popped and became even more painful than her base line. PT's family also called and asked that something be done. Case was reported to [Administrator]. Pt was given oxy [Oxycodone] 5mg to help ease her discomfort. Pt reported 0 improvement in pain after 30 minutes. On-call [provider] was notified of the situation and agreed that we should listen to pt's request and send her out to hospital for evaluation. 911 was called, pt was ambulanced to [Hospital omitted]. Transportation team notified of potential need to bring her back tonight. Hospital was contacted, given report, and asked that pt not be sent back via ambulance. ER [emergency room ] took number to facility to call us and let us know when she will need to be transported back. h. On 9/10/23 at 4:02 AM, a progress note documented, Pt returned back to the facility from [Hospital omitted] ED [emergency department] at 02:45. Pt's Diagnosis for this visit is subluxation of right patella, initial encounter. Instructions are: Patient must be non-weight bearing in her right leg and in her long-leg immobilizer at all times while moving. Imaging tests of XR knee 1 to 2 views RT were completed. i. A provider note dated 9/28/23 documented, on 9/9/23 Pt went to the [Hospital omitted] ER r/t (related to) knee pain. She states was being transferred by staff and felt knee pop and subsequently was in a lot of pain. Pt was sent to ED for further evaluation upon request. ED diagnosed a subluxation of R patella, that was reduced upon arrival. New orders to non-weight bear on R leg and be in long-leg immobilizer at all times while moving. A physical therapy evaluation dated 9/8/23 revealed: a. Lower extremity- RLE strength =2-/5 (Part moves partial range on a gravity eliminated plane); LLE strength= 2-/5 (Part moves partial range on a gravity eliminated plane) b. Pain assessment included, Pain at rest-intensity = 3/10; Frequency/Duration=Daily; Location: R knee; Pain description/Type: Aching and sharp. Pain with movement-intensity = 7/10; Frequency/Duration=Daily; Location: R knee; Pain description/Type: Aching and sharp. c. Functional Assessment included, Bed mobility = Max; Transfers = Total dependence w/ attempts to initiate; Gait=Level surfaces = DNT (do not try) d. Assessment Summary Impressions included, .Pt had a recent GLF (ground level fall) resulting in R knee injury. Pt is in a knee immobilizer and reports increased pain .Pt presents as a high fall risk with decreased functional strength and activity tolerance, balance deficits, and increased need for assistance with gait, transfers and bed mobility tasks. An after visit summary from the hospital dated 9/9/23 included instructions that Patient must be non-weight bearing in her right leg and in her long-leg immobilizer at all times while moving. The reason for the visit stated Knee pain-acute traumatic injury, and the diagnosis was subluxation of right patella, initial encounter. The triage notes stated Pt reports she dislocated her R knee 1 month ago. She was non weight bearing per her recovery plan until today when at [facility] she was prompted to get up and have her brief changed by CNA's and she felt her R knee slide and pop. Pt did not fall in this incident. Pt currently in R knee brace. Pt endorses numbness and tingling in R knee and both ankles. Pulses present. On 10/10/23 at 10:03 AM, an interview was conducted with CNA 1. CNA 1 stated resident 73 was transferred multiple times every day. CNA 1 stated resident 73 was usually in her recliner until after dinner each day. CNA 1 stated CNA's go into resident 73's room to reposition her and change her brief. CNA 1 stated resident 73 was incontinent but she knew when she needed to be changed and was able to call for assistance when she needed a brief change. On 10/10/23 at 10:20 AM, an interview was conducted with the Unit Manager (UM). The UM stated when a resident was injured, the staff should get the nurse immediately. The UM stated the administrator was notified immediately after the nurse assessed resident 73 on the date of the incident. On 10/10/23 at 3:20 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated on 9/9/23 during shift change, she was taking report from the daytime nurse. RN 2 stated a CNA came and told her that resident 73 was crying and was in p [TRUNCATED]

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards of food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator, reach-in freezer, and dry food storage were open to air. Findings include: On 10/2/23 at 8:05 AM, an initial walkthrough of the kitchen was conducted. a. The reach-in freezer was observed to have a box of beef patties open to air, a box of country fried steak was open to air, and a box of egg rolls was open to air. b. The dry storage room was observed to have a box of buttermilk biscuit mix that was open to air. c. The walk-in refrigerator was observed to have a box of [brand name] sausage links was open to air. d. The walk-in freezer was observed to have a box of pre-cut carrots was open to air, a box of cookie dough was open to air, a box of puff pastry was open to air, a box of egg omelets was open to air, and a box of frozen waffles was open to air. On 10/10/23 at 11:47 AM, a second walkthrough of the kitchen was conducted. a. The dry storage room was observed to have a box of buttermilk pancake mix was open to air, a box of [brand name] ranch dressing mix was also open to air. b. The walk-in freezer was observed to have a box of cookie dough open to air, and a box of garlic breadsticks was open to air. c. The reach-in freezer was observed to have a box of puff pastry open to air, and a box of chicken patties open to air. On 10/10/23 at 1:20 PM, an interview was conducted with the Dietary Manager (DM). The DM stated when food items were taken from the food storage areas his expectation was that the packages inside the boxes be rolled up and re-sealed, and the boxes should be re-closed. The DM stated that the consultant dietitian completed kitchen audits quarterly and information from the audit was kept in a file. The DM stated that he did a monthly audit of the kitchen for the Quality Assurance monthly meeting. The DM stated his audit included looking for cleanliness, items that were in need of repair, and safety issues. The DM stated he had a check-list that he used to do his monthly audits. The DM stated he had the consultant dietitian educate staff about sanitation, hand washing and storage. The DM stated kitchen staff turned over so much. The DM stated consistency in the kitchen was an ongoing thing.

Based on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 2 out of 31 sampled residents, the tube feeding did not have the bag labeled with the formula type, rate of infusion, resident identification information, date and time of administration, or the nurse initials who initiated the infusion. Resident identifier: 16 and 26. Findings Include: 1. Resident 16 was initially admitted to the facility on [DATE] and again on 6/24/23 with diagnoses which included pneumonia, metabolic encephalopathy, urinary tract infection, sepsis, acute kidney failure, multiple sclerosis, weakness, left hand contracture, essential hypertension, anxiety disorder, dysphagia, pseudobulbar affect, major depressive disorder, unspecified convulsions, and mood disorder. On 10/3/23 resident 16's care plan was reviewed. Resident had a care plan with a Focus that stated, I require tube feeding related to: Weight loss. The Goal stated, I will be free of aspiration. I will maintain adequate nutritional and hydration status as evidenced by: stable weight and no s/sx [signs or symptoms] of malnutrition or dehydration throughout my stay. The insertion site will be free of s/sx of infection throughout my stay. The Interventions included Change feeding bags, graduate and syringe every 24 hours. HOB [Head of Bed] elevated 45 degrees during and thirty minutes after tube feed. Listen to lung sounds every shift. Monitor/Document/Report to MD [medical director] PRN [as needed]: Aspiration-Fever, SOB [shortness of breath], Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, Distension, Tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Provide local care to G-tube site as ordered and monitor for signs or symptoms of infection. RD [Registered Dietitian] to evaluate caloric intake and estimate needs. Make recommendations for changes to tube feeding as needed. ST [Speech Therapy] evaluation and treatment as ordered. Tube feeding and water flushes as ordered. On 10/03/23 at 8:49 AM, an observation of resident 16 was made. Resident 16's tube feed bag was infusing. A label was observed on the tube feed bag. The label had resident 16's name on it. The label did not include the formula type, the rate of infusion, the date and time of administration, or the nurse initials who initiated the infusion. 2. Resident 26 was initially admitted to the facility on [DATE] and again on 2/15/23 with diagnoses which include cerebral palsy, unspecified protein-calorie malnutrition, demyelinating disease of central nervous system, dysphagia, neuromuscular scoliosis, intestinal obstruction, chronic idiopathic constipation, muscle spasm, dehydration, spastic quadriplegic cerebral palsy, profound intellectual disabilities, and insomnia. Resident 26's care plan was reviewed on 10/5/23. Resident 26 had a care plan with a Focus dated 3/9/23 that stated, The resident requires tube feeding r/t [related to] dx [diagnosis] and long-term use. The Goal stated, The resident will be free of aspiration through the review date. The resident will remain free of side effects or complications related to tube feeding through review date. The resident's insertion site will be free of s/sx [signs or symptoms] of infection through the review date. The resident will maintain adequate nutritional and hydration status aeb (as evidenced by) weight stable, desired wt [weight] gain to IWR [ideal weight range], 171-209# [pounds], no s/sx of malnutrition or dehydration through review date. The interventions stated, Monitor/document/report PRN any s/sx of: Aspiration - fever, SOB [shortness of breath], tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Obtain and monitor lab/diagnostic work as ordered. Report results to MD [medical director] and follow up as indicated. RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. On 10/02/23 at 9:53 AM, an observation of resident 26 was made. Resident 26's tube feed was observed infusing at a rate of 80 milliliters per hour (ml/hr) with a water flush at 80 ml/hr. The TF bag was labeled with the resident name, dated 10/1/23 at 1700, Jevity 1.5, with approximately 350 ml remaining in the bag. The water bag was not labeled with the any information and had approximately 700 ml remaining. The resident was observed with the head of bed elevated. The left side of the bed was against the wall and a floor mat was located on the right side. The resident was observed on an air mattress. On 10/3/23 at 10:25 AM, an observation of resident 26 was made. Resident 26 was lying in bed with the head of the bed elevated. Resident 26 had a tube feed running at 80 ml/hr for 20 hours with an 80 ml flush every hour. Two bags were hung up and connected to resident 26's enteral feed. The tube feed bag was not dated or labeled. The water bag was not dated or labeled. On 10/4/23 at 1:47 PM, an observation of resident 26 was made. Resident 26 was lying in bed with the head of the bed elevated. Resident 26 had a tube feed running at 80 ml/hr for 20 hours with an 80 ml flush every hour. Two bags were hung up and connected to resident 26's enteral feed. The tube feed bag was not dated or labeled. The water bag was not dated or labeled. On 10/05/23 at 8:04 AM, an observation of resident 26 was made. Resident 26 was lying in bed with the head of the bed elevated. Resident 26 had a tube feed running at 80 ml/hr for 20 hours with an 80ml flush every hour. Two bags were hung up and connected to the resident 26's enteral feed. The tube feed bag was not dated or labeled. The water bag was not dated or labeled. Resident 26's orders were reviewed. Resident 26 had an order that stated, Enteral Feed Order two times a day [Enteral] Flush feeding tube with water at 80 ml/hr x 20 hrs via pump on at 1700, OFF at 1300. Resident 26 had an order that stated, Enteral Feed Order two times a day [Enteral] Nutrition via pump - Isosource 1.5 or Jevity 1.5 (if no Isosource) at 80 ml per hour for 20 hours via pump per G-tube. ON at 1700 and OFF at 1300. On 10/05/23 at 8:05 AM, an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that the nurse was responsible for preparing and setting up the tube feed for residents. RN 1 stated that nurses got the bag out of the med room, added the feed to one bag, add the water to the other, and made sure that it was warm. RN 1 stated that there was a label that came with tube feed, and nurses wrote the name of the formula, the date, the time it was hung, and who hung it. RN 1 stated that the label went directly on the tube feed bag. RN 1 stated that resident 26's feed started at 5:00 pm, so the tube feed bag would have been prepared by the nurse who worked yesterday. On 10/05/23 at 8:09 AM, an observation of resident 26's tube feed bag was made with the RN 1. RN 1 stated, Looks like there's no label. Usually the label is right there, and the RN pointed to the front of the bag of formula. RN 1 stated, I'm not sure which formula it is. It's usually Isosource, if it's completely out, we use the Jevity. On 10/10/23 at 9:57 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that the nurses were responsible for preparing and setting up the tube feed for the residents. The DON stated that the bags of tube feed are labeled by the nurses. The DON stated that the label included the residents name, the room number, the date, the formula, and the formula rate are included on the label. The DON stated that she addressed the missing label on resident 26's tube feed with the nurses. The DON stated that the nurses claimed that they did add the label to the tube feed bag, and it was possible that the label had fallen off. Review of the [NAME] Nursing Procedures documented under Tube Feedings and Preparation of equipment to Make sure the formula is labeled clearly with the patient identification information, the type of formula, the method of administration, the date and time of preparation, and the name of the person preparing the formula if appropriate. Wolters Kluwer. [NAME] Nursing Procedure. Seventh Edition. Philadelphia, PA. (2013), pp. 801.

Based on observation, interview, and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 2 out of 23 sampled residents, a resident with a change of condition had a delay in treatment. In addition, a resident that was transferred improperly sustained a fracture. Resident identifiers: 10 and 55. Findings include: 1. Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . anxiety disorder, and [CONDITION(S)]. On 11/15/21 at 2:29 PM, an interview was conducted with resident 55. Resident 55 stated that her leg was fractured when the Certified Nursing Assistants (CNAs) transferred her wrong. Resident 55 stated she had weakness on her left side and she was trying to tell the CNAs how to transfer her but they would not listen. Resident 55 stated she was transferred to the hospital and now she had to wear a brace. Resident 55's medical record was reviewed on 11/16/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented resident 55 as requiring extensive assistance of two plus persons for transfers. A care plan focus initiated on 7/5/21, documented Activities of daily living (ADL) / Level of Assistance Required on Admission and adaptive equipment used: 2 Person supportive assist, Extensive, Wheelchair (Manual or electric). A care plan goal initiated on 7/5/21 and revised on 11/10/21, documented I will have no decrease in my current mobility status during my stay. and I will have no falls during my stay. Interventions initiated on 7/5/21, included the following: a. Encourage as much independence as possible. b. Praise all efforts of self care. c. Provide any adaptive equipment needed to assist me with obtaining my independence with my adls: Trapeze, Cane, Slide board, Walker, Brace, Bed rails, Wheelchair, etc. d. Staff to assist with adl's and mobility as needed. e. Therapies to evaluate and treat as ordered. On 10/17/21 at 8:35 AM, a Nurses Note documented Staff member reported pt (patient) is (sic) stated she was transferred incorrectly and that her L (left) knee is painful. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed CNAs to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt reported 11 out of 10 pain. On-call notified. X ray 2V (2 view) ordered of L knee, and [MEDICATION(S)] scheduled q (every) 4 hours x 7 days, per [name of physician]. On 10/17/21 at 9:45 AM, a Nurses Note documented Received notification from on-call physician, [name of physician], that [MEDICATION(S)] order has been changed to PRN (as needed) rather than scheduled. Per pt's husband request, on-call physician ordered pt to be sent to ER (emergency room ) for evaluation and to r/o (rule out) fx (fracture). On 10/17/21 at 2:10 PM, a Nurses Note documented Per [name of local hospital] staff, pt has been admitted to [name of local hospital] for surgery r/t (related to) L hip fx. Received a phone call from pt's spouse. Pt's husband kindly asked for staff to be educated on the importance of respecting pt's instructions during a transfer. On 10/17/21 at 6:38 PM, a Nurses Note documented At report, NOC (night) nurse stated at 0530 (5:30 AM) ice pack was applied to pt's L knee and PRN Tylenol was administered. Staff member reported to me pt stated she was transferred incorrectly on NOC shift, and that pt is reporting pain in L knee. NOC staff member reported that pt was turned counter-clockwise, according to pt's instruction. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed staff to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt heard a crack during transfer. Pt requested another order for pain medication d/t (due to) 11 out of 10 pain. INTERVENTION: Left message with on-call physician. On-call physician, [name of physician], X ray 2V ordered of L knee. Regarding pt's need for pain medication, pt has a hx (history) of AKI (acute kidney injury). [MEDICATION(S)] scheduled q 4 hours PO (by mouth) 50 mg (milligrams) x 7 days. Received notification from on-call physician, [name of physician], that [MEDICATION(S)] order is to be changed to PRN [MEDICATION(S)] PO 50 mg x7 days rather than scheduled. PRN [MEDICATION(S)] administered. Per pt's husband request, on-call physician ordered pt to be sent to ER for evaluation and to r/o fx. Per [name of physician], afternoon and evening doses of scheduled [MEDICATION(S)] d/c'd (discontinued). On 10/17/21 at 10:16 AM, the local hospital History and Physical documented a x-ray imaging result of the left tibia and fibula. The impression documented an old fibular head and proximal tibial fractures. No acute fracture identified. On 10/17/21 at 10:46 AM, the local hospital History and Physical documented a x-ray imaging result of the left femur two views. The impression documented a displaced left femoral neck fracture. On 10/17/21, the local hospital Progress Note documented that resident 55 presented today for a displaced left femoral neck fracture. Orthopedics was concerned about the acuteness of resident 55's injury and resident 55 would undergo a computed tomography (CT) scan for further clarification. On 10/17/21 at 12:57 PM, the local hospital Progress Note documented a CT of the left hip was obtained and the impression documented a displaced femoral neck fracture which appears to be chronic and may be a pathologic fracture as there appears to be soft tissue mass in the fracture plane. Evaluation was suggested. On 10/18/21 at 8:57 AM, the local hospital Progress Note documented a CT of the left knee was obtained and the findings documented a lipohemarthrosis to the left knee. Diffuse osseous demineralization was present. No displacement of the articular surfaces of the knee joint. There was a fracture involving the anterior margin of the medial femoral condyle best seen on the axial images. The impression documented there was a nondisplaced acute intra-articular fracture involving the medial femoral condyle. On 10/21/21 at 5:55 PM, an Admission Summary documented Resident readmitted in a stretcher for [CONDITION(S)] (urinary tract infection) and L tibia fracture that has immobilized. History includes [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, anxiety, [CONDITION(S)], ESBL (extended spectrum beta-lactamase) resistance, and [CONDITION(S)] (hypertension). brace on L leg, 2 persons assist with bed mobility and transfers, redness under R (right) breast, wound in coccyx, pain level 7/10 in L leg and pain med (medications) administered as ordered, . On 10/22/21 at 7:26 PM, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 'I'm alright.' Pt was recently in the hospital for a sudden sharp pain in L hip after transferring from wheelchair to bed in facility. Pt was noted to have a fibular head and proximal tibial fracture, old vs acute was noted in hospital H/P (history and physical). Pt notes pain is controlled. Denies any acute sxs (signs or symptoms) or illness. Recommend getting DEXA (Dual-energy X-ray absorptiometry) scan in the future to screen for [CONDITION(S)]. Patient agrees to screening. Will continue to monitor. On 10/25/21 at 5:34 PM, a Nurses Note documented Spoke with [name of PA] on phone. She would like to get the patient a DEXA scan to check for [CONDITION(S)]. Pt has had recent broken bones. Filled out transportation/appt (appointment) sheet for appointment to be scheduled. On 10/26/21 at 11:26 AM, a New Order Note documented Patient is a 2-person transfer. Please have CNAs communicate with PT team during the week if they need to be educated on how to transfer patient properly. On 10/26/21 at 11:28 AM, a New Order Note documented Keep left leg extended when transferring patient or repositioning patient in bed. On 10/29/21 at 4:23 PM, a New Order Note documented Per Orthopedic Surgeon [name of surgeon on 10/28/21, continue minimal weight bearing LLE (left lower extremity) for four weeks. Pt is to be up in wheelchair at least once per shift. On 11/16/21 at 11:47 AM, an interview was conducted with resident 55. Resident 55 stated that two CNAs were transferring her at the time of the incident. Resident 55 stated it was approximately 3:00 AM, and she had to use the restroom really bad. Resident 55 stated she can only assist during transfers with her right side due to a stroke. Resident 55 stated the CNAs transferred her on left side twisting her left leg and she heard two pops. On 11/16/21 at 11:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated when she came on shift the night nurse reported that resident 55 was having pain in her knee and an ice pack and Tylenol were given to resident 55. RN 2 stated that after she was finished counting the narcotic medications with the night nurse the day shift CNAs reported that resident 55 was in a lot of pain. RN 2 further stated the day shift CNAs reported that resident 55 had instructed the nightshift CNAs to turn her to the right during transfer and the CNAs did not listen to her. RN 2 stated she asked resident 55 about her pain and resident 55 stated she was still in a lot of pain. RN 2 stated she called the on call doctor and the doctor would not order any narcotics for resident 55 until the X-ray results came back. RN 2 stated resident 55's husband was at the facility and questioned when the X-ray was going to be at the facility. RN 2 stated she was unsure when the X-ray technician would arrive but the X-ray had been ordered. RN 2 stated resident 55's husband requested that resident 55 be sent to the ER. RN 2 stated resident 55 complained of left knee pain but no hip pain. RN 2 stated she had reported the incident to the Director of Nursing (DON) and the PA. On 11/16/21 at 12:01 PM, an interview was conducted with CNAs 2. CNAs 2 stated when she reported to the floor to start her shift resident 55 had her call light on and asked her to remove the ice pack. CNAs 2 stated she asked resident 55 what happened and resident 55 reported when the night shift CNAs transferred her to the bathroom she heard a pop in her knee. CNAs 2 stated the night nurse reported the CNAs took resident 55 to the bathroom at 3:00 AM and nothing had been reported to him regarding the incident. CNAs 2 stated she had sent a message to CNAs 3 to find out what had happened. CNAs 2 stated that CNAs 3 reported they did everything resident 55 asked them to do and pivoted resident 55 on her left leg. CNAs 2 stated the right leg was resident 55's strong leg. CNAs 2 stated that CNAs 3 reported resident 55 complained her knee was hurting and she forgot to report the incident to the nurse. CNAs 2 stated resident 55 was a two person transfer because she could not use her left leg. On 11/16/21 at 1:57 PM, an interview was conducted with RN 4. RN 4 stated he was not notified of anything unusual regarding resident 55 the day of the incident. RN 4 stated when he came back to the facility to work his next shift he was notified that resident 55 had a fracture from the CNAs moving her improperly. RN 4 stated resident 55 had complained of knee pain frequently and he would put [MEDICATION(S)] Gel on resident 55's knee. [Note: Out of 51 opportunities resident 55 received the [MEDICATION(S)] Gel on 7 occasions for the month of October 2021.] On 11/17/21 at 11:07 AM, an interview was conducted with CNAs 4. CNAs 4 stated resident 55 required three CNAs to transfer. CNAs 4 stated resident 55's wheelchair was positioned at the head of the bed for transfers. CNAs 4 stated two CNAs were positioned under resident 55's arms holding the pants and the third CNAs would hold the injured leg. CNAs 4 stated that two CNAs were required to transfer resident 55 prior to the injury. On 11/17/21 at 11:13 AM, an observation was conducted of CNAs 4, CNAs 5, and CNAs 6 transferring resident 55 from her bed to wheelchair. CNAs 4 positioned the wheelchair at the head of the bed with the seat area of the wheelchair positioned to face the foot end of the bed. CNAs 5 was positioned at resident 55's feet and CNAs 4 and CNAs 6 were positioned at resident 55's head. The CNAs in unison positioned resident 55 to a sitting position at the side of the bed. CNAs 4 and CNAs 6 positioned their arms under resident 55's arms holding her pants and CNAs 5 stabilized resident 55's left leg. In unison the CNAs positioned resident 55 to a standing position with resident 55's left leg stabilized and straight. Resident 55 was able to stand and bear weight on the right leg with maximum assist from the CNAs. The CNAs in unison pivoted resident 55 on her right foot and resident 55 was able to sit in the wheelchair. On 11/17/21 at 11:25 AM, an interview was conducted with resident 55. Resident 55 stated on the day of the injury the CNAs placed the wheelchair at the foot of her bed with the seat opening facing the head of her bed. Resident 55 stated when the CNAs stood her up she was pivoted towards her left side to the wheelchair and her left leg twisted underneath her. On 11/17/21 at 12:22 PM, an interview was conducted with the DON. The DON stated the day nurse received report that during the transfer resident 55 had a fracture or heard something pop. The DON stated she had reached out to the CNAs that were assisting with the transfer and the way she understood the CNAs did everything that resident 55 told them to do and the CNAs did not hear anything pop but resident 55 had. The DON stated resident 55 had complained of pain and the nurse gave her an ice pack and Tylenol and reached out to the Medical Director for a X-ray. The DON stated both CNAs were standing on each side of resident 55 to help with the transfer. The DON stated the CNAs had not worked with resident 55 before so they asked resident 55 for specific instructions on transferring. The DON stated she had reported the incident to the Administration and Cooperate Nurse and in the mean time she was trying to find out exactly what had happened. The DON was asked if the CNAs had been trained on resident transfers. The DON stated the CNAs would give report to each other every shift on instructions regarding the residents. The DON stated the CNAs would try to follow the instructions per the resident. On 11/17/21 at 1:00 PM, an interview was conducted with CNAs 3. CNAs 3 stated she worked night shift. CNAs 3 stated resident 55 wanted to get out of bed and she usually did not get out of bed at night. CNAs 3 stated she had never transferred resident 55 before and had asked resident 55 how to transfer her. CNAs 3 stated she had positioned the wheelchair at the foot of resident 55's bed. CNAs 3 stated if facing resident 55's bed the wheelchair was positioned to the right. CNAs 3 stated she had not realized the wheelchair was positioned for getting resident 55 into bed because resident 55's right side was her strong side. CNAs 3 stated when they transferred resident 55 the resident reported that something had popped and complained of knee pain. CNAs 3 stated she had asked resident 55 if she would still like to go to the bathroom and resident 55 stated yes. CNAs 3 stated when resident 55 was finished with the bathroom they transferred resident 55 back to bed without incident. CNAs 3 stated she had reported the incident to the nurse on shift, RN 4, that resident 55 was having pain because resident 55 had heard something pop, and was requesting a pain pill. 2. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/21 at 9:59 AM, an observation was made of resident 10 lying in bed with a family member sitting at the bedside. Resident 10 only smiled and did not answer questions directed at her. An interview was conducted with Resident 10's family member (FM). The FM stated the facility did not listen to the family's concerns about resident 10 having a [CONDITION(S)] and that resident 10 was recently hospitalized with an infection in her blood. The FM stated resident 10 became unresponsive and that was the only reason they sent her to the hospital. The FM stated resident 10 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The FM stated the facility would not listen to the family members when they asked for the resident's care to be improved. On 11/15/21, resident 10's medical record was reviewed. Resident 10 had a care plan focus created on 3/3/21, that revealed the resident had a potential for the following: a. bladder incontinence related to dementia b. history of [CONDITION(S)] c. [CONDITION(S)] disorder d. physical limitations e. impaired mobility Resident 10 had a care plan goal created on 3/3/21 with a target date of 3/25/21, that [CONDITION(S)] (blood infection) would be minimized/prevented via prompt recognition and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following care plan interventions were initiated on 3/3/21, and still in place at the time of the survey for resident 10 to attain that goal: a. monitor for signs and symptoms (s/sx) of discomfort on urination and frequency. b. provide assistance with toileting and toilet hygiene as needed. c. report to medical doctor any decline in incontinence. d. weekly and PRN skin evaluations. e. Monitor/document for s/sx of [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A quarterly MDS assessment dated [DATE], revealed resident 10 was always incontinent of urine and stool and required a 2 person physical assist for toilet use and hygiene cares. On 10/12/21, a Progress Note revealed the PA was notified of resident 10 being slow to respond. The PA ordered lab testing to include a complete blood count (CBC), complete metabolic panel (CMP), [CONDITION(S)] stimulating hormone (TSH) with reflex, a lipid panel, a glycated hemoglobin (A1C), and a vitamin D level to be drawn on 10/13/21. On 10/13/21, a Social Work Note revealed resident was in bed watching television, social worker assisted resident to eat some of her meal. This has been her baseline since arriving to our facility. No documentation was located within the progress notes of lab testing being drawn on 10/13/21, as ordered by the PA. The lab process checklist filled out on 10/12/21, by the nursing staff revealed the CBC, CMP, TSH with reflex, lipid panel, A1C, and vitamin D level were ordered to be drawn on 10/13/21. The lab requisition sheet filled out on 10/13/21, revealed that the CBC, CMP, TSH with reflex, lipid panel, A1C, and vitamin D level were not drawn until 10/14/21. The lab process checklist in the second section titled TO BE COMPLETED ONCE LAB RESULTS HAVE BEEN RECEIVED: revealed the lab results were received on 10/15/21. The sheet revealed If the lab results are critical, contact the provider. [Note: No documentation was located indicating the provider had been contacted with resident 10's lab results 10/15/21.] On 10/16/21 at 11:41 AM, a Nurses note revealed that resident 10 was not feeling well, will only respond with nodding her head yes and no. Vital signs taken blood pressure (BP) 78/57, heart rate (HR) 105, oxygen saturation (O2 sats) 88% on 2 liters (L) of oxygen. Oxygen increased to 3L by nasal cannula. Resident 10 will remain in bed, will reassess later. On 10/16/21 at 3:55 PM, a Nurses Note revealed that resident 10 had been increasingly sleepy and lethargic today. Vital signs at 3:10 PM were BP 92/33, HR 85, O2 sats 91% on 2 L. Found lab results from CMP and CBC drawn on 10/14/21. Labs had critical values. Sodium 154, BUN 122, creatinine 1.71, chloride 112 and hematocrit 47.2. Called on-call provider who ordered a peripheral intravenous (IV) line to administer 2 L of [MEDICATION(S)] 5% in water (D5W) at 500 milliliters (ml)/hour (hr) today. Then tomorrow administer 1 L of D5W at 500 ml/hr. Repeat basic metabolic panel on 10/18/21. Attempted to place peripheral IV was unsuccessful. Contacted outside IV line placement resource to come as soon as possible. The October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/21 at 6:17 AM, resident 10 was given 1 L D5W. On 10/17/21 at 11:46 PM, an Alert Charting Progress note revealed resident 10 tolerated 3 L of D5W well, although continues to have low BP. Medical Doctor (MD) notified. On 10/18/21 at 12:10 PM, a Nurses Note revealed the PA ordered to send resident 10 to the ER for evaluation and treatment due to increased lethargy and disorientation. Resident 10's BP was 68/38, resident 10 had projective vomit before emergency transport arrived. Family wanted resident 10 sent to the ER. On 10/18/21 at 11:43 AM, a transfer record revealed resident 10 was transferred to a local hospital for further evaluation and treatment. [Note: This was 6 days after the labs were ordered to be drawn to evaluate resident 10's change in status on 10/12/21.] On 10/18/21 at 5:07 PM, a history and physical revealed resident 10 was admitted to the local hospital for septic shock, [CONDITION(S)], and acute renal failure On 11/17/21 at 2:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated all critical lab values were called to the PA or there was an on call PA. LPN 1 stated the hospital was not always good about getting the lab results back to the facility, so the staff would call and get them. LPN 1 stated if the lab values were critical then the hospital was better at getting them to the facility. LPN 1 stated if there was a critical lab value then the staff would call the PA, or use the text messaging system to send out to the administration and the manager. LPN 1 stated lab values were kept in the electronic medical record and the paper chart. LPN 1 stated they were supposed to make a progress note in the medical record then scan it and put it in the paper chart. LPN 1 stated lab results were expected the same day they were drawn, urgent labs (STAT) were expected within hours of when they were drawn. On 11/17/21 at 3:00 PM, an interview was conducted with LPN 3. LPN 3 stated the lab process checklist was completed in order to follow through with labs and to ensure nothing got missed, the checklist stays in the blue folder at the desk until it was finished and marked off, then it goes to the unit manager. LPN 3 stated if lab values were critical the nursing staff got a hold of the MD right away. On 11/17/21 at 3:04 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated when she received the lab process checklist, lab requisition, and lab results she checked them and made sure they were put in the chart and recorded. UM 1 stated the lab results were then scanned into the electronic medical record. UM 1 stated the requisition and the lab process checklist were kept in the binder in the UM office. UM 1 stated there was a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/18/21 at 9:00 AM, a follow up interview was conducted with LPN 1. LPN 1 stated the lab checklist had been in place for at least 4 to 5 months. LPN 1 stated the process had been in place for quite some time but was unable to quantify the exact amount of time. On 11/18/21 at 9:15 AM, a follow up interview was conducted with the UM 1. UM 1 stated that resident 10 having to be sent to the hospital was unfortunate and possibly a result of a miscommunication between the day nurse and the night nurse. UM 1 stated the day nurse placed the lab paperwork in the provider bin and did not review the lab values. UM 1 stated the night nurse received report that the labs were drawn but nothing was done. UM 1 stated the lab checklist was put on paper in June of 2021 but has been a process at the facility for a long time, it started when a resident needed [CONDITION(S)] and did not receive it. UM 1 stated she was the developer of the lab process checklist. UM 1 stated resident 10 should have been dealt with sooner, there was a delay in treatment. UM 1 stated she was unsure if the delay in treatment would have changed the outcome but it did not make the situation or resident 10 better. UM 1 stated it was expected of the nursing staff to assess the residents and call the PA if needed. UM 1 stated the nurses all have the skills and equipment to draw blood for labs and start IV therapy if needed. UM 1 stated resident 10's veins were quite small and the nurse was unable to obtain an IV access. UM 1 stated the nursing staff did not try to draw blood. UM 1 stated she was in the facility the day the blood was needed and could have drawn the labs but no one made her aware of the need. UM 1 stated an outside service was called to come in, sometimes they do not come in when we ask them to, this instance they came when they could. UM 1 stated the nursing staff should have assessed resident 10 and determined that waiting was not in the best care for resident 10 and called the provider for further instructions or to send resident 10 to the ER. UM 1 stated the staff were educated monthly on how to assess residents and how to care for abnormal assessments. UM 1 stated the lab did not call the facility to make them aware of the critical lab values but it was ultimately the nursing staff and facilities responsibility to check for the labs and care for the residents. On 11/18/21 at 10:20 AM, an interview was conducted with the PA. The PA stated the facility would let her know about resident needs or abnormal labs via text messaging or by a phone call for a critical value or an urgent need. The PA stated if there was a critical lab then she would like the staff to call her, I do not want things to slip through the cracks. The PA stated there was a provider available 24 hours a day every day of the week and the providers can do a Telemed visit if needed. The PA stated the expectation from the providers was to send a resident to the ER and not wait for the out sourced therapy company to come draw labs or start an IV if the resident was in a bad condition. The PA stated that way the resident could get stabilized and treatment was not delayed. The PA stated that the out sourced company used by the facility for labs and IV therapy was not STAT. The PA stated the nursing staff should all be able to draw blood and start IV's. The PA stated she wished there were skills labs available to the staff to update those skills. The PA stated I hate to hear, let me call the PICC (peripherally inserted central catheter) nurse to start that IV. On 11/18/21 at 11:58 AM, an interview was conducted with the DON. The DON stated labs were drawn by MD order, the labs were put in the electronic medical record, on the lab requisition sheet, added to the calendar, and we keep the lab requisition open so both shifts can see it. The DON stated they have the checklist so that it was a step by step process. The DON stated if there was an abnormal assessment the nursing staff should let the PA or the provider know immediately and follow the orders given. The DON stated if the medical condition warrants the resident to be sent to the hospital then the staff need to send them. The DON stated the nurses were expected to draw blood when labs were needed, especially when they were STAT labs. The DON stated when STAT labs were drawn by the nursing staff, the facility would call the lab company to come pick up the labs and take them to the hospital. The DON stated the lab would then let them know the results and the nursing staff would make the provider aware. The DON stated the turn around time for this was about 4 to 8 hours for STAT labs and 24 hours for routine labs. The DON stated STAT labs were known to be STAT because they would call the out sourced lab to have them come pick them up, the nursing staff should mark the labs as STAT on the sheet but if it was not marked the lab would still be expected as STAT if the courier was called to come get them. The DON stated the expectation of the nursing staff by the administration was to let the provider know if the lab results were not within normal limits. The DON stated her expectation would have been for the nurses to send resident 10 to the ER and not wait for the outside IV therapy service to come in and start the IV. The DON stated there was a break in the system and we need to educate the nurses on judgement, when to send the resident to the hospital, and how to get the resident the treatment they need right away.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed without eye protection during an outbreak, staff did not sanitize their hands while passing food trays to residents, used meal trays were taken from resident rooms and placed back on the food cart next meal trays that had not been delivered, staff did not sanitize hands between passing medications to different residents, and staff entered a resident's room while a continuous positive airway pressure ([CONDITION(S)]) machine was in use without the appropriate personal protective equipment (PPE). Resident identifier: 5 Findings included: 1. On 11/17/21 at 9:25 AM, an observation was made of Licensed Practical Nurse (LPN) 2. LPN 2 did not use hand sanitizer or wash her hands before gathering medications for different residents or after administering medications to different residents. LPN 2 was observed to adjust her cloth mask many times during the morning medication pass with no hand sanitizer used. On 11/17/21 at 9:30 AM, an observation was made of LPN 2. LPN 2 was observed to have a cloth mask and eye protection in place. Signage outside of resident 5's room stated the following PPE must be worn when entering the room: a gown, N95 mask, gloves, and face shield when [CONDITION(S)] machine was running and for 30 minutes after [CONDITION(S)] machine was turned off. LPN 2 was observed to enter resident 5's room wearing only a cloth mask and eye protection while the [CONDITION(S)] machine was running. LPN 2 did not donn a N95 mask, gown, face shield, or gloves. A cart was observed outside resident 5's room storing N95 masks, face shields, gowns, and gloves. On 11/17/21 at 9:40 AM, an interview was conducted with LPN 2. LPN 2 stated PPE should be worn when going into a room that has a [CONDITION(S)] machine running. LPN 2 stated when there was signage outside the room and an isolation cart the staff know there was a [CONDITION(S)] machine in the room. LPN 2 stated she entered resident 5's room with only a cloth mask and eye protection in place when she should have donned a N95 mask, face shield, gown, and gloves to give the resident her medications. 2. On 11/17/21 at 8:57 AM, CNA 1 was observed to be wearing glasses without side shields. An interview was conducted with CNA 1. CNA 1 stated staff were required to wear glasses with side shields or a face shield. CNA 1 stated she should be wearing shields on the sides of her glasses but she did not have side shields on her glasses today. 3. During meal observations the following observations were made of cross contamination through lack of hand hygiene between trays and cross contamination with dirty and clean trays on meal delivery carts. a. On 11/15/21 at 12:27 PM, CNA 7 was observed to gather a meal tray for the resident in room [ROOM NUMBER]. CNA 7 was observed to handle the resident's used beverage mug and reposition resident's bedside table. CNA 7 did not sanitize their hands prior to gathering the next resident meal tray for delivery. b. On 11/15/21 at 12:34 PM, CNA 7 was observed to deliver a meal tray to resident room [ROOM NUMBER] A. CNA 7 was observed to provide set up assistance for resident. CNA 7 did not sanitize their hands prior to gathering the next resident meal tray for delivery. c. On 11/15/21 at 12:36 PM, CNA 7 was observed to gather a used meal tray from resident room [ROOM NUMBER] A. At this time, the left side of the meal cart still contained three undelivered trays. CNA 7 was observed to place the used meal tray onto the cart with the other meals that had not yet been delivered. d. On 11/15/21 at 12:37 PM, CNA 8 delivered a meal tray to room [ROOM NUMBER]. CNA 8 repositioned the resident's bedside table and touched some of the resident's used beverage mugs. CNA 8 did not sanitize their hands prior to gathering the next resident meal try for delivery. e. On 11/15/21 at 12:43 PM, CNA 8 was observed to gather a used meal tray from resident room [ROOM NUMBER] B. At this time, the middle section of the meal cart still contained four undelivered trays. CNA 6 was observed to place the used meal tray onto the cart with the other meals that had not yet been delivered. On 11/15/21 at 12:49 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated when she got a tray out of the meal cart, the meal ticket had the resident name, room number, and what limits the resident has with eating if any. NA 1 stated she would knock on the resident door, show the resident what the meal was and assist them if needed. NA 1 stated after seeing each resident she would sanitize and after three times of sanitizing she would wash her hands with soap and water. NA 1 stated they do not wear gloves but they always use sanitizer after each resident room. On 11/18/21 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated COVID testing was done twice a week during outbreak and all staff were to wear a surgical mask with eye protection while in the building or near residents. The DON stated unvaccinated staff were to wear a N95 mask and eye protection if they were within 6 feet of a resident for longer than 15 minutes. The DON stated if a [CONDITION(S)] machine was being used or for 30 minutes after it was shut off the staff were to wear a N95 mask, face shield, gown, and gloves. The DON stated the staff were aware when the [CONDITION(S)] machines were off if it was an incoherent resident. The DON stated the coherent resident's would tell the staff when they shut their [CONDITION(S)] machine off. The DON stated the rooms with [CONDITION(S)] machines were labeled with signage and had isolation carts outside the doors. The DON stated when food trays were being passed the staff were supposed to sanitize before touching the trays and after they take a tray to a resident. The DON stated dirty or eaten trays were not to go in the cart with the clean and uneaten trays, they were to be taken back to the kitchen. The DON stated when the nurses were passing medications hands were to be sanitized before administration of medications to each resident, after leaving the resident's room, and after adjusting PPE.

Based on interview and record review it was determined the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility and to other officials. Specifically, for 1 out of 23 sampled residents, an incident where a resident was improperly transferred by staff that resulted in a fracture was not reported to the State Survey Agency or adult protective services. Resident identifier: 55. Findings included: Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . anxiety disorder, and [CONDITION(S)]. On 11/15/21 at 2:29 PM, an interview was conducted with resident 55. Resident 55 stated that her leg was fractured when the Certified Nursing Assistants (CNAs) transferred her wrong. Resident 55 stated she had weakness on her left side and she was trying to tell the CNAs how to transfer her but they would not listen. Resident 55 stated she was transferred to the hospital and now she had to wear a brace. Resident 55's medical record was reviewed on 11/16/21. On 10/17/21 at 8:35 AM, a Nurses Note documented Staff member reported pt (patient) is (sic) stated she was transferred incorrectly and that her L (left) knee is painful. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed CNAs to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt reported 11 out of 10 pain. On-call notified. X ray 2V (2 view) ordered of L knee, and [MEDICATION(S)] scheduled q (every) 4 hours x 7 days, per [name of physician]. On 10/17/21 at 2:10 PM, a Nurses Note documented Per [name of local hospital] staff, pt has been admitted to [name of local hospital] for surgery r/t (related to) L hip fx (fracture). On 10/17/21 at 6:38 PM, a Nurses Note documented At report, NOC (night) nurse stated at 0530 (5:30 AM) ice pack was applied to pt's L knee and PRN (as needed) Tylenol was administered. Staff member reported to me pt stated she was transferred incorrectly on NOC shift, and that pt is reporting pain in L knee. NOC staff member reported that pt was turned counter-clockwise, according to pt's instruction. Upon assessment, swelling just superior to L knee noted on lateral side. Pt stated she has been applying ice pack. Pt stated she specifically instructed staff to not turn her to the right upon transfer. Pt stated CNAs did anyway. Pt heard a crack during transfer. Pt requested another order for pain medication d/t (due to) 11 out of 10 pain. INTERVENTION: Left message with on-call physician. On-call physician, [name of physician], X ray 2V ordered of L knee. Regarding pt's need for pain medication, pt has a hx (history) of AKI (acute kidney injury). [MEDICATION(S)] scheduled q 4 hours PO (by mouth) 50 mg (milligrams) x 7 days. Received notification from on-call physician, [name of physician], that [MEDICATION(S)] order is to be changed to PRN [MEDICATION(S)] PO 50 mg x7 days rather than scheduled. PRN [MEDICATION(S)] administered. Per pt's husband request, on-call physician ordered pt to be sent to ER (emergency room ) for evaluation and to r/o (rule out) fx. Per [name of physician], afternoon and evening doses of scheduled [MEDICATION(S)] d/c'd (discontinued). On 10/17/21 at 10:46 AM, the local hospital History and Physical documented a x-ray imaging result of the left femur two views. The impression documented a displaced left femoral neck fracture. On 10/17/21, the local hospital Progress Note documented that resident 55 presented today for a displaced left femoral neck fracture. Orthopedics was concerned about the acuteness of resident 55's injury and resident 55 would undergo a computed tomography (CT) scan for further clarification. On 10/17/21 at 12:57 PM, the local hospital Progress Note documented a CT of the left hip was obtained and the impression documented a displaced femoral neck fracture which appears to be chronic and may be a pathologic fracture as there appears to be soft tissue mass in the fracture plane. Evaluation was suggested. On 10/18/21 at 8:57 AM, the local hospital Progress Note documented a CT of the left knee was obtained and the findings documented a lipohemarthrosis to the left knee. Diffuse osseous demineralization was present. No displacement of the articular surfaces of the knee joint. There was a fracture involving the anterior margin of the medial femoral condyle best seen on the axial images. The impression documented there was a nondisplaced acute intra-articular fracture involving the medial femoral condyle. On 10/21/21 at 5:55 PM, an Admission Summary documented Resident readmitted in a stretcher for [CONDITION(S)] (urinary tract infection) and L tibia fracture that has immobilized. History includes [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, anxiety, [CONDITION(S)], ESBL (extended spectrum beta-lactamase) resistance, and [CONDITION(S)] (hypertension). brace on L leg, 2 persons assist with bed mobility and transfers, redness under R (right) breast, wound in coccyx, pain level 7/10 in L leg and pain med (medications) administered as ordered, . On 10/29/21 at 4:23 PM, a New Order Note documented Per Orthopedic Surgeon [name of surgeon on 10/28/21, continue minimal weight bearing LLE (left lower extremity) for four weeks. Pt is to be up in wheelchair at least once per shift. On 11/16/21 at 11:47 AM, an interview was conducted with resident 55. Resident 55 stated that two CNAs were transferring her at the time of the incident. Resident 55 stated it was approximately 3:00 AM, and she had to use the restroom really bad. Resident 55 stated she can only assist during transfers with her right side due to a stroke. Resident 55 stated the CNAs transferred her on left side twisting her left leg and she heard two pops. On 11/16/21 at 11:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated when she came on shift the night nurse reported that resident 55 was having pain in her knee and an ice pack and Tylenol were given to resident 55. RN 2 stated that after she was finished counting the narcotic medications with the night nurse the day shift CNAs reported that resident 55 was in a lot of pain. RN 2 further stated the day shift CNAs reported that resident 55 had instructed the nightshift CNAs to turn her to the right during transfer and the CNAs did not listen to her. RN 2 stated she asked resident 55 about her pain and resident 55 stated she was still in a lot of pain. RN 2 stated she called the on call doctor and the doctor would not order any narcotics for resident 55 until the X-ray results came back. RN 2 stated resident 55's husband was at the facility and questioned when the X-ray was going to be at the facility. RN 2 stated she was unsure when the X-ray technician would arrive but the X-ray had been ordered. RN 2 stated resident 55's husband requested that resident 55 be sent to the ER. RN 2 stated resident 55 complained of left knee pain but no hip pain. RN 2 stated she had reported the incident to the Director of Nursing (DON) and the Physician Assistant. On 11/16/21 at 12:01 PM, an interview was conducted with CNAs 2. CNAs 2 stated when she reported to the floor to start her shift resident 55 had her call light on and asked her to remove the ice pack. CNAs 2 stated she asked resident 55 what happened and resident 55 reported when the night shift CNAs transferred her to the bathroom she heard a pop in her knee. CNAs 2 stated the night nurse reported the CNAs took resident 55 to the bathroom at 3:00 AM and nothing had been reported to him regarding the incident. CNAs 2 stated she had sent a message to CNAs 3 to find out what had happened. CNAs 2 stated that CNAs 3 reported they did everything resident 55 asked them to do and pivoted resident 55 on her left leg. CNAs 2 stated the right leg was resident 55's strong leg. CNAs 2 stated that CNAs 3 reported resident 55 complained her knee was hurting and she forgot to report the incident to the nurse. CNAs 2 stated resident 55 was a two person transfer because she could not use her left leg. On 11/16/21 at 1:57 PM, an interview was conducted with RN 4. RN 4 stated he was not notified of anything unusual regarding resident 55 the day of the incident. RN 4 stated when he came back to the facility to work his next shift he was notified that resident 55 had a fracture from the CNAs moving her improperly. RN 4 stated resident 55 had complained of knee pain frequently and he would put [MEDICATION(S)] Gel on resident 55's knee. [Note: Out of 51 opportunities resident 55 received the [MEDICATION(S)] Gel on 7 occasions for the month of October 2021.] On 11/17/21 at 11:25 AM, an interview was conducted with resident 55. Resident 55 stated on the day of the injury the CNAs placed the wheelchair at the foot of her bed with the seat opening facing the head of her bed. Resident 55 stated when the CNAs stood her up she was pivoted towards her left side to the wheelchair and her left leg twisted underneath her. On 11/17/21 at 12:22 PM, an interview was conducted with the DON. The DON stated the day nurse received report that during the transfer resident 55 had a fracture or heard something pop. The DON stated she had reached out to the CNAs that were assisting with the transfer and the way she understood the CNAs did everything that resident 55 told them to do and the CNAs did not hear anything pop but resident 55 had. The DON stated resident 55 had complained of pain and the nurse gave her an ice pack and Tylenol and reached out to the Medical Director for a X-ray. The DON stated both CNAs were standing on each side of resident 55 to help with the transfer. The DON stated the CNAs had not worked with resident 55 before so they asked resident 55 for specific instructions on transferring. The DON stated she had reported the incident to the Administration and Cooperate Nurse and in the mean time she was trying to find out exactly what had happened. The DON was asked if the CNAs had been trained on resident transfers. The DON stated the CNAs would give report to each other every shift on instructions regarding the residents. The DON stated the CNAs would try to follow the instructions per the resident. On 11/17/21 at 12:33 PM, an interview was conducted with the Administrator. The Administrator stated because they had ruled out that the injury was not an intentional injury she felt like the incident did not need to be reported. The Administrator stated resident 55 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated there was no intent to harm resident 55 and resident 55 was able to tell her that the CNAs did not intend to hurt her and that was why she felt like the incident did not need to be reported. On 11/17/21 at 1:00 PM, an interview was conducted with CNAs 3. CNAs 3 stated she worked night shift. CNAs 3 stated resident 55 wanted to get out of bed and she usually did not get out of bed at night. CNAs 3 stated she had never transferred resident 55 before and had asked resident 55 how to transfer her. CNAs 3 stated she had positioned the wheelchair at the foot of resident 55's bed. CNAs 3 stated if facing resident 55's bed the wheelchair was positioned to the right. CNAs 3 stated she had not realized the wheelchair was positioned for getting resident 55 into bed because resident 55's right side was her strong side. CNAs 3 stated when they transferred resident 55 the resident reported that something had popped and complained of knee pain. CNAs 3 stated she had asked resident 55 if she would still like to go to the bathroom and resident 55 stated yes. CNAs 3 stated when resident 55 was finished with the bathroom they transferred resident 55 back to bed without incident. CNAs 3 stated she had reported the incident to the nurse on shift, RN 4, that resident 55 was having pain because resident 55 had heard something pop, and was requesting a pain pill.

Based on observation, interview, and record review it was determined the facility did not ensure assessments accurately reflected the resident's status. Specifically, for 2 out of 23 sampled residents, Minimum Data Set (MDS) assessments did not accurately reflect the resident's status. One resident was not accurately assessed to receive tube feedings and one resident was not accurately assessed to have a Preadmission Screening and Resident Review (PASRR) Level II in place. Resident identifiers: 14 and 45. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of resident 14's medical record was completed on 11/17/21. On 12/13/18, a PASRR Level I was completed which read, Level I screen indicates referral for Level II SMI (serious mental illness) is needed. On 1/2/19, a PASRR Level II was completed. On 12/4/20, an annual MDS assessment was completed. A question from the MDS assessment read, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. The question was answered No. [Note: Per resident 14's medical record a level II PASRR was in place.] 2. Resident 45 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/21 at 11:31 AM, resident 45 was observed to have a tube feeding pump next to their bed. At the time the tube feeding was not running or connected to resident 45. On 11/16/21 at 2:42 PM, resident 45 was observed to be laying in bed with the head of their bed elevated greater than 30 degrees and their tube feeding was running and connected at a rate of 90 milliliters (mL) of feeding per hour. A review of resident 45's medical record was completed on 11/17/21. On 10/1/21, a quarterly MDS assessment was completed. A question within the MDS assessment read, Feeding Tube- nasogastric or abdominal (PEG) (Percutaneous Endoscopic Gastrostomy), and the assessment indicated, Not checked (No). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Start Date- 09/17/2020 1400 -D/C (Discontinue) Date- 09/11/2021 1432 (2:32 PM). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Stonehenge Nutritional Risk assessment dated [DATE] read, Texture of Diet: NPO, and, [Resident 45] continues with TF (Tube Feeding) of [MEDICATION(S)] 1.5 90mL/hr x 20hr. On 11/17/21 at 2:34 PM, an interview was conducted with MDS Coordinator 1. MDS Coordinator 1 stated a different MDS Coordinator completed resident 45's quarterly assessment on 10/1/21, but it does appear to be an error in the MDS assessment because resident 45 was provided with tube feedings in September and October of 2021. On 11/17/21 at 3:11 PM, an interview was conducted with MDS Coordinator 2. MDS Coordinator 2 stated resident 45 was on a tube feeding since their admission to the facility. MDS Coordinator 2 stated the MDS Quarterly Assessment from 10/1/21 was coded inaccurately.

Based on interview and record review it was the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 23 sampled residents, the facility did not hold hypertensive medications when the blood pressure (BP) and/or pulse measurements were outside of the physician ordered parameters. Resident identifiers: 9 and 13. Findings include: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 13's medical record was reviewed on 11/17/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure (SBP) < (less than) 120 or diastolic blood pressure (DBP) < 50 and notify the Medical Doctor (MD). A review of the November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 11/1/21, SBP 107 b. On 11/2/21, SBP 115 c. On 11/4/21, SBP 108 d. On 11/7/21, SBP 105 e. On 11/8/21, SBP 119 f. On 11/15/21, SBP 116 g. On 11/16/21, SBP 103 On 11/18/21 at 12:09 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the MD was notified through secure text if resident vital signs were outside of parameters. RN 2 stated she had never been instructed to go against physician orders. On 11/18/21 at 12:09 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated the resident baseline parameters were to hold for a SBP <100, DBP <50, and a heart rate <60. UM 1 stated resident 13 had specific parameters. On 11/18/21 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had standing orders for BP parameters. The DON stated the BP parameters were on a template in the electronic medical record. 2. Resident 9 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21, a review of resident 9's medical record was completed. The following were noted within resident 9's MAR. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *HOLD FOR SBP <100 or DBP <50, THEN NOTIFY MD*. Start Date 11/25/20 at 7:00 AM. i. Documentation from 10/24/21 at 5:25 AM, indicated resident 9 had a BP of 113/48 and resident 9 was provided the [MEDICATION(S)] medication. b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <100 [and] DBP <50 . Active since 11/24/2020 c. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date 11/24/20 at 7:00 PM. Medication was discontinued on 11/05/21 at 6:39 PM. An order was then placed on 11/5/21, that read [MEDICATION(S)] Tablet Give 25 mg by mouth two times a day for [CONDITION(S)] Hold for SBP < 100, DBP 50 and Pulse < 60. On the dates indicated below [MEDICATION(S)] was administered while resident 9 presented with the indicated blood pressures; i. On 9/18/21 at 6:52 AM, resident 9's blood pressure was 92/55 mmHg. [MEDICATION(S)] was provided. ii. On 9/25/21 at 5:46 PM, resident 9's blood pressure was 95/53 mmHg. [MEDICATION(S)] was provided. iii. On 10/15/21 at 5:41 PM, resident 9's blood pressure was 91/52 mmHg. [MEDICATION(S)] was provided. iv. On 10/18/21 at 5:18 AM, resident 9's blood pressure was 93/67 mmHg. [MEDICATION(S)] was provided. v. On 10/20/21 at 5:39 PM, resident 9's blood pressure was 91/56. [MEDICATION(S)] was provided. vi. On 10/24/21 at 5:25 AM, resident 9's blood pressure was 113/48. [MEDICATION(S)] was provided. vii. On 10/30/21 at 4:36 PM, resident 9's blood pressure was 91/43. [MEDICATION(S)] was provided. viii. On 11/11/21 at 5:27 PM, resident 9's blood pressure was 118/48. [MEDICATION(S)] was provided. ix. On 11/14/21 at 4:09 PM, resident 9's blood pressure was 104/49. [MEDICATION(S)] was provided. On 11/16/21 at 11:31 AM, an interview was conducted with RN 3. RN 3 stated for blood pressure medications the medication should be held if the systolic blood pressure is less than 100 or if the diastolic blood pressure is less than 50. RN 3 stated most medications have that written within the administration notes and if a resident's blood pressure was consistently below the parameters RN 3 would send a message to the doctor to let the doctor know about the resident's low blood pressure readings. On 11/16/21 at 11:35 AM, an interview was conducted with the DON. The DON stated for hypertension medications the nurses should know to hold the medication if a resident's systolic blood pressure was less than 100 and the diastolic blood pressure was less than 50. On 11/17/21 at 12:40 PM, a follow up interview was conducted with the DON. The DON stated based on the documentation the facility had provided resident 9 received blood pressure medication when resident 9's systolic blood pressure was less than 100 or the diastolic blood pressure was less than 50.

Based on interview and record review it was determined the facility did not ensure that residents who have not used [CONDITION(S)] drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, for 1 out of 23 sampled residents, a resident was prescribed an antipsychotic medication without a diagnosis to support the use of an antipsychotic medication. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to polyneuropathy, idiopathic peripheral autonomic [CONDITION(S)], convulsions, cerebral aneurysm, protein-calorie malnutrition, essential hypertension, [CONDITION(S)], dehydration, metabolic [CONDITION(S)], and retention of urine. Resident 13's medical record was reviewed on 11/17/21. Physician's orders were reviewed and the following were documented: a. On 7/13/21, [MEDICATION(S)] 25 milligrams (mg) at bedtime (QHS) for hallucinations and [CONDITION(S)]. Order discontinued on 9/16/21. b. On 9/16/21, [MEDICATION(S)] 25 mg QHS for adjunct to antidepressant therapy. On 7/13/21 at 3:28 PM, a Nurses Note documented New orders per [name of Neurological Physician Assistant-Certified]: . Start [MEDICATION(S)] 25 mg at bedtime r/t (related to) hallucinations and [CONDITION(S)]. A Medication Regimen Review dated 9/10/21, documented This resident has an order for [MEDICATION(S)] for [CONDITION(S)], but the only psych diagnoses found in the chart is depression and anxiety due to cerebral aneurysm. These are not labeled indications for this medication. Antipsychotics carry a black box warning when used off label. This was discussed with the medical director and there is evidence to support the use of antipsychotics for depression as an adjunct to antidepressant therapy, and the patient currently taking [MEDICATION(S)]. It was agreed that the benefits of treatment currently outweigh any potential risks at this time. [Note: A diagnosis of depression was unable to be located within resident 13's medical record.] A review of the [CONDITION(S)] Tracking documented the following behaviors related to the use of [MEDICATION(S)]: a. July 2021, resident 13 had 6 verbalizations of hallucinations. [Note: Behavior tracking began on 7/13/21.] b. August 2021, resident 13 had no verbalizations of hallucinations. c. September 2021, resident 13 had no verbalizations of hallucinations. d. October 2021, resident 13 had no verbalizations of hallucinations. e. November 2021, resident 13 had no verbalizations of hallucinations. A review of the [CONDITION(S)] Drug Review meetings documented the following related to the use of [MEDICATION(S)]: a. July 2021, [MEDICATION(S)] started 7/13/21, r/t hallucinations and [CONDITION(S)]. New medication since last review. Hallucinations 3. Followed by neurologist. b. August 2021, Hallucinations 0. Followed by neurologist. c. September 2021, [MEDICATION(S)] started 9/16/2, r/t adjunct therapy for depression. Hallucinations 0. No documentation was able to be located within resident 13's medical record to show that resident 13 had a psychotic diagnosis to support the use of an antipsychotic medication. On 11/18/21 at 9:24 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 13 did not have a lot of behaviors. LPN 2 stated nothing had been reported to her regarding resident 13's behaviors. LPN 2 stated the facility did not put residents on [MEDICATION(S)]. LPN 2 stated if a resident were on [MEDICATION(S)] they would need to have a good reason and the resident would sign a consent form. LPN 2 stated the [MEDICATION(S)] must be working because resident 13 was not having behaviors. [Note: No Acknowledgement of Psychoactive Medication use for [MEDICATION(S)] was able to be located within resident 13's medical record.] On 11/18/21 at 9:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses would communicate with the Physician Assistant (PA) and doctor regarding antipsychotic medications. The DON stated based on the conversation the PA would make the recommendation during the [CONDITION(S)] meetings. The DON stated it would really be based on the nurses input to the PA. The DON stated the Pharmacist and Social Worker attend the [CONDITION(S)] meetings and it was a team effort when initiating an antipsychotic medication. On 11/18/21 at 9:59 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 13 did not really have any behaviors. RN 2 stated when resident 13 was admitted to the facility she had hallucinations but recently resident 13 did not have any hallucinations. On 11/18/21 at 10:01 AM, an interview was conducted with resident 13. Resident 13 stated she had no idea why she was on [MEDICATION(S)]. Resident 13 asked this surveyor if the medication was the antidepressant she takes for her anxiety. Resident 13 stated when she first arrived at the facility she had hallucinations and maybe that was why she was on the [MEDICATION(S)]. Resident 13 stated no one had spoken with her regarding the [MEDICATION(S)] and what the medication was for. Resident 13 stated she did not have hallucinations any more. On 11/18/21 at 10:20 AM, an interview was conducted with the PA. The PA stated resident 13's Neurologist started her on the [MEDICATION(S)]. The PA stated she had referred resident 13 to the Neurologist close to admission to help figure resident 13 out. The PA stated resident 13 had signs and symptoms that required a specialist. The PA stated she would discontinue [MEDICATION(S)] if a resident was admitted to the building with it. The PA stated resident 13 was in a good place with her medications right now. The PA stated she brings resident 13 up in the [CONDITION(S)] meetings because resident 13 was on a [CONDITION(S)]. The PA stated she was just trying to keep resident 13 as comfortable as possible why they were trying to figure her out. On 11/18/21 at 11:56 AM, a follow up interview was conducted with the DON. The DON stated resident 13 was followed by a Neurologist. The DON stated the Neurologist mentioned that resident 13 might have [CONDITION(S)] and prescribed [MEDICATION(S)]. The DON stated resident 13 had been doing a lot better. The DON stated she would have one provider deal with the [MEDICATION(S)]. The DON stated she had to request the visit notes from the Neurologist office and she was told it could take 24 to 48 hours to receive the notes. The DON stated she had requested the notes be sent urgent. On 11/18/21 at 5:21 PM, the Neurology Clinic notes were provided by the Administrator. [Note: The Neurology Clinic notes were not readily accessible at the facility or in resident 13's medical record.] A Neurology Clinic note dated 6/17/21, documented . referral to psychiatry for hallucinations and anxiety, depression seen psychiatry in past . [Note: No documentation was able to be located within resident 13's medical record to show that resident 13 had a psychiatry referral completed.] A Neurology Clinic note dated 7/13/21, documented a chief complaint of seizures. Resident 13 had a history of seizures since 2019. Resident 13 was getting a magnetic resonance imaging scan for [CONDITION(S)] work up for memory difficulty and balance since June 2019. Per nurse, she seems to be hallucinating but is aware that she is hallucinating. Nurse reports that she will ask to have socks removed from her feet even though she knows that she doesn't have socks on. [Note: No additional Neurology Clinic notes were provided after resident 13 was seen by the Neurologist on 7/13/21.]

Based on interview and record review it was determined that the facility did not promptly notify the ordering physician; physician assistant; nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges. Specifically, for 1 out of 23 sampled residents, notification was not made when a resident had critical lab values. Resident identifiers: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/21, resident 10's medical record was reviewed. On 10/13/21, a Comprehensive Metabolic Panel (CMP) was ordered. The CMP was not collected until 10/14/21. The results were available on 10/15/21. The lab report revealed the following: a. Sodium level was High at 154 [Note: Normal sodium values were between 137-146.] b. Chloride level was High at 112 [Note: Normal chloride values were between 102-111.] c. Glucose level was High at 120 [Note: Normal glucose values were between 65-99.] d. Blood urea [MEDICATION(S)] (BUN) level was High at 122 [Note: Normal BUN values were between 8-20.] e. Creatinine level was High at 1.71 [Note: Normal creatinine values were between 0.60-1.10.] f. Creatinine glomerular filtration rate (GFR) was Low at 29 [Note: Normal GFR values were >60.] The physician signed the lab results on 10/18/21. [Note: There was no record of resident 10's physician being informed of these labs sooner than 10/16/21.] On 10/13/21, a Complete Blood Count (CBC) with automatic differential was ordered. The CBC was not collected until 10/14/21. The results were available on 10/15/21, with a High hematocrit of 47.2 [Note: Normal hematocrit values were between 36.0-46.0.] The physician signed the lab results on 10/18/21. [Note: There was no record of resident 10's physician being informed of these labs sooner than 10/16/21.] On 11/17/21 at 2:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the lab results were faxed to the facility and if there were critical lab values they were called directly to the provider or a text message was sent out to the provider, Administrator, and the manager. LPN 1 stated urgent (STAT) labs were expected back the same day they were ordered, non-STAT labs were expected the next day. LPN 1 stated she would call if she had not seen the lab results in a timely manner, 1 to 2 days. LPN 1 stated Non-critical labs were put in the providers box for them to check the next day. LPN 1 stated the labs were documented under nursing progress notes. On 11/17/21 at 3:00 PM, an interview was conducted with LPN 3. LPN 3 stated critical labs were called to the physician right away after they were received. LPN 3 stated the nurses were responsible for physician notification and the Unit Manager (UM) would sometimes help with lab and provider follow up. On 11/17/21 at 3:04 PM, an interview was conducted with UM 1. UM 1 stated there was a delay in treatment with resident 10, the nurses did not communicate well to each other, and the labs were missed. UM 1 stated critical or abnormal labs were called directly to the physician immediately when the lab results were received. UM 1 stated there was a process in place for ordering, obtaining, receiving lab results, and that process was not followed in this case and resident 10's care was delayed. On 11/18/21 at 11:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a break in the system for how labs were received and reported to the physician. The DON stated the labs were not reviewed by the nursing staff correctly and the physician was not made aware of the results timely and this resulted in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review it was determined the facility did not maintain medical records on each resident that were complete, accurate, and readily accessible. Specifically, for 1 out of 23 sampled residents, a residents Neurology Clinical notes were not readily accessible. Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 13's medical record was reviewed on 11/17/21. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 7/13/21, [MEDICATION(S)] 25 milligrams (mg) at bedtime (QHS) for hallucinations and [CONDITION(S)]. Order discontinued on 9/16/21. b. On 9/16/21, [MEDICATION(S)] 25 mg QHS for adjunct to antidepressant therapy. On 7/13/21 at 3:28 PM, a Nurses Note documented New orders per [name of Neurological Physician Assistant-Certified]: . Start [MEDICATION(S)] 25 mg at bedtime r/t (related to) hallucinations and [CONDITION(S)]. On 11/18/21 at 10:20 AM, an interview was conducted with the Physician Assistant (PA). The PA stated resident 13's Neurologist started her on the [MEDICATION(S)]. The PA stated she had referred resident 13 to the Neurologist close to admission to help figure resident 13 out. The PA stated resident 13 had signs and symptoms that required a specialist. The PA stated she would discontinue [MEDICATION(S)] if a resident was admitted to the building with it. The PA stated resident 13 was in a good place with her medications right now. The PA stated she brings resident 13 up in the [CONDITION(S)] meetings because resident 13 was on a [CONDITION(S)]. The PA stated she was just trying to keep resident 13 as comfortable as possible why they were trying to figure her out. On 11/18/21 at 11:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 13 was followed by a Neurologist. The DON stated the Neurologist mentioned that resident 13 might have [CONDITION(S)] and prescribed [MEDICATION(S)]. The DON stated resident 13 had been doing a lot better. The DON stated she would have one provider deal with the [MEDICATION(S)]. The DON stated she had to request the visit notes from the Neurologist office and she was told it could take 24 to 48 hours to receive the notes. The DON stated she had requested the notes be sent urgent. On 11/18/21 at 5:21 PM, the Neurology Clinic notes were provided by the Administrator. [Note: The Neurology Clinic notes were not readily accessible at the facility or in resident 13's medical record.]

Based on interview and record review it was determined, for 1 out of 1 sampled resident, that the facility did not ensure that the resident was free from abuse, neglect or misappropriation of property. Specifically, a Certified Nurse Assistant (CNA) had made multiple unauthorized credit card charges with a resident's debit card. Resident identifier 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/2/2021 the facility CNA abuse investigation was reviewed. The facility initial investigation summary stated that on 2/3/2021 Resident 1's Power of Attorney (POA) contacted the facility to notify them of unusual charges on the resident debit card at a nearby grocery store. Resident 1 had indicated to the POA that CNA 1 had purchased a few items for her on a couple of occasions and had used her debit card for those purchases. The POA indicated that the additional charges on the card exceeded both the number of times and the amount that Resident 1 had authorized. The facility Administrator spoke with Resident 1 who indicated that she did ask CNA 1 to purchase some items for her a few times. The resident reported that the CNA had returned with the requested items and a receipts, which were verified and then thrown out. Review of resident 1's bank statement identified the following transactions that were reported as suspicious by the POA: a. On 2/3/2021, a charge for $37.75 was noted. The transaction method was documented Card Inserted. b. On 2/1/2021 a charge for $33.23 was noted. The transaction method was documented Card Inserted. c. On 1/29/2021 a charge for $19.43 was noted. The transaction method was documented Card Inserted. d. On 1/25/2021 a charge for $51.65 was noted. The transaction method was documented Card Inserted. e. On 1/7/2021 a charge for $20.18 was noted. The transaction method was documented Card Inserted. f. On 12/14/2021 a charge for $17.32 was noted. The transaction method was documented as card number entered by Customer/Merchant. A hand written note stated, same day as $5.20 soups. g. On 12/7/2021 a charge for $25.40 was noted. The transaction method was documented Card Inserted. A hand written note stated, same day as chips/candy. The total amount of unauthorized purchases was $204.96. Review of the resident Minimum Data Set (MDS) Quarterly assessment with an Assessment Reference Date (ARD) on 1/25/21 had a Brief Interview of Mental Status (BIMS) score of 14/15, which indicated that Resident 1 was cognitively intact. Review of the Police records for case #21PG revealed that this was an active and open investigation. The narrative documented On 2/5/2021 officers made contact with resident manager (Registered Nurse (RN) 1) from (name of facility). (RN 1) stated that one of her residents (resident 1) has a credit card. (RN 1) says that this credit card is being abused by one or several of the staff but they have no proof. (RN 1) pulled the credit card transactions and cross referenced them with (resident 1) on when she gave her card out. (RN 1) asked if officers could get video from (name of store) on some of the transactions dates, times, and amounts. (RN 1) asked (name of store) if she should (sic) have video but they told them they would only release the video to officers. I contacted (name of store) and sent them the dates, times and amounts, and credit card information. A (name of store) manager told me he would pull the video and call back when it is ready. The supplemental report further documented Officer was contacted by the manager of (name of facility) (Administrator). She explained that she was informed of the theft case, and explained that she had put an employee on suspension as she believed her to be the suspect in this case. (Administrator) described the suspect as a heavy set hispanic female. Based off of the video footage, I believed this to be the suspect as well. (Administrator) was shown 2 pictures of the suspect, captured from video surveillance. (Administrator) confirmed that this was her employee, and Identified her as (CNA 1). On 3/2/2021 at 10:53 AM, an interview was conducted with RN 1. The RN stated that she was first informed of the allegation on Wednesday night (2/3/2021) at approx. 5:00 to 5:30 PM. The RN stated that the Administrator had told her that the family sent Resident 1's credit card statement, and marked the transactions that were not valid. The RN stated that she contacted CNA 1, she was working the floor, and pulled her into the office to talk with her and the Administrator. RN 1 stated that CNA 1 had reported that she had taken the credit card in the past to buy things that the resident wanted, and always brought the resident the receipt for the purchase. The CNA stated that the last time she used the resident's card was in November 2020. The RN stated that the POA provided the statement for the charges from December 2020 to February 3, 2021. The RN stated that they informed the CNA that there were questionable transactions and she denied it and said that she had not taken her card in a while. At this time, the CNA reported that she had bought items for the resident with her own money. The RN stated that this was not the facility practice and she advised the resident that the Activities Director should purchase items for the residents. RN 1 stated that CNA 1 had said that she knew it was wrong to purchase items with the resident's card, but that she did it anyway. The RN stated that at that point the Administrator informed her that she was suspended pending the investigation, and she walked the CNA out of the building. The RN stated that they called the CNA back into the facility after they obtained photo evidence of the CNA from the police. The police had provided photos of CNA 1 at the location, at the date and time that the credit card transaction occurred. The CNA again denied taking the card and using it. After viewing the photo evidence provided by the police the CNA stated that she purchased a birthday cake and pizza for the resident's friend (name omitted). The RN stated that she spoke to Resident 1 on Monday 2/8/2021. The RN stated that Resident 1 denied requesting CNA 1 purchase a birthday cake and pizza for (friend name omitted). The resident stated that (friend's name) lived in (name of city) and she had never sent her a cake and pizza, as reported by CNA 1. The RN stated that she educated the resident on keeping the credit card in a safe. The RN stated that she had no other involvement in the investigation afterwards. On 3/3/2021 at 11:15 AM, a follow up telephone interview was conducted with RN 1. The RN stated that she spoke to the store director on Friday, 2/5/2021, at approx. 4 PM, and it was at the direction of the store director that she contacted the police. The RN stated that she had asked for pictures or video footage during the time the credit card was used and that was when they said she needed to talk to the police. The RN stated that she notified the police on Friday after speaking to the store director. The RN stated that on 2/3/2021 the Administrator stated that the POA had sent some information with charges on a credit card that they felt were not for the patient. The Administrator had reported that the resident had stated that CNA 1 had taken the card in the past to make purchases for her. On 3/2/2021 at 11:23 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that Resident 1's POA called her and said that she was going through Resident 1's bank account and noticed items that did not look like she would have purchased. The BOM stated that the POA reported that the resident denied making those transactions or authorizing them. The POA talked to the bank and was informed that they were in store purchases, and there was no way for the resident to physical do that. The BOM stated that the POA asked her to help the resident get her purse to locate the credit card. The BOM stated that the resident told her that the key to her locked cabinet was in the top drawer of the dresser. The BOM found the key, located the resident's purse, and the resident found the credit card. The BOM stated that she verified the last 4 numbers of the card that was provided by the POA. The BOM stated that the purse was locked in the end table next to the bed. The BOM stated that she and the resident decided to place the key in the second drawer under some pictures until this was resolved. The BOM stated that prior to locating the credit card she informed the facility Administrator about the POA concerns. The BOM stated that she informed the Administrator that the credit card was in the resident's purse and they had moved the key for the locked cabinet. The BOM asked the resident if anyone else knew the location of the key, and the resident replied that CNA 1 and housekeeping knew where it was located. The BOM stated that Resident 1 did not identify who in housekeeping was aware of the location of the key. The BOM stated that the resident was good friends with CNA 1 and did not want her to get into trouble. The BOM stated that Resident 1 had reported that CNA 1 had purchased soup and a few things for her using her credit card. The BOM stated that the resident was really worried about CNA 1, and knew that the CNA was terminated. The BOM stated that she visited with Resident 1 every morning. All the managers were assigned a team mate/resident(s) and they visited them every morning. The BOM stated that Resident 1 would say that she was really worried about CNA 1, and would speak about her often. The BOM stated that she would reply to the resident that it was out of their hands. The BOM stated that Resident 1 was aware most of the time, with occasional forgetfulness. The BOM stated that she thought it was more of a selective memory, and she did not think that she had any cogitative loss. The BOM stated that the resident was aware of her surroundings. The BOM stated that the POA had canceled the previous credit card and the resident's new card was kept in a safe in the Administrator's office. On 3/2/2021 at 11:46 AM, an interview was conducted with the Restorative Nurse Assistant (RNA). The RNA stated that the Administrator and RN 1 called her in and asked her if she had seen anything awkward or unusual with CNA 1. The RNA stated that she reported to them that she did not think anything was wrong, and did not see anything out of the ordinary with the CNA. The RNA stated that CNA 1 was always friendly with the residents, and she had never heard of any complaints about her. The RNA stated that she was informed of the allegation against CNA 1 by the facility Administrator. The RNA stated that she did not have any knowledge of the CNA using Resident 1's credit card. The RNA stated that CNA 1 told her that Resident 1 had said that she was using her credit card. The RNA stated that CNA 1 was having a hard time with it and had denied it. The RNA stated that she had communicated with CNA 1 by text and asked how she was doing. The RNA stated that she did not talk to CNA 1 about work. The RNA stated that she had not talked to the resident about the allegation. The RNA stated that the resident had asked how the CNA was doing and she told her she was fine. The RNA stated that the last time Resident 1 asked about CNA 1 was last week on Thursday, 2/25/2021. The resident asked how the CNA was doing, and asked that the RNA tell CNA 1 that she hoped she was doing great and that she could call her. The RNA stated that she would let the CNA know. The RNA stated that it was not normal for the CNAs to purchase items for the residents. We are not supposed to, unless the patient goes to the vending matching I will assist. Other than that, no. The RNA stated that CNA 1 did not talk about buying items for the resident. I know that she would bring her food that she made from home or she would buy her Snickers because the resident liked it. The RNA stated that Resident 1 seemed sad when she talked about the CNA and had said that she missed her a lot. On 3/2/2021 at 11:57 AM, an interview was conducted with Resident 1. Resident 1 stated that CNA 1 was her best friend, and was so good to her. Resident 1 stated that CNA 1 bought some items for her using her credit card and she got in trouble for it. Resident 1 reported that CNA 1 had bought her some groceries. The resident stated that the card disappeared, and that she figured that the CNA was afraid to tell her that she lost the card. Resident 1 stated that she gave CNA 1 permission to use her card. The resident stated that the CNA never bought any items without her permission, and never any items for the CNA's personal use. The resident stated that she had a POA. Resident 1 stated that as soon as the card was lost the POA replaced it. The resident then stated that she did not consider the card lost, that CNA 1 had it and had brought it back to her. Resident 1 stated that if the CNA had come to her as soon as she lost the card she would have told the POA. I'd do anything to help her. She is a fine person. On 3/2/2021 at 12:21 PM, an interview was conducted with the facility Administrator. The Administrator stated that she was first informed of the credit card charges by the BOM on 2/3/2021 in the afternoon between 1:00 or 2:00 PM. The Administrator stated that the BOM had reported that the POA had let her know that there were unusual charges on Resident 1's credit card. It was reported by the POA that CNA 1 had gone to the store for Resident 1 and purchased items for her a couple of times. The Administrator stated that she spoke to the resident on 2/3/2021 and she had reported that she had asked CNA 1 to pick some things up for her on a few occasions, small food items such as soups and chips. The Administrator stated that Resident 1 had reported that the CNA brought receipts for the purchases and she would look at them and then throw them away. The Administrator stated that Resident 1 did not feel like CNA 1 misused her credit card, she trusted her. The Administrator stated that CNA 1 told her that she purchased things for the resident out of her own funds and had not asked to be reimbursed. The Administrator stated that CNA 1 had reported that she had permission from Resident 1 to buy items for the resident with her credit card, but that she had not done so recently. The Administrator stated that she suspended the CNA pending the facility investigation and advised her to not return to the building until she heard from her again. The Administrator stated that Resident 1 had the key to her locked cabinet available and visible to others. The BOM had spoken to the resident and they identified a place out of sight to store the key. The Administrator stated that the POA provided the bank statement for Resident 1 and indicated with a question mark the transactions that she was not aware of. She informed them that the card had been canceled and a new one was ordered. The Administrator stated that RN 1 informed the police on 2/5/2021. The Administrator stated that she followed up with the police department on 2/8/2021. The Administrator stated that she spoke to an officer who informed her that they had not turned the case over to a detective yet. The officer said that he had video footage of the dates and times of the purchases, but it had not been viewed yet. The Administrator stated that she asked the officer that if she described the CNA could he confirm if it was her in the video footage. The Administrator stated that after she described the CNA the officer said it was the same person. The officer then texted photos of the CNA at the store and she verified that it was CNA 1 in the photos. The Administrator stated that after she viewed the photos she had the CNA come back to the facility for an interview. The Administrator stated that the CNA continued to deny using the resident's credit card. The Administrator stated that she told the CNA that she had photographs of her using the credit card. The Administrator stated that CNA 1 continued to deny it and said that she hadn't used the credit card since December 2020. The Administrator stated at that time they terminated CNA 1's employment. The Administrator stated that CNA 1 then said that the resident had asked her to purchase a cake and socks and take them to the resident's friend (name omitted). The Administrator then asked her why she had said that she had not used the card since December and the CNA did not have an answer. The Administrator stated that Resident 1 was alert and oriented to person and place, but was not always oriented to situation and time. The Administrator stated that the resident had some confusion. The Administrator stated that the Resident 1's relationship with the CNA was close, and the resident considered her a trusted friend. The resident does not believe that the CNA took money from her. On 3/3/2021 at 1:10 PM, a telephone interview was conducted with the POA. The POA stated that Resident 1 had her credit card with her at the care facility. The POA stated that she had requested help with her shopping from CNA 1. The POA stated that she noticed on the resident's bank account too many charges with too high a dollar amount. The POA stated that she asked the resident what the charges were for and the resident replied no, no, no that was not what I was getting. The POA stated that Resident 1 had reported that in December 2020 she had requested that CNA 1 purchase candy and chips for her using her credit card, and in January 2021 the resident asked CNA 1 to purchase soup for her. The POA stated that she noticed that there were an additional and separate charges at the time of those two requested purchases and they were for a larger amount. The POA stated that she noted this on the bank statement. The POA stated that she started to notice every 2-3 days multiple charges. The POA asked the resident what she was buying, and the resident reported only authorizing the candy and soup purchases. The POA stated that the resident reported that the additional charges were not purchases she had approved. The POA stated that Resident 1 did not believe that CNA 1 had made these purchases and that it had to be someone else. The POA stated that from the police surveillance it was determined that it was CNA 1 who made these fraudulent charges. The POA stated that this was reported to her by the facility Administrator, and she had never spoken to the police department. The POA stated that she provided the facility a copy of the bank statement and they turned that over to the police. The POA stated that from the bank statement and the video footage they were able to determine that it was CNA 1 making the credit card charges. The POA stated that she was not aware of how this all started, and how CNA 1 became aware that the resident had a credit card. On 3/4/2021 at 10:59 AM, a telephone interview was conducted with CNA 1. CNA 1 stated that she worked at the facility for 3 years, and had a relationship with Resident 1. CNA 1 stated that Resident 1 gave her the credit card so she could do personal purchases for her. CNA 1 stated that when Resident 1 needed something and she did not have money, CNA 1 would purchase items for her with her money. CNA 1 stated that Resident 1 told her that she would pay CNA 1 back by allowing her to use her credit card. CNA 1 stated that she bought the resident items for her hair, Cheetos, candy, Top Ramen, and a Christmas cake for her friend. CNA 1 stated that she did not recall the friend's name or the address that she delivered the cake to. The CNA stated that she used Resident 1's credit card a lot of times between 2019 and 2020. I don't remember the amount but I would always give her the receipt and she would look at them and throw them away. Sometimes I would buy her Taco Bell or Carl's Jr. with her credit card or with my money. CNA 1 stated that Resident 1 gave her the credit card for each purchase, or just gave her cash. CNA 1 stated that she did not think she ever made more than one purchase in a single day. CNA 1 stated that Resident 1 kept the credit card in a notebook or on the bedside table with papers. CNA 1 stated that she had been a CNA for [AGE] years and she had never done this before except for this resident. CNA 1 stated that she made these purchases with the credit card because they had become friends and she did it for the resident. CNA 1 stated that there were other CNA's that did the same for other residents, so that was why she did not think it was bad. The CNA stated that Resident 1 was sometimes confused. CNA 1 stated that Resident 1 would forget where items were located and she could not remember who people were. CNA 1 stated that Resident 1 always knew who CNA 1 was. The CNA stated that it would depend on how Resident 1 was on any given day as to how confused she was. She would forget what happen during the day. Sometimes she would forget some people. She would forget what she was about to do or what she had been doing. CNA 1 stated that the facility informed her that she was investigated and terminated for abuse. CNA 1 stated that the RNA was her immediate supervisor and she knew that she was buying items for Resident 1 with Resident 1's credit card. CNA 1 stated that the RNA was not present when the resident requested her to purchase items for her. CNA 1 stated that the RNA was aware that she was making purchases with her own money and the resident's credit card. The supervisor knew the relationship I had with the resident and she didn't exactly tell me not to use the resident's credit card. CNA 1 stated that the resident and the CNA had a friendship and Resident 1 would ask her for favors and the RNA was aware of this.

Based on interview and record review it was determined, for 1 out of 1 sampled resident, that the facility did not ensure that all alleged violations involving abuse, neglect, or misappropriation of resident property were reported immediately, or not later than 24 hours if the events did not involve abuse or result in serious bodily injury to Adult Protective Services (APS). Specifically, the facility did not report the misappropriation of resident property to APS. Resident identifier 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/2/2021 the facility CNA abuse investigation was reviewed. The facility initial investigation summary stated that on 2/3/2021 Resident 1's Power of Attorney (POA) contacted the facility to notify them of unusual charges on the resident debit card at a nearby grocery store. Resident 1 had indicated to the POA that Certified Nurse Assistant (CNA) 1 had purchased a few items for her on a couple of occasions and had used her debit card for those purchases. The POA had stated that the additional charges on the card exceeded both the number of times and the amount that Resident 1 had authorized. The facility Administrator spoke with Resident 1 who indicated that she did ask CNA 1 to purchase some items for her a few times. The resident reported that the CNA had returned with the requested items and receipts, which were verified and then thrown out. No documentation could be found that APS was notified of the incident. On 3/2/2021 at 12:21 PM, an interview was conducted with the facility Administrator. The Administrator stated that she was first informed of the suspicious credit card charges by the BOM on 2/3/2021 in the afternoon between 1:00 or 2:00 PM. The Administrator stated that notification to APS was not done. The Administrator stated that they felt that this was a long term patient for them, they had eliminated the threat, and they felt confident that they had removed any potential for further harm. The Administrator stated that she thought, what would they (APS) do when we have already removed the potential for further harm.

Based on observation, interview, and record review it was determined, for 1 out of 25 sampled residents, that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise. Specifically, a resident lost 33% or 100 pounds of weight within 4 months of being at the facility and received a feeding tube. While the resident had the feeding tube, a physician's orders [REDACTED]. Resident identifier: 32. Findings include: Resident 32 was admitted to the facility initially on 1/25/19 and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/12/19 at 12:19 PM, an interview was conducted with resident 32. Resident 32 stated that she had lost 100 pounds since admit. Resident 32 stated that the weight loss was not planned or wanted. Resident 32 stated that she was so sick that she was not able to eat. On 8/13/19, resident 32's medical record was reviewed. Resident 32 was at the hospital prior to being admitted to the facility. The hospital records contained the following progress notes: a. On 1/22/19 at 11:59 AM, a Hospital progress note documented, This is a [AGE] year old female brought in by EMS (emergency medical services) because of increasing weakness, nausea and lower extremity problems. Patient apparently in the last day or to (sic) call her primary care physician because of difficulty eating, drinking and nauseous (sic) she's had for 3 weeks. She is becoming dehydrated. He (sic) is (sic) also had some diarrhea and has tried [MEDICATION NAME] without much success. She also had some incontinence and is fairly immobile. b. On 1/22/19 at 2:59 PM, a Hospital Progress note documented, [AGE] year old female who presents .with issues of generalized weakness in the setting of prolonged watery loose stools .Patient's history dates back approximately 4 weeks where she developed loose stools, they have been described as watery and somewhat progressive in nature .she's had some associated nausea without vomiting .Patient also reports she's had some difficulty swallowing foods she denies any odynophagia. She also feels like she is losing muscle mass. Over the course of this prolonged diarrheal episode she reports she's been getting progressively weekend (sic) and she is now unable to ambulate, she reports she's exhausted with any attempted movement .It is noteworthy that her weight is approximately 160 kg (kilograms) (352 pounds) her last admission in spring she was 180 kg (396 pounds). (Note: this was a loss of 56 pounds or a 12% weight loss between the two admissions.) c. On 1/22/19 at 3:19 PM, the patient appears dehydrated with dry mucous membranes, her weight is well below baseline She also reports dysphagia plan for swallow evaluation . d. On 1/24/19 at 10:06 AM, a Hospital progress note documented, [AGE] year old female admitted on [DATE] for prolonged episodes of diarrhea in the setting of acute [MEDICAL CONDITION] .Additionally patient has had intermittent [DIAGNOSES REDACTED] and poor by mouth intake may have component of protein calorie malnutrition-[MEDICATION NAME] is pending and the patient's blood pressures have been sluggish this morning adding [MEDICATION NAME] infusing, holding antihypertensives and continuing a [MEDICATION NAME] drip overnight. Overall the patient is quite deconditioned and malnourished in the setting of [MEDICAL CONDITION] Patient does have [MEDICAL CONDITION] but I feel the patient does have clinical signs of protein calorie malnutrition given the mild temporal wasting noted she also reports quite a bit of weight loss. A lot of this weight loss may be related to improvement in her [MEDICAL CONDITION] since last admission . Resident 32's weight trends were reviewed and revealed the following: (Note: all weights are in pounds unless otherwise indicated.) a. At the hospital on [DATE], prior to admit to the facility, resident 32's weight was documented as 347. b. On 1/25/19, 328 (Note: This was the first weight documented at the facility.) c . On 1/28/19, 327 d. On 2/1/19, 325 e. On 2/19/19, 312 f. On 3/5/19, 294 (Note: From admit weight of 328, this was an 11% weight loss in 5 and a half weeks.) g. On 3/26/19, 267 (Note: From the last weight on 3/5/19 of 294, this was a 10% weight loss in 2 weeks.) h. On 4/9/19, 254 (Note: This was a 23% weight loss in 2 and a half months.) i. On 4/16/19, 245 j. On 5/28/19, 222 (Note: This was a 33% weight loss in 4 months.) k. On 6/14/19, 231 l. On 6/17/19, 218 m. On 7/8/19, 220 n. On 7/15/19, 222 The following nursing progress notes, dietary progress notes, lab results, and physician's orders [REDACTED].> a. On 1/27/19 at 9:45 PM, a Nursing note documented, Patient complains of nausea. Patient denies vomiting. [MEDICATION NAME] administered as prescribed for nausea with effective results. Nausea subsided. b. On 1/28/19, a nutrition assessment was completed by the dietary technician. Resident 32's weight at the time of the assessment was 328 pounds. Resident 32's adjusted body weight was calculated to be 194 pounds or 88 kilograms. Resident 32's calorie needs were estimated to be 2205-2645 Calories/day. The factor used to calculate this was 25-30 calories per kilogram. Resident 32's protein needs were estimated to be 88 grams. The factor used to calculate this was 1.0 grams per kilogram. It was documented at that time that the resident leaves 25% plus at most meals. The nutrition note stated Nutritional concerns include swallowing difficulty, mechanically altered diet, [MEDICAL CONDITION] and low intake. Pt (patient) says appetite is slowly improving. She had boost w/ (with) every meal in the hospital and wants to continue that here. Rec (recommend): Ensure TID (three times a day) with meals. c. On 1/29/19 at 10:50 AM, a Nursing note documented, Patient and family met for IDT (interdisciplinary team meeting). They are concerned about patient's lack of intake and patient's aversion to food. Educated on appetite stimulants. Pt would like stool softener scheduled as well. Pt to meet with ST (speech therapy) for eval (evaluation). Notified MD (Medical Doctor) of patient concerns. all questions answered. WCTM (will continue to monitor). (Note: No appetite stimulant was added at this time.) d. On 1/29/19 at 3:17 PM, a Nutrition note documented, Poor appetite. PO (by mouth) intake of 18%. Rec: Ensure TID per pt request. e. On 1/29/19 at 5:00 PM, a physician's orders [REDACTED]. f. On 1/30/19 at 2:58 PM, a Physician's progress note documented, She had episodes of [DIAGNOSES REDACTED] during her hospitalization required [MEDICATION NAME] infusion in addition to her IV (intravenous) fluids resuscitation. However today, she had stability in her blood work, and her oral intake has improved significantly without any symptoms. (Note: resident 32's recorded meal intake at this time averaged 13% since admit on 1/25/19.) g. On 2/9/19, a Physician's progress note documented, PO intake improving gradually with Ensure and fruit. (Note: Meal intakes between 1/30/19 to 2/9/19 were documented to average 9.5%.) h. On 2/20/19 at 3:19 PM, Order by (name withheld) PA (Physician's Assistant) for a dietary consult to discuss magic cups and other dietary changes. i. On 2/21/19, The dietary consult was completed and stated the following: .eating 7%. Eating (approximately) 75% Ensure TID. Reconsider appetite stimulant or TF (tube feeding). Add to NAR (nutrition at risk) discussion. (Note: no other supplement or dietary changes were made.) j. On 2/22/19, On a dietary recommendation form, the request for an appetite stimulant or tube feedings was declined by the physician. The response from the physician was schedule nausea meds (medications) first. At that time, resident 32 had [MEDICATION NAME] ordered for 4 milligrams (mg) every 6 hours as needed. An order was written in addition to the as needed dose of scheduled [MEDICATION NAME] 4 mg 4 times per day. k. On 2/22/19, Resident 32 was discussed at the NAR meeting. The NAR meeting identified that the resident was consuming about 7% of meals related to nausea, vomiting and decreased appetite. The intervention added was to increase Ensure to 4 times per day. l. On 2/22/19 at 5:15 PM, a Nursing note documented, per dietary recommendations increase Ensure to 4 times per day in between meals d/t (due to) decreased appetite eating 7% of meals. WCTM. (Note: documented meal intakes between 2/10/19 to 2/25/19 averaged 4.7%.) m. On 2/27/19 at 1:49 PM, A Physician's Progress Note documented, She complains of some occasional nausea. n. On 2/28/19 at 3:39 PM, a Nursing note documented, Patient complains of nausea. Patient denies vomiting. [MEDICATION NAME] effective. o. On 3/2/19 at 4:06 PM, a Nursing note documented, Patient complains of nausea. Vomiting present. [MEDICATION NAME] given pt reports it was effective. p. On 3/6/19 at 2:54 PM, a Physician's Progress Note documented, Nausea, continue [MEDICATION NAME] when necessary q. On 3/6/19, a Nutrition note documented, PO intake of Reg/NDD2 (regular, national dysphagia diet level 2) is 2%. Pt receives ensure 4 (times per) day. (Percent) intake (of ensure) not recorded in (name of electronic medical record software). Pt says they bring her ensure 4 (times) but she is only able to drink 1 1/2 per day. Pt is still experiencing extreme nausea. Nurses have scheduled [MEDICATION NAME] for pt 4 (times per) day rather than as needed. Pt tried to eat jello but was unable to keep it down. She says she is hungry and is doing as much as she can to eat. No recs (recommendations) at this time. Will discuss in NAR. The nutrition assessment indicated that resident 32 was not meeting her nutritional needs with her current intake. r. On 3/8/19, Resident 32 was reviewed at the NAR meeting. Resident 32 was triggered for a weight loss of -5.6% x 1 week related to nausea and vomiting. No interventions were implemented. The decision was to CTM or continue to monitor. (Note: Resident 32's weight was 294.8 pounds at time of this meeting. This was an 11% weight loss x 5 weeks. Meal intakes were 2%. According to the American Society of [MEDICATION NAME] and Enteral Nutrition, Resident 32 would have qualified for severe malnutrition at this time.) s. On 3/8/19 at 3:31 PM, a Physician's progress note documented, Nausea, continue [MEDICATION NAME] when necessary, GI (gastrointestinal) consult for persistent unexplained nausea. (Note: This was six weeks after resident 32 was admitted to the facility.) (Note: documented meal intakes between 2/26/19 to 3/13/19 averaged 4.2%.) t. On 3/18/19 at 12:25 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given [MEDICATION NAME] before meals. Pt eats small amount of food due to nausea. u. On 3/20/19 at 6:50 PM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given [MEDICATION NAME] before meals. Pt eats small amount of food due to nausea. v. On 3/21/19 at 12:04 AM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt is given [MEDICATION NAME] before meals. Pt eats small amount of food due to nausea. w. On 3/23/19 at 3:21 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled [MEDICATION NAME] before meals. (Note: On 3/26/19, resident 32's weight was taken and measured at 267 pounds. This was a 10% loss in 2 weeks, since her weight taken on 3/6/19 was 294 pounds. This was a significant weight change. Resident 32 was not reviewed again at a NAR meeting until 4/19/19.) x. On 3/28/19 at 1:02 PM, a Social work note documented, SSW (Social Service Worker) spoke with (family member) via phone today. (Family member) is very worried about patient (Family member) reported to SSW that patient was still vomiting-nursing notes reflect otherwise. (Family member) is wondering about GI consult. y. On 3/28/19 at 3:32 PM, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled [MEDICATION NAME] before meals. (Note: documented meal intakes from 3/14/19 to 3/29/19 averaged 2.27%) z. On 3/29/19, A NAR meeting was triggered due to resident's weight trend down 9% in 1 month. Resident was at 268 pounds. The trend down was identified to be related to refusal to eat d/t stomach pain, shingles etc. The intervention was to refer to doctor. aa. On 3/29/19 at 11:50 PM, a Physician's progress note documented, been unable to really eat very well with persistent nausea and occasional vomiting .Persistent nausea and vomiting, start [MEDICATION NAME] 5 mg daily before meals in addition to [MEDICATION NAME]. Gastrointestinal specialist for further investigation of her persistent nausea and vomiting and poor appetite. Poor appetite, start [MEDICATION NAME] 2 mg 4 times a day. (Note: The physician had also recommended a GI consult in a progress note dated 3/8/19.) bb. On 4/1/19 at 1:02 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled [MEDICATION NAME] and [MEDICATION NAME] before meals. Pt reports effective. Pt reports constipation, [MEDICATION NAME] given. cc. On 4/1/19 at 5:06 PM, a Physician's progress note documented, Persistent nausea and vomiting resolved. Continue [MEDICATION NAME] 5 mg daily before meals in addition to [MEDICATION NAME] as needed . Poor appetite, continue [MEDICATION NAME] 2 mg 4 times a day. dd. On 4/5/19 at 6:34 PM, a Nursing Note documented, pt weak and groggy today, difficulty staying awake. Decreased [MEDICAL CONDITION] to all extremities, decreased redness to BLE (bilateral lower extremities), pt worked with PT/OT (physical therapy and occupational therapy) today which she reports made her tired. Poor appetite only drinking sips of ensure . ee. On 4/8/19 at 12:57 PM, a Physician's progress note documented, She complains of nausea, vomiting and constipation with hemorrhoids Persistent nausea and vomiting, bruit on the [MEDICATION NAME], we'll see GI later this week . Poor appetite, start [MEDICATION NAME] 2 mg 4 times a day. ff. On 4/8/19 at 1:55 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Scheduled [MEDICATION NAME] and [MEDICATION NAME] before meals. gg. On 4/10/19 at 9:47 AM, a Physician's progress note documented, She reports significant improvement in her nausea since being started on the [MEDICATION NAME] . Persistent nausea and vomiting, much improved on [MEDICATION NAME], we will continue [MEDICATION NAME] 3 times a day . Poor appetite, start [MEDICATION NAME] 2 mg 4 times a day hh. On 4/12/19 at 2:04 PM, a Physician's progress note documented, She reports that since we started the [MEDICATION NAME] she has not had nausea or vomiting .Persistent nausea and vomiting, much improved on [MEDICATION NAME], we will continue [MEDICATION NAME] 3 times a day. Hold off on GI consult for now . Poor appetite, improving, we will increase [MEDICATION NAME] to 4 mg 4 times a day. ii. On 4/12/19 at 2:49 PM, a Nursing note documented, DC (discontinue) GI consult pt is responding well to [MEDICATION NAME] regime. jj. On 4/12/19 at 5:20 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. kk. On 4/14/19 at 3:18 PM, a Nursing note documented, Resting quietly after lunch. Denies any difficulty or adverse effects to increase in Cyproheptodine for appetite improvement. Stated 'I don't really feel that hungry or wanting food yet, but it's not making nauseated. (Note: documented meal intakes from 3/30/19 to 4/14/19 averaged 6.03%) ll. On 4/15/19 at 11:22 AM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. pt has GI consult apt (appointment) today. Will f/u (follow up) with any new orders or recommendations. mm. On 4/17/19 at 5:12 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. Tol. (tolerating) Cyproheptodine well. Appetite fair. nn. On 4/17/19, a Nutrition note documented, Wt (weight) note: CBW (current body weight): 245# (pounds), Wt loss -3.8% x 1 week. PO intake of Reg/NDD2 diet is 15%. Pt receives Ensure 4x/day intake is 25%. Pt says appetite is improving and so is the nausea and constipation. she has been eating bananas, jello, oatmeal and other fruit and says she tries to drink 2 Ensures/day. Pt had a GI scheduled but canceled it because she is feeling better. Meal intake has improved slightly. No new recs at this time. CTM. oo. On 4/18/19, a note from the Dietitian read as follows: Note wt (loss) cont (continues) and poor PO intake. Res getting [MEDICATION NAME] and [MEDICATION NAME] for appetite stimulants. Note res is trying to eat more and staff encouraging resident to eat. Will follow. pp. On 4/19/19 at 1:14 PM, a Physician's progress note documented, Persistent nausea and vomiting, much improved on [MEDICATION NAME], we will continue [MEDICATION NAME] 3 times a day Poor appetite, improving, continue [MEDICATION NAME] to 4m g 4 times a day. qq. On 4/19/19 at 5:00 PM, a Nursing note documented, Patient has constipation. Patient complains of nausea. Patient denies vomiting. rr. On 4/19/19 at 5:11 PM, a Nursing note documented, NAR NOTE: Pt lost 3.8% weight in 1 week. Pt intake has improved to 15% of meals. Pt's appetite has improved slightly. Pt reported nausea and constipation were gone and she is trying to eat more. No recs at this time. WCTM. (Note: documented meal intakes from 4/15/19 to 4/30/19 averaged 20%.) ss. On 5/1/19 at 12:47 PM, a Nursing note documented, Patient still plans to discharge to home with husband but does not feel strong enough yet. tt. On 5/7/19 at 2:10 PM, a Nursing note documented, BMP (basic metabolic panel) results: Sodium- 151 (high) . uu. On 5/8/19 at 4:18 PM, a Nursing note documented, Verbal orders received to encourage fluids every shift at least 2 liters. vv. On 5/10/19, Lab result: Sodium 151 High (Note: documented meal intakes from 4/25/19 to 5/10/19 averaged 21.4%) ww. On 5/13/19, Lab result: Sodium 154 High xx. On 5/16/19, Lab result: Sodium 156 High yy. On 5/16/19 at 3:47 PM, New Order Note: Sodium Chloride Solution 0.45 % Use 1 liter intravenously every shift for Critical high sodium of 156 Run a 75ml/hr (milliliter per hour). Start after bolus and run until 5/17/19. AND Use 1 liter intravenously one time only for critical high Sodium of 156 for 1 Day 1 liter bolus over 1 hour . zz. On 5/17/19, Lab result: Sodium 153 High aaa. On 5/19/19, Lab result: Sodium 153 High bbb. On 5/20/19 at 4:17 PM, a Nursing note documented, BMP results received with high blood sodium levels and .PA notified. New order received as follows: Sodium Chloride Solution 0.45 % Use 75 ml/hr intravenously every shift for Elevate blood sodium levels. Run continuously at 75ml/hr until Sodium level within normal range. Obtain BMP every day until sodium levels within normal range. ccc. On 5/21/19 at 3:21 PM, a Nursing note documented, New order per (physician's name withheld): Change IV fluid to 1/2 NS (normal saline) at 125 ml/hr x 2 L (liters). Recheck BMP in am. ddd. On 5/21/19 at 3:34 PM, a Nursing note documented, Lab results: Sodium- 153, Potassium- 3.3, Chloride- 112, Glucose- 62 . eee. On 5/22/19, a Nutrition note documented, Pt has been refusing to be weighed. PO intake of Reg/NDD2 diet is 4% and ensure 4x/day is unknown. Pt last month had significant weight loss. Met w/ patient. Pt seems to be having trouble talking because of a mouth issue. Pt also reported that the regular Ensure has been making her stomach upset and she has been throwing up. Pt reported she also wants fresh fruit, chicken broth and pudding to help her appetite. Rec: D/C Ensure 4x/d (4 times per day) and Add Ensure Clear BID (twice per day) . (Note: This assessment and recommendation was completed by a dietary technician.) fff. On 5/22/19, Lab result: Sodium 152 High ggg. On 5/23/19 at 2:04 AM, a Nursing note documented, Patient c/o (complains of) N/V (nausea and vomiting) this shift. PRN (as needed) [MEDICATION NAME] given with therapeutic results. IV 1/2 NS infusing at 125 ml (milliliters) currently, tolerating well. hhh. On 5/23/19, Lab result: Sodium 147 High iii. On 5/23/19 at 3:20 PM, a Nursing note documented, Resident reviewed in skin and weights meeting. Resident refusing ensure r/t (related to) nausea. Will replace with Ensure Clear BID. Resident refuses to get weighed and has been depressed r/t current condition. MD aware and monitoring. jjj. On 5/23/19 at 3:31 PM, a Nursing note documented, Addendum to skin and weights note. Resident has scheduled [MEDICATION NAME] r/t nausea and has requested broths and fresh fruits for her diet. kkk. On 5/23/19 at 7:07 PM, a Nursing note documented, New Order Note: Pt having increased nausea and vomiting. PA notified and new orders received to change [MEDICATION NAME] to [MEDICATION NAME] OTC (over the counter) and start [MEDICATION NAME] Solution ([MEDICATION NAME] HCl) Use 25 mg intravenously every 6 hours as needed for nausea Start Date: 5/23/2019. lll. On 5/24/19 at 2:55 AM, a Nursing note documented, Complained of nausea. [MEDICATION NAME] IV given as ordered. Medication effective. Pt continues on 0.45% normal saline IV at 75 ml/hr. Pt refused all pm medications except [MEDICATION NAME]. She stated she thought the other medications would cause more nausea or vomiting. Pt continues to have a poor po intake. Currently resting quietly in bed . mmm. On 5/24/19 at 12:18 PM, a Nursing note documented, .new order for Ensure Clear BID per dietary . nnn. On 5/24/19 at 6:38 PM, a Nursing note documented, Pt remains nauseous throughout shift. unable to take anything orally without gagging. Continue on IV fluids. ooo. On 5/25/19 at 2:43 AM, a Nursing note documented, Pt had nausea and vomiting. [MEDICATION NAME] IV given with good effect. Pt continues on 0.45% normal saline IV at 75 ml/hr. Pt refusing all oral medications except [MEDICATION NAME]. Pt continues to have a poor po intake. (Note: Documented meal intakes from 5/11/19 to 5/26/19 averaged 3.7%) ppp. On 5/26/19 at 2:16 AM, a Nursing note documented, Pt sent to ER (emergency room ) on 5/25/19 at 2110 (9:10 PM) for evaluation and treatment per (physician). Patient's husband notified. Report given to ER nurse qqq. On 5/26/19 at 2:27 AM, a Nursing note documented, Patient has been admitted to (a local) Hospital. Dx (diagnosis): GI Bleed. Pt is receiving a blood transfusion tonight. Pt to have a GI consult in the morning. rrr. On 5/26/19 at 2:45 AM, a Nursing note documented, Pt stated she thought she was having a Gall Bladder attack and wanted to go to the ER. Pt stated she was having right lower abdomen pain. Vital signs were within normal limits. Pt insisted she go to the ER. MD notified and an order was given to sent (sic) her to the ER. Pt sent to ER. Resident 32's hospital record was reviewed and revealed the following progress notes: a. On 5/25/19, This is a [AGE] year old female brought to the ER by ambulance from .(facility's name) because of vomiting. The patient tells me she's been vomiting intermittently for several weeks but seems to be getting worse. He (sic) can't hold any fluids down, she is bedridden and generally doesn't feel well. She doesn't feel well. She denies any fever, she has had some diarrhea, hasn't had a normal bowel movement some time. She complains of some mild right-sided abdominal pain. The pain is moderate in intensity .The patient had an episode of emesis which ended up being guaiac positive and does look like coffee grounds .patient is typed and crossed .will transfer 1 unit of packed red cells .(the resident) is given 80 mg pantoprazole and started on pantoprazole drip. Patient received a liter of fluid . b. Resident 32's weight at the hospital was documented to be 221 pounds or 100.9 kilograms. c. On 5/26/19, .(The resident) was hospitalized in (MONTH) and transition to (facility's name) for ongoing rehabilitation. Patient states that she has not done well over .there and continues to struggle from a functional standpoint. She's had significant abdominal discomfort, nausea, vomiting. She states it's been ongoing for several months. She was brought to the emergency department for evaluation tonight after she's had ongoing nausea, vomiting, poor oral intake and was noted to have coffee-ground emesis concerning for possible upper GI bleed. The patient is extremely weak. She's been lightheaded dizzy. Says she's not really eat (sic) for quite some time Moderate protein-calorie malnutrition .Patient states she has not been eating for quite some time. She has low protein and [MEDICATION NAME] consistent with moderate protein calorie malnutrition. Hopefully, once renal to evaluate her bleeding and hematologic abnormalities that we will be able to encourage oral intake and improve her malnutrition .my concern his (sic) overall decline over the last several months, she is also lost 20 (sic 200) pounds in the last year and now is no longer ambulatory, has difficulty with feeding and may feed (sic) a feeding tube upon discharge as she can't even tolerate water anymore. d. on 5/27/19, the patient underwent upper endoscopy yesterday .she was found to have erosions in her esophagus, a very tight GE ([MEDICAL CONDITION]) junction, and hemorrhagic gastritis. The patient has not even been able to tolerate water even for the last couple months, she's only hydrating herself with ensure. Family is agreeable to have a small bowel feeding tube in place now, given that she cannot keep up with adequate oral intake. She has lost upwards of 200 pounds in the last year, and a lot of this is likely related to what was found on upper endoscopy. e. On 5/28/19, patient was able to tolerate her small bowel feeding tube yesterday, we slowly titrated up on the tube feeds at 30 cc/h (cubic centimeter per hour) .we're also doing generous water flushes given that she tends to get hyponatremic and has been very dehydrated coming into the hospital. Please see results of the EGS ([MEDICAL CONDITION] gastroscopy) below, but in summary she has significant reasons for not being to tolerate by mouth intake for some time now . On 8/14/19 at 1:32 PM, an interview was conducted with resident 32. Resident 32 stated every time she ate, she would throw up. Resident 32 stated that she then got a bleeding ulcer and was put on a tube feeding. Resident 32 stated she was able to drink the Ensure off and on. Resident 32's husband was present at the time of the interview. He stated that resident 32 never consumed the whole carton of Ensure. Resident 32 affirmed she was never able to consume a whole Ensure. Resident 32 stated that throwing up frequently repressed her appetite. Resident 32 stated she had been throwing up since she first admitted to the facility in January. Resident 32 stated that she developed an aversion to most foods because she would throw them up. Resident 32 stated that even water made her nauseous. Resident 32 stated that the [MEDICATION NAME] worked pretty well for a while, then it didn't. Resident 32 stated that the appetite stimulant helped, but didn't do it again, because I'd eat, then throw it back up again. Resident 32 stated the consistent vomiting stumped everyone at the facility. Resident 32 stated she would fill up one after another of the emesis bags. Resident 32 stated that after the feeding tube was placed her weight loss ceased and and she did not feel hungry anymore. Resident 32 stated because of the weight loss, she had no energy, had a hard time waking up, and all of her hair broke off. Resident 32 stated she had long, thick hair and when you're not getting proper nutrition, hair won't do well. (Note: resident 32 had an identification picture attached to her electronic medical record. In that picture, resident 32 appeared to have significantly more hair than when observed in person). Resident 32 stated that from (MONTH) until May, she was very concerned about the weight loss because she could tell her under garments were getting loose and the reason for the vomiting was unknown. Resident 32's husband stated from (MONTH) until (MONTH) there was a noticeable decline in her physical strength and ability. Resident 32's husband stated when the resident was first admitted , she was able to walk a short distance. Resident 32's husband stated that by May, all she was able to do was sit in a chair and she could not make it the short walk to her bed. On 8/15/19 at 9:21 AM, an interview was conducted with the physical therapy assistant (PTA) and a certified occupational therapy assistant (COTA) who worked directly with resident 32. The COTA stated that resident 32 would improve and decline off and on. The COTA stated that resident 32 came here then started to decline. The COTA stated that resident 32 had vomiting issues and every time she sat up, she threw up. The PTA stated any time we made headway, she would have a complication .that would impede her progress. The COTA and PTA stated that resident 32 was not eating and that was contributing to her weakness. The COTA stated it got to the point resident 32 could not swallow anything. The COTA and PTA stated that every time resident 32 was sat up, she would get nauseous and vomit. The PTA stated it would take 2 to 3 people to stand resident 32 up. The COTA stated that resident 32 would refuse lunches all the time. The PTA stated resident 32 would have soda such as ginger ale and lemon lime soda to try to help with the nausea. On 8/15/19 at 9:55 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated she had worked at the facility for one year. The RD stated that the dietary technicians attended the NAR meeting and would bring recommendations to bring up at the NAR meetings. The RD stated that residents triggered for NAR would be those on weekly weights, had monthly weight changes, on a tube feeding, etc. The RD stated NAR was held once per week. The RD stated that the purpose of the NAR meeting was to make sure that the dietary staff was on the same page as the nursing staff. The RD stated that if a resident had malnutrition she would definitely be more aware if they were meeting their estimated needs. The RD stated that for any resident eating less than 50% of their estimated needs, a multivitamin was recommended. The RD stated that after a resident continued to loose weight after implementing interventions such as Ensure or Boost and an appetite stimulant then a tube feeding would be recommended. (Note: resident 32's physician's orders [REDACTED].) The RD provided copies from the best practices booklet she utilized. In regards to a resident with malnutrition, it stated the following, Significant weight variances are (greater than or equal to) 5% in 1 month, (greater than or equal to) 7.5% in 3 months, (greater than or equal to) 10% in 6 months or (greater than or equal to) 2-3% weekly Use full Special Nutrition Program (SNP) with 2 cal/ml (Calorie per milliliter) med pass per resident's needs .Be aggressive with interventions and change or add to when weight loss continues If weight loss still continues, recommend a 3-day calorie count . (Note: A 3 day calorie count was never initiated. Resident 32 was not placed on the SNP program. Interventions remained the same from 2/22/19 until 5/24/19. Resident 32 was discussed at the NAR meeting only 5 times from admit on 1/25/19 until discharge to the hospital 5/25/19.) On 8/15/19 at 10:58 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that for the NAR meeting, the dietary department had their own system to decide who would get discussed based on weight trends. On 8/15/19 at 11:46 AM, an interview was conducted with the Director(TRUNCATED)

Based on observation, interview, and record review it was determined, for 1 of 25 sampled residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident did not have weights obtained and tracked as ordered by the physician. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 35's medical record was reviewed on 8/13/19. A care plan dated 6/23/19, documented Fluid Volume Alteration (Dehydration) Excess AEB (as evidenced by): Diuretic use. Orders: [MEDICATION NAME]. The goal developed was, Pt (patient) will have adequate hydration as evidenced by health kin turgor and mucous membranes throughout. The interventions developed were, Labs as ordered, Patient education, and Weights. A physician's orders [REDACTED].* Notify physician if greater than 2 LBS (pounds) Gained in 24 Hours* Re-weigh patient if 5% or more of a change in weight. every day shift. A review of the June, July, and (MONTH) 2019 Treatment Administration Record (TAR) documented that resident 35's weight was not obtained on 6/22/19, 6/23/19, 6/24/19, 6/27/19, 7/10/19, 7/19/19, 8/2/19, 8/3/19, 8/8/19 and 8/9/19. A review of the Orders - Administration Notes documented the following entries: a. On 8/8/19, Daily Weights * Notify physician if greater than 2 LBS Gained in 24 Hours*Re-weigh patient if 5% or more of a change in weight. every day shift no time. b. On 8/9/19, Daily Weights * Notify physician if greater than 2 LBS Gained in 24 Hours*Re-weigh patient if 5% or more of a change in weight. every day shift Insufficient staff. A review of the (MONTH) and (MONTH) 2019 TAR documented that resident 35's weight was 192.4 on 7/20/19. On 7/21/19, resident 35's weight was 194.6. There was no documentation located in resident 35's medical record indicating that the physician was notified of the 2.2 pound weight gain. On 8/14/19 at 12:51 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the physician order [REDACTED]. LPN 1 stated that resident 35 has had a lot of heart failure issues. LPN 1 stated that she was not sure if the physician had been notified regarding resident 35's daily weight refusals. LPN 1 stated that resident 35 would get up early for therapy and once she was settled in bed for the day she did not want to get up and get weighed. On 8/14/19 at 2:17 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that the CNA staff or therapy would get the resident weights. CNA 3 stated that the residents on the North end of building were weighed on Tuesdays. CNA 3 stated that therapy would get the resident weights on Tuesday. CNA 3 stated that resident 35 would go to therapy early in the morning and when resident 35 was back in bed she would refuse to get weighed. CNA 3 stated that therapy was probably unaware that resident 35 was a daily weight. On 8/14/19 at 2:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the CNA and nursing staff were involved with obtaining the resident weights. The DON stated that physician notification would be documented in a progress note. The DON provided no additional documentation.