Every finding on record at The Pines at Rutland Center for Nursing & Rehabili

Based on observation, interview, and record review, the facility failed to notify a resident's representative of changes of condition for 1 of 28 residents in the sample (Resident #86). Findings include: Per observations made on 9/30/2025 at 12:50 PM, Resident #86 was seen self-propelling in their wheelchair attempting to leave the dining room. S/he was bare foot, and it was noted by the surveyors that s/he had a bruise on his/her right foot and toes. When asked what had happened to the Resident's foot, the Unit Manager (UM) stated that it happened when s/he was playing with her/his footboard and it fell off the bed and landed on her/his foot.During a phone interview with the Resident #86's Representative, on 9/30/25 at 9:24 AM, s/he said they had concerns with the number of falls that the Resident had been experiencing. S/he wondered what they are doing to prevent her/him from falling. S/he stated that s/he is concerned because they started her/him on a new medication to help her/him sleep at night. When asked what medication s/he was referring to s/he stated that s/he did not know but s/he worried that there was a reason for the falls that the Resident had been experiencing and the medicine would just make her/him sleep. The Resident's Representative stated that s/he had not known about the injury to the Resident's foot and toes prior to our call. Per interview with the UM on 10/1/2025 at 11:00 AM, the UM confirmed that the Resident's Representative had not been made aware of the injury to the Resident's right foot and toes. The UM stated that s/he had not realized that the Resident had a new injury to their right foot and was not sure of how long it had been there or how it happened.

Based on interview and record review, the facility failed to create a comprehensive care plan related to incontinence care for 1 of 28 residents in a standard survey sample (Resident #64). Findings include:Per record review, Resident #64 was admitted with diagnoses that include paraplegia [paralysis of lower extremities], cognitive communication deficit, and anoxic brain injury, (a brain injury caused by a complete lack of oxygen to the brain). Resident has a BIMS score of 15 (Brief Interview for Mental Status, cognitive assessment indicating resident is cognitively intact). Per interview with Resident #64 on 9/30/2025 at 10:24 AM, s/he stated they are always incontinent of bowels and do not have sensation or knowledge of incontinence. The Resident stated they are not checked for incontinence after AM care, which occurs between 8:00 AM-10:00 AM, until 6:00 PM when they are assisted with PM care and helped back to bed. Per record review, Resident #64's Minimum Data Assessment (MDS) dated [DATE] indicates the resident is always incontinent of bowel function. Per a MDS assessment on 8/12/2024 indicates Resident #64 is always incontinent of bowels. Per record review, Resident #64's care plan initiated on 10/24/2024, they are not care planned for bowel incontinence. Per record review of bowel movement documentation from 9/1/2025-10/1/2025, all of Resident #64's bowel movements are documented as incontinent. Per interview with Unit Manager RN (Registered Nurse) on 10/1/2025 at 12:52 PM, they stated that the resident has a foley catheter and believes Resident #64 uses the bed pan for bowel movements.Per interview with Unit Manager RN, and Director of Nursing (DON) on 10/1/2025 at approximately 3:30 PM, the DON confirmed that a resident with chronic incontinence should be care planned for incontinence and confirmed that Resident #64 does not have a care plan for bowel incontinence.

Based on interview and record review the facility failed to inform a resident representative in advance of the risks and benefits of the proposed care, the treatment alternatives, or other options for 1 of 5 sampled residents (Resident #86). Findings include:During an interview with the Resident's responsible party, on 9/30/202 at 9:24 AM, s/he said they had concerns with the number of falls that the Resident had been experiencing. S/he wonders what they are doing to prevent her/him from falling. S/he stated that s/he is concerned because they started her/him on a new medication to help her/him sleep at night. When asked what medication s/he was referring to s/he stated that s/he did not know but s/he worried that there was a reason for the falls that the Resident had been experiencing and the medicine would just make her/him sleep. Per record review a physician's order dated 8/28/2025 states Trazodone 25mg every 24 hours as needed for insomnia for 14 days at bedtime as needed for insomnia. Review of Resident #86's August and September Medication Administration Records (MARs) revealed that s/he received the Trazadone on 8/30, 8/31, 9/3, 9/5, 9/7, 9/9, and 9/11/25, seven times. There is no documented evidence that the Resident's record that facility obtained informed consent from Resident #86's responsible party for the as needed Trazadone. On 9/16/2025 a new physicians order for Trazadone one time daily was initiated. A progress note dated 9/17/2025, states that a message was left with the Resident's responsible party regarding starting new medication. A Psychoactive Medication Consent Form that was completed on 9/17/2025 states that verbal consent was received by the Resident's responsible party on 9/18/2025. This is 21 days after the initial as needed order was obtained.Per facility policy titled PRN [as needed] Psychotropic Medications Guidelines states, Obtain written consent for the administration of psychotropic medications in accordance with state and federal regulations. and The Healthcare Provider will document their discussion with the resident/responsible party regarding the risks and benefits of the use of the medication prescribed.Per facility policy titled Psychotropic Medications the policy statement states A consent from the resident and or responsible party will be obtained when the resident is started on a new psychoactive medication and as per state regulation. The resident and or representative will be notified when the dose of the psychoactive medication has been changed by the healthcare provider. Further review of Resident #86's record reveals a Physician's Note dated 9/16/2025 that states Patient is seen today at the request of her/his nurse for reports of insomnia. Patient had been on trazodone as needed at bedtime and this was quite helpful. Nursing asking if this can be scheduled .Patient appears stable. Nursing is requesting that patient has trazodone 25 mg scheduled for insomnia, this was on [her/his] medication administration record as needed and has follow-up. I have prescribed 25 mg trazadone nightly for insomnia. There was no documented evidence that the Physician discussed the risks, benefits, and treatment alternatives for the use of the trazodone. Per interview with the Unit Manager on 10/1/2025 at 11:00 AM she confirmed that there was no documentation regarding obtaining informed consent until 9/18/2025. Per interview with the facility Administrator, Director of Nursing, and Regional Quality Specialist on 10/1/2025 at 1:15 PM the Administrator confirmed that there was no evidence that the resident's representative had been provided informed consent prior to 9/18/2025.

Based on observation, record review, and interview, the facility failed to ensure quality of care for 1 of 28 residents in a standard survey sample (Resident #15).Findings include:Per record review, Resident #15 has a medical diagnosis of type 1 diabetes mellitus with diabetic retinopathy [an eye disease that affects the retina and can lead to vision loss and blindness]. Resident #15's physician order for blood sugar monitoring reads: Nurse to check finger stick PRN [as needed], every 8 hours as needed for Prophylaxis, Finger sticks for Blood Sugar before meals and at bedtime for diabetic management.Per record review, Resident #15's care plan states, Resident has impaired visual function, has diagnosis of retinopathy. Has difficulty with large print but is able to do own blood sugar readings when placing monitor close to eyes, Nursing will read glucometer after resident checks their own blood glucose with an approved glucometer. Per record review of resident's face sheet, Special Instructions: meds WHOLE with THIN liquids; resident may NOT use their own glucometer; they can poke their own finger but must use our machine and allow us to see the number.Per observation during medication pass on 9/30/2025 at 8:47 AM, Licensed Practical Nurse #1 (LPN) stopped at Resident #15's room and asked, What was your sugar this morning? Resident #15 stated their sugar was 122. The nurse did not visualize the reading displayed on the glucometer, or the glucometer used to obtain the reading. Per interview on 10/1/2025 at 9:20 AM, the Medication Nurse Aide (MNA) stated staff assess Resident # 15's blood glucose by the resident's verbalization of the reading. The MNA stated that Resident #15 checks their blood glucose independently and records their readings on a personal log kept at their bedside.Per interview with LPN #1 on 10/1/2025 at 9:45 AM, they confirmed the resident doesn't use the facility provided glucometer but uses their personal glucometer that is the same as the facility uses. The nurse stated that staff are expected to observe Resident #15 prick their own finger, and independently collect the specimen and nursing verifies the reading by observing the result on the glucometer. LPN #1 confirmed that on 9/30/2025 they did not observe glucometer and assessed the residents blood glucose based on the resident's verbal report. LPN #1 confirmed Resident #15 has visual deficits.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent potential injury for 1 of 28 residents in the sample (Resident #86). Findings include: Review of Resident # 86's care plan revealed a care plan focus initiated on 5/1/2025 of risk for falls with and without injuries r/t, Parkinsons with dementia, Polyosteoarthritis, epilepsy, anemia and mild cognitive impairment, dependence on staff for ADL's [activities of daily living]. use of medications associated with increased risk for falls, impulsivity, and often sits on the floor and incontinence. An intervention initiated on 8/22/2025 states keep [Resident] out of other residents rooms.Per observation on 9/30/2025 at 12:50 PM, Resident #86 was seen self-propelling in their wheelchair attempting to leave the dining room. S/he was bare foot, and it was noted by the surveyors that s/he had a bruise on her right foot and toes.During a phone interview with the Resident #86's responsible party, on 9/30/202 at 9:24 AM, s/he said they had concerns with the number of falls that the Resident had been experiencing. S/he wondered what they are doing to prevent her/him from falling.An incident report dated 8/22/2025 reveals that at 1:00 PM Resident #86 was found in another resident's room and was sitting on the floor next to the bed. Further review of Resident #86's incident reports revealed that over the past 5 months, since 5/8/2025, the Resident has had 20 falls in their room and 19 of those falls were unwitnessed. The Resident had 4 falls in the dining room [ROOM NUMBER] of them were unwitnessed, and 2 unwitnessed falls in the hallway.Per review of Resident #86's care plan, there are no interventions in place that address that Resident #86 wanders throughout the unit and the need for increased supervision due to safety concerns related to wandering. Although there are multiple fall interventions in place, the facility has not identified the need for increased supervision of the Resident to prevent falls and other injuries. Per interview with the Unit Manager on 10/1/2025 at 11:00 AM, she confirmed that Resident #86 does wander throughout the unit and has had numerous unwitnessed falls.

Based on observation, interview, and record review, the facility failed to conduct a trauma informed care assessment to establish possible triggers for re-traumatization for 1 of 2 residents in the sample (Resident #49). Findings include: During unit observations on 9/30/2025 at 10:02 AM Resident #49 was heard from the hall screaming and yelling out obscenities. S/He was found sitting in her/his wheelchair in her/his own bathroom alone. When asked if s/he was okay, s/he swore and said, no I am not ok. When asked if s/he needed help s/he said yes, now get the [expletive] out! The Resident continued screaming until a staff member was approached by a surveyor and was told that the Resident was alone in her/his bathroom screaming out. The staff member stated that this was not unusual behavior for the Resident. Per record review, Resident #49 has a diagnosis of post-traumatic stress disorder (PTSD). Review of the Resident's care plan revealed a care plan focus of mood problem r/t [related to] anxiety, PTSD, and [history] of passive [suicidal ideation] last revised on 7/18/2025. The care plan does not address possible triggers or any interventions to avoid or implement to manage anxiety, PTSD, or suicidal ideation. Upon further record review there was no documented evidence that the Resident was assessed for trauma or evaluated for possible triggers that may cause re-traumatization. Per interview on 10/1/2025 at 12:16 PM, the Social Worker said that the Resident had been living at the facility since 2019, before trauma became a focus. According to the Social worker they did not assess residents who were already in house at the time of the requirement to do so. The Social Worker confirmed that Resident #49 had not been assessed for trauma or triggers and that they did not know what sets her/him off. The Social Worker also confirmed that the care plan did not address the Resident's triggers.

Based on observation, and staff interview, the facility failed to ensure kitchen staff properly air-dried or hand dried pans prior to storage and failed to maintain a clean sanitary food service area. Findings include: During an observation on 11/25/24 at 2:05 PM, there was a baking sheet that was stacked on other baking sheets that was noted to be wet. The baking sheet was placed on the counter by this surveyor and the steam table pans were inspected. There was a wet small steam table pan that had been stacked on others. At this time the Director of Dietary was shown the small steam table pan and when this surveyor was attempting to show her/him the baking sheet it had been removed from the counter and placed back on top of the stacked sheets. The Director of Dietary confirmed that the baking sheet and the steam table pan that had been cleaned and stacked for use were still wet. The pans were found to have been stacked wet and not allowed to air dry prior to stacking. The Director of Dietary went into the dish room and returned stating, I just educated [dietary staff member] not to do that, they are not usually back there. The floor under one of the food prep table legs had two squares of missing tile creating exposed sub flooring with accumulated liquid and food particles. The leg of the table was noted to have a buildup of what appeared to be dirt and grease residue. The gas stove top was noted to have an excess amount of food and grease buildup on and under the burner grates. The Director of Dietary stated that they are taken apart weekly and cleaned. Per review of the kitchen cleaning schedule, staff sign off daily that they have cleaned the stove. This schedule had already been signed off for 11/25/24 however, there was a large amount of food and grease build up on and under the burner grates. The third floor steam table was noted to have pieces of orzo floating in the steam table water. The Director of Dietary and the Kitchen Supervisor confirmed that there was orzo in the steam table water. When asked when the residents were last served orzo the Director of Dietary stated last night. Per the Director of Dietary the steam table water is supposed to be drained and cleaned every night after diner service. The Director of Dietary stated that s/he would provide additional education to the staff member who had failed to do so. Per interview with the facility Administrator on 11/25/24 at 3:15 PM the facility had been making repairs in the kitchen and the above concerns would be addressed. During a walk through of the kitchen the facility Administrator confirmed the above kitchen observations.

Based upon interview and record review, the facility failed to provide adequate supervision to prevent accidents resulting in harm to one resident [Res.#59] of 6 sampled residents. Findings include: Per review of Res.#59's medical record, the resident was admitted to the facility with diagnoses that included generalized muscle weakness, cerebral infarction [stroke], seizures, and dementia. Review of Res.#59's Care Plan reveals the resident was identified as at risk for falls related to a history of falls, dementia, hemiplegia [one-sided paralysis], anxiety, depression, and medications associated with increased fall risk. Regarding toilet use, the Care Plan records Res.#59 requires extensive assistance and sit to stand by 2 staff for toileting. An interview was conducted with the Director of Nursing [DON] on 9/18/24 at 10:02 AM. The DON stated that Licensed Nursing Assistants [LNAs] receive training during orientation regarding following a resident's Kardex. [the 'Kardex' is a documentation system that enables direct care staff to easily reference key patient information that shapes the resident's care plan.] Review of Res.# 59's Kardex for July and August 2024 reveals Res.#59 requires extensive assistance and sit to stand by 2 staff for toileting and regarding transfers, requires extensive assistance and sit to stand by 2 staff to move between surfaces. Per review of Progress Notes for Res.#59, dated 8/7/24, At approx. 6:15 AM this writer was called to [Res.#59's] room by LNA for reports of [Res.#59] falling in the bathroom .[Res.#59] was observed to be uncomfortable and expressing complaints of pain in right leg. Progress notes record at 10:23 AM Resident began to yell out in pain. Upon assessment, resident is touching [h/her] lower back as well as [h/her] right leg . Providers updated and ordered resident to be sent to [NAME] Regional Medical Center for evaluation. Per review of Emergency Department notes from [NAME] Regional Medical Center dated 8/7/24, Res. #59 was inappropriately moved by LNA- patient is a mechanical lift only. Right leg 'popped out' (rotated externally) as patient was pivoting while standing. Patient has dementia history, reports 'very bad' pain. Grimacing .Apparently patient usually utilizes a sit to stand and is unable to transfer on [h/her] own. This morning patient was being attended by a new medical staff who tried to get [h/her] to stand up and make a transfer on [h/her] own. Res.#59 underwent a series of x-rays on 8/7/24 which showed the resident suffered a Tibial plateau fracture (A tibial plateau fracture is an injury where you break your bone and damage the cartilage on top of your tibia (bottom part of your knee)). [https://Orthopaedic Trauma Association ota.org/for-patients/find-info-body-part/3834#/+/0/score, date_na_dt/desc/]. Per review of the facility's investigation of the incident on 8/7/24, it was determined that [LNA #1] did not understand that [Res.#59] required a sit to stand lift for transfers when assisting [him/her] in the restroom .LNA states [s/he] was aware resident was a 1 assist for care and 'assumed' [s/he] was a 1 assist for transfers. Per interview with the Director of Nursing [DON] on 9/18/24 at 10:02 AM, the DON stated LNA#1 was not familiar with Res.#59 and the resident's care requirements. The DON confirmed the facility's investigation demonstrated that Res.#59's Kardex contained the instructions of extensive assistance and sit to stand by 2 staff for toileting and transfers. The DON confirmed that on 8/7/24, contrary to training and specific instructions, LNA #1 attempted toileting and transfer of Res.#59 without a Sit to Stand device and without the assistance of another staff member. The attempted transfer without the proper device and additional staff resulted in harm to Res.#59 in the form of a fractured tibial plateau. The facility completed corrective actions after identifying this deficient practice, prior to the survey entrance; therefore, this deficiency is considered past noncompliance. Per the facility investigation, the facility educated the LNA involved, educated all nursing staff regarding the use of the Kardex and its purpose, and completed several weeks of audits regarding proper implementation of resident Kardex's, which were reviewed and verified.

Based on observations, interview, and record review, the facility failed to assess a resident for the ability to self-administer medications and initiate a care plan related to self-administration of medications for 2 of 8 sampled residents (Residents #82 and #92). Findings include: 1. Per interview on 9/16/24 at approximately 11:30 AM, Resident #92 was observed to have two medications in her/his room, the first called Mannitol Supplement (the label indicates it is a supplement that is useful to prevent urinary tract infections) and and the second was an Albuterol Inhaler (used to treat difficulty breathing) on the windowsill. When s/he was asked what the medications were, s/he explained that family members bring in the Mannitol supplement as s/he has a history of urinary tract infections. S/he uses the Albuterol inhaler to prevent wheezing. S/he tells the nursing staff when s/he uses the inhaler and has not discussed the Mannitol so far. Resident #92 confirmed that s/he does not have a lock box to store his/her medications. Per interview on 9/18/2024 at approximately 8:06 AM with the ADON (Assistant Director of Nursing), s/he confirmed that Resident #92 uses an Albuterol inhaler independently but does not know of the Mannitol Supplement. S/he stated that residents who request to self-administer medications must be able to self-report the use of the medication, and they must have a medication self-administration assessment and a locked area to store the medication. S/he confirmed that Resident #92 did not have evidence of a self-administration assessment and that the self-administration of medications was not reflected on the Resident's care plan or in their medical record. Per interview on 9/17/2025 at approximately 2:20 PM, the Administrator confirmed that the facility does not have a policy for self-administration of medications. 40258 2. During an interview with Resident #82 on 9/16/24 at 12:06 PM there was one black pill in a medication cup on the over bed table. There were also two rust colored pills in a medication cup on the bedside table. When Resident #82 was asked what they were s/he pointed to the black pill and stated I was not taking my pills fast enough for the nurse this morning so s/he left this here for me to finish up. When asked what the two rust colored pills were s/he stated that they were Ibuprofen. The nurse leaves them here for me in case I need them. Per record review there was no documented evidence that Resident #82 had been assessed for the ability to self-administer medications. Review of Resident #82's care plan revealed no care plan for self-administration or medications left at bedside. There was also no physician order for self administration present in the record. Per interview with the Unit Manager on 9/16/2024 at approximately 3:30 PM, Resident #82 does not have a physicians order and has not been assessed or care planned for self-administration of medications. The Unit Manager confirmed that unless there is a self-administration assessment stating the Resident can self administer and medications can be left at bedside, the nurses should be staying with Resident #82 while s/he takes her/his medications and they should not be left at bedside.

Based on interview and record review, the facility failed to provide pharmaceutical services to meet each resident's needs for 1 of 32 sampled residents (Resident #11). Findings include: Per record review, Resident #11 has diagnoses that include quadriplegia (paralysis of all four limbs) and muscle spasms. On 7/16/24, Resident #11 was assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). On 9/18/24 at 10:47 AM, Resident #11 explained that for months, s/he misses 1-2 doses a month of his/her Finasteride and Dantrolene because the medications are not available from the pharmacy. S/He expressed that s/he is very frustrating because it has become a pattern, staff have not addressed the issue, and it continues to happen. Per record review, Resident #11 has a physician order for Dantrolene Sodium Oral Capsule 25 MG 1 capsule by mouth for muscle spasms, twice a day starting 11/30/23 and changing to three times a day starting on 8/22/24. Per review of Resident #11's Medication Administration Records (MAR) from 6/1/24 through 9/18/24, Resident #11 was not administered 7 prescribed doses of Dantrolene. One dose is left blank on the MAR for the following dates: 6/12/24, 8/8/24, 8/23/24, and 8/26/24. One does on 8/22/24 and two doses on 8/28/24 are marked 9 indicating a nursing note was written as to why it was not administered. Notes corresponding to these dates indicate that the Dantrolene medication was not available. Per record review, Resident #11 has a physician order for Finasteride Tablet 5 MG Give 0.5 tablet by mouth once a day for alopecia (hair loss) starting on 4/21/2018. Per review of Resident #11's MARs from 6/1/24 through 9/18/24, Resident #11 was not administered 6 prescribed doses of Finasteride. Doses on 6/12/24 and 8/7/24 are left blank on the MAR. Doses on 6/30/24, 7/1/24, 7/29/24, and 8/7/24 are marked as 9 and a dose on 9/17/24 is marked as 5, both indicating a nursing note was written as to why it was not administered. Notes corresponding to these dates indicate that the Finasteride medication was not available. Per interview on 8/18/24 at 1:46 PM, the Unit Manager explained that there have been issues with Resident #11 getting his/her Finasteride and Dantrolene regularly. S/He has contacted the pharmacy every month about this and it keeps happening. S/He explained that is happening with medications that are unable to be combined in a bubble pack and it is happening to other residents on the unit in addition to Resident #11. S/He explained that the leadership team is aware that there are issues with getting all resident medications from the pharmacy on time. Per interview on 8/18/24 at approximately 2:00 PM, the Administrator and Director of Nursing both confirmed that they were unaware that there have been issues with the pharmacy not delivering all ordered medications.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored for 1 of 8 of the applicable sample (Resident # 92). Findings include: Per interview on 9/16/24 at approximately 11:30 AM, Resident #92 was observed to have two medications in her/his room, the first called Mannitol Supplement (the label indicates it is a supplement that is useful to prevent urinary tract infections) and the second was an Albuterol Inhaler (used to treat difficulty breathing) on the windowsill . When s/he was asked what the medications were, s/he explained that family members bring in the Mannitol supplement as s/he has a history of urinary tract infections. S/he uses Albuterol to prevent wheezing. S/he tells the nursing staff when s/he uses the inhaler and has not discussed the Mannitol so far. Resident #92 confirmed that s/he does not have a locked box to store their medications. S/he leaves them on the windowsill of his/her bedside table. Per interview with the Administrator on 9/17/2024 at approximately 10:05 AM, s/he confirmed that Resident #92 should have a lock box in their room to secure self-administered medications in. S/he also confirmed that the facility had no policy regarding securing self-administered medications.

Per interview and record review, the facility failed to provide activities of daily living care (ADL) based on resident preference for 1 of 32 sampled residents (Resident #11). Findings include: Per record review, Resident #11's care plan reads, [Resident #11] has an ADL self-care performance deficit [related to] Quadriplegia [paralysis of all four limbs], with the following interventions, DRESSING: [extensive] assistance by 1 staff to dress, revised on 8/21/22, and TRANSFER: Mechanical sist to stand Lift with extensive assist of 2 staff for transfers, revised on 5/26/24. On 7/16/24, Resident #11 was assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Per interview on 9/17/24 at 9:50 AM, Resident #11 stated that s/he prefers to get up by 8:00 AM or before breakfast. S/He explained that this preference is not always honored, as aides do not start his/her morning care until 9:00 AM about 1-3 times a week, and on a few occasions 10 AM or later. S/He revealed that s/he is frustrated because this has been happening for months and is upset that it is becoming the norm. On 9/18/24 at 10:47 AM, Resident #11 explained that this preference is an intervention in his/her care plan and has been for a while. S/He had also explained that s/he had sent an email to the social service department alerting them that his/her care plan preference is not always honored. Per record review of Resident #11's care plan, there are no interventions regarding his/her preference to get out of bed prior to 8 AM. A review of historical care plans reveals the following intervention was added on 4/9/21 resident request to be up by 8 am. This intervention was no longer in his/her care plan starting 11/6/23. Per review of a 2/19/24 email, Resident #11 emailed the social service department of his/her concern that s/he is not regularly getting out of bed before 8:00 AM. Per interview on 8/18/24 at 10:50 AM, the Unit Manager stated that s/he was aware that Resident #11 had a preference to get out of bed in the morning before 8:00 AM. S/He explained that Resident #11's preferences should be included in their care plan and Kardex (a quick reference of care plan interventions) and confirmed that it was not.

Per interview and record review, the facility failed to file in the resident's clinical record signed and dated x-ray reports for 1 of 32 residents (Resident #24). The failure to ensure radiology results were filed in the resident's clinical record placed him/her at risk for unmet care needs. Findings included: Record review reveals that Resident #24 had a physician order for a chest x-ray dated 8/29/24, and a left hand x-ray dated 6/25/24. A review of Resident #24's medical record does not include a signed and dated copy of the x-ray reports or results of either x-ray. The record does not include any physician or nursing documentation that the above x-ray reports were received and reviewed by the physician. Per interview on 9/18/24 at 12:17 PM, the Unit Manager (UM) explained that s/he is not aware of how x-ray reports are entered into a resident's record. S/He explained that the providers, who work for the community health center, not for the facility, do not utilize the facility's electronic health record system to document. The UM explained that the community health center providers have access to x-ray results through a portal that s/he does not have access to. The UM confirmed that the x-ray reports were not in Resident #24's facility medical record. Per interview on 9/18/24 at 12:54 PM, the Administrator and Director of Nursing explained that some facility staff do have access to the portal where x-ray results are kept but it is the provider's responsibility to upload the reports and their notes saying the reports were reviewed into the facility's medical record. Per interview on 9/18/24 at 3:53 PM, a community health center Advanced Practice Registered Nurse (APRN) explained that s/he receives most x-ray reports through a portal and will review them once they come in. S/He stated s/he is unsure how they get into the facility's medical record. If an x-ray result is faxed directly to the facility, s/he reviews them and then gives them back to the facility initialed and dated to indicate that they have been reviewed. The APRN is not sure what they do with the x-ray reports after that.

Based on observations, interviews, and record reviews the facility failed to ensure services provided met professional standards of quality regarding resident medications administered as ordered for 3 of 35 sampled residents (Resident #266, #6, & #59) and regarding tube feeding and weight monitoring for 1 resident [Resident #59]. Findings include: Review of The National Library of Medicine Nursing Rights of Medication Administration (ncbi.[NAME].nih.gov) notes the nurse is frequently the final person to ensure medication is correctly prescribed and dispensed before administration. The standard professional medication administration practice is to follow the five rights of administration The five rights are the right patient (resident), the right medication, the right route, the right dose, and the right time. 1. Resident #266 was administered the wrong dose of medication one hundred times between April 22, 2023, and August 9, 2023. Resident #266 has among other diagnoses arthritis of the left knee. Record review revealed , the following medical order written on April 22, 2023 Lidoderm Patch 5% (Lidocaine) Apply to left knee topically in the morning for knee pain . Document Removal box. Indicate removal time below. On August 9, 2023 at approximately 2 PM the Director of Nursing (DON) advised the surveyor that the medication had been taken from house stock (medications that are kept on hand in large quantities and not ordered from the pharmacy monthly). However, the house stock that had been used since the order was written in April was 4% Lidocaine not the ordered 5% Lidocaine. Additionally, it was noted on the Medication Administration Record (MAR) that there was a box to sign off when the medication was provided but there was not a box to document removal of the medicated patch as had been ordered. On August 9, 2023, at approximately 2 PM the DON confirmed the medication had been provided in the wrong dose and the removal of the medicated patch had not been documented 100 times. 2. Per record review of Resident #6's care plan, Resident #6 requires care and treatment related to having a colostomy (a surgical opening in the colon where waste gets diverted from), gastroesophageal reflux disease, irritable bowel syndrome, heart disease, depression, potential nutritional deficiency, chronic pain, osteoarthritis, and urinary incontinence (uncontrolled leakage of urine). Review of Resident #6's medication administration record (MAR) reveals a physician order for cholestyramine Light Packet 4 GM [Gram] Give 1 packet by mouth three times a day for loose stools Mix in 8oz liquid, with meals please, don't give with medications, with a start date of 7/8/22 and scheduled to be administered at 8:00 AM, 12:00 PM, and 5:00 PM. The package insert for this medication states: SINCE CHOLESTYRAMINE MAY BIND OTHER DRUGS GIVEN CONCURRENTLY, IT IS RECOMMENDED THAT PATIENTS TAKE OTHER DRUGS AT LEAST ONE HOUR BEFORE OR 4 TO 6 HOURS AFTER CHOLESTYRAMINE (OR AT AS GREAT AN INTERVAL AS POSSIBLE) TO AVOID IMPEDING THEIR ABSORPTION. Per observation and interview on 8/8/23 at 12:33 PM, a Licensed Practical Nurse was bringing medications to Resident #6 and indicated that they were Imodium (loperamide A-D; anti-diarrheal medication), cholestyramine (bile acid eliminator), and eye drops. S/he stated that S/he was not aware that the order said not to administer cholestyramine with any other medications. Per interview on 8/9/23 at 11:15 AM, the Pharmacist stated that cholestyramine should be given an hour before or 4 hours after other medications because it will impede the absorption of other medications given within that time frame. Per review of Resident #6's Medication Administration Audit Report from 12:00 AM on 8/1/23 through 12:58 PM on 8/8/23, of the 23 times Resident #6 was administered cholestyramine, S/he received additional oral medications (that would be absorbed in the digestive system) all 23 times. Medications that were documented as administered within 3 minutes of administration of cholestyramine include Cymbalta (antidepressant), magnesium oxide (supplement), mirabegron (treats overactive bladder), multi vitamin, potassium chloride (supplement), raloxifene (treats osteoporosis), Eliquis (anti-coagulant), Lomotil (anti-diarrheal), senna (laxative), Tums (antacid), acetaminophen (pain reliever), Lyrica (nerve pain reliever), metoprolol (beta blocker; for irregular heartbeat), and loperamide A-D (anti-diarrheal). Per interview on 8/9/23 at approximately 2:30 PM, the Administrator confirmed that Resident #6's physician's orders for cholestyramine had not been followed. 3.) Per review of Res. #59's medical record, the resident is diagnosed as being in a Persistent Vegetative State, breathes through a Tracheostomy [small surgical opening that is made through the front of the neck allowing air to flow in and out of the windpipe], and is fed solely through a tube [G-tube] into h/her stomach. The resident's medical history and diagnoses include Dysphagia [difficulty in swallowing food or liquid], Quadriplegia [pattern of paralysis that can affect a person from the neck down], Anoxic Brain Damage [damage to the brain due to a lack of oxygen supply], and Severe Sepsis with Septic Shock [Septic shock is the last and most severe stage of sepsis. Sepsis occurs when your immune system has an extreme reaction to an infection]. Review of Physician Orders for Res.#59 reveal a medication order dated 5/17/23 for Bacillus Coagulans-Inulin: Give 1 tablet via G-Tube two times a day related to SEVERE SEPSIS WITH SEPTIC SHOCK -Start Date 5/17/23 8:00 PM. The medication was discontinued on 7/8/23. Review of Res.#59's Medication Administration Records [MARs] for May, June, & July 2023 document the medication was not given 51 times as ordered. Review of Nursing Notes for the 51 omissions include notations reading Unavailable, medication not in stock, On order from pharmacy, Awaiting for pharmacy to send, Medication not available, medication unavailable to administer, Medication not available in-house stock. 14 of the 51 omission notations record that the supervisor, unit manager or both were notified or made aware of the missed medication. Per review of the facility's Unavailable Medication Policy (issued 2/2015, revised 5/2023), the policy states Policy: If a medication is unavailable, for any reason, the facility shall act promptly to notify the Pharmacy and the appropriate practitioners to obtain a new medication supply/order. The policy's Procedure includes: Upon identification that medication is unavailable for administration as per physician order, the nurse is to notify the Nursing Supervisor/Designee immediately. If Medication is not available, notify the Physician/NP, inform the practitioner if there is a comparable medication available that can be given as an alternate. Call the Pharmacy and order the medication per physician's order. If the pharmacy does not have the medication or it cannot be delivered timely, the pharmacy is responsible for getting the medication delivered from a backup pharmacy. Document name of Pharmacist and Pharmacy response in progress note/nursing notes. The Unavailable Medication Policy's Documentation section includes the instructions; Document medication not given on EMAR [Electronic MAR]. Document in Progress notes Physician/NP notified, and their response and that medication was ordered with the Pharmacy. Document Physician/NP orders. An interview was conducted with the facility's Administrator [ADM], Director of Nursing [DON] and Assistant Director of Nursing [ADON] on 8/9/23 at 11:34 AM. The 3 staff members confirmed the steps, procedures, and documentation requirements of the facility's Unavailable Medication Policy. The staff members also confirmed that the facility's Pharmacy Service sends records documenting the delivery dates and times of ordered medications, along with the resident's name and specific medication ordered/delivered, and the Pharmacy Service Receipt records are kept and available on the resident units Nursing Station. Additional record review reveals a Consultant Pharmacist's Medication Regimen Review- for recommendations created between 6/5/23 and 6/6/23, includes routing for Nursing. Nursing Report/DON Report. The Pharmacist's recommendation records the order for Bacillus Coagulans-Inulin: Give 1 tablet via G-Tube two times a day related to SEVERE SEPSIS WITH SEPTIC SHOCK with the notation Please have a provider evaluate this drug indication/diagnosis/need to see if it can get a stop date/treatment duration. Please have a provider assess for alternatives if this drug is unavailable or back ordered and discontinue order if applicable per provider. Per record review and confirmed during the interview with the ADM, DON, and ADON on 8/9/23, there are no records that the resident's Physician was notified that the medication was not administered any of the 51 times the medication was documented as Unavailable, medication not in stock, On order from pharmacy, Awaiting for pharmacy to send, etc. There was no documentation that the Pharmacist's recommendation was followed and the Physician contacted to assess for alternatives if the drug was unavailable or other options. Further review and confirmed during interview reveal the Bacillus Coagulans-Inulin medication, ordered related to Severe Sepsis with Septic Shock, was never delivered to the facility, nor were there pharmacy records documenting that the medication was ordered and needed to be delivered. The ADM, DON, and ADON were unable to explain why the medication was documented by Nursing as administered 49 times by 11 different nurses when the medication was not in stock, not available, and never delivered by the pharmacy. The ADON reported that staff had recently undergone in-service training on medication administration policies and procedures. The ADON confirmed per record review that Res.#59's medication errors continued after the staff had received the medication training. Per review of Res. #59's medical record, the resident is diagnosed as being in a Persistent Vegetative State and is fed solely through a tube [G-tube] into h/her stomach. Review of Res.#59's Care Plan reveals the resident identified as being in a persistent vegetative state requiring nutrition/ hydration support. Review of Physician Orders for Res.#59 reveal an order dated 5/22/23 for one time a day Two Cal HN formula [tube feeding] to run at 55cc [cubic centimeters] per hour for 16 hours. Total volume of formula 880cc/24 hours. Start feeding at 6am Stop feeding at 10pm. Per observation on 8/7/23 at 11:37 AM, Res.#59 was in bed with the tube feeding formula attached to an electronic pump and to the resident. The pump displayed the current infusion rate of the tube feeding as 37cc/hr. An interview was conducted with Res.#59's primary Nurse on 8/7/23 at 11:43 AM. The Nurse stated that the ordered rate for the tube feeding was 37cc/hr. and confirmed that the resident was currently receiving the tube feeding at that rate. The nurse was asked to review and confirm the Physician's tube feeding order. The nurse confirmed that the order for the tube feeding rate was 55cc/hr., not 37cc/hr., and that the tube feeding was infusing at the incorrect rate since 6:00 AM. The Nurse also stated s/he had been the resident's primary nurse for several days and had been infusing the tube feeding at the incorrect rate while he was assigned to the resident. Further review of Physician Orders for Res.#59 reveals an order for Weekly weight- every day shift every Mon- Start Date- 5/22/23. Review of Res.#59's medical record beginning 5/22/23 reveals 8 times out of 11 dates between the start date of 5/22/23 and 7/31/23 with no recorded weight. Review of recorded weights for Res.#59 between 5/10/23 [124.2 lbs.] and 8/3/23 [116 lbs.] record a weight loss of 6.6 %. A Nutritional Assessment was conducted on 5/22/23 which noted There is evidence of weight loss, with a recommendation for An increase in Tube Feeding rate to 55 cc/hr. x 16 hr. Review of Res.#59's medical record includes a note labeled Weight Warning dated 7/10/23, which notes a -3.0% change from last weight and that the increase in Tube Feeding rate of Two Cal HN @ 55cc per hour continues. An interview was conducted with the facility's Administrator [ADM], Director of Nursing [DON] and Assistant Director of Nursing [ADON] on 8/9/23 at 11:34 AM. The 3 staff members confirmed Res.#59's Care Plan identified the resident as being in a persistent vegetative state requiring nutrition/ hydration support with Care Plan interventions that included Tube feeding and flushes as ordered. Weights and labs to be reviewed as needed, and Give medications as ordered. The 3 staff members confirmed Res.#59 did not receive the tube feedings as ordered, weights were not reviewed or completed as ordered, and medications were not administered as ordered or per Res.#59's Care Plan. Reference: [NAME] A, [NAME] LM. Nursing Rights of Medication Administration. 2022 Sep 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. PMID: 32809489.

Based on interview and record review, the facility pharmacist failed to identify and report medication scheduling errors for 1 of 5 sampled residents (Resident #6) resulting in the potential for decreased therapeutic effects of other medications. Findings include: Per record review of Resident #6's care plan, Resident #6 requires care and treatment related to having a colostomy (a surgical opening in the colon where waste gets diverted from), gastroesophageal reflux disease, irritable bowel syndrome, heart disease, depression, potential nutritional deficiency, chronic pain, osteoarthritis, and urinary incontinence. Review of Resident #6's physician orders reveal the following order cholestyramine Light Packet 4 GM Give 1 packet by mouth three times a day for loose stools Mix in 8oz liquid, with meals please, don't give with medications, with a start date of 7/8/22 and scheduled to be administered at 8:00 AM, 12:00 PM, and 5:00 PM. The package insert for this medication states: SINCE CHOLESTYRAMINE MAY BIND OTHER DRUGS GIVEN CONCURRENTLY, IT IS RECOMMENDED THAT PATIENTS TAKE OTHER DRUGS AT LEAST ONE HOUR BEFORE OR 4 TO 6 HOURS AFTER CHOLESTYRAMINE (OR AT AS GREAT AN INTERVAL AS POSSIBLE) TO AVOID IMPEDING THEIR ABSORPTION. Per Resdeint #6's physician orders, the following oral medications (that would be absorbed in the digestive system and have the potential for impeded absorption) are scheduled to be administered concurrently or within four hours after the above order: multivitamin, Eliquis (anti-coagulant), senna (laxative), and tums (antacid), are scheduled to be administrated with cholestyramine; and Cymbalta (antidepressant), magnesium oxide (supplement), mirabegron (treats overactive bladder), potassium chloride (supplement), raloxifene (treats osteoporosis), Lomotil (anti-diarrheal), acetaminophen (pain reliever), Lyrica (nerve pain reliever), metoprolol (beta blocker; for irregular heartbeat), loperamide A-D (anti-diarrheal), and gabapentin (nerve pain reliever) are scheduled to be administrated within 3 hours after a scheduled dose of cholestyramine. Review of the past 12 months of Consultant Pharmacist's Medication Regimen Review recommendations does not reveal that the pharmacist identified the administration timing irregularity for Resident #6's order for cholestyramine. Per interview on 8/9/23 at 11:15 AM, the Pharmacist stated that cholestyramine should be given an hour before or 4 hours after other medications because it will impede the absorption of other medications given within that time frame. Per interview on 08/09/23 at 4:27 PM, the Director of Nursing confirmed that the Pharmacist did not make any recommendations to change the time administration times for Resident #6's order for cholestyramine in the past 12 months.

Based on staff interview and record review the facility failed to ensure that the attending physician reviewed and addressed recommendations made by the licensed consulting pharmacist for 2 of 5 residents in the applicable sample(Residents #266 & #59), and failed to ensure that a medication was available for administration per physicians orders for 2 of 5 residents in the applicable sample (Residents #26 & #59). Findings include: 1.) Per record review Consultant Pharmacist's Medication Regimen Review recommendations for Resident #266 dated 4/27/23, 5/5/23, and 6/6/23 were not acted upon until 8/5/23. Provider orders for Resident #266 (who has among other diagnosis arthritis of the left knee) contained the following order Lidoderm Patch 5% (Lidocaine) Apply to left knee topically in the morning for knee pain indicate Facility Time code and Check off Document Removal box. Indicate removal time below start date 4/22/23. A review of the Medication Administration Record shows the medication was initiated on 4/22/23 and applied daily (with the exception of several days when the resident was hospitalized ) there is no documentation in the MAR to indicate the patch was removed after 12 hours. Per review of the Consultant Pharmacist's Medication Regimen Review for Resident #266 dated 4/27/23, 5/5/23, and 6/6/23 the following recommendations had been made and were not acted upon until 8/5/23. Lidocaine Patches may remain in place for up to 12 hours in any 24-hour period to prevent adverse Cardiac Events. Please speak to the Provider and have them order this medication On for 12 hours and Off for 12 hours or remove per schedule as recommended by the manufacturer. There is no evidence in the medical record that the physician reviewed, acted on, or documented the rationale to continue with the medication orders as written. Per an interview with the Director of Nursing (DON) on 8/9/23 at approximately 3 PM S/he confirmed that the pharmacy recommendations had not been addressed per the regulatory requirements. 2.) Per review of Res. #59's medical record, the resident is diagnosed as being in a Persistent Vegetative State, breathes through a Tracheostomy [small surgical opening that is made through the front of the neck allowing air to flow in and out of the windpipe], and is fed solely through a tube [G-tube] into h/her stomach. The resident's medical history and diagnoses include Dysphagia [difficulty in swallowing food or liquid], Quadriplegia [pattern of paralysis that can affect a person from the neck down], Anoxic Brain Damage [damage to the brain due to a lack of oxygen supply], and Severe Sepsis with Septic Shock [Septic shock is the last and most severe stage of sepsis. Sepsis occurs when your immune system has an extreme reaction to an infection]. Review of Physician Orders for Res.#59 reveal a medication order dated 5/17/23 for Bacillus Coagulans-Inulin: Give 1 tablet via G-Tube two times a day related to SEVERE SEPSIS WITH SEPTIC SHOCK -Start Date 5/17/23 8:00 PM. The medication was discontinued on 7/8/23. Review of Res.#59's Medication Administration Records [MARs] for May, June, & July 2023 document the medication was not given 51 times as ordered. Review of Nursing Notes for the 51 omissions include notations reading Unavailable, medication not in stock, On order from pharmacy, Awaiting for pharmacy to send, Medication not available, medication unavailable to administer, Medication not available in-house stock. 14 of the 51 omission notations record that the supervisor, unit manager or both were notified or made aware of the missed medication. Per review of the facility's Unavailable Medication Policy (issued 2/2015, revised 5/2023), the policy states Policy: If a medication is unavailable, for any reason, the facility shall act promptly to notify the Pharmacy and the appropriate practitioners to obtain a new medication supply/order. The policy's Procedure includes: Upon identification that medication is unavailable for administration as per physician order, the nurse is to notify the Nursing Supervisor/Designee immediately. If Medication is not available, notify the Physician/NP, inform the practitioner if there is a comparable medication available that can be given as an alternate. Call the Pharmacy and order the medication per physician's order. If the pharmacy does not have the medication or it cannot be delivered timely, the pharmacy is responsible for getting the medication delivered from a backup pharmacy. Document name of Pharmacist and Pharmacy response in progress note/nursing notes. The Unavailable Medication Policy's Documentation section includes the instructions; Document medication not given on EMAR [Electronic MAR]. Document in Progress notes Physician/NP notified, and their response and that medication was ordered with the Pharmacy. Document Physician/NP orders. An interview was conducted with the facility's Administrator [ADM], Director of Nursing [DON] and Assistant Director of Nursing [ADON] on 8/9/23 at 11:34 AM. The 3 staff members confirmed the steps, procedures, and documentation requirements of the facility's Unavailable Medication Policy. The staff members also confirmed that the facility's Pharmacy Service sends records documenting the delivery dates and times of ordered medications, along with the resident's name and specific medication ordered/delivered, and the Pharmacy Service Receipt records are kept and available on the resident units Nursing Station. Per record review and confirmed during the interview with the ADM, DON, and ADON on 8/9/23, there are no records that the resident's Physician was notified that the medication was not administered any of the 51 times the medication was documented as Unavailable, medication not in stock, On order from pharmacy, Awaiting for pharmacy to send, etc. Additional record review reveals a Consultant Pharmacist's Medication Regimen Review- for recommendations created between 6/5/23 and 6/6/23, includes routing for Nursing. Nursing Report/DON Report. The Pharmacist's recommendation records the order for Bacillus Coagulans-Inulin: Give 1 tablet via G-Tube two times a day related to SEVERE SEPSIS WITH SEPTIC SHOCK with the notation Please have a provider evaluate this drug indication/diagnosis/need to see if it can get a stop date/treatment duration. Please have a provider assess for alternatives if this drug is unavailable or back ordered and discontinue order if applicable per provider. Per record review and confirmed during interview, there was no documentation that the Pharmacist's recommendation was followed and the Physician contacted to assess for alternatives if the drug was unavailable or other options. Further review and confirmed during interview reveal the Bacillus Coagulans-Inulin medication, ordered related to Severe Sepsis with Septic Shock, was never delivered to the facility, nor were there pharmacy records documenting that the medication was ordered and needed to be delivered. The ADM, DON, and ADON were unable to explain why the medication was documented by Nursing as administered 49 times by 11 different nurses when the medication was not in stock, not available, and never delivered by the pharmacy. 40258 Per record review Resident #26 was transferred from the facility to the hospital on 5/30/23 where S/he was diagnosed with sepsis (a life-threatening complication of an infection). On 6/2/23 Resident #26 returned to the facility with an order for Augmentin Oral Suspension Reconstituted 250-62.5MG/5ML (milligram/milliliter) Give 11 ml by mouth two times a day related to sepsis, pneumonia for 3 days. Review of nursing progress notes written between 6/2 - 6/5/23 and the resident's June medication record, the Augmentin had not been received from the pharmacy and was not administered until 6/5/2023. A progress note written on 6/5/23 at 9:00 AM reflects that the provider (physician) was notified that the Augmentin wasn't received from the pharmacy. There is no evidence in the record that the physician had been notified that the Augmentin was not being administered per order prior to 6/5/23. Resident #26 missed six doses of Augmentin between 6/2 - 6/5/23 before the provider was notified and the medication was obtained from the pharmacy. Per interview with a Licensed Practical Nurse (LPN) on 8/9/23 at 11:28 AM, medications typically do not arrive from the pharmacy until late, around 10:00 PM. If a medication does not arrive, the nurse will contact the pharmacy to alert them and determine why it did not arrive. The pharmacy often states that the medication will be on the next delivery, but if it is not, it is too late to do anything about it until the next day. Sometimes the facility will obtain the medication from a local pharmacy if they are unable to get it from their contracted pharmacy. The LPN confirmed that the physician should have been notified when the medication was unavailable and had not been notified until 6/5/23. During interview on 8/9/23 at approximately 2:30 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the ADON confirmed that Resident #26 had not received the Augmentin upon return from the hospital per physician's order, and that the physician had not been notified and a new order obtained until 6/5/2023.

Based on interview and record review, the facility failed to implement care plan interventions regarding tube feeding and medications for 1 resident [Res. #59] of 35 sampled residents. Findings include: Per review of Res. #59's medical record, the resident is diagnosed as being in a Persistent Vegetative State and is fed solely through a tube [G-tube] into h/her stomach. The resident's medical history and diagnoses include Dysphagia [difficulty in swallowing food or liquid], Quadriplegia [pattern of paralysis that can affect a person from the neck down], Anoxic Brain Damage [damage to the brain due to a lack of oxygen supply], and Severe Sepsis with Septic Shock [Septic shock is the last and most severe stage of sepsis. Sepsis occurs when your immune system has an extreme reaction to an infection]. Review of Res. #59's Care Plan reveals the resident identified as being in a persistent vegetative state requiring nutrition/ hydration support. Care Plan interventions include Tube feeding and flushes as ordered. Weights and labs to be reviewed as needed. Review of Physician Orders for Res.#59 reveal an order dated 5/22/23 for one time a day Two Cal HN formula [tube feeding] to run at 55cc [cubic centimeters] per hour for 16 hours. Total volume of formula 880cc/24 hours. Start feeding at 6am Stop feeding at 10pm. Per observation on 8/7/23 at 11:37 AM, Res.#59 was in bed with the tube feeding formula attached to an electronic pump and to the resident. The pump displayed the current infusion rate of the tube feeding as 37cc/hr. An interview was conducted with Res.#59's primary Nurse on 8/7/23 at 11:43 AM. The Nurse stated that the ordered rate for the tube feeding was 37cc/hr. and confirmed that the resident was currently receiving the tube feeding at that rate. The nurse was asked to review and confirm the Physician's tube feeding order. The nurse confirmed that the order for the tube feeding rate was 55cc/hr., not 37cc/hr., and that the tube feeding was infusing at the incorrect rate since 6:00 AM. The Nurse also stated S/he had been the resident's primary nurse for several days and had been infusing the tube feeding at the incorrect rate while he was assigned to the resident. Further review of Physician Orders for Res.#59 reveals an order for Weekly weight- every day shift every Mon- Start Date- 5/22/23. Review of Res.#59's medical record reveals 8 times out of 11 dates between the start date of 5/22/23 and 7/31/23 with no recorded weight. Review of recorded weights for Res.#59 between 5/10/23 [124.2 lbs.] and 8/3/23 [116 lbs.] record a weight loss of 6.6 %. Review of Res.#59's medical record includes a note labeled Weight Warning dated 7/10/23, which notes a -3.0% change from last weight and that the increase in Tube Feeding rate of Two Cal HN @ 55cc per hour continues. Further review of Res.#59's Care Plan reveals multiple times Give medications as ordered listed as an intervention to be implemented regarding Res. #59's care and treatment. Review of Physician Orders for Res.#59 reveal a medication order dated 5/17/23 for Bacillus Coagulans-Inulin: Give 1 tablet via G-Tube two times a day related to SEVERE SEPSIS WITH SEPTIC SHOCK -Start Date 5/17/23 8:00 PM. Review of Res.#59's Medication Administration Records [MARs] for May, June, & July 2023 document the medication was not given 51 times as ordered and per plan of care. An interview was conducted with the facility's Administrator [ADM], Director of Nursing [DON] and Assistant Director of Nursing [ADON] on 8/9/23 at 11:34 AM. The 3 staff members confirmed Res.#59's Care Plan identified the resident as being in a persistent vegetative state requiring nutrition/ hydration support with Care Plan interventions that included Tube feeding and flushes as ordered. Weights and labs to be reviewed as needed, and Give medications as ordered. The 3 staff members confirmed Res.#59 did not receive the tube feedings as ordered, weights were not reviewed or completed as ordered, and medications were not administered as ordered per Res.#59's Care Plan.

Based on interview and record review, the facility failed to revise a comprehensive care plan to include interventions that addresses the resident's goal to maintain his or her highest practicable well-being regarding walking for 1 of 35 residents (Resident #80). Findings include: Per interview on 8/7/23 at 10:38 AM, Resident #80 revealed that it has been a few weeks since S/he has been walked by staff, which S/he needs help with because S/he had a stroke. S/He stated that S/he really wants to get back to it because S/he wants to be more independent. Review of Resident #80's care plan reveals, [Resident #80] has limited physical mobility stroke, initiated on 10/8/19 and last revised on 8/25/22, and interventions include Ambulation: [Resident #80] has a FMP [functional maintenance program] on hold, last revised on 8/25/22, and [Resident #6] is able to ambulate with therapy FMP on hold], last revised on 8/25/22. Per interview and record review on 8/8/23 at 2:20 PM, the Therapy Director stated that Resident #80 is on a walking program. S/He revealed an in-service record, dated 6/13/23, in which staff are trained on the specifics for walking Resident #80 and describes the task as staff to ambulate [with] patient [at] railing in hallway, [NAME] strap [walking assistance strap] on LLE [lower left extremity], wheelchair follow 28 x 2 [feet] to maintain mobility, 2-5 times a week. Record review of Resident #8's nursing staff tasks reveal the following task, NURSING REHAB: Staff to ambulate with patient with rails in hallway, ([NAME] strap left lower extremity mobility aid) and mod assist up to 30 feet or as tolerated, to maintain mobility, last revised 12/23/22, and does not include the use of a wheelchair or a weekly frequency. Review of task documentation from 7/11/23 through 8/9/23 shows that Resident #80 ambulated 4 times with staff. Per interview on 8/8/23 at 4:01 PM, a Licensed Nurse Aide revealed that S/he had documented this task as completed but explained that Resident #80 had only taken a few steps in his/her room, not in the hall. Per interview on 8/09/23 at 4:01 PM, the Assistant Director of Nursing confirmed that there is no evidence in Resident #80's record that S/he refused to walk and that there are no interventions in his care plan that match the walking program instructions made by physical therapy.

Based upon observations, interview, and record review, the facility failed to ensure tube feedings were administered as ordered and weight status was monitored as ordered for 1 resident [Res. #59] of 35 sampled residents. Findings include: Per review of Res. #59's medical record, the resident is diagnosed as being in a Persistent Vegetative State and is fed solely through a tube [G-tube] into h/her stomach. The resident's medical history and diagnoses include Dysphagia [difficulty in swallowing food or liquid], Quadriplegia [pattern of paralysis that can affect a person from the neck down], and Anoxic Brain Damage [damage to the brain due to a lack of oxygen supply]. Review of Res.#59's Care Plan reveals the resident identified as being in a persistent vegetative state requiring nutrition/ hydration support. Review of Physician Orders for Res.#59 reveal an order dated 5/22/23 for one time a day Two Cal HN formula [tube feeding] to run at 55cc [cubic centimeters] per hour for 16 hours. Total volume of formula 880cc/24 hours. Start feeding at 6am Stop feeding at 10pm. Per observation on 8/7/23 at 11:37 AM, Res.#59 was in bed with the tube feeding formula attached to an electronic pump and to the resident. The pump displayed the current infusion rate of the tube feeding as 37cc/hr. An interview was conducted with Res.#59's primary Nurse on 8/7/23 at 11:43 AM. The Nurse stated that the ordered rate for the tube feeding was 37cc/hr. and confirmed that the resident was currently receiving the tube feeding at that rate. The nurse was asked to review and confirm the Physician's tube feeding order. The nurse confirmed that the order for the tube feeding rate was 55cc/hr., not 37cc/hr., and that the tube feeding was infusing at the incorrect rate since 6:00 AM. The Nurse also stated S/he had been the resident's primary nurse for several days and had been infusing the tube feeding at the incorrect rate while he was assigned to the resident. Further review of Physician Orders for Res.#59 reveals an order for Weekly weight- every day shift every Mon- Start Date- 5/22/23. Review of Res.#59's medical record beginning 5/22/23 reveals 8 times out of 11 dates between the start date of 5/22/23 and 7/31/23 with no recorded weight. Review of recorded weights for Res.#59 between 5/10/23 [124.2 lbs.] and 8/3/23 [116 lbs.] record a weight loss of 6.6 %. A Nutritional Assessment was conducted on 5/22/23 which noted There is evidence of weight loss, with a recommendation for An increase in Tube Feeding rate to 55 cc/hr. x 16 hr. Review of Res.#59's medical record includes a note labeled Weight Warning dated 7/10/23, which notes a -3.0% change from last weight and that the increase in Tube Feeding rate of Two Cal HN @ 55cc per hour continues. An interview was conducted with the facility's Administrator [ADM], Director of Nursing [DON] and Assistant Director of Nursing [ADON] on 8/9/23 at 11:34 AM. The 3 staff members confirmed Res.#59's Care Plan identified the resident as being in a persistent vegetative state requiring nutrition/ hydration support. The 3 staff members confirmed Res.#59 did not receive the tube feedings as ordered and weights were not reviewed or completed as ordered, with the resident identified as suffering a negative change in weight.

Based on interview and record review the facility failed to ensure that resident medical records reflected accurate medication administration for 1 of 34 residents in the sample (Resident #31). Findings include: Review of a medical record for resident #31 reveals a physician medication order listed on the Medication Administration Record (MAR) for the months of July and August as indicated: Administer suppository if no BM [bowel movement] in 3 days, every shift for bowel management. The name, dose, and administration method of the suppository is not listed. It is noted that this resident had received a suppository frequently on all shifts as indicated by a check mark above nurse's initials. The bottom page of the MAR shows a Chart Code indicating that a check mark means administered. Review of Licensed Nurse Assistant (LNA) documentation under the tasks tab shows bowel movements (BM) on 7/12, 18, 23, 26, 27, and 31st. The August documentation shows a BM on 8/6. The record indicates that suppositories were given to the resident after these dates on all 3 shifts. Interview on 08/09/23 at 2:30 PM with resident #31 stated I only have suppositories once in a while and if I do, I get it on the day shift because there's only one girl, I trust to clean me up. I have not had very many suppositories. Interview on 08/09/23 at 2:35 PM with the Unit Manager and a Licensed Practical Nurse (LPN) confirmed that the documentation appears as if the resident is constantly receiving a suppository per the check marks as indicated by the coding chart at the bottom of the MAR, but they do not believe resident #31 is actually getting them.

Based on staff interviews and record review the facility failed to provide adequate supervision or assistance devices to prevent accidents for one applicable resident (Resident #2). Findings include: Per record review Resident #2 has multiple [DIAGNOSES REDACTED]. Per review of Resident #2's activities of daily living care plan, s/he was non-ambulatory and required one assist with personal hygiene, dressing, and bathing. Per review of the nurse's notes dated [DATE], the nurse heard a sound, went to Resident #2's room and found the resident lying on his/her back between the beds on the floor. The Licensed Nursing Assistant (LNA) had been performing a bed bath at this time. Resident #2 was assessed and had a large hematoma (blood filled bump) and abrasion on his/her head. Resident #2 was sent to the Emergency Department via ambulance for an evaluation. Per physician progress notes [REDACTED].#2 was on comfort measures, had a fall during a bed bath at the nursing home, and had a consequent head injury. Per review of the facility incident report from [DATE], Resident #2 had expired on the evening of [DATE]. Per interview with a Licensed Nursing Assistant (LNA) on [DATE] at 10:00 AM, s/he stated that on [DATE] at approximately 4:00 PM, s/he walked into Resident #2's room to perform afternoon care. S/he gathered all supplies needed for care and set them on the bedside table. S/he had finished performing care on all of Resident #2's body except for his/her bottom area. S/he washed Resident #2's front and then positioned Resident #2 to cleanse his/her back. The LNA positioned Resident #2 on his/her right side with his/her left leg over the right leg. S/he stated that s/he turned his/her head away from Resident #2 for approximately 3 seconds to get some ointment; and as s/he turned his/her head back; Resident #2 had rolled off the bed and hit the floor. The LNA stated s/he was on the left side of the bed; the bed was at waist level, Resident #2 did not use side rails, and that Resident #2 was positioned in the middle of the bed, closer to the edge of the right side of the bed away from the LNA. Per interview with a Licensed Practical Nurse on [DATE] at 2:05 PM, s/he stated that s/he was passing medications and was just in Resident #2's room and had seen the LNA performing care for Resident #2. S/he stated that s/he had left the room and seconds later s/he had heard a loud thud. S/he went into the room and found Resident #2 lying on the floor on his/her back in a pool of blood. S/he stated that the bed was in a high position and that the resident did not have side rails.

Based on observation, interview and record review the facility failed to provide goods and services necessary to avoid physical harm for 1 applicable resident. (Resident #1). Findings include: Per staff interview and record review, Resident #1's ventilator was left in standby mode by a Respiratory Therapist (RT). Resident #1 was ventilator dependent. Per record review, the RT was performing [MEDICAL CONDITION] hygiene (suctioning for secretions) for resident at approximately 4:00 PM on 11/11/15. The process takes approximately 12-15 minutes. After the RT finished with the resident he/she proceeded to exit the room to see other residents. The RT responded to a ventilator alarm in Resident #1's room at approximately 4:45 PM and found the resident without signs of life. Per record review, the on call Registered Nurse (RN) Supervisor was called to the floor to assess the resident. The resident's color was sallow, apical pulse sounds were absent and a Do Not Resuscitate order was verified. The resident was pronounced dead by the RN Supervisor and another floor RN at the time of 4:45 PM. The physician and family were notified. Per interview on 11/24/15 at 10:37 AM with the Manager of Respiratory Therapy he/she confirmed that placing a ventilator in standby mode would cause it to cease breathing for the resident. Per observation on 11/24/15 at 10:37 AM the Drager ventilator machine has an alarm pause button located at the top right hand corner of the machine and the reset button is located directly underneath this button. The Manager of Respiratory therapy demonstrated how the ventilator machine is put into Standby mode and how one would manually need to reset the machine so the alarm would not go off. He/she demonstrated that the operator would need to push the start button on the machine to take the machine off of Standby mode. The ventilator was pulled from use on 11/11/15 and representatives from the Rutland Regional Medical Center (RRMC) Biomed department and the ventilator company, Drager, were deployed to inspect the machine on 11/12/15. The Logbook Screen confirmed that the ventilator was in Standby mode on 11/11/15 from 16:17:22 to 16:47:09 (4:17 PM to 4:47 PM). Per interview on 11/24/15 at 11:39 AM with the Manager of Respiratory Therapy and RRMC Risk Management Registered Nurse he/she confirmed that the RT manually put the ventilator machine into Standby prior performing [MEDICAL CONDITION] hygiene to suction/lavage the resident for secretions. He/she confirmed that the RT stated that he/she could not recall whether or not he/she took the machine off of Standby mode to restart the mechanical ventilation for the resident. The RT confirmed during a telephone call on 11/24/15 that h/she placed the ventilator in standby mode and could not recall if h/she restarted the ventilator as required. The above is to be considered past non-compliance due to the following: 1. The RT was placed on administrative leave and subsequently was terminated. The ventilator involved in the incident was removed from service and evaluated for proper function. 2. All RTs have received education/training on the proper procedure for [MEDICAL CONDITION] hygiene prior to caring for any respiratory or ventilated residents. 3. The policy and procedure for [MEDICAL CONDITION] hygiene has been revised so ventilators will no longer be placed in standby mode during the procedure. 4. Monthly audits are to be conducted for each RT for 3 months.

Based on observation, interview and record review the facility failed to ensure that one applicable resident ( Resident #1) received proper treatment and care for standard respiratory care. Findings include: Per staff interview and record review, Resident #1's ventilator was left in standby mode by a Respiratory Therapist (RT). Resident #1 was ventilator dependent. Per record review, the RT was performing [MEDICAL CONDITION] hygiene (suctioning for secretions) for resident at approximately 4:00 PM on 11/11/15. The process takes approximately 12-15 minutes. After the RT finished with the resident he/she proceeded to exit the room to see other residents. The RT responded to a ventilator alarm in Resident #1's room at approximately 4:45 PM and found the resident without signs of life. Per record review, the on call Registered Nurse (RN) Supervisor was called to the floor to assess the resident. The resident's color was sallow, apical pulse sounds were absent and a Do Not Resuscitate order was verified. The resident was pronounced dead by the RN Supervisor and another floor RN at the time of 4:45 PM. The physician and family were notified. Per interview on 11/24/15 at 10:37 AM with the Manager of Respiratory Therapy he/she confirmed that placing a ventilator in standby mode would cause it to cease breathing for the resident. Per observation on 11/24/15 at 10:37 AM the Drager ventilator machine has an alarm pause button located at the top right hand corner of the machine and the reset button is located directly underneath this button. The Manager of Respiratory therapy demonstrated how the ventilator machine is put into Standby mode and how one would manually need to reset the machine so the alarm would not go off. He/she demonstrated that the operator would need to push the start button on the machine to take the machine off of Standby mode. The ventilator was pulled from use on 11/11/15 and representatives from the Rutland Regional Medical Center (RRMC) Biomed department and the ventilator company, Drager, were deployed to inspect the machine on 11/12/15. The Logbook Screen confirmed that the ventilator was in Standby mode on 11/11/15 from 16:17:22 to 16:47:09 (4:17 PM to 4:47 PM). Per interview on 11/24/15 at 11:39 AM with the Manager of Respiratory Therapy and RRMC Risk Management Registered Nurse he/she confirmed that the RT manually put the ventilator machine into Standby prior performing [MEDICAL CONDITION] hygiene to suction/lavage the resident for secretions. He/she confirmed that the RT stated that he/she could not recall whether or not he/she took the machine off of Standby mode to restart the mechanical ventilation for the resident. The RT confirmed during a telephone call on 11/24/15 that h/she placed the ventilator in standby mode and could not recall if h/she restarted the ventilator as required. The above is to be considered past non-compliance due to the following: 1. The RT was placed on administrative leave and subsequently was terminated. The ventilator involved in the incident was removed from service and evaluated for proper function. 2. All RTs have received education/training on the proper procedure for [MEDICAL CONDITION] hygiene prior to caring for any respiratory or ventilated residents. 3. The policy and procedure for [MEDICAL CONDITION] hygiene has been revised so ventilators will no longer be placed in standby mode during the procedure. 4. Monthly audits are to be conducted for each RT for 3 months.