**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 38 sampled residents, the facility did not ensure that each resident with limited mobility received appropriate services, equipment and assistance to maintain or improve mobility with the maximal practical independence unless a reduction in mobility was demonstrated unavoidable. Specifically, a resident with limited range of motion to his hand was not being provided range of motion services or devices to prevent further contracture. Resident identifier: 30. Findings include: Resident 30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting right dominant side, third nerve palsy, intellectual disabilities, restlessness and agitation, adult failure to thrive, cognitive communication deficit, and hydrocephalus. On 5/6/24 at 11:55 AM, an observation was made of resident 30 in the dining room. Resident 30 was observed to have a padded device on his right wrist. The padded device was observed to not be in residents hand but around his wrist. There was nothing observed in his other hand. On 5/7/24 at 12:46 PM, an observation was made of resident 30's right hand. Resident 30's thumb nail was observed to go beyond the end of his thumb. The remaining 4 fingers were clenched very tightly in a fist. Resident 30 had a padded device on his right arm above his wrist. The ADON (Assistant Director of Nursing) opened resident 30's right hand at the request of the State Survey Agency (SSA) surveyor. Resident 30's right hand finger nails were observed to be long past the end of his fingers. In the palm of his hand, the skin was intact. On 5/8/24 at 6:31 AM, an observation was made of resident 30 in the dining room area. Resident 30's right hand was observed and was closed in a clenched fist. Resident 30 had a padded device on his right wrist that extended to the end of his fist. On 5/8/24 at 11:41 AM, an observation was made of resident 30 in the dining room area. Resident 30 was not wearing a glove on his left hand. The right hand had a padded device that encircled his hand. Resident 30 was observed to have unintentional movements of his head and left arm. The finger nails on resident 30's left hand were observed to be trimmed to the tips of his fingers. On 5/8/24 at 12:04 PM, an observation was made of resident 30 trying to remove the padded device from his right hand. A staff member came to check on resident 30. The staff member removed the padded device from resident 30's right hand. The nails on resident 30's right hand were observed to be longer than those on the left. Resident 30 used a communication sheet to ask to have a towel put in the palm of his left hand. The staff member asked if resident 30 wanted the padded device on his left hand and resident 30 nodded his head to indicate No. The staff member left and stated she would get a towel for resident 30. Resident 30's medical records were reviewed 5/6/24 through 5/14/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 30 had a BIMS (Brief Interview for Mental Status) of 3, indicating severe cognitive impairment. The assessment also revealed resident 30 had impairment to one side to his upper extremity, relied on a wheelchair for ambulation, required substantial/maximal assistance for eating, dependent for oral hygiene, required substantial/maximal assistance for toileting, and required substantial/maximal assistance for showering or bathing. Physician orders revealed: a. On 12/27/23 OT [Occupational Therapy] eval and treatment. b. On 12/28/24 PT [Physical Therapy] eval [evaluation] and treatment. c. 3/6/24 PT eval and treatment; OT eval and treatment. d. 4/7/24 Needs to have glove to left hand applied and released q (every) 4 hours to check skin integrity. It should be noted that resident 30 did not have orders for any devices or treatments related to his right hand. A care plan focus area initiated on 12/22/23 revealed, Resident has cerebral palsy. The goal was, Will be able to function at the fullest potential possible as outlined by the treatment team. Interventions included, .Maintain good body alignment to prevent contractures. Use braces and splints as ordered; Therapy to monitor/document and treat as indicated. Encourage resident/caregivers to use and correctly apply all splints and braces . Another care plan focus area initiated on 12/22/23 revealed, ADL [activities of daily living] self care performance deficit r/t [related to] severe malnutrition; hx [history] of intellectual impairment following radiation for cerebral AVM [arteriovenous malformation]; nonverbal; failure to thrive; dysphagia; hydrocephalus; 3rd cranial nerve palsy; R [right] hemiparesis; tremor to LUE [left upper extremity]; agitation; picks at left arm and eye; has contracture management of right elbow and hand. The goal was, Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with limited assist through the review date. Interventions included, Apply hand roll to right hand for 4 hours a day, being managed by skilled therapy (initiated on 4/24/24); Therapy evaluation and treatment as per MD [medical doctor] orders; . A care plan focus area initiated on 12/29/23 revealed, Mother wants [resident's name removed] to wear gloves to left hand to prevent resident from scratching face. The goal was, Will remain free of complication related to gloves to left hand use including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Interventions included, Evaluate/record continuing risk/benefits, alternative need for ongoing use, reason for glove to left hand use; Discuss with resident, family/caregivers, the risk and benefits, when should/will be applied, routines while restrained and any concerns or issues regarding gloves to left hand use and record; Ensure that resident is positioned correctly with proper body alignment; Ensure valid consent on chart prior to initiating gloves to left hand; Monitor/document/report to MD PRN changes regarding effectiveness of gloves to left hand less restrictive device, if appropriate, any negative or adverse effects noted included: decline in mood, change in behavior, decrease in adl self performance, decline in cognitive ability or communication, contracture formation, skin breakdown, s/s [signs and symptoms] of delirium, falls/accidents/injuries, agitation, weakness; Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. A daily skilled progress note dated 12/24/23 at 1:39 PM revealed, .Assistive device Patient has contractures to both arms .Waiting for PT eval .Active SX (symptoms) : contractures or limited ROM (range of motion). Other observations and interventions include Patient has contractures to both arms. Has involuntary movements with left arm. A safety device evaluation dated 3/29/24 revealed, Identified medical condition: developmental delay; Associated health conditions: poor impulse control, impaired cognition; and unsteady gait; Measures tried before implementing the recommended device: supervised activities; Device recommended: .gloves to left hand due to history of scratching face and causing injury; Explain why or why not: does not limit resident's mobility; What does this device enable the resident to do: potentially prevents the resident from injury; Consent received from: mother. A Visual Bedside [NAME] report which was current as of 5/8/24 revealed, Special Instructions: .picks at skin and left eye. Care to be provided by Certified Nursing Assistants (CNAs) included, Other: Maintain good body alignment to prevent contractures; Use braces and splints as ordered. CNA tasks were reviewed which included nail trimming for the past 30 days. There was no documentation that resident 30's nails had been trimmed. On 2/5/24 at 8:16 PM, the eMAR (electronic Medication Administration Record) note revealed, Needs to have gloves to left hand applied and released q (every) 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 2/6/24 at 12:17 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 2/6/24 at 4:17 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 2/6/24 at 9:47 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 2/6/24 at 12:48 PM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 2/6/24 at 5:26 PM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Resident does not have glove on and nursing staff unable to find it at this time. On 4/8/24 at 8:12 PM, an eMAR Medication Administration Note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mother took the glove home to wash. Resident was given wash cloth to protect it. On 4/8/24 at 11:07 PM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mother took the glove home to wash. Resident was given wash cloth to protect hand. On 4/9/24 at 4:12 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mother took the glove home to wash. Resident was given wash cloth to protect hand. On 4/10/24 at 12:40 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mother took the glove home to wash and still had not returned it. Resident was given wash cloth to protect hand. On 4/10/24 at 4:41 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mother took the glove home to wash and still had not returned it. Resident was given wash cloth to protect hand. On 5/5/24 at 2:40 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Glove with mom per resident. On 5/5/24 at 4:50 AM, an eMAR note revealed, Needs to have gloves to left hand applied and released q 4 hours to check skin integrity. every 4 hours .Mom has it per resident A PRN/Weekly Skin Evaluation dated 5/8/24 revealed, Resident has advanced healed scratches on bilateral, lateral forearms near elbows. Tx [treatment] RN [Registered Nurse] notified. No s/s [signs and symptoms] of infection at site, scratches ar [sic] in advanced stage of healing. Order is to keep open to air and monitor for s/s of infection until resolved. Provider notified. An Occupational Therapy Progress Report and Updated Therapy Plan with certification period of 3/6/24 - 3/19/24 revealed, #6-New Goal: Pt [patient] will tolerate gentle PROM [passive range of motion] to R [right] hand as well as regular cleaning/drying coupled with the use of hand rolls to reduce tone/contracture and decrease risk of skin breakdown/infection. An Occupational Therapy Progress Report and Updated Therapy Plan with certification period of 5/1/24-5/28/24 revealed, Goal #6-Continue .Pt will tolerate gentle PROM to R hand as well as regular cleaning/drying coupled with use of hand rolls to reduce tone/contracture and decrease risk of skin breakdown/infection .baseline (3/19/24) Pt tolerates PROM, g/h [glenohumeral], hand rolls; Previous (4/16/24) Pt tolerates PROM, g/h, hand rolls; Current (5/1/24) Pt tolerates PROM, g/h, hand rolls . On 5/7/24 at 12:50 PM, an interview was conducted with the ADON who stated the padded device on resident 30's right hand was to prevent him from scratching himself. The ADON stated every 4 hours the device needed to be removed and resident 30's hand should be washed and dried. On 5/8/24 at 12:08 PM, an interview was conducted with Physical Therapy Assistant (PTA) 3. PTA 3 stated the padded device on resident 30's hand was a Mit. PTA 3 stated the mit was for resident 30's protection. PTA 3 stated resident 30 cognitively could pick and choose which hand he wanted to have the mit on. PTA 3 stated resident 30 did not have a glove for his left hand, but could use the mit. PTA 3 stated when resident 30 had the mit on his right hand he was usually doing things with his left hand. PTA 3 stated that occupational therapy had been working with resident 30 using a hand roll. On 5/8/24 at 1:28 PM, an interview was conducted with Physical Therapist (PT) 1 who stated resident 30 was getting physical therapy 5 times weekly. PT 1 stated he was not sure how often resident 30 received occupational therapy or speech therapy. PT 1 stated he was working with resident 30 on sitting, balance, and walking. PT 1 stated resident 30 was using towel rolls for his right hand and coordination training for his left hand. On 5/8/24 at 2:21 PM, an interview was conducted with Registered Nurse (RN) 3 who stated resident 30 wore mit on his right hand or his left hand. RN 3 stated the mit was taken off when resident 30 was in bed. RN 3 stated resident 30 would tend to scratch the inside of his elbows while in bed. RN 3 stated she would put a monitor note in the computer to ensure resident 30 was checked on frequently. On 5/13/24 at 9:06 AM, an interview was conducted with RN 1. RN 1 stated resident 30 wore the mit on his right hand and liked it on to prevent himself from scratching his face. RN 1 stated resident 30 was able to tell staff if he wanted the mit off. RN 1 stated it was usually taken off every 4 hours to check his skin integrity in and around resident 30's hand. RN 1 stated resident 30 used the rolled up wash cloth during the day to prevent contractures, and he did not like anything in his hand at night. On 5/13/24 at 9:29 AM, an interview was conducted with CNA 3 who stated resident 30 wore the mit a lot during the day. CNA 3 stated sometimes resident 30's mother took the mit home to wash it. CNA 3 stated the glove was to protect his hand and help the contracture. CNA 3 stated resident 30 wore the mit at night to protect from scratching himself. CNA 3 also stated that resident 30 wore the mit while taking a nap. CNA 3 stated resident 30 was able to let staff know if he did not want to wear the mit. CNA 3 stated he just got the mit last week. CNA 3 stated she did not know if the mit came from physical therapy, occupational therapy or his mother. On 5/14/24 at 7:35 AM, an interview was conducted with Nursing Assistant (NA) 1 who stated resident 30 was wearing the mit on his left hand. NA 1 stated she had not seen resident 30 use anything for his right hand. On 5/14/24 at 7:54 AM, an interview was conducted with the Director of Therapy (DOT). The DOT stated resident 30 came in with a glove and was supposed to wear it on his left hand. The DOT stated sometimes resident 30 preferred to wear it on his right hand. The DOT stated therapy staff were trialing a couple of devices for his right hand. The DOT stated devices for resident 30's right hand were received last week. The DOT stated resident 30 did not have anything for his right hand prior to last week. The DOT stated resident 30 had his hands stretched twice daily. The DOT stated resident 30 usually clenched his hand with the fingernails outside of his palm, but that depending on his shaking. On 5/14/24 at 8:04 AM, an interview was conducted with CNA 7. CNA 7 stated that resident 30 had his nails trimmed or filed every time he had a shower and that he showered every other day. CNA 7 also stated resident 30's nails were trimmed at the request of his family. CNA 7 stated resident 30 used a sponge or a wash cloth in his hand pretty frequently and was able to let staff know if he wanted to use it or not. On 5/14/24 at 3:18 PM, a second interview was conducted with the DOT. The DOT stated therapy staff had not measured resident 30's contractures. The DOT stated staff kept progress reports. The DOT stated resident 30 could do active range of motion. On 5/14/24 at 3:18 PM, an interview was conducted with OT 1. OT 1 stated resident 30 would not complete range of motion exercises if therapy staff did not remind him. OT 1 stated resident 30's range of motion was improving. OT 1 stated during the next recertification period staff would start setting goals for resident 30. OT 1 stated resident 30's next recertification period started on 5/29/24. OT 1 stated recertification was completed once per month unless something happened at which time they could do it sooner. OT 1 stated measuring contractures was case by case and once there started to be some movement the therapy staff would start measuring. OT 1 stated resident 30 had started to get some movement in his hand within the last week and a half.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 257 was admitted to the facility initially on 1/17/23, and re-admitted on [DATE] with diagnoses that included type 1 diabetes, end stage renal disease, dependence on renal dialysis, chronic diastolic and systolic heart failure, morbid obesity, muscle weakness, and bilateral below the knee amputation. Resident 257 was initially unavailable for interview, and after re-admission to the facility, refused to be interviewed. Resident 257's medical records were reviewed between 4/3/24 and 5/14/24. An admission MDS assessment dated [DATE] revealed resident 257 had a BIMS of 15 indicating that he was cognitively intact. The assessment also revealed that resident 257 required substantial/maximal assistance with transferring from bed to chair/chair to bed, and was dependent while in his wheelchair for ambulation. Physician orders included dialysis on Monday, Wednesday, and Friday, including transport and pickup. A care plan care area initiated on 1/15/24 included, At risk for falls r/t blind, weakness, DM [diabetes mellitus] with neuropathy, wound to penis. The goal was, Will not sustain serious injury through the review date. Interventions included, Anticipate and meet needs; Be sure call light is within reach and encourage to use it to call for assistance; Education to driver to ensure resident is properly secured in transportation van r/t fall on 1/15/24; Keep needed items, water, etc. in reach. A care area initiated on 4/15/24 included, At risk for re-traumatization r/t history of trauma. Resident not properly secured in a vehicle, which caused him to get hurt. The goal was, Will have no evidence of emotional, physical and psychological problems by review date. Interventions included, Anticipate and meet needs; Explain all procedures to before starting and allow to adjust to changes; Offer mental health support as needed to identify triggers and work on developing coping skills to manage. A Pain management Review assessment dated [DATE] revealed the reason for the review was, change in condition. Additional information stated that resident 257 had a complaint of pain. The intensity of the pain was rated as 6/10 by resident 257. The pain was documented as headache and neck pain. The pain was described as aching. Medications that had relieved pain in the past were listed as, apap [acetaminophen]. The assessment stated that resident 257 had no indicators of pain. The goal was, able to move with no pain. A nursing progress note dated 1/15/24 at 12:33 PM revealed, Resident had an incident in the van returning from dialysis. He stated he was not properly strapped in and the driver hit the brakes throwing the pt backwards in his w/c. He said he hit is head and hurt his back and neck. No visible injuries noted. pt a&o x 4. Neuro checks started. DON and NP notified. A nursing progress note dated 1/15/24 at 6:54 PM revealed, Resident had an incident in the van returning from dialysis. He stated he was not properly strapped in and the driver hit the brakes throwing the pt backwards in his w/c. He said he hit his head and hurt his back and neck. No visible injuries noted. pt a&o x 4. neuro checks started. Does not want any family member notified. Provider ordered to send to ED for further eval due to complaint of pain in neck. Has no complaint of nausea and vomiting. A nursing progress note dated 1/15/24 at 6:58 PM revealed, Resident was encouraged by RN (registered nurse) to go to the hospital with risk of having spinal fracture or head injuries r/t fall but he stated he does not want to go to the hospital. He stated to RN that he does not want to go to the hospital. He feels fine other than being sore from the fall. Denies headache, nausea and vomiting. He told RN if he starts to feel weird then he will let staff know but at this time it is not necessary to go to the hospital. Xray to cervical and thoracic spine ordered and resident agreed. Provider order prn flexeril 5 mg q (every) 6 hrs (hours) prn x 7 days and Tramadol 50 mg q 8 hrs prn x 14 days. Will educate resident. A nursing progress note dated 1/15/24 at 7:31 PM revealed, Provider notified of resident's refusal to be evaluated to hospital as of this time. NP plan to eval him tomorrow. A laboratory/radiology note dated 1/16/24 at 7:57 AM revealed, Results reviewed by provider. NNO (no new orders). A laboratory/radiology note dated 1/16/24 at 12:32 PM revealed, Cervical spine 2-3 views/Report PDF (portable document format)/ thoracic spine 2 views shows no acute fracture and provider reviewed. Resident was updated as well with results. Has no bruising or any skin injuries to neck and upper back, and per resident pain has decreased with prn Tramadol. Remained alert and oriented x 4 with no complaint of nausea, vomiting or headache. A NP progress note dated 1/16/24 at 3:27 PM revealed, .reports post fall pain, pain medication and muscle relaxant effective, imaging negative for acute fracture .Injuries details: injury, recent fall, back pain .Chief complaint: fall, end-stage renal disease, dependence on dialysis .reports post-fall pain, pain medication and muscle relaxant effective, imaging negative for acute fracture. Musculoskeletal: back pain; Neurological: back pain .Back: abnormal-limited mobility status, w/c dependent extensive assistance with ADLs (activities of daily living), post fall for pain with palpatation, negative for pain with strength resistance. On 4/3/24 at 11:49 AM, an interview was conducted with the ADM and DON. The ADM stated that he thought the DON told him about the resident fall in the van on 1/16/24, the day after the incident occurred. The ADM stated he knew it was reportable, but then stated it took a while to determine if it was reportable or not. The ADM stated it was his understanding that the resident was not injured. The ADM stated he asked the resident if he was okay and the resident stated that he was not having any pain. The DON stated that she was told by the van driver that the resident was not belted in and when the van turned, the resident fell backward. The DON stated the incident should be reported within 24 hours. The DON stated that when she interviewed resident 257, he told her he had pain in his shoulder. The DON stated the physician ordered pain medication and instructed that the resident be sent to the ED. The DON stated that resident 257 refused to go to the ED, and refused again when he was asked by the night nurse if he wanted to go. The DON stated that a mobile x-ray was ordered and provided at the facility. The DON stated the x-ray was negative. The ADM stated the van drivers were re-educated after the incident occurred, and the van driver was suspended. The ADM stated when he interviewed the van driver, he asked about what education he had received and created spot-checks to be completed 1-2 times per week where the ADM would observe the resident being prepared for transport. The ADM stated he had created an excel spreadsheet for documentation. The ADM stated the incident was also discussed in the QAPI (Quality Assessment and Performance Improvement) meeting. The ADM stated he spoke to the resident about the incident and spoke to the van driver again about the education that all the van drivers had received. The ADM stated there were other residents that were transported on the day of the incident and he spoke with them. The ADM stated all residents reported that they felt safe. The ADM stated he had not reviewed the fleet manual recently. The ADM stated the annual evaluations mentioned in the fleet manual were mostly for job satisfaction. The ADM stated he had not done any ride-alongs with any van drivers. The ADM stated he did not know if Human Resources kept track of any competencies for the van drivers. The DON stated all residents who needed to be transported were at risk if they were not secured properly in the van. The DON stated that education was provided to staff on 1/16/24. The DON stated the van drivers do not transfer residents, but they pick them up from wherever they are in the building. The ADM stated he did not know if there was a physical report completed about the incident. On 4/4/24 at 8:33 PM, an interview was conducted with the Transportation Manager (TM) who stated that he was the director of transportation and there were 2 other staff members that were providing transportation between 2 buildings. The TM stated he had been a facility driver for 10 years. The TM stated he was the driver who transported resident 257 to his dialysis appointments most of the time. The TM stated on the day that resident 257 sustained a fall in the van, it was cold and windy. The TM stated he was in a hurry and forgot to secure the front ratchet straps on the wheelchair. The TM stated the seatbelt was placed on the resident. The TM stated he was preparing to turn a corner and had to speed up when the resident fell backward. The TM stated the resident stated his back hurt and that he did not hit his head. The TM stated the handles of the wheelchair prevented the resident's head from hitting the floor of the van. The TM stated he pulled the van over and was able to get resident 257 upright, strapped down and back to the facility. The TM stated resident 257 was evaluated upon returning to the facility. The TM stated he transported resident 257 on Mondays, Wednesdays and Fridays to the dialysis facility. The TM stated he provided education to other van drivers. The TM stated the education consisted of making sure the resident was strapped in securely and that the seatbelt was secured. The TM stated before a driver was cleared to drive residents, they participated in ride alongs to observe every thing they needed to do during a transport. The TM stated there were 4 ratchet straps that should be secured on all 4 corners of the wheelchair. The TM stated the two front straps were attached above the wheels of the chair, and the back straps were attached at each corner onto the frame of the chair. The TM stated the way the seatbelt was placed depended on the chair. The TM stated if there was a problem with a resident's shoulder, the belt would be placed under the arms of the chair, otherwise, the belt was placed across the resident. The TM stated he did not keep any documentation of the training that he had provided to the drivers. The TM stated there was a handbook that new drivers were required to read and sign. The TM stated the driving manual covered weather conditions while driving and other aspects of driving. On 4/4/24 at 9:15 AM, an interview/observation was conducted with transportation driver (TD) 2 who stated she had been driving for 3 year. TD 2 stated she had completed the training and drove along with the TM for 2 weeks before she was able to transport residents. TD 2 stated the process she followed to secure a resident was she connected the 2 straps onto the back of the wheelchair frame and locked the brakes on the wheelchair. TD 2 stated she secured the 2 straps onto the front of the wheelchair and finally put the seatbelt on the resident. TD 2 was observed to put the seatbelt across the front of the resident in the van and buckle it into the buckle near the floor of the van. The belt was observed to be across the midsection of the resident and across his chest. TD 2 stated she had not had any accidents with residents while transporting. TD 2 stated she had residents that had started to slide out of their chairs. TD 2 stated in that situation, she pulled over, adjusted the resident in their chair and resumed the transport. On 4/4/24 at 10:59, a second interview was conducted with the TM. The TM restated that he did the training with the drivers. The TM stated the drivers would ride along with him during transport for 2 weeks, then he would observe them on their last day to ensure they were properly securing the resident in the van. The TM stated if another one of the drivers had an incident while driving, he would be the person that would monitor that driver. The TM stated he scheduled all of the transportation a appointments. The TM stated he had to do some of the driving because of short staffing. The TM stated the Fleet Safety Program was the manual that was required to be read and signed prior to the drivers going out for transport. The TM stated there was a staff shortage on the day resident 257 sustained a fall in the van and he was in a hurry to get the resident back to the facility. The TM stated he was written up after the incident with resident 257 and had to show the Administrator (ADM) how the resident was placed in the van. On 5/7/24 at 11:00 AM, a second interview was conducted with TD 2. TD 2 stated the training provided to new drivers included how to hook up the wheelchairs and seat belting the resident. TD 2 stated drivers were required to read the fleet safety program manual and sign off on completion. TD 2 also stated that there was on-line trainings that were required to be completed annually and included various subjects related to resident care. TD 2 stated the on-line trainings did not cover how to secure the different straps or seat belts, but the manual did and she passed off how to use them safely with the TM. TD 2 stated if a resident were to start sliding out of the wheelchair she would pull over in a safe place, make sure the resident was okay and get them back into the chair. TD 2 also stated she would assess for injuries and if there was an injury she would call for medical attention and call a supervisor. TD 2 stated if there was a reason she could not get the resident back to the facility safely, she would call for assistance and stay with the resident until help arrived. TD 2 stated she had been educated as to how to seatbelt a resident while in the van. TD 2 stated the strap should be placed as tight as possible to the resident. TD 2 stated she tried to get the belt through the arm rests and securely across the resident's chest. On 5/7/24 at 12:28 PM, an interview was conducted with TD 3. TD 3 stated the training she had received was about putting the hooks on the wheelchair, making sure the brakes were on, and putting the seatbelt on the resident. TD 3 stated she started with transportation 9 years ago. TD 3 stated drivers were required to complete annual training on the computer. TD 3 stated she did a ride-along for a week so she could observe what to do before transporting on her own. TD 3 stated she also received education about how to unhook the resident's chair and take the resident out of the van. TD 3 stated annual training included driving, weather conditions, and the proper way to secure residents of different weights. TD 3 stated that TM watched the drivers about every 6 months to be sure they were transporting residents safely. TD 3 stated if a resident refused to put a seat belt on during transportation, she would get a nurse or the TM to speak with the resident. TD 2 stated if the resident continued to refuse, she would refuse to transport the resident for safety reasons. TD 3 stated most of the training the drivers received was on a personal basis On 5/7/24 at approximately 1:00 PM, a third interview was conducted with the TM. The TM stated when placing a seatbelt on a resident, it had to be placed as securely as possible. The TM stated if the resident was smaller in stature the seat belt would be placed under the armrests of the wheelchair. The TM stated that resident 257 was not large in stature, but was bigger. The TM stated if a resident was not belted in correctly, they could fall completely backwards. The TM stated the ADM provided education about the proper way to strap a resident in the van. Ono 5/7/24 at 1:58 PM, an observation was made of TD 3 preparing a resident for transport. TD 3 connected one of the back straps to the frame of the wheelchair. Then she secured the right strap to the frame. TD 3 walked to the right side of the van and secured the front strap to the front leg of the wheelchair. TD 3 stated she always made sure the wheels were locked, and it was observed that they were. TD 3 returned to the back of the van and lifted up the ramp, locked it in place and closed the back of the van. Finally, TD 3 walked to the left side of the van and attached the left strap to the front of the wheelchair and double-checked to be sure the straps were tight. TD 3 explained how the seatbelt worked. She stated the belt was attached to the van. TD 3 pulled the belt across and in front of the resident. TD 3 did not place the belt under the arm rests of the wheelchair. The belt was observed to be across the residents chest and lap. The seatbelt was secured into the buckle that was on the floor. On 5/7/24 at 2:10 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated the Fleet Management Program was a specialty program that was required to be completed by the facility insurance. 5. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia, delusional disorder, bipolar disorder, traumatic brain injury (TBI), limitation of activities due to disability, muscle weakness, cognitive communication deficit, and cervical disc disorder. On 3/10/23 an admission MDS assessment revealed, resident 20 required extensive two person assistance with bed mobility and transfers. Functional limitation in range of motion documented resident 20's upper extremity impairment on one side, and lower extremity impairment on both sides. Resident 20's used a wheelchair for mobility. Resident 20's BIMS was a 14 out of 15 which indicated cognition was intact. a. On 5/2/23 at 2:11 PM, a facility incident report documented, resident 20 came back from an appointment and told us about and incident while in the transport van. Resident claimed that he was sitting in his electric wheelchair inside the van but was not seat belted in the van. The van stopped abruptly, and he was thrown from his chair landing his bottom on the footrests of his w/c and hitting his head and neck on the seat. He states he was helped back into the w/c then brought back to our facility. Resident 20 was checked for injuries, and neuro checks started, No injuries seem [sic] at this time. Has some pain in neck, back and head. A section titled 'Witnesses' documented a statement, Resident was sliding off of his wheelchair but did not completely off his seat. Parked the van and asked 2 bikers on the road to help him reposition back in his chair and placed a seatbelt on him. On 5/2/23 at 2:40 PM, a nursing progress note documented, resident 20 came back from his appointment with [a local urology clinic] and told us that he was sitting in his electric wheelchair inside the van but was not seat belted in the van. The van stopped abruptly, and he was thrown from his chair landing his bottom on the footrests of his w/c and hitting his head and neck on the seat of the w/c. He states he was helped back into the w/c by driver and passersby then brought back to our facility. Pt. checked for injuries. None seen at this time. Neuro checks started . On 5/2/23, a physician's order documented an X-ray bilateral hips. On 5/2/23 a Radiology Interpretation documented a left hip bilateral with pelvis 2 views. Findings included, 1. No definite radiographic evidence of acute fracture or dislocation. If symptoms persist, follow-up radiographs or CT [Computed Tomography] in order to evaluate for initial radiographically occult fracture. 2. Chronic nonunion fracture of right femoral neck. 3. Moderate degree of osteopenia/osteoporosis. 4. Moderate osteoarthritis. [It should be noted, that no documentation of the x-ray results could be located in resident 20's medical record.] On 5/3/23 at 9:52 AM, a pain interview documented that resident 20 was interviewed regarding his pain. Resident 20 stated he was having back and neck pain that was aching and sore. On 5/3/23 at 3:03 AM, a nursing progress note documented, resident 20 states that he is sore from the incident . On 5/4/23 at 11:22 PM, a nursing progress note documented, resident 20 reports some back and hip pain with post fall. CT scheduled for Friday to r/o [rule out] injury. On 5/5/23 at 6:51 AM, a nursing progress note documented, a CT scan was ordered for Fx [fracture] of spine r/t osteoporosis and recent fall one time only . Awaiting CT scan to be scheduled. [It should be noted, no documentation of the CT scan results could be located in the medical record.] Resident 20's MAR documented an order for Acetaminophen to give 650 mg [milligrams] by mouth every 4 hours as needed for pain . Resident 20 received acetaminophen on the following dates: a. On 5/2/23 at 7:27 AM with a pain score of 4 out of 10. b. On 5/5/23 at 7:53 AM with a pain score of 8 out of 10. On 4/4/24 at 1:57 PM, an interview was conducted with TD 1. TD 1 stated she was a transportation driver and had worked at the facility for 6 months. TD 1 stated that her training included shadowing the TM for 3 to 4 days. TD 1 stated that the TM followed her to the first appointment, said she did a good job, and then she was on her own. TD 1 stated she Not sure what he was checking or observing for. TD 1 stated that the TM watched her load the passengers, buckle them in, drive them to the appointment, and take them out. TD 1 stated that she recalled the incident with resident 20. TD 1 stated that she positioned the resident front facing, tried to move a buckle strap from behind him, but it would not budge. TD 1 stated that resident 20 refused to be positioned sideways so that the buckle strap would secure into the latch. TD 1 stated she could not properly buckle resident 20. TD 1 stated that resident 20 requested to just go back to the facility without the seatbelt secured. TD 1 stated that they were traveling down a hill and he was wearing basketball shorts and slid. TD 1 stated that resident 20 did not have his w/c seat belt buckled and he slipped and his knees hit the front passenger chair. TD 1 stated that resident 20 did not fall out of his chair. TD 1 stated that the street they were on had an incline that could help get resident 20 back into his seat, and that he had slouched in his seat and half of his butt was in the chair and the other half was out of the chair. TD 1 stated that she did not notify anyone of the incident because resident 20 had asked her not to notify her supervisor. TD 1 stated later the ADM called and spoke with her and stated that the way the resident was facing he could not have fallen out of his chair and broken his back based on the way he was facing in the van. TD 1 stated that the ADM realized her story made a lot of sense. TD 1 stated that for an incident like that she should have immediately called 911 for assistance, taken pictures of the scene and should have not transported the resident without a seatbelt. TD 1 stated that she was listening to the resident and did not buckle him because he was refusing to buckle. TD 1 stated that during her training they did not discuss what to do when a resident refused to be buckled or to inspect the vehicles before use. TD 1 stated that after the incident she did not have any additional training, write ups, or changes to her schedule. TD 1 stated she received verbal teaching during transport to face the residents sideways in the vehicle and to make sure residents were buckled. On 4/4/24 at 2:29 PM, an interview was conducted with the ADM. The ADM stated that he did not know a ton of details on the incident with resident 20, can't remember. I don't think I reported it and I don't know why. Looking at it now I should have. The ADM stated that resident 20 informed the nurse about the incident. The ADM stated that he called TD 1 and she told him a completely different story. The ADM stated that the TM said he would provide education and a warning. The ADM stated there was No paper trail, just verbal. The ADM stated that now he would perform an in-service form with education. The ADM stated that TD 1 reported that she helped resident 20 into the chair. The ADM stated that the nurse documented that resident 20 had fallen out of his wheelchair and his bottom landed on the footrest. The ADM stated that he believed TD 1's version of the events because there was not enough room for it to have occurred as the resident reported. The ADM stated that when the van returned from the incident that day he went outside and met with resident 20 and TD 1. The ADM stated that it would have been impossible for TD 1 to lift resident 20 if he really did fall down. It should be noted that the ADM did not know that TD 1 stopped bikers to aid in assisting resident 20 back into his w/c. The ADM stated that he took TD 1's word for it, and did not verify any of the details of the incident. The ADM stated that the van had a ramp, and once it was locked in there was maybe a foot and half a foot space. The ADM stated that he was outside when resident 20 exited the van and he met them when they arrived back at the facility. The ADM stated that TD 1 called someone after the incident but couldn't remember who it was. The ADM stated that the TM notified the DON. The ADM stated that he spoke to the TD 1 and resident 20 outside and asked resident 20 if he was okay. The ADM stated that was when he got both of their stories. The ADM stated that the nurse performed a head-to-toe assessment. The ADM stated that it would be documented, but did not know where that information was located. It should be noted that no documentation of an assessment s/p (status post) fall could be found. The ADM stated that resident 20 did not complain of pain or injuries. The ADM stated that the drivers should contact TM when there was an incident and then the TM should contact him. The ADM stated that they would then determine what aid was necessary and contact the appropriate agencies. The ADM stated that the process was that they analyze the situation, give education and training, and spot check. The ADM stated that he would go out and do random audits to visualize that they were doing what should be done, whatever had not been done prior to the incident. The ADM stated that the drivers should follow the facility policy and procedures. The ADM stated that transportation staff should perform safety checks, adhere to whatever was in the fleet manual, verify that the mobility device was secured and that the resident was seat belted. The ADM stated the drivers should not operate the vehicle without buckling the resident in. The ADM stated if a resident refused, he would involve the clinical team of the facility, and explain why they should buckle them in. The ADM stated that if a resident refused to be seat belted in the vehicles the staff should not transport the resident. The ADM stated, I can remember being outside, the way it was described over the phone, and then TD 1 called TM and the DON was informed and then we met them outside the facility. The ADM stated that he recalled meeting resident 20 when he returned from his appointment and asked him if he was okay. The ADM stated that he met him outside at the van if I did. I don't really remember with certainty what happened. I recall hearing both stories and I recall both stories being different. The ADM stated he took TD 1's story at its word and did not investigate the incident. b. On 1/11/24 at 10:07 PM, an facility incident report documented, Floor nurse was informed by resident that he had burned himself while outside smoking. Wound nurse in to assess. Burn site located to right lower abdominal quadrant . Resident reported he was outside smoking with his cigarette dropped and he did not notice it fell onto his shirt and burned through . New smoking eval to be complete [sic]. Apron is to be worn as protectant intervention. On 1/11/24 at 10:15 PM, a nursing progress note documented, Resident reported burning himself while smoking. Wound nurse in to assess . Protective apron to be inplace. Resident 20's care plan dated 8/7/23, documented a focus area Potential for injury r/t Smoking, interventions included, encourage resident to utilize smoking apron during smoking activities dated 1/11/24. A smoking evaluation dated 8/7/23, documented resident 20 is alert and oriented and is able to light a cigarette and dispose [sic] them properly. A smoking evaluation dated 1/11/24, documented resident 20's need of adaptive clothing/device/assistance included a smoking apron. Resident was educated on using an apron when smoking for safety . A smoking evaluation dated 4/18/24, documented resident 20's need of adaptive clothing/device/assistance included a smoking apron. On 5/13/24 at 9:16 AM, an interview was conducted with NA 1. NA 1 stated that none of the resident in the facility needed to be monitored with smoking, and no one needed to wear protective aprons or use special devices while smoking. On 5/13/24 at 9:24 AM, an interview was conducted with RN 1. RN 1 stated that there were not any residents that needed special equipment or protective clothing while smoking. RN 1 stated that there were not any residents that required monitoring during smoking. On 5/13/24 at 9:27 AM, an interview was conducted with LPN 1. LPN 1 stated that she thought there was only one resident that needed someone to be with him while he smoked. LPN 1 stated it was resident 31. LPN 1 stated that there were not any other residents that required help, assistive devices or protective clothing. On 5/13/24 at 9:33 AM, an interview was conducted with MT 1. MT 1 stated that the only resident that required assistance with smoking was resident 31. MT 1 stated that resident 31 wore oxygen and staff needed to make sure he was not wearing his oxygen when he smoked. On 5/13/24 at 9:38 AM, an interview was conducted with CNA 3. CNA 3 stated that the only resident that needed assistance with smoking was resident 2. CNA 3 stated that resident 2 just needed assistance with ambulation but did not need to be monitored. CNA 3 stated that no other resident required monitoring or protective clothing while smoking. [It should be noted none of the staff interviewed knew that resident 20 required a protective apron while smoking.] On 5/13/24 at 12:39 PM, an interview was conducted with resident 20. Resident 20 stated that he had an apron and should wear it when he smoked. Resident 20 stated that he did not always wear his apron because he forgot to put it on. Resident 20 stated that the staff did not help him put the apron on or remind him to wear it, and that he was suppose to put it on himself. Resident 20 stated that he could not always remember to put it on but was supposed to start wearing an apron after he was burned while smoking. On 5/13/24 at 1:40 PM, an interview was conducted with the DON. The DON stated that when a resident was first admitted and smoked, the resident was evaluated. The DON stated the evaluation included watching the resident smoke and watch if the resident leaned to the side or forward, if they had a tremor, how they light the cigarette and if they could safely extinguish it. The DON stated that resident 20 was a full quadriplegic but can move his arms and right hand and that he had limited sensation. The DON stated that resident 20 was evaluated when he was first admitted and was able to demonstrate he could smoke safely. The DON stated after resident 20 was burned he then needed a protective apron while smoking, and that when he wanted to smoke he let staff know and staff assisted with putting his apron on. The DON s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 39 was admitted to the facility on [DATE] with diagnosis which included anoxic brain damage, metabolic encephalopathy, aphasia, severe protein calorie malnutrition, dysphagia, cognitive communication deficit, underweight, and lack of coordination. On 5/14/24 at 10:57 AM, an observation was made of resident 39. Resident 39's tube feeding formula container was empty and the pump was turned off. There was a date of 5/13/24 at 3:30 AM on the bottle of formula and the bag of water. The pump was turned on a revealed it was to infuse at 55 millimeters (ml) per hour of formula and 30 mls every hour of water. The pump revealed that the total volume of formula infused was 1123 mls and 624 mls of water over the last 24 hours. The pump further revealed resident 39 was infused 2194 mls of formula and 1284 ml of flush over the previous 48 hours. At 11:12 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 was observed to enter resident 39's room. NA 1 stated resident 39's tube feeding was running when she checked on her at 6:00 AM. NA 1 stated she had not checked on her since 6:00 AM. On 5/14/24 at 11:04 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 39's tube feed was shut off because one of her bosses notified her that the feeding pump was alarming and that her boss shut the pump off. RN 1 stated that the feeding pump had been off for about 15 minutes. On 5/14/24 at 11:09 AM, an observation of resident 39 was made. Resident 39 was laying in bed with the head of bed flat. Nurse Aide (NA) 1 was dressing resident 39. RN 1 was replacing resident 39's tube feed formula. RN 1 stated that resident 39's tube feed was continuous and they did not keep track the volume infused. RN 1 stated that resident 39's head of bed would be elevated but that she slid down in the bed where her head was no longer elevated. RN 1 stated that they used pillow to try and proper her up. One pillow was observed in the room, when RN 1 was asked if staff only use one pillow she stated that they would get more pillows to sit resident 39 up. RN 1 stated that there was not a way to ensure resident 39 was elevated 30 degrees while the tube feed was running. NA 1 stated that resident 39 moved around a lot in her bed and tended to scoot down in her bed. On 5/14/24 at 1:08 PM, an observation was made of resident 39. Resident 39 was in bed, the head of the bed was elevated. Resident 39's body was down in the bed lying flat with her head turned to the left. Resident 39's Medical record was reviewed from 4/3/24 through 5/14/24. On 3/10/24 a quarterly Minimum Data Set (MDS) assessment documented resident 39 had a Brief Interview for Mental Status (BIMS) of 99, indicating sever cognitive impairment. The MDS documented resident 39's Nutritional Status, that she had a Feeding tube providing 51% or more of total calories received. The MDS documented Other Health Conditions documented resident 39 had vomiting. A care plan dated 11/29/22, documented resident 39 requires gastrojejunostomy tube feeing r/t G-tube [gastric tube] complication . Interventions included, HOB [Head Of Bed] elevated 45 degrees during and thirty minutes after tube feed . Elevate HOB at least 30-45 degrees at all times during feeding. RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendation for changes to tube feeding as needed. A physician order dated 11/29/22 documented, every shift ELEVATE HOB AT LEAST 30-45 DEGREES AT ALL TIMES DURING FEEDING AND 1 HOUR AFTER. A physician order dated 12/6/23 documented, every shift Osmolite 1.5 at 55 ml/hr [hour] + 30 ml q hr H2O continuous feeds. Resident 39's weights were as follows: a. On 11/14/24 was 94.6 pounds, b. On 2/12/24 was 94.0 pounds, c. On 4/15/24 was 97.2 pounds d. On 5/13/24 was 97.3 pounds with a Body Mass Index of 19.0 A Nutrition admission evaluation dated 12/5/22, documented resident 39 was NPO [nothing by mouth] with reliance on enteral feeding for 100% of nutrition needs Estimated nutrition needs: Energy 1200 (30 Kcal/kg [kilocalorie per kilogram]) . is at nutrition risk r/t NPO status reliance on enteral feeding to meet 100% of nutrition needs . will strive for gradual wt [weight] increase . A Nutrition quarterly evaluation dated 8/27/23, documented resident 39 was NPO with reliance on enteral feedings for 100% of nutrition needs. She has a PEG [percutaneous endoscopic gastrostomy] tube . Enteral feeding provides; TV= 1540 2310 kcal (56 kcal/kg) 97 g protein (2.3 g/kg) 1170 ml Free Fluid + water flush of 440 ml today/day= 1610 ml (39 ml/kg) . [Resident 39] is at nutrition risk r/t NPO status, reliance on enteral feeding to meet 100% of nutrition needs, hx [history] protein-calorie malnutrition . A nutrition quarterly evaluation dated 2/26/24, documented resident 39 was NPO with reliance on enteral feedings for 100% of nutrition needs . Based on average run time of 22 hrs TV= 1210 ml . [It should be noted there is no documentation of resident 39's formula intake or number of hours of feeding.] It should be noted that Osmolite 1.5 at 55 ml per hour continuous would provide 1320 mls of formula for 1980 kcals and 82 grams of protein per 24 hours. According to the tube feeding pump resident 39 was provided a total volume of formula of 1123 mls from 24 hours and 1,071 mls the previous 24 hours. On 5/14/24 at 12:44 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that resident 39's orders for continuous tube feed is based on 22 hours a day and that it was not practical to be based on 24 hours a day because resident 39 was unhooked for showers or nursing cares. The RD stated that the last nutritional needs evaluation was done when she was first admitted in 2022 and that since her weight had not changed her needs would not be significantly different. The RD stated she did not know how much total volume of formula was infused into resident 39 over a 24 hour period. The RD stated she depended on nursing staff to notify her if a resident was not getting tube feedings according to orders. The RD stated she was aware that resident 39 went out with family and did not have her tube feeding running for the full 22 hours. On 5/14/24 at approximately 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a resident receiving a tube feed should have their upper body elevated at least 30 degrees. The DON stated that the nurses did not document the total volume infused and was not sure if the RD looked at the feeding pump for volume infused. The DON stated that resident 39 was not receiving a continuous tube feeding because of showers, cares and that her family took her out of the facility and so they estimate the total volume of formula. On 5/14/24 at 2:21 PM, a follow-up interview was conducted with the DON and Corporate Resource Nurse (CRN) 1. CRN 1 stated she talked to the facility RD about changing resident 39 to bolus feeding to make sure she maintained an upright position. The DON stated resident 39 was not provided bolus feedings before because she was nauseated, so a smaller amount was better for resident 39. Based on observation, interview and record review, for 2 of 38 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, resident's tube feedings were not administered as ordered, and a resident was not being positioned appropriately while the tube feeding was administered. Resident identifiers: 26 and 39. Findings include: 1. Resident 26 was admitted to the facility initially on 8/31/21 and re-admitted on [DATE] with diagnoses that included alcoholic polyneuropathy, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, major depressive disorder, anxiety disorder, dysphagia, hypo-osmolality and hyponatremia. On 5/7/24 at 3:25 PM, an interview was conducted with resident 26 who stated she received tube feedings for 4 hours every night. Resident 26 was observed to be very thin. Resident 26 stated she normally had a tube feeding pump in her room, but it was not there and she did not know why. Resident 26's medical records were reviewed between 5/6/24 and 5/14/24. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident 26 had a BIMS (Brief Interview for Mental Status) of 12 indicating moderate cognitive impairment. The assessment also revealed resident 26 required extensive 1 person physical assistance with eating, which included tube feeding. Physician orders dated 4/3/24 revealed, Osmolite 1.5 at 70 ml [milliliters]/hr [hour] x 10 hours, 120 ml H20 [water] flush q [every] 4 hours. On at 1800 [6:00 PM] off at 0600 [6:00 AM]. Two times a day for dysphagia. Orders dated 4/4/24 included, Regular diet, mechanical soft-ground texture, thin liquids, pleasure feeds as tolerated. A care plan focus area initiated on 3/26/22 revealed, [Resident 26] has nutrition problem or potential nutrition problem r/t [related to] ETOH [alcohol] w/ [with] withdrawal and seizure; chronic hyponatriemia; malnutrition . Low BMI [body mass index]. She receives a fortified diet. She has appropriate PO [oral] intake. Is on supplemental enteral NOC [nocturnal] feeds after surgery on neck. PO feeds have been started. The goal was, [Resident 26] will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx [signs and symptoms] of malnutrition through review date. Interventions included, .Diet as ordered by the physician. Fortified meals . 1/10/23- diet order per MD [medical doctor]: pleasure feeds as tolerated; .Monitor/record/report to MD PRN s/sx of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss; Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated; Provide, serve diet as ordered, Monitor intake and record q meal. RD [Registered Dietitian] to evaluate and make diet change recommendations PRN; Supplement per order: MedPass tid [three times daily], enteral NOC feeds per order. A care plan focus area initiated on 10/11/22 revealed, Requires tube feeding r/t dysphagia, swallowing problem for tonsilar cancer resection and removal. The goal was, Will maintain adequate nutrition and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions included, HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed; Check for tube placement and gastric contents/residual volume per facility protocol and record; Discuss with family/caregivers any concerns about the tube feeding, advantages, disadvantages and potential complications; Elevate HOB at least 30-45 degrees at all times during feeding; Monitor/document/report to MD PRN: Aspriation-fever, SOB [shortness of breath], tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration; Needs assistance with tube feeding and water flushes. See MD orders for current feeding orders; Provide local care to feeding tube site as ordered and monitor for s/sx of infection; RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed . Resident 26's MAR/TAR (Medication Administration Record/Treatment Administration Record) was reviewed for the months of March 2024, April 2024 and May 2024. a. March enteral feed order initiated on 3/27/24 revealed, Two times a day for dysphagia, Osmolite 1.5 at 70 ml/hr x 8 hours, 120 ml H2O flush q r hours. On at 2000 [8:00 PM], off at 0600 [6:00 AM]. Order date 3/27/24, discontinued on 4/3/24. b. April enteral feed order initiated on 4/3/24 revealed, Two times a day for dysphagia, Osmolite 1.5 at 70 ml/hr x 10 hours, 120 ml H2O flush q 4 hours. On at 1800, off at 0600. Discontinued on 5/8/24. c. May enteral feed order initiated on 5/8/24 revealed, Two times a day for dysphagia, Osmolite 1.5 at 70 ml/hr x 10 hours, 120 ml H2O flush q 4 hours, On at 2000, Off at 0600. The order was revised to read x 12 hours, back to x10 hours, then revised again to 12 hours with, On at 2000, Off at 0800. The revisions were all made on 5/8/24. It should be noted that after staff were asked about the timing and number of hours the tube feeding was being infused, the order revisions were made. It should also be noted that no documentation was found with information regarding the times tube feedings were started and stopped or the amount of formula that was administered. A physician note dated 11/3/23 revealed, Weight 95.4 pounds, an increase of 4 pounds in 7 months .Regular diet, mechanical soft texture. A physician note dated 3/8/24 revealed, .weight 97 lbs [pounds], an increase of 2 pounds in 5 months .Protein Calorie Malnutrition: Feeding tube cares per protocol. Osmolite 1.5 at 70 ml/hour over 8 hours. A physician note dated 4/7/24 revealed, .weight 91.9 pounds, no change in 4 months .Protein calorie malnutrition: Regular diet, pureed texture. Aspiration precautions. Feeding tube care as per protocol. A NP [Nurse Practitioner] progress note dated 4/8/24 at 11:29 AM revealed, Past History Medical: .ongoing medical history of malignant mass of tonsil status post surgical resection .RD follow-up, with recent recommendation for diet texture change. A nutrition progress note dated 2/28/24 at 10:09 AM revealed, Discussed in NAR [nutrition at risk] committee meeting with wound nurse, DM [dietary manager]. Wt 96.4 Previous wt 97.6 Wt change: wt is within UBW [usual body weight]; 90-100 lbs but has been trending down Diet order: Regular mechanical soft/ground pleasure food as tolerated. Intakes: variable avg [average]. 50% Enteral feeds: Osmolite 1.5 @ 70 cc [cubic centimeters]/hr NOC feeds x 6 hours + 120 ml H2O flush q 4 hours. Skin is intact A/P [assessment/plan]: non-significant wt change x 30 days (3.8% loss) Wt appears to be trending down. Recommend increasing enteral feeding hours to 8 hour NOC feeds. This will provide TV [total volume] = 560, 840 kcal [kilocalories], 38 g protein, 425 ml H2O + 720 ml from flush for total fluids of 1145 provided via feeding tube. Enteral feeds continue to be supplemental to po feeds. Will monitor weekly. A nutrition progress note dated 3/6/24 @ 7:05 PM revealed, Discussed in NAR committee meeting with wound nurse, DM. Wt 97 Previous wt: 96.4 Wt change: wt is within UBW; 90-100 lbs Diet order: Regular mech soft/ground pleasure foods as tolerated. Intakes: variable. avg. 50% Enteral feeds: Osmolite 1.5 @ 70 cc/hr NOC feeds x 8 hours + 120 ml H2O flush q 4 hours. Skin is intact Labs: no new labs. A/P: non-significant wt change x 30, 90, 180 days. No changes recommended at this time. Continue weekly wts. A nutrition progress note dated 3/13/24 at 12:50 PM revealed, Discussed in NAR committee meeting with wound nurse, DM. Wt: 96.3 Previous wt: 97 lbs. BMI 17.1 [Resident 26] receives enteral NOC feeds + po meals. Please see recent quarterly nutrition assessment for additional information. Have recommended SLP [Speech Language Pathologist] eval and tx r/t some increased difficulty with swallowing. A Weight Change Note dated 3/27/24 at 2:42 PM revealed, NAR committee meeting with RD, wound nurse, SLP. Resident was unavailable for RD to interview which was attempted several times. Wt: 93.6 Previous wt: 95.9 Wt change: -8.1% x 90 days. wt is within UBW: 90-100 lbs but trending down for several weeks. BMI: 16.6 Diet order: Regular mech soft/ground pleasure foods as tolerated. Intakes: variable. avg: 50% Enteral feeds: Osmolite 1.5 @ 70cc/hr NOC feeds x 8 hours +120 ml H2O flush q 4 hours. Skin is intact . A/P: significant wt change 90 days in spite of increasing enteral feeds and beginning SLP services. New orders for additional increase of supplemental NOC enteral feedings to 10 hours. This provides TV = 700 ml, 1050 kcals, 48 g protein, 1252 ml free fluid (enteral feed + flush). Will continue weekly wts. Orders updated. Pt education provided. NP and family updated. Resident continues to be seen by ST [Speech Therapist]. A nutrition progress note dated 4/3/24 at 1:29 PM revealed, Discussed in NAR committee meeting with wound nurse, DM, SLP. Wt 96.2 Previous wt: 93.6 Wt change: +2.8% x 1 week, wt is within UBW: 90-100 lbs. BMI: 17.0 Diet order: Regular pureed texture (resident requested down grade per SLP). Intakes: variable. Skin: intact enteral feeds: NOC enteral feedings of Osmolite 1.5 @ 70 ml/hr x 8 hours. Last weeks recommendation to increase to 10 hours was not implemented A/P: Non-significant wt changes x 30, 90, 180 days. Wt is within UBW range. Have enquired with nursing regarding enteral orders. Wt is up from last week but intakes remain poor. Recommend increasing enteral feedings to 10 hours. See previous nutrition note for TV and nutrition information. Will continue to follow weekly at this time. A nutrition progress note dated 4/24/24 at 1:31 PM revealed, Discussed in NAR committee meeting with wound nurse, SLP, DM. Wt: 94.2 previous wt: 96.6 Wt change: no sig [significant] changes noted. wt is within UBW : 90-100 lbs. Diet order: Regular mech soft, ground, thin liquids, intakes: variable. Skin: intact Enteral NOC feeds per orders. A/P: Resident is nutritionally stable on current POC [Plan of care]. No changes recommended. Monitor weekly. A Nutrition progress note dated 5/1/24 at 1:58 PM revealed, Discussed in NAR committee meeting with ADON [assistant director of nursing]. SLP discussed with RD that resident progression in therapy is minimal and enteral feedings will need to continue and/or be increased. Wt: 94 Previous wt: 94.2 Wt change: no sig changes noted. wt is within UBW: 90-100 lbs. Diet order: Regular mech soft, ground, thin liquids. Intakes: variable. Skin: intact Enteral NOC feeds per orders. A/P: Wt has trended down but remains within UBW range. Will continue current interventions. Consider increasing TF. Monitor weekly. A nutrition progress note dated 5/8/24 at 12:50 PM revealed, Discussed in NAR committee meeting with wound nurse, DM, SLP. Wt: 93 Previous WT: 94 Wt change: no sig wt changes, wt trending down BMI: 16.5 Diet order: Regular pureed texture (resident requested down grade per SLP). Intakes: <50% Skin: intact Enteral feeds: NOC enteral feedings of Osmolite 1.5 @ 70 ml/hr x 10 hours. A/P: Non-significant wt changes x 30, 90, 180 days. Wt is within UBW range but trending down. Recommend increasing enteral feeds to 12 hours. This will provide TV= 840, 1260 kcal, 54g. PO foods will remain pleasure feeds. Will continue to follow weekly at this time. Resident 26's meal intake percentage was reviewed and revealed daily intakes for May 2024 as follows: a. On 5/1/24: 1:53 PM 50% 10:35 PM 10% b. On 5/2/24: 12:00 PM 50% c. On 5/3/24: 12:45 PM 15% d. On 5/4/24: 11:04 AM 20% 5:25 PM 25% e. On 5/5/24: 12:00 PM 50% f. On 5/6/24: 1:41 PM 35% 5:30 PM 15% g. On 5/7/24: 9:37 AM 25% 12:00 PM 25% 5:30 PM 50% h. On 5/8/24: 7:13 PM 70% i. On 5/9/24: 7:14 PM 25% j. On 5/10/24: 1:24 PM 50% 5:30 PM 20% k. On 5/11/24: 1:14 PM 100% l. On 5/12/24: 7:30 AM 25% 1:48 PM 25% 5:55 PM 20% m. On 5/13/24: 12:49 PM 20% 5:30 PM 90% On 5/8/24 at 1:47 PM, an interview was conducted with RN (Registered Nurse) 3. RN 3 stated resident 26 was administered tube feedings at night and had oral intake during the day. RN 3 stated resident 26's tube feeding was turned off before the day shift started. RN 3 stated resident 26 does well eating during the day. RN 3 stated resident 26's weight had been steady for over a year. RN 3 stated there were 2 current tube feeding orders. RN 3 acknowledged one order was for administration for 10 hours, the other stated, On at 1800 and off at 0600. On 5/8/24 at 2:21 PM, a second interview was conducted with RN 3 who stated that she had contacted the RD to verify the tube feeding order. RN 3 stated that the RD confirmed that resident 26's tube feeding order should start at 8:00 PM and finish at 6:00 AM. RN 3 stated she had corrected the orders. On 5/13/24 at 9:02 AM, an interview was conducted with RN 1. RN 1 stated the tube feeding times for administration were a range and could finish at 8:00 AM. RN 1 stated that resident 26 admitted from the hospital with a tube feeding. RN 1 stated when a tube feeding order was received, the nurse put in what time the tube feeding was to be provided, and what the formula was and the rate. RN 1 stated the nurses were required to check to ensure the tube feeding was running correctly. RN 1 stated nurses could adjust the Kangaroo Pumps if needed. RN 1 stated nurses administered whatever was on the MAR every shift. RN 1 stated she checked the MAR and then checked the pump to ensure it was running as ordered. RN 1 stated if there was a problem during the shift with the pump or tube feeding, the nurses would be notified by the CNA's as they had more interaction with the residents. On 5/14/24 at 7:08 AM, a follow-up interview was conducted with resident 26 who stated her tube feed was discontinued a couple of hours ago. Resident 26 stated she thought her weight loss was related to a swallowing issue. Resident 26 stated she did not feel that she was improving. Resident 26 stated her weight was being monitored. Resident 26 stated she did not remember what time her tube feeding was started on the previous evening. On 5/14/24 at 7:18 AM, an interview was conducted with Medication Technician (MT) 4. MT 4 stated she did not know what time resident 26's tube feeding was discontinued. MT 4 stated the nurses were responsible for hooking up and discontinuing the tube feedings. On 5/14 24 at 7:19 AM, a second interview was conducted with RN 1. RN 1 stated resident 26's tube feed was discontinued at 7:00 AM. RN 1 was observed to look in the medical record to see what time the task was checked off. RN 1 stated the medical record documented the the tube feed was started at 8:15 PM. RN 1 acknowledged that the tube feeding order was to start at 8:00 PM and stop at 8:00 AM. RN 1 stated the reminder in the medical record popped up early, at 7:00 AM. RN 1 stated resident 26 sometimes requested to have the tube feeding taken off at 7:00 AM so she could go to the bathroom. RN 1 stated irregular administration and discontinuation of the tube feeds was the reason why resident 26's weight was being monitored. RN 1 stated if the tube feeding was not administered as ordered, resident 26 would not be getting the intended calories. RN 1 stated resident 26's tube feeding was usually put on when she went to bed and that resident 26 sometimes went out to smoke so the administration times varied. RN 1 stated the MAR was where tube feeding administration was documented. RN 1 stated there was a box to check when the tube feeding was turned on and turned off. RN 1 stated she was not required to document how much formula was infused. RN 1 stated the order would have to specifically state that the volume had to be documented. RN 1 stated the RD would come and speak with the nurses if she had concerns about resident 26. RN 1 stated Certified Nursing Assistants (CNAs) were tracking the amount of food eaten at each meal. On 5/14/24 at 9:30 AM, RN 1 was observed to check resident 26's kangaroo pump for information about the amount of formula that was infused. There was no information in the pump history. RN 1 stated when the pump was turned off the information from the infusion was cleared, but kept the setting that was entered. RN 1 stated the machine was turned all the way off or it would continue to beep all day long. On 5/14/24 at 12:07 PM, an interview was conducted with the RD. The RD stated the DON notified her when a resident with a tube feeding was being admitted . The RD stated after she received the notification from the DON she reviewed the resident's orders and completed an assessment within 7 days. The RD stated resident 26 was followed in the NAR meeting every week and recommendations were based on weight and laboratory results. The RD stated resident 26 had been receiving tube feedings for a long time. The RD stated resident 26's weight went up and down depending on how much oral intake she was able to eat. The RD stated resident 26 had requested a modified texture diet. The RD stated resident 26's weight had always been between 90-100 pounds. The RD stated her weight had been lower based on other circumstances. The RD stated resident 26 had been stable in the past but had been trending down recently. The RD stated resident 26 was unhappy when her weight got up to 100 lbs. The RD stated she had made changes to resident 26's diet based on her preferences. The RD stated stable meant that there were no significant weight changes. The RD stated resident 26 wanted to have NOC feedings. The RD stated pleasure feeding meant that the majority of her nutrition intake was not from oral intake. The RD stated resident 26's estimated needs should be calculated at least annually and documented. The RD stated she had not completed resident 26's estimated needs calculation for her most recent assessments. The RD stated she did not know how much of the tube feeds resident 26 was actually getting.