Every finding on record at The Terrace Transitional

Based on interview and record review, it was determined there was a delay in care for a resident complaining of leg numbness and weakness for 1 of 4 sampled residents. Resident identifier: 1. Findings Include: Resident 1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of wedge compression fracture of the thoracic (t) vertebra of t7-t8 , multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia. On 6/26/2024 at 12:38 PM, a provider documented a cranial nerve exam and neurological exam was conducted on resident 1 due to complaints of being unable to move or feel their legs for the last day. The provider documented no abnormalities were noted. Resident 1 had been able to feel and move their lower extremities at the time of the exam. On 6/29/2024 at 4:48 AM and 11:54 AM, licensed practical nurses documented resident 1 had complained of lower extremity paralysis. There was no provider documentation or communication located to indicate the provider had been made aware of resident 1's change of condition. On 6/30/2024, a registered nurse documented resident 1 had been seen by the provider and sent to the emergency room due to hypoxia, nausea, and new onset paralysis to lower extremities. At 1:30 PM, the provider documented resident 1 had been sent to the emergency room due to a new diagnosis of peripheral neuropathy and no movement to their lower extremities post vertebral compression fracture. It should be noted resident 1 had a 5 day hospital admission with diagnoses including but not limited to Cauda equina compression, epidural abscess, and osteomyelitius of the thoracic vertebra. On 10/7/2024 at 2:19 PM, an interview was conducted with the Administrator (ADM). The ADM stated they were recently made aware that resident 1 had made claims of a fall at the facility and staff had not been taking care of them. The ADM stated there was no documented incident of a fall and there had been no report of a fall. On 10/7/2024 at 2:42 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated the last encounter they had with resident 1 was when resident 1 voiced they were unable to move or feel their legs and the NP observed a lack of movement in resident 1's lower extremities. The NP stated they sent resident 1 to the hospital but they were unsure if resident 1 was faking or exaggerating their symptoms. The NP stated they remembered they rounded on resident 1 on a Sunday and immediately sent them out that day due to their symptoms and their past medical history. The NP stated resident 1's lumbar back all of a sudden got worse and they were unable to move their legs and with their history, they knew this was going to happen eventually. On 10/8/2024 at 9:48 AM, a follow up interview was conducted with the ADM. The ADM stated they were unable to provided further documentation to show the provider had been notified of resident 1's condition on 6/29/2024.

Based on observation, interview, and record review, it was determined that the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors made multiple observations of the lunch and meal services being served and delivered later than the posted meal times, there were multiple resident complaints about food being served late and cold, and there were multiple recent resident council notes documenting resident complaints about food being served cold and late. Resident Identifiers: 12 and 28. Findings Include: The following meal times were provided upon entrance: Breakfast 7:30 AM Residents to dining hall by 7:15 AM Food comes out by 7:30 AM Hall 100 trays served at 8:00 AM Hall 200 trays served at 8:30 AM Hall 100 trays back to kitchen by 9:00 AM Hall 200 trays back to kitchen by 9:30 AM Lunch 11:30 AM Residents to dining hall by 11:15 AM Food comes out by 11:30 AM Hall 100 trays served at 12:00 PM Hall 200 trays served at 12:30 PM Hall 100 trays back to kitchen by 1:00 PM Hall 200 trays back to kitchen by 1:30 PM Dinner 5:30 PM Residents to dining hall by 5:15 PM Food comes out by 5:30 PM Hall 100 trays served at 6:00 PM Hall 200 trays served at 6:30 PM Hall 100 trays back to kitchen by 7:00 PM Hall 200 trays back to kitchen by 7:30 PM. The following meal times were posted outside of the facility dining room: Breakfast: Hall 100 served by 7:50 AM Hall 200 served by 8:10 AM Lunch food came out in the dining room by 11:30 AM Hall 100 trays served at 11:50 PM Hall 200 trays served at 12:10 PM [It should be noted the posted meal times were different from the ones provided upon entrance.] On 8/25/24 at 1:53 PM, an interview was conducted with Resident 12. Resident 12 stated that sometimes the food was not served hot. On 8/25/24 at 10:21 AM, an interview was conducted with Resident 28. Resident 28 stated that the food served was not always served hot. On 8/25/24, an observation was made of the lunch time meal service in the dining room and hallways. The first resident was served in the dining room at 11:55 AM. The first resident in the 100 hall was served at 12:21 PM. The first resident was served in the 200 A hallway at 12:39 PM and 200 B hall was 12:58 PM. On 8/28/24, an observation was made of the lunch meal. The 100 hallway cart was observed to leave the kitchen at 8:10 AM. The 200 hallway meal cart was delivered at 8:23 AM. On 8/28/24, the last cart was delivered to the 200 hallway at 12:44 PM. According to the posted meal times at the facility, the latest any meals should be delivered is to the 200 hall at 12:30 PM. Meals were served to the dining room starting at 11:54 AM. According to the posted meal times at the facility, meals should have started being served at 11:30 AM. According to the posted meal times at the facility, trays for the 100 hall should have been delivered starting at 12:00 PM. Residents in this hall did not start to receive their meals until 12:15 PM. A review of the facility's resident council notes for March 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for April 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for May 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for July 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for August 2024 revealed complaints from residents that one roommate in a double bed room will receive their meal while the other roommate does not. On 8/29/24 at 9:21 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that kitchen staff always delivered meals out of the kitchen on time and that if meals were late, it was likely that nursing staff that were behind on passing trays. [It should be noted observations were made of the meals leaving the kitchen after the posted meal times]. On 9/29/24 at 10:27 AM, an interview was conducted with the facility administrator (ADM). The ADM stated that he expected meals to be sent out to residents on time within a 5-10 minute window of the posted meal times. 50200

Based on interview, observation and record review it was determined, for 12 of 36 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, there were observations of resident's call lights alarming up to 30 minutes before assistance was provided, residents complained of long call light wait time and resident council minutes revealed resident concerns with staffing. Resident identifiers: 10, 12, 14, 20, 29, 34, 38, 56, 58, 70, 133 and 383. Findings include: 1. Observations of Call lights: a. On 8/25/24 at 8:26 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8:54 AM. b. On 8/25/24 at 8:27 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8:57 AM. c. On 8/25/24 at 11:04 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by the Administrator at 11:36 AM. d. On 8/25/24 at 8:27 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8/25/24 at 8:35 AM. e. On 8/25/24 at 11:06 AM, an observation was made of resident 56's call light alarming. Resident 56's call light was answered at 11:21 AM. 2. Resident interviews: a. On 8/25/24 at 11:26 AM, an interview was conducted with resident 56. Resident 56 stated she did not feel like there was enough staff. Resident 56 stated at night time it took a long time for her call light to be answered. Resident 56 stated her call light was on for about 20 minutes before the surveyor entered the residents room. Resident 56 stated that morning before breakfast she waited an hour and a half for her call light to be answered. Resident 56 stated she needed a liner in her brief changed because it was wet. Resident 56 stated staff were unable to change her before breakfast. Resident 56 stated she had to eat breakfast with a wet liner in her brief. Resident 56 stated half of the time, staff told her that she needed to wait till after the meal trays were picked up to be changed. Resident 56 stated some staff were doing a really good job and others were not good. Resident 56 stated she reported staffing concerns to a nurse manager who was no longer employed at the facility. b. On 8/25/24 at 10:04 AM, an interview was conducted with resident 70. Resident 70 stated that he did not like using the call light because staff did not respond all the time or it took over 30 minutes for staff to come and help him. c. On 8/25/24 at 11:20 AM, an interview was conducted with resident 58. Resident 58 stated he felt like there was a long wait for the call lights to be answered. d. On 8/25/24 at 11:24 AM, an interview was conducted with resident 38. Resident 38 stated staff did not get to her roommate as quickly as they should. Resident 38 stated her roommate called for a nurse last night and it took staff a long time to respond. e. On 8/25/24 at 11:38 AM, an interview was conducted with resident 14. Resident 14 stated sometimes she felt there needed to be more staff. Resident 14 stated sometimes it took a while depending on the situations that were going on with other residents. Resident 14 stated she needed assistance getting out of bed first thing in the morning and pushed her call light. Resident 14 stated staff tried to get there as quickly as they could but she had an incontinent episode a could weeks ago. Resident 14 stated she wanted to make sure she was getting the same attention as other residents. f. On 8/25/24 at 11:55 AM, an interview was conducted with resident 383. Resident 383 stated the facility needed more Certified Nursing Assistants (CNA) because they were overworked and unable to answer call lights in a timely manor. Resident 383 stated a staff member could only do what they could do. g. On 8/25/24 at 11:57 AM, an interview was conducted with resident 133. Resident 133 stated staff were over worked. Resident 133 stated on Friday he turned on the call light, then had to get the phone in his room and call the front desk for assistance. Resident 133 stated he needed to use the urinal and was unable to get up by himself. Resident 133 stated he was going to have a shower and get his face shaved on 8/24/24 but he did not get the shower or his face shaved because there were not enough staff. h. On 8/25/24 12:21 PM, an interview was conducted with resident 20. Resident 20 stated her call light was on for a long time and staff did not come answer the call light. Resident 20 stated staff were on their phones a lot. i. On 8/25/24 at 12:58 PM, an interview was conducted with resident 34. Resident 34 stated there was not enough staff. Resident 34 stated the weekends seemed to be the worse and for the most part the CNA's were doing the work of two people. Resident 34 stated one time he had to wait over four hours to get changed. j. On 8/25/24 at 1:50 PM, an interview was conducted with resident 12. Resident 12 stated that the call lights were never answered and he had to wait a long time before staff would come in. Resident 12 stated that it was worse on the weekends. k. On 8/25/24 at 2:06 PM, an interview was conducted with resident 10. Resident 10 stated that the night staff did not answer call lights. l. On 8/25/24 at 2:30 PM, an interview was conducted with resident 29. Resident 29 stated on the weekends there were longer response times to call lights. Resident 29 stated sometimes he had to wait up to an hour for the call light to be answered. 3. Staff Interviews: a. On 8/27/24 at 3:11 PM, an interview was conducted with CNA 6. CNA 6 stated staffing was usually pretty good. CNA 6 stated if staff were looking at what they needed to do during shift and planned their day, then staff were able to get everything done. CNA 6 stated answering call lights were hard during meal times. CNA 6 stated residents call lights alarmed at the same time and it was hard to answer all the call lights. b. On 8/28/24 at 10:42 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she had been asked to pick up an open shift at the facility weekly do to staff shortages. RN 1 stated that she knew that residents had complained about long call light wait times. RN 1 stated she tried to help out with answering the call lights, but she had her own job to complete. RN 1 stated she did not believe there was enough staff to work the halls. c. On 8/28/24 at 10:52 AM, an interview was conducted with RN 2. RN 2 stated that she did not feel like she was able to complete all of her duties in the facility due to staffing shortages. RN 2 stated she had been asked to stay late, come in early, or work overtime the last few months. d. On 8/28/24 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she had been asked to come in early, stay late after her shift, and to pick up overtime. LPN 1 stated that weekend staffing was poor as management was not in the building to help answer call lights and assist residents. LPN 1 stated residents complain about the long call light wait times. e. On 8/29/24 at 9:35 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident's were frustrated because there were a lot of call lights on at one time. NA 1 stated residents will think they have been waiting a long time when it had only been a couple of minutes. NA 1 stated weekend staffing was different. NA 1 stated management was not in the facility on the weekends, so staff were not as on top of things as they needed to be. NA 1 stated it was harder to work on the weekends. NA 1 stated sometimes it was hard to get all the residents changed because there were back to back call lights and no one else was able to help. NA 1 stated she was left in the dining room by herself over the weekend because another CNA needed to use the bathroom. f. On 8/29/24 at 9:47 AM, an interview was conducted with CNA 7. CNA 7 stated staffing was good and the nurses were helpful to CNA's. CNA 7 stated there might be a day that the floor was short a CNA but there was a nurse on call that called another CNA into work. CNA 7 stated the the nurse on call had helped fill in at times. CNA 7 stated there were some residents that complained of long call light times. CNA 7 stated usually during meals when staff were passing meal trays in the hallway and staff answered call lights when they were done passing meal trays. 47431 4. Resident Council Minutes: a. A review of the facility's resident council notes for March 2024 revealed complaints that nurses were good, but residents felt they were overwhelmed. Medication delivery was rushed. b. A review of the facility's resident council notes for April 2024 revealed complaints about call lights during night shift were struggling again. Complaints of new CNAs, residents saying they did not seem to understand what to do and ongoing complaints of evening shift. c. A review of the facility's resident council notes for May 2024 revealed complaints that call lights were sometimes good and sometimes not good on night shift. They have seen an improvement on evening shifts call light responds. d. A review of the facility's resident council notes for July 2024 revealed night shifts call lights were getting better but sometimes still long. There was still room for improvement, issues with CNAs and night shift but were getting better. On 8/28/24 at 11:16 AM, an interview was conducted with the Administrator (ADM). The ADM that the facility was always hiring new staff, even when it was not needed. The ADM stated that the nursing staff numbers remained the same on the weekdays and the weekends, but the difference is that the leadership staff were not in the building to help with the overflow of resident requests. The ADM stated that the facility did utilize agency nursing staff for approximately 3 to 4 shifts a week. The ADM stated that he was aware that some residents have complained about the long call light wait times. 47432 50200

Based on observation, interview, and record review it was determined, for 10 of 36 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of the food, there were multiple resident council complaints about the flavor of the food, and a test tray was bland to the taste with overcooked foods. Resident identifiers: 10, 12, 14, 20, 28, 34, 38, 56, 59, and 68. Findings Include: On 8/25/24 at 12:51 PM, an interview was conducted with resident 10. Resident 10 stated that the food served at the facility was not good. Resident 10 stated that the food served gave her diarrhea. Resident 10 stated that the eggs and oatmeal served were not good and caused her to have constipation. At 2:02 PM, an additional interview was conducted with Resident 10. Resident 10 stated that the food served was so bad that she had called her son to bring her food from fast food for lunch. On 8/25/24 at 1:53 PM, an interview was conducted with resident 12. Resident 12 stated that the food served at the facility did not taste good. Resident 12 stated that sometimes the food was served hot. On 8/25/24 at 11:35 AM, an interview was conducted with resident 14. Resident 14 stated that the food served at the facility was bland. On 8/25/24 at 12:16 PM, an interview was conducted with resident 20. Resident 20 stated that the food served at the facility was not good and causes her to have diarrhea. On 8/25/24 at 10:21 AM, an interview was conducted with resident 28. Resident 28 stated that the food served at the facility did not always taste good and that the food served was not always served hot. On 8/25/24 at 12:06 PM, an interview was conducted with resident 34. Resident 34 stated that the kitchen staff had a tendency to be lazy and served the same foods frequently. On 8/25/24 at 11:24 AM, an interview was conducted with resident 38. Resident 38 stated that the food served was not good. Resident 38 stated that the food served was too spicy. On 8/25/24 at 11:24 AM, an interview was conducted with resident 56. Resident 56 stated that the food served at the facility was bland to the taste. On 8/25/24 at 12:25 PM, an interview was conducted with resident 59. Resident 59 stated that he did not like the food served at the facility. Resident 59 stated that he had friends bring food into the facility for him and his wife. On 8/25/24 at 2:51 PM, an interview was conducted with resident 68. Resident 68 stated that the food served at the facility was terrible. Resident 68 stated that anything served that required preparation tended to not be good. On 8/28/24 at 8:21 AM until 8:50 AM, an observation was made of the 200 hallway. Trays were observed to be served to residents. Plates were observed without the heating pellet system. The pellet heating system was used to keep meals warm while they were delivered to residents. On 8/28/24, a test tray was obtained from the kitchen. The last try plated was at 12:44 PM. According to the menu posted at the facility, the entree should have been breaded chicken. The entree received was not breaded and had a slight purple color when cut into. The meat was try and chewy. The carrots were overcooked and mushy. A review of the facility's resident council notes for the month of March 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of April 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of May 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of July 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of August 2024 revealed complaints about the salads served at the facility. The resident council notes had complaints of items being out of stock in the kitchen. On 8/29/24 at 9:21 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the facility used a pellet system to keep meal trays warm for residents who ate in their rooms. The DM stated that the pellet system should always be used to keep meals warm. On 8/29/24 at 10:27 AM, an interview was conducted with the facility administrator (ADM). The ADM stated that meals should be served within a 5-10 minute window. The ADM stated that the pellet system was recently purchased to help keep meals warm prior to being served to address resident and resident council complaints of cold food. The ADM stated that the only reason the pellet system would not be used was if the kitchen ran out of pellets before they finished serving meals or if residents did not return their trays timely prior to the next meal service. The ADM stated that the facility purchased 110 pellets for a facility census of 80. The ADM stated that his expectation for kitchen staff was that the food starts improving and gets better. The ADM stated that he had seen food quality improve with new kitchen staff.

Based on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 3 of 36 sampled residents, a resident did not have a Valproic acid level, thyroid-stimulating hormone (TSH), complete blood count (CBC), and a comprehensive metabolic panel (CMP) completed as ordered by the physician. Another resident did not have a TSH redrawn six weeks after the June levels were drawn. In addition, another resident did not have a urinalysis (UA) with culture and sensitivity (C&S) obtained that was orded by the physician. Resident identifiers: 22, 34, and 58. Findings included: 1. Resident 58 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, disorder of urea cycle metabolism, disorientation, unspecified psychosis not due to a substance or known physiological condition, and personal history of urinary tract infections. Review of records was completed on 8/25/24 through 8/29/24. An admission Minimum Data Set assessment dated [DATE], revealed that resident 58 had a Brief Interview of Mental Status score of 9 which indicated moderately impaired cognition. A review of physician's orders revealed an order started on 8/7/24, for a UA C&S one time only related to disorientation, unspecified until 8/7/24 at 11:59 PM, to obtain urine was marked completed on 8/7/24. On 8/7/24 at 2:14 PM, a Nursing Progress Notes revealed the following. Nurse went in the resident's room for morning medication pass and the resident was lying on the side of his bed. His emergency contact was notified, and the provider was notified. Resident had a new order for a UA due to some confusion. On 8/8/24 at 5:56 PM, a Fall Committee Interdisciplinary Team progress note revealed the following, Resident was currently resting in bed. Resident denied pain or discomfort related to fall. His emergency contact was notified, and the provider was notified. Resident has a new order for a UA C&S due to some confusion. The UA C&S results were unable to be located. On 8/27/24 at 3:30 PM, an interview with Director of Nursing (DON) 2 was conducted. DON 2 stated she was unable to locate the lab results for the UA C&S or any progress notes from 8/7/24. 30563 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominate side, intracranial injury without loss of consciousness, muscle weakness, hypothyroidism, hypertension, pressure hydrocephalus, epilepsy, schizophrenia, and major depressive disorder. Resident 22's medical record was reviewed on 8/25/24 through 8/28/24. On 10/23/23, resident 22's TSH level was 0.079 which was low. It was written on the laboratory results Reduce Levothyroxine to 125 mcg [micrograms] recheck in 6 weeks. Signed with a date of 10/26/23. A physician's order dated 10/26/23, revealed TSH one time a day for lab. On 12/7/23, there was a laboratory results that revealed Test not performed. Insufficient specimen to perform or complete. A physician's order dated 2/4/24, revealed CBC and CMP urgently for lethargy. On 2/5/24, there was a laboratory results form that revealed Test not performed. The required specimen for the test ordered was not received . Comp. [comprehensive] Metabolic Panel . The CBC revealed Test not performed. Whole blood specimen partially or completely clotted. A common cause is insufficient mixing upon collection. A physician's order dated 3/29/24, revealed TSH 4/1/24 one time only for 2 days only signs off if obtained. A physician's order dated 4/3/24, revealed T3 [Triiodothyronine] and T4 [Thyroxine] one time only for lab for 1 day. A physician's order dated 7/12/24, revealed Valproic Acid one time only related to epilepsy. On 7/15/24, there was a laboratory results form that revealed A lavender top tube was received with no test indicated. On 7/22/24 at 2:30 PM, Valproic Acid 105 microgram per milliliter which was high. There was a signature dated 7/26/24, and revealed to recheck in two weeks. A physician's order dated 7/24/24, revealed Valproic Acid one time only related to epilepsy. A physician's order dated 7/27/24, revealed Valproic Acid one time only related to epilepsy. On 7/28/24, Valproic Acid was . not performed. No serum received. A physician's order dated 8/9/24, revealed Valproic Acid one time only related to epilepsy. A nursing progress note dated 8/9/24 at 7:31 AM, revealed Date for Valproic acid draw changed to 8/12 as phlebotomist will be here that day, provider notified and is ok with having lab drawn on Monday On 8/15/24, Valproic Acid was not performed. Gel barrier tube was unsuitable for test orders. On 8/22/24, Valproic acid was not performed. No serum received. On 8/27/24 at approximately 2:00 PM, an interview was conducted with DON 1. DON 1 stated from 7/28/24, the wrong tube was sent to the laboratory and there was a physician's order to redraw in two weeks. DON 1 stated there was a note that the Valproic acid was not performed in two weeks and the provider was notified. DON 1 stated the nursing note revealed no new orders. DON 1 stated the laboratory note from the 8/22/24, that Valproic was not done and provider was notified. DON 1 stated that since they notified the physician that the Valproic acid was not done, there were no new orders, so there was no need to follow-up on the Valproic Acid after 7/22/24, even though it had been attempted twice. On 8/28/24 at 12:19 PM, a follow-up interview was conducted with DON 1. DON 1 stated the laboratory process started with nursing staff communicating with the physician for an order. DON 1 stated all physician's orders were entered into the medical record. DON 1 stated there was a phlebotomists who worked at the facility and drew the residents specimen. DON 1 stated then the laboratory was called to pick up the specimen. DON 1 stated the results were in the residents medical record. On 8/28/24 at 12:48 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated there was a four step action plan for the laboratory process. The CRN stated the action plan was started on 8/8/24. The CRN stated the policy was reviewed. The CRN stated there was now an in house phlebotomist and staff were auditing five random charts per week for laboratory orders and results. The CRN stated the TSH was not done 12/7/23, because the specimen was insufficient and the TSH was not rechecked. 47432 3. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including primary osteoarthritis left shoulder, type 1 diabetes mellitus with diabetic neuropathy, type 1 diabetes mellitus with diabetic chronic kidney disease, hypothyroidism, Alzheimer's disease, dementia, and mood disorder due to known physiological condition with depressive features. Resident 34's medical record was reviewed from 8/25/24 through 8/29/24. Resident 34's Medication Administration Record (MAR) and Treatment Administration Record were reviewed for the months of June, July, and August 2024. Resident 34 had an order placed on 6/3/24, that revealed, TSH and Lipid Panel on 6/5/24 (send to dialysis with pt [patient]) one time only for spin and call for lab p/u [pick up] when he returns for 1 day. Resident 34's June 2024 MAR documented that this order was never completed. This order was discontinued on 6/5/24. Resident 34 had an order placed on 6/5/24, that revealed, TSH and Lipid Panel on 6/7/24 (send to dialysis with pt) one time only for spin and call for lab p/u when he returns for 1 Day. Resident 34's June 2024 MAR documented that this order was never completed. This order was discontinued on 6/7/24. Resident 34 had an order placed on 6/7/24 that revealed, TSH and Lipid Panel on 6/7/24 (send to dialysis with pt) one time only for spin and call for lab p/u when he turns for 1 Day. Resident 34's June 2024 MAR documented that this order was not not completed until 6/10/24 at 9:41 AM. The lab report for the labs drawn on 6/10/24, was reviewed. According to the lab report, the sample was not collected until 6/14/24, was received by the laboratory on 6/15/24, and the results were reported to the facility on [DATE]. On 6/19/24 at 4:27 PM, a nursing progress note revealed, Provider reviewed the labs for 6/14/24 and the [sic] let the following new orders: Draw a T3 and T4. The lab report for the labs ordered on 6/19/24, was reviewed. According to the lab report, the sample was collected on 6/20/24, was received by the laboratory on 6/22/24, and the results were reported to the facility on [DATE]. On 6/24/24 at 10:15 AM, a nursing progress note revealed, NP [nurse practitioner] looked over t4 and t3 labs that came back. she gave new order to increases [sic] Synthroid from 125 mcg to 150 mcg q [every] daily. she also has a [sic] order for TSH to be recheck [sic] in 6 weeks resident notified of new orders. There were no orders for Resident 34's TSH to be rechecked in six weeks located in the in the medical record. On 8/28/24 at 12:48 PM, an interview was conducted with the CRN. The CRN stated that the facility had a four step action plan for labs as of 8/8/24. The CRN stated that Resident 34's TSH should have been rechecked six weeks after the t3 and t4 labs were drawn. The facility Laboratory Testing Policy/Procedure revised 11/2016 revealed, POLICY: It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, PA [Physician's Assistant], NP or clinical nurse specialist and to promptly notify the ordering entity of test results. PROCEDURES: 1. Laboratory and radiology services will be arranged as ordered. 2. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending physician, PA NP or clinical nurse specialist promptly or as specified in the order. 3. Notification of test results will be documented in the resident's clinical record. 4. Results of all diagnostic services shall be made a part of the resident's medical record.

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, for 1 out of 36 sampled residents, a medication was touched by bare hands and administered to a resident and hallway meal trays were not delivered in a sanitary manner. Resident identifier: 28. Findings Included: 1. On 8/27/24 at 7:44 AM, an observation was made of Registered Nurse (RN) 4 during medication pass. RN 4 removed a pill that was taped back into a bubble pack. RN 4 was unable to remove the pill from the tape and pulled the pill off the tape and dropped the pill into the medication cup. RN 4 administered the pill to resident 28. On 8/27/24 at 7:50 AM, an interview was conducted with RN 4. RN 4 stated that she would not tape medications back into the bubble pack. RN 4 stated she would discard the medication and should not have given the medication to the resident. On 8/27/24 at 8:57 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated she personally did not know that the nurses taped medications back into the bubble packs. DON 1 stated that the nurses should not be taping medications back into the bubble packs and the medications should be discarded. 2. During the lunch meal service on 8/25/24, the following observations were conducted. a. At 12:23 PM, Certified Nursing Assistant (CNA) 6 was observed to place the lid of the chocolate milk in the palm of their hand to pour a resident a cup of the chocolate milk. CNA 6 was observed to place the lid back on the jug of chocolate milk. b. At 12:26 PM, CNA 5 was observed to serve a meal tray to resident room [ROOM NUMBER] bed B. CNA 5 did not perform hand hygiene upon exiting room [ROOM NUMBER] and obtained another meal tray from the meal cart. c. At 12:30 PM, a staff member was observed to serve a meal tray to resident room [ROOM NUMBER]. The staff member did not perform hand hygiene upon exiting room [ROOM NUMBER] and obtained another meal try from the meal cart from resident room [ROOM NUMBER]. d. At 12:34 PM, a staff member was observed to serve a meal tray to resident room [ROOM NUMBER]. The resident in room [ROOM NUMBER] was on enhanced barrier precautions. The staff member did not perform hand hygiene upon exiting room [ROOM NUMBER]. e. At 12:42 PM, an observation was made of CNA 1. CNA 1 delivered a food tray into a resident room, handed the resident their utensils and did not perform hand hygiene after exiting the room and picking up another tray. f. At 12:43 PM, an observation was made of CNA 2. CNA 2 delivered a food tray to a resident and then picked up a different tray and served the tray without hand hygiene being performed. g. At 12:44 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene before delivering a food tray to a resident. h. At 12:45 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. i. At 12:47 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. j. At 1:02 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. k. At 1:04 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. l. At 1:05 PM, an observation was made of CNA 1. CNA 1 touched their face, picked up a food tray, delivered the food tray to a resident and did not perform hand hygiene. 3. During the breakfast meal service on 8/28/24, the following observations were conducted. a. At 8:24 AM, an observation was made of CNA 3. CNA 3 did not perform hand hygiene after he delivered a tray to a resident. b. At 8:30 AM, an observation was made CNA 3. CNA 3 did not perform hand hygiene after he delivered a tray to a resident and assisted the resident to sit up in bed. On 8/28/24 at 8:27 AM, an interview was conducted with CNA 4. CNA 4 stated that the received training on how to pass food trays to residents in the halls. CNA 4 stated that after a tray was given to a resident hand hygiene should be performed. CNA 4 stated that if at any time you assisted the resident or came into contact with the resident then hand hygiene should be performed. On 8/28/24 at 8:55 AM, an interview was conducted with CNA 3. CNA 3 stated that before meal service hand hygiene should be performed. CNA 3 stated that hand hygiene should be performed before and after entering a residents room. CNA 3 stated that hand hygiene should be performed after delivering a meal tray to a resident. 47431 33215

Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, for 2 out of 5 sampled staff members, the facility did not follow their abuse policy by screening prospective employees licenses prior to employee working with residents. Findings included: A review of employee records revealed the following: Employee 1 was a Nursing Assistant (NA) hired by the facility on 7/31/23, and started working on the floor on 8/10/23. There was no record of Employee 1's license being checked to verify that a previous license had not been obtained. Employee 2 was a Certified Nursing Assistant (CNA) was hired by the facility on 2/2/23, and started working on the floor on 3/6/23. Employee 2's license was verified on 7/28/23. A review of the facility's abuse policy and procedures revealed the following: . a. Screening: Prospective Employees 1. Prior to hire, the Facility will screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit such abuse, neglect, exploitation, or misappropriation of resident property. This screening will include but not be limited to: Attempting to obtain information from previous employers and/or current employers, whether favorable or unfavorable Documentation of status and any disciplinary actions from licensing or registration boards and other registries. Reviewing the prospective employee's employment history, especially when there is or may be a pattern of inconsistency. 4. All CNAs and licensed employees will have their certificates or licenses verified through the State Board of Nursing. On 8/27/24 at 2:02 PM, an interview was conducted with the Human Resources (HR). The HR stated that a staff member's license or certification verification form was completed upon hire and then the CNA registry was checked. The HR stated that all licenses and certifications were to be checked prior to working with residents. The HR stated that the license check was printed off and then uploaded into the employee file. On 8/29/24 at 11:34 AM, an interview was conducted with the Administrator (ADM). The ADM stated that HR was the department that verified licenses for employees. The ADM stated that before staff could access the computers their licenses must be checked. The ADM stated that employee license verification must be done prior to the employee working with residents. The ADM stated that when a NA was hired, the process was to always check to see if they had a previous license. The ADM stated that he did not have any proof that the license was checked for Employee 1. The ADM stated he was not sure why it took several months for verification of Employee 2's license.

Based on observation and interview the facility did not provide, 4 of 36 sampled residents, the right to have secured and confidential personal and medical records. Specifically, the computer screen was left open on the medication carts with resident personal information and a nurse report paper was left face up on the medication cart with resident personal information. Resident identifiers: 4, 8, 70, and 76. Findings included: On 8/25/24 at 1:46 PM, an observation was made of Licensed Practical Nurse (LPN) 2. LPN 2 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked away from the computer down the hallway. Residents 8, 70, and 76 were observed to be near the medication cart. On 8/26/24 at 7:23 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked into resident room [ROOM NUMBER]. Resident 4 was observed to be walking by the medication cart. On 8/27/24 at 7:30 AM, an observation was made of a nurse shift report left on top of a medication cart in the 200 hallway face up with resident personal information and unattended. An observation was made that the medication cart was left unattended for a period of 15 minutes. It was observed that resident 4 was walking the 200 hallway. On 8/29/24 at 11:07 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated that nurses should lock their computer screen any time they leave the medication cart unattended. DON 1 stated that nurse reports with any resident information should never be left out in the open.

Based on observation and interview, it was determined for 1 out of 36 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was covered in towels in a shower chair with the sides of her buttocks exposed and being pulled backwards through the hallway. Resident Identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, adjustment disorder with anxiety, cognitive communication deficit, and muscle weakness. On 8/26/24 at 11:16 AM, an observation was made of resident 56 being pulled backwards in a shower chair by Certified Nursing Assistant (CNA) 3. Resident 56 was observed to be covered in towels with the sides of her buttocks exposed in the 200 hallway. A care plan Focus revealed ADL [activities of daily living] Self Care Performance Deficit r/t [related to] hemiplegia, stroke, weakness, edema, COPD [chronic obstructive pulmonary disease]. An intervention initiated on 7/18/24, included BATHING Requires staff participation with bathing. On 8/26/24 at 11:21 AM, an interview was conducted with resident 56. Resident 56 stated that this was the first time she had been pulled backwards through the hallway. Resident 56 stated that she had always been dressed in a shirt and at least a brief before she exited the shower room. Resident 56 stated she would prefer to be fully dressed after her shower before she was brought back to her room. On 8/26/24 at 11:42 AM, an interview was conducted with CNA 3. CNA 3 stated that it was not unusual for him to bring residents back to their rooms covered in towels to prevent the resident from getting their clothes wet. On 8/27/24 at 12:10 PM, an interview was conducted with Director of Nursing (DON). DON stated that it was not standard practice for residents to be wheeled backwards through the hallway covered in towels. DON stated that residents should be fully clothed with no sensitive area exposed.

Based on interview and record review, the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 36 sampled resident, staff were not aware of who and why a resident was ordered prophylaxis antibiotics. Resident identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, and anxiety. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. A care plan dated 3/3/24, revealed Is on Antibiotic Therapy r/t [related to] UTI. The goal was Will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included Administer medication as ordered and Observe for possible side effects every shift. On 6/2/24 at 1:48 PM, a Nurse Practitioner / Physician's Assistant Progress Note revealed, She has had recurrent UTI. She wants prophylaxis abx [antibiotic] to help prevent recurrence. ASSESSMENT AND PLAN: Recurrent UTI: Start Florastor 1 by mouth every morning. Start Keflex 500 mg [milligrams] by mouth every morning no intake, vitamin C at thousand milligrams by mouth every morning as prophylaxis to help prevent recurrence of UTI. A nursing progress note dated 6/2/24 at 3:09 PM, revealed Resident c/o [complained of] UTI like s/s [signs and symptoms]. Per provider request resident to have 1000mg q [every] AM, Florastor q AM and Keflex 500mg q AM. A physician's order dated 6/3/24, revealed Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth in the morning for Prophylaxis. On 8/27/24 at 12:59 PM, an interview was conducted with Director of Nursing (DON) 2. DON 2 stated resident 56 had history of reoccurring UTI's. DON 2 stated her last UTI was on 2/27/24. On 8/28/24 at 3:44 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was unsure which provider started the Keflex. The CRN stated that there was no information from a urologist regarding the Keflex.

Based on interview and record review, the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Specifically, for 1 out of 36 sampled residents, a resident did not have any transfer documentation in their medical record when they were transferred to the hospital. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] with diagnoses that include, but were not limited to, hereditary and idiopathic neuropathy, asthma, cognitive communication deficit, weakness, reduced mobility, borderline personality disorder, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, malingerer, and panic disorder. Resident 8's medical record was reviewed from 8/25/24 to 8/29/24. Resident 8's progress notes revealed the following: a. On 7/26/24 at 12:12 AM, a nursing note documented, Resident's roommate came out into the hall asking for help and stating that [resident name redacted] was on the floor. When I walked in, she was lying on the floor in front of her TV, lying on her R [right] side. I tried to assess for any injury. [Resident name redacted] was making intelligible comments, and she was unable to help get herself into a sitting position. Her roommate reported that 'she hit her head pretty hard'. She also said that she thinks that 'she may have been knocked out, she wouldn't answer me for several minutes'. EMS [emergency medical services] called and Resident transported via ambulance to [name of hospital redacted]. b. On 7/26/24 at 2:00 AM, a nursing note documented, returned from [name of hospital redacted] ED [emergency department] 7/26/24: Diagnosis from Today's Visit: 1. Altered Mental Status 2. Compression Fracture of L5 [fifth lumbar vertebra] vertebra 3. T12 [twelfth thoracic vertebra compression fracture f/u [follow up] Dr. [doctor] [name redacted] (Neurosurgery). On 8/27/24 at 11:58 AM, an interview was completed with the Corporate Resource Nurse (CRN). The CRN stated that when a resident was discharged or transferred to a hospital a face sheet, a list of resident's medications, and a copy of the bed hold agreement would go with the resident. The CRN stated that there was no information on resident 8's transfer to the hospital.

Based on interview and record review it was determined, for 2 of 36 sampled resident, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications 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, blood pressure medication was administered when a residents blood pressure was outside of the physician ordered parameters. In addition, another resident missed his antipsychotic and diuretic medication because he was scheduled for dialysis during the scheduled administration time. The same resident was not administered insulin according to physician's orders. Resident identifiers: 22 and 34. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominate side, intracranial injury without loss of consciousness, muscle weakness, hypothyroidism, hypertension, pressure hydrocephalus, epilepsy, schizophrenia and major depressive disorder. Resident 22's medical record was reviewed 8/25/24 through 8/28/24. Resident 22 had a physician's order dated 7/3/2020 for Propranolol 20 MG (milligrams) once daily. The parameters were to Give 20 mg by mouth one time a day . Hold if BP [blood pressure] < [less than] 120/70 or HR [heart rate] <60 related to essential hypertension. *HOLD IF BP <120/60, OR HR<60. According to the August 2024 Medication Administration Record (MAR) the Propranolol 20 MG was administered to resident 22 when blood pressure was outside of parameters: a. On 8/3/24, 111/80 b. On 8/21/24, 117/75 c. On 8/22/24, 117/75 According to the August 2024 MAR the Propranolol 20 MG was held and not administered when the blood pressures were: a. On 8/1/24, 11/86 b. On 8/6/24, 112/73 c. On 8/8/24, 109/71 d. On 8/10/24, 119/91 e. On 8/14/24, 108/78 f. On 8/28/24, 98/60 According to the July 2024 MAR the Propranolol 20 MG was administered with the following blood pressures: a. On 7/3/24, 117/89 b. On 7/11/24, 118/70 c. On 7/17/24, 101/67 d. On 7/19/24, 101/67 e. On 7/20/24, 101/67 According to the July 2024 MAR the Propranolol 20 MG was held and not administered with the following blood pressures: a. On 7/1/24, 116/66 b. On 7/6/24, 110/81 c. On 7/8/24, 106/71 d. On 7/18/24, 101/67 e. On 7/21/24, 102/83 f. On 7/29/24, 107/71 On 8/28/24 at 8:27 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated blood pressure medications were administered according to the physician ordered parameters. LPN 1 stated usually the physician's parameters were to hold if the diastolic number was less than a certain number. LPN 1 stated she did not understand the parameters for resident 22's blood pressures and would need to clarify with the physician before administering the Propranolol. On 8/28/24 at 8:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a resident had blood pressure medications, parameters were checked prior to administering the medications. RN 1 stated if the blood pressure was within parameters then she would administer the medication. RN 1 stated she would hold the medication if the blood pressure was outside parameters. RN 1 stated with resident 22's parameter orders she would hold the medication if either systolic or diastolic were under the parameters. RN 1 stated she would hold if the heart rate was less than 60. On 8/28/24 at 8:41 AM, an interview was conducted with LPN 3. LPN 3 stated if a resident had blood pressure medications with parameters, she would check the blood pressure and heart rate. LPN 3 stated then she would administer or hold the medication according to parameters. LPN 3 stated she would document why medications were not administered. LPN 3 stated she administered resident 22's medications on 8/28/24. LPN 3 stated resident 22's blood pressure was 98/60 so she held the Propranolol. LPN 3 stated typically physician ordered parameters would say to hold if the systolic was under a certain number. LPN 3 stated according to resident 22's parameters she would hold the Propranolol if either systolic was under 120 or diastolic was below 60. LPN 3 stated she did not understand the parameters for resident 22 and should have clarified the physician ordered parameters. On 8/28/24 at 8:44 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated for blood pressure medications with physician ordered parameters, the nurses should take the residents blood pressure and heart rate then compare those to the parameters. DON 1 stated the nurse would then administer or hold the medication. DON 1 stated with resident 22's medication should be held if any of the numbers were low. DON 1 stated she would have to verify the parameters for resident 22 because there were 2 different blood pressure parameters. DON 1 stated the physician was to be notified if the blood pressure or heart rate were below the parameters. DON 1 stated that the parameters should have been to hold the medication if blood pressure was less than 120/60. DON 1 stated there was a free text area in the physician's order and the nurse must have accidentally wrote 120/70 and it should have been 120/60. 47432 2. Resident 34 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including primary osteoarthritis left shoulder, type 1 diabetes mellitus with diabetic neuropathy, type 1 diabetes mellitus with diabetic chronic kidney disease, hypothyroidism, Alzheimer's disease, dementia, end stage renal disease, and mood disorder due to known physiological condition with depressive features. Resident 34's medical record was reviewed from 8/25/24 through 8/29/24. Resident 34's Medication MAR and Treatment Administration Record (TAR) were reviewed for the months of June, July, and August 2024. The following orders were noted to have irregularities: a. Abilify Oral Tablet 2 milligram Give 1 tablet by mouth one time a day for anxirty [sic] /depression. This order was placed on 6/20/24 with a start date of 6/21/24. It should be noted that the order was listed as being scheduled for 7:00 AM, administration. For the month of July 2024, resident 34's MAR showed that resident 34 missed 12 doses of Abilify. The dates that resident 34 missed doses were 7/1/24, 7/3/24, 7/5/24, 7/9/24, 7/10/24, 7/12/24, 7/15/24, 7/19/24, 7/23/24, 7/24/24, 7/26/24, and 7/29/24. The reason documented on the MAR for the 12 missed doses was, Absent from facility. For the month of August 2024, resident 34's MAR showed that resident 34 missed ten doses of Abilify. The dates that resident 34 missed the doses were 8/2/24, 8/7/24, 8/9/24, 8/12/24, 8/14/24, 8/16/24, 8/19/14, 8/21/24, 8/22/24, and 8/26/24. The reason documented for the missed doses on the MAR was, Absent from facility. The reason documented for the missed doses on 8/7/24 and 8/12/24, was as other/see nurse notes. Resident 34's progress notes were reviewed. There were no nursing progress notes that documented a reason for the missed doses of the medication. It should be noted that resident 34 had orders to attend hemodialysis Mondays, Wednesdays, and Fridays at an offsite location. Resident 34's listed pickup and transport time was 6:00 AM. b. Torsemide Tablet Give 80 milligram by mouth one time a day for edema. This order was placed on 6/11/22. It should be noted that the order was listed as being scheduled for 7:00 AM, administration. For the month of July 2024, resident 34's MAR showed that resident 34 missed 12 doses of Torsemide. The dates that resident 34 missed the doses were 7/1/24, 7/3/24, 7/5/24, 7/9/24, 7/10/24, 7/12/24, 7/15/24, 7/19/24, 7/23/24, 7/24/24,7/26/24, and 7/29/24. The reason documented on the MAR for the 12 missed doses was, Absent from facility. For the month of August 2024, resident 34's MAR showed that resident 34 missed nine doses of Torsemide. The dates that resident 34 missed the doses were 8/2/24, 8/8/24, 8/12/24, 8/14/24, 8/16/24, 8/19/24, 8/21/24, 8/22/24, and 8/26/24. The reason documented for the missed dotes on the MAR was, Absent from facility. The reason documented for the missed dose on the 8/12/24 was, other/see nurse notes. Resident 34's progress notes were reviewed. There were no nursing progress notes documented for 8/12/24. It should be noted that resident 34 had orders to attend hemodialysis Mondays, Wednesdays, and Fridays at an offsite location. Resident 34's listed pickup and transport time was 6:00 AM. c. Novolog Injection Solution 100 Unit/milliliters (Insulin Aspart) Inject as per sliding scale: if 180-230 = 2; 231-280 =4; 281-330 = 6; 331-380 = 8; 381-430 = 10 below 60 or above 400, notify provider, subcutaneously at bedtime for DM II [type 2 diabetes mellitus].This order was placed on 6/11/24. For the month of June 2024, resident 34's MAR showed that resident 34 received 2 units of insulin on 6/30/24. Resident 34's blood glucose had been reported as 156, which was outside the listed parameters of 180-230 that would indicate a need for 2 units of insulin to be administered. On 8/28/24 at 3:50 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that resident 34 should not have missed his Abilify or Torsemide. The CRN stated that the facility should have communicated with the facility physician to determine if the scheduled medication times could be adjusted on the days that resident 34 went to dialysis. The CRN stated that the facility did not follow resident 34's insulin parameters for the dose given on 6/30/24. The CRN stated that the facility was on a four step action plan for this reason.

Based on interview and record review, the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, for 1 out of 36 sampled residents, the resident did not have gabapentin available. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, morbid obesity, reduced mobility, and muscle weakness. On 8/25/24 at 11:36 AM, an interview was conducted with resident 14. Resident 14 stated she had a sciatica problem and it flared up in the morning. Resident 14 stated she had requested to see the physician regarding changing times of her muscle relaxer. Resident 14 stated her pain was 10 out of 10 every morning and the pain woke her up at night. Resident 14's medical record was reviewed on 8/25/24 through 8/28/24. Resident 14 had physician's orders for gabapentin 400 milligrams (mg) three times a day for neuropathy. According to the nursing progress notes on 8/25/24 at 8:35 AM, gabapentin was not administered because Resident out. According to nursing progress notes on 8/25/24 at 1:20 PM, gabapentin was not administered because Needs RX [prescription] from pharmacy. The August 2024 Mediation Administration Record revealed resident 14 was not administered gabapentin on 8/25/24 at 8:00 AM and 2:00 PM. Resident 14 was administered cyclobenzaprine 10 mg every eight hours as needed for spasms on 8/25/24 at 6:43 AM. In addition, a Lidocaine External Patch 5% was applied at 7:30 AM on 8/25/24, to resident 14's lower back. A care plan dated 5/8/24, revealed Has chronic pain r/t [related to] DM [diabetes mellitus], CHF [congestive heart failure], morbid obesity. The goal was Will not have an interruption in normal activities due to pain through the review date. Interventions included Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Will voice a level of comfort through the review date; Follow pain scale to medicate as ordered; and Pain assessment every shift. On 8/29/24 at 9:35 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident 14 did not ask for a lot of assistance. NA 1 stated she had complained of pain and NA 1 reported the pain to the nurse. NA 1 stated resident 14 was waiting for the medication to kick in. NA 1 stated resident 14 had neuropathy in her feet. NA 1 stated resident 14 was able to verbalize her needs. On 8/27/24 at 3:19 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 14 walked to the nurses cart and asked the nurse for pain medications if she was in pain. CNA 6 stated resident 14 was alert and oriented to be able to verbalize her pain. On 8/27/24 at 1:13 PM, an interview was conducted with Director of Nursing (DON) 2. DON 2 stated that gabapentin needed a prescription from the physician. DON 2 stated that was why resident 14 did not have the gabapentin available. DON 2 stated other interventions were used for pain on 8/25/24.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 36 sampled residents, a resident that was considered an elopement risk with a wandergaurd left the facility unattended and the resident was a smoker without a smoking assessment. In addition, another resident that had an unwitnessed fall and did not have neurological checks completed. Resident identifiers: 59 and 185. Findings included: 1. Resident 185 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, acute on chronic systolic congestive heart failure, moderate protein-calorie malnutrition, chronic obstructive pulmonary disease, mild intellectual disabilities, cognitive communication deficit, urinary tract infection, dementia, alcohol abuse, and essential hypertension. Resident 185's medical record was reviewed on 8/25/24. On 7/8/23 at 6:22 PM, the Elopement/Wandering Evaluation documented that resident 185 was a High Risk for wandering with a score of 11. A resident with a score of 10 to 55 was considered a High Risk. On 7/9/23 at 10:29 AM, a Nursing progress note documented Note Text: Pt. [patient] attempt to check out stating that he want [sic] to go home and get his money and shoes. Pt. was assist back to his room and friend on his contact was called. Pt. exhibit confusion. A care plan Focus initiated on 7/10/23, documented Elopement risk/wanderer r/t [relate to] History of attempts to leave facility unattended. The intervention initiated on 7/10/23, documented Document wandering behavior and attempted diversional interventions. On 7/10/23 at 3:22 PM, a Nursing progress note documented Note Text: Verbal Consent for Wander Guard and Patient Education This progress note documents an important discussion and intervention with the patient regarding their desire to leave the facility and concerns about their safety. The patient expressed a willingness to leave, even mentioning the possibility of exiting through a window if necessary. The nurse . [name redacted] and I obtained verbal consent from the patient to implement a wander guard system, and we also provided education on the importance of following the medical team's orders and ensuring a safe departure if and when it becomes appropriate. During a conversation with the patient, they expressed a strong desire to leave the facility, stating that they were ready to leave by any means necessary, including through a window. Recognizing the potential risk to their safety, the nurse . director and I engaged in a discussion with the patient to address their concerns and explore alternative solutions. We explained the concept of a wander guard system, which is designed to enhance patient safety by preventing unauthorized exits from the facility. After providing a clear explanation of the purpose and functionality of the wander guard, we obtained verbal consent from the patient to implement this measure. The patient demonstrated understanding of the purpose of the system and agreed to its implementation. Additionally, we took the opportunity to educate the patient on the importance of following the medical team's orders and completing the full course of antibiotics as prescribed. We emphasized that staying in the facility and receiving proper treatment would enhance their overall well-being and increase the chances of a successful recovery. We addressed any concerns or questions the patient had, ensuring they were well-informed and involved in their care decisions. A physician's order dated 7/10/23 at 3:41 PM, documented Check Wandergaurd Placement at the beginning of every Shift every shift for wander guard. Discontinued on 9/23/23. On 7/13/23, a St. Louis University Mental Status (SLUMS) Examination documented that resident 185 had dementia with a score of 1 to 20. An admission Minimum Data Set assessment dated [DATE], documented that resident 185 had a Brief Interview for Mental Status (BIMS) score of 11. A BIMS score of 8 to 12 indicated moderate impairment. On 7/25/23, a SLUMS Examination documented that resident 185 had dementia with a score of 1 to 20. On 7/26/23 at 4:01 PM, a Nursing progress note documented Note Text: Resident removed wander guard on NOC [night] shift, wander guard was found on bed table, Wander guard reapplied to right wrist. On 8/26/23 at 1:47 PM, a Nursing progress note documented Note Text: Resident removed wander guard this afternoon and returned it to his nurse stating that 'it slows him down.' New straps are pending delivery so there is no wander guard on at this time. Resident is currently lying down in his bed. Provider notified. Staff notified. Will reapply wander guard as soon as able to. On 8/26/23 at 8:10 PM, a Nursing progress note documented Note Text: Resident cut his wandergaurd off today. It was placed in the top drawer of the nurses cart, we are awaiting a delivery of new bands. Resident has been compliant with staying in the facility today. Will continue to monitor closely. On 9/16/23 at 2:55 PM, a Nursing progress note documented Note Text: Resident asked if he could go out this morning. When asked who he was going with he said no one. He was told that he couldn't leave the building by himself. He said he thought so, but he wanted to try. On 9/22/23 at 3:48 PM, a Nursing progress note documented Note Text: Resident called a friend this morning and she came to the facility and signed him out. They have not returned yet. He did take all medicaiton [sic] this morning. He has the wander guard on the right ankle. He has his belongings packed in boxes and sitting in front of his bed. On 9/23/23 at 2:42 PM, a Nursing progress note documented Note Text: resident went out to smoke with other residents. CNA [Certified Nursing Assistant] called saying resident was down by [name redacted] gas station refusing to come back to facility. Resident stated to CNA that Resident was 'going to get on the bus and go were the homeless people are.' ON callnursing [sic] manger [sic] reported above. On call nursing manager to call back with plan. (Note: Resident 185 did not have a smoking evaluation completed and a care plan that addressed smoking had not been developed.) On 9/23/23 at 2:52 PM, a Nursing progress note documented Note Text: on call nursing manger said to go over to [name redacted] store and try to get resident back. If resident will not come then call the police. on my way to store another floor nurse will watch my patients. On 9/23/23 at 3:19 PM, a Nursing progress note documented Note Text: Returned from [name redacted] store. On Call nursing supervisor called and reported that there was no sign of CNA or resident at [name redacted] and on my way back to facility. There [sic] The CNA who saw the resident at [name redacted] store was on his way home from work. 911 called reported protected patient missing last seen at [name redacted] store to catch a bus to where the homeless people are. Police officer to come to the facility. On 9/23/23 at 3:53 PM, a Nursing progress note documented Note Text: Police Officer [name redacted] came and got the information needed, looked at chart picture we have of resident. Policer [sic] is going to look for resident and bring him back if he can. On 9/23/23 at 10:35 PM, a Nursing progress note documented Note Text: R [resident] returned to facility tonight. R was alert and oriented X3 [person, place, and time]. Head to toe assessment done. No apparent signs of injuries noted. Skin looked intact. Vitals taken BP [blood pressure]: 131/76, Pulse 94, Resp [respirations] 18, Temp [temperature] 98. R was compliant and pleasant. Wander guard noted to hisL [sic] [left] foot. On 9/23/23 at 10:42 PM, a Skin Evaluation documented no apparent signs of injuries noted. Skin looked dry, warm and intact. No edema noted. A care plan Focus initiated on 7/10/23, documented Elopement risk/wanderer r/t History of attempts to leave facility unattended. The interventions initiated on 9/23/23, documented Q15 [every fifteen] minute checks, Supervision when outside of building and Wander Guard to left ankle. A physician's order dated 9/24/23 at 6:00 AM, documented Wander Guard placement and function every shift for wander guard. On 9/24/23 at 2:46 PM, the Elopement/Wandering Evaluation documented that resident 185 was a low risk for elopement with a score of 6. A resident with a score of 0 to 9 was considered a Low Risk. On 9/24/23 at 6:29 PM, an Alert Note progress note documented Note Text: Resident is alert, ox4 [oriented times four to person, place, time, and event], follows all commands, answers questions appropriately. Resident has not tried to leave facility grounds this shift. Resident was placed on Q [every] 15min [fifteen minute] watch while in building, 1:1 [one on one] while out smoking at approximately 15:00 [3:00 PM]. Reported to on coming nurse the above restrictions and gave her the q 15min monitor sheet. On 9/25/23 at 9:00 AM, an Interdisciplinary Team (IDT) Note progress note documented Text: IDT reviewed incident that occurred 9/23/2023. At approximately 2:30 pm, it was identified that resident had left the facility alone. Resident reported to a staff member that he 'wanted to live with the homeless people'. Facility was thoroughly searched, as well as, surrounding areas. Emergency response was issued to locate the resident (Police, UTA [Utah Transit Authority], emergency room s, Homeless Shelters convenience stores) were all notified. Emergency contact and primary physician were notified as well. Employees searched the streets of [NAME] for 6 hours until dark. At approximately 2122 [9:22 PM], resident returned to facility. Head to toe assessment completed, no injury noted. Wander guard placement/functionality assessed and found to be in working order. Provider notified. Police were also notified of residents return. Intervention: Resident was placed on Q15 minute visual checks and supervision when resident is outside of the building. On 9/25/23 at 6:36 PM, a Nursing progress note documented Note Text: Resident has had 15 minute checks and has been present for them. He walked past the nurse on the 200 hall way and the nurse followed behind. He went out the 200 side door and the door did not alarm. He had taken his wander guard off. He was followed inthem [sic] parking lot and the nurse was talking with him and asking him to stop and talk with her. He did go with a staff member and back into the building. He then became one on one in nurse management office. He has been watched closely. A new wander guard was put on his left ankle. On 9/25/23 at 8:49 PM, a Therapy progress note documented Note Text: The patient is experiencing difficulties remembering how to check himself out of the SNF [Skilled Nursing Facility] and has presented with increased memory loss that adversely impacts his safety, independence and well-being. He could benefit from ST [Speech Therapy] sessions implementing compensatory strategies so that he can return to his PLOF [prior level of functioning] successfully. On 9/26/23 at 7:38 PM, an Alert Note progress note documented Note Text: Resident remain on Q 15 minute checks, 1:1 when he goes out to smoke. Resident has stayed all day in his room. Resident is withdrawn, not interacting with staff or residents as before. On 9/28/23 at 2:21 PM, an Alert Note progress note documented Note Text: Resident continues to be Q15 minute checks. Resident has remained mostly in room except to smoke. Resident stated today that he wants to get on a bus and go to [NAME], Utah. Resident 1:1 when he is out smoking. On 9/29/23 at 4:51 PM, an Alert Note progress note documented Note Text: Resident remains on Q 15 minute check. Resident caught smoking in his restroom by night shift staff. Resident has tried to use the back door exit at end of hall to go smoke. Resident is 1:1 when he smokes. Resident expresses desire to 'leave this place'. On 10/5/23 at 5:00 PM, a Nursing progress note documented Note Text: Resident transferred to [Long Term Care Facility name redacted] with all belongings, medications (controlled and scheduled)via [name redacted] transportation. The exhibit 358 form submitted to the State Survey Agency (SSA) was reviewed. On 9/23/23 at 2:30 PM, it was identified that resident 185 had left the facility alone with mild cognitive impairment. He had last been heard to say that he wanted to live with the homeless people. Emergency response was issued to locate the resident were all notified. Resident 185 did not have any emergency need for medications and the weather was favorable. Emergency contact and primary physician were notified as well. Eight individuals employed by the facility searched the streets of [NAME] for six hours until dark to find resident 185. The facility pulled the eight individuals off of the search for the day around 8:30 PM, when it was no longer light outside. The facility anticipated continuing the search on Sunday morning. All the while, the plan was to have Police, UTA, emergency room s, etc. keep an eye out for resident 185 through the night. On 9/23/23 at 9:22 PM, resident 185 showed back up to the facility stating that he was cold so he came back. Resident 185's evaluation will be performed to make sure there were no injuries as well as to determine careplan adjustments going forward. The exhibit 359 form submitted to the SSA was reviewed. The Summary of interviews with witnesses documented that there were no witnesses to the incident. It was identified that resident 185 had gotten out of the facility when a CNA left the building to go home at 2:40 PM, and resident 185 was walking down the sidewalk behind the gas station in close proximity to the facility. The CNA attempted to get resident 185 to go back to the building but resident 185 refused. The CNA alerted staff at the facility that resident 185 had gotten out of the building. The CNA was off the clock and did not feel like he needed to stay with resident 185 so he left. From that time forward the facility was not able to locate resident 185. The Unit Manager had noted that resident 185 in the past had expressed desires to leave the facility, but had never acted on that desire. Resident 185 had times when he had been more lucid than others. Resident 185 was a supervised smoker and had a wandergaurd anklet on. As much as the facility could ascertain, resident 185 slipped away while out on supervised smoking when the staff member was taking another resident back. On 8/26/24 at 11:41 AM, an interview was conducted with CNA 4. CNA 4 stated that he was off shift driving home when he saw resident 185 at the bus stop by the local convenient store. CNA 4 stated that he called the facility to let them know. CNA 4 stated that he asked resident 185 to get in the vehicle so he could take him back to the facility but resident 185 would not get in the vehicle. CNA 4 stated that resident 185 was a supervised smoker and resident 185 had a wander guard on his ankle. CNA 4 stated that resident 185 liked to cut off the wandergaurd and would use a butter knife. CNA 4 stated if a resident was a supervised smoker he would put a smoking apron on the resident, make sure the resident was ashing their cigarette appropriately, watch the resident for safety, and dispose of their cigarette. CNA 4 stated that he was unsure if resident 185 had the wandergaurd on or not the day of the elopement. CNA 4 stated that resident 185 liked to hang around the exit door of the facility and staff would try to keep resident 185 occupied in the activities room. CNA 4 stated that the distraction would work sometimes to keep resident 185 away from the doors. CNA 4 stated that he should have stayed with resident 185 at the bus stop and it had been a learning experience. On 8/26/24 at 11:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was on call the night that resident 185 had eloped and she got the call from the floor nurse. LPN 1 stated that resident 185 was always trying to get to the bank or had a destination in mind. LPN 1 stated that resident 185 was a supervised smoker the day he eloped and she believed that resident 185 had snuck away. LPN 1 stated that resident 185 had been homeless before and thought he might be headed back there. LPN 1 stated that she spent the day looking for resident 185, like six hours. LPN 1 stated that the floor nurses did the elopement assessments. LPN 1 stated there were things to consider if the resident was a high risk. LPN 1 stated if the resident could actively leave the facility then yes they would put in a process. LPN 1 stated the high risk would depend on the resident's cognition and history. LPN 1 stated that she could not remember what interventions were in place for resident 185. On 8/26/24 at 2:18 PM, an interview was conducted with CNA 5. CNA 5 stated if a resident was a supervised smoker she would get the residents ready by the door. CNA 5 stated that some CNAs would let the residents get their cigarettes prior to going out or the CNA would take the box out with them. CNA 5 stated that two staff would take the residents all out and we would make sure the residents got their smokes. CNA 5 stated that she would watch the residents all smoke and when the resident were finished the staff would take the residents back in the facility. CNA 5 stated if the resident was a wander risk the resident usually would have a wandergaurd on and the alarm would go off if the resident went out the door. CNA 5 stated the wandergaurd was an extra check. CNA 5 stated that usually their was someone outside during the smoke break while the other staff member was bringing the residents in. CNA 5 stated if there was only one staff member during the smoke break it was usually at night when there was less staff. CNA 5 stated she would monitor the smoke break the entire time until the residents were all finished. CNA 5 stated that there were also smoke aprons for the residents. On 8/26/24 at 3:01 PM, an interview was conducted with the Administrator (ADM). The ADM stated that CNA 4 was driving down the road and saw resident 185 and CNA 4 thought he would check it out. The ADM stated that CNA 4 stopped to check on resident 185 to see if he was okay. The ADM stated that CNA 4 asked resident 185 if he wanted to get in his van and go back to the facility and resident 185 replied no. The ADM stated that CNA 4 stated that the situation felt weird but CNA 4 thought it was okay for resident 185 to be out there. The ADM stated that CNA 4 left and called the nurse. The ADM stated that resident 185 had said that he was going to the ghetto so the ADM called resident 185's family to see where that might be. The ADM stated that resident 185 walked into the building on his own right as they called off the search. The ADM stated the staff increased monitoring and needed to get resident 185 to a better environment. The ADM stated that resident 185 had the wandergaurd on and 15 min checks. The ADM stated the wandergaurd system for the facility would alarm but it would not lock the doors. The ADM stated that resident 185 continued to try and leave the facility. The ADM stated that education with the staff members was provided. The ADM stated when resident 185 admitted to the facility he was not a wander risk and there were no notes that indicated he was a wander risk. The ADM stated that resident 185 was not exit seeking but anxious and staff would walk the building with resident 185. The ADM stated that staff met as a team after resident 185 had eloped and decided that resident 185 was able to leave the building and get himself back was he really a risk. The ADM stated that resident 185 was reassessed as a low elopement risk. On 8/26/24 at 4:35 PM, an interview was conducted with CNA 6. CNA 6 stated that she could not remember any circumstances regarding resident 185. CNA 6 stated that she thought she worked on a hall that resident 185 was not on so she did not have much interaction with resident 185. CNA 6 stated any resident who was deemed unsafe to smoke for any reason would be a supervised smoker. CNA 6 stated there was a list of residents that were smokers so the staff did not miss anyone. CNA 6 stated the staff did not have time to take the smokers out extra if their smoke time was missed. CNA 6 stated whom ever was assigned to the smoke break and that resident would ensure the resident got their smoke break. CNA 6 stated that the residents were gathered by the door by the nurses station on the 200 hall. CNA 6 stated the staff would make sure the resident was wearing a smoking apron and would get the residents ready to go outside. CNA 6 stated there was a coded lock box due to residents complaining of missing smokes. CNA 6 stated another staff member would assist to get everyone outside. CNA 6 stated that staff would control the lighter for the residents depending on the circumstances. CNA 6 stated that sometimes the extra staff member would stay outside if the staff member was able. CNA 6 stated if there were two staff one would push the residents into the facility and the other staff member would stay outside while the residents finished smoking. CNA 6 stated if there was one staff member then technically yes there might be a moment when the residents were unsupervised outside but she would push the residents just inside the door so she could watch the residents that were still outside. CNA 6 stated if there was a resident with a wandergaurd or the resident was an elopement risk she would push them into the facility first so she knew that they were safe. The facility policy and procedure Elopement/Unsafe Wandering was reviewed. The policy and procedure had a revision/review date of 1/2022. Policy It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Purpose This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. Procedure 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an Elopement/Wandering Evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors will be identified as At Risk and will have an individualized care plan developed that includes measurable objectives and timeframes. a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. b. Interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. 3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions. 5. When the resident has been located and/or returns to the facility: a. An assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. b. Notify search teams that the resident has been located. c. The attending Physician and Resident Representative will be notified of the resident's return and the resident status. d. Document relevant information in the resident's medical record. 6. Complete an Elopement/Wandering Evaluation of the resident post elopement incident with continued follow ip documentation for a minimum of 72 hours following the incident. 7. The Interdisciplinary Team will review of [sic] the elopement incident, to include an investigation to determine safety of the environment and probable causal factors leading to the elopement. A summary of the investigation and recommendations will be documented in the resident's medical record. 8. The resident's care plan will be updated and include interventions to address the possible need for the increased level of supervision. The facility policy and procedure Smoking Policy was reviewed. The policy and procedure had a revision date of 12/2019. POLICY: It is the policy of this facility to provide to its' residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility. PURPOSE: To satisfactorily address the wishes of both smoking and non-smoking residents without compromising the safety of either. PROCEDURES: 1. This facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. 2. Upon admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until assessment is reviewed by the interdisciplinary team. The Interdisciplinary Team will accomplish this using the Smoking Assessment form and a review of the resident's clinical record. At the end of this period it will be determined if the resident will be allowed to smoke either under supervision or independently with or without protective devices. In either case, no lighting materials (e.g., matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the resident, either on their person or in the facility 3. The results of the evaluation will be placed in the resident's chart and the IDT recommendations will be care planned. 4. Upon quarterly review by the IDT, or at any time a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility non-smoking policy using the Smoking Assessment form. 5. If a resident decides to begin smoking after initially being assessed as a non-smoker, the facility will follow the above procedures. 6. The frequency of smoking for residents that are determined not safe will be the following times with staff supervision 06:30 [6:30 AM] 11:30 [AM] 15:30 [3:30 PM] 20:30 [8:30 PM] 09:30 [9:30 AM] 13:30 [1:30 PM] 18:30 [6:30 PM] 22:30 [10:30 PM] These times will be no more than twenty (20) minute increments or 2 cigarettes 7. If it is determined that a resident is a safe smoker, smoking materials will still be retained by nursing staff and they may come and request 1 or 2 cigarettes at the time they desire to go out to smoke unsupervised There will be no smoking between the hours of 23:00 [11:00 PM] and 6:30 [AM] by any resident even if they are deemed safe 8. The facility reserves the right to immediately confiscate smoking materials as well as to rescind the individual smoking privileges if failing to take such measures would jeopardize resident safety. 9. If a resident continues to be non-compliant with the smoking policy set forth they will be given a written thirty (30) day notice and placed on fifteen (15) minute checks until they leave the facility 10. The facility reserves the right at any time to modify or change the smoking policy to maintain the safety of the facility and the residents. All smokers will be advised and given a copy of the new policy. 30563 2. Resident 59 was admitted to the facility on [DATE] and readmitted d 2/27/24 with diagnoses which included erosive arthritis, type 2 diabetes mellitus, protein-calorie malnutrition, hyperkalemia, depression, pain left knee, fatigue, need assistance with personal care, fracture of one rib left side, and history of falling. On 8/25/24 at 12:23 PM, an interview was conducted with resident 59's family member. Resident 59's family member stated resident 59 had fallen three or four times and had been hurt. Resident 59's medical record was reviewed on 8/25/24 through 8/29/24. Fall risk assessments revealed that resident 59 was at medium risk for falls on 1/30/24 and 2/25/24. Resident 56 was assessed as a high risk for falls on 4/7/24. A care plan dated 1/30/24, revealed that resident 56 Has had an actual fall: 1/30/2024 no injury 2/25/2024 no injury 2/29/2024 no injury 4/6/2024 rib fracture 7/5/2024 slight left rib fracture. The goal was Will resume usual activities without further incident through the review date. The interventions included 4/6/2024 Intervention: Therapy to evaluate and treat as appropriate; 7/5/24: Bed in lowest position and; Continue interventions on the at-risk plan. On 1/30/24 at 8:55 AM a nursing progress note revealed, Resident had a fall today while in the shower. He slipped and fell on his right knee. He was in the shower with [name removed], his wife. The CNA was not present at the time of the fall. Both the resident and his wife deny that he hit his head. They stated he slipped while ambulating on the wet floor to get to his walker. He c/o [complaints of] right knee tenderness. No other injuries were noted upon assessment. No bruising was noted. He does have 2 small abrasions, these were cleaned and dried and left open to air. NP [Nurse Practitioner] [name removed] was notified and she responded, 'knee x-ray please if still in pain.' Resident denies any pain at this time and stated he does not want an x-ray. Will continue to monitor. Will notify family. There were no neurological assessments located in resident 56's medical record after the fall on 1/30/24. On 8/29/24 at 8:40 AM, an interview was conducted with Director of Nursing (DON) 1 and Corporate Resource Nurse (CRN). The CRN stated if the fall was unwitnessed, then neurological assessments were completed. The CRN stated if a resident was found on the floor, the nurse should conduct a full body assessment. The CRN stated after a fall the nursing staff notified the Medical Doctor and the resident's representative. The CRN stated alert charting was implemented for 72 hours. The CRN stated within 24 business hours the Interdisciplinary Team reviewed the fall and looked for a more permanent intervention. The CRN stated there were no neurological assessments completed after the fall on 1/5/24.

Based on interview and record review, the facility did not provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility. Specifically, for 2 out of 36 sampled residents, resident's were transported to the hospital and were not informed of the facility bed-hold policy. Resident identifiers: 8 and 56. Findings included: 1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, bipolar disease, and anemia. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. Resident 56's progress notes revealed on 4/5/24 at 6:20 PM, Called to residents' room by her mother stating her daughter doesn't seem right, I entered the room and noticed residents' right side of mouth drooping, resident slurring her words, very dry mouth, unable to tell me her name, could not tell me what day it was or who the president was, she was able to recognize her mother, extremely drowsy falling asleep while attempting to speak, unable to hold her eyes open but does respond to painful stimuli, all sedating medication have been held all day d/t [due to] lethargy and excessive sleepiness per nursing report, . 911 called resident transported to hospital, mother was here and aware, another nurse called on call provider and on call nursing. There was no information regarding a bed hold agreement in resident 56's medical record. On 8/29/24 at 8:32 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that there was an envelope with paperwork the nurse sent to the hospital with the resident. The CRN stated the bed hold form was given in the envelope that was sent with the resident to the hospital. The CRN stated there was a form on the envelope that had the information provided on it. The CRN stated that form was then scanned into the residents medical record. The CRN stated that there were no bed holds in resident 56's medical record. 50200 2 Resident 8 was admitted to the facility on [DATE] with diagnoses that include, but were not limited to, hereditary and idiopathic neuropathy, asthma, cognitive communication deficit, weakness, reduced mobility, borderline personality disorder, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, malingerer, and panic disorder. Resident 8's medical record was reviewed on 8/25/24 to 8/29/24. Resident 8's progress notes revealed the following: a. On 7/26/24 at 12:12 AM, a nursing note documented, Resident's roommate came out into the hall asking for help and stating that [resident name redacted] was on the floor. When I walked in, she was lying on the floor in front of her TV, lying on her R [right] side. I tried to assess for any injury. [Resident name redacted] was making intelligible comments, and she was unable to help get herself into a sitting position. Her roommate reported that 'she hit her head pretty hard'. She also said that she thinks that 'she may have been knocked out, she wouldn't answer me for several minutes'. EMS [emergency medical services] called and Resident transported via ambulance to [name of hospital redacted]. b. On 7/26/24 at 2:00 AM, a nursing note documented, returned from [name of hospital redacted] ED [emergency department] 7/26/24: Diagnosis from Today's Visit: 1. Altered Mental Status 2. Compression Fracture of L5 [fifth lumbar vertebra] vertebra 3. T12 [twelfth thoracic vertebra compression fracture f/u [follow up] Dr. [doctor] [name redacted] (Neurosurgery). There was no information regarding a bed hold agreement found in resident 8's medical record. On 8/27/24 at 11:58 AM, an interview was conducted with the CRN. The CRN stated that when a resident was discharged or transferred to a hospital a face sheet, a list of the resident's medications, and a copy of the bed hold agreement would go with the resident. The CRN stated the packet with the bed hold agreement was given to EMS, but it never came back with the resident from the hospital.

Based on observation and interview, the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, an opened multi-dose vial in the medication cart had exceeded the 28 day expiration date, an insulin pen was not dated with the date it was opened, and bubble packs had medication taped back in. Resident identifiers: 28. Findings included: 1. On 8/27/24 at 7:00 AM, the medication cart at the top of the 100 hallway was inspected. An observation was made that the medication cart contained a Lispro insulin vial with an open date of 7/21/24, and a used glargine insulin pen with no open or expiration date on it. An interview was conducted with Registered Nurse (RN) 3. RN 3 stated that opened insulin was good for 28 days and then it must be discarded. RN 3 stated she was unsure when the insulin pen was opened and the vial of insulin needed to be removed from the cart. 2. On 8/27/24 at 7:44 AM, an observation was made of RN 4 during medication pass. RN 4 was observed to untape the back of a medication bubble pack and administered the medication to resident 28. On 8/27/24 at 7:50 AM, an interview was conducted with RN 4. RN 4 stated that she would not tape medications back into the bubble pack. RN 4 stated she would discard the medication and should not have given the medication to the resident. On 8/27/24 at 8:57 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated she personally did not know that the nurses taped medications back into the bubble packs. DON 1 stated that the nurses should not be taping medications back into the bubble packs and the medications should be discarded. DON 1 stated that all undated open medications needed to be discarded. DON 1 stated that insulin needed to be replaced after 28 days of it being opened. 30563 3. On 8/25/24 at 8:15 AM, an observation was made of the medication cart in the 100 hallway. There was a ball with intravenous antibiotic on top of the medication cart. The antibiotic was observed to be unattended on the medication cart. On 8/29/24 at 11:05 AM, an interview was conducted with DON 1. DON 1 stated medications should not be left unattended at anytime.

Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, and misappropriation of resident property. Specifically, a resident reported an unauthorized bank transaction in the amount of $300 that was done by Nurse Assistant (NA) 1. Resident identifier 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spondylopathy lumbar region, cognitive communication deficit, osteoporosis, chronic kidney disease, type 2 diabetes mellitus, agoraphobia with panic disorder, schizoaffective disorder, major depressive disorder, anxiety disorder, insomnia, and hypertension. On 3/16/23 resident 1's medical records were reviewed. On 11/24/22, the Annual Minimum Data Set (MDS) Assessment documented that resident 1 had a Brief Interview for Mental Status (BIMS) score of 10, which would indicate a moderate cognitive impairment. The assessment documented that resident 1 did not have any hallucinations or delusions. The assessment documented that resident 1 required one person extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. On 11/4/22 at 10:30 AM, a grievance form documented that resident 1 reported that her bank account was short roughly $1400. Resident 1 called her banking institution and discovered several fraudulent charges to DoorDash, Amazon, [NAME], and other food services. The form documented that resident 1 reported that her bank was investigating the matter. The conclusion documented on the form was to allow resident 1 and their family representative to work with the bank to investigate the incident. On 3/1/23 at 10:30 AM, a grievance form documented that resident 1 reported that NA 1 stole a check and cased it for $300 on 11/15/22. The grievance form documented that resident 1 denied writing the check. The conclusion documented that the facility would reimburse resident 1 the $300, and NA 1 was no longer employed by the facility. On 3/1/23 at 10:30 AM, the facility investigation documented that resident 1 reported to the Administrator (ADM) that she had a check cashed by someone that she did not know. The date the alleged incident occurred was on 11/15/22. The report documented that the name written on the check was identified as NA 1, and that NA 1 was employed at the facility during the time the check was cashed. The report documented that resident 1 had no recollection of writing the check and that there was no record of the check on her carbon copy. Resident 1 denied knowledge of or giving permission to NA 1 to take the check. The report verified that a check for $300 with NA 1's name was cashed. The report documented that NA 1 was terminated for other reasons prior to the identification of the misappropriation of property on 3/1/23. The report documented that the Director of Nursing (DON) noted that NA 1 was not dependable and did not show up for shifts, and was subsequently terminated for a no call no show. The report documented that the local police department was notified of the incident. Review of NA 1's personnel file documented a date of hire as 11/3/22. Review of NA 1's timecard revealed the following: a. On 11/7/22 clocked in at 5:55 PM, clocked out at 6:10 AM. b. On 11/8/22 clocked in at 5:55 PM, clocked out at 6:30 AM. c. On 11/9/22 clocked in at 5:45 PM, clocked out at 6:15 AM. d. On 11/10/22 clocked in at 9:50 PM, clocked out at 6:10 AM. e. On 11/11/22 clocked in at 5:54 PM, clocked out at 10:11 PM. f. On 11/13/22 clocked in at 6:23 PM, clocked out at 5:18 AM. g. On 11/17/22 clocked in at 9:12 PM, clocked out at 6:08 AM. h. On 11/22/22 clocked in at 5:59 PM, clocked out at 9:52 PM. i. On 11/23/22 clocked in at 10:11 PM, clocked out at 6:03 AM. j. On 11/24/22 clocked in at 10:04 PM, clocked out at 6:06 AM. k. On 11/25/22 clocked in at 6:54 PM, clocked out at 6:11 AM. On 11/30/22, NA 1 was terminated from the facility. Review of the facility Policy and Procedures for Abuse: Prevention of and Prohibition Against documented that each resident had the right to be free from misappropriation of property. The policy documented that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy documented that if an allegation of abuse, neglect, or misappropriation of property involved an employee that the facility would immediately remove the employee from the care of any resident and suspend the employee pending the investigation. The policy was last revised in October 2022. On 3/16/23 at 11:16 AM, an interview was conducted with the ADM. The ADM stated that at the time of the incident NA 1 was not yet certified. The ADM stated that NA 1 was terminated for performance reasons, and that this was prior to him being made aware of the cashed check. The ADM stated that when he was informed of the incident by resident 1 he started an investigation. The ADM stated that resident 1 showed him a copy of the check that was cashed online and it was written out to NA 1. The ADM stated that resident 1 denied writing the check and did not have any information on the duplicate check carbon copy. The ADM stated that the facility reimbursed resident 1 for the missing funds and reported the incident to the police department. On 3/16/23 at 11:56 AM, the ADM stated that resident 1's bank reimbursed the resident for all the unauthorized transactions in November 2022. The Administrator in Training (AIT) stated that there were two cases opened with the police department, one for the fraudulent charges and another for the check. On 3/16/23 at 12:51 PM, an interview was conducted with resident 1. Resident 1 stated that an aide had made some transactions on her bank account in November 2022. Resident 1 stated that her debit card went missing and she did not know until she went to the bank to get her balance. Resident 1 stated that this was when she noticed that money was missing. Resident 1 stated that the bank helped her setup her banking account online and that was when she noted all the unauthorized transactions. Resident 1 stated that she just noticed a week ago that 3 checks were missing and NA 1 cashed one of them. Resident 1 stated that she suspected someone that worked at the facility for taking her debit card but did not know who until the check was cashed. Resident 1 stated that she did not think to check on her belongings as everyone was nice. Resident 1 stated that at night after she takes her sleep aide she was out and did not know what was going on. Resident 1 stated that she believed the debit card and checks were taken when she was sleeping. Resident 1 stated that the check was dated 11/14/22 and was posted on 11/15/22. Resident 1 stated that she looked in her checkbook and the check was not there. Resident 1 stated that when she informed the bank they said they could not pay her back because it was after 90 days. Resident 1 stated that at first she could not remember the aide but she recognized the name. Resident 1 stated that the facility reimbursed her the money. Resident 1 stated that NA 1 took advantage of her situation because she was difficult to wake up. Resident 1 stated that she spoke to the police and they were opening an investigation. Resident 1 stated that the police wanted information on the debit charges and the check. Resident 1 stated that she had a copy of the cashed check on her computer. Resident 1 stated that NA 1 had only worked at the facility for a few months. Resident 1 stated that at the time of the incident her debit card and checks were located in her wallet in the top drawer of the night stand. Resident 1 stated that this was really upsetting, because she had no money and then owed money to the bank for the overdraft that this caused. Resident 1 stated that there were a lot of charges. Resident 1 stated she asked the bank why the clerk cashed the check because it was not her signature or writing. Resident 1 stated that she put a hold on the other missing checks and the bank changed her account number. Resident 1 stated that the bank reimbursed her for all the debit card transactions including all the overdraft charges. Resident 1 stated that it was stressful at the time because she had to wait for the bank to put the money back in the account. Resident 1 stated it took about 72 hours for the bank to reimburse her.

Based on observation, interview, and record review it was determined, for 12 of 27 sampled residents, that the facility did not serve food that was prepared by methods that conserved nutritive value, flavor, and appearance or serve food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of cold and unappetizing food. In addition, green beans and peas were overcooked and resident council minutes revealed residents' complaints of food quality. Resident identifiers: 1, 7, 13, 20, 34, 37, 41, 45, 49, 55, 59, and 61. Findings Included: 1. On 12/13/22 at 2:56 PM, resident 1 was interviewed. Resident 1 stated that the eggs were usually cold and not good. 2. On 12/13/22 at 3:01 PM, resident 7 was interviewed. Resident 7 stated that the food was always cold by the time they received it. 3. On 12/13/22 at 1:35 PM, resident 13 was interviewed. Resident 13 stated that the food was cold. 4. On 12/13/22 at 1:08 PM, resident 20 was interviewed. Resident 20 stated that the food was the worst part of the facility. The food was always pancakes and eggs, and that the food was always cold. The resident stated that the tortilla they received for lunch was cold and they did not like the menu. 5. On 12/13/22 at 1:35 PM, resident 34 was interviewed. Resident 34 stated that the food needed improvement; they were served potatoes or pancakes every day. 6. On 12/13/22 at 2:20 PM, resident 37 was interviewed. Resident 37 stated that they were served too many beans; the food tasted like Miralax and it had the same effect as Miralax. 7. On 12/13/22 at 1:25 PM, resident 41 was interviewed. Resident 41 stated that the food was cold all the time, though it usually tasted good, and that the coffee was always hot. 8. On 12/13/22 at 1:43 PM, resident 45 was interviewed. Resident 45 stated that the foods served were repetitive and frequently served with gravy. 9. On 12/14/22 at 8:40 AM, resident 49 was interviewed. Resident 49 stated that the food had no flavor; the resident did not receive coffee or orange juice this morning. 10. On 12/13/22 at 1:29 PM, resident 55 was interviewed. Resident 55 stated that the food was not great and was usually cold. 11. On 12/13/2022 at 2:21 PM, resident 59 was interviewed. Resident 59 stated that the meat tasted freezer burnt, and the resident does not eat it. 12. On 12/13/2022 at 1:12 PM, resident 61 was interviewed. Resident 61 stated that all of the food served was cold, the tortillas were cold at lunch, and that the food served was not good. On 12/14/2022 at 11:32 AM, a test lunch tray was requested after observing the trayline. At 11:39 AM the test tray was placed onto the 200 hallway delivery cart. At 11:47 AM, the meal trays were served to the 200 hallway. An observation was made of the meal trays. There were no hot pellets observed between the base and the meal plate prior to serving. The following temperatures were obtained: [Note: All temperatures were in degrees Fahrenheit.] a. Chicken King Casserole was 162 b. Peas were 121 c. Green Beans were 115 d. Salad was 52 e. Gelatin Dessert was 59. Resident council minutes revealed the following complaints of food: a. 8/9/2022 .mentioned they do not like Sausage Patties, or French toast sticks . b. 9/13/2022 Residents would like more protein options for breakfast besides sausage c. 10/11/2022 Residents would appreciate grilled cheeses to not be pre-cooked d. 11/08/2022 .Food has been cold but staff is being replaced so hopefully food quality will improve . On 12/15/22 at 1:40 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the facility recently purchased a new plate warmer. The DM stated that the plate warmer was broken for about 4 weeks and residents complained of cold food. The DM stated kitchen staff warmed plates in the oven and steamer during that time. The DM stated she had never seen pellet warmers between the plate and the base.

Based on observation and interview it was determined, for 5 of 27 sampled residents, that the facility did not provide a safe, clean comfortable and homelike environment. Specifically, resident wheelchairs were dirty and a lift was dirty. Resident identifiers: 13, 17, 33, 34, and 52. Findings include: 1. On 12/13/22 at 1:45 PM, resident 33 was observed in her wheelchair. Resident 33 wheelchair was observed to have a soiled wheelchair cushion, the sides and wheels of her wheelchair were soiled. On 12/15/22 at 12:46 PM, an observation was made of resident 33's wheelchair. Resident 33's wheelchair was observed to have a soiled cushion. In addition, the sides and wheels of her wheelchair were soiled. 2. On 12/15/22 at 12:26 PM, an observation was made of resident 52's wheelchair. Resident 52's wheelchair was observed to have a green pad on it. There was food and debris on the pad. There was a strong urine odor. There was debris on the sides of the cushion and the wheels were soiled. 3. On 12/15/22 at 12:55 PM, an observation was made of resident 34. Resident 34's wheelchair was observed to be soiled on the cushion and on the sides and the back where the motor was. 4. On 12/15/22 at 12:47 PM, an observation was made of resident 17's electric wheelchair. Resident 17's wheelchair was observed to be soiled on the arm rests, and there was crumbs and debris under the joystick. Resident 17's cushion had debris and a white substance dried on it. 5. On 12/13/22 at 1:35 PM, an observation was made or resident 13's room. Resident 13's dresser had 3 of the 6 handles broken. Resident 13 stated the handles will just break again anyway. Resident 13's wheelchair was observed to be dirty. Resident 13 stated the Certified Nursing Assistants (CNA) cleaned wheelchairs at night. 6. On 12/15/22 at 12:45 PM, an observation was made of a sit to stand lift outside room [ROOM NUMBER] and 134. The lift was observed to be soiled on the foot rests. On 12/15/22 at 12:15 PM, an interview was conducted with CNA 4. CNA 4 stated the night shift CNAs should be cleaning the wheelchairs. On 12/15/22 at 12:28 PM, an interview was conducted with CNA 3. CNA 3 stated there was a nightly list for CNAs to be cleaning wheelchairs on night shift. CNA 3 stated there was a list in the CNA binder at the nurses station. CNA 3 was unable to find a list of wheelchairs cleaned. CNA 3 stated there was nothing specifically signed off when the wheelchair was cleaned. On 12/15/22 at 12:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was an assignment book with which wheelchairs were cleaned on which days. The DON stated there was no log or anything because it had not been a problem having the wheelchairs cleaned. The DON stated if staff noticed a dirty wheelchair, they cleaned it. The DON stated CNAs were to wipe the lifts down between each resident.

Based on observations and interviews, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, uncooked meats were stored above ready to eat foods, there were soiled areas in the kitchen, cracked paint, missing grout and broken tiles. Findings Include: 1. On 12/13/2022 at 9:46 AM, an initial tour of the kitchen was conducted. The following was observed: a. In the walk-in refrigerator, a box of raw hamburger patties was found stored above breadsticks. b. Inside the walk-in freezer there were large chunks of ice on the floor and ice circles hanging from the ceiling. c. The door handle from the kitchen to the dining room was observed to have crumbs and debris in it. d. There was cracked paint and drywall under the vents above the stove. e. Underneath the prep sink a tile was missing. f. There was missing grout on the tile in front of the oven. g. Crumbs and debris were found around the edges of the flooring. 2. On 12/15/2022 at 1:37 PM, a follow up tour of the kitchen was conducted. The following was observed: a. There was raw bacon and sausage stored above oatmeal, mixed vegetables, and rolls in walk-in refrigerator. b. There was a container labeled egg salad with no date in the walk-in refrigerator. c. Inside the walk-in freezer there were large chunks of ice on the floor and ice circles hanging from the ceiling. d. A three drawer plastic compartment with serving utensils was observed to be soiled with food on both the inside and outside of the drawers. e. The shelf above trayline basins was observed to be soiled under the shelf. f. Dietary Aide (DA) 1 was observed to be standing by the trayline rolling silverware in napkins. DA 1 was observed to not have her hair restrained. DA 1 was observed to put on a beanie right after the surveyors entered. g. There was cracked paint and drywall observed under the vents above the stove. h. Underneath the prep sink a tile was missing. i. There was missing grout on the tile in front of the oven. j. Crumbs and debris were observed around the edges of the flooring. k. The door handle on the door from the kitchen to the dining room was observed to have crumbs and debris on its surface. On 12/15/22 at 1:37 PM, Cook 1 was interviewed. Cook 1 stated the inside and outside of the 3 drawers with the utensils in it was cleaned weekly with soap. On 12/15/22 at 1:40 PM, the Dietary Manager (DM) was interviewed. The DM stated the 3 drawers with the utensils were to be cleaned on a weekly basis. The DM stated the drawers were not on the cleaning schedule so she did not know what day they were cleaned. The DM stated uncooked meats were supposed to be stored on the bottom right shelf of the walk-in refrigerator to prevent meat juices from dripping and contaminating ready-to-eat foods. The DM stated the kitchen was supposed to be swept every night. The DM stated that the ice in the freezer was from the defrost cycle. The DM stated she had not noticed the missing grout and cracked tile. The DM stated the door handles were scheduled to be cleaned nightly. The DM stated the tray line was cleaned nightly. 30563

Based on observation, interview and record review, it was determined that for 1 of 6 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, a resident who took [MEDICATION NAME] every 4 hours for pain was without his [MEDICATION NAME] for over tweleve hours. These findings were cited at a harm level after the resident stated he had been in pain during that time. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/14/17 at 9:02 AM, Registered Nurse (RN) 1 was observed while administering [MEDICATION NAME] 30 mg (milligrams) to resident 1. Resident 1 reported a pain level score of 9 (based on a pain score of 1-10 with 10 being excruciating). Resident 1 stated that his left leg was raising hell and that the pain curved around to his lower back that was exquisite. Resident 1 stated that the [MEDICATION NAME] usually decreased his pain to a 4. Resident 1 stated that he would optimally like for his pain to be a 1-2. On 6/14/17 at approximately 9:40 AM, resident 1 was re-interviewed. Resident 1 stated that the [MEDICATION NAME] decreased his pain to a 3. Resident 1 stated that he took the [MEDICATION NAME] every 4 hours around the clock. Resident 1 stated that his [MEDICATION NAME] was not available for him to take about a month ago. Resident 1 stated that during the period that his [MEDICATION NAME] was not available, his pain was so severe that caused him anxiety, restlessness and that he was sweating. Resident 1 stated that the nurses told him that they were unable to contact the physician. Resident 1 stated that he was in so much pain that he asked the nursing staff to borrow the [MEDICATION NAME] from another resident. Resident 1 stated that he was without the [MEDICATION NAME] for 14 hours. Resident 1's medical record was reviewed on 6/14/17. On 1/5/17, resident 1's primary care physician wrote an order to administer [MEDICATION NAME] 30 mg by mouth every 4 hours as needed for pain. The care plans developed for resident 1 revealed a focus area of, (Resident 1) exhibits or is at risk for alterations in comfort related to chronic pain, MS ([MEDICAL CONDITION]). (Resident 1) exhibits decreased mobility and stays in bed all day. He has depression as well. The care plan was developed on 10/24/13 and revised on 7/13/15. The goal documented was, (Resident 1) will achieve acceptable level of pain control. The interventions developed to achieve the goal included: Monitor for medication pocketing; Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors; Utilize pain scale; Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated; Monitor frequency of episodes of breakthrough pain to determine the need for pain med (medication) adjustment; Monitor for non-verbal signs/symptoms of pain and medicate as ordered; Complete pain assessment per protocol; Assist resident to a position of comfort, utilizing pillows as appropriate positioning devices. On 4/7/17, a facility employee completed a Pain Evaluation for resident 1. Resident 1 was assessed as having chronic pain that was described as sharp, aching, soreness, worse on movement, deep and pins and needles sensations. The facility staff member documented that resident 1's mood, activity, and position worsened the pain. Additionally, the facility staff documented the position changes and medications made the pain better. The facility staff member documented, Resident has chronic generalized pain. He is aware of pain management techniques including prn (as needed) pain meds. The [MEDICATION NAME] 30 mg Narcotic Logs from 4/1/17 through 5/27/17 were reviewed. The licensed nursing staff documented that resident 1 received six doses of the [MEDICATION NAME] every day, except for 4/5/17, 4/19/17, 5/1/17 and 5/20/17 at which times resident 1 received five doses of the [MEDICATION NAME]. On 5/28/17, resident 1 received a dose of [MEDICATION NAME] 30 mg on at 1:00 AM, 5:00 AM, and 9:00 AM at which time resident 1's supply of [MEDICATION NAME] 30 mg was out. On 5/29/17 at 1:00 AM, resident 1's supply of [MEDICATION NAME] became available. The licensed nurse documented that [MEDICATION NAME] 30 mg was administered at 1:00 AM. (Note: Resident 1 was without a supply of [MEDICATION NAME] for over twelve hours.) Review of the PRN PAIN MANAGEMENT FLOW SHEET for April 2017 revealed that resident 1 complained of generalized pain with a pain rating of 7 - 9. (Note: According to the PRN PAIN MANAGEMENT FLOW SHEET, a pain rating of 7-8 meant that resident 1 had Severe/Horrible Pain and a pain rating of 9-10 meant that resident 1 had Excruciating Pain.) Review of the PRN PAIN MANAGEMENT FLOW SHEET for May 2017 revealed that resident 1 complained of generalized pain with a pain rating of 8 daily. The electronic progress notes from 4/1/17 to 6/14/17 were reviewed. There was no documentation available for review related to resident 1's [MEDICATION NAME] 30 mg not being available for administration on 5/28/17 and 5/29/17. On 6/14/17 at 10:35 AM, the Director of Nursing (DON) was interviewed related to resident 1's supply of [MEDICATION NAME]. The DON stated that renewal sheets were prepared for the physician to sign every Monday. The DON stated that the physician and the facility would send a facsimile to the pharmacy with the renewal orders to be filled. The DON stated that the pharmacy did not receive the renewal orders for resident 1's [MEDICATION NAME]. On 6/14/17 at 11:50 PM, the DON was re-interviewed related to resident 1's supply of [MEDICATION NAME]. The DON stated that the [MEDICATION NAME] could not have been pulled from the pyxis machine because [MEDICATION NAME] 30 mg tablets were not available for administration. The DON stated that she was notified that resident 1 was out of [MEDICATION NAME] on 5/28/17 at approximately 9:30 PM. The DON stated that she immediately placed a phone call to resident 1's primary care physician, who also functioned as the facility Medical Director. The DON stated that resident 1's primary care physician stated that he would immediately call the pharmacy to refill the [MEDICATION NAME] 30 mg supply. On 6/14/17 at 2:20 PM, RN 2 was interviewed related to resident's 1's supply of [MEDICATION NAME]. RN 2 stated that resident 1 typically requested his [MEDICATION NAME] 30 mg every 4 hours for pain rated between 7-8 with an occasional rating of 10. RN 2 reported that resident 1 had pain in his knees occasionally but mostly in his back. RN 2 stated that the night nurse conducted an inventory of all medications at the beginning of each week to identify any resident who would potentially run out of medications over the weekend. RN 2 stated that on each Wednesday a report was given to the Medical Director of the facility which included a list of residents and what medications needed to be renewed before the weekend. RN 2 stated that she was annoyed and surprised to find out that resident 1's [MEDICATION NAME] was not available for administration on 5/28/17. RN 2 stated that when she realized that resident 1's [MEDICATION NAME] was unavailable on 5/28/17, she had left multiple voice messages for the pharmacy. RN 2 stated she had also sent multiple text messages to and left multiple voice messages for resident 1's primary care physician (PCP), who also functioned as the facility Medical Director. RN 2 stated that a Certified Nursing Assistant (CNA) had told her that resident 1 had requested to go to the emergency room . RN 2 stated that she told resident 1 that she was doing the best that I could do. RN 2 stated that the [MEDICATION NAME] had not been delivered from the pharmacy at the end of her shift which was 6:00 PM. RN 2 further stated that resident 1 had previously requested to go to the emergency room when his [MEDICATION NAME] was not available for administration. On 6/14/17 at 6:10 PM, RN 3 was interviewed related to resident 1's supply of [MEDICATION NAME]. RN 3 stated that she had received a report from RN 2 stating that resident 1's [MEDICATION NAME] was not available for administration. RN 3 stated that RN 2 had contacted the pharmacy and resident 1's PCP earlier in the day. RN 3 stated that RN 2 reported that resident 1's PCP had responded to the multiple text messages and voice messages at 5:00 PM stating that he would send in a script in an hour. RN 3 stated that resident 1 mentioned being sent to the ER several times and had asked a CNA to borrow the [MEDICATION NAME] from another resident. RN 3 stated that she waited until 7:00 PM then called the pharmacy. RN 3 stated that the pharmacy had not received a prescription from resident 1's PCP. RN 3 stated that she left another voice message and text message for resident 1's PCP. RN 3 stated that she called the pharmacy again between 8:30 PM and 9:00 PM and was told that the pharmacy had not heard from resident 1's PCP. RN 3 stated that resident 1's [MEDICATION NAME] supply was delivered to the facility at approximately 12:30 AM. On 6/19/17, the facility administrator e-mailed written statements from RN 2 and RN 3 to the state agency. The following was documented: a) 6/15/17 at 4:20 PM: RN 2 - On may (sic) 28th the nurse coming off shift (I believe it was (RN 3)) let me know (resident 1) had only one dose of his prn (as needed) narc (narcotic). It was unclear at that point (6am) if a script (prescription)had been sent into (sic) pharmacy by the physician. I left a message with the pharmacy early to find out if they did get a script and if they were sending it. They called back and stated they did not have a new script. I contacted (resident 1's PCP) via text that he was out. I also texted himabout (sic) another patient. He responded about the other patient but did not respond about (resident 1's) narc. I gave (resident 1) his last dose at about 0900 (9:00 AM). I spoke with the patient and let him know that he was now out and I was working on getting a new script for him. He was calm. His pain was subjective. He was not complaining of being in any kind of pain or distress at that point. He was appreciative that I was working on it. Soon after that a cna reported to me that (resident 1) said he may want to go to the ER because he did not have his pain medication. He never stated that to me. I mentioned it to (another facility licensed nurse) at that point. (The other facility licensed nurse) may have spoke with him I can't remember. In the mean time (another licensed nurse) was working on B hall and was trying to get ahold (sic) of (resident 1's PCP) about another patient. I told her please ask him the status on (resident 1's) script. Through out (sic) the day we continued to try to get a response from (resident 1's PCP). (Name redacted) finally heard back from him about 4 (PM) and (resident 1's PCP) said he was hiking and would send the script after 6pm. Through out the day I checked in with (resident 1) several times. He knew that I was working on the issue and continued to be appreciative by saying things like 'I appreciate (sic) sweetheart'. 'I know it's not your fault'. Tylenol was offered and I gave it to him however I am not sure on those specific times I gave it. He never verbalized to me that his pain was uncontrolled or that he needed further interventions. Each time I went in his room he was calm, pleasant and he was understanding towards me and the situation. b) 6/16/17 at 11:00 AM: RN 3 - Fwd: Received report at 1800 (6:00 PM) was told that the doctor was contacted and he was refilling meds (medications) in 1 hr (hour). I called pharmacy to verify the refill was called in but it hadn't been done, this was around 1900 (7:00 PM). I called the physician and left a voicemail message and he didn't respond. I recalled physician a hr (hour) later with no response. I sent him a text message also and no response. Approximately around 2200 (10:00 PM), I called the on call provider and told them about the situation and was told he was reached by a manager and he was sending the prescription into the pharmacy. I recalled the pharmacy to verify that it had been called in and it hadn't so I recalled the physician to explain that the pharmacy stated there was no prescription called in or on file, this was0000 (sic) (12:00 AM). I gave the physician the number I had received from the pharmacy to place the refills at and received confirmation within a few minutes that the physician had called it in. Prescription was sent stat (immediately) and resident received his medication around 01:30 (1:30 AM). Through out the night I was updating resident on what was happening and the status of the refill.

Based on interview, record review, and observation, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 5 of 34 sample residents. Specifically, pain management was not appropriately monitored, and wound orders were not implemented appropriately. This failure resulted in harm for 2 residents. Resident identifiers: 14, 48, 49, 61, and 77. Findings include: HARM 1. Resident 77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 77's medical record was reviewed on [DATE]. A physician's note dated [DATE] for resident 77 was reviewed. The note stated that resident 77 had recently been seen in the emergency room for increased weakness, and left shoulder pain. The physician also documented that multiple lung nodules had been identified during the last emergency room visit which were indicative of a primary [MEDICAL CONDITION] or possible metastasis. The physician documented that resident 77's shoulder pain was likely caused by metastatic disease. On [DATE] facility staff completed an admission Minimum Data Set (MDS) for resident 77. The Care Area Assessment portion of the MDS indicated that a care plan should have been developed for resident 77. On [DATE], resident 77's care plans were reviewed. No care plan had been developed for resident 77's pain. On [DATE] facility staff completed an initial Nursing Assessment for resident 77. Facility staff documented on the assessment that resident 77 was not on a scheduled pain medication regime, received pain medication as needed, was experiencing pain in his left shoulder, and that the pain was aching, gnawing, sore, and worse on movement. The assessment also indicated that resident 77's pain was worse with activity and certain positions, but that repositioning, moving, medication, and/or heat helped relieve some of the pain. The assessment also indicated that resident 77 had an acceptable level of pain up to a 5 on a pain scale from 0 to 10. On [DATE] facility staff completed a Nursing Assessment for resident 77. Facility staff documented on the assessment that resident 77 had been in pain during the last 5 days, and that the pain had limited the resident's day-to-day activities. Facility staff also documented that the pain had reached an 8 on the pain scale in the last 5 days. Facility staff did not indicate a pain description, what made the pain worse, or what made the pain better. Resident 77's Medication Administration Record (MAR) for [DATE] was reviewed. The MAR indicated that resident 77's pain was monitored from [DATE] through [DATE]. On all of the days listed, facility staff documented that the resident indicated he was in pain. Facility staff also documented resident 77's pain, using a pain scale from 0 to 10 on the dates listed above. On each day, resident 77 indicated that his pain was a 6, 7, 8 or 9. (Note: Resident 77 was not asked a number for his pain on one of the days, and there were only two days that he indicated his pain was at a 6. It should also be noted that the MAR indicated that resident 77's pain level was to be documented four times a day, however was only documented zero to 3 times each day on the days listed above.) Resident 77's [DATE] MAR also indicated that resident 77's pain score was not documented on the MAR after [DATE], even though the resident was at the facility through [DATE], when he passed away. Resident 77's [DATE] MAR also indicated that resident 77's physician added an as needed pain medication for breakthrough pain to resident 77's pain regimen on [DATE]. Facility staff documented that resident 77 used the medication one to four times each day from [DATE] through [DATE]. However, no pain scores were recorded before or after administering the additional pain medication as a way of determining the effectiveness of the pain medication regimen. Resident 77's [DATE] MAR indicated that on [DATE] and [DATE] before resident 77 died , facility staff did not document resident 77's level of pain. Nursing notes for resident 77 were reviewed. The following entries were made in resident 77's medical record by facility staff: a) [DATE] Resident stated his pain is a ,[DATE] and this is normal for him. b) [DATE] Resident complained of back pain, controlled by (as needed) pain regimen. c) [DATE] Resident spending most all time in bed sits up on side but then lays back down. Refusses (sic)to go to dining room. Much wincing with movement and reports increase (sic) pain in shoulders and back . Notified house (physician) . Resident is declining. d) [DATE] Resident declining very weak drinking only small amts (amounts) of liquids only no food. noted increased pain wincing moaning attempted to turn resident on side. Resident refuses to lie on side immediately rolled onto back. Also resident states I feel mixed up I should already be dead. i'm very sick. e) [DATE] 2:00 PM Physician contacted concerning (resident 77's) increased pain and reports of anxiety. Plan for pain and anxiety management made . (Note: No documentation could be located to indicate what the plan was to address resident 77's pain.) f) [DATE] 6:30 PM Resident increase (sic) pain and at times very anxious confussed (sic). Not eating refuses when assistance offered. decrease fluid intake. much encouragement given. (Note: The physician ordered an antianxiety medication and increased resident 77's pain medication on [DATE]. However, no monitoring tools were implemented to determine if resident 77's pain was effectively controlled.) g) [DATE] Oncologist recommending no further treatment to be provided at this time and recommended hospice . h) [DATE] 4:53 AM Resident continuing to (complain of) pain to neck and back. (As needed) given at 1800 (6:00 PM), and 0000 (midnight)as well as scheduled ER (extended release)[MEDICATION NAME]. Repositioning ineffective, movement limited to pain. Resident grimacing, attempting to speak with staff but states cant make thoughts come out. Notified (physician) of increasing pain. Resident refusing to go to bed (due to) pain and 'worry I can't get out of it.' Difficulty swallowing medications, (as needed) crushed and placed under tongue. Ice pack applied. Orders received to try position changes, (range of motion), distraction, ice pack and breathing techniques. if those not effective give (as needed) [MEDICATION NAME] 10 (milligrams) at (9:00 AM) (four hours after last (as needed)), order one time only, and notify (physician) of what helped. Ice pack applied. Resident states no to breathing techniques, intermittent confusion noted throughout night, (physician) states to monitor and have (morning) nurse notify if persisting. (Note: No documentation could be found to indicate that the physician was contacted regarding resident 77's pain until [DATE].) i) [DATE] 5:49 AM States ice pack ineffective j) [DATE] Resident continues to complain of pain in neck and back . k) [DATE] Resident continues to decline. Comfort measures givenrefussed (sic) all (oral) intake. Very confussed (sic). Complaints of pain notable anxiety. Much difficulty swallowing medication. New order to (discontinue antianxiety medication and [MEDICATION NAME]). Start [MEDICATION NAME] . and [MEDICATION NAME]. Resident unable to understand changes. l) [DATE] Resident expired at (7:30 AM). On [DATE] at 1:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the pain monitoring. The DON stated that the facility had identified the issue with pain monitoring in [DATE], but had only focused on the as needed pain medications as part of their plan of correction, and not the scheduled pain medications. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE], [DATE] and [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 49's medical record was reviewed. A nurses note dated [DATE] at 7:43 AM revealed, Late entry for [DATE]: After resident was changed to go to her [MEDICAL TREATMENT] appoint (appointment) by the nurse and CNA (Certified Nursing Assistant), she was placed back in her WC (wheelchair) with her call light in place and sat at the foot of her bed per her request so that she could listen to her television while she waited for her ride to go to her appoint. The resident was sitting in her WC listening to her television, before her room mate had left the room, her room mate had placed some chips at the foot of her bed for (resident 49) to snack on. (Resident 49) leaned forward and reached for some chips and fell out of her chair landing prone on the floor. Resident did not use the call light to ask for assistance. Resident obtained a hematoma over her left eye and had a bloody nose. Resident complained of pain to her Rt (right) foot and leg and requested to go to the hospital to be checked out. Family was contacted. MD (medical doctor) and on call was notified. Resident was sent to (hospital) nonemergent transport to the ER (emergency room ) for eval (evaluation) and TX (treatment). She was later admitted for a broken Rt leg. A nurses note dated [DATE] at 17:25 (5:25 PM) revealed, skin evaluated today. No open areas found on buttocks or coccyx, all areas blanched well and were normal in color for ethnicity. Small DTI (deep tissue injury) noted on right heel . (NOTE: No documentation could be located in the medical record that resident 49's physician had been notified of the DTI to resident 49's right heel.) A nurses note dated [DATE] at 15:50 (3:50 PM) revealed, Revaluated (sic) 'DTI' on heel, resident allowed more visibility of heel due to comfort and positioning. Heel was found to have no DTI just normal discoloration in skin for ethnicity. A nurses note dated [DATE] at 15:34 (3:34 PM) revealed, (Resident 49) has a new onset/change in skin integrity as evidenced by ulcer-pressure. Location: .Left heel 5.2 cm (centimeter) x 6 cm, left lateral ankle blister: 1.6 cm x 5.4 cm . (NOTE: The nurses note refers to the 'left' heel and ankle. On [DATE] at 9:45 AM the facility Director of Nursing (DON) stated that the nurses were documenting about resident 49's right heel since resident 49 was initially admitted with a left AKA. No documentation could be located in the medical record that resident 49's physician was notified of the new wounds and their measurements. No physician orders could be located in the medical record to treat the newly acquired wounds.) A nurses note dated [DATE] at 15:34 (3:34 PM) revealed, A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: MASD-moisture associated skin damage(s): left lateral leg, coccyx sacral region, left heel and inner thighs . (NOTE: The nurses note refers to the 'left' heel and ankle. On [DATE] at 9:45 AM the facility DON stated that the nurses were documenting about resident 49's right heel since the resident was initially admitted with a left AKA. No documentation could be located in the medical record that resident 49's physician was notified of the MASD to the wounds.) A nurses note dated [DATE] at 16:41 (4:41 PM) revealed, Skin check was completed this shift, (resident 49) continues with a wound to her right knee, blister to lower lateral right leg, that is open with wound bed. She continues with a blood blister to her right heel. Wounds have no s/sx (signs and symptoms) of infection, no draining, redness, or swelling. WCTM (will continue to monitor). (NOTE: No documentation could be located in the medical record that resident 49's physician had been notified of the wounds or the need for treatment.) A nurses note dated [DATE] at 14:54 (2:54 PM) revealed, Wound evaluation completed today. Wounds are healing well .Sure prep was applied to right heel, which remains intact. Wound on right lateral distal calf noted to have maceration around wound beds, wound has slough in wound bed and, no pain noted at wound site. Dressing orders changed to better treat wound . (NOTE: No documentation could be located in the medical record that resident 49's physician had been notified that the wound on the right lateral distal calf was noted to have maceration around the wound beds and slough in the wound bed. Additionally, no physician orders were written until [DATE].) A nurses note dated [DATE] at 00:00 (midnight) revealed, A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure area(s): location(s): coccyx/buttocks, tx ongoing, wounds healing. External device removed and site inspected: skin intact beneath braces . A nurses note dated [DATE] at 10:32 AM revealed, New orders received from surgeon regarding patient's leg. Discontinue boot. To go to wound clinic 3 times a week for ulcer on ankle. (NOTE: No documentation could be located in the medical record that wound clinic services had been set up for resident 49 for treatment 3x weekly.) A nurses note dated [DATE] at 18:48 (6:48 PM) revealed, Pt (patient) had apt (appointment) today with (physician) vascular surgeon .Pt has new order to (sic) [MEDICATION NAME] gel on right leg sores prn for pain. Dr recommended that pt have a right AKA due to ischemis (sic) and pressure ulcers to right leg and ankle and heel. A nurses note dated [DATE] at 13:52 (1:52 PM) revealed, (Resident 49's) wounds were assessed. She continues with a vascular ulcer to her right lateral leg, moderate amount of serosanguinous drainage observed. Area was cleaned and a new bandage was placed. She has an unstageable wound to her right heel. Area was cleaned and skin prepped and ace wrapped . (NOTE: No documentation could be located in the medical record that resident 49's physician had been notified of the moderate amount of sersanguinous drainage to the right lateral leg wound or the unstageable wound to her right heel.) A nurses note dated [DATE] at 8:00 AM revealed, A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: MASD-moisture associated skin damage(s): location(s): coccyx pressure area(s): location(s) right heel. A nurses note dated [DATE] at 8:00 AM revealed, A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: MASD-moisture associated skin damage(s): location(s): right heel pressure and stasis ulcer upper ankle . (NOTE: No documentation could be located in the medical record that resident 49's physician was notified of the moisture associated damage to the right heel pressure ulcer nor to the right lateral stasis ulcer.) A nurses note dated [DATE] at 12:37 PM revealed, .She continues with a vascular ulcers (sic) to her lateral lower extremities. They appear necrotic with slough around the edges .WCTM. (NOTE: No documentation could be located in the medical record that resident 49's physician was notified of the newly acquired necrosis to the right lateral vascular ulcer.) A nurses note dated [DATE] at 15:44 (3:44 PM) revealed, (Resident 49) sent out to surgery for [REDACTED]. A review of the Skin Integrity Reports revealed the following measurements and information regarding resident 49's wounds: 1. Right Heel: a. [DATE] Appearance: blood blister necrotic Length: 6 cm Width: 5.2 cm Depth: None Recorded Drainage: Minimal Bloody Wound Edges: Healthy Odor: No b. [DATE] Appearance: DTI Length: 2.5 cm Width: 5.5 cm Depth: None Recorded Drainage: None Wound Edges: Healthy Odor: No c. [DATE] Appearance: DTI Length: 2.5 cm Width: 5.0 cm Depth: None Recorded Drainage: None Wound Edges: Healthy Odor: No d. [DATE] Appearance: DTI Length: 2.5 cm Width: 4.5 cm Depth: None Recorded Drainage: None Wound Edges: Healthy Odor: No 2. Right Lateral Distal Calf: a. [DATE] Appearance: [MEDICATION NAME] 90%, Slough 10% Length: 3.5 cm Width: 3.3 cm Depth: 0.2 cm Drainage: Moderate Serosanguineous Sourrounding Tissue: Healthy Wound Edges: Macerated Odor: No No other measurements could be located in the medical record. On [DATE] the facility DON (Director of Nursing) found additional measurements for resident 49's right heel pressure ulcer and right lateral leg vascular ulcer. The DON stated that the additional measurements were in the former wound nurse desk drawer. 1. Right Heel: a. [DATE] Appearance: Necrotic 70%, Slough 30% Length: 5.1 cm Width: 3.2 cm Depth: None Recorded Drainage: Minimal Serosanguineous Surrounding Tissue: Inflamed Wound Edges: Healthy Odor: No b. [DATE] Appearance: Necrotic 85%, Slough 15% Length: 5.3 cm Width: 3.5 cm Depth: None Recorded Drainage: Moderate Serosanguineous Surrounding Tissue: Inflamed Wound Edges: Healthy Odor: No c. [DATE] Appearance: Necrotic 85%, Slough 15% Length: 5.3 cm Width: 3.5 cm Depth: None Recorded Drainage: Moderate Serosanguineous Surrounding Tissue: Inflamed Wound Edges: Healthy Odor: No d. [DATE] Appearance: Necrotic 85%, Slough 15% Length: 5.5 cm Width: 4.4 cm Depth: None Recorded Drainage: Moderate Serosanguineous Surrounding Tissue: Inflamed Wound Edges: Healthy Odor: No e. [DATE] Appearance: Necrotic 85%, Slough 15% Length: 5.3 cm Width: 4.1 cm Depth: None Recorded Drainage: Minimal Serosanguineous Surrounding Tissue: Inflamed/Indurated Wound Edges: Healthy Odor: No 2. Right Lateral Ankle a. [DATE] Appearance: [MEDICATION NAME] 70%, Slough 30% Length: 3.6 cm Width: 3.3 cm Depth: 0.2 cm Drainage: Moderate Serosanguineous Surrounding Tissue: Healthy Wound Edges: Healthy Odor: No b. [DATE] Appearance: Necrotic 70%, Slough 30% Length: 4.2 cm Width: 3.7 cm Depth: 0.2 cm Drainage: Moderate Serosanguineous Surrounding Tissue: Indurated Wound Edges: Macerated Odor: No c. [DATE] Appearance: Necrotic 80%, Slough 20% Length: 5 cm Width: 4.3 cm Depth: 0.2 cm Drainage: Moderate Serosanguineous Surrounding Tissue: Inflamed/Indurated Wound Edges: Macerated Odor: yes d. [DATE] Appearance: Necrotic 80%, Slough 20% Length: 5.8 cm Width: 4.3 cm Depth: 0.2 cm Drainage: Moderate Serosanguineous Surrounding Tissue: Inflamed/Indurated Wound Edges: Macerated Odor: Yes e. [DATE] Appearance: Necrotic 80%, Slough 20% Length: 6.1 cm Width: 5.1 cm Depth: 0.2 cm Drainage: Minimal Serosanguineous Surrounding Tissue: Deep Purple/Maroon Wound Edges: Macerated Odor: Yes No documentation could be located on the Skin Integrity Reports that resident 49's physician had been notified of the increasing size and necrosis to the right heel pressure ulcer. No documentation could be located in the Skin Integrity Reports that resident 49's physician had been notified of the increasing size, necrosis and odor to the right lateral leg vascular ulcer. A review of resident 49's physician orders revealed the following: a. A physician's order dated [DATE] revealed, Right heel: apply sure-prep to heel twice a day. (NOTE: The physician orders written on [DATE] were written 30 days after the suspected DTI of resident 49's right heel and 10 days after the measurement of 5.2 cm x 6 cm of resident 49's right heel.) b. A physician's order dated [DATE] revealed, Right lateral distal calf: Cleanse wound with wound cleanser, apply sure prep to peri-wound, apply hydrogel to wound bed, cover with opti-foam one time a day every other day for vascular wound. Replace if dressing is soiled or becomes dislodged. (NOTE: The physician orders written on [DATE] were written 3 days after the measurement of 3.5 cm x 3.3 cm x 0.2 cm with 10% slough of resident 49's right lateral distal calf.) c. A physician's order dated [DATE] revealed, Start wound clinic 3 times a week for ankle ulcer. (NOTE: Resident 49 was not set up with the wound clinic until [DATE] and the appointment was canceled after her vascular appointment on [DATE].) d. A physician's order dated [DATE] revealed, Right heel: Clean with wound cleaner, apply skin prep and non adherent dressing, wrap with kerlix and secure with coban, covering heel and lateral lower extremity, one time a day for wound care. (NOTE: The physician orders written on [DATE] were written 17 days after resident 49's right heel was noted to have 70% necrotic tissue on [DATE].) e. A physician's order dated [DATE] revealed, Right lateral lower extremity: Clean are (sic) with wound cleaner, apply [MEDICATION NAME] impregnated hydrogel gauze and cover with 4 x 4 [MEDICATION NAME] one time a day for vascular ulcer. (NOTE: The physician orders written on [DATE] were written 17 days after resident 49's right lateral lower extremity was noted to have 70% necrotic tissue on [DATE] and 11 days after it was noted to have gained an odor on [DATE].) A review of resident 49's TARs (Treatment Administration Records) revealed the following: a. Resident 49's TAR for [DATE] revealed that resident 49 did not receive the treatment of [REDACTED]. The TAR revealed that resident 49 did not receive the treatment of [REDACTED]. b. Resident 49's TAR for [DATE] revealed that resident 49 did not receive the treatment of [REDACTED]. c. Resident 49's TAR for [DATE] revealed that resident 49 did not receive the treatment of [REDACTED]. d. Resident 49's TAR for [DATE] revealed that resident 49 did not receive the treatment of [REDACTED]. e. Resident 49's TAR for [DATE] revealed that resident 49 did not receive the treatment of [REDACTED]. A review of resident 49's care plan dated [DATE] and revised on [DATE] revealed the following: a) (Resident 49) is at risk for skin breakdown as evidenced by shear/friction risks due to brace, limited mobility, incontinence. The Goal for resident 49 was (Resident 49) will not show signs of skin breakdown x 90 days. The interventions for resident 49 were apply barrier cream with each cleansing, assist resident in repositioning frequently, encourage resident to consume all fluids during meals, evaluate for skin risk factors per protocol, observe skin condition with ADL (activities of daily living) care daily and report abnormalities, pressure redistribution surfaces to bed as per protocol, pressure redistribution surfaces to chair as per protocol, provide peri care/incontinence care as needed, weekly skin assessment by licensed nurse. b) (Resident 49) exhibits or is at risk for compromised peripheral circulation. The Goal for resident 49 was (Resident 49) will experience maximum peripheral circulation with minimal complications x 90 days. The interventions for resident 49 were .assess and monitor for numbness, tingling, throbbing, and/or burning in affected extremities and report abnormalities to the physician, .float heels as indicated, monitor skin for skin breakdown and report as indicated. (NOTE: No order to float resident 49's heels could be located in the physician orders or on the TARs as an intervention.) c) (Resident 49) has actual skin breakdown related to vascular ulcer to lower tight (sic) calf, DTI to right heel. The goal for resident 49 was wound will remain free from signs and symptoms of infection x 90 days and wound will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] and drainage and presence of granulation x 90 days. The interventions for resident 49 were to .float heels while in bed, .monitor for signs and symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, .provide wound treatment as ordered. On [DATE] at 9:45 AM, an interview was conducted with the facility DON. The DON stated that the boot was not too tight for resident 49 but that the boot had rubbed against the bottom of her leg causing the pressure sore on the heel and against the leg irritating the right lateral ankle, causing it to create a sore. The DON stated that it was concerning that nobody had called resident 49's physician to inform him of the wounds, to start wound care timely or to call and inform him when the wounds worsened. On [DATE] at 10:15 AM, an interview was conducted with the facility van driver. The van driver stated that the order had to be put into the physician's orders, then printed out and given to her by the nurses in order for her to set up the appointments. The van driver stated that she did not know if resident 49 had been to the wound clinic. On [DATE] at 12:05 PM, an interview was conducted with the DON. The DON stated that the appointment for the wound clinic had been set up for [DATE]. The DON stated that resident 49 had an appointment with her vascular surgeon on [DATE] and the decision was made for the right leg AKA so the wound clinic appointment for [DATE] was canceled. The DON stated that she did not know why the appointment had not been made at the wound clinic for resident 49 after the order on [DATE] nor why the physician was not notified that she did not go to the wound clinic. POTENTIAL FOR HARM 3. Resident 48 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 48's medical record was reviewed. Resident 48's MDS (Minimum Data Set) assessment dated [DATE], revealed that resident 48 had triggered in the CAA (Care Area Assessment) section for being at risk for pressure ulcers and had been care planned. Physician orders dated [DATE] for resident 48 revealed Float heels while in bed. On [DATE] at 2:15 PM, an observation was made of resident 48 lying on her bed with her heels not floated. (Note: The heels were resting directly on a pillow.) On [DATE] at 12:10 PM, an observation was made of resident 48 lying on her bed with her heels not floated. On [DATE] at 8:30 AM, an observation was made of resident 48 lying in her bed with her heels not floated. On [DATE] at 2:20 PM, an observation was made of resident 48 lying in her bed with her heels not floated. On [DATE] at 9:45 AM, The DON stated that her expectation for any resident would be that the nurses would call the resident's physician to inform them of any new wound or change to any existing wound, to get orders at that time, to keep the physician updated as to the wounds progress and to follow physician orders. 4. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 14's medical record was reviewed. Resident 14's [DATE] MAR indicated that resident 14 had an order for [REDACTED]. During that 10 day period, resident 14's pain score was recorded 6 times, all of which were 7 or higher. (Note: The [MEDICATION NAME] was discontinued on [DATE].) Resident 14's [DATE] MAR indicated that resident 14 had an order for [REDACTED]. From [DATE] through [DATE] resident 14's pain score was recorded on 11 of the 15 days. During that time, resident 14's pain score was documented as having been between a 6 and 9.8. The [DATE] MAR did not indicate that resident 14's pain was to be monitored. No pre or post medication scores were documented, nor were there any tools in place to indicate whether or not resident 14's pain was being adequately managed. On [DATE] at 11:30 AM, an interview was conducted with resident 14. Resident 14 stated that her back was hurting, and she was currently at a 5 on a 1 to 10 pain scale. The resident stated that she was aware that the facility had discontinued her [MEDICATION NAME], but was unsure why they had done so. Resident 14 also stated that she sometimes got as high as a 9 on the pain scale, and that if the facility could do anything else to decrease her pain that would be good. 5. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>On [DATE] resident 61's medical record was reviewed. Resident 61's [DATE] MAR was reviewed. On 25 of the 31 days facility staff documented that resident 61 indicated that he was in pain. However, no pre or post medication scores were documented, nor were there any tools in place to indicate whether or not resident 61's pain was being adequately managed. Resident 61's [DATE] MAR was reviewed. On 20 of the 30 days facility staff documented that resident 61 indicated that he was in pain. However, no pre or post medication scores were documented, nor were there any tools in place to indicate whether or not resident 61's pain was being adequately managed. Resident 61's [DATE] MAR was reviewed. On 18 of the 20 days reviewed in October, facility staff documented that resident 61 indicated that he was in pain. However, no pre or post medication scores were documented, nor were there any tools in place to indicate whether or not resident 61's pain was being adequately managed. On [DATE] at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when a resident was in pain, facility staff were supposed to document the level of pain on the pain monitoring sheet. LPN 2 stated that resident 61 was unable to indicate verbally that he was in pain, and so he had to be monitored for non-verbal signs of pain such as facial grimacing. LPN 2 stated that resident 61 often grimaced, but she assumed his pain was under control. (Cross refer to F157 and F314)

Based on the observation, interview and record review it was determined that the facility did not provide appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and to restore, if possible, normal eating skills for a resident who was fed by a naso-gastric tube for 1 of 34 sample residents. Specifically, a resident's tube feeding was not monitored appropriately and the resident subsequently complained of extreme thirst stating she would rather be dead than this thirsty. This resulted in a finding of psychosocial harm for the resident. In addition, the resident did not have weights or laboratory values obtained to ensure her tube feeding was adequate. Resident identifiers: 74. Findings include: Resident 74 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/17/16 at 8:30 AM, an observation was made of resident 74. Resident 74 was lying in bed with a tube feeding pump administering formula at 65 ml (milliliters) per hour. On 10/19/16 at 3:15 PM, an observation was made of resident 74. Resident 74 was observed to have dry chapped lips that had dry flaking skin on her lips. Resident 74 had a white substance around her lips with a thick mucus that expanded when she tried to talk. There were no ice chips observed at her bedside. Resident 74 stated that she was thirsty and needed ice chips. On 10/20/16 at 7:55 AM, an other interview was conducted with resident 74. Resident 74 stated that she was thirsty and needed ice chips because her mouth was painfully dry. Resident 74's medical record was reviewed on 10/20/16. Resident 74's weights documented in the electronic medical record were: (Note: All weights were in pounds.) a. 5/6/16, 196.6 b. 6/3/16, 205.6 c. 7/12/16, 207.6 d. 8/9/16, 215.6 e. 9/7/16, 221.0 (Note: Resident 74 did not have any weights obtained since being readmitted to the facility on [DATE] with a tube feeding.) Resident 74's physicians orders revealed the following: a. 10/13/16, .[MEDICATION NAME] 1.2 CAL (calorie) (at) 65 ml/hr. Administer via continuous feed total volume 1560 ml (milliliters) (per) 24 hrs (hours). b. 10/13/16, Every 4 hours Flush NG (nasogastric) tube with 150 ml of water. Total volume of flush (equals) 900ml/24 hours (excluding medication flushes). Resident 74's discontinued physicians orders revealed the following: a. 10/7/16, Flush tube with 100 ml of water Total volume of flush (equals) 400 ml/24 hours. b. 10/7/16, .[MEDICATION NAME] 1.2CAL (at) 55 ml/hr.30 ml/HR, increase by 10ml every 4 hours until goal rate (55ml/hr) is reached. (Note: The flushes and formula provided 1980 calories, 72.6 grams of protein, and 1465 ml of free water per 24 hours.) Resident 74's progress notes revealed the following entries: a. 10/8/16, .continually wanting water to sip on. Provided swabs and oral care. b. 10/9/16, .Patient remains lethargic but will arouse when spoken to. c. 10/10/16, .She yelled out for much of the night, 'I'm thirsty'. d. 10/11/16, .Resident remains lethargic and largely inactive.tube noted to clog during morning mediation administration.tube replaced e. 10/12/16, .NJ (nasojejunem) tube noted to be clog (sic) during morning medication administration. f. 10/13/16, .Resident remains lethargic, continues to call out for water. g. 10/14/16, .Resident continues to call out for water. h. 10/14/16, pt (patient) given HS (hours of sleep) meds (medications) as ordered via feeding tube, pt stated, 'I don't want a feeding tube anymore, why do I have to have this' I told patient that she needed it to get food, and without it she could die, pt stated 'I don't care.' I told her that I care, and that we all do, she asked for water to drink and I swabbed her mouth and explained the risk of aspiration, again she stated, 'I don't care.'. i. 10/15/16, .Continually asks for sips of water. Mouth care completed frequently. Resident advised that she cannot have anything by mouth at the moment, resident continues to ask for water and ice chips. j. 10/16/16, Resident continues on tube feeding via NJ tube, continues to yell 'I need more water' even when swabs given. Picked up graduate while nurse priming tube feeding and attempted to drink water from graduate. Then continues to yell 'water, water, I need more water.' Swabs given, resident not satisfied with oral care. k. 10/16/16, Resident given swabs of H2O (water), continues to yell in room awakening other residents. States 'I'm going to fall on this floor looking for water if you don't give it to me.'. l. 10/17/16, (Resident 74) was awake most of the night yelling out 'I'm thirsty', I'm thirsty', 'water', 'water please'. She begs and pleads for water. She says she would rather be dead than have to be so thirsty all the time. m. 10/18/16, .Always thirsty, wants to eat something. n. 10/18/16, This resident has been voicing her desire for more fluid, spoke with PA (Physicians Assistant) received new orders for [MEDICATION NAME] for her dry mouth and also resident may have ice chips as needed for a dry mouth. The facility Registered Dietitian (RD) documented the following: a. 10/10/16, A Nutrition Assessment was completed today. Resident recently readmitted from hospital. Resident is at nutritional risk: swallowing difficulty r/t (related to) motor causes due to neurological or muscular disorders as evidenced by medical record. Resident is receiving [MEDICATION NAME] 1.2 (at) 55 ml (times) 24 hours via NG tube. Recommend increasing water flushes to 100 ml every 4 hours excluding medication flushes. Recommend advancing diet per SLP (Speech Language Pathologist) evaluation recommendations. Will continue to monitor nutritional status - Will FU (follow up) PRN (as needed) and quarterly. b. 10/13/16, Recommend gradually increasing enteral feeding to [MEDICATION NAME] 1.2 (at) 65 ml/hr (times) 24 hours via NJ tube. Recommend increasing water flushes to 150 ml every 4 hours excluding medications flushes. Will continue to monitor nutritional status- Will (follow up as needed) and quarterly. A care plan revealed dated 10/10/16 and updated 10/13/16 revealed, Resident requires enteral nutrition to provide 100% of estimated need. The goal developed was, Resident will tolerate enteral nutrition and water flushes provided 1872 kcal (Kilocalories), 86 gr (grams) of Pro (Protein), and 1560 ml total volume; water flushes 150ml every 4 hours provides additional 900 ml. The intervention developed was Provide enteral feeding per physician orders [REDACTED]. A Nutritional Assessment form dated 10/10/16 documented by the RD was reviewed. It was documented that resident 74's estimated nutritional needs were 2033 Calories, 56 grams of protein, and 1735 ml of free water. The laboratory values used by the RD dated 9/23/16 were BUN (Blood Urea Nitrogen) 30 mg/dL (milligrams per Deciliters), Creatinine1.56 mg/dL, protein 6.3 g/dL (grams per Deciliter) and [MEDICATION NAME] 3.0 g/dL with a Globular Filtration Rate (GFR) of 33 ml/min/1.73m2. (Note: The RD used 25ml/kg of adjusted body weight to calculate fluid needs. Resident 74's usual body weight documented was 190 pounds and estimated fluids needs of 2159 to 2591 ml per 24 hours.) Laboratory values submitted to the surveyors on 10/24/16 were dated 10/21/16 revealed that resident 74 had an elevated BUN Level of 49 with an elevated creatinine level of 1.49 mg/dL. The reference range according the the laboratory results form were BUN 7-18 and Creatinine was 0.55-1.02. Resident 74's [MEDICATION NAME] level was 2.4g/dL which was low according to the reference range of 3.4-5.0. A total protein level was 6.2 g/dL with a reference range of 6.4-8.2. The BUN/Creatinine Ratio was 32.0 ratio that was high the reference range was 7.0 - 24.0. The estimated GFR was low at 35 with a reference range on 60-130. Resident 74's Medication Administration Record [REDACTED]. On 10/20/16 at 10:04 AM, an interview was conducted with the RD. The RD stated that resident 74 readmitted from a hospital on 55 ml per hour of [MEDICATION NAME] 1.2 calorie formula. The RD stated that resident 74 was nauseated and vomited which indicated she was not tolerating the tube feeding. The RD stated that the rate was decreased and slowly increased until she was tolerating the formula. The RD stated that she used 25 ml/kg of adjust body weight for water needs. The RD stated that was low. The RD stated that she was waiting for a weight and laboratory results to assess resident 74's nutritional status since the administration on the tube feeding. The RD stated that the facility's weight policy was to weigh each resident weekly for the first month and then monthly after being stable. The RD stated that she did not know the resident's hydration status because there were no current laboratory values or weights. The RD stated that she was aware that resident 74 was complaining of being thirsty so she increased the resident's free water flushes on 10/13/16. (Note: The RD increased fluid to 2158 ml per 24 hours.) On 10/19/16 at 3:50 PM, an interview was conducted with Director of Nursing (DON). The DON stated that the nursing staff must have forgot to document the 9 flushes in October. The DON stated that resident 74 complained of a really dry mouth. The DON stated that laboratory results were not obtained per RD recommendations. The DON further stated that resident 74 refused to be weighed but there was no documentation that resident refused. On 10/20/16 at 11:00 AM, an interview was conducted with the resident 74's PA. The PA stated that he would expect to have weights obtained every other day and laboratory values obtained weekly to determine if the tube feeding formula and rate were appropriate. The PA stated that they wanted to get a swallow study obtained and was not sure if it had been completed. The PA stated that it was very important to monitor weight and laboratory values since resident 74 had only been on the tube feeding since 10/7/16.

Based on observation, interview and record review, it was determined the facility did not have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Specifically, (1) The Restorative Nursing Program was not implemented due to low staffing; (2) Residents were not receiving assistance in the dining room as needed; (3) Showers were not completed as scheduled; and (4) Call lights were not answered in a timely manner. Resident identifiers: 3, 17, 20, 47, 52, 78, 79, 86, 111, and 124. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/6/15, resident 20 was interviewed. Resident 20 stated that she did not always receive her shower due to short staffing. Resident 20 stated that the Certified Nursing Assistants (CNAs) did not always have time to give her her shower. Resident 20 stated that she did not receive her shower on 7/3/15 due to short staffing. On 7/9/15 resident 20's medical record was reviewed. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) assessement dated 6/8/15. Facility staff assessed resident 20 as requiring extensive assistance with a one person physical assist with hygeine. Additionally, facility staff assessed resident 20 as requiring physical help in part of the bathing activity with a one person physical assist. On 7/8/15 at approximately 10:30 AM, CNA 10 was interviwed. CNA 10 stated that the CNAs did not have time to complete the showers. CNA 10 stated that showers were missed frequently and that residents did not receive their showers on their scheduled days due to staffing being short. On 7/8/15 at approximately 1:00 PM, CNA 4 was interviewed. CNA 4 stated that residents did miss showers due to CNAs not having time to shower the residents. On 7/8/15, Registered Nurse (RN) 1 was interviewed. RN 1 stated that CNAs had reported to her that residents had missed showers due to not having enough staff. 2. The following observations were made of call lights alarming and being answered by facility staff: a. On 7/6/15 at 2:00 PM, room [ROOM NUMBER]'s call light began alarming. Facility staff answered the call light at 2:11 PM. b. On 7/6/15 at 2:00 PM, room [ROOM NUMBER]'s call light began alarming. Facility staff answered the call light at 2:14 PM. c. On 7/6/15 at 1:25 PM, room [ROOM NUMBER]'s call light began alarming. The facility Administrator was observed to enter room [ROOM NUMBER] at 1:39 PM. The facility Administrator was observed to leave room [ROOM NUMBER] and inform Licensed Practical Nurse (LPN) 1 that the resident in room [ROOM NUMBER] was ill and required assistance. At 1:40 PM, LPN 1 and a surveyor entered room [ROOM NUMBER] to find that the resident in room [ROOM NUMBER] had vomitted on herself and the floor. d. On 7/8/15 at 8:40 AM, room [ROOM NUMBER]'s call light began alarming. Observations revealed LPN 1 telling a facility Laundry worker, at 8:50 AM, to answer the light in room [ROOM NUMBER] and that, He probably only needs his breakfast tray picked up. At 8:52 AM, the facility Laundry worker was observed to leave room [ROOM NUMBER] and inform LPN 1 that the resident in room [ROOM NUMBER] needed to use the bathroom. At 8:55 AM, a facility CNA was observed to enter room [ROOM NUMBER] to assist the resident. e. On 7/7/15 at 9:57 AM, the call light for room [ROOM NUMBER] sounded. At 10:02 AM, the facility Activity Director (AD) entered the room. The AD exited the room and notified the charge nurse that the resident needed assistance. At 10:03 AM, the Medical Records (MR) Director entered room [ROOM NUMBER] and turned off the call light. At 10:04 AM, an interview was conducted with the resident in room [ROOM NUMBER]. The resident stated that she had to have her brief changed. At 10:05 AM, a facility CNA entered the room to assist the resident in room [ROOM NUMBER] with changing her brief. f. On 7/7/15 from 9:31 AM until 9:46 AM, an observation was made of a call light alarming for room [ROOM NUMBER]. There were no staff observed to check on residents during the 15 minutes that the call light was alarming. 3. On 7/6/15 at 1:00 PM, an interview was conducted with resident 79. Resident 79 stated that there were not enough staff. Resident 79 stated that she had to wait for long periods of time for staff to assist her to the bathroom. On 7/7/15 at 8:12 AM, an interview was conducted with resident 17. Resident 17 stated that there were not enough staff. Resident 17 stated that he had to wait to go to bed because there was only 1 aide to assist all the residents in his area to bed. Resident 17 further stated that he needed his urinal to be cleaned during the night but there were not enough staff to answer his call light. On 7/7/15 at 1:32 PM, an interview was conducted with resident 52. Resident 52 stated that there were not enough staff to get her out of bed around 10:30 AM. Resident 52 stated that staff would get her up usually around 11:00 or 11:30 AM because there were not enough staff. On 7/6/15 at 2:04 PM, an interview was conducted with resident 86. Resident 86 stated that he wanted more showers than were scheduled. Resident 86 stated he told staff that he wanted more showers but there were not enough staff for him to take more showers. On 7/06/15 at 1:45 PM, resident 111 was interviewed. Resident 111 stated that very often he waited for call lights to be answered for 15-20 minutes. On 7/06/15 at 2:30 PM, resident 124 was interviewed. Resident 124 stated that in the afternoon, from 2 PM to 10 PM, he would have to wait for 45 minutes for the call light to be answered. On 7/07/15 at 9:20 AM, resident 3 was interviewed. Resident 3 stated that staff were nice, but the facility was shorthanded. Resident 3 stated that she needed to wait for 20 - 30 minutes for the call lights to be answered. On 7/07/2015 at 10:10 AM, resident 78 was interviewed. Resident 78 stated that she was not showered for a week after admission to the facility. Resident 78 futher stated that she had asked for a shower, but the staff were unable to provide the shower. Resident 78 stated that she had waited for 30 minutes or longer for her call light to be answered. On 7/07/15 at 1:45 PM resident 47 was interviewed. Resident 47 stated that residents waited the longest, to have their light answered, between the hours of 2 - 10 PM, when the facility staff were trying to give residents a shower. Resident 47 stated that residents waited for 20 minutes or longer to have their call light answered during showers. 4. On 7/12/15 at 9:40 PM, an interview was conducted with LPN 3. LPN 3 stated that there were more staff than usual for the 200 hall. LPN 3 stated that having extra staff was helpful. LPN 3 stated that usually the facility did not allow for 4 aides and a floating aide. On 7/12/15 at 9:42 PM, an interview was conducted with CNA 3. CNA 3 stated that there were currently 4 aides and a floating aide for the 200 hall. CNA 3 stated that she was unable to get all of her assigned duties done when there were not enough aides scheduled. CNA 3 stated usually there were 3 aides assigned for the 200 hall. On 7/12/15 at 9:45 PM, an interview was conducted with CNA 12. CNA 12 stated that when there were only 3 CNAs it was hard to get showers done. CNA 12 stated that if she was unable to complete all of the assigned showers one evening that the showers would be scheduled for the next evening. CNA 12 stated sometimes there could be up to 10 showers to complete which was not possible to complete with 3 CNAs. On 7/12/15 at 10:00 PM, an interview was conducted with CNA 1. CNA 1 stated that there were not enough staff. CNA 1 stated that there were new staff members which were not oriented to the residents or facility. CNA 1 stated new CNAs needed more orientation with staff before allowing them to work alone. CNA 1 stated that he usually had to work alone with 13 residents from 2:00 PM until 10:00 PM. CNA 1 stated that currently there were 2 aides working with 13 residents. CNA 1 stated that when he was working alone and a resident that required 2 person assistance needed assistance that a nurse would help. On 7/12/15 at 10:10 PM, an interview was conducted with CNA 13. CNA 13 stated that there were not enough staff for the grave yard shift. On 7/12/14 at 10:15 PM, an interview was conducted with CNA 14. CNA 14 stated that when there were only 3 aides for the 200 hall, Only 90% of the showers were done. CNA 14 stated that when there were 10 showers to be completed with only 3 aides that the showers were not completed. CNA 14 stated that there needed to be more staff. (Cross refer to F312, and F318).

Based on interview, observation and record review it was determined, for 1 of 45 sample residents, that a resident was not allowed to choose activities and make choices about aspects of his life in the facility that were significant to the resident. Specifically, a resident was waiting for a wheel chair to be delivered, that had been removed by staff, so he could move about the facility and go to meals and activities. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/7/15, resident 74 was interviewed. Resident 74 stated that he would get out of bed if he had a wheel chair. Resident 74 stated that he got out of bed on Father's Day and was so happy. Resident 74 further stated that the hospice nurse had told him that she had ordered him a wheel chair custom for his height and weight. Resident 74 further stated that if he had a wheel chair he could have a choice as to what activities he would like to go to. Resident 74 stated that a wheel chair was delivered to him but the facility staff looked at the wheel chair and told him that it was too small and took the wheel chair away. On 7/13/15 at 1:00 PM, resident 74's Hospice Nurse Case Manager (HNCM) was interviewed via telephone. The HNCM stated that the hospice company had provided resident 74 with a custom wheel chair from (name of company) DME (Durable Medical Equipment). The HNCM stated that the wheel chair was specific for resident 74's height and weight. The HNCM stated that she was unaware that the wheel chair was missing and that resident 74 was still waiting for the wheel chair to be delivered. The HNCM further stated that she was unaware that resident 74 was lying in bed daily waiting for the wheel chair. On 7/13/15 at 1:05 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 74 did not have a wheel chair. RN 1 stated that if a resident needed a wheel chair that the staff could go and get a wheel chair from the utility closet. RN 1 stated that she knew nothing about a custom wheel chair being delivered for resident 74. During the interview with RN 1, resident 74 began telling RN 1 that he would love to get out of bed but did not have a wheel chair. Resident 74 was heard telling RN 1 that a wheel chair had been delivered to him but the facility staff told him that it was too small and removed the wheel chair from his room. Resident 74 stated, Stupid me I didn't try it the day they brought the chair and I guess I should have to see if it really was too small. I feel stupid for not trying it that day but I just assumed I could try it later. When the staff said the wheel chair was too small, I took their word for it. On 7/13/15 at 1:15 PM, RN 1 was observed in the supply closet looking for a wheel chair for resident 74. Observations revealed the (name of DME company) wheel chair was at the back of the supply closet surrounded by multiple wheel chairs. The surveyor pointed the wheel chair out to RN 1. RN 1 then stated, Thank goodness you spotted the chair, I would not have seen it. RN 1 stated that she did not know that a wheel chair had been provided by the Hospice Company. The wheel chair was observed to have all new tags in place and appeared to be unused. On 7/13/15 at 1:30 PM, an employee from the DME company was interviewed via telephone. The employee stated that the DME company had delivered the wheel chair to resident 74 on 6/23/15. On 7/13/15 resident 74's medical record was reviewed. Review of the medical record revealed the following entries in the Medical Social Worker Visit Note: 1. 6/3/15 - Narrative Notes - Pt (patient) was awake today, lying in bed. Pt states that he plans to get out of bed next week and would like to be taken outside for a walk in his wheel chair. Pt seems to enjoy having visitors. He spends most of his time sleeping in bed. 2. 6/23/15 - Narrative Notes - Pt was in bed, sleeping when SW (Social Worker) arrived. Pt woke easily and seemed to be happy to have a visitor. Pt becomes SOB (short of breath) with conversation. Pt seemed to be in good spirits today. Pt only wanted to talk about his going outside with his sons on father's day. He was very proud of himself and was very happy to have gone outside in a wheel chair. Pt is excited to continue to get out of bed with the help of facility staff. Pt is very weak and unable to support his own weight in transferring. He must be transferred using a lift by facility staff. Pt also states that he wants to use his new wheel chair for meals.

Based on observation, interview, and record review it was determined, for 5 of 45 sample residents, that the facility did not ensure that residents with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, residents were not receiving the Restorative Nurse Aide (RNA) program that was ordered by the physician and/or recommended by the Physical Therapist, therefore causing a decrease in range of motion. Resident identifiers: 6, 52, 60, 67, and 71. Findings include: 1. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/15 resident 60's medical record was reviewed. Review of the physician's orders [REDACTED]. CNA (Certified Nursing Assistant) will perform UE (upper extremity) range of motion exercises 6 X (times) weekly. CNA will work with (Resident 60) on improving transfer skills 6 X weekly. On 7/6/15, 7/7/15, and 7/8/15 resident 60 was observed to be sitting in his wheel chair moving about the facility. Resident 60's left lower extremity was observed to be contracted at the knee thus causing resident 60's lower leg to be pulled up under the wheel chair seat. Resident 60 was observed to propel himself in the wheel chair with his right leg. No observations were made of resident 60's left lower extremity being on a wheel chair foot rest. On 7/9/15, resident 60 was interviewed. Resident 60 stated that he had a significant amount of pain in his left lower extremity. Resident 60 stated that the staff had not provided Restorative Nursing services. Resident 60 further stated that he was angry that he had decreased range of motion in his left lower extremity. Observations of resident 60 from 7/6/15 - 7/9/15 revealed no observations of resident 60 receiving the physician ordered RNA program. On 7/8/15 at 9:30 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that the Minimum Data Set (MDS) Coordinator was the nurse overseeing the RNA Program. The DON further stated that she did not have designated Restorative Nursing Aides (RNAs) to perform the RNA program but rather the Certified Nursing Assistants (CNAs) working the floor did the RNA program for the individual residents in their section. On 7/8/15 at 9:45 AM, the MDS Coordinator Nurse was interviewed. The MDS Coordinator confirmed that she was responsible for the RNA program. The MDS Coordinator confirmed that she did not have designated RNAs to complete the program but the floor CNAs were completing the RNA program. The MDS Coordinator further stated that the Physical Therapy (PT) Director had helped her (the MDS Coordinator) write some of the RNA programs. Review of the MDS Coordinator's RNA program revealed four facility residents, including resident 60, that were supposed to be receiving RNA services. The MDS Coordinator confirmed that the four residents, including resident 60, were the only residents receiving RNA services. Review of the Restorative Nursing Program Progress Notes and Summary revealed the following: a. Goal: (Resident 60) will maintain / improve his current functional mobility, optimal range of motion. b. Plan: CNA will provide Range of Motion exercises 6 X weekly. CNA will work with (Resident 60) on improving transfer skills 6 X weekly. Review of the above mentioned form revealed the form to be blank. No documentation could be found to show that resident 60's progress was being monitored. On 7/8/15 at 10:00 AM, the facility PT Director was interviewed. The PT Director provided the surveyor with a list of 10 residents that he had developed an RNA program for. Resident 60 was not one of the ten residents that the PT Director had a program for. The PT Director stated that he should have been better at updating his list of residents receiving RNA services and he should have been better at writing RNA programs. The PT Director stated that his expectation was that the residents that he had written RNA maintenance programs for, were in fact receiving those services. On 7/8/15 at 10:30 AM, CNA 10 was interviewed. CNA 10 stated that he was the CNA providing care to resident 60. CNA 10 stated that the CNAs did not have time to perform the RNA program duties. CNA 10 confirmed that the CNAs were not providing the RNA program to resident 60. On 7/8/15 at 1:00 PM, CNA 4 was interviewed. CNA 4 stated the the CNAs were not providing the RNA maintenance programs to the residents. CNA 4 further stated that the RNA program duties were not occurring due to time constraints. Review of resident 60's medical record revealed that resident 60 had received PT services from 4/9/15 - 6/7/15. The following was documented in the Physical Therapy Recertification/Mobility Summary: Summary of Patient/Client Current Status: This pt (patient) has been able to get up out of his bed more and spend increased amounts of time up in his wheelchair. He has improve (sic) Left knee ROM (range of motion) which has improved his ability to sit in the wheelchair safely and comfortably without his foot falling of (sic) the foot rest and dragging on the floor. Pt has made some improvements with transfers but still needs maxA (maximum assistance). Pt has less c/o (complaints of) pain. ; Summary of Skilled Services Provided: Manaul (sic) therapy for stretching the left LE (lower extremity) hamstrings and external rotatores (sic) of the left hip. Stretching with deep tendon pressure and massage and PNF (?) contract relax techniques to improve stretches. Exercises for lower extremity strengthening with AAROM (active range of motion) and help to the left leg. Transfer training with tactile cues for timing and sequencing of movement. On 7/8/15 at 10:45 AM, the Physical Therapy (PT) Director was reinterviewed. The PT Director stated that he was aware that the RNA maintenance programs were not occurring. The PT Director further stated that he was frustrated that the programs were not occurring. The PT Director stated that when resident 60 was discharged from therapy, resident 60 was able to put his left leg onto the wheelchair foot rest. The PT Director stated that resident 60 had some range of motion in his left LE at the time of discharge from PT. The PT Director stated that since resident 60 has been discharged from therapy and not received the RNA services that resident 60 had experienced a decline and that resident 60 now needed a different foot rest for his wheel chair due to the Left LE contracture becoming worse. The PT Director further stated that had resident 60 received the RNA services, resident 60's contracture may not have gotten worse. On 7/13/15, the facility Administrator provided surveyors with the following PT evaluation dated 7/10/15: Reason for Referral: Nursing has noted this pt has recently had increased difficulty keeping his left foot on the foot rest of his wheelchair because of muscle spasms and discomfort. Pt is able to put his foot on the foot rest and use a velcro strap to hold it one (sic) but recently has been electing not to do that as much because of pain and discomfort. Pt was previously able to maintain his foot on the wheelchair foot rest for longer periods of time but did complain of discomfort with positioning on occasion. Pt. will be see (sic) for positioning to see if he needs stretching or wheelchair adjustments to improve his seating and positioning in the wheelchair. 2. Resident 52 was readmitted on [DATE] with [DIAGNOSES REDACTED]. On 7/7/15 at 2:15 PM, an observation was made of resident 52's right hand. Resident 52 was unable to open her hand. An interview was immediately conducted with resident 52. Resident 52 stated that therapy staff were working with her leg using electrical stimulation. Resident 52 stated that she had a brace for her hand but that she had to ask staff to put it on. Resident 52 stated that there was no other therapy provided for her hand. Resident 52's medical record was reviewed on 7/9/15 On 5/28/15 an admission MDS assessment revealed that resident 52 had limited Range of Motion (ROM) to both lower and upper extremeities. On 7/8/15 at 9:45 AM, an interview as conducted with the MDS Coordinator. The MDS Coordinator stated that resident 52 was recently discharged from physical therapy. The MDS Coordinator stated that resident 52 was not currently on any Restorative Services. On 7/8/15 at 10:00 AM, an interview was conducted with the PT Director. The PT Director stated that resident 52 was provided electrical stimulation for her leg. The PT Director stated that he was aware of the contracture to resident 52's left hand and that staff were not providing ROM or other services. 3. Resident 6 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 7/8/15 at 10:23 AM, resident 6 was observed sitting in bed. Resident 6 was unable to open her right hand without using her other hand. Resident 6 was then observed to be propelled by staff in a wheel chair. On 7/8/15 at 12:21 PM, an observation was made of resident 6. Resident 6 was observed to propell herself down the hall in a wheel chair. Resident 6 was not observed to have staff ask resident if she would like to walk with assistance. Resident 6's medical record was reviewed on 7/9/15. An MDS assessment dated [DATE] revealed that resident 6 had limited ROM to her lower and upper extemities. A Restorative Nursing Program form provided by the PT Director revealed that resident 6, Using a gait belt and her walker help her walk part way to meals or activities, You (sic) she will need a person to follow with a wheelchair because of her poor endurance. On 7/8/15 at 10:49 AM, an interview was conducted with CNA 2. CNA 2 stated that she had not been instructed to provide ROM or other Restorative Nursing Services for resident 6. On 7/8/15 at 1:50 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 6 refused to walk at times. CNA 4 further stated she did not know that resident 6 needed to be walked. CNA 4 stated that she did not document if resident 6 refused to walk to dining or other activities. CNA 4 stated that it would be good for resident 6 to recieve ROM services but there were not enough staff to provide RNA services during the day shift. On 7/8/15 at 1:24 PM, an interview was conducted with the PT Director. The PT Director stated that resident 6 was to receive RNA services by the facility CNAs. The PT Director stated that resident 6 needed to walk to the dining room and activities. The PT Director stated that all CNAs were resposible for providing RNA services. 4. Resident 71 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 71's medical record was reviewed on 7/7/15. On 7/7/15, an order was written for (Resident 71) to participate in the Restorative Nursing Program. CNA will assist (resident 71) with putting on her left hand splint 7 x (times) weekly. CNA to check with therapy for any questions. CNA will observe for signs of pain or discomfort. On 7/8/15 at 1:16 PM, PT 2 was interviewed. PT 2 stated that resident 71 was on the Restorative Nursing Program and was to be receiving range of motion services on her left hand. On 7/8/15 at 10:30 AM, resident 71 was interviewed. Resident 71 stated that the therapist gave her a splint for her left hand about ten days ago and stated that someone was suppose to be putting it on her daily, but had not received any range of motion or had the splint applied. On 7/8/15 at 11:45 AM, CNA 8 was interviewed. CNA 8 stated that she was not aware that resident 71 was to have a splint applied to her left hand. CNA 8 stated that the CNAs were to be providing restorative nursing services. CNA 8 stated that she had not been educated or trained on how to apply the splint or what kind of range of motion services to perform on resident 71's left hand. On 7/8/15 at 1:16 PM, PT 2 was re-interviewed. PT 2 stated that the CNAs were to be providing range of motion services to resident 71's left hand six times a week beginning on 6/20/15. On 7/8/15 at 2:10 PM, PT 2 was again interviewed. PT 2 stated that he did not initiate the range of motion services on 6/20/15 like he should have. PT 2 stated that he had not provided education or training to the CNA staff on what kind of range of motion to perform on resident 71's left hand (i.e. Active Range of Motion, Passive Range of Motion, flexion or extension). 5. Resident 67 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/15 resident 67's medical record was reviewed. Review of the physician progress notes [REDACTED]. The physician documented the following in the Plan section of resident 67's progress notes: Contractures managed with [MEDICATION NAME], of which she was due to receive a dose when I evaluated her this afternoon. I have also spoken with physical therapy regarding this; they will have the activities coordinator work with range of motion exercises to try and alleviate some of the pain caused by the contractures. Review of the medical record revealed the following care plan dated 6/2/15: (Resident 67) will participate in the Restorative Nursing Program r/t (related to) her risk for impaired physical mobility, decreased strength and endurance. On 7/8/15 the MDS Coordinator was interviewed. The MDS Coordinator stated that resident 67 was receiving RNA services. The MDS Coordinator provided surveyors with a copy of resident 67's RNA program. The RNA program was reviewed for resident 67 and the following Goals were documented: CNA will provide daily assistance with walking using gaitbelt or platform walker no more than 60 feet 6 X weekly and CNA will perform ROM exercises 6 X weekly. No observations were made of resident 67 receiving RNA services. On 7/8/15 at 9:30 AM, the facility DON was interviewed. The DON stated that the MDS Coordinator was the nurse overseeing the RNA Program. The DON further stated that she did not have designated RNAs to perform the RNA program but rather the CNAs working the floor did the RNA program for the individual residents in their section. On 7/8/15 at 9:45 AM, the MDS Coordinator Nurse was interviewed. The MDS Coordinator confirmed that she was responsible for the RNA program. The MDS Coordinator confirmed that she did not have designated RNAs to complete the program but the floor CNAs were completing the RNA program. On 7/9/15 at 12:05 PM, the PT Director was interviewed. The PT Director stated that the RNA program was a major concern within the facility. The PT Director stated that the RNA program did not work correctly due to short staffing. The PT Director stated that the facility CNAs did not have time to perform the RNA duties. The PT Director stated that the RNA program should be consistently performed by one person. The PT Director confirmed that resident 67 should be receiving RNA services. On 7/9/15 at 1:30 PM, the Therapeutic Recreation Specialist (TRS) was interviewed. The TRS stated if resdient 67 wanted to exercise, she (the TRS) would take resident 67 to the therapy room to have resident 67 use therapy bars for walking. The TRS further stated that she did not perform ROM exercise for resident 67. The TRS confirmed that she had not had training in performing ROM exercises for resident 67's contractures. On 7/8/15 at 10:30 AM, CNA 10 was interviewed. CNA 10 stated that the CNAs did not have time to perform the RNA program duties. On 7/8/15 at 1:00 PM, CNA 4 was interviewed. CNA 4 stated that the CNAs were not providing the RNA maintenance programs to the residents. CNA 4 further stated that the RNA program duties were not occurring due to time constraints. On 7/9/15 at 2:00 PM, CNA 2 was interviewed. CNA 2 stated that the facility CNAs do not have time to perform the RNA program. CNA 2 stated that this had been reported to the facility DON and Administrator but additional staff had not been hired to perform the RNA program.

Based on interview, observation and record review it was determined the facility did not ensure, for 1 of 11 sample residents, that acceptable parameters of nutritional status were maintained, such as body weight and protein levels. Specifically, one resident receiving a tube feeding lost a significant amount of weight and his [MEDICATION NAME] level decreased after admission to the facility. In addition, the facility did not implement recommendations from the facility Registered Dietitian timely, and weekly weights were not obtained. Resident identifier: 7. Findings include: Resident 7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/16/13 and 5/28/13. Resident 7's weights recorded in the "Weights and Vitals Summary" revealed: (Note: All weights were in pounds.) a. 3/19/13 169.4 b. 3/25/13 165.4 c. 4/5/13 155.4 d. 4/8/13 156.6 e. 4/22/13 158.6 f. 5/6/13 152.0 g. 5/13/13 150 h. 5/20/13 147.2 (Note: Resident 7 lost 13.1 % of his body weight since admission (60 days) and 7.1% over a 1 month period of time. Resident 7 also did not have weekly weights to monitor.) Resident 7's "Nutrition Notes" were reviewed and revealed the following: A. On 3/21/13 an inital assessment was completed. The intial assessment revealed that resident 7's current diet order was listed as: "NG ([MEDICAL CONDITION]) TF (tube feeding) [MEDICATION NAME] 1.2 at 70 mls (milliliters)/ (per) hr (hour) continuous, Flush 90 mls H20 (water) 4x (times)/day." The current formula order was calculated by the facility Registered Dietitian (RD) to provide 2016 calories per 24 hours and 93.56 grams (g) of protien. Resident 7's estimated nutritional needs calculated by the facility RD were 1925 calories per day and 77-92 grams of protein per day. Resident 7's usual body weight was between 163-170 pounds. The facility RD wrote, "TF appears to be well tolerated." The RD's plan for resident 7 was ". . .Monitor TF rate, tolerance, residuals. Monitor wt (weight) (changes), . . " B. On 4/4/14 a form titled "Medical Nutrition Assessment - Enteral Assessment" revealed, "RN (Registered Nurse) reporting that he is c/o (complaining of) nausea now that TF (changed) to run at night. We had (changed) to night feeds d/t (due to) TF being turned off frequently during the day." The form further revealed, "I talked to Director of Nursing to get a new wt (weight), noticed they were missing." Resident 7's current order was [MEDICATION NAME] 1.2 at 105 mls/hr from 1700-0900 hrs." The facility RD calculated the current order provided the same amount of calories and protein. The RD's new plan was "Rec'd (Recommend) goal rate 84 mls for 20 hrs (allowing for breaks for physical therapy). New goal rate meets nutritional needs given (decreased) rate." (Note: The RD did not calculate the amount of calories or protein the new rate would provide to resident 7.) C. On 5/9/13 a form titled "Medical Nutrition Assessment -Enteral Assessment" revealed that the facility RD documented resident 7's current enteral prescription was [MEDICATION NAME] 1.2 @ (at) 60 mls for 20 hours. The RD documented that amount of formula would provide 1440 calories per day and 66.6 grams of protein. The RD estimated resident 7's nutritional requirements were 1725-2070 calories per day and 69-83 grams of prothein. The RD also documented resident 7 lost 10.27% of his body weight over 60 days. The RD further documented, "(Resident 7) cont (continued) to be at high nutritional risk d/t continued n/v (nausea and vomiting), (decreased) po (oral) intake despite diet advancement from pureed diet, conti wt loss. We cont to be unable to run the TF continuously (and) at goal. Had been hopeful that the GI (gastrointestinal) studies/scopes etc would have given more light as to the problem. . . Going to try an elemental feed to see if it makes a different (sic) he may need jejunal feeds if he is having [MEDICAL CONDITION] issues or maybe even consider TPN (Total Parental Nurition)? Conti to encourage po intake when he is not nauseated or sick to his stomach." The RD's new plan revealed, "Rec'd [MEDICATION NAME] goal of 95 mls for 20hrs continous providing 1900 kcals, 97 gm PRO (protein)/day, 1587 of free H2O with additional H2O for fluid flushes." Resident 7's March, April and May 2013 Medication Administration Records (MARs) were reviewed and revealed the following diet: A. On 3/20/13, [MEDICATION NAME] 1.2 at 70 cc (cubic centimetre)/hr continuous to provide ___ calories. (Note: The amount of calories was not completed.) B. On 4/3/13, [MEDICATION NAME] 1.2 at 105 cc/hr to start at 1700-0900 (5:00 PM - 9:00 AM). C. On 4/6/13, [MEDICATION NAME] 1.2 at 84ml/hr for 20 hours. D. On 4/17/13, Ensure clear with breakfast, Vanilla mighty shake with lunch, Chocolate mighty shake with dinner. Resident 7 had 39 opportunities to drink the supplements but refused or had nausea all but 10 times from 4/17/13 to 4/30/13. Resident 7 refused all supplements in May 2013. E. On 5/3/13, "TF- Tube Feeding [MEDICATION NAME] 1.2 for 20 hrs/per day via PEG tube start at 1400 (2:00 PM) and end at 1000 (10:00 AM). Document amount tolerated for shift and amount of time it is tolerated. Titrate accordingly." (Note: There was no goal rate documented for the tube feeding.) F. On 5/26/13, "TF- Tube Feeding Vital AF 1.2 for 20 hrs/per day via PEG tube state at 1400 (2:00 PM) and end at 1000 (10:00 AM). Document amount tolerated for shift and amount of time it is tolerated. Titrate accordingly up to optimum of 95ml/hr." Resident 7's nursing notes revealed the following: A. 3/23/13, "Cont to get OOB (out of bed) per self and unplug or turn off feeding pump. . .Tol (tolerates) NG feeds (with no) GI distress. . . " B. 3/24/13, "NG tube (with) [MEDICATION NAME] 1.2 @ 77cc/hr. . . " (Note: Resident 7's tubefeeding order was for [MEDICATION NAME] 1.2 at 70 mls per hour.) C. Late entery for 3/21/13 - ". . .Pt has NG tube (with) [MEDICATION NAME] 1.2 (at) 70 ml/hr, running (without) complications et (and) flushing well. Pt is NPO (no oral intake) et receives meds through NG tube. . ." D. 3/29/13, ". . . NG flushes well. Feeding running (at) 70 ml/hr. . . c/o nausea relieved by prn (as needed) Mecloprimide. . ." E. 3/30/13 at 2231 (10:31 PM), ". . .Tolerating feeding at 70 ml/hr some c/o nausea (with) prn [MEDICATION NAME] effective. . ." F. 3/31/13 at 0930 (9:30 AM), " . . .NG flushes well. No c/o nausea at this time. Feeding running at 75 ml/hr. . . " G. 4/2/13 at 1930 (7:30 PM), "NG tube clogged attempted x 2 to flush NG not patent. Will sent patient to radiology tomorrow per MD. . . " H. 4/2/13, ". . .NG clogged. Unable to take food, formula, meds or H2O all shift. afebrile. Orders to sent to hospital for MBS (Modified [MEDICATION NAME] Study) et replacement of NG if necessary in am because very confused during NOC (night). . ." (Note: Tube Feeding rate was changed on 4/3/13 to 105 mls/hour for 20 hours.) I.. 4/3/13 6:00 PM- 6:00 AM, ". . .NG placement confirmed per auscultation rate (at) 105cc/hr. (At) 2100 (9:00 PM) res had lg (large) amount emesis - appearted to be coke and K+ (potassium) liquid - (No) formula rate of TF (decreased) to 50 cc. res very afraid of more emesis. tol (decreased) rate during NOC. Will advance as tol. . ." J. 4/4/13, ". . .c/o nausea controlled (with) prn [MEDICATION NAME]. Rate of [MEDICATION NAME] 1.2 increased by 5ml/ hr q (every) 4 hrs during shift (and) well-tolerated by pt. . ." K. 4/5/13, ". . .(Increased) formula rate to 84ml/hr et tolerates. . ." (Note: Tube Feeding rate was changed to 84 mls/hour for 20 hours on 4/6/13.) L. 4/6/13, " . . .TF held from 1000 - 1400 (10:00 AM - 2:00 PM) per MD orders. Rate set at 64ml/hr, tolerated well. . ." M. 4/6/13 2349 (11:49 PM), ". . .Tolerating feeding at 84 ml/hour. Pt continues to disconnect NG from feeding to use restroom. Encouraged to have staff present and to take feeding tube and assist (with) him to restroom. . . No c/o nausea." N. 4/9/13, ". . .Occ (occasional) c/o nausea. placement confirmed placement of NG by auscultation. . . .Flushed (without) diff (difficulty). Found res turning off feeing pump et disconnecting NG ad lib (as desired) to toilet self. Encouraged to call for assist so nurse can flush tube. . ." O. 4/10/13 12:30 PM, "Care meeting:. . .The resident has had weight loss recently d/t (due to) periods of nauesa. The tube feeding has been adjusted as well as the time the feeding is running to help decrease the nausea. The MD and resident are aware of the weight loss. . ." P. 4/11/13, "Pt vomiting brown chunky emisis. . . MD stated to put feeding & meds on hold until MG can be replaced in AM. . ." Q. 4/13/13 1400 (2:00 PM), ". . . Speech therapist fed patient one yogurt and 10 min later had nausea and vomiting 50 mL orange fluid apparent. Vomiting for 30 min. DR (Doctor) notified ordered [MEDICATION NAME] 25 mg per rectum q 6h prn. This nurse administered medication in rectum without difficulites patient said he was feeling very good and happy he wasn't throwing up. . ." R. 4/15/13, ". . .[MEDICATION NAME] 1.2 84 mL/hr. No c/o pain or SOB. C/o nausea with two episodes of vomiting. . ." S. 4/17/13, ". . .c/o nausea - emesis x 2. TF turned off - did not want TF on during NOC. . ." T. 4/18/13, "res is not tol TF @ all. NG placement confirmed per auscultation and flushes easily but everytime TF is attempted to be started within 30 min res is nauseated and vomiting refused meds d/t nausea. . ." U. 4/19/13 1540 (3:40 PM), "Late entry from 4/18/13. Patient feeling sick to his stomach refused medications. This nurse tried turning off feeding tube. Patient ate chocolate pudding, chocolate shake, and yogurt. Pt stated he was going to throw up. Phenegran PR was given. Pt threw-up chocolate liquid. . . " V. 4/19/13 at 1810 (6:10 PM), "at 1500 (3:00 PM) pt became nauseated & vomited. Administered [MEDICATION NAME] rectally as ordered. Improvement noted. Pt was able to eat 25% of dinner (and) drank 240 (mls of fluid). Stopped tube feeding (at) 1500 (3:00 PM) d/t n/v. Pt didn't want it back till (after) dinner to see if his dinner will stay down. Started (at) a slower rate (and) slowly increase back to 84 mL/ hr. . . " W. 4/20/13, "GI consult to be obtained d/t (increased) regurgitation not r/t (related to) swallow problems. X. 4/20/13 at 1040 (10:40 AM), ". . .No vomiting at this time. [MEDICATION NAME] given for upset stomach. . ." Y. 4/21/13 at 0205 (2:05 AM), "Pt has some c/o upset stomach. [MEDICATION NAME] effective. Pt c/o nausea at 0045 (12:45 AM). Requested to have feeding tube removed not turned down. Pt sat up and at 0450 (4:50 AM) RN returned and pt still wanted tube not connected. Given [MEDICATION NAME] per request at this time and will return in 30 minutes to reeval (reevaluate). 0245 (2:45 AM) pt found vomiting small amounts of (?) liquid. Feeding continued to be held prn [MEDICATION NAME] per rectal given. Will return to check nausea status in one hour. 0418 (4:18 AM) Pt check at 0345 (3:45 AM). Pt states (decrease) in nausea. Feeding restarted at 65 ml/hr and will titrate up to ordered 84 ml/hr as tolerated." Z. 4/21/12 1000 (10:00 AM), "Nurse was unable to hook up tube feed d/t nausea (and) vomiting refused meds d/t n/v. Pherergan (sic) via suppository relieved n/v at this time. Currently resting in bed . . ." aa. 4/21/13 1810 (6:10 PM), "Pt refused meds all day d/t n/v . . ." bb. 4/22/13 1800 (6:00 PM), ". . .c/o nausea had some vomiting, prn phenagran given rectal with relief noted. Difficulty getting TFing restarted without nausea. . ." cc. 4/23/13 at 6:00 AM -6:00 PM, ". . . n/v during shift. Not able to tolerate TF, oral intake or meds. Rectal phenegran was non-effective . . . Did not work with therapy d/t nausea (and( vomiting. . ." dd. 4/24/13 6:00 AM-6:00 PM, ". . .Stil has n/v . . . " ee. 4/24/13 6:00 PM- 6:00 AM, ". . .@ 0200 (2:00 AM) requested TF turned off d/t nausea. . ." ff. 4/25/13 at 1240 (12:40 PM) ". . .c/o nausea. . .Feeding not running d/t nausea/ vomiting. . ." gg. 4/25/13 shift 6:00 PM - 6:00 AM, "Res c/o n/v et GI distress all shift refused HS meds, H2O flushes and TF. Requested [MEDICATION NAME]. . ." hh. 4/26/13 shift 6:00 AM - 6:00 PM, ". . . c/o nausea. . . Pt refused feeding d/t nausea. . .pt ready to have TF started (after) dinner. . ." ii. 4/27/13 at 0407 (4:07 AM), ". . .Some nausea earlier refused feeding until approx (approximately) 2200 (10:00 PM). Restarted at 70mL/hr (without) diff. Now at 84 ml/hr as ordered. No further episodes of nausea. . . 0415 (4:15 AM) pt nauseated and 'stomach on fire' feeding held. . .0615 (6:15 AM) pt feeding held still. Pt still nauseated and refusing to be attached." jj. 4/27/13 6:00 AM - 6:00 PM, "Refused to have tube feeding turned on due to nausea and vomiting." kk. 4/27/13 6:00 PM - 6:00 AM, ". . .TF continued to be held throughout shift d/t persistent nausea & vomiting. Pt was able to keep down some H2O (and) cold cereal eaten during the evening. . ." ll.. 4/29/13 at 0337 (3:37 AM), ". . .C/o nausea at 0200 (2:00 AM). PRN [MEDICATION NAME] effective. Pt turned off feeding tube sometime prior and fell asleep (without) telling staff. Once staff noticed feeding started. Feeding stopped from 0000 (12:00 AM) to 0200 (2:00 AM) per pt refusal d/t nausea. Restarted at 0200 at 70 ml tolerating well. At 0330 (3:30 AM) (increased) to 78 ml/hr. . ." mm. 4/29/13, "Continues n/v. Refused phenegran on shift. NG flushed, only tolerated 60 ml at a time refused medications (and) tube feeds d/t n/v. . ." nn. 4/29/13, ". . .Scheduled meds withheld/refused d/t nausea throughout shift. . . " oo. 4/30/13 6:00 AM - 6:00 PM, ". . . still c/o nausea and vomiting. prn phenegran PR given with minimal effect. Refused all meds and TF. . ." pp. 5/1/13 6:00 AM - 6:00 PM, ". . .Came back (with) PEG tube. . ." qq. 5/2/13 at 1010 (10:10 AM), ". . . Tube was disconnected when nurse went in at 0800 (8:00 AM). Pt stated that he did not disconted (sic) tubing (and) turn off machine. Night nurse stated that he did not disconnect it. . . " rr. 5/2/13 at 1820 (6:20 PM), "Pt c/o nausea (and) vomiting tube feed held until 1800 (6:00 PM), now running at 60 ml/hr. [MEDICATION NAME] suppository given. Stated helpful. . ." ss. 5/3/13 6:00AM - 6:00 PM, "Resident extremely weak. Unable to stand is laying in bed. Given prn pain meds (with) effect. Denies nausea and vomiting at this time. Wound appointment cancelled due to extreme weakness which resident approved. . ." tt. 5/3/13 6:00 AM - 6:00 PM, " Pt has appointment for abdominal CT (computed tomography) for 5/3 at 1500 (3:00 PM). (Name of physician) ordered that be done today. Pt has increased weakness and transport has been made aware of appointment. Also scheduled a colonscopy at 4:00 on Monday 5/6. . . Pt returned from CT scan. . .Also shows [MEDICAL CONDITION] of arteries leading to small bowel. . . Pt refused to have feeding turned on after returning from CT due to more nausea and vomiting. Pt vomited before going to CT after drinking the dye. Dr stays they may be able to balloon the arteries leading to small bowel if needed." uu. 5/4/13, ". . .Refused all other scheduled meds d/t nausea. Allowed feeding tube to be connect and ran at 2039 (8:39 PM) starting at 40 ml/hr tolerated well and rate (increased) to 45 ml 2.8 hours later. Increased to 50 ml two hours later and is not at 55 ml/hr. No c/o nausea so far. . ." vv. 5/4/13 at 0800 (8:00 AM), " . . Feeding currently running (at) 60 ml/hr. Refused all meds except [MEDICATION NAME]. . . Pt c/o nausea when feeding was (increased) to 50 ml/hr at 1630 (4:30 PM). Feeding (decreased) to 45 ml/hr, pt stated that 'that's better' . . ." ww. 5/5/13 0114 (1:14 AM), " Stated (increased) ABD (abdomial) pain and refused to try to (increase) feeding. Pt asleep and (increased) to 55ml at 0030 (12:30 AM) - no c/o nausea or vomiting at this time. . . 0535 (5:35 AM) Pt continued to tolerate feeding. (Increased) to 60 ml/hr at 0300 (3:00 AM). No c/o nausea or vomiting." xx. 5/5/13 0840 (8:40 AM), ". . .C/o 'stomach burning'. Tube feed removed (at) 0630 (6:30 AM). On hold d/t clear liquid diet. Pt understood. [MEDICATION NAME] suppository given for c/o nausea. Pt stated helpful. . ." yy. 5/6/13 at 0119 (1:19 AM), ". . .Some nausea shortly after drinking bowel prep. Some vomiting. Remaining prep and water infussing via peg tube by gravity (without) nausea or vomiting. . ." zz. 5/7/13 6:00 AM - 6:00 PM, ". . .Completed colonscopy today. Found moderate [DIAGNOSES REDACTED]. Recommendation was a high fiber diet. Has not been able to take medication or been able to be placed back to tube feeds d/t nausea. PR phenegran given with very little relief. . ." aaa. 5/7/13 6:00 PM- 6:00 AM, ". . .c/o buttocks pain, controlled (with) prn [MEDICATION NAME]. TF tolerated via PEG tube from 0000-0200 (12:00 AM - 2:00 AM) (at) 40 ml/hr, then stopped d/t nausea. . ." bbb. 5/8/13 at 0900 (9:00 AM), ". . .Pt states that he doesn't want to get sick. Tube feed disconnected at 0200 d/t nausea. Not replaced. . ." ccc. 5/8/13 at 6:00 PM - 6:00 AM, ". . .tol TF on from 1830 (6:30 PM) to 0330 (3:30 AM). (No) c/o pain until 0330 (3:30 AM) then c/o abd discomfort. ate a few bites of supper and threw it up but ate oreo cookies (without) diff. . ." ddd. 5/9/13, ". . . C/o dizziness and some nausea. . ." eee. 5/9/13 at 1310 (1:10 PM), "Care meeting - Resident weight decline - Resident has had x-rays CT scans and a colonscopy over the last week. Resident has had nausea/vomiting as well as he disconnects the tube (at) will. Resident history is that he eats little. He states, 'I have had acid reflux which makes me vomit after meals.' RD working (with) resident as needed. . . " fff. 5/9/13 6:00 PM - 6:00 AM, ". . . Pt refused TF @ HS (hours of sleep) but did tolerate TF from 0200 to 0430, but then vomitted (sic). PRN [MEDICATION NAME] suppository given (and) effective/ TF stopped." ggg. 5/10/13 6:00 PM - 6:00 AM, ". . .Pt tolerated TF via PEG tube for only 1 hr from 2015-2115 (8:15 PM - 9:15 PM) (and) again became nauseated. Pt requested feeding to be turned off, but refused any PRN nausea meds. . . " hhh. 5/11/13, " . . . pt nausea and general discomfort, meds given for nausea. . ." iii. 5/11/13 6:00 PM - 6:00 AM, "Refused meds, ref (refused) TF. Stated he would 'throw up' if he got anything. . ." jjj. 5/12/13 6:00 AM - 6:00 PM, . . "Pt c/o of (sic) soreness to coccygeal (sic)region. Pressure sore, stage 2, found (with) excorriation (sic) of surrounding tissue. . . Feedings were given for 7 hrs. . . Pt vomited (at) 1745 (5:45 PM) and feedings were stopped. . ." kkk. 5/13/13 0507 (5:07 AM), "Pt continued at 55 ML/hr for approx 3 hours until nauseated and emesis was expelled. Feeding stopped per request PRN [MEDICATION NAME] given for (increased) pain. . . " lll. 5/13/13 6:00 AM- 6:00 PM, "Patient in bed all day complaining of n/v and pain. Gave PRN [MEDICATION NAME] (at) 0730 (7:30 AM) and 1330 (1:30 PM) with very little relief noted. Though patient was noted to having (sic) TF going for a total of 2.75 hours today (at) 55 ml. . Was sent to ER (at) 1440 (2:40 PM) after not being able to get pain or nausea vomiting under control and emesis turning into a dark brown color. . .Pt returned. . .Feeding started at 55ml/hr. Pt tolerated for one hour then some emesis noted. PRN [MEDICATION NAME] and [MEDICATION NAME] given. . ." mmm. 5/14/13 6:00 AM - 6:00 PM, "Continues to be nauseated. Vomiting throughout shift. Been on TF for only 2.25 hours at 55 ml/hr. Given phenegran. . ." nnn. 5/15/13 6:00 PM - 6:00 AM, "Pt c/o nausea (at) 0830 (8:30 AM). Tube feed stopped - . . .Pt was 'nauseous' (and) refused to be on tube feed. . ." ooo. 5/16/13 6:00 PM - 6:00 AM, ". . .Refused scheduled HS meds (and) TF d/t nausea (and) vomiting. . ." It should be noted that facility nurses first documented resident 7 was nauseated on 3/29/13, which was 8 days after admission. The nurses also documented resident 7 began refusing medications due to nausea on 4/18/13. Resident 7's physican's order dated 5/26/13 revealed "TF-Tubefeeding Vital AF 1.2 for 20hrs/per day via PEG tube start at 1400 (2:00 PM) and end at 1000 (10:00 AM) Document amount tolerated for shift and amount of time it is tolerated. Titrate accordingly up to optimum of 95 ml/hr - Twice a Day Everyday." Resident 7's Laboratory Values were reveiwed and revealed the following: a. 3/20/13: [MEDICATION NAME] level was 2.9 gm/dL (deciliter) (Note: Normal range for [MEDICATION NAME] was 3.4-5.0 as indicated on the laboratory report.) b. 4/30/13: [MEDICATION NAME] level was 2.6 gm/dL. c. 5/13/13: [MEDICATION NAME] level was 2.4gm/dL. A care plan dated 3/21/13 and revised on 3/27/13 revealed "Alteration in Nutrition Status Diagnosis/disease condtion/treatment neck brace/aspiration risk, Chewing difficulty, Swallowing difficulty". The goals for resident 7 were to "Meet nutritional needs while on TF, Maintain weight, Safe and comfortable ingestion of fluids." The interventions in place to achieve the goals were "Monitor TF rate, tolerance, and administer free water as ordered, Monitor wt, speech therapy to continue to evaluate, TF as ordered" On 4/27/13 a new intervention was "may have cold cereal soaked in milk. Soft mashable foods, all liquids." (Note: No documentation was located in resident 7's medical record indicating resident 7's weight loss was unavoidable.) On 5/16/13 at 2:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the [MEDICATION NAME] formula was ordered two times and cancelled both times in the facility order system. The DON stated the formula [MEDICATION NAME] which the facility RD recommended on 5/9/13 had been discontinued. On 5/28/13 1:00 PM, a follow up interview was conducted with the DON. The DON stated resident 7 was started on the Vital AF formula on 5/21/13 after returning from a local hospital emergency room . The DON stated she was not sure why the physican's order was dated for 5/26/13 for the Vital AF formula to start. The DON further stated that resident 7 did not have an open area when the physician ordered a wound consult. The DON stated resident 7's wound clinic appointment was cancelled because resident 7 had nausea and vomiting. The DON stated prior to resident 7 attending a wound clinic appointment the wound opened up and became a pressure ulcer. On 5/16/13 at 2:20 PM, an interview was conducted with the facility RD. The RD stated resident 7 was waiting for [MEDICATION NAME] formula. The RD stated resident had blood veins to the stomach were calcified and resident 7 did not want surgery. The RD stated resident 7 turned off the feeding tube when he was nauseated. The RD stated she expected the [MEDICATION NAME] formula would decrease his nausea and vomiting. The RD stated she did not know why the facility did not have the formula. On 5/28/13 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 7 was feeling much better with decreased nausea since the elemental formula was started. RN 1 stated resident 7 was able to tolerate the formula better with the change in formula. On 5/28/13 at 11:00 AM, an interview was conducted with resident 7's Physician. Resident 7's Physician stated resident 7 had a problem with vomiting. The Physician stated resident 7 would tell staff he was nauseated and turn off his tube feeding. The Physician stated resident 7 had a PEG tube placed and an endscopy which revealed no problems. The Physician stated resident 7 had been evaluated by the emergency room (ER) Physician several times. The Physician stated resident 7's vomiting caused [MEDICAL CONDITION] varies. The Physician stated he was unsure if the nauesa and vomiting was a behavior or a physical problem. The Physican stated resident 7 was started on IV (intravenous) [MEDICATION NAME] after his last ER visit. The Physician stated resident 7 appeared less nauseated since his last ER visit. The Physician further stated he was unsure if the IV [MEDICATION NAME] helped with the vomiting or the change in formula. Resident 7's Physician did not state that resident 7's weight loss was unavoidable.