Every finding on record at Westwood Post Acute

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#45) of three residents reviewed out of 29 sample residents. Resident #45 was admitted on [DATE] for long-term care with a diagnosis of bipolar (mental illness), borderline personality disorder, intellectual disability and dysphagia/oropharyngeal phase (difficulty in swallowing due to issues in the part of the throat located behind the mouth). On [DATE] Resident #45 had an episode of choking after she grabbed a handful of leftover refried beans and shoved them into her mouth before the staff could stop her and she aspirated. The resident required the Heimlich maneuver (abdominal thrusts used to remove food or particles stuck in the airway) and suctioning. The [DATE] physician's order revealed, based on assessments from the speech therapist (ST), Resident #45 required one-on-one supervision during meals, cueing for small bites/sips, slow rate, redirection to prevent wandering and an upright positioning with all oral intake. Observations during the survey revealed the one-on-one staff member did not offer Resident #45 cueing for small bites/sips, slow rate or an upright position with oral intake. Additionally, the one-on-one staff member left the resident alone during the meal. The facility's failure to ensure identified interventions for Resident #45's known choking risk were implemented consistently created the potential for serious harm for Resident #45. Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy The facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for Resident #45 after the resident had a choking incident on [DATE]. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for Resident #45. B. Imposition of immediate jeopardy On [DATE] at 8:15 a.m., the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #45 received appropriate supervision during times of intake. C. Facility plan to remove immediate jeopardy On [DATE] at 3:20 p.m., the facility submitted a plan to remove the immediate jeopardy, The removal plan read: 1. Corrective action On [DATE] Resident #45 was placed on one-on-one supervision to ensure continuous monitoring during mealtimes and to reduce the risk of choking. The resident will be reviewed weekly by the interdisciplinary team (IDT) to determine appropriateness of remaining on one-on-one supervision. By [DATE] an audit of all nursing staff cardiopulmonary resuscitation (CPR) certifications, specifically including verification of Heimlich maneuver training, will be completed. On [DATE], there are seven staff members who are CPR and Heimlich maneuver trained in the facility. The facility will have a minimum of one person who is CPR certified and Heimlich maneuver trained in the facility and observing meals at all times. 2. Identification of others On [DATE] all residents were screened utilizing the swallowing disorder section from their most recent minimum data set (MDS) assessment. For any residents identified as having swallowing difficulties, the IDT ensured care plans were reviewed and appropriate interventions were implemented. Communication will occur with staff by updating care plans and by updating Kardex (staff directive tool). The director of nursing (DON) or designee will perform education to all nursing staff by [DATE] or before the start of their next shift. Education will be in person by the DON or designee. 3. Systematic changes On [DATE] the DON or designee conducted in-service training on the Foreign Body Airway Obstruction policy for all currently scheduled facility and agency staff. Staff not present on [DATE] will receive education prior to the start of their next scheduled shift. On [DATE] the speech language therapist (SLP) or a designee who has been trained by the SLP, provided training to all nursing and agency staff regarding expectations when assigned as a one-on-one during meals. Training included the following key points: -The resident must not be left unattended during meals. -Staff must intervene if the resident begins to fall asleep. -Staff must implement appropriate interventions (discovered in the care plan or Kardex) if the resident exhibits unsafe eating behaviors. -Staff not trained on [DATE] will be educated prior to their next shift. On [DATE] the DON or designee educated nursing and agency staff on all relevant physician's orders related to Resident #45. Staff not in attendance on [DATE], will receive training before their next scheduled shift. On [DATE] the DON or designee reviewed the care plan interventions for Resident #45 with all available nursing and agency staff. Staff not trained on [DATE] will be educated before their next scheduled shift. D. Removal of immediate jeopardy The NHA was notified the immediate jeopardy was removed on [DATE] at 3:30 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. II. Facility policy and procedure The Foreign Body Airway Obstruction (choking) policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 11:00 a.m. It read in pertinent part: The facility will ensure that all direct care staff and any other designated staff be trained and certified in performing CPR to include the Heimlich maneuver if a choking event/foreign body obstruction should occur. Residents should be assessed to determine if they are at a higher risk for foreign body obstruction/ choking episodes and care planned accordingly. Document the event and response to the interventions implemented. III. Resident #45 A. Resident status Resident #45, age less than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included bipolar, borderline personality disorder, intellectual disability and dysphagia/oropharyngeal phase. The [DATE] MDS assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident experienced coughing and choking during meals and had complaints of difficulty or pain with swallowing. The resident required set-up and supervision with eating. B. Resident observation and interview During a continuous observation of the lunch meal on [DATE], beginning at 11:30 a.m. and ending at 1:00 p.m. the following was observed: At 11:30 a.m. certified nurse aide (CNA) #1 was sitting next to Resident #45. The resident was served mechanical soft ham, sweet potatoes and a dinner roll. Between 12:00 p.m. and 12:40 p.m., Resident #45 fell asleep at the table with her head back while chewing nine times. When the resident would wake up, she would continue to chew the food that was remaining in her mouth, put more food into her mouth and then fall asleep again without finishing chewing her food. CNA #1 was sitting with the resident and left her alone for two to three minutes twice, prompted her to wake up three times and did not wake the resident when she fell asleep four times. During a continuous observation of the lunch meal on [DATE], beginning at 11:30 a.m. and ending at 1:00 p.m., the following was observed: At 11:30 a.m. CNA #4 was sitting with Resident #45. At 11:55 a.m. the resident was served her lunch, which consisted of a mechanical soft riblette meat, macaroni and beans. Between 11:55 a.m. and 12:30 p.m., the resident used her hands to scoop handfuls of beans and macaroni into her mouth. The resident did not completely chew her food before putting more food into her mouth. CNA #4 reminded Resident #45 to use her silverware twice but the resident would not consistently use it. CNA #4 watched Resident #45 eat with her hands and did not cue or encourage her to take small bites/sips or to eat at a slow rate. Resident #45 was interviewed on [DATE] at 1:12 p.m. She said she was on a soft diet but she was not sure why. C. Record review The nutrition care plan, initiated on [DATE], revealed Resident #45 was at nutritional risk related to bipolar disorder, intellectual disability, dysphagia and kidney disease. Interventions initiated on [DATE] included offering fluids in between meals during snack times and speech therapy (ST) to evaluate and provide treatment as indicated. Resident #45's [DATE] CPO revealed the following physician's orders: Give thickened liquid nectar consistency for history of choking, ordered on [DATE]. Provide skilled ST 12 times for four weeks for cognitive-communication impairment and oropharyngeal dysphagia. Treatment may include education of safety precautions, education of safe swallow strategies and diet modifications, ordered on [DATE]. Regular diet: mechanical soft texture, thin liquids and double portions, ordered on [DATE]. Provide one-on-one supervision during meals, cueing for small bites/sips, slow rate, redirection to prevent wandering, and upright positioning with all oral intake, ordered on [DATE]. The dietary interview and prescreen assessment, dated [DATE], revealed Resident #45 was prescribed a regular diet, puree texture and thickened nectar liquids. The risks identified for not following the order included choking. Resident #45's progress notes dated [DATE] through [DATE] revealed: A physician note, dated [DATE], revealed Resident #45 had an event of choking. The resident grabbed a handful of leftover refried beans and shoved them into her mouth before the staff could stop her and she aspirated. The resident required the Heimlich maneuver and suctioning. A speech therapy evaluation was ordered and the resident's diet was changed to puree texture with thin liquids. A speech therapy note, dated [DATE], revealed Resident #45 was assessed per the physician's order. A cognitive assessment was completed and the score demonstrated the resident had moderate cognitive impairments and required cueing for orientation, short term recall and problem solving. A speech therapy note, dated [DATE], revealed during an observation of meal service, the ST noted if Resident #45 did not receive cueing during the meal, she became impulsive and would take large bites and eat at a quicker rate. The ST recommended moderate verbal cues for safe swallowing strategies and a continuation of the pureed diet. A nursing note, dated [DATE], revealed Resident #45 was observed in the dining room eating food off of dining room tables from other residents' who were finished and not finished with their trays. A behavior note, dated [DATE], revealed Resident #45 was observed eating her roommate's snacks. A speech therapy note, dated [DATE], revealed Resident #45 had displayed behaviors of taking food from other residents' trays during meals. A specialized restorative program was created for supervision and cueing of the resident during meals to help encourage intake of her meal and prevent the resident from taking others food. During her session with the therapist, the resident required frequent cueing for small bites, slow rate and upright positioning. A behavior note, dated [DATE], revealed Resident #45 was observed in the dining room sticking her hand into another resident's food and then eating it. A behavior note, dated [DATE], revealed Resident #45 had obtained money from another resident and was observed trying to get a soda from a vending machine. A speech therapy note, dated [DATE], revealed Resident #45 was reassessed for swallowing functioning. Speech therapy recommended one-on-one supervision during meals with cueing for strategies and an advanced diet upgrade to mechanical soft with double portions. A speech therapy note, dated [DATE], revealed Resident #45 had been upgraded to a mechanical soft diet with thin liquids, but continued to demonstrate disorganized thought patterns and reduce safety awareness. IV. Staff interviews CNA #1 was interviewed on [DATE] at 2:30 p.m. CNA #1 said Resident #45 had a one-on-one caregiver because she went into other residents' rooms and stole their snacks and cigarettes. CNA #1 said the resident needed supervision with meals because she ate too quickly and needed to be prompted to slow down. CNA #1 said if the resident fell asleep while she was eating that would put her at risk for choking. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 1:30 p.m. LPN #1 said he had worked with Resident #45 since her admission but he did not know why she had a one-on-one caregiver or why she needed supervision during meals. Registered nurse (RN) #2 was interviewed on [DATE] at 1:56 p.m. RN #2 said Resident #45 had a one-on-one caregiver because of her wandering into other resident's rooms and her risk of aspiration during meals. RN #2 said the resident was impulsive and made poor decisions in terms of eating safely, chewing completely and eating slowly. The registered dietitian (RD) was interviewed on [DATE] at 2:21 p.m. The RD said she completed annual and quarterly assessments based on the residents' MDS assessment schedule. She said if she needed to do additional assessments, the nurses would notify her. The RD said Resident #45 was originally placed on a pureed diet because the staff reported the resident choking on food. The RD said ST then evaluated the resident and upgraded her to mechanical soft textures. The director of rehabilitation (DOR), who was also a speech therapist, was interviewed on [DATE] at 2:30 p.m. The DOR said when Resident #45 admitted to the facility she was initially put on a pureed diet due to choking. The DOR said the resident was demonstrating unsafe eating due to behaviors, not physical deficits. The DOR said she assessed the resident from a behavioral standpoint and determined she was able to eat mechanical textures with cueing and prompting for safety. The DOR said the therapy department had recommended the one-on-one caregiver during meals to assist Resident #45 in developing better eating habits and monitoring her for safety. She said if the resident was sleeping while chewing, it put the resident at risk for choking and aspiration. The DOR said she was not aware that the one-on-one caregiver was not following speech therapy's recommendations for providing the resident with cues and prompts during meals. The DON was interviewed on [DATE] at 2:24 p.m. The DON said if a resident fell asleep while eating, it put the resident at risk for choking and aspiration. The DON said she was not aware that the one-on-one caregiver with Resident #45 was not adequately providing the resident with cues and prompts during meals and was not preventing her from sleeping while chewing. The NHA was interviewed on [DATE] at 2:15 p.m. The NHA said Resident #45 would continue with one-on-one staff supervision while eating until the speech therapist determined she was safe to eat independently.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to: -Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and, -Provide for the selection of a neutral arbitrator agreed upon by both parties. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, dated November 2023, was provided by the nursing home administrator (NHA) on 4/10/25 at 3:00 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety. Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties. A neutral arbitrator is an impartial, unbiased party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by both parties to resolve their dispute. Residents (or representatives) are given the opportunity to suggest an arbitrator and venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative). Arbitration agreements provide for the selection of a venue that is both convenient to and suitably meets the needs of both parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, 'convenience' for the resident (or representative) may be determined by his or her ability to get to the venue. II. Facility's binding arbitration agreement A copy of the facility's binding arbitration agreement was provided by the NHA on 4/7/25 at approximately 2:00 p.m. The agreement read in pertinent part, The arbitration shall be administered and conducted by a contracted provider in accordance with its comprehensive arbitrations rules and procedures. Within 15 days after a claim for arbitration is made, the demand shall be filed by the contracted provider (dispute resolution specialist) and a single arbitrator will be selected from a list provided by the named provider pursuant to its rules to conduct the arbitrations. The arbitrator shall have the jurisdiction to decide whether the claims may be arbitrated pursuant to this agreement. The hearing arising under this voluntary arbitration agreement shall be held in the county where the facility is located. -The facility's binding arbitration agreement failed to include the selection of a neutral arbitrator agreed upon by both parties and failed to contain language that provided for the selection of a venue that was convenient to both parties. III. Staff interviews The social services assistant (SSA) was interviewed on 4/10/25 at 2:49 p.m. The SSA reviewed the arbitration agreement and said the facility's arbitration agreement did not include information indicating a resident could speak with federal, state and local surveyors or ombudsman. He said the information was included in the facility's admission agreement (a separate document) instead. The SSA said there was no language in the facility's arbitration agreement regarding a selection of venue by both parties or a neutral arbitrator agreed upon by both parties. The SSA said he was trained on the arbitration agreement for the past month. He said he had not had any residents refuse to sign the arbitration agreement.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to personal funds, survey results, bedholds, re-admissions, PASSAR recommendations, quality of care, activities of daily living, activities, ancillary services, accidents/hazards, respiratory, dialysis, mental/psychosocial concerns, drug regimen, dental, hydration, snacks, arbitration, immunizations, safe and comfortable environment. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) plan, revised April 2014, was received from the nursing home administrator (NHA) on 3/8/25 at 1:09 p.m. It revealed in pertinent part, The facility shall develop, implement and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The object of the QAPI plan is to: -Provide means to identify and resolve present and potential negative outcomes related to resident care and services; -Reinforce and build upon effective systems and processes related to the delivery of quality care and services; -Provide structure and process to correct and identify quality and/or safety deficiencies; -Establish and implement plans to correct deficiencies,; -To monitor the effects of these action plans on resident outcomes; -Help departments, consultants, and ancillary services that provide direct care or indirect care to residents to communicate effectively; -To delineate lines of authority, responsibility and accountability; and, -Provide means to centralize and coordinate comprehensive QAPI program, as basis for demonstrating that there is an effective ongoing program. The QAPI committee shall oversee implementations of the QAPI plan. A QAPI coordinator shall coordinate QAPI committee activities including documentation. The committee shall meet monthly to review reports, evaluate the significance of data and monitor quality related activities of all departments, services or committees. The QAPI committee shall oversee authorized QAPI activities including data collection tools, monitoring tools, and the basis for appropriateness and effectiveness of the QAPI activities. The community shall approve any corrective actions including changes in the policy and our procedures, employee practices standards of care and shall also monitor all corrective activities for appropriateness and or the need for alternative measures. The committee may recommend ways to reinforce and expand identified positive approaches and outcomes to various departments or services. Individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function. II. Cross reference citations Cross reference F567 management of funds: The facility failed to ensure resident accounts were updated with the current facility name. Cross reference F577 right to survey results: the facility failed to have state inspections readily available and up to date. Cross reference F625 notice of bed hold policy: The facility failed to provide residents or POA bed hold information at time of transfer. Cross reference F626 permitting residents to return to the facility: The facility failed to re-admit residents after a hospital transfer. Cross reference F644 coordination of preadmission admission screening and resident review (PASRR): The facility failed to ensure PASRR recommendations were followed for specialized services. Cross reference F659 quality of care: The facility failed to ensure qualified staff provided nail care for residents with diabetes. Cross reference F677 activities of daily living (ADL) care for dependent residents: The facility failed to ensure dependent residents received assistance with ADLs. Cross reference F679 activities meet interests/needs of each resident: The facility failed to ensure residents had a personalized activity program. Cross reference F685 treatment and services to maintain hearing/vision: The facility failed to ensure residents received timely services for ancillary services. Cross reference F689 accident hazards: The facility failed to supervise a resident who was a choking risk during meals. Cross reference F695 respiratory care: The facility failed to properly clean and store a continuous positive airway pressure (CPAP) machine. Cross reference F698 dialysis: The facility failed to ensure physician's orders were in place for bruit and thrill for a resident receiving dialysis. Cross reference F699 trauma informed care: The facility failed to identify triggers that could cause re-traumatization. Cross reference F756 drug regimen review: The facility failed to ensure monthly medication reviews (MMR) were completed. Cross reference F791 dental services: The facility failed to ensure residents received timely dental services. Cross reference F807 hydration: The facility failed to ensure residents were provided adequate hydration. Cross reference F809 snacks at bedtime: The facility failed to ensure residents were offered snacks at bedtime. Cross reference F848 arbitration agreements: The facility failed to provide the arbitration agreement that was presented to residents contained language that provided for the selection of a venue that was convenient to both parties. Cross reference F883: immunizations: the facility failed to notify the power of attorney (POA) of immunization administration. Cross reference F921 safe/functional/sanitary/comfortable environment: the facility failed to ensure the communal resident shower was kept clean and sanitary. III. Staff interviews The NHA was interviewed on 4/10/25 at 6:52 p.m. He said the QAPI committee met once monthly. He said the QAPI committee looked at eight to ten areas on a monthly basis. The NHA said this meeting was used to discuss new identified concerns within the facility by reviewing resident council minutes, grievances, identified trends and incidents. The NHA said once an identified area was identified the committee assessed the situation to find a root cause. The NHA said it was his responsibility to follow up on identified areas and put a performance improvement plan (PIP) in place. The NHA said the PIP would then be discussed at the next meeting to ensure there was progress in a positive manner. The NHA said the QAPI committee had not identified any concerns when it came to: meal assistance, hydration, choking hazards, dialysis, discharges, re-admission, personal funds and posted survey results. The NHA said infection control was discussed at all QAPI meetings. He was not aware there was an issue with continuous positive airway pressure (CPAP) machines cleaning until it was identified during the survey. The NHA said the facility had issues with snacks about six months ago and changed how the snacks were being distributed due to residents hoarding snacks. He said he became aware that there were not enough snacks available to residents during the survey. The NHA said the facility was not aware that the pharmacy medication reviews were not occurring monthly reports until it was brought to attention during the survey.

Based on observations, record review and interviews the facility failed to provide snacks in one of one nourishment rooms for residents who required bedtime snacks and residents who wanted snacks during off hours. Specifically, the facility failed to ensure residents were offered and provided nourishing snacks in accordance to their needs and preferences. Findings include: I. Facility policy and procedure The Offering/Serving Snacks policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/14/25 at 2:55 p.m. It revealed in pertinent part, It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime and on a daily basis. Dietary services staff deliver snacks to each nurses' station. The charge nurse is made aware of the delivery of snacks. Intake of snacks is documented in the medical record. The Food and Nutrition Services policy and procedure, revised October 2017, was provided by the NHA on 4/14/25 at 2:55 p.m. It revealed in pertinent part, Nourshing snacks are available to the residents 24 hours a day. II. Resident group interview A group interview was conducted on 4/9/25 at 1:00 p.m. with six alert and oriented residents (#5, #35, #47, #48, #49 and #53), per the facility and assessments. The residents said they had concerns with not receiving bedtime snacks. The group said if they wanted a snack during the day they would have to ask. The residents confirmed snacks were not offered. III. Observations On 4/7/25 at approximately 2:00 p.m. the refrigerator on the Santa Fe unit was observed to be empty and had no snacks. On 4/8/25 at 11:00 a.m., the refrigerator on the Santa Fe unit was observed to be empty. The refrigerator in the nourishment room was observed on 4/9/25 at 3:29 p.m. The refrigerator had two cookies, two apple sauces, two yogurts and two half peanut butter sandwiches. The refrigerator was observed on 4/10/25 at 4:10 p.m. with the registered dietitian consultant (RDC) and it contained three apple sauces. During an observation in the kitchen on 4/10/25 at 6:34 p.m. an unidentified dietary aide loaded a cart with snacks to take to the locked refrigerator in the breakroom. The cart contained six puddings, ten wrapped cookies, four yogurts, four applesauces and thirty-two sandwiches. IV. Staff interviews The dietary manager (DM) was interviewed on 4/10/25 at 9:45 a.m. She said the dietary aides took the resident snacks out to the refrigerator in the locked breakroom between 6:30 p.m. and 7:00 p.m. The DM said the facility had a problem with leaving the snacks in the refrigerators on the hallways because there was a resident who would take the majority of the snacks to his room. The DM said the snacks in the breakroom refrigerator were for the certified nursing aides (CNA) and nurses to provide to the residents when the residents requested a snack after dinner. The DM said the residents could also come down to the kitchen anytime before 10:00 p.m. and request snacks. The DM said the snacks the dietary aides brought out in the evenings were sandwiches, pudding, yogurt and applesauce. The DM said the residents had a list on the wall in their rooms that included the meal times and the list of snacks. The DM said the residents who were not able to ambulate by themselves to the kitchen at night, not able to articulate to the staff they wanted a snack, or who had to find a staff member to request a snack, had limited access to obtaining snacks from the kitchen or the locked refrigerator. Certified nurse aide (CNA) #6 was interviewed on 4/10/25 at 11:30 a.m. CNA #6 said the nourishment refrigerator was where the snacks for the residents were stored. She said that they would go to the kitchen if there were no snacks in the nourishment refrigerator. The registered dietitian (RD) was interviewed on 4/10/25 at 2:00 p.m. The RD said snacks should be available at all times. She said the DM was responsible to ensure snacks were readily available. The DM was interviewed again on 4/10/25 at 6:34 p.m. She said upon observing the snacks available in relation to the number of residents in the facility, there was not a sufficient amount of snacks for the number of residents that resided in the facility. She said the kitchen would increase the amount of snacks so every resident could have more than one snack if they wanted. 20287

Based on record review and interviews, the facility failed to ensure that personal funds accounts were managed adequately for four (#19, #22, #27 and #42) of 10 residents out of 31 sample residents. Specifically, the facility failed to have Resident #19, Resident #22, Resident #27 and Resident #42 sign a new resident fund management service (RFMS) authorization and agreement form to handle the residents' funds when the facility underwent a name change. Findings include: I. Facility policy and procedure The Management of Residents' Personal Funds policy, revised March 2021, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It read in pertinent part, The resident may have the facility hold, safeguard, and manage his or her personal funds. Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record. II. Record review The Resident Fund Management Service Authorization and Agreement form was provided by the business office manager (BOM) on 4/10/25 at 10:50 a.m. -Review of the documentation revealed the facility's name was not accurate on the form for Resident #19, Resident #22, Resident #27 and Resident #42. III. Staff interviews The BOM was interviewed on 4/10/25 at 3:24 p.m. The BOM said she had only been working at the facility since November 2024. The BOM said the facility's name change happened in February 2023. The BOM said she was not working at the facility when the facility's name change occurred. She said the signature page for the residents to sign was printed off from the online RFMS program. The BOM said she was not sure why Resident #19, Resident #22, Resident #27 and Resident #42 were not asked to sign a new RFMS authorization and agreement form when the facility changed its name. She said she thought the previous BOM had the residents sign a new form with the new facility name on it. She said she was unable to find a form with the facility's new name on the form for the four residents. She said if the residents had signed a new form, it would have been uploaded in the online RFMS system. She said Resident #19, Resident #22, Resident #27 and Resident #42 did not have a form with the facility's new name uploaded in the system. The BOM said she would have Resident #19, Resident #22, Resident #27 and Resident #42 sign a new RFMS authorization and agreement form and upload it to the RFMS system. The BOM said once she had the residents sign a new form, it would upload to the system right away. The NHA was interviewed on 4/10/25 at 3:40 p.m. The NHA said he was hired at the facility in January 2025 and was not at the facility when the name changed. The NHA said the facility's name change occurred in February 2023. The NHA said residents were informed about the name change. The NHA said senior management came to the facility and met with staff and residents to notify them of the name change. The NHA said the residents were asked to sign a new admission agreement but he was not sure if the residents were asked to sign a new RFMS. The NHA said the previous BOM would have context of what was said and done. The NHA said he could not answer as to why a new form was not signed by Resident #19, Resident #22, Resident #27 and Resident #42. The NHA said he attempted to contact the previous BOM to ask, but he said he was unsuccessful.

Based on record review and interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for four (#9, #13, #16 and #35) of five residents reviewed for unnecessary medications out of 31 sample residents. Specifically, the facility failed to: -Have a monthly medication review (MMR) completed for Resident #9, Resident #13, Resident #16, and Resident #35; and, -Failed to have licensed pharmacist signature on monthly medication review (MMR). Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy and procedure, revised May 2019, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It revealed in pertinent part, The consultant pharmacy reviews the medication regimen of each resident at least monthly. The consultant pharmacist performs a medication regimen review (MMR) for every resident on the facility receiving medications. MMR are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The goal of the MMR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MMR involves a thorough review of the residents medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities. The medication regimen and associated treatment goals involve collaboration with the resident (or representative), family members and in the interdisciplinary team (IDT). As such, the MMR includes review of the residents (or representatives) stated preference, the comprehensive care plan and information provided about risk and benefits of the medication regimen. Within 24 hours of the MMR, the consultant pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity. The report must contain: resident name, the name of medication, identified irregularity, and the pharmacists recommendations. The attending physician documents in the medical record that the irregularities have been reviewed and what (if any) action was taken to address it. The consultant pharmacist provides the director of nursing (DON) and the medical director with a written, signed and dated copy of all medication regimen reports. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included obstructive sleep apnea (breathing repeatedly stops or becomes shallow during sleep due to a blockage in the upper airway) major depression disorder, dementia), Parkinson's disease (neurological disorder affecting movement), hemiplegia left side (loss of movement on one side of the body), type two diabetes (abnormal glucose control) and hypertension (high blood pressure). The 1/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for toileting, dressing, personal hygiene, and transfers. He required set up assistance for eating. It revealed the resident was on an antidepressant (mood stabilizer), anticonvulsant (anti seizure), hypoglycemic (reduces glucose) and antiplatelet (prevents blood cells from sticking) medication. The section of the MDS assessment that prompted documentation to indicate that a drug regimen review was completed was left blank. B. Record review A request was made for the February 2025 and March 2025 MMR. The regional director of clinical services (RDCS) provided documentation on 4/9/25 at 1:43 p.m. that revealed Resident #9 medications were assessed remotely by the pharmacist 2/28/25. The PH recommended to consider therapy modification and/or monitoring for toxicity of vitamin D. The DON documented she reviewed the recommendation on 3/1/25 that indicated to monitor the resident for toxicity. -However, the recommendations failed to have the physician's signature indicating the recommendation had been addressed by the physician. -The facility did not provide documentation indicating a MMR was completed for March 2025 for Resident #9. III. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included bipolar (mood disturbances), dementia, chronic obstructive pulmonary disease (COPD - abnormal oxygen exchange) and type two diabetes (abnormal glucose control). The 3/18/25 MDS assessment revealed the resident had short-term and long-term memory problems per staff assessment. He required moderate staff assistance with dressing. He required set up assistance for toileting, personal hygiene. He required supervision for transfers. It revealed the resident was taking an antipsychotic medication. The section of the MDS assessment that prompted documentation to indicate that a drug regimen review was completed was left blank. B. Record review A request was made for the February 2025 and March 2025 MMR as they were not located in the EMR. The RDCS provided documentation on 4/9/25 at 1:43 p.m. The information indicated the residents medications were assessed on 3/28/25 and the PH had no recommendations. It documented it was reviewed by the DON on 3/1/25 on the MMR. -However, the DON reviewed the MMR 27 days prior to the completion of the MMR. -The facility did not provide documentation indicating a MMR was completed for February 2025 for Resident #13. IV. Resident #16 A. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included bipolar disorder, schizophrenia (mental illness) and COPD. The 12/31/24 MDS revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required substantial staff assistance to toileting, dressing and transfers. The MDS assessment revealed the resident was on an antipsychotic, antidepressant, diuretic, opioids and hypoglycemic medications. The section of the MDS assessment that prompted documentation to indicate that a drug regimen review was completed was left blank. B. Record review A request was made for the February 2025 and March 2025 MMR as they were not located in the EMR. The RDCS provided documentation on 4/9/25 at 1:43 p.m. It documented Resident #16 medications were assessed on 3/31/25 and the PH was recommended for a risk versus benefit to be completed. It was noted by the DON on 3/1/25. -However the date DON signed was 30 days prior to the assessed date of 3/31/25. The recommendations failed to have a physician's signature. V. Resident #35 A. Resident status Resident #35, age less than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included catatonic schizophrenia (mood and movement abnormality), bipolar disease, dysphagia (difficulty swallowing) and hypertension. The 1/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was dependent on staff for toileting, dressing, personal hygiene and transfers. He required set up assistance for eating. The MDS assessment revealed the resident was receiving an antipsychotic, antianxiety, anticoagulant and antibiotic medications. The section of the MDS assessment that prompted documentation to indicate that a drug regimen review was completed was left blank. B. Record review A request was made for the February 2025 and March 2025 MMR as they were not located in the EMR. The RDCS provided documentation on 4/9/25 at 1:43 p.m. for MMR. Resident #35 medications were assessed on 3/31/25 and the PH was recommending monitoring for toxicities for Calctrol/cholecalciferol. It was noted by the DON on 3/1/25 per the physician monitor for toxicity and address as needed. -However the date DON signed was 30 days prior to the assessed date of 3/31/25. -Additionally, the recommendations failed to have the physician's signature indicating the recommendation had been addressed by the physician. The recommendations failed to have a physician's signature. VI. Staff interviews The DON was interviewed on 4/10/25 at 2:25 p.m. She said the facility had changed pharmacy providers in January 2025. She said they were working out the particulars with them still. The DON said medications should be reviewed monthly for all residents to reduce the risk of drug interactions, reduce the use of unnecessary medications and to keep the residents safe. The PH was interviewed via telephone on 4/10/25 at 3:42 p.m. She said the consultant pharmacist who visited the facility monthly for the psychotropic medication meeting was unavailable today. The PH said medications could be reviewed monthly remotely and then the documents were sent to the facility with any recommendations. The PH said the forms that were sent to the facility did not have a pharmacy signature on the sheets. The PH said MMRs were important to ensure all medications were working as expected with no side effects. She said the MMRs were also used to make recommendations for monitoring, diagnoses and duration of medication use. The RDCS was interviewed on 4/10/25 at 4:00 p.m. She said the signature on the recommendations were the DONs. The RDCS indicated the DON placed her signature on the forms when she contacted the physician on recommendations verbally. The RDCS said it appeared the DON signed 3/1/25 on the MMR when she meant to sign 4/1/25.

Based on observations, record review and interviews the facility failed to ensure drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for six residents (#5, #35, #47, #48, #49 and #53) of six resident out of 31 sample residents. Specifically, the facility failed to ensure Resident #5, Resident #35, Resident #47, Resident #48, Resident #49 and Resident #53 consistently had access to water to ensure proper hydration. Findings include: I. Professional reference According to Treas, [NAME], [NAME] (2022) [NAME] Advantage for Basic Nursing (3rd edition) page 939. The amount of water a person required varies according to the environmental humidity and temperature, activity level, age, and metabolic needs. The average adequate intake is about 2.7 liters of water per day for adult women and 3.7 liters for men. II. Resident group interview A group interview was conducted on 4/9/25 at 1:00 p.m. with six alert and oriented residents (#5, #35, #47, #48, #49 and #53), per the facility and assessments. The residents said they did not receive fresh ice water daily. The residents said they used to get fresh water passed to their rooms but no longer did. The residents said they wanted to receive ice water daily. III. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included severe protein malnutrition, multiple sclerosis (chronic disease), dysphagia (difficulty swallowing) and dementia. The 1/19/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of ten out of 15. The resident required assistance with all of her activities of daily living (ADL). B. Resident interview Resident #5 was interviewed on 4/7/25 at 1:50 p.m. Resident #5 said that she was supposed to keep hydrated, but she did not have a water pitcher. She said they did not pass water to the rooms daily. She said she would like more to drink. C. Observations On 4/7/25 at 12:45 p.m., the resident was lying in bed. She had her meal in front of her. She received a 240 cubic centimeters (cc) glass of cranberry juice. She drank all of the cranberry juice. On 4/8/25 at 5:10 p.m., the resident received a 240 cc glass of cranberry juice. She drank the entire glass of cranberry juice. She was not provided additional beverages during the meal. On 4/9/25 at 9:00 a.m., the resident received her meal. She was provided a 240 cc glass of cranberry juice and a 240 cc glass of milk. The milk was poured into her cereal. -At 9:30 a.m., she drank all of the cranberry juice and the majority of the milk remained in the cereal bowl. She continued to not have a water pitcher in her room. On 4/9/25 at 3:49 p.m., the resident's room was observed with licensed practical nurse (LPN) #1. LPN #1 confirmed the resident had no water pitcher or bottle in her room. D. Record review The 12/3/24 nutritional risk review assessment revealed the resident was consuming an average of less than 1200 cc a day. -Review of the resident's electronic medical record revealed no assessment which indicated the resident's fluid needs. The 12/4/25 nurse practitioner note documented fluids were encouraged. The 1/6/25 nurse practitioner note documented the resident was educated to increase her water intake. The care plan, revised 2/2/25, identified the resident required assistance with meals, and has been recommended for nectar thick liquids but has signed a waiver for thin liquids. IV. Staff interview LPN #1 was interviewed on 4/9/25 at 3:49 p.m. LPN #1 said each resident needed to have a water pitcher or bottle. He said the certified nurse aides (CNA) were responsible to pass water to the residents each shift. He said Resident #5 was not able to get her own water due to her dexterity in her hands and mobility. The registered dietitian (RD) was interviewed on 4/10/25 at 2:00 p.m. The RD said she encouraged fluid intake for all residents. She said she recommended 1500 cc of fluid intake for the residents. She said she reviewed Resident #5 on a regular basis because she had nutritional risk factors. She said the resident should have a water pitcher in her room. She said she was not aware Resident #5 did not have a water pitcher. She was not sure if there were hydration rounds being offered to the residents. The director of nursing (DON) was interviewed on 4/10/25 at 3:00 p.m. The DON said it was important for the residents to receive fresh water daily. The DON said ice water was to be passed every shift.

Based on observations, record review and interviews, the facility failed to ensure one (#9) of three residents who required respiratory care received care consistent with professional standards of practice out of 31 sample residents. Specifically, the facility failed to follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine. Findings include: I. Facility policy and procedure The CPAP/BiPAP support policy and procedure, revised March 2015, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It revealed in pertinent part, To provide the spontaneously breathing resident with continuous positive airway pressure (CPAP) with or without supplemental oxygen. General guidelines for cleaning the machine: wipe machine down with warm soapy water and rinse at least once a week and as needed. Clean humidifier weekly and air dry. Masks, nasal pillow, and tubing: clean daily by placing in warm water, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. Head gear (strap) wash with warm water and mild detergent as needed and allow to air dry. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO) diagnoses included obstructive sleep apnea (breathing repeatedly stops or becomes shallow during sleep due to a blockage in the upper airway), major depression disorder, dementia, Parkinson's disease (neurological disorder affecting movement), hemiplegia left side (loss of movement on one side of the body), type two diabetes (abnormal glucose control) and hypertension (high blood pressure). The 1/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for toileting, dressing, personal hygiene, and transfers. He required set up assistance for eating. It revealed the resident had shortness of breath or trouble breathing when laying flat and used a non-invasive mechanical ventilator like CPAP or BiPAP and oxygen therapy. B. Resident interview Resident #9 was interviewed on 4/7/25 at 2:07 p.m. He said the staff helped him put on his CPAP at night. Resident #9 said the staff cleaned the machine and pieces that went on his face with a white wipe, but he was unsure how often it was cleaned. Resident #9 said the staff put the mask and head gear into the top drawer of his nightstand after he used it and he's never seen them put it into a bag for storage. C. Observations and staff interviews On 4/7/25 at 2:07 p.m. Resident #9's CPAP tubing, mask and head gear were observed loose in the top drawer of his night stand. There was visible debris in the drawer and several personal items loose in the drawer with the CPAP mask and head gear. On 4/9/25 at 3:58 p.m. Resident #9's CPAP tubing, mask and head gear were observed loosely stored in the top drawer of his nightstand. The top drawer had several personal items loose in the drawer. On 4/10/25 at 9:00 a.m. certified nurse aide (CNA) #2 was observed in Resident #9 room. CNA #2 was looking in the top drawer of the night stand. CNA #2 said Resident #9 had a CPAP machine on his night stand that he used at night. CNA #2 said the respiratory nurse was responsible to help the resident apply it at night and remove it in the morning. CNA #2 said the mask and head gear should be stored in a bag after it was cleaned to prevent contamination. CNA #2 left Resident #9's room and returned with a clean trash bag and a container of Super Sani-wipes (germicide disposable surface wipe). CNA #2 applied gloves and took a Sani-wipe and began wiping the CPAP tube, head gear and mask with the wipe. CNA #2 then placed the tubing, mask and head gear into the trash bag she brought into the room. CNA #2 said there was a cell phone, a pair of scissors, an open bag of fresh scent cloth wipes (incontinence wipes), beads, a wooden cross and eye glass case in the drawer where the CPAP was being stored. CNA #2 then removed her gloves and washed her hands with soap and water prior to leaving Resident #9's room. -However, per the respiratory contractor's (RC) interview CPAP machines should not be cleaned with Super Sani-cloth wipes (see interview below). D. Record review The April 2025 CPOs revealed the following physician's order: Use CPAP wipe to clean the inside of the mask, use fresh clean wipe to clean the hard outer shell of mask and tubing, and a fresh clean wipe to clean the outside of the BiPAP unit, once daily for obstructive sleep apnea, ordered on 2/13/22. -Review of the resident's electronic medical record (EMR) did not indicate how the staff were supposed to store the CPAP when not in use. The respiratory care plan, revised on 2/6/16, revealed Resident #9 had altered respiratory status/difficulty breathing related to obstructive sleep apnea and required CPAP for symptom management. Interventions included administering medications as ordered, applying the CPAP at bedtime for sleep apnea, coordinating services with the respiratory therapy, monitoring for signs or symptoms of respiratory distress and reporting to the physician, monitoring/documenting/ reporting abnormal breathing patterns to the physician and pacing/scheduling activities providing adequate rest periods. -The care plan failed to document how staff should clean and store the CPAP when not in use. III. Staff interviews Registered nurse (RN) #3 was interviewed on 4/10/25 at 9:42 a.m. She said the nursing staff had to assist Resident #9 with applying his CPAP. RN #3 said when the CPAP was not in use the mask and head gear were to be cleaned and stored in a plastic bag to keep it from getting dirty and prevent infection. RN #3 said the CPAP parts that touched the residents face should not be cleaned with Super Sani-cloth wipes because it could cause a reaction due to the chemicals in it. The infection preventionist (IP) was interviewed on 4/10/25 at 12:00 p.m. She said a CPAP machine should be cleaned daily and stored above the bed. The IP said the CPAP reservoir should be cleaned weekly and as needed with distilled water only. The IP said the face mask, head gear should be cleaned daily with mild soap and water and rinsed well and left to air dry. The IP said once dry it should be placed into a bag to prevent infection. The IP said Super Sani-cloth wipes could be used to clean the CPAP as well. RN #1 who was also the respiratory nurse was interviewed on 4/10/25 at 12:10 p.m. She said it was the responsibility of the floor nurse assigned to assist the resident in applying CPAP and removing and cleaning the CPAP after use. RN #1 said the CPAP should be cleaned with warm soapy water, rinsed and placed on a paper towel to dry. RN #1 said once the CPAP was dry it should be stored in a clean plastic bag to prevent contamination. The RC was interviewed via phone on 4/10/25 at 12:18 p.m. He said the manufacturers' recommendations for CPAP were to be cleaned with mild soap and water. He said Super Sani cloth wipes were not recommended because it could break down the plastic pieces used to create a seal for proper function. The director of nursing (DON) was interviewed on 4/10/25 at 2:32 p.m. She said the CPAP should be cleaned daily and placed into a plastic bag to prevent infection. The DON said the nurses should follow manufacturers' recommendations of mild soap and water to clean machines.

III. Resident #211 A. Resident status Resident #211, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included bipolar and schizoaffective disorder. The 3/5/25 minimum data set (MDS) assessment revealed the resident was unwilling to complete the BIMS assessment and a staff assessment for mental status was completed. The staff assessment revealed the resident was only orientated to himself and his location. The resident had impaired short term and long term memory with severely impaired decision making. The resident required set up assistance with eating, toileting, personal hygiene, showering, dressing, and transfers and ambulated independently. B. Record review -Review of Resident #211's admission agreement, dated 2/18/25, did not reveal the resident and/or his representative were provided with information on the facility's bed hold policy upon his admission to the facility on 2/10/25. Review of Resident #211's EMR revealed the resident was transferred to the hospital on 3/5/25. -Further review of Resident #211's EMR failed to reveal whether the resident or his representative were provided with a written bed hold policy upon the resident's transfer to the hospital. C. Staff interviews The social services director (SSD) was interviewed on 4/9/25 at 3:30 p.m. The SSD said Resident #211 was transferred to the hospital on 3/5/25 for a mental health evaluation. The SSD did not know if the resident or his representative had been provided a bed hold policy when he left for the mental health evaluation. The NHA was interviewed on 4/10/25 at 3:46 p.m. The NHA said the facility had not provided Resident #211 or his representative with a bed hold policy when he was transferred to the hospital on 3/5/25. Based on record review and interviews, the facility failed to provide notice of bed hold policy and return for two (#35 and #211) of four residents reviewed for hospital transfers out of 31 sample residents. Specifically, the facility failed to provide Resident #35 and #211 with a written notice of bed hold policy and return when transferred to the hospital to address acute care needs. Findings include: I. Facility policy and procedure The Bed Holds and Returns Policy and procedure, revised October 2022, was received by the nursing home administrator (NHA) on 4/14/25. It revealed in pertinent part, Residents and/or representatives are informed (in writing) of the facility and state bed hold policies. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during a period of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided with written notice about these policies at least twice. Notice one is provided well in advance of any transfer (in the admission packet) and notice two is provided at the time of transfer (or, if the transfer was an emergency, within 24 hours). Multiple attempts to provide the residents/representatives with notice two should be documented in cases where staff were unable to reach and notify the representative timely. II. Resident #35 A. Resident status Resident #35, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included catatonic schizophrenia (mood and movement abnormality), bipolar disease (mood swings), dysphagia (difficulty swallowing) and hypertension (high blood pressure). The 1/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was dependent on staff for toileting, dressing, personal hygiene and transfers. He required set up assistance for eating. B. Resident interview Resident #35 was interviewed on 4/9/25 at 1:00 p.m. He said he had gone to the hospital recently and was not informed of the facility's bed hold policy. C. Record review According to the resident's electronic medical record (EMR), Resident #35 was transferred to the hospital on 1/22/25. -Review or the Skilled Nursing/Nursing Facility To Hospital Transfer form, dated 1/22/25, did not indicate if a written bed hold policy was given to the resident at the time of the resident's transfer to the hospital. -Review of Resident #35's progress notes from 1/22/25 to 1/25/25, when the resident returned from hospital, failed to indicate if the facility provided the resident with a bed hold policy at the time of his transfer to the hospital on 1/22/25 or within 24 hours of the transfer. D. Staff interviews Registered nurse (RN) #3 was interviewed on 4/10/25 at 2:02 p.m. RN #3 said when a resident was transferred to the hospital, she had to prepare the paper work, which included the resident's advanced directives, face sheet, transfer communication form and a copy of the resident's current physician's orders. RN #3 said bed hold paper work was required to be provided to the resident when the resident was gone from the facility for more than three days. RN #3 said the bed holds should be signed before a resident was transferred from the facility, but she said some residents were not able to sign their own paperwork. RN #3 said a family representative should be called to obtain signature/verbal consent for bed holds if the resident could not sign for themselves. RN #3 said the nurse sending the resident to the hospital would document in a progress note if the bed hold was given to the resident or if the resident's representative was called. The director of nursing (DON) was interviewed on 4/10/25 at 2:09 p.m. The DON said a written bed hold policy should be given to the resident at the time of their transfer to the hospital or within 24 hours of the transfer. The DON said staff could get verbal consent from the resident's responsible party and it should be documented in the resident's medical record who was notified of the bed hold policy.

Based on record review and interviews, the facility failed permit a resident to return after a hospitalization or therapeutic leave for one (#212) of three residents out of 31 sample residents. Specifically, the facility failed to reassess Resident #212's status at the time the resident sought to return to the facility after a transfer to the hospital, and did not allow the resident to return to the facility, based upon her status at the time of her transfer to the hospital. Findings include: I. Facility policy and procedure The Facility Initiated Transfer or Discharge policy, revised October 2022, was provided by the nursing home administrator (NHA) on 4/10/25 at 2:51 p.m. It read in pertinent part, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the residents welfare and the resident's needs cannot be met in the facility. A resident's declination of treatments is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The facility will document that the resident, or if applicable, resident's representative received documentation of the risks of refusing treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident's needs or protect the health and safety of others. If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include the specific resident needs that cannot be met, the facility's attempts to meet those needs, and the receiving facility's service(s) that are available to meet those needs. If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: -Ascertain an accurate status of the resident's condition-this can be accomplished via communication between hospital and nursing home staff and/or through visits by nursing home staff to the hospital; - Find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the resident's needs. For example, a resident now requires ventilator care or dialysis, and the nursing home is unable to provide this same level of care; and, Work with the hospital to ensure the resident's condition and needs are within the nursing home's scope of care, based on its facility assessment, prior to hospital discharge. II. Resident #212 A. Resident status Resident #212, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with mood disturbances, quadriplegia (paralysis of all four limbs), post traumatic stress disorder, agoraphobia (extreme anxiety disorder) and anxiety. The 9/16/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview of mental status (BIMS) score of four out of 15. The MDS assessment indicated the resident had delusions and behaviors towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated the resident did not have an active discharge plan. B. Record review Review of Resident #212's hospital records, prior to her admission to the facility on 9/10/24, revealed the following documentation: The 8/26/24 hospital referral revealed that during Resident #212's hospital stay, the resident continuously called out, displayed agitation, yelled throughout the shift and refused medications and food. The 9/10/24 hospital discharge summary revealed the resident had post traumatic stress disorder, anxiety, delusions and dementia with behavioral disturbances. The resident refused all psychiatric medications while in the hospital and required intravenous (IV) antipsychotics. Resident #212's discharge care plan, initiated 9/12/24, revealed the resident's guardian wished for the resident to remain in the facility for long term care. Interventions (dated 9/12/24) included offering support through listening in one-on-one situations, arranging for consultation as indicated by change or decline in function, including the resident and/or resident's representative in the treatment plan, notifying the physician of any significant changes with psychosocial well-being and updating when indicated by change in condition or treatment plan. Resident #212's psychosocial care plan, revised 9/17/24, revealed the resident exhibited delusions regarding calling business partners, making business deals, running errands and dealing with lawsuits. The resident had a phobia of her door being closed, including the window and blinds and would often yell out for help. The resident had delusions with persecutory themes often calling out stop, don't hit me. Interventions (initiated 9/17/24) included providing the resident with her preferred soda with a straw, providing the resident with sweet treats, documenting and recording behavior episodes, encouraging the resident to verbalize her feelings, establishing a rapport with the resident and observing and documenting changes in behavior, including frequency of occurrence and potential triggers. Resident #212's psychosocial/refusal of care care plan, revised 9/24/24, revealed the resident refused care and services within her rights as manifested by noncompliance/refusal of medications. Interventions (initiated 9/14/24) included collaboration with the interdisciplinary team (IDT) to identify underlying causes, determining resident's experiences and preferences to eliminate/mitigate triggers, to the extent possible, encouraging the resident to set up a schedule for care which was acceptable for him/her to the extent possible and re-approaching when the resident was refusing care, to the extent possible. Review of Resident #212's October 2024 CPO revealed the following physician's orders: May transfer out to hospital related to AMS (altered mental status), ordered 10/31/24. Discharge skilled physical therapy as the resident was transferred to the hospital, ordered 10/29/24. Review of Resident #212's progress notes from 9/10/24 through 10/31/24 revealed the following: Resident #212 had nine documented episodes of refusing medications and seven documented episodes of yelling out. The physician's note, dated 9/12/24, revealed Resident #212 had a history of refusing medications, food and supplements at the hospital and the facility. The resident was admitted with a guardian due to impaired insight, unsafe home conditions and an inability to care for herself. She suffered from multiple wounds in varying degrees of deterioration. The resident was completely immoble due to severe disability and frailty with contractures. The physician's note, dated 9/23/24, revealed the physician discontinued all of the resident's medications except for pain medication and stool softeners. The physician's note, dated 10/4/24, revealed Resident #212 had been assigned a one-to-one sitter. Between 10/15/24 and 10/31/24, the progress notes revealed a progression of pain for the resident, with the resident agreeing to and requesting pain medications. A change of condition note, dated 10/31/24, revealed Resident #212 suffered from uncontrolled pain with altered mental status. The physician recommended the resident be sent out to the hospital. The resident was transported to the hospital. -The note did not indicate the facility was transferring the resident to the hospital based on resident behaviors or needs the facility was unable to meet. Resident #212's hospital transfer form, dated 10/31/24, revealed the resident was transferred to the hospital due to altered mental status, increased hallucinations and paranoia and pain in her leg. -The transfer form did not indicate the facility would not accept the resident back at the facility. Review of Resident #212's progress notes from 11/1/24 to 11/6/24 (after the resident was transferred to the hospital) revealed the following: A nurse note, dated 11/1/24 , revealed Resident #212 had been presenting with increased paranoia and agitation. She had a one-on-one sitter in place related to behaviors of yelling out and screaming for help but had been stable with a sitter in place. The resident had now demonstrated yelling out while having staff sitting with her. The resident was not agreeable to allowing a medical workup in the facility and requested to be transported to the hospital. An IDT note, dated 11/4/24, revealed the IDT decided to issue an immediate discharge for Resident #212 on the basis the resident had increased behaviors without a clear behavior management plan. The resident did not qualify for hospice and her safety and quality of life had become a concern due to the need for a higher level of care and not being suited for the facility. -However, the hospital records prior to the resident's admission to the facility, indicated the resident had displayed the same behaviors (delusions, yelling out and refusing medications) prior to the resident's admission to the facility and the facility felt they could meet the resident's needs at that time (see hospital records above). -The note failed to indicate if the facility had reassessed the resident after her transfer to the hospital to determine if she was able to return to the facility. -Additionally, the note did not indicate how the facility had attempted to meet the resident's needs or why they could no longer meet her needs. A physician's progress note, dated 11/5/24, revealed Resident #212 was being medically discharged on the basis she needed a higher level of care that could not be provided in the facility. The resident refused her psychiatric medications and had increases in yelling out, hallucinations and delusions. Her increases in behaviors were disrupting the continuity of care for residents in the facility and some other facility residents had become frightened due to the constant yelling, making multiple complaints that Resident #212 disrupted their care and sleep. The resident needed a higher level of care for safety and quality of life. -However, the physician's note failed to specify what higher level of care was needed for Resident #212, why the facility could not meet her needs and how the facility had attempted to meet her needs and failed. -Additionally, the note failed to indicate if the facility or the physician had reassessed the resident after her transfer to the hospital to determine if she was able to return to the facility. A social services note, dated 11/6/24, revealed an immediate discharge notice was sent to Resident #212's guardian via email. The discharge notice, dated 11/6/24, revealed Resident #212 was discharged effective 10/31/24 due to the facility being unable to meet the welfare of the resident. -However, hospital records prior to the resident's admission to the facility on 9/10/24 revealed the behaviors (delusions, yelling out, and refusing medications) the resident displayed after admission to the facility were consistent and regular behaviors for Resident #212 (see hospital records above). -Review of Resident #212's electronic medical record (EMR) revealed there was no documentation to indicate the facility had reassessed the resident after her transfer to the hospital to determine if the resident was able to return to the facility. III. Staff interviews The social services director (SSD) was interviewed on 4/9/25 at 3:30 p.m. The SSD said Resident #212 was disruptive, yelled out and was not a good fit at the facility. The SSD said she could not say what specifically, other than a one-on-one sitter, the facility had done to attempt to meet the resident's needs before her hospitalization on 10/31/24. The SSD said the facility intended to readmit Resident #212 after she was evaluated and treated at the hospital, but after meeting to discuss the resident, the IDT decided she needed a higher level of care due to her yelling out and refusal to take psychotropic medications. The SSD said no one from the facility went to reassess the resident at the hospital or reassess her through hospital records. She said the IDT determined that an immediate discharge would be issued to the resident. The SSD said she could not say why the facility did not instead issue a 30 day notice and assist the guardian with finding another facility. The NHA and the regional director of clinical services (RDCS) were interviewed together on 4/9/25 at 4:27 p.m. The NHA said he was not working at the facility at the time of Resident #212's discharge, but the RDCS recalled the resident's discharge. The RDCS acknowledged the facility assessment indicated the facility was able to accept residents with dementia and currently had residents who were confused, yelled out and refused to take medications. She said Resident #212 was not accepted back to the facility after her transfer to the hospital on the basis that her increased behaviors and yelling out disrupted the other residents and this could have put her at risk of being harmed by another resident. The RDCS said Resident #212's refusal to take psychiatric medications and increased behaviors required a higher level of care for her. The RDCS said no one from the facility went to reassess the resident at the hospital or reassess her through hospital records and there was no documentation of communication with the hospital assessing how the resident's care and treatment could be altered in order for her to be accepted back. The RDCS said she could not say specifically, what higher level of care the resident required that could not be provided by the facility nor could the RDCS say how the resident's behaviors, which she acknowledged were consistent with advancing dementia, necessitated an immediate discharge without advanced notice.

Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#40) of two residents reviewed for PASRR out of 31 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #40. Findings include: I. Resident #40 A. Resident status Resident #40, age 71, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia with mood disturbances, major depressive disorder, traumatic brain injury and schizophrenia. The 3/29/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment indicated the resident had no behaviors. The assessment revealed the resident had been identified as having a Level II PASRR. B. PASRR Level II Notice of Determination for MI (mental illness) evaluation Resident #40's PASRR Level II, provided to the facility on [DATE], included the evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder. The resident was to receive a neurocognitive evaluation (an assessment to determine how different parts of the brain function to understand the impact of neurological conditions and brain injuries.) C. Record review Resident #40's mood and behavior care plan, revised 7/16/24, revealed the resident had a Level II PASRR due to a diagnosis of major depressive disorder and schizophrenia. Interventions, initiated dated 8/7/23, included to document all behaviors and provide medications as ordered. -The care plan failed to include the PASRR Level II recommendation for Resident #40 to have a neurocognitive evaluation (see PASRR Level II above). -The March 2025 CPO failed to reveal any orders for a neurocognitive evaluation since the resident's admission to the facility on [DATE]. -Progress notes were reviewed from 1/1/25 through 4/2/25 and no social services notes were found regarding PASRR or recommendations for Resident #40. There were no PASRR progress notes revealing communication with the State Mental Health Agency regarding a delay or inability to follow Resident #40's PASRR Level II recommendations. II. Staff interviews The social services director (SSD) was interviewed on 4/9/25 at 3:30 p.m. The SSD said the recommendations made by the State Mental Health Agency were included in the PASRR Level II and were the expectations of the state. The SSD said the facility had a provider that performed neurocognitive evaluations and she was aware of how to send a referral. She said during her quarterly and annual resident assessments, she reviewed if there were any changes in a resident's status that would require a review of the resident's PASRR. She said she did not know why a neurocognitive evaluation was never scheduled for Resident #40. III. Facility follow-up The SSD provided an update on Resident #40's PASRR recommendations on 4/10/25 at approximately 10:00 a.m. She said she had sent a referral for Resident #40 to receive a neurocognitive evaluation on 4/10/25 at 7:43 a.m.

Based on observations, record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for one (#20) of three residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #20, who had a diagnosis of diabetes, had his fingernails cut by staff who were trained to perform the task. Findings include: I. Resident status Resident #20, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia, diabetes, quadriplegia, contractures of the left and right hands, diabetes and anoxic brain injury. The 3/19/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview of mental status (BIMS) score of six out of 15. The resident had impairments of both upper extremities and used a wheelchair to ambulate. The MDS assessment indicated the resident had a diagnosis of diabetes mellitus. B. Observations On 4/8/25 at 12:26 p.m. Resident #20 was sitting in his wheelchair in the activities room. Activities assistant (AA) #1 was sitting with the resident. At 12:37 p.m. AA #1 removed the splint device from the resident's contracted right hand and began to cut the fingernails on his hand. After cutting the fingernails on Resident #20's proceeded'to cut the fingernails on his left hand, put lotion on both of his hands and put the splint device back on his right hand. C. Record review A physician follow up note, dated 3/25/25, revealed Resident #20 had type 2 diabetes mellitus controlled with a diabetic diet. II. Staff interviews The activities director (AD) was interviewed on 4/9/25 at 1:42 p.m. The AD said activities staff could not trim or cut the fingernails for residents who had diabetes.'He said he could cut the nails of diabetic residents because he was a certified nurse aide (CNA). He said he was not aware AA #1 had cut Resident #20's fingernails. Registered nurse (RN) #2 was interviewed on 4/9/25 at 1:56 p.m. RN #2 said CNAs could not cut diabetic fingernails because it was not in their skill set. RN #2 said diabetic residents had elevated blood sugars and did not heal well, so if a CNA cut their nails, it could put the resident at risk for wounds and infections if the CNA accidently cut the resident's skin. The director of nursing (DON) was interviewed on 4/9/25 at 2:24 p.m. The DON said the podiatrist cut the fingernails and toenails of the diabetic residents. The DON said nurses could cut diabetic residents nails but CNAs could not due to their skill set. She said if a CNA cut the nails, it could put the resident at risk for wounds and infections if the CNA accidently cut the skin. The DON was unaware the AD believed he could cut diabetic residents' nails and she was unaware'AA #1 had cut Resident #20's nails. She said she would conduct training with the staff.

IV. Resident #20 A. Resident status Resident #20, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, quadriplegia, contractures of the left and right hands, diabetes and anoxic brain injury. The 3/19/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident had impairments of both upper extremities, used a wheelchair to ambulate and was always incontinent of bowel and bladder. The resident was dependent on staff for eating, toileting, personal hygiene, shower, dressing and transfers. B. Resident observation During a continuous observation on 4/7/25, beginning at 11:41 a.m. and ending at 2:49 p.m., the following was observed: At 11:41 a.m. the resident was sitting in his wheelchair in the dining room. At 12:33 p.m. a staff member took the resident from the dining room to a television room. At 1:32 p.m. a staff member took Resident #20 to the activities room for an activity. At 2:49 p.m. the resident was taken back to the dining room for a different activity. -Resident #20 was not offered repositioning or toileting assistance during the over three hour continuous observation. During a continuous observation on 4/8/25, beginning at 8:54 a.m. and ending at 12:55 p.m., the following was observed: At 8:54 a.m. Resident #20 was sitting in his wheelchair in the television room. At 9:25 a.m. the resident was taken to the gym for therapy. At 10:00 a.m. Resident #20 was taken to the dining room for chair exercises. The resident remained in the dining room for the food committee, asleep in his wheelchair. At 11:40 a.m. the resident was served his lunch in the dining room. At 12:15 p.m., when the resident was finished eating, he was taken to the television room. At 12:26 p.m. an activities assistant came and took Resident #20 to the activities room for an activity. At 12:48 p.m. registered nurse (RN) #1 came and took the resident from the activities room to the therapy gym to retrieve his incentive spirometer (lung expansion device) and then took him to his room for a breathing treatment. At 12:58 p.m., RN #1 said she was not aware Resident #20 had not been changed in almost four hours.She found a CNA to help change the resident. C. Record review Resident #20's ADL care plan, revised 8/27/24, revealed the resident had a self-care performance deficit related to impaired physical mobility due to quadriplegia and contractures. Interventions (initiated 2/18/23) included providing the resident with total assistance by two staff members for toileting. The bowel and bladder care plan, revised 5/7/24, revealed Resident #20 was at risk of skin breakdown and pressure injury development related to impaired physical mobility, bowel and urinary incontinence and requiring total assistance with bed mobility and repositioning. Interventions (initiated 2/18/23) included to encourage/assist the resident with repositioning frequently as the resident allowed. A nursing bowel and bladder assessment, dated 3/10/25, revealed the resident was incontinent, required extensive assistance with toileting and was on a two-hour check and change schedule. A physician follow up note, dated 3/27/25, revealed Resident #20 had multiple comorbidities requiring medication management that necessitated frequent clinical evaluations. Without regular monitoring and management, the resident was at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. The resident had functional impairments with potential high risk for frequent falls, bowel or bladder complications, and new or worsening wounds and required frequent monitoring. D. Staff interviews CNA #1 was interviewed on 4/8/25 at 2:30 p.m. CNA #1 said Resident #20 required total assistance from the staff for changing after an episode of incontinence. She said he was non-verbal and could only respond to yes or no questions and if he was asked, he could express to staff if he needed to be changed. Licensed practical nurse (LPN) #1 was interviewed on 4/9/25 at 1:30 p.m. LPN #1 said Resident #20 required extensive two-person assistance with being changed after an episode of incontinence. LPN #1 said the resident was incontinent of bowel and bladder and needed to be checked on by staff every two hours to prevent skin breakdown. CNA #5 was interviewed on 4/9/25 at 1:45 p.m. CNA #5 said Resident #20 required total assistance from the staff for changing after an episode of incontinence. CNA #5 said the staff did not document after they had changed him, but to prevent skin breakdown, he needed to be checked on every two hours. The director of nursing (DON) was interviewed on 4/9/25 at 4:27 p.m. The DON said residents who were incontinent needed to be checked on every two hours to ensure they had not had an episode of incontinence. The DON said it was important to check on the residents at least every two hours to prevent skin breakdown which could lead to pressure injuries. The DON was not aware Resident #20 had gone three to fours hours without being changed on 4/7/25 and 4/8/25. 52094 Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities for three (#5, #20 and #30) of four residents reviewed for ADLs out of 31 sample residents. Specifically the facility failed to: -Ensure Resident #5 and Resident #30 received timely meal assistance; and, -Offer timely toileting assistance and repositioning for Resident #20. Findings include: I. Facility policy and procedure The Activity of Daily Living (ADL) policy was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m The policy read in pertinent part, Based on the resident`s comprehensive assessment and consistent with the resident`s needs and choices, ensure a resident`s abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following ADLs: Eating, to include meals and snacks. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included severe protein malnutrition, multiple sclerosis, dysphagia and dementia. The 1/19/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of ten out of 15. The resident required assistance with all of her ADLs. The assessment indicated the resident required supervision or touching assistance while eating. B. Observations On 4/7/25 at 12:15 p.m. Resident #5 was served her lunch meal, which consisted of ham and sweet potatoes. The ham was not cut up as directed on her meal ticket (see record review below). During a continuous observation on 4/8/25, beginning at 5:10 p.m. and ending at 5:30 p.m., the following was observed: At 5:10 p.m., Resident #5 was served a shredded steak sandwich on a hoagie roll. She picked at the shredded beef but she did not touch the bread. At 5:20 p.m., she had eaten the dessert. At 5:30 p.m., she was observed to leave the table and did not receive any assistance or encouragement to eat. She consumed less than 25% of her meal, however, staff did not offer her an alternative when she consumed less than 25% of her meal. Review of Resident #5's dinner meal documentation on 4/7/25 revealed staff documented the resident ate 25% to 50% of her meal. -However, the resident consumed less than 25% of her meal (see observation above). During a continuous observation on 4/9/25, beginning at 11:45 a.m. and ending at 12:25 p.m. the following was observed: At 11:45 a.m., Resident #5 received her lunch meal, which consisted of a bowl of cream of potato soup and a fruit tart. At 12:01 p.m., she ate the creamed broth of the soup but left the potatoes in the bowl. She additionally ate the inside of the fruit tart. Staff did not offer the resident encouragement or assistance during the meal. At 12:25 p.m., the resident left the table. She was not offered an alternative and was not offered encouragement. C. Record review Resident #5`s nutrition care plan, initiated 1/14/25, revealed the resident was at potential risk for altered nutritional status and she required assistance during meals. Interventions included cutting up the resident's meat portions and assisting the resident with meals as needed. Review of Resident #5`s April 2025 CPO revealed a physician's order for the resident to receive verbal cueing at meals, ordered 3/22/25. D. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 4/9/25 at 9:45 a.m. CNA #7 said Resident #5 was able to feed herself. However, she said she was not a big eater. She said the resident needed prompting to eat. She said the resident was able to choose what she wanted to eat. CNA #7 said the resident's meat portions needed to be cut for her. The registered dietitian (RD) was interviewed on 4/10/25 at 2:00 p.m. The RD said Resident #5 could feed herself, however, she said she required encouragement to eat. She said staff needed to ensure they were documenting the resident's meal intake accurately. The RD said the dietary manager was to ensure an alternative meal was offered when Resident #5 consumed less than 50% of her meal. III. Resident #30 A. Resident status Resident #30, age 86, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/7/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required partial to moderate assistance with ADLs. She required set up assistance for eating. B. Observations During a continuous observation on 4/7/25, beginning at 12:15 p.m. and ending at 12:37 p.m. the following was observed: At 12:15 p.m., Resident #30 received her lunch meal, which consisted of mechanical soft ham, sweet potatoes, broccoli and a cookie. At 12:20 p.m., she was not eating her meal and had not received any encouragement. At 12:27 p.m., she was eating the cookie, she had not touched her main entree. At 12:30 p.m., the table mate was telling the resident to drink her milk. At 12:37 p.m., she pushed herself from the table and wheeled herself out of the dining room. No one stopped her to ask if she wanted an alternative meal, or to provide any encouragement to eat. During a continuous observation on 4/8/25, beginning at 5:10 p.m. and ending at 5:35 p.m. the following was observed: At 5:10 p.m., Resident #30 received her dinner meal. She received a steak sandwich, french fries and an oatmeal pie. At 5:11 p.m., the resident said she wanted the rice crispy treat which the regular diet received. The registered dietitian told her that she could not have the rice crispy treat because she was on a mechanical soft diet. The resident did not have her teeth in her mouth. At 5:20 p.m., she continued to She was not offered an alternative meal when she did not eat her meal and she was not provided any encouragement from the staff to eat the main part of her meal. At 5:28 p.m., the activity assistant stopped by the table and said hello to the residents at the table. She was not provided any encouragement to eat. At 5:35 p.m., she left the dining room with her roommate. She only consumed the oatmeal pie. During a continuous observation on 4/9/25, beginning at 11:58 a.m. and ending at 12:30 p.m., the following was observed: At 11:58 a.m., the resident received her meal, she pushed the plate away from her. She was served ice cream and she was eating the ice cream. At 12:15 p.m., she finished the ice cream. She did not receive any encouragement. At 12:20 p.m., the resident's roommate who sat at the same table encouraged the resident to drink her milk. At 12:30 p.m., the resident left the dining room. She consumed only the ice cream. C. Resident representative interview Resident #30's representative was interviewed on 4/8/25 at 9:52 a.m. The representative said Resident #30 was able to feed herself. She said Resident #30 did not receive encouragement to eat the main portion of her meals. She said the staff automatically provided the resident with an ice cream rather than a nutritional alternative to the meal, instead of waiting to see if she would eat other portions of the main meal. D. Record review Resident #30's nutrition care plan, initiated 2/13/25, identified the resident was at risk for altered nutritional status. Pertinent interventions included providing encouragement during meals. The 1/7/25 nutritional assessment revealed the resident had denture problems, she fed herself and she was missing her upper and lower dentures. -The assessment did not indicate the resident required cueing at meals. E. Staff interviews CNA #7 was interviewed on 4/10/25 at 9:46 a.m. She said Resident #30 was able to feed herself, but did require assistance and encouragement. She said she liked to eat her dessert first. She said she could be resistive to assistance at times, however, different approaches should be attempted. She said the facility should find a way to incorporate more dessert-like nutritional items in the resident's diet. The RD was interviewed on 4/10/25 at 2:00 p.m. The RD said Resident #30 was reviewed quarterly. She said the resident was able to feed herself, however, she said she needed encouragement to eat. She said the resident should be encouraged to eat the main meal and offered alternatives prior to an ice cream being served.

Based on observations, record review and interviews, the facility failed to provide one (#30) out of five residents out of 31 residents with an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to ensure Resident #30 received a personalized activity program. Findings include: I. Resident #30 A. Resident status Resident #30, age 86, was admitted on [DATE]. According to the April 2025 computerized physician ' s orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial to moderate assistance with activities of daily living (ADL). She required set up assistance for eating. The 1/27/25 MDS assessment revealed it was very important for Resident #30 to do activities she liked such as religious activities and pets. B. Resident representative interview Resident #30 ' s resident representative was interviewed on 4/8/25 at 9:52 a.m. The representative said Resident #30 always enjoyed religious activities. She said she always attended church services. She said Resident #30 really enjoyed animals, especially dogs. She said her face lit up when she was near a dog. C.Observations On 4/8/25 at 1:47 p.m. Resident #30 was sitting in her wheelchair in her doorway. She was not involved in any meaningful activities while there was an activity going on in the Galaxy Room. A staff member stopped to talk to her for a minute. She did not get invited to the activity in the Galaxy Room. During a continuous observation on 4/9/25, beginning at 9:10 a.m. and ending at 9:55 a.m., Resident #30 was sitting in her doorway in her wheelchair. Several staff members passed her. She was not invited to participate in the exercise group that was occurring in the dining room. During a continuous observation on 4/10/25, beginning at 2:00 p.m. and ending at 2:55 p.m. Resident #30 was sitting in her wheelchair in her doorway. She was not participating in any meaningful activities. C. Record review The participation record from 3/10/25 to 4/10/25 revealed the resident was not offered any religious activities or animal visits. The activities care plan, revised on 3/25/25, revealed the resident had interests in many activities such as Bingo musical groups and bean bag toss. Pertinent interventions included reminding the resident to attend the activities and providing her with a monthly activity calendar. -The care plan failed to include that it was very important for the resident to attend religious activities and have animal visits. The 3/25/25 activity participation review documented the resident enjoyed a variety of groups and outings. The goal was to keep the resident ' s activity program the same with the resident attending groups such as socials, music Bingo and exercise type groups. -The assessment did not include the resident ' s preference of pet visits or religious activities. II. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 4/8/25. CNA #7 said Resident #30 liked to participate in Bingo and movie nights. She said Resident #30 would get angry at staff when she did not want to participate in an activity. She said staff should provide further encouragement in a different manner if Resident #30 refused to participate. The activity director (AD) was interviewed on 4/10/25 at 2:45 p.m. The AD said Resident #30 liked to participate in Bingo, [NAME] ball and shopping. The AD said Resident #30 participated in more activities some days than others. He said she liked to spend time with her roommate mostly. He said she participated in Bingo two times and all of the other activities. He said the facility tried to keep her as busy as possible. He said the goal was to get her involved with activities at least five times a week. He said she would get easily angry and would throw objects at the staff. He said activity staff should ask her to participate. The AD said she needed to be reminded and taken to activities. The AD said she would not know if there was an activity going on without being informed. The AD said staff should come back and offer activity again.

Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#30) of one resident reviewed for vision out of 31 sample residents. Specifically, the facility failed to follow up on Resident #30's referral for cataract surgery. Findings include: I. Facility policy and procedure The Hearing and Vison policy, undated, was provided by the nursing home administrator (NHA) on 4/14/25 at 1:47 p.m. It read in pertinent part, The facility ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social service designee is responsible for assisting residents and their families in location and utilizing any available resources, for the provision of the vision services that the resident needs. Once vision or hearing services have been identified, the social worker will assist the resident by making appointments and arranging for transportation. II. Resident #30 A. Resident status Resident #30, age 86, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) with a score of three out of 15. The resident required assistance with all of her activities of daily living. The MDS assessment indicated the resident needed corrective lenses. B. Resident representative Resident #30's representative was interviewed on 4/8/25 at 9:52 a.m. The representative said Resident #30 was seen by an eye doctor in February 2025 and was supposed to have further tests done for cataract surgery. She said that had not been done. C. Record review The ancillary services care plan, initiated on 2/13/25, revealed the resident had routine ancillary needs that included optometry (eye doctor), dentistry and podiatry (foot doctor). Pertinent interventions included for the social services department to coordinate ancillary services. The 2/18/25 optometrist report documented the resident was evaluated for cataracts with blurry vision in the right and left eye. The plan was for the resident to have a referral for cataract surgery. Review of Resident #30's electronic medical record (EMR) did not reveal documentation indicating the resident had been referred to an ophthalmologist for cataract surgery as recommended on 2/18/25. III. Staff interviews The social service director (SSD) was interviewed on 4/10/25 at 10:33 a.m. The SSD said the nurses notified her when a resident needed a vision appointment. She said when she received the referral for Resident #30 in February 2025 she gave it to the transportation staff member. She said she had not followed up on the referral. The transportation coordinator (TC) was interviewed on 4/10/25 at approximately 3:00 p.m. The TC said she had not received the referral for Resident #30's cataract surgery. She said it was accidentally missed. She said she was working on getting it scheduled.

Based on observations, record review and interviews, the facility failed to ensure one (#112) of one resident reviewed for dialysis care out of 31 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure the resident's arteriovenous fistula (AVF) shunt was assessed on a daily basis. Findings include: I. Facility policy and procedure The Hemodialysis Catheters-Acccess and Care policy, dated February 2023, was received from the nursing home administrator on 4/11/25 at 4:03 p.m. The policy read in pertinent parts, Care of AVFs: -Keep the access site clean at all times; -Check the color and temperature of the fingers and the radial pulse of the access arm when performing routine care at regular intervals; -Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. The nurse should document in the resident's medical record every shift as follows: -Location of the catheter; -Condion of the dressing; -If dialysis was done during the shift; -Any part of report from dialysis nurse post-dialysis being given; -Observations post dialysis. II. Resident #112 A. Resident status Resident #112 was admitted on [DATE] and readmitted from the hospital on 3/30/25. According to the April 2025 computerized physician orders (CPO) diagnoses included, chronic obstructive pulmonary disease and renal kidney failure. The 2/12/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required partial to moderate assistance with activities of daily living. The MDS assessment did not indicate the resident received hemodialysis. -However, the resident received hemodialysis. III. Record review Review of the April 2025 CPO revealed there was not a physician's order to monitor the shunt for patency. The electronic medical record (EMR) was reviewed from 3/30/25 to 4/9/25 and showed no documentation that the shunt was assessed for patency which included the thrill and bruit. The medication administration record (MAR) and the treatment administration record (TAR) for April 2025 revealed no documentation that the shunt was assessed for the thrill and bruit. The dialysis care plan, revised 11/27/24, identified the resident required dialysis related to a diagnosis of end stage renal disease. Pertinent interventions included checking shunt for bruit and palpate shunt for thrill by lightly placing fingertips over access site and feeling for vibration twice daily. The care plan directed staff to notify the medical provider if bruit was not heard or thrill or felt. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/9/25 at 3:40 p.m. LPN #1 said Resident #112 went to hemodialysis three times a week. He said the resident had a shunt port in his left upper extremity. He reviewed the EMR and confirmed there was not a physician's order to monitor and assess the AVF. LPN #1 said he had not assessed the AVF. The director of nursing (DON) was interviewed on 4/9/25 at 4:03 p.m. The DON said she reviewed the physician's orders for Resident #112 and said there was not a current order to have the AVF assessed. She said the AVF needed to be assessed each shift to ensure proper functioning. She said when the resident was readamitted the order was not reentered into the resident's EMR. She said nursing management completed audits to ensure batch orders, assessments and necessary physician's orders were completed. The regional director of clinical services (RDCS) was interviewed on 4/9/25 at 4:24 p.m. The RDCS said she would complete a MDS correction for the MDS, since Resident #112's MDS was coded incorrectly. V. Facility follow up A physician's order was obtained on 4/9/25 (during the survey) which read, Check shunt for bruit and palpate shunt for thrill by lightly placing fingertips over access site and feeling for vibration twice daily,If bruit is not heard or thrill not felt, notify medical provider. On 4/11/15 at 4:03 p.m. the facility sent additional information which showed the thrill and bruit was checked on 4/1/25, 4/5/25 and 4/8/25 on the communication forms. -However, the AVF was not consistently checked twice a day.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#40 and #42) of four residents reviewed out of 31 sample residents. Specifically, the facility failed to: -Identify Resident #40 and Resident #42's history of trauma and identify triggers which may retraumatize them; and, -Ensure services and individualized care approaches were provided for Resident #40 and Resident #42. Findings include: I. Facility policy and procedure The Trauma Informed Care and Culturally Competent Care policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/11/25 at 3:53 p.m. It revealed in pertinent part, Purpose: to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Tramua-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid retraumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. Triggers are highly individualized. Some common triggers may include: experience a lack of privacy or confinement in a crowded or small space; exposure to loud noises, or bright/flashing lights; certain sights, such as objects; and/or, sounds, smells and physical touch. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. II. Resident #40 A. Resident status Resident #40, age 71, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included dementia with mood disturbances, major depressive disorder, traumatic brain injury (TBI) and schizophrenia (mental illness). The 3/29/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of 10 out of 15. He required maximum assistance from staff with hygiene, showering, toileting, dressing and transferring. B. Resident observation and interview An attempt was made to interview the resident on 4/7/25 at 10:32 a.m. When spoken to, the resident stared and did not respond. C. Record review The trauma informed care plan, revised 9/23/24, revealed the resident had a history of trauma related to sexual assault at a very young age by a minister and the resident would often talk about it. The resident had been involved in a car accident causing a TBI and had a history of incarceration. The care plan indicated social services referred him to a local mental health center for talk therapy to work through past traumas. Interventions (dated 8/7/23) included monitoring the resident for signs and symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and reporting abnormal findings to the physician. The psychosocial care plan, revised 7/16/24, revealed the resident had a history of suicidal ideations. Interventions (dated 2/15/24) included sending the resident to the hospital for observation and a psychological evaluation, monitoring the resident for behavior episodes and attempting to determine underlying cause and consider location, time of day, persons involved, and situations and documenting behavior and potential causes. The March 2025 CPO revealed the following physician's orders: Abilify (antipsychotic) Tablet 10 milligram (mg)- give one by mouth for major depressive disorder with psychotic features, ordered on 11/5/24; Record episodes of the following behaviors: negative statements, crying and tearfulness. Interventions: one-on-one, position change, offer food and fluids, toileting, redirection and refer to nurse notes, ordered on 2/15/24; Sertraline (antidepressant) Capsule 200 mg, give one by mouth for major depressive disorder, ordered on 2/15/24; and, Buspirone (anti-anxiety medication) Tablet 5 mg- give one by mouth two times a day for anxiety-ordered on 3/27/25. The 7/28/23 Pre-Admission Screen and Resident Review (PASRR) level II notice of determination for MI (mental illness) evaluation and psychological assessment revealed: The PASRR Level II included the evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder and schizophrenia. The evaluator identified several traumas to include: incarceration in 2013 for menacing, sexual abuse at the age of 14 by a religious figure, derogatory responses from a parent after learning of the sexual abuse (insinuations the resident enjoyed the abuse), motor vehicle accident resulting in traumatic brain injury, reoccurent suicidal thoughts and theft of possessions and displacement once incarcerated. The resident's menacing charges were related to threats he had made to a woman who dispersed his social security checks for decades and threats to kill a priest and [NAME] at a cathedral. The threats caused the church to close until the resident was apprehended. -There was no mention in the resident's care plan of a history of homicidal ideations nor were there behavior monitoring for suicidal or homicidal ideations. The social services social history assessment, dated 7/11/24, listed all significant life events that included transportation accident, physical abuse, sexual abuse and sudden death of a person close to him. Psychiatric follow up note, dated 3/10/25, revealed the resident was being followed due to a diagnosis of major depressive disorder, dementia with behavioral disturbance and seizures. The nurse practitioner (NP) conducting the follow up indicated the resident expressed feelings of loneliness and concerns about his seizure condition. The NP noted the resident's psychotropic medications were partially helpful in treating his condition. The NP noted the resident's recent history to include an episode of suicidal ideatons on 2/8/25 where the resident had to put on 15 minute staff checks. -A review of the resident's EMR failed to reveal the facility assessed the resident to identify potential triggers that could cause re-traumatization or behaviors towards others. D. Staff interviews Certified nursing aide (CNA) #1 was interviewed on 4/8/25 at 2:30 p.m. She said the nurse management or the social worker would let the CNA's know specific behaviors and interventions for residents with behaviors. CNA #1 said she was not aware Resident #40 had a history of suicidal or homicidal ideations. Licensed practical nurse (LPN) #1 was interviewed on 4/9/25 at 1:30 p.m. He said Resident #40 had behaviors of anxiety but he did not know if the resident had specific triggers. LPN #1 said the resident did not have a history of suicidal or homicidal ideations. -However, the 7/28/23 PASRR Level II and the 3/10/25 NP note documented the resident had a history of suicidal and homicidal ideations (see record review above). LPN #1 said when the social worker wanted the staff to be aware of specific behaviors and non pharmacological interventions, there would be a physician's order with the resident specific behaviors and the individualized interventions identified for that resident. CNA #5 was interviewed on 4/9/25 at 1:45 p.m. She said she knew Resident #40 and that he had behaviors of sundowning (a neurological phenomenon that causes increased confusion and restlessness in people with dementia starting in late afternoon) but he showed these behaviors throughout the day. CNA #5 said the resident perseverated on death and believing he was dying, was confused about time and schedules and was frequently anxious. She said the resident did not have a history of suicidal or homicidal ideations, but there had been a period of time when the resident was not allowed to have plastic bags or sharp items in his room but the CNA was not sure why or exactly when. -However, the 7/28/23 PASRR Level II and the 3/10/25 NP note documented the resident had a history of suicidal and homicidal ideations (see record review above). Registered nurse (RN) #2 was interviewed on 4/9/25 at 1:56 p.m. She said Resident #40 told her he was depressed often and talked about being paranoid about things that happened to him at a previous facility (suspecting the facility of theft). RN #2 said when the resident was very depressed, he displayed behaviors of mutism (inability to speak), would just stare at the staff and not respond to them. She said she was not aware if the resident had a history of suicidal or homicidal ideations but it would be important for the care staff to know that about the resident. The social services director (SSD) was interviewed on 4/9/25 at 3:30pm. She said she reviewed the residents PASRR evaluations for past mental health history and triggers and then incorporated the information into the resident's care plan. The SSD said if there were suicidal or homicidal ideations identified in the PASRR, she would add those to the resident's care plan and put in a behavior tracking order for monitoring of suicidal and/or homicidal ideations. She said she was the one who determined what behaviors were added to behavior monitoring documentation. The SSD said Resident #40 displayed behaviors of anxiety and perseverance on items he believed were stolen from another facility and believing he was actively dying. She said she was aware of his history of suicidal and homicidal ideations from his PASRR. She said the suicidal and homicidal ideations should be included on the resdient's care plan. She said she did not know why those behaviors were not on his care plan. The SSD said it would be helpful for the nurses and the CNAs to be aware of a resident's history of ideations in order to support the resident and be aware the resident was at higher risk. The SSD said the social worker should be notified immediately of any concerning behaviors or comments. The director of nursing (DON) was interviewed on 4/9/25 at 4:27 p.m. The DON said she was not aware of Resident #40's history. She said suicidal and homicidal ideations were important behaviors for the nurses and CNAs to be aware of to properly monitor and care for a resident. 20287 III. Resident #42 A. Resident status Resident #42, age 73, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included post traumatic stress disorder (PTSD), schizoaffective disorder, bipolar (mental illness) and history of falls. The 2/22/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The assessment indicated the resident had a diagnosis of PTSD. B. Resident interview Resident #42 was interviewed on 4/7/25 at 3:20 p.m. The residnet said she had a diagnosis of PTSD related to being raped with a weapon. She said the facility had not asked her any questions in relation to the past traumatic event. She said they just do not talk about it. C. Record review The psychosocial care plan, revised on 3/25/25, revealed the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to PTSD and a hisotry of, sexual assault (reports rape with weapon). Pertinent interventions included encouraging the resident to verbalize feelings, monitoring for signs and symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report abnormal findings to the physician. The 2/21/25 social history assessment did not document any information in regards to the individual support needed for the resident's diagnosis of PTSD. -Review of Resident #42's electronic medical record (EMR), revealed the facility failed to implement person-centered, non-pharmacological approaches e to meet the individual needs of Resident #42. -Further review of the resident's EMR did not reveal documentation that the facility completed an assessment to identify ways to eliminate or mitigate triggers that may cause re-traumatization of the resident. D. Staff interviews The SSD was interviewed on 4/10/25 at 10:33 a.m. The SSD confirmed Resident #42 had a diagnosis of PTSD. She said the resident was seen twice a month. She said the last visit was on 3/19/25, because the facility had a new provider. She said she was not aware of any assessment that could be completed to determine which triggers could cause re-traumatization of the resident. She said was aware of Resident #42's trauma , however she was not aware of what specific triggers would trigger a re-traumatization. The DON and the regional director of clinical services (RDCS) were interviewed together on 4/10/25 at 4:03 p.m. The DON said the resident was seen by a mental health provider. She said she reviewed the care plan and confirmed Resident #42's care plan did not have resident specific triggers and interventions which could cause re-traumatization. The RDCS said the facility started using a new assessment a month ago that could be used to assess residents for triggers specific to PTSD. She said she would ensure the SSD would complete this assessment for Resident #42.

Based on observations, record review and interviews, the facility failed to provide one resident (#30) with professional quality of care out of 31 residents. Specifically, the facility failed to ensure Resident #30 received timely dental service. Findings include: I. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia, dysphagia (difficulty swallowing) and adult failure to thrive. The 1/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required assistance with all of her activities of daily living. The MDS assessment was not completed for the resident's dental status. -However, the resident was edentulous. B. Resident #30's representative interview The resident representative was interviewed on 4/10/25 at 1:00 p.m. The resident representative said she was notified the resident was going to see the dentist next week. She said she knew the resident was not wearing the dentures, but did not know they needed adjusting. C. Observations On 4/7/25 at 12:15 p.m. Resident #30 was eating her meal in the dining room. She was not wearing her dentures. On 4/8/25 at 1:47 p.m. Resident #30 was sitting in her wheelchair in the doorway of her room. She did not wear her dentures. On 4/8/25 at 5:10 p.m. Resident #30 was eating her meal in the dining room. She was not wearing her dentures. C. Record review The activities of daily living (ADL) care plan, initiated on 5/9/24 and revised on 10/26/24, revealed the resident had an ADL self-care performance deficit related to confusion, dementia, impaired balance and limited mobility. Pertinent interventions included the resident had all of her teeth extracted and would need dentures once as her gums healed (10/26/24). The ancillary services care plan, initiated on 2/13/25, revealed the resident had routine ancillary needs that included optometry (eye doctor), dentistry and podiatry (foot doctor). Pertinent interventions included notifying the dentist immediately to schedule a dental visit within three days if the resident reported tooth pain (2/13/25). The 12/6/24 progress note documented the residents' gums were healed. The 2/16/25 progress note documented the resident was having difficulty with chewing food with dentures. The dentures were loose and difficulty staying in place. The resident voiced some discomfort to gumlines. The registered nurse was to notify the social worker to add to the dental list for evaluation. -A review of Resident #30's electronic medical record (EMR) did not reveal any documentation that the resident had been seen by the dentist after it was reported she was having difficulties chewing food with dentures. D. Staff interview Certified nurse aide (CNA) #7 was interviewed on 4/10/25 at 9:46 a.m. CNA #4 said Resident #30 received new dentures this year. She said Resident #30 had no dentures for a long time after her teeth were extracted. She said Resident #30 did not wear her dentures all the time. CNA #7 said she thought Resident #30's dentures did not fit well and they caused the resident pain. She said the CNAs informed the nurse about the ill-fitting dentures. She said Resident #30 refused the CNA's and daughters help to put the resident's dentures in. She said the staff should try a different method, different time, or a different staff member to work with Resident #30 if she refused. Licensed practical nurse (LPN) #2 was interviewed on 4/10/25 at 11:29 a.m. LPN #2 said Resident #30 did not like wearing her dentures. She said Resident #30 stopped complaining about the dentures. She said the resident refused to wear them, even with her daughter's help. She said she did not think the resident was refusing to wear her dentures because of pain. She said she thought the resident was not used to the dentures. The social services director (SSD) was interviewed on 4/10/25 at 10:39 a.m. She said the dentist visited the facility every Tuesday. She said the dentist did not see Resident #30 on Tuesday (4/8/25). She said Resident #30 received new dentures in January 2025 and they were adjusted. She said she was not notified that the resident's dentures did not fit.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#30) of five residents reviewed for immunizations out of 31 sample residents. Specifically, the facility failed to ensure consent was obtained from Resident #30's representative prior to administering the pneumococcal vaccination. Findings include: I. Resident #30 A. Resident status Resident #30, age 86, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure. The 1/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial to moderate assistance with ADLs. The MDS assessment indicated the resident was not up to date on the pneumococcal vaccine because it was offered and declined. B. Resident representative interview Resident #30's representative was interviewed on 4/8/25 at 9:52 a.m. The representative said she was not notified and did not give consent for Resident #30 to receive the pneumococcal vaccination prior to the administration of the vaccine. She said she had taken Resident #30 out for a visit and Resident #30 complained of her arm hurting as she had received a vaccination. The representative said she called the facility and the nurse confirmed the resident received the Prevenar 20 vaccination. C. Record review Review of Resident #30's electronic medical record (EMR) revealed the resident received the Prevnar 20 immunization on 3/26/25. The resident vaccination consent for vaccinations, dated 3/21/25, revealed the consent was signed by the infection preventionist (IP). The consent form was for the pneumococcal (Prevenar 20). The consent documented, I have authority to complete this registration process and to make my health care decisions (or the healthcare decisions for the named patient). I have been given online links/documents to read about the disease and vaccines. I believe I understand the benefits and risks of the vaccine. Review of Resident #30's EMR failed to show the resident's representative was notified or gave consent for the administration of the pneumococcal vaccination. II. Staff interviews The director of nursing (DON) was interviewed on 4/10/25 at 1:52 p.m. The DON said the IP was responsible to maintain the immunization records and ensure the residents received the immunizations if needed. She said she reviewed Resident #30's record and confirmed the IP incorrectly signed the consent for Resident #30's pneumococcal vaccination. She said the responsible party was to sign the consent and to give permission for the vaccination. She said she would provide education to the IP.

Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the residents' shower room was maintained in a safe and sanitary condition. Findings include: I. Observations On 4/8/25 at 2:13 p.m. the facilities shower room was observed. There was black residue on the surface of the grout lines going around the perimeter of the inside of the shower. II. Resident representative Resident #30's representative was interviewed on 4/8/25 at 9:43 a.m. She said the shower room was not clean and needed to have a good cleaning. She said it had been like that for some time. III. Staff interviews and observations The shower room was observed with the maintenance director (MTD) and the nursing home administrator (NHA) on 4/8/25 at 2:45 p.m. The MTD said the housekeeping staff cleaned the shower daily and deep cleaned the shower once a week. The MTD said the black residue could be soap (however the liquid body soap in the shower room was orange) or it could be splattered caulking (the caulking in the shower was gray). The MTD and the NHA said they were unable to identify the black residue so they requested a comprehensive mold test The MTD was interviewed again on 4/8/25 at 3:35 p.m. He said he had a professional commercial shower sanitizer . He said he was not able to test for mold, only sanitize the shower. The MTD was interviewed again on 4/8/25 at 4:00 p.m The MTD said the facility was able to schedule testing with an environmental testing company for the following morning. IV. Facility follow up On 4/14/25 at 9:22 a.m. the NHA provided the results from the mold tape inspection via email. The report included the observations of potential water damage, potential visual growth and excessive humidity and moisture in the shower. The laboratory results revealed common allergens were present but no fungal growth.

Based on record review and staff interviews, the facility failed to ensure residents were free of any significant medication errors for one (#6) of four residents out of 29 sample residents related to anticoagulants and insulin management. Resident #6 had several significant health conditions requiring close monitoring with personal care services including physician services and nursing assessment with medication and treatment administration to ensure the resident's highest optimal health condition possible. Resident #6 was at high risk for the development of life threatening blood clots that could cause blockages in the heart, lungs and other vital organs potentially shutting the organs down. The facility's nursing staff were to administer physician ordered medication (warfarin) in proper dosages as calculated by the resident physician based on results of regularly assessed lab work. Warferain is a medication that prevents blood clots from forming or growing larger and causing blockages in the blood and blood vessels. The facility put Resident #6 health in jeopardy by failing to ensure all medications were ordered and administered according to physician orders. The most significant medication errors occurred when Resident #6 was not given his prescribed dose of warfarin as a result of several errors and omissions in administration. The resident medication was not consistently available for administration and he missed doses of the medication. Additionally, there were errors in the amount (doses) of medication the resident was given due to the nursing staff's failure to follow and/or confirm the written administration orders in the resident's medication administration record (MAR). The facility's failure to administer the resident's warfarin medication as prescribed by the resident's physician put the resident at increased risk of serious problems such as strokes, heart attacks, deep vein thrombosis (DVT-a blood clot in a deep vein of the leg, pelvis, and sometimes arm) and pulmonary embolism (a sudden blockage in the blood vessels that send blood to your lungs). The facility failed to prevent a potentially life-threatening medication error placing Resident #6 at risk of serious harm due to a failure to receive care and treatment per acceptable professional standards of practice. Findings include: I. Immediate jeopardy A. Failure to administer medications as ordered The facility nursing staff failed to provide Resident #6 with all prescribed medication in accurate dosage on several occasions throughout the three months from December 2023 to February 2024. Resident #6 had missed several medications prescribed over several weeks of care to treat his diagnosed medical conditions and treat symptoms of illness including abnormal blood clotting; inability to regulate glucose levels in the bloodstream; high blood pressure; urinary tract infection; unrelieved pain; anxiety and depression. The resident missed several significant prescribed medications including warfarin; insulin lispro and insulin glargine for diabetes management; lisinopril and metoprolol succinate for blood pressure regulation. In addition, the resident also missed other medications due to those medications being unavailable (see record review below). The facility was not aware of the extent of the errors until it was brought to their attention during a recent survey (from 2/13/24 through 3/8/24). The facility was not able to explain why the nurses had failed to reorder the unavailable medications and why nursing staff were routinely marked in the MAR that the medication was not available without notifying the resident physician and contacting the pharmacy for a STAT (urgent) reorder of the medication. In addition, the facility leadership were unaware that not all of the nurses (facility hired and agency contracted) had access to the emergency medication backup kit by which to access the unavailable medications to give to the residents in the event of pharmacy ordering and delivery delays. A review of the MAR and the resident progress notes revealed the nurses, most of whom were agency nurses and not regular employees of the facility, documented on the MAR that some medications were unavailable but provided no documentation of why the medications were unavailable or what was being done to secure the unavailable medications. Additionally, a note dated 2/13/24 documented by the resident's nurse practitioner (NP) revealed the facility's nursing staff failed to correctly document the physician's orders to decrease Resident #6's warfarin dose from 5 mg to 4 mg but instead added the 4 mg order without discontinuing the 5 mg. As a result, the resident received 9 mg of warfarin on 2/10/24, instead of the newly ordered 4 mg dose of warfarin causing the resident to be overdosed on warfarin. Current facility leadership was unable to provide any other documentation of that situation. B. Facility notice of immediate jeopardy On 3/5/24 at 6:00 p.m., the nursing home administrator (NHA), clinical nurse consultant (CNC) #2 and interim director of nursing (IDON) were notified of the facility's failure to prevent the occurrence of significant medication errors with place Resident #6 at risk of serious harm likely to occur due to a failure to administer the resident warfarin, insulin and blood pressure medications as prescribed resulting in an immediate jeopardy situation. C. The facility's plan to remove immediate jeopardy On 3/6/24 at 3:15 p.m., the NHA, IDON and CNC #1 presented the following plan to address the immediate jeopardy situation. It read in pertinent part: On 3/5/24 the IDON completed (an) audit of all carts for medication availability. Medications that were identified as unavailable were ordered from (the) pharmacy for same day delivery. Notifications would be made to the provider, resident and/or resident representative if the medication is not available or if there would be a delay in administering the medication. On 3/5/24, the interim DON educated staff to call the IDON immediately if the medication was unavailable. Her direct cell phone number was given to all nurses on shift and posted at both nursing stations to ensure access to her. On 3/6/24, an audit of all residents who were prescribed warfarin and insulin for the past 30 days was conducted to determine if the deficient practice has impacted other residents. Residents who were not administered (warfarin or insulin) medications due to the medication not being available would have a risk management assessment completed, and the (physician) provider was to be notified for additional orders, as indicated. Actions to Prevent Occurrence/Recurrence: All nurses would be educated by 3/15/24 on how to access the (pharmacy name/e-kit name) system and all facility staff nurses would be provided access to retrieve medications from this e-kit device when a medication was not available. All agency nurses were to refer to the agency (staff information) binder located at each nursing station for the protocol for retrieving medications from the e-kit (e-kit name). The binder will contain information on how the agency nurse can obtain login and access to the (name of the e-kits), and then how to obtain the medications. On 3/6/24, the Unavailable Medications policy was reviewed by the DON (director of nursing) to ensure the facility was following the policy. A nursing in-service was initiated on 3/6/2024 to review this policy with staff. All nurses will be educated before their next shift. Beginning 3/6/24 The IDON completed corrective action and one-to-one education on above listed topics with all licensed nurse(s) identified as being deficient in their practice resulting in this citation. The DON or designee will educate all newly hired licensed nurses on medication administration and reconciliation guidelines and review the unavailable medication policy on day one of orientation before licensed nurses work on the floor. To ensure transcription accuracy, the night shift nurse will run an order listing report for that day and double-check all new orders for accuracy. The DON or designee will monitor compliance by having the night nurse sign the order listing report indicating the review was completed and placing it in the DON mailbox daily. The audits will continue until compliance can be maintained for three consecutive months. Beginning on 3/6/24, the IDON or designee will review the missing medications report daily to ensure medications that are marked as unavailable have proper follow-up. A meeting has been scheduled for the DON and ADON on 3/11/24 at 10:00 a.m. to meet with the pharmacy consultant to review medication availability and ordering medications timely to ensure the medication ordering and delivery process is in place. The Administrator implemented a QAPI PIP (quality assurance and performance improvement, performance improvement plan) as a means to gather and process information from the audit. Findings will be reported at the monthly QAA (quality assessment and assurance ) meeting for a minimum of three months. D. Removal of immediate jeopardy On 3/6/24 at 3:15 p.m., the NHA was notified, based on the review of the facility's plan for removal of immediate jeopardy was accepted and the level of deficient practice remained at a D scope and severity, isolated no actual harm with potential for more than minimal harm. II. Professional reference According to [NAME] Nursing Drug Handbook 2020, Kizior, R. J. and [NAME], K.J., St. Louis Missouri 2020, page (pp). 1287 read in pertinent part: Medication safety is a high priority for the health care professional. Prevention of medication errors and improved safety for the patient are important, especially in today's healthcare environment when today's patient is older, sometimes sicker, and drug therapy regimens can be more sophisticated and complex. According to [NAME]'s Drug Guide 2024, Warfarin, retrieved on 3/4/24 from https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51797/all/warfarin#1, Administer medication at the same time each day. Medication requires 3-5 days to reach effective levels; Notify the physician of missed doses. Inform the patient that the anticoagulant effect may persist for 2-5 days following discontinuation. Lab Test Considerations: Monitor prothrombin time (PT) (a blood test that measures how long it takes the blood to clot), international normalized ratio (INR) (a calculation based on the PT results used to monitor people who are being treated with the anticoagulant medication Warfarin), and other clotting factors frequently during therapy; monitor more frequently in patients with renal impairment. Therapeutic PT ranges 1.3-1.5 times greater than control; however, the INR, a standardized system that provides a common basis for communicating and interpreting PT results, is usually referenced. Normal INR (not on anticoagulants) is 0.8-1.2. An INR of 2.5-3.5 is recommended for patients at very high risk of embolization (for example, patients with mitral valve replacement and ventricular hypertrophy). Lower levels are acceptable when risk is lower. According to [NAME]'s Drug Guide 2024, Insulin Lispro, retrieved on 3/4/24 from https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51852/all/insulin%20lispro, Insulin lispro and Insulin glargine are high alert medication: This medication bears a heightened risk of causing significant patient harm when it is used in error. According to Health Match What Can Happen If You Stop Taking Your High Blood Pressure Medication? (5/2/22), retrieved on 3/4/24 from https://healthmatch.io/high-blood-pressure/what-happens-when-you-stop-high-blood-pressure-medication#will-you-ever-be-able-to-stop-taking-your-medication, It's important not to stop taking your pills, even for a few days, without consulting your doctor. Not taking your medication can cause your blood pressure to go out of control. This can cause a large number of problems, including Permanent damage to your arteries; and or an increased risk of aneurysm, which most often form in the aorta, but can develop anywhere. III. Facility policies and procedures The Administration Medication policy, revised April 2019, was received on 2/20/24 at 12:10 p.m., from CNC #1. It read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders, including any required time frame. -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The Medications Ordering and Receiving from the Pharmacy Provider: Medication Shortage policy, dated 2007, was received on 2/20/24 at 12:10 p.m. from CNC #1. It read in pertinent part, The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs. Nursing staff shall if the shortage will impact the patient's immediate need of the ordered product: a. Notify the attending physician of the situation, and explain the circumstances, expected availability and optional therapy(ies) that are available. b. Obtain a new order and cancel/discontinue the order for the non-available medication. c. Notify the pharmacy of the replacement order. The Unavailable Medication policy revised February 2023, was provided by the IDON on 3/7/24 at 1:34 p.m. and revealed in pertinent part, Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable. Determine the reason for unavailability, the length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring the resident while the medication is on hold. If a resident misses a scheduled dose of medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report and monitoring the resident for adverse reactions to the omission of the medication. The Emergency Medications policy revised April 2021, was provided by the IDON on 3/7/24 at 1:34 p.m. and revealed in pertinent part, The emergency medication kit will include medications and biologicals that are essential in providing emergency treatment. The contents of each emergency medication kit will be clearly listed. A physician's order is required to administer emergency medications and biologicals. IV. Resident #6 A. Resident status Resident #6, under the age of 65, was admitted on [DATE]. According to the March 2024, computerized physician's orders (CPO), diagnoses included chronic diastolic (congestive) heart failure, diabetes, mood disorder, chronic obstructive pulmonary disease (COPD), gout, hypertension, history of pulmonary embolism, atrial fibrillation and asthma. According to the 12/19/23 minimum data set (MDS) assessment, the resident had intact cognition as evidenced by a brief interview for mental status (BIMS) score of 15 of 15. The resident took antipsychotic, antidepressant, anticoagulant, diuretic, opioid, antiplatelet and hypoglycemic medications daily. B. Resident and resident representative interview Resident #6 was interviewed on 2/13/24 at 2:18 p.m. Resident #6 said he took a lot of prescribed medication and over the counter vitamins and minerals. The resident said on numerous occasions he noticed a few of his medications were missing because he counted them every time he received them. The resident said he asked the nurse every time about the missing medication and the nurse would either say which one was missing or nothing was missing. Resident #6 said he continued to notice missing medication every day from admission (12/17/23) up through the beginning of February 2024. The resident said he believed the problem stemmed from staff not ordering the medication on time and therefore they ran out for weeks at a time. Resident #6's representative was interviewed on 2/15/24 at 1:16 p.m. The resident's representative said from admission the resident was not getting all of his prescribed medications which was very concerning. The resident's representative said she was concerned that the staff did not know what they were doing. The resident representative said she asked to meet with the DON but never heard back from the DON. C. Record review A review of Resident #6's medical record, the March 2024 CPO and MAR reviewed the following medication orders and inaccurate medication administration: Warfarin Warfarin sodium tablet 6 mg, give one tablet by mouth at 6:00 p.m., to prevent blood clots, start date 12/16/23 and discontinued 1/6/24. -However, the medication was not administered on 12/25/23, 12/26/23, and 12/28/23 due to not being available. A physician's note dated 12/27/23 read in part: Patient INR (blood work to test warfarin level) came back at 6.0; however, he missed doses of the medication, will continue medication at normal range and recheck INR tomorrow. The patient takes warfarin for a history of deep vein thrombosis, pulmonary embolism and atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in your heart). A physician's note dated 1/2/24 read in part: INR with a value of 1.8, value for the patient should be 2.0 to 3.0. Will recheck INR tomorrow after the patient (resumes) receiving full doses before increasing. A physician's note dated 1/3/24 read in part: Patient states that he has had issues with staff not giving him his warfarin doses, there is no issue with the patient's compliance. I do not intend to change his warfarin dosing at this time due to missed doses. Continue warfarin 6 mg every evening. INR monitored weekly, ordered one-time STAT (right away) to establish a baseline. A physician's note dated 1/4/24 read in part: Patient's INR still pending to follow the decision whether to increase or not. Review of the system is otherwise negative. An NP provider exam note dated 1/5/24 read in part: The 1/3/24 INR result was 20.05, reordered STAT as this was not consistent with the patient's condition during the visit. I do not intend to change his coumadin (warfarin) dosing at this time; the lab is likely inaccurate INR. Warfarin sodium tablet 7 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 1/6/24 and discontinued 1/9/24. An NP provider exam note dated 1/9/24 read in part: INRs done by laboratory continue to have likely inaccurate results. The most recent result (1/5/24) was 0.0. The INR result before that (1/4/24) was 1.68. The patient bought his own INR test kit and used it while in the room with me. The value on the patient's home kit was 2.2 on 1/9/24. I do not intend to change his coumadin dosing at this time due to past missed doses (of warfarin). Warfarin sodium tablet 6 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 1/9/24 and discontinued 1/18/24. An NP provider exam note dated 1/18/24 read in part: Reason for appointment: INR monitoring. Lab results: INR 25.73 ppm. 1/10/24: Unchanged order for warfarin sodium oral tablet, give 6 mg by mouth one time a day for blood clots. INR was 3.1 on 1/18/24, plan to reduce the dose slightly to 5 mg once a day. Warfarin sodium tablet 5 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 1/18/24 and hold from 1/29/24 to 1/31/24. -However, the 1/31/24 dose was not held. Warfarin sodium tablet 2.5 mg, give one tablet by mouth one time for prevention of blood clots until 2/1/24 at 11:59 p.m., give a total of 7.5 mg at 4:00 p.m., start date 2/1/24. Warfarin sodium tablet 2.5 mg, give one tablet by mouth one time only for INR result of 1.56, for one day, start date 2/2/24. Warfarin sodium tablet 2.5 mg, give one tablet by mouth one time only for INR result of 1.56, for one day and also administer scheduled 5 mg dose (total dose 7.5 mg), start date 2/4/24. Warfarin sodium tablet 5 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 1/18/24. Hold this dose from 2/7/24 to 2/9/24. Discontinue 1/12/24. -The 2/9/24 dose was signed as administered and not held. Warfarin sodium tablet 5 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 1/18/24. Hold this dose from 2/7/24 to 2/9/24. Discontinued on 2/12/24. -However, the 2/9/24 dose was not held and was given at the same time as the warfarin sodium tablet 4 mg dose that was ordered to start on 2/7/24 (see order below). -Additionally, this order was given at the same time as the order below without an order to administer both doses at the same time (see below). -The resident was given a total of 9 mg of warfarin on 2/10/24 and 2/11/24 without an order to give the resident that high of a dose. Warfarin sodium tablet 4 mg, give one tablet by mouth at 4:00 p.m., to prevent blood clots, start date 2/7/23. Hold this dose from 2/12/24 to 2/15/24. -However, the 2/14/24 dose was not held. An NP provider exam note dated 2/13/24 read in part: Last INR was 3.7, now only on 4 mg, medication is on hold today and tomorrow. Recheck INR on 2/14/24. There was a triage note in my box stating the patient was to receive 9 mg of warfarin on 2/10/2024, his INR was 2.38 at that time. On 2/12/2024 his INR was reported at 3.7. After reviewing the order history, it would appear that orders relayed to nursing to decrease warfarin dosing from 5 mg to 4 mg were misentered resulting in a total of 9 mg dosing. His usual dosing was meant to be reduced from 5mg to 4mg due to excessive INRs. Clearly, the patient was overdosed however the 4 mg dosing may still be correct and I intend to keep it at this level until verified through trial. Insulin and blood pressure medications Insulin glargine inject subcutaneous solution by pen injector 300 units per milliliter (ml), inject 86 units subcutaneously one time a day for diabetes, start date 12/16/23. Insulin lispro subcutaneous solution pen-injector 200 unit/ml, inject subcutaneously before meals for diabetes, as per sliding scale: if 150-200=4 units; 201-250=8 units; 251-300=10 units; 301-350 =12 units for > 351 give 14 units and call the physician provider, start date 12/18/23, discontinued 1/15/24. -The insulin lispro 7:30 a.m. dose was missed: 12/21/23, 12/24/23, 12/25/23 and 12/31/23; and, -The insulin lispro 11:00 a.m. dose was missed: 12/21/23, 12/24/23, 12/25/23 and 12/31/23. Lisinopril tablet 10 mg, give one tablet by mouth at bedtime for hypertension (high blood pressure), start date 12/16/23 and discontinued 1/18/24. Lisinopril tablet 10 mg, give two tablets by mouth at bedtime for hypertension, start date 1/18/24. -The lisinopril 7:00 p.m. dose was missed: 12/21/23, 12/23/23, 12/31/23, 1/3/24, 1/7/24, 1/8/24, 1/14/24, 1/15/24 and 1/16/24. Metoprolol succinate extended release, give two tablets by mouth two times a day for hypertension, start date 12/16/23. -The metoprolol succinate 7:00 a.m. dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/23/23, 12/24/23, 12/25/23, 12/27/23, 12/28/23, 12/31/23 and 1/7/24; and, -The metoprolol succinate 7:00 p.m. dose was missed: 12/22/23, 12/25/23 and 1/3/24. Other medications Macrodantin (Nitrofurantoin Macrocrystal) (antibiotic) capsule 100 mg, give one capsule by mouth in the morning, prophylactically, for chronic urinary tract infection, start date 12/19/23. -The macrodantin (antibiotic) 8:00 a.m., dose was missed: 12/21/23, 12/23/23 and 12/31/23. Spironolactone tablet 50 mg, give one tablet by mouth one time a day for (a diuretic) for hypertension, start date 12/16/23. -The spironolactone 9:00 a.m., dose was missed: 12/21/23, 12/24/23, 12/25/23, 12/27/23 and 12/31/23. Allopurinol 100 milligrams (mg), give one tablet by mouth one time a day for uric acid reducer, start date 12/16/23. -The allopurinol 7:00 a.m., dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/24/23, 12/25/23, 12/29/23, 12/30/23, 12/31/23, 1/2/24, 1/3/24, 1/4/23, 1/7/24, 1/8/24, 1/10/24 to 1/12/24, 1/14/24 and 1/15/24. Aspirin tablet, give 81 mg by mouth one time a day for inflammation, start date 12/16/23. -The aspirin 7:00 a.m. dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/24/23, 12/25/23 and 12/31/23. Gabapentin capsule 300 mg, give two capsules by mouth in the morning and three capsules at bedtime for neuralgia (nerve pain), start date 12/16/23. -The gabapentin 8:00 a.m. dose was missed: 12/21/23, 12/24/23, 12/27/23, 12/28/23, 12/31/23, 1/25/24 and 1/26/24; -The gabapentin 8:00 p.m. dose was missed: 12/25/23, 1/3/24 and 1/30/24. Morphine sulfate tablet extended release 15 mg give one tablet by mouth two times a day for pain, start date 12/16/23. -The morphine sulfate 7:00 a.m., dose was missed: 12/21/23, 12/24/23, 12/31/23, 13/24, 1/24/24 and 1/25/24; and, -The morphine sulfate 5:00 p.m., dose was missed: 12/30/23, 1/2/24, 1/24/24 and 1/27/24. Pregabalin capsule 150 mg, give one capsule by mouth two times a day for muscle pain, start date 12/16/23. -The pregabalin 7:00 a.m. dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/24/23, 12/27/23, 12/28/23, 12/29/23, 12/31/23, 1/2/24, 1/10/24, 1/25/24 and 1/26/24; and, The pregabalin 7:00 p.m. dose was missed: 12/25/23, 12/28/23, 1/3/24, 1/24/24 to 1/26/24. Trazodone HCl tablet 50 mg, give two tablets by mouth at bedtime for insomnia, start date 12/16/23. -The trazodone 7:00 p.m. dose was missed: 12/25/23, 1/3/24, 1/14/24, 1/15/24 and 1/24/24. Wellbutrin tablet extended release 300 mg, give one tablet by mouth one time a day for depression, start date 12/16/23. -The wellbutrin 7:00 a.m. dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/24/23, 12/29/23, 12/30/23 and 12/31/23. -Ziprasidone HCl (antidepressant) capsule 20 mg, give one capsule by mouth two times a day for mental disorder, start date 12/16/23. The ziprasidone 7:00 a.m. dose was missed: 12/19/23, 12/21/23, 12/22/23, 12/24/23, 12/25/23, 12/27/23, 12/31/23, 1/30/24 and 1/31/24; and, -The ziprasidone 7:00 p.m. dose was missed: 12/24/23, 12/25/23, 12/26/23, 12/28/23, 1/3/24, 1/9/24, 1/28/24, 1/30/24 and 1/31/24. -The majority of the above-missed doses had linked documentation explaining that the medication was not unavailable for administration but a few missed medication doses lacked any documentation to explain why the medication was not given to the resident. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/15/24 at 10:12 a.m. LPN #2 said the discrepancy with missed medication was the result of poor documentation, failure to administer medications as prescribed and a lack of communication with the resident's physician to get new prescriptions and discontinue unneeded medications. LPN #5 was interviewed on 2/15/24 at 11:32 a.m. LPN #5 said the omission of medication administration as observed in the resident's MAR was the result of not getting the medication timely from the pharmacy. LPN #6 was interviewed on 2/15/24 at 12:02 p.m. LPN #6 said Resident #6 was not always in his room and she could not find him so he often did not get his prescribed medications. LPN #6 said the issue with the observed missing medication administration in the MAR was the result of the nurse not documenting why the medication was not given. The pharmacy consultant (PC) was interviewed on 2/20/24 at 1:28 p.m. The PC checked the resident medication record and order history and said per the pharmacy records there were no medication reorder requests for Resident #6 and the reason for all of his missed medications was likely a reordering issue on the part of the facility. CNC #1 was interviewed on 2/20/24 at 4:00 p.m. CNC #1 said the assistant director of nursing (ADON) was supposed to complete daily audits to check each resident's medication supply and ensure that the medication administration nurses were recording prescribed medication timely. The ADON position was currently vacant. CNC #1 said the facility had an emergency backup medication supply in a locked unit. Not all nurses had access to get medications from the backup medication system. The previous nursing leadership team failed to resolve the issue. CNC #1 said the facility was resolving the issue so that all medication administration nurses would be assigned a code so they could access the backup medication system in the event of a resident's prescribed medication being unavailable. Additionally, they were retraining all nurses on the process of reordering resident medications. CNC #1 provided a list of medications available in the facility emergency medication kit warfarin was available in the e-kit in 1mg, 2 mg, and 5 mg doses and metoprolol 25 mg was available in the e-kit. Agency licensed practical nurse (ALPN) #1 was interviewed on 3/5/24 at 11:30 a.m. ALPN #1 said if she needed to get into the emergency medication kit (e-kit) she would find the DON or ask other nurses if they knew how to get in the e-kit. She said she was not trained by the facility on how to retrieve medications from the e-kit. ALPN #2 was interviewed on 3/5/24 at 11:32 a.m. ALPN #2 said she was agency staff and was not at the facility consistently but she was supposed to have codes and passwords to get into the e-kit. ALPN #2 said she was not given any codes or passwords to access the e-kit, nor was she told how to get into the e-kit. ALPN #3 was interviewed on 3/5/24 at 11:34 a.m. ALPN #3 said it was her first day working at the facility and no facility staff educated her on how to use the e-kit to retrieve medications. The IDON was interviewed on 3/5/24 at 12:45 p.m. The IDON said the facility hired 92-94 percent agency nursing staff and that the facility only had two facility hired nurse employees. The IDON said the week before this interview she had verbally trained the two facility hired nurses on the proper procedure to get medications from the e-kit. She said she would need to call the pharmacy to ask if anticoagulants were in the emergency kit but did not think that warfarin was included in the e-kit because there are various doses of the medication (see interview above with CNC #1 and below with the IDON for more information about the e-kit contents). The IDON said it was the DON's job to review medications each morning but the DON position was currently vacant and the facility was in the process of hiring a new DON, so the reviews of missing medications had not been done recently. The IDON said she did not know why Resident #6's medications were not reviewed in December 2023 and January 2024, so that medication errors could have been found and corrected. The assistant director of nursing (ADON) was interviewed on 3/5/24 at 3:45 p.m. The ADON said she was new to the position and she did not have any documentation of what medications were in the e-kit. She said she did not know where a list of what was inside the e-kits would be in the facility. The ADON showed the e-kit and showed there was no current list on the kit to describe what the contents were and she did not know what was inside the emergency medication kits. The IDON was interviewed again on 3/6/24 at 2:00 p.m. The IDON said she did not know why the agency nursing were only documented medications as missing and unavailable without providing further documentation details. She said when a medication was unavailable to give to a resident its cause should have been reviewed by the DON by the following day and the resident's physician shoul [TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (#15) of four residents reviewed for ADL care assistance out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with diagnoses of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The resident was dependent on staff for all of his ADLs. The resident expressed not getting out of his wheelchair, not bathing or receiving oral hygiene in weeks and not getting assistance with his meals regularly. The resident felt uncomfortable, itchy and his skin was burning due to not being bathed and wearing the same clothes for days. The resident said his current status affected his state of mind, he was frustrated and did not want to live anymore. Due to the facility's failure to provide adequate assistance to Resident #15 for his ADLs, the resident experienced a decline in his state of mind. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, revised March 2018, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It revealed in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting), dining (meals and snacks); and, communication (speech, language, and any functional communication systems). Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. II. Resident #15 A. Resident status Resident #15, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The 2/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for all ADLs including bathing, personal hygiene and eating. The assessment documented the resident had an indwelling catheter, colostomy, had a UTI within the last 30 days and had septicemia (blood infection). The resident's mood interview revealed the resident scored a 15 on the depression scale indicating the resident was experiencing moderate to severe depression. The interview revealed the resident had little interest or pleasure in doing things; was feeling down, depressed or hopeless; was having trouble falling asleep, staying asleep or sleeping too much; was feeling tired or having little energy; had a poor appetite; was feeling bad about himself; had troubles concentrating; had thoughts he would be better off dead or of hurting himself in some way. The resident did not reject care assistance or present with any behavioral symptoms. The 3/28/23 MDS assessment documented the resident interview for daily preferences indicated it was very important for the resident to choose what to wear; choose between a tub bath, shower, bed bath or sponge bath; choose bedtime; and be able to go outside to get fresh air when the weather was good. B. Resident interview and observation Resident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a lot of concerns regarding his care. Resident #15 said he refused to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. -During the interview, Resident #15's call light was not within reach. His call light was clipped onto his bedside table. The bedside table was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Resident #15 had a call light that was activated by the resident blowing into it. Resident #15 said he preferred to stay in his power wheelchair so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said he preferred to have showers on Tuesdays, Thursdays and Saturdays before breakfast was served. Resident #15 said he received pain medication around 4:00 a.m. to 5:00 a.m., 12:00 p.m. and in the evening. Resident #15 said he had a lot of pain due to his condition and preferred to have a shower in the morning after his first dose of pain medication because he was in the least amount of pain at that time. -During the interview, Resident #15 had body odor, food on his clothes, his teeth were yellow and he had bad breath. Resident #15 said he often stayed in the same clothes for four to five days at a time. Resident #15 said he was embarrassed and felt like his body and breath smelled bad. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this, he got a urinary tract infection (UTI) and ended up with sepsis. Resident #15 said he got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well which also led to the development of the wound. Resident #15 said when he got to the hospital his clothes were soaked in urine from his shoulders to his toes. Resident #15 said his skin was itchy and dry. Resident #15 said he would ask staff to lotion his hands and feet but they would tell him they were busy. -Resident #15's hands and feet were observed to be dry and flaky. Resident #15's toenails were long and beginning to curl around the tip of his toes. Resident #15 said the staff only assisted him with eating french fries for lunch. -The resident's lunch tray was on his bed that had a sandwich, a glass of milk and a dessert all which were wrapped in plastic wrap. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. Resident #15 said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he was unsure of the last time he had a shower or had his teeth brushed. Resident #15 was observed to have a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet due to the hole in his catheter tubing. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. Resident #15 said his clothes were soaking wet. Resident #15 had sweat dripping from his forehead which he said was a symptom of his body spasms. Resident #15 said the care he received affected his state of mind. He said he felt frustrated and did not want to live anymore. Resident #15 began crying during the interview. During the interview, Resident #15 continued to have body odor, bad breath and yellowed teeth. Resident #15 had a white build-up around his mouth. He said he was extremely thirsty and starving. Resident #15 said his colostomy was full of gas that morning (2/14/24). Resident #15 said he had not been assisted with his breakfast and he was so hungry his stomach was full of gas. -Resident #15 had a breakfast tray on his bedside table that had half a bagel and two links of sausage. -Resident #15's lunch tray from 2/13/24 remained on his bed. The sandwich and dessert were still wrapped in plastic wrap. Resident #15 said the staff did not assist him with his meal for lunch the previous day (2/13/24). -There was a glass of milk on the resident's table that was room temperature to touch and had a dead fly in it. C. Record review The ADL care plan, initiated on 1/2/23 and revised on 9/26/23, revealed Resident #15 had an ADL self-care performance deficit due to a traumatic spinal cord injury [AGE] years ago resulting in quadriplegia. The interventions included providing the resident with an electric wheelchair for mobility, providing total assistance with bathing, checking and trimming nails as needed, providing total assistance for bed mobility, providing total assistance for dressing, providing total assistance with eating, providing total assistance for personal hygiene and oral care, providing total assistance for toileting, providing total assistance of two staff members and mechanical lift for transfers, providing physical and occupational evaluations as needed and providing a restorative nursing program. The psychosocial care plan, initiated on 9/26/23, revealed Resident #15 had a history of refusing care and services which were within his rights. Resident #15 frequently refused to go to bed and refused care and treatments. Resident #15 frequently attempted to split staff and make false allegations of being denied care. Two staff members should be present when providing care to the resident. The interventions included providing behavioral and psychological services as indicated, collaborating with the interdisciplinary team to identify underlying causes of refusals, determining Resident #15's experiences and preferences to eliminate triggers, encouraging active participation with care, encouraging to set up a schedule for care which was acceptable for him, informing the resident of risks and ramifications of continued non-compliance and re-approaching the resident when he refused care. The 1/15/24 emergency department encounter note documented in pertinent part, The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival. According to the resident and staff interviews, the resident was supposed to be bathed three times per week. -However, his bathing day preferences were not indicated in the medical record. The November 2023 shower documentation revealed Resident #15 received a bath on 11/9/23, 11/11/23, 11/16/23 and 11/25/23. -It indicated Resident #15 was provided bathing on four of 13 opportunities. The December 2023 shower documentation revealed Resident #15 received a bath on 12/14/23, 12/16/23, 12/21/23, 12/23/23, 12/28/23 and 12/30/23. -It indicated Resident #15 was provided bathing on six of 13 opportunities. The January 2024 shower documentation revealed Resident #15 received a bath on 1/2/24, 1/6/24 and 1/23/24. -It indicated the resident was provided bathing on three of 12 opportunities. The February 2024 shower documentation revealed Resident #15 received a bath on 2/6/24 and 2/13/24. -It indicated Resident #15 was provided bathing on two of six opportunities. -However, despite the shower records documenting the resident received a bath on 2/13/24, Resident #15 said he refused his shower on 2/13/24 due to pain (see resident interviews above). -Certified nurse aide (CNA) #1 said he did not provide Resident #15 a shower on 2/13/24 because the resident refused. -Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates or that the staff had attempted to try at another time to complete the shower when he refused. -The medical record did not reveal the resident preferred to shower prior to breakfast related to his pain levels. III. Staff interviews CNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident with dry clothing. CNC #1 said she was unsure why CNA #1 documented the resident had a shower yesterday (2/13/24) because it was clear the resident had not had a shower in awhile. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning (2/14/24). CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. CNC #1 said the UTI was related to the resident's poor hygiene (cross-reference F690 for catheter care). CNA #1 was interviewed on 2/15/24 at 10:05 a.m. He said there was a piece of paper in the nurses station that had the shower schedule on it. CNA #1 said Resident #15 preferred to have showers on Tuesdays, Thursdays and Saturdays. CNA #1 said he did not give Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower and only wanted to be shaved. CNA #1 said he did not remember documenting that he gave Resident #15 a shower on 2/13/24. CNA #1 said Resident #15 refused his shower on 2/13/24 because he was in pain. CNA #1 said he wrote that the resident refused due to pain and put it in a box outside the director of nursing's (DON) office. CNA #1 said he did not talk to the licensed nurse on the unit regarding the resident's shower refusal due to pain. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. CNC #1 said the staff spoke with Resident #15 regarding his shower time. CNC #1 said it made sense that Resident #15 preferred to have his showers prior to breakfast due to his pain levels. CNC #1 said she would assist the facility in creating new shower preferences for all of the residents who resided at the facility. CNC #1 said there were a lot of holes in Resident #15's shower documentation indicating he missed showers. CNC #1 said some days it was documented that he had several showers. CNC #1 said the staff needed education on proper shower documentation. Cross-reference: F726 for staff competencies. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals. CNA #2 was interviewed on 2/20/24 at 1:56 p.m. She said CNAs were responsible for providing oral care to the residents. CNA #2 said oral hygiene should be performed when getting the resident ready for the day and when assisting them to bed.

Based on observations, interviews and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#15 and #11) of three residents reviewed for catheter care out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with a diagnosis of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The facility failed to provide the resident with catheter care per standards of practice, which resulted in Resident #15 being admitted to the hospital on 1/14/24 and diagnosed with severe sepsis (blood infection) related to a catheter associated urinary tract infection (CAUTI). The hospital paperwork documented the CAUTI was related to poor hygiene and catheter care. The hospital paperwork documented the resident was soaked in urine upon arrival to the emergency department. The resident had a large sacral decubitus ulcer and cellulitis of the scrotum likely associated with poor hygiene. The resident was started on intravenous (IV) antibiotics. The resident was readmitted to the facility on [DATE] and continued on IV Meropenem (an antibiotic medication) until 2/5/24. Additionally, the facility failed to provide consistent catheter care for Resident #11. Cross-referenced to F880 failure to use aseptic technique while replacing a suprapubic catheter and F726 failure to ensure sufficient competent nursing staff. Findings include: I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction.I. Professional reference According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 6/6/19), retrieved on 3/1/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf, Proper Techniques for Urinary Catheter Maintenance: Following aseptic insertion of the urinary catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine hygiene is appropriate. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. II. Facility policy and procedure The Catheter Care, Urinary policy, revised August 2022, was provided by the corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Empty the collection bag at least every eight hours using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container. III. Resident #15 A. Resident status Resident #15, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included sepsis (infection of the blood), urinary tract infection (UTI), depression, quadriplegia, neurogenic bladder (slow movement of the bladder), neuromuscular dysfunction of bladder and colostomy status. The 2/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for all activities of daily living (ADLs). The MDS assessment documented the resident had an indwelling catheter, had a UTI within the last 30 days and had septicemia (blood infection). B. Resident interview and observations Resident #15 was interviewed on 2/13/24 at 4:07 p.m. Resident #15 said he had a catheter. He said his catheter was not emptied for an extended period of time in January 2024. He said his catheter backed up and soaked all of his clothes. He said because of this he got a UTI and ended up with sepsis. Resident #15 said he also got a wound on his scrotum because of the moisture from the catheter backing up. He said the staff at the facility did not clean his scrotum well, which also led to the development of the wound. At 5:20 p.m. Resident #15's catheter bag was hanging over the edge of his electric wheelchair. The catheter bag was three-fourths full of urine. The resident did not have a leg anchor to attach the catheter bag to his leg to alleviate the catheter from pulling. Resident #15 said the facility did not provide him with leg anchors which caused a pulling sensation on his bladder. He said it hurt when the catheter bag was pulled. He said he had a midline IV access site on his arm that was no longer in use. Resident #15 said he was on IV antibiotics after being in the hospital in January 2024. Resident #15 was interviewed again on 2/14/24 at 8:59 a.m. Resident #15 said he refused to shower yesterday (2/13/24) because he was in a lot of pain. He said he did refuse care at times because he did not feel the staff knew what they were doing. Resident #15 said he would refuse to go to bed because he was afraid the staff would leave him in bed and he would not have access to his call light for assistance. Resident #15's call light was not within reach during the interview. His call light was clipped onto his bedside table which was pushed up against his roommate's bed. Resident #15 was unable to get his power wheelchair close enough to the call light to initiate it. Because of his quadriplegia, Resident #15's call light was initiated by him blowing into it. Resident #15 said he preferred to stay in his power wheelchair, so if he needed help he could use his wheelchair to go down the hallway and find staff. Resident #15 said when his clothes were wet it caused him to have spasms that caused him to sweat and caused pain. He said his clothes were soaking wet. Resident #15 had a one inch hole in the tubing of his catheter. Resident #15 said his body was itching and it felt like his skin was burning because his clothes were so wet. C. Record review The urinary care plan, initiated on 1/2/23 and revised on 1/5/23, revealed Resident #15 had a suprapubic catheter due to his diagnosis of a neurogenic bladder. The interventions included: providing the resident with a 24 French suprapubic catheter, positioning the catheter bag and tubing below the level of the bladder, changing the catheter as needed for displacement, infection and obstruction, checking the tubing for kinks when providing care to the resident and each shift, monitoring and documenting signs of pain or discomfort due to the catheter and monitoring and recording and reporting signs or symptoms of a UTI to the physician. The February 2024 CPO revealed Resident #15 had the following physician orders related to his catheter: -Suprapubic catheter size French #24/30 milliliters (ml) balloon. Monitor every shift for placement and functioning. Change as needed if dislodged, leaking or plugged, ordered 10/4/23; -Change suprapubic catheter 24 French, 10 cubic centimeter (CC) bulb attached to gravity drainage bag as needed for being pulled out, leaking or plugged, ordered 6/12/23; -Flush suprapubic catheter with 60 ml of normal saline at bedtime every Friday for patency, ordered 12/22/23; and, -Exchange suprapubic catheter immediately for infection, ordered 2/14/24. The 1/15/24 emergency department encounter note documented in pertinent part, The resident had significant skin breakdown around his abdominal wall and his scrotum and was soaked in urine upon arrival. The 1/15/24 infectious disease hospital note documented in pertinent part, The resident presented to have purulence (pus) around the suprapublic site. The 1/16/24 hospitalist progress note documented in pertinent part, The resident had likely recurrent CAUTI related to poor hygiene and catheter care. The resident had scrotal cellulitis and his urine was growing mixed flora (an unusual growth of multiple types of bacteria). The 1/17/24 inpatient hospital pain progress note documented in pertinent part, Resident #15 arrived at the emergency department and was found to be tachycardic (rapid heart rate), tachypneic (rapid breathing), febrile (fever) with an elevated white blood cell and lactate meeting systematic inflammatory response syndrome (SIRS) (an exaggerated defense response from your body to a harmful stressor) criteria. The patient had a large sacral decubitus (open wound) ulcer and cellulitis (infection of the skin) of his scrotum likely associated with poor hygiene. IV antibiotics were initiated. IV. Resident #11 A Resident status Resident #11, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO diagnosis included quadriplegia, neuromuscular neurogenic dysfunction of the bladder (lack of bladder control), overactive bladder, benign prostatic hyperplasia with lower urinary tract infection and diabetes. The 2/14/24 MDS assessment revealed the resident was cognitively intact with a BIMS with a score of 15 out of 15. The resident had impaired functional ability on both sides of the upper (shoulders, elbows, wrists and hands) and lower (hips, knees, ankles and feet) extremities due to quadriplegia and used a motorized wheelchair to get around. The resident needed substantial assistance with personal grooming and was dependent on staff to complete most ADLs. The resident did not reject or refuse care. The resident had an indwelling catheter (suprapubic catheter). B. Resident interview and observation Resident #11 was interviewed on 2/15/24 at 10:02 a.m. Resident #11 said the staff did not check on his catheter regularly to empty his leg drainage bag when it was full. He said he usually had to ask staff to empty the bag unless it was bedtime and staff emptied the bag to change it over to the larger overnight bag. -At the time of the interview, the resident's urine drainage bag was more than two-thirds full and bulging with dark amber urine. Resident #11 was interviewed on 2/15/24 at 1:33 p.m. Resident #11 said staff had not emptied his drainage bag today (2/15/24) and the floor nurse had not checked his suprapubic stoma (insertion site) since yesterday (2/14/24). Resident #11 said he was experiencing some abdominal discomfort. -At the time of the interview, the resident's urine drainage bag was full almost to the section of the bag where the tubing entered the ag. The drainage bag was bulging with amber-colored urine. Resident #11 said the nurses were supposed to irrigate his suprapubic catheter twice a day and he was lucky if they irrigated the catheter once a day. C. Record review The February 2024 CPO revealed the following physician orders related to Resident #11's suprapubic catheter: -Irrigate the suprapubic catheter twice a day with sterile water at 7:00 a.m. and bedtime, start date 9/11/23; and, -Suprapubic catheter #24 French with a 5 cubic centimeters (cc) bulb, drain to a gravity drainage bag. Monitor placement and patency during and after care every shift (6:00 a.m., 2:00 p.m. and 10:00 p.m.) every shift., start date 5/23/23. Review of Resident #11's December 2023 treatment administration records (TAR) revealed irrigation of the resident's suprapubic catheter was not completed on the following dates: -12/27/23 at 7:00 a.m.; and, -At bedtime on 12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23. Review of Resident #11's January 2024 treatment TAR revealed irrigation of the resident's suprapubic catheter was not completed on the following dates: -1/18/24 at 7:00 a.m.; and, -At bedtime on 1/21/24, 1/27/24 and 1/28/24. Review of the December 2023 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates: -12/27/23 at 6:00 a.m.; and, -12/9/23, 12/10/23, 12/17/23, 12/21/23, 12/22/23, 12/23/23, 12/26/23 and 12/31/23 at 2:00 p.m. Review of the January 2024 TAR revealed monitoring for placement and patency of Resident #11's suprapubic catheter was not completed on the following dates: -1/18/24 at 6:00 a.m.; -1/21/24 and 1/27/24 at 2:00 p.m.; and, -1/21/24 at 10:00 p.m. -A review of the medical record revealed no documentation of why the treatments were not provided. Progress notes revealed the resident had complications with the resident's catheter being dislodged. The condition was discovered on 12/11/23 during the scheduled order for the nurse to monitor the catheter for placement. The comprehensive care plan, revised on 10/13/23, revealed a care focus on managing the resident's suprapubic catheter with the goal of ensuring that the resident remained free from catheter-related trauma. Interventions included providing catheter care every shift, monitoring, documenting and reporting signs and symptoms of urinary tract infection. -There were no interventions to address the physician's order to irrigate the resident catheter. V. Staff interviews Registered nurse (RN) #1 was interviewed on 2/14/24 at 9:59 a.m. RN #1 said Resident #15 had a catheter. RN #1 said the certified nurse aides (CNA) were responsible for emptying the resident's catheter bag when needed. RN #1 said he observed Resident #15's catheter around 7:30 a.m. on 2/14/24 and did not notice any abnormalities. RN #1 said he did not empty the catheter bag at that time and noted it to have approximately 350 ml of urine in it. CNC #1 was interviewed on 2/14/24 at 10:08 a.m. CNC #1 said she had just visited with Resident #15. CNC #1 said Resident #15 had a hole in his catheter tubing and his clothes were soaked in urine. CNC #1 said the staff were replacing the catheter and providing the resident dry clothing. CNC #1 said Resident #15 needed a shower as it appeared he had not had one in a while. CNC #1 said the care Resident #15 received was not acceptable. CNC #1 said the resident had emotional harm and was in distress when she was in his room that morning. CNC #1 said Resident #15 had been admitted to the hospital in January 2024 with sepsis related to a UTI. RN #1 was interviewed again on 2/14/24 at 2:59 p.m. He said hand hygiene should be performed prior to catheter care. He said it was important to wear gloves. RN #1 said the first step to performing catheter care was assessing the resident's blood pressure and the output of the catheter. RN #1 said he would then gently remove the catheter. RN #1 said he would then dispose of the old catheter, take off his gloves, perform hand hygiene and put new gloves on. RN #1 said he then cleaned the area and lubricated the area. RN #1 said he would then insert the catheter and inflate the balloon based on the physician's orders. RN #1 said he would then gently tug on the catheter to ensure it was patent. RN #1 said he would ensure the catheter was draining. RN #1 said he would then remove his gloves and perform hand hygiene. Cross-reference F880 due the catheter care not being completed in a sanitary manner and F726 for competent nursing staff. CNC #1 was interviewed again on 2/15/24 at 3:27 p.m. She said catheter bags needed to be emptied once a shift or as needed. CNC #1 said the nurse should visually look at the catheter every shift to ensure it was functioning properly. CNC #1 was interviewed again on 2/20/24 at 12:37 p.m. CNC #1 said Resident #15's concerns regarding his care were valid. CNC #1 said she understood why Resident #15 refused care at times. CNC #1 said the facility needed to rebuild rapport with Resident #15 to help reduce his care refusals. 41032

Based on observations, record review and interviews, the facility failed to ensure two (#11 and #4) of two residents out of 29 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #11 was admitted to the facility for long term care on 5/17/23 for long term care with diagnoses of quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. Upon admission, Resident #11 weighed 188 pounds (lbs) and he reported he preferred to eat vegetarian meals. Resident #11 was started on Glucerna (diabetic nutritional supplement) once a day on 7/20/23. On 7/6/23, Resident #11 weighed 182.4 lbs. Resident #11 had lost 5.6 lbs, which was not considered significant. On 12/13/23, Resident #11 weighed 166.8 lbs. Resident #11 lost 10.6 lbs or 6% (percent) of his body weight in one month, which was considered significant. At this time the registered dietitian (RD) completed an assessment and increased Resident #11's Glucerna to twice a day. Resident #11 often refused the Glucerna. Resident #11 lost an additional 7.2 lbs from 12/13/23 to 1/23/24. On 1/25/24 30 cubic centimeters (cc) of liquid protein was ordered two times a day for the resident's skin and protein status. On 2/8/24, Resident #11 weighed 156.4 lbs. Resident #11 lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24, a period of six months, which was considered significant. The facility failed to implement person centered effective nutritional interventions, meet the resident's dietary preferences to prevent significant weight loss and consistently weigh the resident to monitor his weight. Additionally, the facility failed to offer diabetic education to Resident #4 upon admission and ongoing throughout his stay at the facility. Findings include: I. Facility policy and procedure The Nutrition (Impaired)/Unplanned Weight loss-Clinical protocol, revised September 2017, was provided by corporate nurse consultant (CNC) #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). The Therapeutic Diets policy, revised October 2017, was provided by CNC #1 on 2/15/24 at 10:00 a.m. It read in pertinent part, A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives. II. Resident #11 A. Resident status Resident #11, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. The 2/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with eating, oral hygiene, toileting and personal hygiene. He was dependent on staff for showering. The assessment documented the resident was 76 inches (six foot, four inches) tall and weighed 156 lbs. It indicated the resident had no weight loss or weight gain in the last six months. -However, Resident #11 had sustained a significant weight loss of 25.8 lbs (14.2%) in the last six months. B. Observations and resident interview During a continuous observation of the lunch meal service on 2/14/24 beginning at 11:24 a.m. and ending at 1:03 p.m., the following was observed: At approximately 12:20 p.m., an unidentified dietary staff member put a cookie and an individual sized bag of potato chips on Resident #11's meal tray. Resident #11 was interviewed on 2/14/24 at 1:54 p.m. Resident #11 said he preferred not to eat meat. He said he had been a vegetarian for [AGE] years. Resident #11 said he only got a cookie and a bag of chips for lunch. He said the menu item was a sloppy joe and he was unable to eat it due to his preferences. Resident #11 said he had to purchase most of his own food since the facility did not accommodate his preferences. Resident #11 said he had lost weight since he was admitted to the facility. Resident #11 did not feel his nutrition needs were being met. Resident #11 said he preferred to stay in bed until 11:00 a.m. Resident #11 said if he got up before then he was in his wheelchair for several hours which caused him pain (see weight change note below). C. Record review The nutrition care plan, initiated on 5/25/23 and revised on 2/15/24 (during the survey), revealed Resident #11 had potential for alteration in body composition integrity (muscle and fat wasting) and potential for unintended weight changes related to worsening condition secondary to numerous comorbidities including: type one diabetes mellitus, quadriplegia, history of pressure ulcer and depression. The interventions included: monitoring, recording and report to the physician signs and symptoms of malnutrition as needed (5/25/23), obtaining and monitoring lab/diagnostic work as ordered and reporting results to physician to follow up as needed (5/25/23), monitoring need for occupational therapy to screen for adaptive equipment (5/25/23), providing and serving supplements as ordered (2/15/24, added during the survey), providing and serving diet as ordered (5/25/23), offering vegetarian items per resident preferences and obtaining preferences (2/15/24, added during the survey), evaluating the resident by the registered dietitian (RD) as needed (5/25/23) and obtaining weights per facility protocol (5/25/23). Resident #11's weights were documented in the resident's medical record as follows: -On 5/18/23, the resident weighed 188 lbs; -On 6/14/23, the resident weighed 185.5 lbs; -On 7/16/23, the resident weighed 182.4 lbs; -On 7/31/23, the resident weighed 182.6 lbs; -On 8/3/23, the resident weighed 182.2 lbs; -On 8/14/23, the resident weighed 182.4 lbs; -On 9/7/23, the resident weighed 175.8 lbs; -On 11/10/23, the resident weighed 177.4 lbs; -On 11/17/23, the resident weighed 177.4 lbs; -On 12/13/23, the resident weighed 166.8 lbs; -On 1/23/24, the resident weighed 159.6 lbs; and, -On 2/8/24, the resident weighed 156.4 lbs. -The resident lost 25.8 lbs (14.2%) from 8/3/23 to 2/8/24 in six months, which was considered significant. The 7/8/21 preadmission screening and resident review (PASRR) documented the resident preferred to eat a vegetarian diet. The PASRR documented vegetarian diet options should be offered to the resident at every meal. The 5/18/23 dietary interview assessment documented Resident #11 had a good appetite. Resident #11 said he preferred to have 2% milk and cranberry juice to drink at breakfast and dinner. The resident did not like to snack between meals. Resident #11 did not like fried eggs and did not eat meat. The resident was on a regular diet and did not have any food allergies. The resident was aware the alternative meals were available upon request. The resident preferred to eat in his room. The resident typically ate breakfast, lunch and dinner. The resident preferred to follow a vegetarian diet and enjoyed cheese sandwiches, quesadillas, fish, eggs, salads and burritos for lunch and dinner. The 12/14/23 interdisciplinary (IDT) weight variance assessment documented by the registered dietitian (RD) revealed the resident weighed 166.8 lbs and had lost 5.6% of his body weight in one month (however, the resident had sustained a 6% weight loss in one month). The resident was currently receiving Glucerna or Boost Glucose Control (diabetic nutritional supplement) once a day and liquid protein. The resident was on a vegetarian diet. The resident previously weighed 177.4 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 experienced a 5.6% weight loss in 30 days. The resident's current body mass index (BMI) was 20.3, which was considered within normal limits for his height and age. Resident #11 continued to have good intakes and would consume greater than 75% of his meals. Resident #11 received liquid protein and another supplement to assist with his protein intakes. The assessment documented the weight was questioned. Glucerna was increased to twice a day to assist. The RD documented he would continue to monitor. The new intervention was to increase the supplement to twice a day. The IDT member who participated in the review was the RD. -Despite the 12/14/23 IDT note documenting the resident had a 5.6% weight loss, the resident had sustained a 6% (10.6 lbs) weight loss, which was considered significant, from 11/17/23 to 12/13/23, in one month. The physician order revealed the Glucerna eight ounces was increased to two times a day for weight management on 12/14/23. The resident went to the hospital from 1/7/24 to 1/15/24. According to the hospital records, Resident #11 weighed 165 lbs on 1/7/24. On 1/15/24, while he was still in the hospital, he weighed 165 lbs. -The resident had a 10.6 lbs weight loss prior to his admission to the hospital and he was not weighed until 1/23/24, which was eight days after his readmission, where he sustained an additional 7.2 lbs weight loss. The 1/25/24 IDT weight variance assessment documented by the RD revealed the resident weighed 159.6 lbs. The resident had lost 10% of his body weight in two months. The resident was currently receiving Glucerna or Boost Glucose Control twice a day. The resident was on a vegetarian diet. The resident previously weighed 166.8 lbs. The resident was receiving Ativian (antianxiety medication) and Morphine (pain medication). The resident was a slow eater; had poor ability to feed himself; complained of the taste of the food, disliked the food, disliked the diet and was a picky eater; and, had variable intake. The resident had a recent illness within the last 30 days, a recent significant change in medications and was on psychotropic medication. The resident had a recent illness. The resident had a decline or had low hemoglobin and/or hematocrit and had a decline or low albumin. The assessment documented the root cause analysis was Resident #11 continued to lose weight. The resident had a BMI of 19.4 which was within normal limits for his height and age. Resident #11 was a vegetarian and ordered mostly special meals. The resident said he refused meals, because the facility did not offer vegetarian options. The RD spoke with the dietary manager and they have several vegetarian options including grilled cheese, cheese pizza, bean and cheese burritos, salads, eggs and vegetable burgers. The RD notified the resident of the options and the resident said he was not aware the kitchen had these options. The RD documented the kitchen staff reported to the RD that they had notified the resident of these options previously. The RD encouraged the resident to order meal choices he wanted. The RD recommended starting the liquid protein supplement to assist with the resident's low protein status and continuing the Glucerna. The RD documented he would continue to monitor the resident. The IDT member who participated in the review was the RD. -Despite the IDT note documenting the RD met with Resident #11 regarding his vegetarian diet, the resident was not provided with vegetarian options during the survey (see observations above). The resident had a 10% (17.8 lbs) weight loss, which was considered significant, from 11/17/23 to 1/23/24, in two months. -While some nutritional interventions were implemented to address the resident's significant weight loss of 10% (17.8 lbs) from 11/17/23 to 1/23/24 (a period of two months), the facility failed to monitor the resident's weight more frequently to see if the implemented interventions were effective and the resident continued to lose weight. Liquid Protein 30 cc two times a day for low protein and skin integrity. Liquid protein 30 milliliters (ml) twice a day, mixed with juice, ordered 1/25/24. The RD said he recommended the liquid protein upon the resident's request (see interview below). -Despite the addition of the Liquid Protein intervention, the facility again failed to implement more frequent monitoring of the resident's weight to determine if the new intervention was effective, and the resident continued to lose weight. The February 2024 medication administration record (MAR) revealed Resident #11 consumed an average of 41% of the ordered Glucerna from 2/1/24 to 2/14/24. The 2/15/24 dietitian note documented the RD met with Resident #11 to review the resident's weight and discuss the menu options. The resident said he had been ordering smaller meals and was no longer ordering off the always available menu like he used to. Resident #11 reported he was a picky eater and had concerns about the food. The RD documented the nutrition services director (NSD) was present during the conversation to assist with the menu discussion. The resident reported he was a very picky eater and did not like the selection of food being offered. The RD documented he reminded the resident of the discussion they had regarding the always available menu options. The resident said he was picky regarding those options as well. The resident said he liked spaghetti with marinara, fish sticks with tarter sauce and yogurt. The RD mentioned to the resident the other options that were offered and the resident said he wanted more variety. The RD documented the current options available were reviewed with Resident #11 which included bean and cheese burritos that were currently on backorder, grilled cheese, quesadillas and Resident #11 said he needed salsa and sour cream, vegetarian burgers, salads, yogurt, fruits, eggs and other vegetables. Resident #11 raised his voice and said he was tired of those options and the facility was forcing him to purchase his own frozen meals to eat. The resident continued to raise his voice and became visibly frustrated. Resident #11 continued to criticize the quality of the food and said the food options did not meet his preferences or cooking techniques. The RD notified the resident that there are menu options the kitchen can provide and the staff can make a more personalized menu to try and assist the resident. The resident became emotional and said I am just done with this. The RD encouraged the resident to suggest additional meals that he would like, so the facility could build a menu that represented his wants and needs. Resident #11 said he would think of options. The RD documented the resident had several organic snacks in his room that he had purchased. -The resident had a 14.2% (25.8 lbs) weight loss, which was considered significant, from 8/3/23 to 2/8/24, in six months. While interventions were put in place, the interventions were not assessed for their effectiveness. The resident only accepted Glucerna, on average, 41% of the time. -The facility did not provide the resident with his dietary preferences, which resulted in a decreased oral intake. Cross-reference F806 for preferences. The 2/15/24 weight change note documented at 7:41 a.m. revealed the resident had refused his weight that week. The RD documented he would continue to request weekly weights (see RD and resident interview). D. Staff interviews The RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #11 preferred to be a vegetarian. The RD said Resident #11 did eat fish. The RD said Resident #11 was a very picky eater. The RD said he would visit with the resident and try to establish the resident's food preferences and help create a menu for Resident #11 that was nutritionally balanced. The RD said Resident #11's lunch of chips and cookies was not a complete meal and did not provide the resident with adequate nutrition. The NSD said the kitchen had been offering Resident #11 alternative items such as a bean burrito, grilled cheese and cheese quesadilla. The NSD and the RD said they understood that Resident #11 was tired of the alternative options. The RD said resident preferences and nutrition interventions should be included in the care plan. The RD said the certified nurse aides (CNA) documented the resident frequently consumed greater than 75% of his meals. The RD said the CNAs should not document the resident was consuming more than 75% of his meals if he was only consuming cookies and chips. The RD said that was not a complete meal. The RD said he had not provided any recent education on accurate meal consumption documentation. The RD said the CNAs should look at the meal as a whole and refer to MyPlate (food pyramid) as a representation of a complete nutritionally balanced meal. The RD said it was important for meal intakes to be documented accurately to help with his nutritional assessments. The RD said Resident #11 triggered as a significant weight loss in December 2023. The RD said he completed an assessment and increased the Glucerna supplement to twice a day to improve oral nutrition intake. The RD said the resident triggered significant as a weight loss again in January 2024. The RD said at that time he spoke with the resident and the resident requested a protein supplement to help with his skin integrity and protein status. The RD said no further nutrition interventions had been implemented to prevent further significant weight loss. The RD said the resident's comprehensive care plan did not include the resident's significant weight loss, dietary preferences or nutrition interventions that were implemented to help prevent further weight loss. The RD said he completed the IDT assessment and did not have collaboration from other members of the team. The RD said he believed the resident's physician was aware of the weight loss but did not have any documentation indicating the physician had been notified of the significant weight loss. The RD said the facility's policy was to weigh a resident upon admission and then be weighed weekly for three to four weeks to create a baseline. The RD said if the resident's weight was stable the resident was then weighed monthly. The RD said he had requested the nursing staff to weigh Resident #11 weekly in December 2023, so he could monitor the weights more closely. The RD said the facility did not obtain weekly weights for Resident #11. The RD said he was aware that Resident #11 refused his weekly weight on 2/15/24. The RD said he was not aware that Resident #11 preferred to stay in bed tuntil 11:00 a.m. and the staff attempted to get his weight prior to 11:00 a.m. The RD said Resident #11 had been in and out of the hospital a couple times and the resident recently got a colostomy bag. The RD said he had not reviewed the February 2024 MAR to determine if Resident #11 was accepting the Glucerna. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said the facility needed to review weight loss as an IDT team weekly. CNC #1 said the provider needed to be notified if a resident had a significant weight loss. CNC #1 said Resident #11's significant weight loss needed to be reviewed with the IDT to discuss nutrition interventions. III. Resident #4 A. Resident status Resident #4, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO, diagnoses included depression, hypoglycemia (low blood sugar) type one diabetes mellitus, gastroparesis (slowed movement of the stomach), visual loss, need for assistance with personal care, schizophrenia (mental illness), cocaine dependence and heart failure. The 12/27/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance for eating. He required supervision for oral hygiene, toileting and personal hygiene. He required substantial assistance for showering. The assessment indicated he was on a therapeutic diet. His vision was adequate and he did not have corrective lenses. -However, the resident was blind. B. Resident interview Resident #4 was interviewed on 2/13/24 at 12:59 p.m. Resident #4 said the food was not good. He said the food was often served late. He said it was difficult to manage his diabetes since the meals were frequently late. He said the facility did not follow standardized portion sizes. Resident #4 said he was blind so it made it difficult for him to know how many carbohydrates he was consuming when the portion sizes were different each day. C. Record review The nutrition care plan, initiated on 9/20/23, revealed Resident #4 had potential for alteration in body composition integrity (body and fat wasting) and potential for unintended weight changes related to worsening of his condition secondary to numerous comorbidities such as: type one diabetes, schizoaffective disorder, chronic kidney disease, gastroparesis (slow stomach movement), hypertension (high blood pressure), gastro-esophageal reflux disease (GERD), depression and chronic heart failure. The interventions included obtaining and monitoring lab as ordered and reporting abnormalities to the physician, completing an occupational therapy screen as needed, providing a bowl for the resident's food if requested, providing and serving the diet as ordered, providing double portions as requested even if the resident did not eat it all as he was a picky eater, completing a nutritional evaluation as needed and completing weights per facility protocol. The meal preferences care plan, initiated on 9/2023 and revised on 10/30/23, revealed Resident #4 had a history of voicing that staff were not taking his orders correctly or some of the items he ordered were missing on his meal trays. Resident #4 preferred to have his order read back to him after being taken. Resident #4 became verbally aggressive with staff related to his food items being missed, not getting what he ordered or his order being taken incorrectly. Staff needed to take Resident #4's orders and deliver his meals with two staff members present. The interventions included anticipating and meeting the resident's needs, providing positive interaction, following up on grievances as needed, discussing the resident's behavior, intervening as necessary to protect the rights and safety of others, praising the resident for behavior improvement and taking the resident orders and delivering meals with a second staff member present. The diabetic care plan, initiated on 9/20/23, revealed the resident had type one diabetes mellitus that was managed by insulin and diet. Resident #4 could titrate his insulin dosing as requested for carbohydrate counting. Resident #4 was not to exceed 12 units of insulin per physician order and his history of diabetes. The interventions included administering medications as ordered, educating the resident on medications and potential side effects, referring to nephrology as indicated, allowing Resident #4 to adjust his own insulin needs based on blood sugar levels and food consumed and monitoring the resident's blood sugar before each meal and before bedtime. The visual impairment care plan, initiated on 9/20/23, revealed Resident #4 was legally blind. The interventions included announcing oneself when entering the resident's area, answering the call light timely, placing the call light within reach, ensuring there is adequate lighting, involving the resident in auditory activities, keeping the resident environment free of small objects, keeping visual devices clean and assisting as needed for placement, providing medication as ordered, monitoring the resident's eyes for irritation, monitoring for changes in ability to perform activities of daily living and providing a clean and hazard free environment. D. Staff interviews The RD and the NSD were interviewed together on 2/15/24 at 11:59 a.m. The RD said Resident #4 did not want nutrition education. The RD said Resident #4 was non-complaint with his diet and made his own food choices. The RD was interviewed again on 2/15/24 at 1:23 p.m. The RD said he was unable to find documentation in Resident #4's medical record that diabetic nutrition education had been offered to the resident. The RD said he attempted to provide Resident #4 diet education on 2/15/24 (during the survey process). The RD said the resident was upset regarding the portion sizes at the facility. The RD said Resident #4 said the portion sizes were never consistent which made it difficult to dose his insulin correctly. Cross-reference F804 failure to follow the correct portion size. The RD was interviewed again on 2/15/24 at 3:59 p.m. The RD said he was contracted through the facility. The RD said he reviewed his billing documentation. The RD said he found documentation that he billed for diabetic education for Resident #4 several months ago but the resident refused. The RD said there was no documentation in the resident's medical record indicating diabetic education had been offered. CNC #1 was interviewed on 2/20/24 at 12:37 p.m. CNC #1 said diabetic education should have been offered to Resident #4 and documented in his medical record if he refused it.

Based on observation, record review and interviews, the facility failed to ensure two (#272 and #7) residents out of 28 sample residents were free from significant medication errors. Resident #272, was admitted on [DATE] for long term care with a goal to return home. The resident was prescribed medication of Ativan for his anxiety disorder. The facility ran out of the prescribed medications and he missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 9/4/23) from progressing to the resident experiencing withdrawal symptoms and subsequently being hospitalized on [DATE] (six days after the facility identified the medication was out of stock). In addition, the facility failed to: -Ensure medications were ordered from the pharmacy STAT (urgent or rushed) to prevent missed medication doses for Resident #272; -Ensure nurses were educated on the availability and use of the emergency medication kit; -Ensure the emergency medication kit was accessible to nursing staff; -Ensure nurses were educated on the side effects and signs and symptoms of benzodiazepine withdrawals. -Ensure insulin (medications used to regulate blood glucose levels) pens were primed prior to medication administration for Residents #7. Findings include: I. Resident #272 A. Professional reference According to American Addiction Center, [NAME] Withdrawl Symotoms Symptoms accessed on 10/9/23 at https://americanaddictioncenters.org/benzodiazepine/length-of-withdrawal, it read n pertinent part, Benzodiazepines ([NAME]) are all designed as central nervous system depressants; however, they each may work slightly differently at targeting certain symptoms. Withdrawal side effects are not generally lethal, although they are best managed with professional medical attention and supervision. [NAME] withdrawal symptoms may include: Nausea Panic attacks Tremors Anxiety Sweating Headaches Heart palpitations Muscle pain Seizures Most benzodiazepine ([NAME]) withdrawal symptoms start within 24 hours and can last from a few days to several months, depending on the length of the abuse and the strength of the [NAME] used. B. Facility policy and procedure The Medication Order and Receipt Record policy, last revised April 2007, was provided by the nursing home administrator (NHA) on 9/28/23. The policy read in part, Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered and or received shall also be entered into the medication order and receipt record. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available. C. Resident status Resident #272, age under [AGE] years old, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO) diagnoses included major depressive disorder, recurrent, moderate anxiety disorder and quadriplegia. According to the most recent minimum data set (MDS) dated [DATE] the resident had intact cognition with a score of 15 out of 15 for the brief interview mental status (BIMS). The resident did not have any rejection of care behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. D. Resident interview Resident #272 was interviewed on 9/26/23 at approximately 11:00 a.m. The resident said he went into withdrawal because the facility did not want to give him his prescribed medication which led to him calling 911 and being hospitalized to get the medicine and care he needed. He said after missing four days of medications that were prescribed three times a day he became agitated, scared, restless and confused. He physically had suffered from sweating, shaking, racing thoughts, headaches and abdominal cramps. The resident said the staff did not seem to care or recognize that he was having withdrawal side effects. The resident said he even informed the staff he was not feeling right but they did not take action. The resident said he had to call 911 because the facility did not want to get him medications in time and they did not want to send him out to a hospital. E. Record review The September 2023 computerized physician orders revealed the resident was ordered Ativan oral tablet 0.5 MG (Lorazepam); give one tablet by mouth three times a day related to anxiety disorder, unspecified. The September 2023 medication administration record (MAR) revealed the resident had missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23 (see below). 9/4/23 Morning dose The MAR read the drug was not given and to review the nursing progress note. -The 9/4/23 9:26 a.m. nursing progress note was reviewed on 9/27/23 it revealed Ativan was reordered. Mid day dose The MAR read the drug was not given and to review the nursing progress note. -The 9/4/23 11:35 a.m. nursing progress note was reviewed on 9/27/23 it revealed Awaiting delivery for Ativan. Night dose The MAR read the drug was not given and to review the nursing progress note. -The 9/4/23 8:46 p.m. nursing progress note was reviewed on 9/27/23 it revealed Ativan was reordered and the pharmacy was called. 9/5/23 Morning dose The MAR entry was not completed by the nurse and therefore the administration record was blank. Mid day dose The MAR read the medication was held by the physician due to lack of availability of the medication. Night dose The MAR read the medication was held by the physician due to lack of availability of the medication. 9/6/23 Morning dose The MAR entry read the medication was administered by a nurse. -The drug was still not available at the time and the medication was on hold by the physician due to lack of availability. Mid day dose The MAR entry was not completed by the nurse and therefore the administration record was blank. Night dose The MAR read the medication was held by the physician due to lack of availability of the medication. 9/7/23 Morning dose The MAR read the medication was held by the physician due to lack of availability of the medication. Mid day dose The MAR read the medication was held by the physician due to lack of availability of the medication. Night dose The MAR read the medication was held by the physician due to lack of availability of the medication. 9/8/23 Morning dose The MAR read the medication was held by the physician due to lack of availability of the medication. Mid day dose The MAR read the medication was held by the physician due to lack of availability of the medication. Night dose The MAR read the drug was not given and to review the nursing progress note. -The 9/8/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan. 9/9/23 Morning dose The MAR read the drug was not given and to review the nursing progress note. -The 9/9/23 nursing progress note was reviewed on 9/27/23 it revealed no notes were entered related to Ativan for the morning dose. Mid day dose The MAR read the drug was not given and to review the nursing progress note. The 9/9/23 2:11 p.m. nursing progress note was reviewed on 9/27/23 it revealed Ativan 0.5 mg out of stock,provider notified of needing medication script after nurse spoke to pharmacy. Medication script to be provided to the pharmacy. Night dose The MAR read the drug was held because the resident was hospitalized . -The 9/9/23 8:20 p.m. nursing progress note was reviewed on 9/27/23 it revealed the resident was hospitalized . Review of the progress notes from 9/4/23 to 9/9/23 did not capture the resident had a change of condition. The progress notes address the Ativan medication was out of stock and what was mentioned (see above). The hospital discharge notes dated 9/10/23 at 12:02 a.m. read the resident was hospitalized for benzodiazepine withdrawal. (Benzodiazepines are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures). It is important to talk to your provider about weaning you off your Ativan. It is very important that wean off on a scheduled medically supervised taper, as weaning off too rapidly can be dangerous. The 9/10/23 progress note documented the resident returned from the hospital. Per hospital report, the residnet was diagnosed with urinary tract infection (UT) and ordered antibiotics for seven days. After Ativan was restarted, the resident stated he was feeling better. -However, a review of the hospital discharge notes in the resident's medical record revealed the resident was hospitalized for benzodiazpine withdrawl (see above). There were no documentation of the resident's stay in the hospital or of the resident having a UTI. F. Staff Interviews Licensed practical nurse (LPN) #1 was interviewed on 9/26/23 at 6:17 p.m. He said he would reorder medications once he realized a specific medication was out of stock. Once he identified a medication was out of stock he would let his supervisor know, notify the provider and the pharmacy. He said he was unfamiliar with benzodiazepine withdrawal signs and symptoms and he was unfamiliar with the potential side effects of missing benzodiazepine medications consecutively for a few days. The pharmacy consultant was interviewed on 9/27/23 at 5:05 p.m. She said when medications were running low on stock (approximately three days prior to medications running out) the nurse should place an order through contacting the pharmacy the facility works with. The pharmacy consultant said she reviewed the resident's MAR for the month of September 2023 and said the resident missed 18 doses, however, she did not have any recommendations or concerns for the facility because at the time she reviewed the MAR the situation was resolved since the facility received the out of stock medications by 9/10/23. The director of nursing (DON) was interviewed on 9/27/23 at 5:07 p.m. She said the Ativan was out of stock and the resident missed his doses from 9/4/23 to 9/10/23. The side effects of stopping a benzodiazepine without weaning them off could lead someone to become uncomfortable, anxious, experience panic attacks, sweat and having headaches. The DON said she was uncertain as to why he missed so many doses because she had an emergency kit in her office and a backup pharmacy. The DON said during the time period the medications were out of stock, the facility had access to Ativan in the emergency kit in her office. The emergency kit in her office had seven days of mediations available for someone that has Ativan ordered three times a day. The minimum data set coordinator (MDSC) was interviewed on 9/28/23 at 9:11 a.m. She said the facility dropped the ball regarding the resident's benzodiazepine withdrawal due to the medications being out of stock. The nursing home administrator (NHA) and the MDSC were interviewed on 9/28/23 at 10:05 a.m. They said they were not aware of the missed medication doses until it was identified during the survey process.The process to obtain out of stock medications were the nurses' responsibility. The medication should be ordered through pharmerica and the medications should be ordered upon identifying there was a seven day supply left. The nurse should call the physician to notify them and call the pharmacy to order the medication. The nurse has the option to order the medication immediately (STAT) which would be delivered within two to four hours. No staff in the facility knew about the emergency medication kit in the DON's office, therefore no staff used it. They said the nurses would be trained on the use of the emergency kit and the nurses would document low stock medications on the nursing shift report which will be reviewed by administration the following morning to ensure medications were always stocked. The emergency kit would be moved out of the DON's office and stored on each medication cart to promote ease of accessibility. 47064 II. Resident #7 A. Professional reference According to the Lantus insulin package insert, retrieved on 10/3/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf instructions for use; do a safety test before each injection to: check pen and the needle to make sure they were working properly. To make sure that you get the correct Lantus dose. Select 2 units by turning the dose selector until the dose pointer was at the two mark. Press the injector button all the way in. when insulin comes out the needle tip your pen was working correctly: this may need to be repeated up to three times before seeing insulin. If no insulin comes out after the third time, the needle may be blocked. B. Facility policy The Insulin Administration policy and procedure, revised September 2014, was received from the nursing home administrator (NHA) on 9/28/23 at 12:27 p.m. It revealed in pertinent part, to provide guidelines for the safe administration of insulin to residents with diabetes. C. Resident status Resident #7, younger than [AGE] years old, admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus (abnormal blood glucose) and chronic kidney disease (abnormal kidney function). The 7/31/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident received insulin for the past seven days. D. Physician orders The CPO documented: Lantus solo star solution pen-injector 100 units/milliliter (ml) Inject 25 units subcutaneous every evening for diabetes. E. Observations On 9/26/23 at 4:49 p.m. licensed practical nurse (LPN) #1 was administering medications to Resident #7. He collected the Lantus solo star pen, applied a new needle cap to the pen and dialed the pen to 25 units. LPN #1 injected the insulin into the resident's right arm. LPN #1 failed to prime the insulin pen prior to dialing up the ordered 25 units of insulin. F. Staff interviews LPN #2 was interviewed on 9/26/23 at 5:28 p.m. She said she was unaware of insulin pens needing to be primed prior to administration of insulin to a resident. LPN #1 was interviewed on 9/26/23 at 5:38 p.m. He said he did not prime the insulin pen prior to the administration to Resident #7 as the pen had already been used and pens were to be primed only on initial use and not with every injection. LPN #1 said if a resident did not get the correct amount of insulin it would not help regulate blood glucose levels appropriately. The director of nursing (DON) was interviewed on 9/26/23 at 5:45 p.m. She said best practice was for the insulin pen to be primed to remove bubbles from the needle and ensure the needle was functioning correctly for administration of insulin. The DON said the needle should be primed with two units to ensure the correct amount of insulin was administered to the resident. The DON said not priming the pen could result in the incorrect dose of insulin being administered to a resident.

Based on record review and interviews, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one (#1) of three residents reviewed for nutritional status out of 11 sample residents. Specifically, the facility failed to reevaluate interventions for Resident #1, address underlying gastrointestinal (GI) discomfort, and difficulty chewing related to poor dentition timely to prevent significant weight loss. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission weight was 143.3 lbs (pounds). She had a 6.35% weight loss from [DATE] to [DATE] considered significant in less than 30 days), a 7.3% weight loss considered significant from [DATE] to [DATE] and additional 4.82% weight loss from [DATE] to [DATE], which was a total weight loss of 17.38% in a little over two months (see record review below). She was down to 114 lbs on [DATE] prior to discharge to the hospital on [DATE]. Although, the facility implemented several supplements, snacks, a speech evaluation and updated Resident #1's likes and dislikes, weekly weights (which reportedly she refused at times) and antidepressant medications; the facility's failure to address Resident #1's poor intake of meals, supplements and follow-up on ordered interventions resulted in the resident having significant weight loss, stage 4 pressure ulcer which became infected and the resident was urgently transferred to the hospital on [DATE] where she died of septic shock due to sacral [CONDITION(S)]. Resident #1 did not have her diet downgraded to help with chewing difficulty until [DATE], Resident #1 did not have medication added to help with GI discomfort until [DATE] and the facility failed to ensure a GI consult was completed which was ordered on [DATE] (see below). Moreover, the facility failed to educate Resident #1 and her family of continued poor intake timely with risks of continued decline including risks for pressure ulcer development infection and death. Cross-reference F686 failure to prevent, assess, monitor and timely treat a facility acquired sacral pressure injury for Resident #1, who had been assessed as being at risk for pressure ulcer development. Findings include: I. Facility policy The Food and Nutrition Services policy was provided by clinical nurse consultant (CNC) #2 on [DATE] at 10:20 a.m. It documented, in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements. Reasonable efforts will be made to accommodate resident choices and preferences. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. II. Resident status Resident #1, under [AGE] years old, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She expressed feeling down, depressed or hopelessness two to six days out of the week. She had problems falling/staying asleep or sleeping too much two to six days out of the week. She had a poor appetite or overeating 12 to 14 days out of the week. She did not exhibit any behaviors or reject care. She required limited one-person assistance with eating. It was documented Resident #1 had no dental concerns and was not at risk for protein calorie malnutrition. She did not have weight loss or weight loss was unknown and she was not on a mechanically altered diet. She was not on a restorative nursing program for eating or swallowing assistance. The [DATE] minimum data set (MDS) assessment revealed Resident #1 was moderately impaired with a brief interview for mental status (BIMS) score of 15 out of 15. She did not express feeling down, depressed or hopelessness. She had feelings of tiredness or having little energy two to six days out of the week. She had poor appetite or overeating two to six days out of the week. She did not exhibit any behaviors or reject care. She required extensive one-person assistance with eating. She had mouth or facial pain, discomfort or difficulty with chewing and she was at risk for protein calorie malnutrition. She was not on a prescribed weight loss program and not on a mechanically altered diet. She was not on a restorative nursing program for eating or swallowing assistance. II. Record review Resident #1's weights were as follows: -On [DATE] it was documented Resident #1 was weighed three times, at 1:50 p.m. her weight was 142.2 lbs, at 3:02 p.m. her weight was 143.3 lbs and at 3:23 p.m. her weight was 143 lbs; -On [DATE] her weight was 139.5 lbs; -On [DATE] her weight was 139 lbs; -On [DATE] her weight was 134.2 lbs, which was a 8.8 lbs weight loss since her admission on [DATE], 6.35% which was considered significant. In addition, the resident was not weighed again until 30 days later; -On [DATE] her weight was 124.4 lbs, which was a 9.8 lbs additional weight loss since [DATE], 7.3% which was considered significant. In addition, the resident was not weighed again until 12 days later; -On [DATE] her weight was 118.4 lbs, which was an additional 6 lbs weight loss in 12 days, which was 24.6 lbs since her admission on [DATE], 17.38% which was considered significant. From [DATE] to [DATE], the resident weight remained in the range of 115 to 119 lbs. -On [DATE] her weight was 114.7 lbs, this was 3.7 lbs weight loss since [DATE] and she developed a wound to her coccyx on [DATE] (cross-reference F686); -On [DATE] her weight was 114 lbs. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -However, the resident weight was not consistently obtained every Sunday as indicated per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's MOST (medical orders for scope of treatment) form dated [DATE] revealed Resident #1 was Full COR (resuscitation) and selected to have use of intubation, advanced airway intervention, mechanical intervention, cardioversion as indicated, transfer to the hospital if needed and intensive care. -It was documented she did not want artificial nutrition by tube. The nutritional care plan, initiated [DATE] and revised on [DATE], [DATE], [DATE], [DATE] and [DATE] revealed Resident #1 had left sided weakness due to [CONDITION(S)] ([CONDITION(S)]). She was able to eat independently, had weight loss with a recent hospitalization , and her meal intake was diminished. Interventions included the following: -On [DATE] consistent carbohydrate mechanical soft diet with thin liquids; however the resident's mechanical soft diet was not ordered until [DATE] (see CPO orders below); -On [DATE] monitor meal intakes and check weight as ordered; -On [DATE] labs as available and assist as needed with tray set up; -On [DATE] encourage the resident to come to the dining room; -On ,d+[DATE] supplements as ordered and monitor for acceptance; -On [DATE] snacks twice daily; and, -On [DATE] GI consult as ordered. The activity of daily living (ADL) care plan, initiated [DATE] and revised on [DATE] and [DATE] documented Resident #1 had an ADL deficit related to limited mobility and limited range of motion. There was no intervention documented relating to eating assistance and/or encouragement. -The resident's nutritional care plan was not updated with any further interventions for weight loss other than nutritional supplements, snacks and encouragement to attend the dining room for meals such interventions were not reevaluated for their effectiveness until [DATE] over two months after the facility identified Resident #1 had significant weight loss. By this time, the resident suffered a decline. The diet ordered was a consistent carbohydrate regular diet with thin liquids ordered on [DATE] and discontinued [DATE]. The [DATE] admission nutritional assessment documented Resident #1 was on consistent carbohydrate regular texture with thin liquids diet. She liked most all food and had no dislikes. Resident #1's admission weight was 143 lbs, her height was 65 inches and her BMI (body mass index) was 23.8. Resident #1's meal intake was documented as ,d+[DATE]% for all three meals. Resident #1's nutritional intake was sufficient to meet her needs and the plan was to follow for stable weight. -It did not document Resident #1's usual body weight, ideal body weight or if the resident had a weight loss in the past 30 or 180 days. The [DATE] nutrition/dietary note documented Resident #1's weight was 139.5 down 3.5 lbs in the past week. The resident was observed during lunch she was asleep in bed with her lunch tray next to her. Resident #1's meal intake was ,d+[DATE]% for breakfast and dinner and ,d+[DATE]% for lunch. Resident #1 had inadequate meal intake related to poor appetite and depression. Plan to add Med Pass 120 ml (milliliters) three times daily (which provided 720 calories and 30 grams of protein). The plan was to follow for improved intake. The Med Pass supplement was ordered three times daily on [DATE] and discontinued on [DATE]. The supplement was changed to Sugar Free Med Pass supplement was ordered three times daily ordered on [DATE] and discontinued on [DATE]. The diet order was consistent carbohydrate, no added salt, regular texture and thin consistency ordered on [DATE] and discontinued on [DATE]. The only clarification to the diet order was no added salt and was added to the order, the texture remained regular. The [DATE] nutrition/dietary note documented the last weight was completed on [DATE] and the resident was resistive to weight monitoring. Resident #1's meal intake was ,d+[DATE]% at breakfast and lunch and ,d+[DATE]% at dinner. The plan was to encourage snacks. Plan to follow for improved intake with antidepressant. Offer snacks twice daily was ordered on [DATE] and discontinued on [DATE]. The [DATE] initial psychosocial assessment and history documented Resident #1 was her own responsible party; however, she had a close/strong relationship with her son and daughter-in-law who were very involved with her care. She had mild depression with a PHQ-9 (patient health questionnaire used to diagnose depression) score of five out 27. Resident #1 was prescribed [MEDICATION(S)] 10 mg daily for depression and [MEDICATION(S)] 50 mg for [CONDITION(S)]. The speech evaluation dated [DATE] to [DATE] documented Resident #1 was assessed for dysphagia therapy, speech/language/cognitive therapy. Under initial bedside assessment Resident #1 reported difficulty with mastication of regular mechanical solids secondary to dentition status. Under summary of skill Resident #1 presented with mild dysphagia secondary to problems related to dentition as the resident reported I have to push the food up the roof of my mouth and squeeze the flavor and juices before I can eat it because my teeth hurt right now. Resident #1 expressed a plan to receive dental visit to address pain experienced during mastication of regular texture food. Under discharge summary it was documented Regular textures, thin liquids, distant supervision of oral intake, recommend general swallow precautions and not applicable (N/A) for restorative nursing program. -Despite the resident having difficulty with mastication of regular mechanical solids secondary to dentition status her diet was not modified and a speech evaluation was not implemented again until [DATE]. Discharge recommendations mechanical soft textures, mechanical soft/chopped texture. The mechanical soft diet was not ordered until [DATE] (see below). The [DATE] nutrition/dietary note documented IDT (interdisciplinary team) weight meeting, Resident #1's weight was 134.4 lbs. She had a decrease of 4.8 lbs in 14 days which was a decrease of 9.3% in 30 days. Resident #1's meal intake was ,d+[DATE]% with refused meals [DATE]. She had complaints of diarrhea and constipation. SF (sugar free) Med Pass 120 ml three times a day for 600 calories, but noted refusal of supplements. Medications added for depression. The plan was to change SF Med Pass from to Boost Breeze twice daily, snacks were offered twice daily and speech evaluation. Notify the physician for continued weight loss and continue to monitor weekly weights. Boost Breeze twice daily was ordered on [DATE] and discontinued on [DATE]. -Although the supplement was changed for dislike, the supplement added was a decrease in calorie count from 720 calories to a little over 400 calories (see RD interview below) when the resident had lost 8.8 lbs since her admission on [DATE]. The [DATE] physician encounter note documented protein calorie malnutrition, weight loss from [DATE] to [DATE] down from 148 lbs to 134 lbs, continue supplements and check weight at the end of the month. The [DATE] nutrition/dietary note documented IDT weight meeting. Resident #1's weight was 124.4 lbs which was a decrease of 9.8 lbs, 5% in 30 days. The registered dietician (RD) met with Resident #1 to review food preferences/tolerances. Resident #1 likes chocolate Ensure, chocolate ice cream and Boost Breeze. Resident #1's lunch tray was untouched at bedside. Meal intakes reported were ,d+[DATE]%. Resident #1 was assisted with set up and encouraged to eat; Resident #1 remained tearful, reported an upset stomach related to medication and having no taste. Resident #1 reported the food had no appeal and she just could not eat. Resident #1 was educated that she needed to have food in stomach before accepting morning medication as the medications may cause GI upset/discomfort. The plan was to add a choice of ice cream at lunch and dinner, add chocolate Ensure, and clarify order for snacks to come from food the family has provided. The physician was notified and will continue weekly weight monitoring. In addition, according to the note Resident #1's GI distress was reviewed, staff reported Resident #1 was refusing Boost Breeze due to complaints of diarrhea. Staff will encourage Resident #1 to get out of her room to the dining room to help improve meal intake. Ensure twice daily was ordered on [DATE] and discontinued on [DATE]. Offer snacks from family twice daily was ordered on [DATE] and discontinued [DATE] (this order was previously implemented [DATE]). -There was no further action taken to address the resident's GI distress until [DATE] (see physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident's dietary preferences were reviewed on [DATE] but the resident had 8.8 lbs in 30 days from [DATE] to [DATE] and had lost an additional 9.8 lbs from [DATE] to [DATE], which was 18.6 lbs. In addition, Ensure supplement was added in place of the Boost Breeze but only added twice daily with 18.6 lbs weight loss. The [DATE] physician encounter note documented Resident #1 was crying a lot and refusing to get out of bed. Resident #1 was eating well and responsive to staff, Resident #1 was cooperative with care, taking medications, and her weight was 134 lbs. All previous concerns had been addressed by the providers, nursing will continue to monitor and report change in condition accordingly. -However, Resident #1's weight was down to 124.4 lbs on [DATE] and not 134 lbs as indicated in the note. The [DATE] physician encounter note documented Resident #1 was tearful at the time of the evaluation. Resident #1 was feeling down and depressed, she had a marginal appetite because of her current illness and the fact she was unable to be with her family. It further documented Resident #1 was losing weight progressively likely related to poor oral intake plus underlying dementia, the plan was to address Resident #1's depression and to continue supplements. -There was no additional intervention added at this time, the resident had been trialed on antidepressants, on supplements and snacks and she had not been consuming enough to account for her poor meal intake and previous weight loss. The [DATE] nutrition/dietary note documented Resident #1's weight was down to 118.4 lbs which was a decrease of 6 lbs in past two weeks. Resident #1 had marginal meal intakes of ,d+[DATE]%. She had been moved to the dining room for meals. Weight loss of 20% since admission due to depression, dementia and inability to take sufficient intake. The plan was to follow for acceptance of supplement and increased meal intake in the dining room. The [DATE] nutrition/dietary note documented IDT weight meeting reviewed Resident #1 for improved oral intake. Resident #1's intakes were documented as refused to 50% of meals. Resident #1 was moved to the dining room for meals. Resident #1 had a tooth pulled recently and staff report improved meal intake; contrary to the documented refusal to 50% of meals. The plan was to continue interventions and monitor weekly weights. -The nutrition/dietary note did not document any further intervention as the resident had poor intake. There was no follow-up with Resident #1's complaints of GI distress, inability to take sufficient oral intake, no documentation of restorative dining program and education provided to the resident or family of risk of continued decline, risk of pressure ulcer development and infection related to poor intake nor review of Resident #1's advance directives with her significant weight loss and poor intake. The resident had lost 24.6 lbs since her admission on [DATE], which was a little over two months. The [DATE] physician encounter note documented Resident #1 was still feeling depressed and had a marginal appetite, plan continue supplements and check weight at the end of the month. The [DATE] physician encounter note documented Resident #1 had changes to her antidepressant medications to help improve her depression, continue supplements and monitor weights. The [DATE] physician encounter note documented Resident #1 continued to have ongoing pain to her right upper dental area where she had an extraction. Resident #1's intake remains marginal because she was having difficulty chewing. Resident #1 was well-developed and nourished in no apparent distress, no visible swelling, discharge or redness or warmth to the upper and lower gums. The plan was to continue supplements and monitor weights. -There were no further interventions and no change to Resident #1's diet texture until [DATE] (see physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the [DATE] care conference summary revealed Resident #1 and the social worker were present. Resident #1's care was reviewed including her weight loss. It was documented Resident #1 had 21.9% weight loss since admission, she continued to refuse several meals and was accepting ,d+[DATE]%, she remained a full assist with intake in the dining room, her BMI was 19.2, she was nonverbal, but could make needs known. The plan was to continue to encourage intake. There were no concerns to follow-up with. -There was no documentation of any notification of Resident #1's poor intake to the family and about weight loss. Cross-reference F580 for notification. The [DATE] nutrition re-assessment documented Resident #1's meal intake was ,d+[DATE]%. Resident #1's weight was down to 118.4 lbs. Resident #1 remained on a consistent carbohydrate regular texture with thin liquids diet. Ensure supplement was ordered twice daily and snacks were offered twice daily. Under lab results it was documented on [DATE] Resident #1's [MEDICATION(S)] (protein in your blood plasma, a low [MEDICATION(S)] level might be the result of kidney disease liver disease, inflammation and infection) level was 3.5 (normal 3.5 to 5.0); however the [DATE] lab result was documented Resident #1's [MEDICATION(S)] level at 3.2 (low). Resident #1's meal intakes were marginal and supplements were needed to meet calorie needs for weight gain. The plan was to follow for increased meal intake and acceptance of supplements. Boost Breeze twice daily ordered was on [DATE] and discontinued on [DATE]. However, Ensure was discontinued and Boost Breeze was ordered again even though the resident had previously refused it due to causing diarrhea (see nutrition/dietary notes above). The [DATE] Psychopharm Management documented Resident #1 was currently taking [MEDICATION(S)] daily and [MEDICATION(S)] 150 mg by mouth daily for depression. Resident #1 had delusions, mood swings, tearfulness, refusal of care and confusion. No changes to medications were recommended at that time. Omeprazole 20 mg one capsule once daily was ordered for suspected PUD ([CONDITION(S)] ulcer disease) on [DATE] and discontinued on [DATE]. The lab collected [DATE] documented Resident #1's [MEDICATION(S)] level was 2.8 low. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Consistent carbohydrate mechanical soft diet, no added salt thin consistency was ordered [DATE] and discontinued on [DATE]. A [MEDICATION(S)] Base Patch 72 hour 1.5 mg, apply pact transdermal one time a day was ordered every three days for nausea and vomiting ordered on [DATE] and discontinued on [DATE]. The [DATE] nutrition/dietary note documented Resident #1's weight was 117.6 lbs her diet was downgraded to mechanical soft and antidepressants were started. Review of Resident #1's psychosocial notes revealed staff had been attempting to assist the resident to transfer to another community closer to family. There was no mention of Resident #1's change in condition (weight loss) until follow-up notes on [DATE] and [DATE] in which there was a discussion regarding hospice care. Resident #1 expressed she wanted to pursue further medical interventions rather than seeking comfort care through hospice. The [DATE] nutrition/dietary note documented Resident #1 continued to have poor intake, a GI consult was ordered and a hospice evaluation was discussed. A Gastroenterology consult/referral for intractable nausea and weight loss and possible enteral feeding placement, notify the physician when the appointment was made ordered on [DATE] and discontinued on [DATE]. -The GI consult was not scheduled timely and staff did not provide any documentation of attempts to have the appointment made (see interviews below). [MEDICATION(S)] 4 mg by mouth every eight hours as needed for nausea was ordered [DATE] and discontinued on [DATE]. [MEDICATION(S)] 15 mg by mouth daily was ordered for weight loss and depression ordered on [DATE] and discontinued on [DATE]. -Omeprazole ordered for suspected PUD, KUB for nausea, emesis and constipation, change to mechanical soft diet, GI consult/referral for intractable nausea, weight loss and possible enteral feeding placement and [MEDICATION(S)] for nausea, [MEDICATION(S)] for weight loss, and [MEDICATION(S)] patch for nausea were not implemented until November of 2021. This was over two months later when the resident had lost 24.6 lbs by [DATE]. The lab collected [DATE] documented Resident #1's [MEDICATION(S)] level was 2.5 low. The lab collected [DATE] documented Resident #1's [MEDICATION(S)] level was 1.8 low (see medical director interview below). -The facility did not reassess Resident #1's needs as the only interventions that were implemented included supplements and snacks. The lack of interventions for poor dentition (changing the resident's diet) and addressing Resident #1's GI discomfort (delay in adding Omeprazole) created the likeliness for continued refusals and/or poor intake of supplements and snacks. The facility did not monitor the supplements and snacks for effectiveness as the resident continued to lose a significant amount of weight. The resident subsequently developed an open area on [DATE] to her coccyx, which progressed to a Stage 4 pressure ulcer. The facility ordered additional supplements, Mighty Shake and Juven on [DATE], which was three weeks after she developed the wound and Ensure Plus on [DATE]. The resident was transferred to the hospital on [DATE] where she was diagnosed with septic shock due to sacral [CONDITION(S)] and died [DATE] (cross-reference F686). IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 10:15 a.m. She said she worked at the facility for [AGE] years. She said she took care of Resident #1 when she was at the facility. She said the resident slept a lot, she refused to get out of bed and go to the dining room to eat meals, participate in any activities. She said as soon as staff got her out of bed she wanted to lay back down. CNA #2 was interviewed on [DATE] at 10:35 a.m. She said she worked at the facility for several years. She said she took care of Resident #1 when she was at the facility. She said the resident refused to get out of bed or eat her meals. She said she was very depressed and would just stay in bed, but would always call when she had incontinent episodes. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:07 p.m. She said Resident #1 was resistive with getting out of bed and she refused meals. She said she had multiple supplements ordered; however, she often refused them. She said as soon as staff assisted Resident #1 out of bed, Resident #1 would ask to lie back down. She said Resident #1 wanted to get a G-tube (feeding tube), but she was not sure what happened with the outcome and she was not sure if the resident wanted hospice care. She said she did not observe any sudden changes with her or any new behaviors, since her admission Resident #1 slept a lot and would want to stay in bed. She said the family brought in a refrigerator with snacks they thought she would like, but the resident did not want them. Nurse practitioner (NP) #1 was interviewed on [DATE] at 2:04 p.m. He said he has been rounding at the facility since last [DATE]. He said Resident #1 was not interested in taking her medications, from nurse reports it was sporadic. He said Resident #1's care was initially psychiatric concerns (depression) and then her concerns turned to physiological concerns. He said he spoke with the family in [DATE] regarding her care. She was admitted on [MEDICATION(S)], they adjusted the medication and it was not effective, [MEDICATION(S)] was used to help with pain. He said mental health was recommended and she was being followed; during this time additional antidepressant medication was recommended. He said root cause of her refusals was often being discussed, Resident #1 consistently did not want end of life care, but she had a lack of motivation. Staff looked at the medical cause, the root cause considered to be intractable (hard to control), a KUB for acute complaints of nausea which was negative, tried antiemetics (nausea medication) and dietary assessed Resident #1 twice monthly. Ultimately, that led to discussion with family enteral feeding. -Although interventions were trialed, the immediate interventions after the resident's significant weight loss were not re-evaluated, family notification was not completed and GI consultation was not recommended until the middle of [DATE] and the resident declined by [DATE] when her weight was down to 118.4 lbs. The nursing home administrator (NHA) and transportation assistant (TA) were interviewed on [DATE] at 2:31 p.m. The transportation assistant said she worked for the facility for five years. She said when she received a referral or needed to make a resident an appointment she would fax over the referral to the appropriate hospital/agency, and then next she would call to make sure they received the information. She said it would take a while for the outside hospital to approve the order, so she would make a note on a sheet of scratch paper/note book to remind herself to call the facility back. She said the nurses or physician would notify her through the facility's electronic system to make an appointment. She said she would notify the nurse or the doctor if she was having trouble getting an appointment scheduled. She said she contacted (name of hospital) multiple times to get the GI referral completed for Resident #1, and it took a while to get an appointment set up (she could not provide any documentation that she called one week later). She said NP #1 asked her in passing if the appointment was made for Resident #1, so she called them on that day (sometime in [DATE]), an appointment was made for [DATE], there was no follow-up to have the appointment made sooner (the resident was discharged to the hospital [DATE]). The NHA, interim director of nursing (IDON), clinical nurse consultant (CNC) #2 were interviewed on [DATE] at 10:20 a.m. They said they did not know if education was provided to Resident #1 or her family regarding Resident #1's significant weight loss, refusal of meals and supplements. They could not say if implementation of a proton pump inhibitor (Omeprazole) would have helped the resident with GI discomfort or if a GI consult sooner would have helped the resident. They said during their action plan review for wound care the registered dietitian completed a review of residents with nutritional needs. They did not have a specific action plan for weight loss. Registered dietitian (RD) #1 was interviewed on [DATE] at 10:37 a.m. He said he had been consulting/training at the facility since [DATE] and took over in [DATE]. He said he reviewed Resident #1's care and in his expertise, he would have completed the same care for the resident. He said upon review of a resident he would document the resident's likes and dislikes and bring samples, monitor weights on a weekly basis, if she liked peanut butter and jelly sandwiches he would add that. In terms of encouraging a resident to eat more actual food, the first thing he would add to the meal ticket would be items that the resident liked most, and add a snack in between meals. He said he would ensure a message was sent to the physician because the weight loss was drastic, he would have recommended aggressive treatment, such as GI consult and enteral feeding and education with the resident/family regarding poor intake if the resident wanted aggressive treatment. He said Med Pass provided two calories per milliliter; if it was ordered three times per day it would roughly provide 740 to 760 calories per day. He said Boost Breeze provided a little over 200 calories per carton so if supplements were changed from Med Pass three times a day to Boost Breeze twice daily it would be a decrease in calories. <br[TRUNCATED]

Based on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for one (#1) of five residents reviewed for wounds, out of 11 sample residents. The facility failed to prevent, assess, monitor and timely treat a facility acquired sacral pressure injury for Resident #1, who had been assessed as being at high risk for pressure ulcers. Resident #1 admitted to the facility on [DATE]. She had known psychiatric history (depression) and her condition changed from psychological to physiological, contributing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely implement and/or follow-up on interventions such as treatment orders when the pressure ulcer developed on [DATE]. An air mattress was not implemented until [DATE] which was 16 days after the wound developed, implement antibiotic [MEDICATION(S)] (used to treat skin infections) on [DATE] for increased [CONDITION(S)] lab markers and magnetic resonance imaging (MRI, ordered [DATE]) to rule out possible infection when the resident developed a sacral wound (see record review below). Additionally, the facility failed to notify the physician when the pressure ulcer first developed [DATE] and of changes to the pressure injury on [DATE] including signs of infection (the wound was necrotic and had odor). The pressure injury worsened and the resident was subsequently admitted to hospital on [DATE] with [CONDITION(S)] shock from [CONDITION(S)] to her wound and died on [DATE]. Cross-reference F692 failure to reevaluate interventions for Resident #1, address underlying GI (gastrointestinal discomfort), and difficulty chewing related to poor dentition timely to prevent significant weight loss. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on [DATE] to [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Professional References The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved on [DATE] from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3, or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissue exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged. -In many situations, the level of tissue injury can be accurately assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .g., pain), temperature (e.g., warmer from inflammation, colder as tissues die), firmness (firmer or boggy with tissue destruction and [CONDITION(S)]), color (signs of inflammation consistent with skin tone) and drainage expressed from surrounding tissues as they are palpated. This more thorough assessment of surrounding tissue may alert the clinician to more extensive damage than is readily visible. These additional findings should be described and documented. II. Facility policy and procedure The Pressure Injury Management policy, revised on [DATE] was provided by the chief clinical officer (COO) on [DATE] at 11:30 a.m. It read, in pertinent part, If a resident admits to the facility with a pressure injury or is assessed to have a pressure injury the charge nurse will be responsible to assess the pressure injury to include site/location of the pressure, staging of the pressure injury, size in cm (centimeter) (length x width), appearance of the wound bed, depth, undermining, draining/exudates to include type/amount, color of the wound bed, and surrounding skin color and any pain related to the pressure injury. The charge nurse or designee will be responsible to initiate the evaluation in the resident's medical record. The charge nurse or designee will be responsible to notify the physician and the responsible party regarding the development of the pressure injury. A treatment order will be initiated. The charge nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the resident's identified risk factors and a description of how the pressure injury most probably occurred if known. Risk factors may include but are not limited to: impaired mobility, comorbid conditions, such as end stage renal disease diabetes mellitus, or [CONDITION(S)] disease, drugs such as steroids, impaired diffuse or localized blood flow, resident refusal of some aspects of care or treatment, cognitive impairment, exposure to urinary and fecal incontinence, undernutrition/malnutrition and hydration deficits. III. Resident #1 Resident status Resident #1, age 64, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She expressed feeling down, depressed or hopelessness two to six days out of the week. She had problems falling/staying asleep or sleeping too much two to six days out of the week. She had a poor appetite or overeating 12 to 14 days out of the week. She did not exhibit any behaviors or reject care. She required limited one-person assistance with eating and extensive one-person assistance with bed mobility and hygiene. She was frequently incontinent of bowel and bladder. She did not have wounds; however she was at risk for wound development. She was not on a turning/repositioning program and did not have application of ointments/medications. She did have a pressure reducing device for bed in place and assessment tool Braden (pressure ulcer risk) was completed. The [DATE] minimum data set (MDS) assessment revealed Resident #1 was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. She expressed feeling down, depressed or hopelessness two to six days out of the week. She had feelings of tiredness or having little energy two to six days out of the week. She did not exhibit any behaviors or reject care. She now required extensive one-person assistance with eating and extensive two-person assistance with bed mobility. She was frequently incontinent of bowel and bladder. She did not have wounds; however she was at risk for wound development and was not on a turning/repositioning program as she had moisture associated skin damage with application of ointments/medications. She did have a pressure reducing device for bed and wheelchair in place and assessment tool Braden (pressure injury risk) was completed. VI. Failure to implement preventative treatment and worsening of a pressure ulcer to a stage 4 The baseline skin care plan dated [DATE] was not completed, there was no documentation of any interventions to prevent skin breakdown. The Braden (a tool used for predicting pressure ulcer development) assessment was completed for Resident #1 on [DATE] documented Resident #1 was high risk for pressure ulcer development with a score of 12. A score of nine or below=very high risk, ,d+[DATE] =high risk, ,d+[DATE]=moderate risk and ,d+[DATE]=mild risk. The skin care plan initiated [DATE] unrevised documented in pertinent part, Resident #1 was at risk for pressure injury related to activity intolerance and [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the left non-dominant side. Interventions included administer treatments as ordered and monitor for effectiveness; monitor/document/report PRN (as needed) any changes in skin status, weekly skin assessments, educate the resident/family/caregivers as to causes of skin breakdown; including transfers, positioning good nutrition and frequent repositioning. The [DATE] Braden assessment documented Resident #1 remained at high risk for pressure ulcer development with a score of 12. The [DATE] nutrition/dietary note documented Resident #1's weight was 117 lbs, she went to the dining room for meals and received assistance with eating and socialization. Resident #1's meal intakes remain marginal at ,d+[DATE]% she remained on supplements and antidepressant therapy, the plan was to monitor. The [DATE] nutrition re-assessment documented Resident #1's meal intake was ,d+[DATE]%. Resident #1's weight was down to 118.4 lbs. Resident #1 remained on a consistent carbohydrate regular texture with thin liquids diet. Ensure supplement was ordered twice daily and snacks were offered twice daily. Under lab results it was documented on [DATE] Resident #1's [MEDICATION(S)] (protein in your blood plasma, a low [MEDICATION(S)] level might be the result of kidney disease liver disease, inflammation and infection) level was 3.5 (normal 3.5 to 5.0); however the [DATE] lab result was documented Resident #1's [MEDICATION(S)] level at 3.2 (low). Resident #1's meal intakes were marginal and supplements were needed to meet calorie needs for weight gain. The plan was to follow for increased meal intake and acceptance of supplements. -There was no further IDT review of Resident #1's poor intake with significant weight loss, refusal to get out of bed and increased risk for pressure ulcer development until after the resident developed an unstageable coccyx wound on [DATE], then staged as a stage 4 pressure ulcer on [DATE] which became infected and the resident subsequently died after being sent to the hospital on [DATE] (see below). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] weekly skin assessment documented Resident #1's skin had no bruising, abrasions or wounds, her coccyx was clear. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] weekly skin assessment documented Resident #1's skin had no bruising, abrasions or wounds, her coccyx had redness and cream was applied. The [DATE] Braden assessment documented Resident #1 remained at high risk for pressure ulcer development with a score of 12. The [DATE] weekly skin assessment documented Resident #1's skin turgor was normal, her coccyx had redness. The [DATE] weekly skin assessment documented Resident #1 had a wound to her coccyx dry dressing in place, no orders were in the resident's electronic record. -There were no orders obtained for wound care until [DATE], which was seven days later (see below). -Furthermore, there was notification to the physician or family on [DATE] of the newly identified pressure ulcer documented until [DATE] on a nursing pressure injury initial and weekly monitoring assessment, which was 11 days later. Cross-reference F580 notification. The [DATE] physician encounter note documented Resident #1's skin was warm, dry, and intact, her skin had good turgor without [CONDITION(S)], redness, or cyanosis (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The [DATE] physician encounter note documented Resident #1's skin was warm, dry and intact. The [DATE] physician encounter note documented Resident #1's care was discussed with staff. Resident #1 was in stable condition at baseline with no new concerns. -However, Resident #1 had a wound to her coccyx per interview the physician was not notified of the wound until [DATE] (see below). The [DATE] weekly skin assessment documented Resident #1 had an open area on her coccyx. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -There was no further documentation of wound monitoring of causation (how the wound developed), category/stage, size, tissue types, and evidence of undermining (the destruction of tissue or ulceration extending under the skin edges/margins so that the pressure ulcer is larger at its base that at the skin surface) or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), exudate (fluid that has been forced out of the tissue or capillaries because of inflammation or injury), and odor when the wound first developed on [DATE] until [DATE] (see weekly wound assessments below). The pressure ulcer care plan, initiated [DATE] (11 days after the resident developed a wound) documented in pertinent part, Resident #1 had a risk for pressure injury related to activity and [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the left non-dominant side. Interventions included administer treatments as ordered and monitor for effectiveness; monitor/document/report PRN (as needed) any changes in skin status, weekly skin assessments, educate the resident/family/caregivers as to causes of skin breakdown; including transfers, positioning good nutrition and frequent repositioning. -Intervention not checked/included, was if the resident refused treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. The [DATE] wound physician note documented Resident #1 had an unstageable pressure ulcer to her coccyx. It measured 10 cm (centimeters) x (by) 7 cm x 0.1 cm depth, with a moderate amount of drainage. The wound bed had 30% slough (consistent with dead cells) and 70% granular (area of healing) tissue. Wound debridement (removal of dead tissue) was provided by the wound physician. The wound measurement after debridement was 10 cm x 7 cm x 0.4 cm depth. The plan was to cleanse the wound with normal saline, apply Santyl, Xeroform and cover with a dry dressing daily and as needed. -Although, the wound physician completed an assessment of Resident #1's coccyx wound and continued to follow up until discharge, there was a delay in obtaining an initial assessment of the wound, obtaining initial treatment orders, notification to the physician when the wound first developed and follow-up with ordered diagnostic testing such as x-ray/MRI (see below). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] wound physician note documented Resident #1's wound to her coccyx was a stage 4 wound, it measured 7.9 cm x 6.1 cm x 0.6 cm depth. The wound bed had 60% eschar (necrotic tissue), 20% slough and 20% granulation. There was a small amount of serosanguineous (thin watery pink or red fluid that contains red blood cells) drainage with a mild odor. Wound debridement was provided and post measurements were 7.9 cm x 6.1 cm x 0.7 cm depth. The plan was to cleanse the wound with normal saline apply Santyl to wound and cover with a dry dressing, change daily and as needed. The following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Air mattress to aid in wound healing, check functioning every shift ordered on [DATE] and discontinued on [DATE]; -Juven (therapeutic nutrition powder) by mouth twice daily for wound healing and weight management ordered on [DATE] and discontinued [DATE]; and, -Mighty shake by mouth twice daily for wound healing and weight management ordered on [DATE] and discontinued on [DATE]. -The air mattress was not implemented until [DATE] which was 16 days after a wound to her coccyx was identified, in addition the resident required two person extensive assistance for bed mobility and was identified as high per the MDS assessments (see above). The [DATE] nutrition/dietary note documented Resident #1 had a stage 4 pressure ulcer and she was started on Juven and Mighty shake (this was almost three weeks after the wound was first discovered on [DATE]). The following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Open and complete daily wound monitoring related to pressure injury every shift ordered on [DATE] and discontinued on [DATE]; and, -Ensure Plus by mouth daily for weight management and wound healing ordered on [DATE] and discontinued on [DATE]. The [DATE] wound physician note documented Resident #1's wound to her coccyx was a stage 4 wound, it measured 5.1 cm x 2.5 cm x 1.4 cm depth. There was 10 % slough and 90% granulation to the wound bed. It was documented as improved; however, bone was exposed, a moderate amount of serosanguineous drainage and there was an increase in depth. Wound debridement was provided and post measurements were 5.1 cm x 2.5 cm x 1.5 cm depth. The plan was to cleanse the wound with normal saline, apply alginate with silver (gels on contact with wound exudate or blood creating a moist wound environment for optimal wound healing, silver ions protect the dressing from a range of microorganisms) rope and cover with a dry dressing change daily. The following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound care to coccyx: Cleanse with normal saline or wound cleanser, pat dry, pack with silver alginate rope (a sterile primary dressing for wounds with moderate to heavy exudate to assist with infection reduction and decreasing bioburden) and cover with a dry dressing daily and as needed if dressing becomes soiled or dislodged ordered on [DATE] and discontinued on [DATE]; and, -MRI of the sacrum/coccyx for suspected [CONDITION(S)] ordered on [DATE] and discontinued on [DATE]. -However, the MRI of the sacrum for suspected [CONDITION(S)] was not completed. The [DATE] physician encounter note documented, follow-up for sacral decubitus wound, elevated [CONDITION(S)] markers, weight loss and response to [MEDICATION(S)]. The resident was in supine position in bed. The resident was asleep, but wakes to verbal stimuli. She was oriented to baseline, she was aware of her sacral wound which she denied any pain. The wound was not personally evaluated; however wound care orders were in place and reportedly being completed. The resident did not notice much of a difference in her sleep/wake cycle. The Resident's lab results ESR/CRP (detects or monitors significant inflammation in acute conditions) were elevated ESR at 17 and CRP at 19.9 (normal range is ,d+[DATE] for ESR and <1.0 for CRP), but the resident had normal WBC (white blood cell detects possible infection) without shift. The plan was continue supplements as referral placed for GI consultation, wound physician monitoring the wound and start [MEDICATION(S)] (used to treat skin infections) 100 mg twice daily. -However, there was no order in the resident's record for [MEDICATION(S)]. The [DATE] wound physician note documented Resident #1's wound to her coccyx was a stage 4 wound, it measured 3 cm x 4 cm x 1 cm depth, bone was exposed and there undermining at 7 o ' clock to 5 o ' clock with maximum distance of 4 cm. There was a copious amount of foul purulent drainage which had a strong odor. The wound was deteriorating and the wound bed had 100% slough. The plan was to cleanse the wound with normal saline, pack with one fourth Dakin's moistened gauze and cover with a dry dressing, change daily and as needed, also review and/or order clinical labs and sacral x-ray (MRI ordered on [DATE]). -Furthermore, a review of daily wound monitoring notes dated [DATE] at 6:31 a.m. and 1:42 p.m. revealed there was a change to Resident #1's wound and the physician was not notified. The [DATE] at 6:31 a.m. daily wound monitoring note documented dead tissue in the wound requires surgical debridement, the wound doctor will review. The [DATE] at 1:42 p.m. daily wound monitoring note documented the wound had moderate purulent (pus) drainage. -Review of the wound physician note on [DATE] documented Resident #1's wound was assessed by the wound physician (now a stage 4 pressure ulcer), which continued to deteriorate and subsequently Resident #1 was sent to the hospital on [DATE] with [CONDITION(S)] shock from [CONDITION(S)] to her wound and died on [DATE]. V. Facility action plan The facility action plan, initiated [DATE], was provided by the chief clinical officer on [DATE] at 12:50 p.m. It documented, in pertinent part: -The facility was notified by Resident #1's family of care concerns on [DATE]; -All nurses/CNAs in-serviced on skin/wound policy and procedures as well as on the importance of wound care and repositioning to prevent skin injuries initiated [DATE] and remained ongoing; -Registered dietitian reviewed residents with wounds had appropriate nutritional interventions on [DATE]; -QIS (quality improvement system) was conducted on [DATE]; -QIS reviewed all current pressure injuries to ensure orders, evaluations, and care plans were in place and appropriate completed on [DATE]; -The community re-instituted the 24 hour report for staff to record any new changes in condition completed [DATE]; -An observation of all resident skin with high risk Braden score and without current wound was completed to identify any areas of concern completed on [DATE]; -Pharmaceutical company contracted to provide education related to incontinent care products on [DATE]; and, -Conference call conducted with wound physicians and medical director to discuss the wound management action plan on [DATE]. Additional areas reviewed and remained ongoing were the following: -Daily staffing will be reviewed to ensure adequate staffing levels every day; -Weekly auditing of wound documentation to ensure consistency and accurate information as well as ensuring intervention were in place; -Random audits throughout the week to ensure interventions are being completed as care planned; -Any new skin areas of concern will be added to the risk management incident report. An Acute care plan will be initiated, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Notification of all community acquired or newly admitted with pressure ulcers will be made to clinical corporate staff; -QIS to attend wound rounds to provide additional training and guidance to the wound care team completed on [DATE]; -Air mattresses will have a laminated tag to list settings completed [DATE]. -Review of the facility's action plan, record review including (audits) and observations of current residents with pressure ulcers revealed interventions above were in place. Interviews with staff revealed they had been educated regarding wound care. VI. Interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 10:15 a.m. She said she worked at the facility for [AGE] years. She said she took care of Resident #1 when she was at the facility. She said the resident slept a lot, she refused to get out of bed and go to the dining room, eat meals, and participate in any activities. She said as soon as staff got her out of bed she wanted to lay back down. CNA #2 was interviewed on [DATE] at 10:35 a.m. She said she worked at the facility for several years. She said she took care of Resident #1 when she was at the facility. She said the resident refused to get out of bed or eat her meals. She said she was very depressed and would just stay in bed, but would always call when she had incontinent episodes. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:07 p.m. She said she worked at the facility for [AGE] years. She said Resident #1 was resistant to getting out of bed and she refused meals. She said she had multiple supplements ordered; however, she often refused them. She said as soon as staff assisted Resident #1 out of bed, Resident #1 would ask to lie back down. She said Resident #1 wanted to get a G-tube (feeding tube), but she was not sure what happened with the outcome and she was not sure if the resident wanted hospice care. She said she did not observe any sudden changes with her or any new behaviors, since her admission Resident #1 slept a lot and would want to stay in bed. She said the family brought in a refrigerator with snacks they thought she would like, but the resident did not want them. She said she did not become the wound/treatment nurse until [DATE] so she was not sure when Resident #1's wound first developed. Registered nurse (RN) #1 was interviewed on [DATE] at 3:55 p.m. She said she worked at the facility for over two years. She said if a resident had a newly identified wound she would notify the physician, document an assessment of the wound, obtain treatment orders, and implement interventions as appropriate. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 4:05 p.m. She said she worked per diem as an agency nurse and would pick up shifts at the facility as needed. She said if a resident had a newly identified wound she would notify the physician to obtain treatment orders, then she would notify the director of nursing or wound nurse for further implementation of interventions and educate the certified nurse aides (CNAs) to offer and document repositioning of the resident. Wound physician #1 was interviewed on [DATE] at 9:46 a.m. He said he began rounding at the facility in [DATE]. He said he cared for Resident #1's wound when she resided at the facility. He said he treated Resident #1's large unstageable coccyx wound and believed it was a classic Kennedy ulcer because the resident had such a rapid decline. He said he provided extensive wound debridement, but the wound quickly deteriorated. He said he was not sure if imaging to coccyx was completed because it was ordered during a period when he was on vacation. -Resident #1 was not on Hospice or end of life care and per advanced directives wanted to receive full life sustaining care. Wound physician #2 was interviewed on [DATE] at 10:47 a.m. He said Resident #1's refusal of care and poor nutrition made her wound development unavoidable. He said even if there were multiple interventions such as an air mattress and repositioning in place the lack of the resident not getting any intake would cause the resident's skin to break down. He said the resident's compliance factor was the underlying causal factor. He was not aware of her ordered referral for G-tube/enteral tube and could not speak to if it had been done. -The GI consult for Resident #1 was ordered on [DATE] for weight loss and possible enteral feeding placement, however the appointment was not scheduled timely with her poor intake and significant weight loss (cross-reference F692). The chief clinical officer (CCO), clinical nurse consultant (CNC) #1 and interim director of nursing (IDON) were interviewed on [DATE] at 12:20 p.m. The CCO said the facility investigated Resident #1's care concerns after they were contacted by the resident's family on [DATE] and an action plan for wound care was started on [DATE]. She said staff reviewed all residents, concerns were identified and staff ensured all residents with wounds had completed order, assessments (Braden scale) and documentation of assessments and monitoring. Additional residents were identified so adjustments were made to the residents' care plans to ensure appropriate interventions were in place. She said she did not have documentation of all staff that were trained; however she and other corporate staff completed one-on-one huddles around the clock with staff to ensure staff were educated and trained wound care policy and procedures. The NHA was interviewed on [DATE] at 12:43 p.m. She said nursing staff were responsible for implementing wound care orders, treatment and interventions. She said ultimately it was the DON's responsibility to ensure nursing completed standard of care. She said the DON who was working at the time Resident #1 developed a pressure ulcer that did not ensure staff were completing appropriate wound care per policy. She acknowledge care concerns regarding Resident #1's care and said staff did not follow-up to ensure the MRI was completed after being ordered on [DATE]. Nurse practitioner (NP) #1 was interviewed on [DATE] at 2:04 p.m. He said he has been rounding at the facility since last [DATE]. He said Resident #1 was not interested in taking her medications, from nurse reports it was sporadic. He said Resident #1's care was initially psychiatric concerns (depression) and then her concerns turned to physiological concerns. He said he spoke with the family in [DATE] regarding her care. He said the facility staff typically notified the physician of any newly identified wound or change in condition. He said root cause of her refusals was often being discussed, Resident #1 consistently did not want end of life care, but she had a lack of motivation. He said the rounding office was not notified of the resident's wound until [DATE]; however the wound physician assessed [DATE] and implemented wound care orders. The medical director was interviewed on [DATE] at 1:03 p.m. He said he reviewed Resident #1's records. He said Resident #1's problems started with her stroke. He said in [DATE] Resident #1's [MEDICATION(S)] was 2.7. He said normal [MEDICATION(S)] is 3.5 to 5.0 and if someone had a low [MEDICATION(S)] your body could not fight infection, you would only be able to get by. He said Resident #1's weight loss and wound development was unavoidable and unpreventable because sometime later her [MEDICATION(S)] was down to 1.8 in [DATE]. -Despite the wound being identified as unavoidable Resident #1 had significant weight loss from [DATE] to [DATE], she had been identified as high risk for pressure ulcer development. The facility failed to timely implement and/or follow-up on interventions such as treatment orders when the pressure ulcer developed on [DATE], gastrointestinal (GI) consult that was ordered [DATE] for nausea, weight loss and possible enteral feeding placement; an air mattress not until [DATE] and magnetic resonance imaging (MRI, ordered [DATE]) to rule out possible infection when the resident developed a sacral wound. He said Resident #1 was her own decision maker and was not declared incompetent, and the family could have had strong feelings regarding her care but had no legal standing. He agreed there could have been things the facility could have done differently regarding interventions and better documentation, but believed her stroke was the main reason she declined and struggled with her inability to participate.

Based on observation, record review and interviews, the facility failed to 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 two (#62 & #2) of 31 sample residents. Specifically, the facility failed to appropriately assess and treat both resident #62 and #2's pain. This contributed to the residents experiencing pain on multiple occasions that was above the residents' acceptable level of pain. The findings include: I. Facility Expectations - Pain Management A. According to the facility pain management program policy and procedure: - The resident should be asked every shift about the presence of pain. - Pain assessment should occur at the time of admission, quarterly, change of condition or when the resident presents with a complaint of pain. - Accept the resident's self-report of pain. Remember that cognitively impaired elderly may slightly under report pain, but their self-reports are generally no less valid than those of cognitively intact residents. - The physician will be contacted and provided the following data when pain is not managed: type/location of resident ' s pain, current pain level, acceptable level of pain, and if available the current pain management program . . . - Residents with unstable pain will have an acute care plan. - Use of a PRN medication will be documented on the back of the MAR (medication administration record). Documentation will include: date and time of resident ' s complaint of pain, type/location of resident's pain, pre-medication pain rating using scale identified in the care plan, medication administered, pain rating (or nurses observation) after medication, including time of post pain rating. - Medication for pain should be administered around the clock to maximize efficacy and minimize unwanted side effects, particularly in the elderly, who are most susceptible (to) side effects. - Resident will be instructed by the health care professional to communicate unrelieved pain in order to receive prompt evaluation and treatment. B. Staff Interviews 1. On 7/13/11 at 10:25 a.m. Staff Development Coordinator (SDC) was interviewed about pain assessments. - She indicated that staff receives training on the computer related to pain and then an in-service annually. When asked if she would expect the nurses to document if a resident had increased pain or increased use of PRN pain medication, she indicated that she would expect that and also the physician should be notified. When asked if she would expect the nurses to follow the interventions on the care plans, she stated yes. - She said the facility has a pain management committee that meets once a week. The committee includes the assistant director of nursing (ADON), the Director of Nursing (DON), and the social service team. The SDC said the committee reviews all the residents that have used PRN medication for the week prior. The ADON reviews the MARs and brings the list to the meeting. 2. On 7/13/11 at 11:12 a.m. the charge registered nurse (RN) was interviewed about education and training on pain management. - She indicated that in-servicing was ongoing; she could not remember the exact time she last received education on pain but she knew it was recently. - She indicated that the facility policy was that a pain assessment be completed every shift on every resident and there was a protocol of things that were to be done for the resident, like administering pain medication as ordered, offer repositioning, off-loading, resting and notifying the physician if the resident has increased pain or new on-set of pain. - When asked if she would notify the physician immediately if a resident had complaints of pain at a 8, 9, or 10, she stated, "yes of course, I would never let a resident go for several days having pain at 8, 9, or 10." 3. According to the facility in-service participation record, the nursing staff was educated on pain management and documentation on 11/16/10. II. Failure to manage resident #62's and #2's pain as expected, care planned and as needed to maintain the residents' highest level of physical and mental well-being. A. Resident #2 Resident #2, [AGE] years old, was admitted to the facility on [DATE], with recent readmitted s of 6/23/11 (following hospitalization for possible stroke) and 7/2/11 (following hospitalization for aspiration). According to the facility face sheet, her [DIAGNOSES REDACTED]. According to the resident's minimum data set ((MDS) dated [DATE], the resident's mental status score was 5 (severely impaired). The resident was coded as a 1 (yes) on a scheduled pain regimen, a 1 (yes) in receives PRN pain medication, a 0 (no) in receives non-medication interventions for pain, a 1 (yes) in is pain present, and a 3 (occasionally) in pain frequency. According to the readmission assessment dated [DATE], the resident had a 2 centimeter open area with clear drainage on her coccyx. According to the care plan dated 7/5/11, the resident had a stage II wound to her sacrum. According to the telephone order dated 7/5/11 at 1:55 p.m., the resident had an order to cleanse the wound to buttocks with wound cleanser, pat dry, apply hydrogel and cover with foam dressing. And, change dressing daily and PRN. 1. Record Review According to the CPO, the resident had orders for the following pain medications: - [MEDICATION NAME] 10mg every 6 hours PRN. Start date 7/2/11 - Tylenol 650mg every 6 hours PRN for pain of 1-4. Start date 1/5/11 According to the quarterly pain assessment dated [DATE], the worst the resident's pain gets was at a level of 10 (out of 10) and the best it gets was 0. The resident's present level of pain, quality of pain, duration, onset, variation and the effects of the pain were not documented on the assessment. According to the resident's care plan dated 7/4/11, the resident was at risk for pain related to [MEDICAL CONDITION], arthritis, phantom pain (BKA), headaches (migraine). Her acceptable level of pain was at a level of 3. Interventions included: - pain assessment every shift, - pharmaceutical and non-pharmaceutical interventions and - notify the physician if pain is greater than 3, if interventions are not successful. According to the MAR for June 2011, the resident received PRN pain medication ([MEDICATION NAME] 10 mg) on the following dates from 6/25/11 to 6/29/11: 6/25, 6/26 x 3, 6/27, 6/28, 6/29/11. According to the MAR for July 2011, the resident received PRN pain medication twice as often in July 2011. As of 7/12/11, the resident had received PRN pain medication 14 times between 7/3/11 and 7/12/11 as follows: - 7/3 at 10:30 a.m. received [MEDICATION NAME] 10mg for increased pain and crying. Results documented as sleeping, without signs and symptoms of acute pain. There was no time documented for the results. - 7/3 at 11:00 p.m. received [MEDICATION NAME] 10mg for complaint of left lower extremity pain, severe. Results documented as sleeping at midnight. - 7/4 at 6:45 p.m. received [MEDICATION NAME] 10mg for complaint of pain, crying. Results documented as sleeping at 10:30 p.m. - 7/6 at 6:00 p.m. received [MEDICATION NAME] 10mg for complaint of pain at a 7 out of 10. Repositioned and applied cold cloth with no results. Pain medication administered. Results documented as sleeping at 6:30 p.m. - 7/7 at 3:00 p.m. received [MEDICATION NAME] 10mg for leg pain of 8 out of 10. No results documented. - 7/8 at 7:45 p.m. received [MEDICATION NAME] 10mg for right leg pain at a 9 out of 10. Results documented as no complaint of pain at 8:45 p.m. - 7/10 at 10:30 a.m. received [MEDICATION NAME] 10mg for left leg pain at 8 out of 10. Results documented at a 1 out of 10 at 11:00 a.m. - 7/10 at 8:35 p.m. received [MEDICATION NAME] 10mg for right leg pain. Results documented as asleep at 9:00 p.m. - 7/11 at 7:30 a.m. received [MEDICATION NAME] 10mg for left lower extremity pain of 8 out of 10. The results were documented at a 1 out of 10 at 8:00 a.m. - 7/11 at 12:00 p.m. received Tylenol 650mg for complaint of left lower extremity pain of 5 out of 10. Results documented at 1 out of 10 at 12:45 p.m. - 7/11 at 11:45 p.m. received [MEDICATION NAME] 10mg for complaint of left lower extremity pain of 8 out of 10. Results documented at 2 out of 10 at 12:10 a.m. - 7/12 at 9:00 a.m. received [MEDICATION NAME] 10mg for complaint of left lower extremity pain of 8 out of 10. Results documented at 2 out of 10 at 9:45 a.m. - 7/12 no time noted, received [MEDICATION NAME] 10mg for pre-medication prior to dressing change - complaint of left lower extremity pain/buttocks. Results documented as sleeping at 2:45 p.m. - 7/12 at 11:00 p.m. received [MEDICATION NAME] 10mg for complaint of left lower extremity pain of 8 out of 10. Results documented as asleep at 12:00 a.m. 2. Resident Interviews On 7/6/11 at approximately 2:30 p.m. the resident was interviewed. She was sitting by the door to the outside patio. She indicated that her bottom really hurt and she stated that it hurts all the time. She was attempting to move around in the chair but was unable to reposition herself. On 7/8/11 at 10:35 a.m. the resident was interviewed again. She was sitting by the door to the outside patio area. When asked about her pain, she stated that her bottom really hurt bad and it hurts all the time and so her knee and her leg hurt too. On 7/11/11 at 10:00 a.m. the resident was interviewed and indicated that she had pain in her leg and bottom. She stated that her bottom really hurt bad and it hurts all the time. On 7/12/11 at 10:30 a.m. the resident was sitting at the nursing station. She indicated that she was having pain in her bottom. She indicated that her bottom hurt really bad and it hurts all the time. 3. Observations On 7/12/11 at 2:28 p.m. the LPN indicated that she was going to provide pain medications to the resident for treatment (see above MAR indicated [REDACTED] - At 2:45 p.m. the LPN was observed in the presence of the Staff Development Coordinator (SDC) as she completed the dressing change to the resident's coccyx. The nurse asked the resident how her pain was and the resident indicated that she has pain all the time, her butt and her leg hurt. The nurse replied that she did not know the resident's leg hurt. The SDC asked the resident if she felt that her pain medication was helping and the resident replied yes. As the nurse began to move the resident to prepare for the dressing change, the resident began to scream "my leg, my leg." The nurse continued to move the resident. Once the resident was on her side, the nurse began the dressing change. The resident began to cry out that her knee was hurting a lot. She requested a pain pill and the nurse replied that she had just received one. The resident continued to cry out in pain, even sobbing at times during the dressing change. The LPN did not stop the dressing change, offer to reposition the resident or attempt any other intervention to relieve the resident's pain. 4. Staff Interview On 7/13/11 at 10:25 a.m. the SDC was interviewed and provided the minutes from the pain committee meetings for the week of 6/25/11 - 7/1/11 and 7/5/11 and 7/10/11. - The minutes from 7/5/11 indicated that resident #2 was readmitted and would continue the [MEDICATION NAME], the [MEDICATION NAME] discontinued, [MEDICATION NAME] IR every 6 hours PRN and review next week. - The minutes from 7/10/11 indicated that resident #2 had frequent PRN use and the physician did not want to schedule (medication) at this time. The SDC was unable to locate any documentation in the medical record that showed the physician was notified of the resident's frequent complaints of pain, frequent use of PRN medication after 7/10/11 (See above; pain medication was administered 3 times on 7/11 and 7/12/11), or at levels of pain well above the resident's acceptable level when medicated. No further documentation was received as of 7/21/11. On 7/13/11 at 11:20 a.m. the LPN involved in the dressing change on 7/12/11 indicated that she had received education on pain management, but could not remember the last time that had occurred. B. Resident #62, [AGE] years old, was admitted to the facility on [DATE]. According to facility face sheet, the resident's [DIAGNOSES REDACTED]. According to the minimum data set ((MDS) dated [DATE] the resident's BIM score was 15 (cognitively intact). 1. Record Review The resident's care plan for pain was dated 9/16/10. The resident's goal was to have pain controlled at the resident's acceptable level of pain. The most current acceptable level of pain was a level of 4. The interventions on the care plan were: - notify the physician for pain greater than the resident's acceptable level of 4, - pain assessment every shift, - Tylenol as scheduled and for break-through pain, and - offer/provide alternative non-pharmaceutical interventions. According to the most recent quarterly pain assessment, the resident's acceptable level of pain was a 3 (not 4 as documented in the care plan above and on the MARs). According to the computerized physicians orders (CPO), the resident had orders for the following medications: [REDACTED] - Tylenol 650mg four times a day. Start date 11/22/10 - [MEDICATION NAME] 0.5mg three times a day. Start date 3/10/11 - Tylenol 650mg every four hours PRN. Start date 11/22/10 - [MEDICATION NAME] 1mg every 8 hours PRN. Start date 11/27/10 - [MEDICATION NAME]. Start date 7/10/11 According to a progress note dated 6/30/11 and completed by the nurse practitioner (NP), the resident's chief complaint was pain in her abdomen. Labs were ordered and the NP wrote to call if pain worsens or persists. According to the July 2011 MAR, every shift pain assessment as of 7/11/11 documented that the resident had not had any pain for the month. According to the July 2011 MARs the resident's acceptable level of pain was a 4 until 7/11/11, when it was changed to a 2. Review of the nurse notes (NN) dated from 6/30/11 through 7/11/11 at 3:30 p.m., revealed no communication with the resident's physician with regard to the resident's pain after 6/30/11, and until 7/10/11. On 7/10/11, the on-call physician was contacted at 3:30 p.m. and gave new orders for [MEDICATION NAME] PRN. 2. Observations and Interviews Observations and interviews revealed the resident was in pain as of 7/6/11. (1) 7/6/11 On 7/6/11 at 9:55 a.m. observed resident in her room lying on her bed. She was rubbing her stomach and changing her position frequently during observation/interview time. On 7/6/11 at 9:29 a.m. interviewed the resident and she stated that her stomach hurts all the time. She stated that the nurse practitioner (NP) had been in and had seen her about 8-10 days ago and was going to look into what might be causing her pain. (2) 7/7/11 On 7/7/11 at 10:22 a.m. the resident was interviewed. She indicated that she was having pain in her stomach. She indicated that the nurse asked her about her pain at about 10:00 a.m. and that she had rated her pain at a 6 on the 1-10 scale. The charge nurse entered the interview area and after hearing the resident's statement, she indicated that she had asked the resident about her pain because she was completing a pain assessment. When asked what helped relieve her pain, the resident stated that nothing helped; it always hurt. The resident reported that her pain was a 5 right on the 1-10 scale at the time of the interview. On 7/7/11 at 10:25 a.m. a certified nurse aide (CNA) was observed to ask the resident how she was and the resident stated that she was having pain in her stomach that never goes away. The CNA asked the resident what she wanted for lunch, took her order and continued down the hallway. - On 7/7/11 at 10:30 a.m. the resident was observed to ask the nurse for a PRN pain medication, stating to the nurse that her stomach hurts all the time. The nurse offered the resident [MEDICATION NAME] or Tums. The nurse did not assess the resident's pain. - The nurse told the resident that she would have to wait until 11:00 a.m. or 11:30 a.m. for her scheduled pain medication. The nurse asked the resident if she was having anxiety; the resident replied yes. The nurse administered PRN anxiety medication. The nurse did not offer or administer the resident's PRN Tylenol for the resident's complaint of pain. On 7/7/11 at 10:44 a.m. the resident was interviewed again. She indicated that the nurse had told her that she would have to wait until 11:00 a.m. or 11:30 a.m. for pain medication but then asked her if she had anxiety. She said she had stated yes. The resident indicated the nurse had given her medication for the anxiety. - She indicated she believed the anxiety was caused by her pain and that the pain also affected her mentally. The resident indicated that the best her pain gets was at a 2 and the worst it gets was a 6, on the 1-10 scale. - She indicated that she didn't think she should have to be in pain all the time. She stated that the pain has been there for about 4 months and that in the beginning, she told the nurses all the time but nothing changed. - She said she doesn't tell the nurses anymore about her pain; she just asks for pain medication. She said she can only get Tylenol for the pain. - She indicated that the nurses do not ask her every day if she is having pain. On 7/7/ 11 at 11:37 a.m. the LPN was interviewed. She indicated that neither the charge nurse nor the CNA had reported to her that the resident was having pain. - When asked why she did not assess the resident's pain when the resident stated to her that she was in pain, the LPN indicated that she had offered the resident [MEDICATION NAME] or Tums. She indicated that the resident complains all the time about pain in her stomach. - When asked if the resident complains all the time about pain in her stomach, why were the every shift pain assessments all zeros, the LPN indicated that this was because the pain was all in the resident's head, a psychological thing. The LPN further stated that the resident gets relief from the Tylenol, so the pain was not recorded. On 7/7/11 at 11:55 a.m., the resident was observed standing in the doorway of her room. The director of nursing (DON) was walking past her room. - The resident stopped the DON and told him she was having pain in her stomach. He spoke to her for approximately one minute, told her he would be right back, he walked away and returned in approximately two minutes. - The DON entered the resident's room and closed the door. At approximately 12:10 p.m. the DON was observed exiting the resident's room. - The DON approached the medication Licensed Practical Nurse (LPN) and was observed educating her about assessing pain when a resident offers a complaint to her about pain. On 7/7/11 at 12:32 p.m. the DON was interviewed. - He indicated that he was aware the resident had behaviors related to increased health concerns and anxiety. He indicated that the resident also has a hernia that was not being treated according to her physician. - When asked what his expectation was when a resident complained of pain, he indicated that he would expect the nurse to complete an assessment whenever the resident complained of pain. - He indicated that if the resident complained of pain to another staff member other than a nurse, that staff member has been educated to immediately report it to the nurse. He indicated that when a resident has a new onset of pain or increase in pain, his expectations were that the nurses should notify the physician. - The DON stated that he was not aware of the physician visit on 6/30/11 and the recommendation to follow up if the resident's pain worsened or persisted. (3) 7/11/11 On 7/11/11 at 8:43 a.m. the resident was interviewed. - She stated that the physician had started her on [MEDICATION NAME] for her anxiety and it caused her to have nausea and a headache. - She stated that her pain had started early this morning at a level of 6 on a scale of 1-10. She said it had gone down to a 2 on a scale of 1-10, but her pain was 6 on the 1-10 scale now. - She stated that the DON told her that the pain in her stomach was caused by her anxiety. The resident appeared anxious, clammy, pale and was unable to sit still. On 7/11/11 at 10:58 a.m. a CNA familiar with the resident was interviewed about the resident's complaints of pain and anxiety. The CNA indicated that the resident complained of pain and anxiety about three times a week. She indicated that she informed the nurse every time the resident complained of pain and/or anxiety. On 7/11/11 at 11:52 a.m. the DON was interviewed and asked about the delay in notification of the physician related to the resident's complaint of increased, continuous pain. He indicated that he would have expected the nurse to notify the physician on the same day he completed the assessment and notified the LPN about the complaint of pain (See above; he completed the pain assessment on the resident on 7/7/11 and staff did not notify the physician until 7/10/11.) (4) 7/12/11 On 7/12/11 at 11:45 a.m. the resident was interviewed and stated that her pain was a 4 out of 10. She said she had received Tylenol about an hour ago when her pain had been at a level of 6 out of 10. She indicated that she was in pain every day so bad that she could cry. Tears ran down her face and she wiped them away.