Every finding on record at Agawam West Rehab and Nursing

Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who was dependent on staff members for bathing, dressing, incontinence care, bed mobility, and positioning, the Facility failed to ensure his/her safety was maintained during care, when during the provision of care, Certified Nurse Aide (CNA) #1 positioned Resident #1 on his/her side in bed then turned away from him/her to obtain a wet cloth, and Resident #1 rolled off the bed and onto the floor. Resident #1 sustained a laceration to the back of his/her head, was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she required staples to close the wound and was diagnosed with an epidural hematoma (a collection of blood between the skull and outermost protective membrane of the brain).Findings include:Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/30/25, indicated that on 09/23/25, around 6:30 P.M., CNA #1 was providing care to Resident #1 while standing at the bedside when Resident #1 unexpectedly rolled off the bed and onto the floor, was assessed to have a cut to the back of his/her head, and he/she was sent to the ED for further evaluation.Review of the Hospital Discharge/Transfer Note, dated 09/26/25, indicated the Facility sent Resident #1 to the Hospital ED after staff was attempting to change him/her and he/she accidentally rolled off of the bed and hit his/her head, his/her CT scan (a medical imaging procedure that uses x-rays to create detailed, cross-sectional images of the body's internal structure) indicated he/she sustained a left lateral epidural hematoma. Resident #1 was admitted to the Facility in December 2024, diagnoses included Dementia, Dysphagia (difficulty swallowing) and Glaucoma (a condition of increased pressure within the eyeball causing gradual loss of sight).Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/24/25, indicated he/she was severely cognitively impaired and dependent on staff for hygiene, dressing, bed mobility, and transfers in and out of bed.Review of Resident #1's Activities of Daily Living (ADL) Care Plan, reviewed and renewed with his/her Quarterly MDS Assessment, dated 06/24/25, indicated he/she was dependent on staff for hygiene, dressing, bed mobility, and transfers in and out of bed.Review of a Nursing Progress Note, dated 09/23/25, which included an SBAR (a communication tool that stands for Situation, Background, Assessment, and Recommendation) that indicated Resident #1 experienced a fall from bed while a CNA was performing care, and that he/she sustained a visible injury to his/her head with active bleeding noted, and that he/she was sent to the Hospital ED for further evaluation and treatment.During a telephone interview on 10/14/25 at 3:50 P.M., Family Member #1 said a nurse from the Facility called him on 09/23/25 to notify him that Resident #1 had fallen, and that he was surprised the fall happened because Resident #1 was unable to turn or move him/herself on his/her own. Family Member #1 said Facility staff told him that while a CNA was in the process of bathing Resident #1, the CNA had rolled him/her onto his/her side in bed, and that Resident #1 subsequently fell out of the bed and onto the floor. During an interview on 10/15/25 at 9:00 A.M., CNA #1 said she was familiar with Resident #1's care needs because he/she was on her assignment and that Resident #1 was totally dependent on staff for everything, including bed mobility, bathing, and incontinent care.CNA #1 said during the evening shift on 09/23/25, she was preparing to provide incontinent care to Resident #1 while he/she was lying in his/her bed. CNA #1 said Resident #1's bed was in the highest position, said she rolled Resident #1 away from her, so he/she was positioned on his/her left side, and that she was standing behind him/her. CNA #1 said she had Resident #1's bathing supplies placed on a table diagonally behind her and off to the side. CNA #1 said she needed a wet cloth that was on the table, that Resident #1 was out of her reach when she turned to grab the cloth, and said when she turned back towards Resident #1, he/she had rolled from the bed and onto the floor.CNA #1 said Resident #1 landed on his/her back, he/she was bleeding from a cut on the back of his/her head, and that she yelled for help while she applied a cloth to the back of Resident #1's head. During an interview on 10/15/25 at 12:30 P.M., (which included a review of his written witness statement, dated 09/13/25), Nurse #1 said Resident #1 required extensive assistance and was dependent on staff for all his/her ADLs, including dressing, bathing, incontinent care, and bed mobility, and if he/she was placed in a particular position while in bed, he/she generally remained in that position.Nurse #1 said he was working on 09/23/25 and at approximately 6:45 P.M., CNA #1 told him his assistance was needed in Resident #1's room because Resident #1 fell out of bed and his/her head was bleeding. Nurse #1 said he responded to Resident #1's room, where he observed him/her to be lying on the floor positioned on his/her back and noticed that he/she was bleeding from a wound on the back of his/her head.Nurse #1 said CNA #1 told him that she was about to provide personal care to Resident #1, that she briefly turned away from him/her to reach for a face cloth, and when she turned back around, Resident #1 had fallen out of bed onto to the floor. Nurse #1 said he notified the Assistant Director of Nursing (ADON) who assisted with notification phone calls (to the Physician and Family Member #1), he called 911, and Resident #1 was transferred to the Hospital ED for evaluation.During an interview on 10/15/25 at 3:13 P.M., (which included a review of her written witness statement, dated 09/23/25), CNA #2 said she was working on 09/23/25 and was in the back hall when she heard CNA #1 screaming for help. CNA #2 said when turned the corner from her hallway, she saw CNA #1 in Resident #1's doorway yelling for help.CNA #2 said when she arrived to Resident #1's room, she saw him/her lying on his/her back next to his/her bed, and she said his/her head was bleeding. CNA #2 said Resident #1 was not on her assignment, but she knew that he/she was dependent on staff for all his/her care, including bathing, feeding, bed mobility and transfers, and that he/she is unable to move him/herself around in bed.During an interview on 10/15/25 at 4:06 P.M., Unit Manager #1 said she learned of Resident #1's fall when she came to work the following day and that she was told that during care, Resident #1 rolled off the bed and sustained a laceration to his/her head that required staples.During an interview on 10/15/25 at 4:40 P.M., the Assistant Director of Nursing (ADON) said Nurse #1 called her on 09/23/25 to tell her Resident #1 fell out of bed and was bleeding.The ADON said when she arrived to Resident #1's room, he/she was actively bleeding from the back of his/her head, that Nurse #1 had been applying pressure to the wound, but the bleeding continued. The ADON said she contacted the on-call Provider and Family Member #1 and it was determined that they would send Resident #1 to the Hospital ED for evaluation.The ADON said she obtained an initial statement from CNA #1 who told her that she was providing care to Resident #1, had placed him/her on his/her side to position him/her for incontinent care, said she turned away from him/her to get a washcloth, and she said when she turned back around, Resident #1 had rolled off the bed onto the floor.The ADON said it was important to make sure a resident is in a safe position before turning away from them.During an interview on 10/15/25 at 5:00 P.M., the Director of Nursing (DON) said on 09/23/25, she received a telephone call from the ADON informing her that Resident #1 had fallen out of bed during care and that he/she was bleeding.The DON said she conducted a re-enactment of the incident with CNA #1 on 09/24/25. The DON said CNA #1 demonstrated how she rolled Resident #1 onto his/her left side and how she turned away to obtain incontinent supplies from the tray table located diagonally behind her. The DON said CNA #1 told her she did not leave Resident #1's bedside, that Resident #1 was just out of her reach, and when she turned back to face him/her, he/she had rolled off the bed and onto the floor.On 10/15/25, the Facility was found to be in past Non-Compliance with an effective date of 9/26/25, and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) Upon return from the Hospital, Resident #1's care plan was immediately updated to:- require two staff members be present at all times for personal care and bed mobility.- a perimeter mattress with positioning wedges are always provided while in bed. B) On 09/24/25, the Staff Development Coordinator (SDC) re-educated CNA #1 on Positioning/ADL Care, which included but was not limited to the following:-When providing care to a resident in bed, do not leave them unattended until they are safely positioned - this includes reaching for personal care items such as barrier creams, linens, briefs, etc. followed by a written competency, and demonstration. C) On 09/24/25, the Staff Development Coordinator (SDC) or her designee re-educated all clinical staff (Nursing and CNAs) where Resident #1 resides on Positioning/ADL Care, followed by written competencies, and demonstrations. D) On 09/26/25, the Facility completed a whole house Fall From Bed Audit that encompassed the dates between 07/24/25 and 09/24/25 to determine whether residents who fell were provided with the level of assistance they required during the event, determined the root cause for the fall, and identified any interventions that were added as a result of the fall. E) The Director of Nursing, Staff Development Coordinator or their Designee are conducting weekly audits, followed by random audits to ensure all residents are receiving the necessary level of assistance needed for bed mobility, including turning and repositioning a resident in bed to provide care, as well as ensuring residents' care plans are updated and accurate. F) The deficient practice will be presented at the next monthly Quality Assurance Improvement (QAPI) meeting and will continue to be discussed at monthly QAPI meetings as needed to ensure substantial compliance is achieved and maintained. G) The Director of Nursing and/or their Designee are responsible for overall compliance.

Based on observation, record review, and interview, the facility failed to ensure that garbage was disposed of properly. Specifically, the facility failed to ensure the area on the ground around three trash dumpsters outside of the facility building was kept free of various debris, garbage and waste. Findings include:Review of the facility policy for Food Related Garbage and Rubbish Disposal, last revised 11/5/24 indicated garbage and rubbish will be disposed of in accordance with current state laws regulating such matters.>Policy Interpretation and Implementation:-all garbage and rubbish containing food wastes shall be kept in containers. -garbage and rubbish containing food waste will be stored in a manner that is inaccessible to vermin.-storage areas will be kept clean at all times and shall not constitute a nuisance. -outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 9/11/25 at 12:09 P.M., the surveyor and the District Dietary Manager observed the area where three dumpsters for the kitchen garbage were located outside the facility building and observed the following: -the ground surrounding all three of the dumpsters was covered with various debris. -there was an accumulation of trash on the ground including gloves, unidentified broken debris, decomposing flat cardboard boxes, many plastic containers and bags, wet/decomposing papers, condiment containers, small milk cartons, potato chip bags, cereal bowls, bottle caps, drink covers, plastic cutlery, a free-standing open rubbish bin, a chair, a rolling walker, two nursing medication carts and electrical equipment. During an interview at the time, the District Dietary Manager said that the dumpster area should not be dirty because it can attract rodents and insects to the area. On 9/11/25 at 12:16 P.M., the surveyor and the Food Service Director (FSD) observed the dumpster area located outside of the main kitchen. During an interview at the time, the FSD said that the dumpster area was not sanitary, and the accumulated trash can bring rats and other rodents to the area. The FSD also said that in the past raccoons have gotten into the trash and have caused large messes surrounding the dumpster area. On 9/11/25 at 12:31 P.M., the surveyor and the Director of Nursing (DON) observed the dumpster area located outside of the main kitchen. During an interview at the time, the DON said that all the trash observed on the ground outside of the dumpsters should have been contained inside of the dumpsters and it had not been. During an interview on 9/11/25 at 1:23 P.M., the Maintenance Director said that the maintenance staff was responsible for cleaning the area outside of the dumpster daily. The Maintenance Director said that the dumpster area should not have been unclean because it can attract the wildlife in the area.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents at high risk. Specifically, the facility failed to utilize pasteurized eggs in the preparation of over easy (eggs fried on both sides with a runny yolk) eggs to safely accommodate residents' choice during the breakfast meals and ensure that the unpasteurized eggs being used were cooked until all parts of the egg were completely firm to prevent the potential spread of foodborne illness. Findings include:Review of the facility's policy titled Raw Eggs, last revised 11/5/24, indicated:-It is the policy.to ensure the eggs used at the facility are properly prepared to eliminate the risk of residents contracting Salmonella Enteritidis. -All eggs must be thoroughly cooked until the yolks and whites are firm and served immediately. The temperature must reach at least 160 degrees to kill any bacteria.-Unless the eggs are pasteurized, soft cooked, under cooked, sunny side up eggs, poached eggs, over easy eggs, will not be served. Review of the facility invoices from the facility vendor dated 7/23/25, 7/30/25, 8/13/25, 8/20/25, 8/27/25, 9/3/25 and 9/10/25, indicated that the eggs purchased to make the over easy eggs in the facility were not pasteurized. On 9/10/25 at 7:04 A.M., the surveyor and the Food Service Director (FSD) observed that the eggs in the walk-in refrigerator were un-pasteurized. During an interview at the time, the FSD said that these eggs were provided to the residents fully cooked, with a firm and set yolk. On 9/10/25 at 7:15 A.M., the surveyor observed eight eggs on the warming table in the main kitchen for the breakfast meal with runny, not set, orange yolks. During an interview on 9/10/25 at 11:51 A.M., the Director of Nursing (DON) said that the eggs the kitchen staff had been using were not pasteurized eggs, and the eggs should not have been un-pasteurized for the use of over-easy eggs.

Based on record reviews, and interviews, the facility failed to resolve a grievance timely for one Resident (#7) out of a total sample of 24 residents. Specifically, for Resident #7, the facility failed to ensure that a reported grievance of missing hearing aids was resolved in a reasonable time period. Findings include: Review of the facility policy for Resident and Family Concerns and Grievances, last revised 10/5/24, indicated:-to provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations.-the facility will follow up with the Resident or their family members, guardian or representative within 72 hours of the filing of the grievance.-the facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty (30) calendar days from the day the grievance is received. -in the event the facility cannot resolve the grievance within thirty (30) calendar days, the facility will notify the resident, their family members, guardian, or representative of the status and estimated completion date of the grievance resolution.-the facility will document all steps of the grievance resolution in the facility's records, including whether or not the resident/family was satisfied with the resolution. The documentation will be kept for a minimum of three years. Resident #7 was admitted to the facility in June 2024, with diagnoses including Post Traumatic Stress Disorder (PTSD) and hearing impairment in right ear. Review of the Grievance Form dated 12/5/24, and completed by a facility employee on behalf of Resident #7 indicated:-the Resident was reporting missing hearing aids-the hearing aids were not found after a complete search and staff will continue to look for them. -the sections on the Grievance Form confirming/substantiating the grievance and noting corrective action to be taken because of the grievance were left blank.-the date assigned for resolution was 12/5/24 and was signed by the facility Administrator and Social Worker (SW). Review of Resident #7's Audiology Consultation, dated 1/6/25 indicated:-facility unable to locate hearing aids.-Nurse notes he/she was recently transferred to this wing and that many of his/her items were missing. Nurse contacted SW and they will work on finding the devices.-if they are not found, we can process the warranty for replacement devices, but the charger does not have a replacement warranty and will need to be purchased again.-if hearing aids are not found, process the Loss and Damage warranty by calling. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7:-was moderately cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 10 out of a possible score of 15.-hearing was adequate and he/she did not have hearing aids in place. During an interview on 9/10/25 at 9:55 A.M., Resident #7 said that he/she was missing his/her hearing aids and that the facility SW had the hearing aids. During an interview on 9/11/25 at 10:09 A.M., the SW said that Resident #7's grievance had been filed in December 2024 regarding his/her missing hearing aids and had been resolved by the Administrator. The SW also said that the hearing aids had not been located nor had an attempt been made to obtain a new pair through the Consulting Audiologist. The SW said that Resident #7's grievance should have been resolved much sooner and had not been. During an interview on 9/11/25 at 10:30 A.M., the Director of Nursing (DON) said that Resident #7's grievance should have been resolved within three days, and it had not been. The DON also said that the missing hearing aids had not been addressed until the surveyor brought it to the facility's attention.

Based on record review and interview, for one of eight sampled residents (Resident #3), the facility failed to ensure they obtained written informed consent for his/her psychotropic medication prior to administering the medication. Findings include: Review of the facility's policy titled Psychotropic Medication Management, revised 10/24/24, indicated that psychotropic medications will be administered upon a physician's order and informed consent by the resident or the Durable Power of Attorney/Responsible Party. Resident #3 was admitted to the facility in February 2025, diagnoses included bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), anemia (low red blood cells) osteoarthritis of the right and left knee (cartilage at the ends of bones has worn down), diabetes mellitus (trouble controlling blood sugar), hypertension (high blood pressure), and atrial fibrillation (irregular heart beat). Review of Resident #3's Minimum Data Set (MDS) Admission Assessment, dated 02/09/25, indicated he/she had moderate cognitive impairment with a score of 8 out of 15 on his/her Brief Assessment for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggest a resident is cognitively intact). Further review of the medical record indicated Resident's #3's Health Care Proxy was not activated indicating Resident #3 was able to make his/her own decisions. Review of Resident #3's Medication Administration Record (MAR) for the Month of February 2025, indicated he/she had physician's orders for and was administered the following: 8:00 A.M.-Quetiapine fumerate (anti-psychotic medication) oral tablet 300 milligrams (mg), give three tablets one time a day, start date 02/04/25, end date 02/28/25. 8:00 P.M.-Quetiapine fumerate oral tablet 100 mg, give nine tablets by mouth at bedtime, start date, end date 02/28/25. Review of Resident #3's MAR for the Month of March 2025, he/she had physician's orders for and was administered the following: 8:00 P.M.-Quetiapine fumerate oral tablet 100 mg, give 900 mg by mouth at bedtime, start date 03/13/25, end date 04/22/25. Review of Resident #3's medical record indicated there was no documentation to support that written informed consent for Quetiapine had been obtained prior to the start of administration on 02/03/25. Further review Resident #3's medical record indicated a written informed consent for quetiapine fumarate had not been obtained until 03/11/25, (37 days after the quetiapine fumerate had been initiated). Review of Resident #3's Informed Consent for Psychotropic Medication, dated 03/11/25, indicated the dosage range of Seroquel (quetiapine fumerate) for which the consent had been obtained, was 0 mg-800 mg, which did not coincide with Resident #3's current medication order of quetiapine fumerate 900 mg at bedtime. During an interview on 05/15/25 at 3:15 P.M., the Director of Nurses (DON) said that she was unable to locate and provide any documentation to support that the Facility had obtained written and signed informed consent for the use of quetiapine fumerate for Resident #3 prior to 03/11/25. The DON said that informed consent for quetiapine fumerate should have been obtained upon admission, prior to quetiapine administration on 02/03/25. In addition, the DON said that the Psychotropic Medication Informed Consent signed on 03/11/25 did not reflect Resident #3's current medication order.

Based on records reviewed and interviews, for one of eight sampled residents (Resident #7), who had an above the knee amputation, and whose Physician Orders and Plan of Care indicated that he/she required the use of bedrails for transfers, turning and positioning, the Facility failed to ensure that he/she had the necessary assistive equipment to maintain his/her safety when the left bedrail had fallen off the bed but was not repaired or replaced timely and on 04/02/25, Resident #7 sat up on the side of his/her bed reached for the bedrail, and when it wasn't there, lost his/her balance and fell . Findings include: Review of the Facility Fall Reduction Policy, dated as revised 10/30/24, indicated its purpose was to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/08/25, indicated that Resident #7 had an unwitnessed fall from his/her bed. The Report indicated that Resident #7 reported that as he/she was sitting on edge of bed he/she lost his/her balance and fell forward. The Report indicated that Resident #7 initially denied pain but later complained of right hip pain and was transferred to the emergency department for evaluation and treatment per physician recommendations. The Report indicated that Resident #7 was diagnosed with a pathological, closed sub-capital fracture of the right femur due to secondary osteoporosis. Review of Resident #7's Emergency Medicine Progress Note, dated 04/02/25, indicated that he/she presented at the Emergency Department (ED) after a fall. The Note indicated that Resident #7 reported that when he/she was trying to sit up in bed at the Facility, the bedrail was missing from the bed, he/she fell forward from a sitting position, directly onto the floor, and struck his/her forehead. Resident #7 was admitted to the Facility in July 2022, diagnoses included left leg above the knee amputation (AKA), insomnia, generalized anxiety disorder, and repeated falls. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/13/25, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #7 was independent with rolling in bed, required substantial assistance to sit on the edge of the bed and to transfer from bed to wheelchair. Review of Resident #7's Mobility Care Plan, reviewed and renewed with Quarterly MDS completed 02/13/25, indicated he/she required assistance with mobility related to his/her AKA. The Care Plan interventions indicated Resident #7 required bedrails to enable transfers from bed to chair and to enable turning and repositioning in bed. Review of Resident #7's Nurse Progress Note, dated 03/30/25, indicated Resident #7 self-transferred in and out of bed to his/her wheelchair four times without using the call bell and did not ask for staff assistance. Review of Resident #7's Physician's Orders, for April 2025, indicated he/she had orders dated effective 01/28/24, for two bilateral quarter length bedrails as an enabler for turning and repositioning in bed. Review of Maintenance Work Order #7090, created on 04/02/25 at 7:09 P.M. (after the 2:30 A.M. fall) indicated Resident #7's left bedrail needed urgent repair or replacement. Further review of the work-order indicated it was replaced at 12:00 P.M. During an interview on 05/14/25 at 3:05 P.M., Resident #7 said that he/she used bilateral bedrails to reposition in bed, sit up to the edge of bed, and during transfers. Resident #7 said on 04/02/25, at the time of the fall, the left bedrail was broken and was not on the bed. Resident #7 said he/she could not remember how long the bedrail had been broken but recalled that a CNA (exact name unknown) had been unable to reattach the bedrail because the screws were missing. Resident #7 said the CNA had assured him/her that she would notify the maintenance department. Resident #7 said that he/she sat on the edge of the bed, reached for the left bedrail, lost his/her balance, and fell forward off the bed, striking his/her right knee on the floor and hitting his/her head on the bedside table. During a telephone interview on 05/16/25 at 1:43 P.M., Nurse #5 said that she worked full time on the 11:00 P.M. to 7:00 A.M. shift on Resident #7's unit and was familiar with his/her care needs. Nurse #5 said that Resident #7 frequently sat up to the edge of the bed without assistance and sometimes transferred in and out of bed without ringing for staff assistance, despite re-education. Nurse #5 said that Resident #7 required assistance with transfers due to his/her frequent falls. Nurse #5 said that on 04/01/25 at around 11:00 P.M. during the change of shift a Certified Nurse Aide from the evening shift told her that Resident #7's left bedrail was broken and that he (the CNA) would put a maintenance work order in to have it repaired. Nurse #5 said that early the next morning, on 04/02/25 at approximately 2:30 A.M., Resident #7 had a fall from his/her bed. Nurse #5 said when she responded to Resident #7's fall she observed that he/she had fallen from the left side of his/her bed and landed on the floor in the middle of the room. Nurse #5 said the broken bedrail would have been on the same side as his/her left leg amputation. During a telephone interview on 05/15/25 at 8:23 A.M., Certified Nurse Aide (CNA) #1 said that Resident #7 recently moved onto the unit where he (CNA #1) typically worked, while his/her room was being renovated and that he was familiar with his/her care needs. CNA #1 said that Resident #7 used bilateral bedrails to assist with mobility in bed and during transfers. CNA #1 also said that Resident #7 required assistance with transfers but frequently self-transferred. CNA #1 said that when he responded to a loud crash on 04/02/25 at 2:30 A.M., found Resident #7 on the floor and observed that his/her bedside table was tipped over. CNA #1 said he observed that the bedrail was missing from the left side of Resident #7's bed and was leaning up against the wall. During an interview on 05/15/25, Unit Manager #1 said that Resident #7 required bilateral bedrails for mobility when in bed. Unit Manager #1 said that Resident #1's bedrail was broken prior to the fall and the repair request had not been entered into the maintenance work order system until after the fall. Unit Manager #1 further said she was not sure how long the bedrail had been broken. During an interview on 05/15/25 at 10:37 A.M., the Director of Maintenance said he was not made aware that Resident #7's bedrail needed repair, prior to the fall on 04/02/25. The Director of Maintenance further said that the work order system was available to all staff, on all units. During an interview on 05/15/25 at 3:15 P.M. the Director of Nurses said that the repair request for the bedrail should have been submitted at the time staff discovered the need for repair.

Based on records reviewed, observations and interviews for one of eight sampled residents (Resident #7) who was alert, oriented and made his/her own medical decisions, the Facility failed to ensure that he/she was assessed for the use of bedrails and that alternatives were trialed, prior to installing bilateral bedrails. Findings include: Review of the Facility Policy titled Side Rail Assessment, dated as revised 11/05/24, indicated the use of bedrails must be first evaluated for their appropriateness in relation to the resident's condition. The Policy indicated the alternatives explored, rationale and reason for use and condition of the resident (including the resident's cognitive ability and understanding of the use of bedrails) must be documented. The Policy further indicated that the continued use of bedrails must be assessed for appropriateness annually or more often if necessary. Resident #7 was admitted to the Facility in July 2022, diagnoses included left leg above the knee amputation (AKA), insomnia, generalized anxiety disorder, and repeated falls. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 02/13/25, indicated Resident #1 was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Further review of the MDS indicated Resident #7 was independent with rolling in bed and required substantial assistance to sit on the edge of the bed and to transfer from bed to wheelchair. Review of Resident #7's Mobility Care Plan, reviewed and renewed with Quarterly MDS completed 02/13/25, indicated he/she required assistance with mobility related to his/her AKA. The Care Plan interventions, initiated 01/29/23, indicated Resident #7 required bedrails to enable transfers from bed to chair and to enable turning and repositioning in bed. Review of Resident #7's Physician's Orders, for April 2025, indicated he/she had an order dated effective 01/28/24, for two bilateral quarter length bedrails as enablers for turning and repositioning in bed. Review of Resident #7's Medical Record indicated there was no documentation to support that he/she was assessed for the use of bedrails or that appropriate alternatives to bedrails were trialed prior to their use, and that the continued use of bedrails were assessed for appropriateness annually as per facility policy. Review of a Physical Therapy Screen, dated 04/14/25, indicated that Resident #7's bed frame, mattress and bedrails were appropriate for his/her needs. The Screen did not include an evaluation of alternatives that were attempted prior to installation or use of bed rails, and how those alternatives failed to meet the Resident's assessed needs. On 05/14/25 at 2:15 P.M., the Surveyor observed that Resident #7's bed had bilateral quarter length bedrails in the upright position. During an interview on 05/14/25 at 3:05 P.M., Resident #7 said that he/she used bilateral bedrails when repositioning in bed and during transfers for as long as he/she had been living at the Facility. Resident #7 said he/she felt he/she needed bedrails but did not recall anyone discussing the risks associated with their use. During a telephone interview on 05/15/25 at 8:23 A.M., Certified Nurse Aide (CNA) #1 said that Resident #7 used bilateral bedrails to assist with mobility in bed and during transfers. CNA #1 also said that Resident #7 required assistance with transfers but frequently self-transferred. During an interview on 05/15/25, Unit Manager (UM) #1 said that Resident #7 required bilateral bedrails for mobility when in bed. During an interview on 05/15/25 at 3:15 P.M. the Director of Nurses said that the Facility was unable to provide any documentation to support that Resident #7 had been assessed for the use of bedrails, according to Regulations and Facility Policy.

Based on record review and interviews, for one of eight sampled residents (Resident #3), whose physician's orders included the administration of a medication to manage his/her bipolar disorder, the Facility failed to ensure he/she was free from significant medication errors, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered incorrect dosages of the medication for multiple days. Findings include: Review of the Facility's policy titled Administering Medication, dated as revised 10/15/24, indicated the following: -Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards. -Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's attending physician or the facility's medical director for further instructions. Review of the Davis's Drug Guide for Nurses-19th edition (2025), indicated the usual dosage of quetiapine is 400 milligrams (mg)-800 mg per day. Resident #3 was admitted to the facility in February 2025, diagnoses included but was not limited to bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), hypertension (high blood pressure), and atrial fibrillation (irregular heart beat). Review of Resident #3's Medication Administration Record (MAR) for the Month of February 2025, indicated he/she had physician's orders and was administered the following: - 8:00 A.M.-Quetiapine fumerate (anti-psychotic medication) oral tablet 300mg, give three tablets one time a day, start date 02/04/25, end date 02/28/25. - 8:00 P.M.-Quetiapine fumerate oral tablet 100 mg, give nine tablets by mouth at bedtime, start date 02/03/25, end date 02/28/25. Review of the Resident #3 Hospital Discharge Summary, dated 02/02/25, indicated his/her physician's orders were for quetiapine 900 mg (no frequency indicated) Review of Resident #3 Hospital Active Medication List, dated 02/02/25, indicated the following: -Quetiapine 300mg tablet, give 3 tablets (total of 900 mg), per Psych (no frequency indicated). -Quetiapine 900 mg, tablet, by mouth, daily at bedtime. Review of the Hospital Psychiatric Consultation note, dated 02/01/25, indicated to administer quetiapine 900 mg, by mouth, daily at bedtime. During an interview on 05/15/25 at 10:15 A.M., Nurse Practitioner (NP) #1 said Resident #3 should not have been receiving quetiapine 900 mg, twice a day, from 02/03/25 through 02/28/25 (25 days). NP #1 said Resident #3's order for quetiapine should have been for 900 mg once a day at bedtime as indicated in his (NP) progress notes. Review of the Nurse Practitioner's Progress Note, dated 02/05/25, indicated to continue quetiapine 900 mg at HS (bedtime). During an interview on 05/15/25 at 12:50 P.M, Nurse #1 said that she had called the on-call provider on 02/03/25, during the evening shift, to obtain admission medication orders for Resident #3. Nurse #1 said that she had utilized the Hospital Discharge Summary and the Hospital Medication List to obtain telephone orders. Nurse #1 said that 900 mg of quetiapine, twice a day, had sounded like a lot of medication, but that she had reviewed the medications with the on-call provider and proceeded to enter the medication orders into the electronic medical record. Nurse #1 said that she was not sure what the usual dose of quetiapine was, and said she could have called the on-call provider back to clarify the dosage, but that she did not. During an interview on 05/15/25 at 10:00 A.M., Unit Manager #2 said that she had called the Provider on 02/28/25, because Resident #3 was lethargic and his blood pressure and heart rate were not stable. Unit Manager #2 said that during the telephone call with the Provider, she read through the list of medications Resident #3 was currently receiving and that the Provider had said that's a lot of Seroquel (quetiapine). Unit Manager #2 said she then reviewed Resident #3's Hospital Discharge Summary and noticed that the Seroquel (quetiapine) had been transcribed twice a day instead of once a day, by mistake. Review of Resident #3's Med Error report, dated 02/28/25 indicated Unit Manager #2 had called the Provider due to Resident #3's lethargy. The Report indicated that Unit Manager #2 reconciled Resident #3's admission medication orders with his/her current medication orders and obtained new orders to taper Seroquel (quetiapine), discontinue Remeron (anti-depressant), obtain an electrocardiogram (EKG-a test that records the electrical activity of the heart), encourage fluids, and obtain vital signs every four hours for seven days. During an interview on 05/15/25 at 3:15 P.M., the Director of Nurses (DON) said that her expectation was that nursing staff would have read the Psychiatric Consultation note and the Provider note and noticed the medication order discrepancy.

Based on records reviewed and interviews, for two of eight sampled residents (Resident #2 and Resident #3), who were dependent on assistance from staff for activities of daily living, the facility failed to ensure they maintained complete and accurate medical records. Findings include: Review of the Facility policy titled, Charting and Documentation, revised 11/05/25, indicated that each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized person. Resident #2 was admitted to the Facility March 2025, with diagnoses including cerebral infarction (blood flow to the brain is interrupted causing brain tissue damage), diabetes mellitus (difficulty controlling blood sugar), and osteomyelitis (inflammation of bone caused by infection). Review of Resident #2's Minimum Data Set (MDS) Admission Assessment (a comprehensive assessment of each resident's functional capabilities), dated 03/30/25, indicated he/she was dependent on staff assistance for all activities of daily living (ADL), bed positioning, transfer, and mobility. Review of Resident #2's ADL Flow Sheet (CNA documentation), dated 03/25/25 through 03/31/25, indicated for the following shifts, documentation was incomplete: -7:00 A.M. to 3:00 P.M. 1 day (out of 7 days) all ADL care areas were left blank. -3:00 P.M. to 11:00 P.M. 2 days (out of 7 days) all ADL care areas were left blank. -11:00 P.M. to 7:00 A.M. 5 days (out of 7 days) all ADL care areas were left blank. Review of Resident #2's ADL Flow Sheets dated 04/01/25 through 04/17/25, indicated that for the following shifts, documentation was incomplete: -7:00 A.M. to 3:00 P.M. 3 days (out of 17) all ADL care areas were left blank. -3:00 P.M. to 11 P.M. 5 days (out of 17) all ADL care areas were left blank. -11:00 P.M. to 7:00 A.M. 8 days (out of 17) all ADL care areas were left blank. Resident #3 was admitted to the facility in February 2025, diagnoses included anemia (low red blood cells) osteoarthritis of the right and left knee (cartilage at the ends of bones has worn down), diabetes mellitus (trouble controlling blood sugar), bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), hypertension (high blood pressure), and atrial fibrillation (irregular heart beat). Review of Resident #3's Minimum Data Set (MDS) Admission Assessment (a comprehensive assessment of each resident's functional capabilities), dated 02/9/25, indicated he/she was dependent on staff assistance for all ADLs, bed positioning, transfers and mobility. Review of Resident #3's ADL Flow Sheet (CNA documentation) dated 02/03/25 through 02/28/25, indicated for the following shifts, documentation was incomplete: -3:00 P.M. to 11:00 P.M. 11 days (out of 26) all ADL care areas were left blank. -11:00 P.M. to 7:00 A.M. 10 days (out of 26) all ADL care areas were left blank. During an interview on 05/15/25 at 9:15 A.M., Unit Manager #1 said the CNAs are responsible for completing documentation on the ADL flow sheet by the end of their shift.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate medical record when, 1) nursing documentation in Resident #1's Medication Administration Record (MAR) was incomplete, with spaces for medication administration left blank, and 2) required information in the Controlled Substance Register (record/log book used by the facility for maintaining accurate records of all narcotics and other controlled medications ordered and administered to each resident) related to resident specific medications and physician's orders, was inaccurate and incomplete. Findings include: Review of the facility's policy titled, Administering Medication, revised 10/15/24, indicated: - The individual administering the medication shall sign off on the Electronic Medication Administration Record (eMAR) date for that specific day before administering the medication. - Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall chart in the eMAR and sign off for that particular drug and document a rationale. - If it is discovered the person administering medications has forgotten to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed. If the response indicates the medication/treatment was administered, the staff member shall return to the facility, sign off on the eMAR to indicate a late entry. A late entry note will be documented indicating the administration of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed. Review of the facility's policy titled, Charting and Documentation, revised 11/05/24, indicated: - Each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons. - A medication administration record shall be maintained which records the date and time each medication ordered by the physician that is given and by whom the medication was administered. 1) Resident #1 was admitted to the facility in January 2022, diagnoses included other specified disorders of the brain, other malformations of the cerebral (part of the brain) vessels, and anxiety disorder. Review of Resident #1's Physician's Order Summary Report, dated 03/28/25, indicated his/her current and active orders included the following: - Ativan (an anti-anxiety medication), give 0.25 milligrams (mg) by mouth every 24 hours for anxiety with a start date of 02/08/24. - Clonazepam (an anti-anxiety medication), give 0.75 mg by mouth in the evening for anxiety, send half tablets of 0.25 mg each to equal 0.75 mg with a start date of 11/21/22. - Oxycodone HCl (an opioid pain medication) oral tablet, 5 mg, give one tablet by mouth three times a day for pain with a start date of 01/20/24. - Oxycodone HCl oral tablet, 5 mg, give one tablet by mouth every 24 hours for pain with a start date of 02/20/24. - Oxycodone HCl capsule, 5 mg, give one tablet by mouth every six hours as needed for moderate to severe pain with a start date of 02/18/24. Review of Resident #1's January 2025 MAR indicated that for the following scheduled medications, the dates and times were left blank: - Clonazepam 0.75 mg: 01/14/25 at 8:00 P.M. - Oxycodone 5 mg: 01/14/25 at 8:00 P.M. and 01/30/25 at 2:00 P.M. Review of Resident #1's February 2025 MAR indicated that for the following scheduled medications, the date and times were left blank: - Clonazepam: 02/01/25 and 02/22/25 at 8:00 P.M. - Oxycodone: 02/01/25 and 02/22/25 at 8:00 P.M. Review of Resident #1's March 2025 MAR indicated that for the following scheduled medications, the date and times were left blank: - Clonazepam: 03/06/25, 03/24/25, and 03/25/25 at 8:00 P.M. - Oxycodone: 03/01/25 at 2:00 P.M., 03/06/25, 03/24/25 and 03/25/25 at 8:00 P.M. Review of the Controlled Substances Register for Resident #1 indicated that the Clonazepam and Oxycodone were all signed off as being administered. During an interview on 03/26/25 at 11:11 A.M., Nurse #1 said when a nurse administers a medication to a resident, they are required to document it in the electronic health record (EHR). Nurse #1 said when they document the administration in the EHR, the MAR will show a checkmark followed by the nurse's initials, and if the MAR is blank, that means that the nurse did not document that they gave the medication. Nurse #1 said when there are blank spaces on the MAR, it appears as though the nurse did not administer the medications on those dates and times. During an interview on 03/26/25 at 4:18 P.M., Unit Manager #1 said during medication pass, the nurse is required to sign off (document) on each medication they administer in the EHR, there should be no blank spaces on the MAR and when there were blank spaces, that means the nurse did not document the medication administration. After reviewing Resident #1's January, February, and March 2025 MARs with the surveyor, Unit Manager #1 said there were several blank spaces throughout the MARs and there should not have been. During an interview on 03/26/25 at 5:10 P.M., the Assistant Director of Nursing (ADON) reviewed Resident #1's January, February, and March MARs with the surveyor. The ADON said that when passing medications, the nurse is required to sign off as having given the medications in the computer. The ADON said there should not be any blank spaces on the MARs because that means the nurse who was on duty passing the medications did not document as they should have. 2. Review of the facility's policy titled Medication Ordering and Receiving from Pharmacy: Receiving Controlled Substances, dated November 2021 indicated: - An individual resident's controlled substance record is prepared by the pharmacy or the facility for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance: 1) Name of resident 2) Prescription number 3) Drug name, strength (if designated), and dosage form of medication 4) Date received 5) Quantity received 6) Name of person receiving the medication supply Review of the Controlled Substance Register pages specific to Resident #1's medications indicated the following: - Page 1: Ativan, missing the prescription number and prescription date. - Pages 3, 15, and 38: Oxycodone, incomplete dosage directions, missing the prescription number and prescription date. - Pages 19, 22, 27, and 30: Oxycodone, incomplete dosage directions. - Page 7: Clonazepam, missing the prescription number and prescription date. - Page 16 and 37: Clonazepam, incorrect dosage directions. During an interview on 03/26/25 at 3:00 P.M., Nurse #1 reviewed the pages related to Resident #1 in the Controlled Substance Register with the surveyor, and after reviewing, said she noted several problems with them. Nurse #1 said that for every medication, there should be a prescription number and a prescription date, as well as clear medication information such as the name of the medication, the dosage/strength of the medication and and directions for administration. Nurse #1 said that there were several pages that were missing the prescription numbers and dates, that the pages for Clonazepam included directions to administer two half tablets as needed daily (and there was no order for this), and for the Oxycodone, none of the pages showed accurate administration directions for what was ordered by the physician. Nurse #1 said they failed to include a scheduled dose of Oxycodone 5 mg daily at 1:00 A.M., 5 pages failed to include the PRN (as needed) dose and directions, and three pages had no directions at all. During an interview on 03/26/25 at 3:41 P.M., Nurse #3 reviewed the pages of Resident #1's Controlled Substance Register with the surveyor. Nurse #3 said that for every medication listed, there should also be a prescription number, prescription date and that information was missing on many of the pages. In addition, Nurse #3 said Resident #1 did not receive PRN Clonazepam, could not remember him/her ever having that ordered, and it should not have been written on the Clonazepam pages. Nurse #3 said that many of the pages for Resident #1's medications in the Controlled Substance Register were incomplete and/or inaccurate. During an interview on 03/26/25 at 4:18 P.M., Unit Manager #1 reviewed the pages of Resident #1's Controlled Substance Register with the surveyor. Unit Manager #1 said that for the Oxycodone pages, the directions were incomplete, with all of the pages not including an additional scheduled 1:00 A.M. dose, some of the pages did not have any administration directions at all, and some pages failed to include the PRN dosages. Unit Manager #1 also said that every page should have a prescription number and prescription date recorded on the pages, however that information was missing from several of the pages. During an interview on 03/26/25 at 5:10 P.M., the Assistant Director of Nursing (ADON) reviewed the pages of Resident #1's Controlled Substance Register with the surveyor and said that they were missing accurate directions as well as missing prescription numbers and dates, all of which were required.

Based on interview, record and policy review, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for three Residents (#3, #62 and #39) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident's #3 and #62, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of the Resident's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). 2. For Resident #39, offer the opportunity to formulate an Advance Directive for the Resident after his/her HCP had been deactivated by the Physician. Findings include: Review of the facility policy for Advance Directives, initiated 10/16/23, indicated the following: -If utilizing a MOLST form, the order will take effect after signatures of the resident/resident representative and is signed by the Provider. -The Advance Directive shall be reviewed and updated upon resident request, with the comprehensive care plan, and with significant changes in condition. -If a resident is incapacitated at the time of admission and is unable to receive information (due to the incapacitating conditions or a mental disorder) or articulate whether or not he or she has executed an advance directive, then the facility may give advance directive information to the resident's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual or to a surrogate or other concerned persons in accordance with the law. -The facility is not relieved of its obligation to provide this information to the resident once he or she is no longer incapacitated or unable to receive such information. The facility shall implement and establish follow-up procedures to provide the information to the resident directly at the appropriate time. 1a. Resident #3 was admitted to the facility in July 2005, with a diagnosis of Schizophrenia (a mental illness that affects how a person thinks, feels and behaves). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of a total score of 15. Review of the clinical record indicated a MOLST form dated 11/4/23, that had not been signed by the Resident, Resident Representative or Physician with the request for the following: -Do Not Resuscitate (DNR) -Do Not Intubate and Ventilate (DNI/ DNV) -Do Not Use Non-Invasive Ventilation (DNIV) -Do Not Transfer to Hospital (DNH) Further review of Resident #3's clinical record indicated: -A HCP Designation Form that appointed a HCP on 7/24/07 -The Physician had invoked the Resident's HCP on 10/6/15 During an interview on 7/15/24 at 3:11 P.M., Social Worker (SW) #1 said that she reviews MOLST forms quarterly. SW #1 said that Resident #3's MOLST form was not valid because it had not been signed by the HCP or the Physician and a new MOLST should have been completed but was not completed. 45429 1b. Resident #62 was admitted to the facility in December 2023 with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #62 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of a total score of 15. Review of the clinical record revealed a MOLST form dated 2/23/24 that had not been signed by the Resident, Resident Representative or Physician with the request for the following: -Do Not Resuscitate (DNR) -Do Not Intubate and Ventilate (DNI) -Do Not Use Non-Invasive Ventilation (DNIV) -Do Not Transfer to Hospital (DNH) Further review of Resident #62's clinical record indicated: -A HCP Designation Form that appointed a HCP on 8/14/14. -The Physician had invoked the Resident's HCP on 4/14/23. During an interview on 7/15/24 at 12:07 P.M., SW #1 said that the MOLST form on file was not valid because it had not been signed by the HCP and the Physician. SW #1 also said that a new MOLST form should have been completed and it had not been. 2. Resident #39 was admitted to the facility in November 2016, with a diagnosis of spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord and nerves and can cause pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #39 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total score of 15 points. Review of Resident #39's clinical record indicated: -The Resident's HCP had been activated on 11/18/16. -The Resident's MOLST had been signed by the HCP on 11/27/16, with the request for DNR and DNI. -The Resident's HCP was de-activated by the Physician on 5/11/23, and he/she was deemed to have capacity to make medical decisions on his/her own behalf. Review of the clinical record indicated no evidence that Resident #39 had been provided with the opportunity to formulate an Advance Directive after his/her HCP had been de-activated by the Physician. During an interview on 7/15/24 at 12:02 P.M., SW #1 said that a new MOLST should have been established once the Resident was determined to have capacity for informed medical decision making.

Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner [NP]) of a significant change in condition for two Residents (#62 and #86) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. For Resident #62, when the blood sugar reading was greater than 400 mg/dL. 2. For Resident #86, when the Resident experienced an unplanned, significant weight loss of -10.73% in one month. Findings include: 1. Resident #62 was admitted to the facility in December 2023 with a diagnosis of Diabetes Mellitus Type 2 (DM II- a chronic medical condition where the body cannot effectively use insulin [hormone that regulates blood glucose/sugar] or produce enough insulin, and has trouble controlling blood sugar levels). Review of the facility's policy for Hyperglycemic (high blood sugar) Protocol, last revised 11/5/2019, included: -Early signs and symptoms of hyperglycemia may include increased thirst, increased urination, appearing tired, restlessness. -Later signs and symptoms of hyperglycemia may include lethargy, dehydration, decreased awareness, loss of consciousness. -If an Accu-check (a blood glucose measuring system) reveals a blood glucose level above 300 mg/dL (milligrams per deciliter) or level identified per individual orders, hyperglycemia should be suspected. -If any of the above signs or symptoms are identified .report the resident's diabetic condition to the Physician immediately. -Follow the resident's individual hyperglycemic protocol, if ordered by the Physician. Review of Resident #62's care plan for Insulin Dependent Diabetes last revised 5/18/23, indicated: -an intervention to monitor for signs and symptoms of hyperglycemia . -and report abnormal findings to the Physician. Review of Resident #62's care plan for Maintaining Blood Glucose Levels initiated on 7/2/24, indicated: -an intervention to monitor for a change in condition and . -notify the Physician. Review of the Resident's July 2024 Physician's orders included: -Insulin Glargine (long-acting insulin) - Subcutaneous Solution Pen- (injection between the skin and muscle for treatment of Diabetes) 100 UNIT/ML (units/milliliter); Inject 12 units subcutaneously at bedtime for Diabetes, initaited 7/2/24 -NovoLog FlexPen (fast acting insulin injection) Solution Pen-injector 100 UNIT/ML; Inject as per sliding scale: >if blood sugar is 200 - 249 mg/dL = give 2 units (u). >250 - 299 mg/dL = give 4u. >300 - 349 mg/dL = give 6u. >350 - 400 mg/dL = give 8u. >401 - 450 mg/dL = give 10u., call MD (Doctor of Medicine/ Physician) for FBS (fasting blood sugar) above 400 mg/dL, subcutaneously before meals for Preventative care, initiated 7/2/24 Review of the Resident's July 2024 Medication Administration Record (MAR) indicated the following blood sugar levels recorded at 4:30 P.M. on the following days: -7/5/24 = 404 mg/dL -7/6/24 = 425 mg/dL -7/7/24 = 416 mg/dL -7/8/24 = 411 mg/dL -7/11/24 = 442 mg/dL Review of the Resident's progress notes from 7/5/24 through 7/11/24 did not indicate any notification to the Physician related to a blood sugar result greater than 400 mg/dL. During an interview on 7/16/24 at 12:03 P.M., Unit Manager (UM) #2 said that the Physician should have been notified when Resident #62's blood sugar was over 400 mg/dL. UM #2 also said that it should have been documented in the Nurses progress notes and it had not been. 50138 2. Resident #86 was admitted to the facility in March 2024, with diagnoses including Diabetes (elevated levels of glucose in the blood), Anemia (condition that develops when the blood produces a lower than normal amount of red blood cells and/or hemoglobin [protein in red blood cells that carries oxygen from the lungs to other organs/tissues] to carry oxygen to the body's tissues), and Atrial Fibrillation (A-fib: irregular, rapid heartbeat that can lead to blood clots and other heart related complications). Review of facility policy titled Weight Assessment & Interventions dated 11/1/15, indicated: -It is the policy of this facility to prevent significant unplanned or unavoidable weight loss for our residents. -Criteria threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: a. 1 month 5% weight loss is significant, greater than 5% is severe b. 3 months 7.7% weight loss is significant, greater than 7.5% is severe c. 6 months 10% weight loss is significant, greater than 10% is severe -Nursing staff will measure resident weights on admission, and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. -Weights will be recorded in the resident's medical record -Any weight change of 5 pounds or more within 30 days will be retaken for confirmation and if the weight is verified nursing will notify the Provider and the Dietary Manager/Dietician. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #86: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total score of 15. -had identified weight loss. -recieved nutrition via tube feeding. Review of Resident #86's comprehensive care plan for Nutritional Risk, last revised 3/22/24, indicated an intervention to monitor for weight changes and notify Physican and Registered Dietician (RD) as needed. Review of Resident #86's weight record indicated the following weights: -6/1/24: 123 pounds (lbs.) -7/1/24: 109.8 lbs. (a significant change of -10.73%) Review of the Dietary assessment dated [DATE], indicated that Resident #86: -Was below ideal body weight with gain desirable. -Had triggered for significant weight loss and recommended re-weight. -No changes in the Plan of Care made at this time. -Resident was at risk for malnutrition. Review of Resident's #86 Dietary Progress Note dated 7/2/24, indicated the following: -A weight warning triggered due to (significant/severe) weight loss (-10.73%) -The accuracy of documented weight from 7/1/24 was in question. -A re-weight was requested. Review of Resident #86's clinical record did not indicate that a re-weight had been obtained since the 7/1/24 weight indicating a significant weight loss. During an interview on 7/16/24 at 1:35 P.M., Nurse #1 said that he was not aware of a request for a re-weight on Resident #86. During an interview on 7/16/24 at 1:40 P.M., Unit Manager (UM) #1 said she was unaware of the request for a re-weight by the RD and a re-weight should have been done. UM #1 was unable to provide evidence at time of survey end that the Physican had been notified of the significant weight loss for Resident #86.

Based on record review and interview, the facility failed to ensure the timely completion and transmission of the Minimum Data Set (MDS) Assessments as required for four Residents (#65, #33, #92, #72) out of five applicable residents. Specifically, the facility staff failed to ensure that the components of the MDS Assessments were completed and transmitted within the required timeframes when: 1. For Resident #65, the Assessment was transmitted 28 days after the MDS completion date. 2. For Resident #33, the MDS Assessment was completed 17 days after the ARD (Assessment Reference Date). 3. For Resident #92, A Quarterly MDS assessment with an ARD of 5/28/24, completed 6/11/24, was not yet transmitted as required. 4. For Resident #72, the MDS Assessment was completed 22 days after the ARD, and was not yet transmitted as required. Findings include: Review of the CMS Resident Assessment Instrument (RAI) Version 1.18.11 Manual dated October 2023, included the following: -Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process. -The facility is required to set the ARD on the MDS or in the facility software within the required timeframe of the assessment type being completed. -The Quarterly MDS Assessment completion date must be no later than 14 days after the ARD. -The Annual MDS assessment completion date must be no later than 14 days after the ARD. -Assessment Transmission must be within 14 days of the MDS Completion Date. 1. Resident #65 was admitted to the facility in April 2021. Review of the clinical record indicated: -A Quarterly MDS assessment with an ARD of 6/6/24, was completed 6/18/24, and transmitted 7/16/24. -Quarterly MDS assessment transmission occurred 28 days after the MDS completion date of 6/18/24. 2. Resident #33 was admitted to the facility in January 2024. Review of the clinical record indicated: -An Admission MDS assessment with an ARD of 1/15/24, was completed 2/1/24, and transmitted 2/8/24. -MDS completion occurred 17 days after the ARD. 3. Resident #92 was admitted to the facility in June 2021. Review of the clinical record indicated: -A Quarterly MDS assessment with an ARD of 5/28/24, was completed 6/11/24, and had not yet been transmitted. 4. Resident #72 was admitted to the facility in July 2018. Review of the clinical record indicated: -An Annual MDS assessment with an ARD of 6/4/24, was completed 6/26/24, and had not yet been transmitted. -MDS completion occurred 22 days after the ARD. During an interview on 7/16/24 at 8:58 A.M., with MDS Nurse #1 and MDS Nurse #2, MDS Nurse #1 said that the process is for her and MDS Nurse #2 to complete the MDS assessments and then the facility's Corporate MDS staff review and transmit the MDS assessments. MDS Nurse #1 said she and MDS Nurse #2 do not have access or permission to transmit the MDS assessments. MDS Nurse #1 said that the completion date for the MDS assessment would be 14 days from the ARD. The surveyor and MDS Nurse #1 reviewed the MDS assessment documentation. MDS Nurse #1 said that the MDS assessment for Resident #33 was completed late. MDS Nurse #1 also said that Resident #65 and Resident #92 MDS assessments were late to be transmitted. MDS Nurse #1 further said that Resident #72's MDS assessment was late to be completed and late to be transmitted.

Based on interview, record and policy review, the facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition occurred for one Resident (#2) out of a total sample of 24 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness[SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #2 received emergency mental health interventions and experienced limitations in major life activities due to mental illness. Findings include: Review of the facility policy titled Social Services - Coordination with PASRR Program, initiated 2/2/24, indicated the following: -Any resident who exhibits newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the State Mental Health or intellectual authority for a Level II resident review. Resident #2 was admitted to the facility in May 2024, and had diagnoses including Bipolar Disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior), Major Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Suicidal Ideation (verbal expressions of thoughts of harming oneself that may or may not lack specific intent). Review of the PASRR Level I form dated 5/9/24, indicated the following: -Resident #2 had a documented mood disorder (bipolar disorder/major depression). -Resident did not have any treatments due to mental illness. -Resident did not have a history of emergency mental health interventions. -Resident did not have any functional life impairments due to mental illness. -Negative screen result and Level II PASRR evaluation was not needed. Review of Resident #2's Clinical Record indicated the following Nursing Progress Notes: -On 5/13/24, Resident #2 reported intermittent suicidal ideation. The Resident was evaluated by the Nurse Practitioner (NP) and deemed not currently/actively suicidal. Resident did not need to be transferred to the emergency room (ER) at that time. -On 5/14/24, Resident #2 was transferred to the Hospital for suicidal ideation and returned after crisis evaluation in the ER. -On 6/17/24, Resident #2 said to the Nurse that he/she would rather die than eat and had not eaten in 2 days. The NP was made aware and Resident #2 was transferred to the hospital. During an interview on 7/12/24 at 2:38 P.M., the SW (Social Worker) said the Social Service department was responsible for completing the PASRR form and that she reviews the PASRR form prior to the initial social service assessment. The SW said if new information is identified during the assessment process indicating a change from the initial PASRR, she will submit a new PASRR form indicating a request for Level II evaluation. The surveyor and the SW reviewed Resident #2's PASRR Level I evaluation and the SW said that the Resident did not trigger for a Level II on 5/9/24. The SW further said that Resident #2's suicidal ideation would be considered a change and that a PASRR Level II should have been requested, but had not been.

Based on observation, interview, and record review, the facility failed to provide care and services to address a hearing problem for one Resident (#57), out of a total sample of 24 residents. Specifically, the facility staff failed to provide care and services that would maintain or improve Resident #57's hearing and communication when there was a decline in hearing ability, and the Resident/ Resident Representative had consented to be seen for audiology (the science of hearing, balance and related disorders) services. Findings include: Review of the facility policy for Physician Services, initiated 10/16/23, indicated: -Each resident shall be under the care of a licensed Physician. -Physician's services include but are not limited to . ancillary services (Health Care Providers that support Primary Care Providers) of additional Providers based upon the individual need. -Provision for and coordination with the attending provider. Resident #57 was admitted to the facility in November of 2023, with a diagnosis of hearing loss. Review of the Physician's orders indicated an order dated 2/29/24, for ancillary and specialty care as needed. Review of Resident #57's clinical record indicated a Request for Service Form signed by the Resident's Representative requesting Audiology services on 3/7/24. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had moderate hearing loss but was able to understand others without hearing aids. Review of the MDS assessment dated [DATE], indicated the Resident had moderate hearing loss, no hearing aids, and only sometimes understood others. Review of Resident #57's care plan for Communication Deficit initiated on 12/19/23, last revised 6/12/24, indicated that the Resident had a hearing deficit. During an interview on 7/11/24 at 9:44 A.M., Resident #57 said he/she was very deaf, could not understand what the surveyor was asking and could not read lips. The Resident also said that he/she did not have hearing aids and had recently lost his/her hearing. Review of the clinical record did not indicate that Resident #57 had been provided with audiology services as requested on 3/7/24. During an interview on 7/15/24 at 10:15 A.M., the Director of Nursing (DON) said Resident #57 had never been referred to an Audiologist and should have been referred, because the family (Resident's Representative) had consented to audiology services.

Based on observation, interview, policy and record review, the facility failed to ensure that the administration of enteral (also referred to as tube feeding) nutrition was consistent with and followed the Physician's orders for one Resident (#76) out of a total sample of 24 residents. Specifically, the facility staff failed to administer the Physician ordered volume (quantity) of tube feeding for Resident #76, whose sole source of nutrition are enteral feeds thus placing the Resident at risk for altered nutritional status. Findings include: Resident #76 was admitted to the facility in September 2020, with diagnoses including Subarachnoid Hemorrhage (SAH - bleeding in the space between the brain and the tissue covering the brain) and Respiratory Failure (a serious condition that makes it difficult to breathe on your own that develops when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #76: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of a total score of 15. -and received nutrition via feeding tube. Review of facility policy titled Tube Feeding, dated 11/28/23, indicated: -It is the purpose of this policy to ensure safe and effective use of the tube and maintain the integrity of the tube per the Provider's orders. -Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that any necessary interruptions of feeding will not decrease volume infused: >Bolus Feeding (a method of tube feeding that involves administering a limited volume of enteral formula or liquid food through a feeding tube in several doses over brief periods of time throughout the day) procedure includes: -Verify Physician order for enteral feeding via bolus method. -Gather necessary equipment. -Identify resident. -Pour prescribed amount of feeding into syringe. -Refill the syringe until the feeding is complete. -Clamp (close) tube and detach syringe. Review of Resident #76's July 2024 Physician's orders included the following: -NPO (nothing by mouth). -Gastrostomy tube (G-tube: a soft, flexible tube that passes through the abdominal wall and into the stomach) 18 French (6 millimeter [mm] diameter tube) for diet. -Enteral feed order: Osmolite 1.5 CAL (a therapeutic nutrition solution for tube fed residents) bolus 356 milliliters (ml) four times a day. -Flush tube with 150 ml of water every six hours. -Flush tube with 60 ml of water before each medication pass every shift. Review of Resident #76's comprehensive care plan last revised 5/22/24, indicated the Resident: -was at a Nutritional Risk given weight loss -was NPO -had enteral feeding as the sole source of nutrition, and included the following interventions: >Provide enteral feedings and flushes as ordered by Physician to maximize nutritional intake and monitor tolerance. >NPO On 7/15/24 at 11:57 A.M., the surveyor observed Nurse #1 administer 60 milliliters (ml) of water flush to Resident #76 though the G-tube followed by four 60 ml syringes of Osmolite 1.5 CAL tube feeds for a total dose of 240 ml. The surveyor observed Nurse #1 administering an additional 60 ml of water flush after the tube feeds and then closed the G-tube port. During an interview on 7/15/24 at 12:15 P.M., Nurse #1 said the total dose of Osmolite 1.5 CAL that was given to the Resident was about 237 ml. Nurse #1 said that the correct dose that should have been given was 356 ml (with a deficit of 119 ml tube feeds that was not administered) and that he had not given the correct volume as ordered by the Physician. Nurse #1 said it is important for Resident #76 to get the proper volume (tube feeds) because that is Resident #76's only food and nutrition available.

Based on observation, interview, policy and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#15), out of a total sample of 24 residents. Specifically, the facility failed to maintain an oxygen concentrator (a device used to deliver supplemental oxygen) filter for Resident #15 in a clean, safe and functional manner in accordance with Physician orders, placing Resident #15 at risk for impaired oxygen delivery and equipment malfunction. Findings include: Review of the facility policy titled Oxygen Administration and Storage, dated 10/16/23, indicated the following; -It is the purpose of the policy to ensure staff follow safety guidelines and regulation for storage and use of Oxygen. -Filters should be removed and cleaned by rinsing with clear, cool water as needed to maximize flow rate of clean air. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates in part: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. -Equipment maintenance and supervision: *All oxygen delivery equipment should be checked at least once daily *Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Resident #15 was admitted to the Facility in November 2023, with diagnoses including Asthma (a condition in which airways narrow and swell [inflammation] making it difficult to breathe) and Acute Respiratory Failure (an inability to maintain adequate oxygenation for tissues within the body or remove enough carbon dioxide from the body). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a total score of 15. Review of Resident #15's Physician's orders for July 2024 included: -Oxygen: one liter per minute (LPM) via nasal cannula (a device that delivers supplemental oxygen through a tube and into the nose) continuous (non-stop around the clock) for shortness of breath. -Clean filter on oxygen concentrator weekly every night shift (11:00 P.M. - 7:00 A.M.), every Friday for supplemental O2 (Oxygen). Review of Resident #15's comprehensive care plan, last revised 6/11/24, indicated the Resident: -had an alteration to his/her respiratory system. -an intervention to administer medications and treatments as ordered by MD. On the following dates and times, the surveyor observed the Oxygen flow rate for Resident #15 was set at 1 LPM via nasal cannula and a thick coating of gray dust on the oxygen concentrator filter: -7/11/24 at 8:53 A.M. -7/12/24 at 11:15 A.M. -7/15/24 at 4:12 P.M. During an observation and interview on 7/15/24 at 4:12 P.M the Unit Manager (UM) said the Physician's orders were that Resident #15's oxygen concentrator filter was to be cleaned weekly on Fridays. The UM said filter cleaning had been signed off as complete on 7/5/24 and 7/12/24. The surveyor and the UM observed the oxygen concentrator filter that was still coated in dust. The UM said the filter cleaning did not appear to have been done as ordered. During a follow-up interview on 7/16/24 at 1:27 P.M., the UM said it is important for the oxygen concentrator filters to be cleaned as ordered to prevent equipment malfunction, allergens, and germs, putting a resident with respiratory diagnosis like Asthma at risk for breathing trouble.

Based on observation, interview, and record review, the facility failed to provide dental care and services as required for one Resident (#39) out of a total sample of 24 residents. Specifically, the facility staff failed to refer Resident #39 for dental services, when the Resident had consents for dental care and services. Findings include: Resident #39 was admitted to the facility in November 2016, with diagnoses including Quadriplegia (condition where all four limbs and body from the neck down are paralyzed. Can be caused by spinal cord injury or medical conditions). Review of Resident #39's clinical record indicated a Request For Service Form signed by the Resident's Representative on 12/3/19 for dental services. Review of the facility policy for Physician Services, initiated 10/16/23, indicated: -Each resident shall be under the care of a licensed Physician. -Physician's services include but are not limited to . ancillary services (Health Care Providers that support Primary Care Providers) of additional Providers based upon the individual need including but not limited to .dental. -Provision for and coordination with the attending Provider. Review of Resident #39's care plans initiated 2/7/21, and last revised 5/30/24, indicated that the Resident was at risk for oral health and dental care problems. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #39 was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 12 out of a total 15 points. Further review of the MDS indicated that the Resident was dependent on staff for assistance with oral hygiene. Review of the July 2024 Physician's orders indicated: -an order to obtain a Dental Consult and treatment for patient health and comfort as needed, dated 12/8/20. During an interview on 7/11/24 at 8:06 A.M., Resident #39 said that he/she has never been seen by the Dentist and would like to be seen. Resident #39 also said that his/her brother helps him/her to clean his/her teeth. Review of Resident #39's medical record failed to indicate whether Resident #39 was ever seen by the Dentist. During an interview on 7/15/24 at 10:17 A.M., the Director of Nursing (DON) said that Resident #39 had not been seen by the Dentist. The DON said the Resident should have been seen because the dental services consent had been signed by the Resident's Representative.

Based on observation, interview, and policy review, the facility failed to maintain safe and sanitary conditions in accordance with professional standards for food service safety on three unit kitchenettes (F Wing, C Wing, and A Wing) out of four applicable unit kitchenettes, to prevent contamination and food borne infections. Specifically, 1) The facility failed to maintain clean and sanitary conditions for the unit kitchenette refrigerators on the F Wing, C Wing and A Wing unit. 2) The facility failed to maintain clean and sanitary conditions for a unit microwave on the F Wing unit. 3) The facility failed to store food safely in the refrigerator in the kitchenette on the A Wing unit. Findings include: Review of the facility policy titled Food Storage Areas last revised June 2023, indicated the following: -Food storage areas will be maintained in a clean, safe and sanitary manner. -Prepared food stored in the refrigerator until service shall be dated. Such food will be tightly sealed with plastic wrap, foil or a lid. On 7/16/24 at 8:34 A.M., the surveyor and Unit Manager (UM) #2 observed a sticky red and brown substance splattered on the inside of the refrigerator door on the upper and lower shelves of the refrigerator located in the F Wing kitchenette. The surveyor and UM #2 also observed food debris splattered inside the microwave located in the F Wing unit kitchenette. During an interview at the time, UM #2 said she thought that housekeeping and/or dietary staff were responsible for cleaning the refrigerator and microwave in the kitchenette. UM #2 said that the refrigerator and the microwave were dirty and should have been cleaned as soon as possible. UM #2 said she would find out who to notify to clean the refrigerator and microwave in the kitchenette. On 7/16/24 at 8:45 A.M., the surveyor and Certified Nurses Aide (CNA) #2 observed a sticky red brown substance splattered on the inside of the refrigerator door on the upper and lower shelves and on the bottom floor inside the refrigerator located in the C Wing kitchenette. During an interview at the time CNA #2 said that the refrigerator was dirty. CNA #2 also said that the refrigerator is always dirty and should have have been cleaned by housekeeping staff. On 7/16/24 at 8:56 A.M., the surveyor and Nurse #2 observed a sticky red substance on the inside refrigerator door on the upper shelf and in the freezer located in the A Wing kitchenette. The surveyor and Nurse #2 also observed three plastic containers of food in the refrigerator that were unlabeled and undated. During an interview at the time, Nurse #2 said that the refrigerator and freezer were dirty, and he was unsure who was responsible for cleaning the refrigerator and freezer. Nurse #2 also said that he did not know how long the unlabeled and undated food had been in the refrigerator but that the food should have been labeled, dated, and discarded after 72 hours. During an interview on 7/16/24 at 11:55 A.M., the Food Service Director (FSD) said that the Dietary department was responsible for the maintenance and cleaning of the appliances located in the unit kitchenettes. The FSD said that there should not have been any liquid or food splatter left in any of the kitchenette appliances. The FSD also said that dietary staff try to clean up spills when they stock the kitchenettes each day and that no routine maintenance and cleaning schedule had been developed or implemented for cleaning the refrigerators and microwaves in the kitchenettes, but there should have been a maintenance and cleaning schedule in place.

Based on interview, policy and record review, the facility failed to maintain complete and accurate medical records, including provision of support services for one Resident (#2) out of a total sample of 24 residents. Specifically, the facility failed to document social service supportive visits for Resident #2 after the Resident required multiple hospital evaluations for suicidal ideation (verbal expressions of thoughts of harming oneself that may or may not lack specific intent). Findings include: Review of the facility policy titled Responding to Intent to Self-harm, revised 3/13/23, indicated the following: -Staff should document behaviors in accordance with the behavior management policy. -Documentation should be ongoing. -Said documentation should include all plans, goals, interventions, behavior tracking, and care plan updates when available. -Always document efforts, situations, observations, date and times, location, witnesses, staff members present, outcomes, who was contacted and who made the contact as well as future plans for safety. Review of the facility policy titled Behavior Management, revised 11/5/19, indicated the following: -Document evaluation of the presence of behavioral symptoms or the potential for behavioral symptoms in the residents' medical record and care plan. -Document the initiation of the behavioral interventions and mental health professional visits (if applicable) in the resident's medical record and care plan. -Document non-pharmacological (without use of medication) interventions attempted and resident response. Review of the facility policy titled Social Services-Behavioral Health, revised 11/15/21, indicated the following: -The identified need, assessment, plan, and outcomes will be documented through the care planning process and in nursing/social service progress notes. Resident #2 was admitted to the facility in May 2024, with diagnoses including Bipolar Disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior), Major Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Suicidal Ideation. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total of 15. -and reported feeling depressed daily in the past two weeks. During an interview on 7/11/24 at 12:01 P.M., Resident #2 said that he/she was admitted to the facility for short-term rehabilitation services but was unable to return to his/her home. The Resident further said that he/she had a history of suicidal ideation, was frustrated with his/her situation, and had been sent out to the hospital for mental health evaluation. Review of the Resident #2's Clinical Record indicated the following Nursing Progress Notes: -On 5/13/24: Resident #2 reported intermittent suicidal ideation. The Resident was evaluated by the Nurse Practitioner (NP) and deemed not currently/actively suicidal. Resident did not need to be transferred to the ER at that time. -On 5/14/24: Resident #2 was transferred to the Hospital for suicidal ideation and returned after crisis evaluation in the ER. -On 6/17/24: Resident #2 said to the Nurse that he/she would rather die than eat and had not eaten in 2 days. The NP was made aware and Resident #2 was transferred to the hospital. Review of the Resident's Plan of Care initiated 5/14/24, indicated Resident #2 was at risk for alteration in mood status due to suicidal ideation and included the following interventions: -Encourage Resident to express feelings. -Monitor/record/report to MD (Physican) as needed mood patterns, sign or symptoms of Depression, anxiety, sad mood as per facility behavior monitoring protocols. Further review of Resident #2's Clinical Record did not indicate that any social service supportive visits occurred after Resident #2 expressed suicidal ideation on the following dates: -5/13/24 -5/14/24 -6/17/24 During an interview on 7/12/24 at 1:19 P.M., the Social Worker (SW) said her process is to check in with Resident #2 daily for support and that she documents those visits in a progress note. The surveyor and the SW reviewed the clinical record and there were no documentation of social service supportive visits.The SW said that she was unable to recall if she met with Resident #2 after 5/13/24 or 5/14/24. The SW said when Resident #2 returned from the hospital on 6/17/24, she met with the Resident for a supportive visit and have provided other visits since then. The SW said that she did not document the supportive visits and should have.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to acquire and dispense [MEDICATION NAME] ([MEDICATION NAME]; an antipsychotic medication), in accordance with the physician's orders [REDACTED].#1 not receiving his/her [MEDICATION NAME] on multiple occasions from 05/15/19 through 06/21/19, he/she was hospitalized four times from 06/21/19 to 07/04/19 because of threatening, aggressive, and violent behaviors. Findings include: Review of the U.S. Food and Drug Administration (FDA) website indicated that on 01/16/19, an update was issued regarding the implementation of modifications to the [MEDICATION NAME] Risk Evaluation and Mitigation Strategy (REMS) Program, which was launched on 10/12/15. The FDA indicated that the modifications would be effective 02/28/19, and included, but were not limited to: prescribers and pharmacies must be certified by 02/28/19 or they would no longer be able to prescribe/dispense [MEDICATION NAME]. Review of the [MEDICATION NAME] REMS Program website indicated that if the prescriber was not certified in the [MEDICATION NAME] REMS Program, the outpatient pharmacy would not receive authorization to dispense [MEDICATION NAME]. The Website indicated that if a prescriber was not certified, the pharmacy should contact the prescriber to inform them they must be certified. The Website indicated that the pharmacy could provide a Dispense Rationale and reattempt authorization, and that Dispense Rationales were valid for 72 hours (3 calendar days) and were limited to no more than three occurrences for an individual patient within a rolling six-month period. Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Physician admission orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the delivery slips from the pharmacy for Resident #1's [MEDICATION NAME] indicated that: - Seven tablets were delivered to the facility on [DATE]; and, - Seven tablets were delivered to the facility on [DATE]. Therefore, Resident #1 did not receive [MEDICATION NAME] as ordered by the physician on 05/15/19 or 05/23/19 because it was not available at the Facility. Review of Resident #1's MAR, dated 06/01/19 through 06/30/19, indicated that Resident #1's [MEDICATION NAME] was not administered on 06/07/19, 06/08/19, 06/09/19, 06/18/19, 06/19/19, or 06/20/19. The MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Review of the delivery slips from the pharmacy for Resident #1's [MEDICATION NAME] indicated that: - Seven tablets were delivered to the facility on [DATE]; and, - Seven tablets were delivered to the facility on [DATE]. Therefore, Resident #1 did not receive [MEDICATION NAME] as ordered by the physician on 06/07/19, 06/08/19, 06/09/19, 06/17/19, 06/18/19, 06/19/19, and 06/20/19 because it was not available at the Facility. Review of Resident #1's Nursing Documentation Note, dated 06/21/19 at 11:56 A.M. and written by Nurse #1, indicated that the pharmacy was contacted because Resident #1's [MEDICATION NAME] had not been sent and he/she missed a few doses. The Note indicated that Nurse #1 was told the physician was not certified to prescribe the medication and that the pharmacy would be unable to fill it. The Note indicated that the Unit Manager and acting Director of Nurses (DON) were notified. The Note indicated that Resident #1 had been louder and angrier than usual. Review of Resident #1's Nursing Documentation Note, dated 06/21/19 at 1:54 P.M. and written by Nurse #1, indicated that Resident #1 walked out of the day room, slammed his/her walker on the ground, and yelled I [***] ing hate you and I'm going to kill you! Review of Resident #1's General Note, dated 06/21/19 at 3:56 P.M., indicated that Resident #1 was sent to the hospital via a Section 12 (an application for authorization for the emergency transportation, typically to a hospital, and restraint of persons posing risk of serious harm to themselves or others by reason of mental illness). Review of Resident #1's Nursing Documentation Note, dated 06/23/19, indicated that he/she was readmitted to the Facility. Review of Resident #1's General Note, dated 06/24/19, indicated that Resident #1 had episodes of verbal outbursts, screaming, swearing, and yelling. The Note indicated that the pharmacy could not fill Resident #1's [MEDICATION NAME] prescription from the hospital because the hospital physician was not certified to prescribe the medication. Review of the delivery slips from the pharmacy for Resident #1's [MEDICATION NAME] indicated that eleven tablets were delivered to the facility on [DATE]. Review of Resident #1's Physician Note, dated 06/26/19 and signed by the Medical Director, indicated that Resident #1 missed taking a couple of his/her [MEDICATION NAME] doses. The Note indicated that the Medical Director was unaware that ordering [MEDICATION NAME] required special program registration. The Note also indicated that another physician (identified by the Director of Nurses as a physician associated with the Facility) was registered and able to prescribe [MEDICATION NAME] for Resident #1. Review of the Facility's Internal Investigation included written statements from staff, dated 06/27/19, indicated that on an unspecified date, Resident #1 barricaded himself/herself in another resident's room. The Investigation also indicated that Resident #1's roommate requested a room change as he/she feared for his/her life because of Resident #1's behaviors. The Surveyor interviewed the Director of Nurses (DON) at 8:17 A.M. and at multiple times on 08/08/19. The DON said she was unclear at the time of survey whether the Facility's Medical Director, who was Resident #1's attending physician, was certified to prescribe [MEDICATION NAME]. The Surveyor interviewed the Pharmacist-in-Charge at 2:01 P.M. on 08/08/19. The Pharmacist-in-Charge said the [MEDICATION NAME] REMS Program was a federally mandated program that required prescribers to be certified with the Program effective 02/28/19. The Pharmacist-in-Charge said that neither the physician who prescribed Resident #1's [MEDICATION NAME] in the Facility, nor the hospital emergency room physician were certified with the Program and so requests to fill Resident #1's [MEDICATION NAME] prescription were denied. The Pharmacist-in-Charge said pharmacies enrolled in the Program were allowed to override denials for authorization to dispense [MEDICATION NAME] up to three times. The Pharmacist-in-Charge said that each time an override was done for Resident #1's [MEDICATION NAME], Facility staff were notified, but said she did not have documentation to indicate which specific staff were notified. There was no documentation to support that the Facility acquired and dispensed Resident #1's daily [MEDICATION NAME] as prescribed by the physician, because the physician was not enrolled in the federally mandated program for prescribers, and therefore the pharmacy was unable to fill the prescription.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to administer [MEDICATION NAME] ([MEDICATION NAME]; an antipsychotic medication) to a resident in accordance with the physician's orders [REDACTED]. As a result of Resident #1 not receiving his/her [MEDICATION NAME] on multiple occasions from 05/15/19 through 06/21/19, he/she was hospitalized four times from 06/21/19 to 07/04/19 because of threatening, aggressive, and violent behaviors. Findings include: Review of [MEDICATION NAME] Prescribing Information from the U.S. Food and Drug Administration, revised (MONTH) (YEAR), indicated that: - If patients miss taking [MEDICATION NAME] for more than two days, they should not restart their medication at the same dosage, but should contact their physician for dosing instructions; - In the event of abrupt discontinuation of [MEDICATION NAME], the patient should be carefully observed for the recurrence of symptoms including psychotic symptoms (which include, but are not limited to: suicidal thoughts, aggression, hostility, delusions, and hallucinations); - When restarting patients who have had even a brief interval off of [MEDICATION NAME] (i.e., two or more days since the last dose), it is recommended that treatment be reinitiated with 12.5 milligrams (mg) once or twice daily; and, - Certain additional precautions may be needed when reinitiating treatment because re-exposure of a patient might enhance the risk of an untoward reaction and an increase its severity. Review of the Journal of the American Medical Association article Serotoni[DIAGNOSES REDACTED] Associated With [MEDICATION NAME] Withdrawal, dated (MONTH) 2013, indicated that the abrupt withdrawal of [MEDICATION NAME] had been associated with [MEDICATION NAME] rebound (symptoms include, but are not limited to: restlessness and agitation), and rapid onset of [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Resident #1 was admitted to the Facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Physician admission orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. In addition, there was no documentation on the MAR indicated [REDACTED]. Review of Resident #1's progress notes indicated that there was no documentation to support why he/she was not administered [MEDICATION NAME] on 06/08/19, 06/09/19, 06/18/19, 06/19/19, or 06/20/19. The Notes also indicated that there was no documentation to support whether the attending physician (the Medical Director) and/or prescriber was notified of the medication shortages. Review of Resident #1's Nursing Documentation Note, dated 06/21/19 at 11:56 A.M. and written by Nurse #1, indicated that the pharmacy was contacted because Resident #1's [MEDICATION NAME] had not been sent and he/she missed a few doses. The Note indicated that Nurse #1 was told the physician was not certified to prescribe the medication, and that the pharmacy would be unable to fill it. The Note indicated that the Unit Manager and acting Director of Nurses (DON) were notified. The Note indicated that Resident #1 had been louder and angrier than usual. Review of Resident #1's Nursing Documentation Note, dated 06/21/19 at 1:54 P.M. and written by Nurse #1, indicated that Resident #1 walked out of the day room, slammed his/her walker on the ground, and yelled I [***] ing hate you and I'm going to kill you! Review of Resident #1's General Note, dated 06/21/19 at 3:56 P.M., indicated that Resident #1 was sent to the hospital via a Section 12 (an application for authorization for the emergency transportation, typically to a hospital, and restraint of persons posing risk of serious harm to themselves or others by reason of mental illness). Review of Resident #1's General Note, dated 06/23/19, indicated that he/she was readmitted to the Facility. Review of Resident #1's General and Nursing Documentation Notes, dated 06/24/19, indicated that Resident #1 had episodes of verbal outbursts, screaming, swearing, and yelling. The Note indicated that the pharmacy could not fill Resident #1's [MEDICATION NAME] prescription from the hospital because the hospital physician was not certified to prescribe the medication. Review of Resident #1's Alert Note, dated 06/25/19, indicated that he/she had been intermittently cursing and threatening homicidal ideation (thoughts of homicide), and wandering into other residents' rooms. The Note indicated that Resident #1 was sent to the hospital via emergency services after attempting to grab the nurse's neck. Review of Resident #1's General Note, dated 06/26/19 at 6:16 A.M., indicated that he/she returned from the hospital. Review of Resident #1's General Notes, dated 06/26/19 at 11:19 P.M., indicated that he/she was sent to the hospital because of aggressive behavior towards staff and other residents, screaming profanities, wandering into other residents' rooms, and threats to kill staff. Review of the Facility's Internal Investigation included written statements from staff, dated 06/27/19, which indicated that on an unspecified date, Resident #1 barricaded himself/herself in another resident's room. The Investigation also indicated that Resident #1's roommate requested a room change as he/she feared for his/her life because of Resident #1's behaviors. Review of Resident #1's Physician Note, dated 06/26/19 and signed by the Medical Director, indicated that Resident #1 was sent to the hospital a couple of times the previous week (06/19/19 - 06/26/19) as he/she got very agitated recently. The Note indicated that Resident #1 missed taking a couple of his/her [MEDICATION NAME] doses, and that the hospital recommended restarting the medication on a titrating dose (the process of adjusting the dose of a medication for the maximum benefit without adverse effects). The Note indicated that the Medical Director was unaware that ordering [MEDICATION NAME] required special program registration. Review of the U.S. Food and Drug Administration (FDA) website indicated that on 01/16/19, an update was issued regarding the implementation of modifications to the [MEDICATION NAME] Risk Evaluation and Mitigation Strategy (REMS) Program, which was launched on 10/12/15. The FDA indicated that the modifications would be effective 02/28/19, and included, but were not limited to: prescribers and pharmacies must be certified by 02/28/19 or they would no longer be able to prescribe/dispense [MEDICATION NAME]. Review of the [MEDICATION NAME] REMS Program website indicated that if the prescriber was not certified in the [MEDICATION NAME] REMS Program, the outpatient pharmacy would not receive authorization to dispense [MEDICATION NAME]. The Surveyor interviewed the Pharmacist-in-Charge at 2:01 P.M. on 08/08/19. The Pharmacist-in-Charge said the [MEDICATION NAME] REMS Program was a federally mandated program that required prescribers of [MEDICATION NAME] to be certified with the Program. The Pharmacist-in-Charge said that neither the physician who prescribed Resident #1's [MEDICATION NAME] in the Facility, nor the hospital emergency room physician were certified with the Program, and so requests to fill Resident #1's [MEDICATION NAME] prescription were denied. The Pharmacist-in-Charge said pharmacies enrolled in the Program were allowed to override denials for authorization to dispense [MEDICATION NAME] up to three times. The Pharmacist-in-Charge said that each time an override was done to fill Resident #1's [MEDICATION NAME], Facility staff were notified. Review of Resident #1's Nutrition Note, dated 06/28/19, indicated that he/she was readmitted from the hospital. Review of Resident #1's Nursing Documentation Note, dated 06/28/19, indicated that he/she was disoriented, incoherent, agitated, and expressed suicidal ideation. Review of the General Note, dated 07/01/19, indicated that Resident #1 continued to require one-on-one supervision for episodes of verbal outbursts, yelling and swearing. Review of Resident #1's Nursing Documentation Note, dated 07/02/19, indicated that he/she continued to exhibit physical and verbal behaviors, and was experiencing delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary). Review of Resident #1's Alert Note, dated 07/04/19, indicated that a physician's orders [REDACTED].#1 to the hospital due to medication non-compliance, aggression, violent, threatening behavior, and asking for razors. Review of Resident #1's clinical record indicated that there was no documentation to support that prior to 06/21/19, Resident #1 exhibited suicidal or homicidal thoughts or actions, violent, aggressive, or threatening behavior at the Facility. The Surveyor interviewed the Administrator and Director of Nurses (DON) at 8:17 A.M. and at multiple times on 08/08/19. The Administrator and DON said staff reported that Resident #1 decompensated following multiple episodes of not receiving his/her [MEDICATION NAME], as evidence by increased behaviors, increased aggression, and repeated transfers to the hospital because of the exhibited behaviors. Review of Resident #1's clinical record and pharmacy delivery slips indicated that there was no documentation to support that the Facility provided Resident #1's prescribed [MEDICATION NAME] in accordance with a physician's orders [REDACTED].

Based on records reviewed and interviews for 1 of 3 sampled closed records (Resident #275), the facility staff failed to follow Resident #275's plan of care and assess, treat, and monitor the resident for pain. Findings include: Review of the Facility Policy, titled Pain Management, dated 11/28/16, indicated at a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain and complete the Pain Presence Monitor Flowsheet. Resident #275 was admitted on ,[DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment, dated 11/14/17, indicated the resident was on a scheduled pain medication regimen. Review of the Hospice care plan, dated 11/15/17, indicated the following interventions: to assess for pain, restlessness, agitation, constipation and other symptoms of discomfort, to medicate as ordered and evaluate effectiveness. Review of the Alteration in Comfort care plan, dated 11/15/17, indicated the following interventions were to: evaluate pain characteristics, utilize pain scale, medicate resident as ordered for pain and monitor effectiveness, monitor for nonverbal signs/symptoms of pain and medicate as ordered, monitor for change in mood or mental status, and monitor for nonverbal signs of pain: increased agitation, grimace, and resistive to care. Review of the Medication Administration Record [REDACTED]. Review of the Controlled Substance Register, Book #269, page 31, indicated an order for [REDACTED]. Review of the Pain Presence Monitor Flowsheet, dated (MONTH) (YEAR), indicated no documentation that the resident was assessed for pain. Further review of the clinical record indicated no further documentation that the resident was assessed for pain. The Surveyor interviewed the resident's invoked Health Care Proxy (HCP) at 9:35 A.M. on 2/1/18. The HCP said when he/she visited him/her on 11/15/17, he/she was anxious, agitated, and grabbing at his/her stomach in pain. The HCP said he/she spoke with the nursing staff and was informed the resident was not medicated because his/her medications had not been received from the pharmacy, 24 hours after admission to the facility. The HCP said he/she took the resident home at 6:45 P.M. on 11/15/17 due to the facility not administering his/her physician ordered pain medication. The Surveyor interviewed Nurse #2 at 2:21 P.M. on 2/1/18. Nurse #2 said she did not administer the scheduled [MEDICATION NAME] for Resident #275 at 2:00 P.M. and 5:00 P.M. on 11/14/17. Nurse #2 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME] for Resident #275. The Surveyor interviewed Nurse #9 at 8:35 A.M. on 2/5/18. Nurse #9 said she did not administer the scheduled [MEDICATION NAME] for Resident #275 at 8:00 P.M. and 11:00 P.M. on 11/14/17. Nurse #9 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME] for Resident #275. The Surveyor interviewed Nurse #10 at 1:43 P.M. on 2/1/18. Nurse #10 said she did not administer the scheduled [MEDICATION NAME] for Resident #275 at 8:00 A.M., 11:00 A.M., 2:00 P.M., and 5:00 P.M. on 11/15/17. Nurse #10 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME] for Resident #275. Review of a Nursing Progress Note, dated 11/15/17 at 18:47 (6:47 P.M.), documented by Nurse #10, indicated the resident's medications were not available, that the pharmacy was notified, and that the resident left AMA (against medical advice) with spouse. The Surveyor interviewed the Director of Nurses (DON) at 9:15 A.M. and at 10:45 A.M. on 2/2/18. The DON said Resident #275's pain should have been assessed at least every shift, and that there was no documentation in Resident #275's clinical record that this was done. The DON said the [MEDICATION NAME] was available in the emergency kit system. The DON said new admissions medications should be received from the pharmacy within 4 hours or so.

Based on records reviewed and interviews for 1 of 3 sampled closed records (Resident #275), the facility staff failed to assess, medicate, and monitor Resident #275, who was on hospice care for end stage [MEDICAL CONDITION], for pain. Findings include: Review of the Facility Policy, titled Pain Management, dated 11/28/16, indicated at a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain and complete the Pain Presence Monitor Flowsheet. Resident #275 was admitted on ,[DATE] with [DIAGNOSES REDACTED]. Review of the Alteration in Comfort care plan, dated 11/15/17, indicated the following interventions: evaluate pain characteristics, utilize pain scale, medicate resident as ordered for pain and monitor effectiveness, monitor for nonverbal signs/symptoms of pain and medicate as ordered, monitor for change in mood or mental status, and monitor for nonverbal signs of pain: increased agitation, grimace, and resistive to care. Review of the Admission Nursing Assessment, dated 11/14/17, indicated the resident was on a scheduled pain medication regimen. Review of the Medication Administration Record [REDACTED]. Review of the Controlled Substance Register, Book #269, page 31, indicated an order for [REDACTED]. Review of the Pain Presence Monitor Flowsheet, dated (MONTH) (YEAR), indicated no documentation that the resident was assessed for pain. Further review of the clinical record indicated no further documentation that the resident was assessed for pain. The Surveyor interviewed the resident's invoked Health Care Proxy (HCP) at 9:35 A.M. on 2/1/18. The HCP said when he/she visited him/her on 11/15/17, he/she was anxious, agitated, and grabbing at his/her stomach in pain. The HCP said he/she spoke with the nursing staff and was informed the resident was not medicated because his/her medications had not been received from the pharmacy, 24 hours after admission to the facility. The HCP said he/she took the resident home at 6:45 P.M. on 11/15/17 due to the facility not administering his/her physician ordered pain medication. The Surveyor interviewed Nurse #2 at 2:21 P.M. on 2/1/18. Nurse #2 said she did not administer the scheduled [MEDICATION NAME] at 2:00 P.M. and 5:00 P.M. on 11/14/17. Nurse #2 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME]. The Surveyor interviewed Nurse #9 at 8:35 A.M. on 2/5/18. Nurse #9 said she did not administer the scheduled [MEDICATION NAME] at 8:00 P.M. and 11:00 P.M. on 11/14/17. Nurse #9 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME]. The Surveyor interviewed Nurse #10 at 1:43 P.M. on 2/1/18. Nurse #10 said she did not administer the scheduled [MEDICATION NAME] at 8:00 A.M., 11:00 A.M., 2:00 P.M., and 5:00 P.M. on 11/15/17. Nurse #10 said she did not check the emergency kit system or call the pharmacy for the [MEDICATION NAME]. A Nursing Progress Note, dated 11/15/17 at 18:47 (6:47 P.M.), documented by Nurse #10, indicated medications were not available, that the pharmacy was notified, and that Resident #275 left AMA (against medical advice) with spouse. The Surveyor interviewed the Director of Nurses (DON) at 9:15 A.M. and at 10:45 A.M. on 2/2/18. The DON said the resident's pain should have been assessed at least every shift and that there was no documentation in the clinical record that this was done. The DON said the [MEDICATION NAME] was available in the emergency kit system. The DON said new admissions medications should be received from the pharmacy within 4 hours or so.

Based on records reviewed and interviews for 1 of 3 sampled closed records (Resident #275), the facility staff failed to administer Resident #275's scheduled medications for 2 days as ordered by the attending physician, resulting in untreated pain. Findings include: Review of the Facility Policy, titled Medication Shortages/Drugs Not Available, dated 12/15/08, indicated if the next available delivery causes delay or missed dose in the patient's medication schedule, take the medication from the emergency stock supply to administer the dose, and if not available from the emergency stock supply, to notify the pharmacist an arrange for an emergency delivery. The Policy indicated if an emergency delivery is unavailable, the licensed nurse contacts the attending physician to obtain orders or instructions. Resident #275 was admitted on ,[DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] - Chlorpromaz (an antipsychotic medication) - 2 out of 2 doses missed - [MEDICATION NAME] (a sedative medication) - 2 out of 2 doses missed - [MEDICATION NAME] (a diuretic medication) - 1 out of 1 dose missed - [MEDICATION NAME] (a medication used to lower the ammonia level related to liver disease) - 5 out of 5 doses missed - [MEDICATION NAME] (a narcotic used to treat moderate to severe pain) - 8 out of 10 doses missed - [MEDICATION NAME] (an antipsychotic medication) - 4 out of 4 doses missed - [MEDICATION NAME] (a diuretic) - 1 out of 1 dose missed Review of a Nursing Progress Note, dated 11/15/17 at 18:47 (6:47 P.M.), documented by Nurse #10, indicated the resident's medications were not available, that the pharmacy was notified, and that the resident left AMA (against medical advice) with spouse. Review of the clinical record indicated no other documentation to indicated the pharmacy was notified of the medications being not available prior to 11/15/17 at 6:47 P.M. The Surveyor interviewed the resident's invoked Health Care Proxy (HCP) at 9:35 A.M. on 2/1/18. The HCP said when he/she visited him/her on 11/15/17, he/she was anxious, agitated, and grabbing at his/her stomach in pain. The HCP said he/she spoke with the nursing staff and was informed the resident was not medicated because his/her medications had not been received from the pharmacy, 24 hours after admission to the facility. The HCP said he/she took the resident home at 6:45 P.M. on 11/15/17 due to the facility not administering his/her physician ordered medications. The Surveyor interviewed Nurse #2 at 2:21 P.M. on 2/1/18. Nurse #2 said she did not administer the scheduled medications on 11/14/17 because they were not available. Nurse #2 said she did not check the emergency kit system or call the pharmacy for the medications. The Surveyor interviewed Nurse #9 at 8:35 A.M. on 2/5/18. Nurse #9 said she did not administer the scheduled medications on 11/14/17 because they were not available. Nurse #9 said she did not check the emergency kit system or call the pharmacy for the medications. The Surveyor interviewed Nurse #10 at 1:43 P.M. on 2/1/18. Nurse #10 said she did not administer the scheduled medications on 11/15/17 because they were not available. Nurse #10 said she did not check the emergency kit system or call the pharmacy for the medications. The Surveyor interviewed the Director of Nurses (DON) at 9:15 A.M. and at 10:45 A.M. on 2/2/18. The DON said the following medications: [REDACTED]. The DON said new admissions medications should be received from the pharmacy within 4 hours or so and if not the pharmacy should be notified.

Based on records reviewed and interviews, for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure staff followed acceptable standards of practice when administering the anticoagulant medication [MEDICATION NAME]: The Facility failed to: - Monitor Resident #1's laboratory blood work with an INR (International Normalized Ratio) - for how long it takes for blood to clot, (normal 2 to 3), when a new medication [MEDICATION NAME] (a corticosteroid) was administered. - Ensure that Resident #1's anticoagulant therapy was administered safely, which included appropriate monitoring after Resident #1 presented with symptoms of bleeding (large hematoma on the back and bruising of the eye); after Resident #1 had active symptoms of bleeding, 3 doses of [MEDICATION NAME] 5 milligrams (mg) were administered on [DATE], [DATE], and [DATE]. - Assess Resident #1's progressively worsening back pain and bleeding on Resident #1's back. - On [DATE], Family Members insisted that Resident #1 be transferred to the Hospital after reassurances from Nurse #1 that Resident #1's condition was unchanged (at his/her usual baseline). Once at the Emergency Department blood tests indicated, Resident #1's INR was critical elevated at 17, and Resident #1 died on [DATE]. - The Medical Examiner determined the cause of death was an acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) as a consequence of: cardiogenic shock, blood loss [MEDICAL CONDITION], and a hematoma. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Nursing 2014 Drug Handbook, for [MEDICATION NAME] indicated, INR determinations are essential for proper control; recommended INR range is usually 2 to 3; signs and symptoms of overdose include excessive bruising, a black box warning indicated that [MEDICATION NAME] can cause major or fatal bleeding and to regularly monitor INR in all patients. A Clinical Pharmacology report, Drug Interactions for Healthcare Providers, not dated, faxed to the Department of Public Health, on [DATE], from the consulting Pharmacist indicated that [MEDICATION NAME] (a corticosteroid) may cause an increase or decrease effect with [MEDICATION NAME]. Corticosteroids should be used cautiously and with appropriate clinical monitoring in patients receiving oral anticoagulants; coagulation indices (e.g. INR - International Normalized Ratio) should be monitored to maintain the desired anticoagulant effect. Resident #1 [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment, dated [DATE] indicated Resident #1 was severely cognitively impaired and was an assist of one for bed mobility and dressing. The Physician's Progress note, dated [DATE], indicated Resident #1 was diagnosed with [REDACTED]. physician's orders [REDACTED].#1's plan of care was changed to include [MEDICATION NAME] 20 mg daily for 5 days to treat gout (a form of arthritis). A nurse progress note, dated [DATE] and timed at 10:05 A.M., indicated Resident #1 had a new red and purple bruise on the right mid back which measured 3.8 cm (approximately 1.5 inches) centimeters (cm.) in length, by 8 cm. (approximately 3.2 inches) in width. A nurse progress note, dated [DATE] and timed at 2:03 P.M. indicated Resident #1 had a new red colored bruise underneath the right eye measuring 0.5 cm. in length by 0.5 cm. in width. The Surveyor interviewed the Director of Nursing at 1:50 P.M. on [DATE]. The Director of Nursing said that there was no care plan for monitoring Resident #1's anticoagulant therapy. A physician's orders [REDACTED].M. and at 1:00 P.M. indicated to monitor Resident #1's bruises in the lower back and under the right eye daily. Review of Resident #1's record, indicated there was no documentation that his/her INR level was checked from [DATE] through [DATE]. Review of Resident #1's medical chart, on [DATE] indicated the Medication Administrative Record, dated ,[DATE] was missing from chart. Resident #1's Medication Administration Record [REDACTED].M. Review of this copied MAR, indicated there were legible initials , indicating Resident #1 was given the [MEDICATION NAME], from [DATE] through [DATE]. The initials were not legible regarding the administration of the [MEDICATION NAME] from [DATE] through [DATE]. However, there was no indication nursing staff documented they withheld the [MEDICATION NAME] after Resident #1 was noted to have spontaneous bleeding. The Surveyor interviewed Nurse #1 at 1:10 P.M. on [DATE], Nurse #2 at 1:00 P.M. on [DATE], Nurse #3 at 1:38 P.M. on [DATE]. Nurse #1, Nurse #2, and Nurse #3 said that said that they did not recall if they administered [MEDICATION NAME] 5 mg to Resident #1 on the days they were assigned to care for Resident #1 but said that if it was ordered they would have given it. Nurse #1, Nurse #2, and Nurse #3 said if [MEDICATION NAME] was held then it would be documented in the nurses's progress note, the physician would have been notified, and a physician's orders [REDACTED]. The physician's orders [REDACTED]. A nurse progress note, dated [DATE] and timed at 12:00 P.M., indicated Resident #1 had a decreased oral intake prior to [DATE] and complained of increased back pain since [DATE]. The progress note indicated and Resident #1's Healthcare Agent requested Resident #1 be sent to the emergency room for evaluation. The Emergency Department (ED) record, dated [DATE], indicated Resident #1 had a massive right back hematoma (a localized swelling that is filled with blood). The ED Physician's Physical Examination for skin evaluation indicated Resident #1 had an at least a 20 cm (approximately 8 inches) wide area of ecchymosis (non-raised bleeding into tissue) wrapped around from his/her back to his/her abdomen. The Hospital Computerized Tomography (CT) report of the abdomen, dated [DATE], indicated Resident #1 had a hematoma, which measured 7.9 cm. by 9.7 cm. by 11.9 cm. A Hospital Laboratory report, dated [DATE] indicated Resident #1 had a critically elevated INR of 17 and low Hgb (hemoglobin) 8.2 (normal 12 to 16 g/dl grams per deciliter) and hematocrit of 24.6 (normal 37 to 47 percent- these levels indicate possible acute bleeding). Resident #1 was treated with 3 units of fresh frozen plasma (a blood product) and Vitamin K 10 units intravenously (a reversal medication, used to stop active bleeding from medication i.e. [MEDICATION NAME]). The Hospital Discharge Summary, dated [DATE], Resident #1 had sustained an acute [MEDICAL CONDITION] infarction, was in the Intensive Care Unit, was made comfort care, and died on [DATE] at 12:02 P.M. The Surveyor interviewed Physician #1 at 12:54 P.M. on [DATE]. Physician #1 said that she was notified that Resident #1 had a hematoma and was aware he/she was prescribed [MEDICATION NAME]. Physician #1 said that she did not order laboratory monitoring of Resident #1's INR after the hematoma developed. Physician #1 said that she was not scheduled to come into the Facility to follow up with Resident #1 until the following week. Physician #1 said that when a new medication ([MEDICATION NAME]) was administered with the [MEDICATION NAME], she did not order increased laboratory monitoring of Resident #1's INR. The Surveyor interviewed Physician #2 at 1:55 P.M. on [DATE]. Physician #2 said that if a Resident on [MEDICATION NAME] developed a new hematoma with no history of trauma, this would indicate the Resident was over anticoagulated (increased INR levels due to [MEDICATION NAME]) and would need further laboratory testing and laboratory monitoring. Physician #2 said if the INR is elevated than the [MEDICATION NAME] medication dose would either be held or treat the Resident with a reversal medication. The Medical Examiner's report, dated [DATE] indicated Resident #1 died on [DATE], cause of death was acute [MEDICAL CONDITION] infarction as a consequence of cardiogenic shock, blood loss [MEDICAL CONDITION], and a hematoma.

Based on records reviewed and interviews for 1 of 4 Residents (Resident #1), the Facility failed to: - Adequately monitor Resident #1 for the complications (bleeding into tissues and worsening back pain where the bleeding occurred) of an anticoagulant, failed to ensure changes were made to the plan of care while prescribed an anticoagulant. - Adequately monitor Resident #1's skin for weekly checks on 6/8/15, 6/15/15 and 6/22/15. - Ensure Resident #1's progressive back pain was monitored and accurately communicated to the Physician. Findings include: 1. Lexicom version 2.8.0, 2016, for [MEDICATION NAME] (an anticoagulant medication) indicated adverse effects include bleeding; may cause major fatal bleeding. For physical monitoring assess for signs and symptoms of bleeding. Bleeding is the major adverse effect of [MEDICATION NAME]. The Facility's Pain Management policy, dated 3/15/16, indicated its purpose was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain to achieve optimal balance between pain relief and preservation of function. The Facility's Skin Care Guideline policy, for a bruise, dated 1/2/14, indicated for a bruise, review all risk factors and conditions that may contribute to the bruise or delay in healing, such as medications and or disease that affect coagulation. Monitor during routine skin assessment rounds. Continue to re-evaluate for healing and deterioration. If the bruise is not improving re-evaluate risk factors and plan of care and notify the physician to report location, current color and size. Resident #1 was admitted to the Facility in June of 2015 and was diagnosed with [REDACTED]. The Admission Minimum Data Set Assessment, dated 6/10/15 indicated Resident #1 was severely cognitively impaired and was an assist of one for bed mobility and dressing. The Physician's Progress note, dated 6/18/15, indicated Resident #1 was diagnosed with [REDACTED]. physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] 20 mg daily for 5 days to treat gout (a form of arthritis). A nurse progress note, dated 8/27/15 and timed at 10:05 A.M., indicated Resident #1 had a new red and purple bruise on the right mid back which measured 3.8 cm (approximately 1.5 inches) centimeters (cm.) in length, by 8 cm. (approximately 3.2 inches) in width. The Surveyor interviewed the Director of Nursing at 1:50 P.M. on 9/27/16. The Director of Nursing said that there was no care plan for monitoring Resident #1's anticoagulant therapy. A nurse progress note, dated 8/27/15 and timed at 2:03 P.M. indicated Resident #1 had a new red colored bruise underneath the right eye measuring 0.5 cm. in length by 0.5 cm. in width. A physician's orders [REDACTED].M. and at 1:00 P.M. indicated to monitor Resident #1's bruises in the lower back and under the right eye daily. Review of Resident #1's record, indicated there was no documentation that his/her INR level was checked from 8/20/15 through 8/30/15. Review of Resident #1's medical chart, on 9/27/16, indicated the Medication Administrative Record, dated 8/2015 was missing from chart. Resident #1's Medication Administration Record [REDACTED].M. (At the Surveyor's request the Hospital faxed a copy of the MAR, dated August 2015 on 9/27/16 at 2:46 P.M. and the back page of this MAR indicated [REDACTED]. The initials were not legible for the administration of the [MEDICATION NAME] from 8/21/15 through 8/30/15. A Pain Assessment note, dated 8/30/15, and timed at 12:00 P.M. documented as signed by Nurse #1, indicated Resident #1 had right lower back pain, rated as a 2 (on a scale of 0 -none to 10-severe). The pain was worse with movement. This is chronic pain that was worse over the last few days. This Pain Assessment documentation is not consistent with Nurse #1's note dated 8/30/15. Nurse #1 started the electronic medical record at 12:00 P.M. and signed and closed this note at 3:49 P.M.). A nurse progress note, dated on 8/30/15, and timed as started at 12:00 P.M., signed and closed out at 3:49 P.M., by Nurse #1 indicated Resident #1 had increased back pain, which had progressively worsened. But later in the same note it states no complaints of pain until transferred to stretcher. This is not consistent with the Pain Assessment note, dated 8/30/15 at 12:00 P.M., indicated Resident #1 had right lower back pain. The physician telephone order, dated 8/30/15 and timed at 12:30 P.M. indicated Resident #1 had decreased right back pain and an enlarging ecchymotic area (there were no measurements for comparison). The Surveyor interviewed Family Member #1 at 2:15 P.M. on 10/4/16. Family Member #1 said that on 8/30/15 at 1:30 P.M. (1.5 hours before Resident #1 was transferred to the hospital)., Resident #1 had severe back pain and Family Member #1 observed a purple bruise on the whole right side of his/her back, from the shoulder down to the buttocks. When he/she reported this to Nurse #1, Nurse #1 was nonchalant, and said that (Resident #1) does this all the time, words to the effect of. Family Member #1 said that Nurse #1 did not get up to assess Resident #1, and he remained seated at the Nurses station. Family Member #1 said that Nurse #1 did not assess Resident #1's back pain or size of the back bruise because he/she was with Resident #1 from 12:00 noon to when Resident #1 left in the ambulance at 3:00 P.M. Family Member #1 said that Resident #1 said my back is killing me. Family Member #1 said I knew she was dying before my eyes. The Surveyor interviewed Nurse Practitioner #1 at 2:45 P.M. on 9/30/16. Nurse Practitioner #1 said she was called by Nurse #1 on 8/30/15 at 12:30 P.M. but was not informed of the urgency of Resident #1's condition, therefore laboratory work was not ordered stat (right away), and was instead scheduled to be obtained the following morning, 8/31/15. Nurse Practitioner #1 said that Nurse #1 said to her that Resident #1 had decreased back pain with increasing ecchymosis (documented by Nurse #1 on the physician's orders [REDACTED].#1 said she was not informed of the size of the ecchymosis compared to baseline. Resident #1 was sent to the hospital on [DATE] and was found to have a critical INR (normal 2 to 3) level of 17. A nurse progress note, dated 8/27/15 and timed at 10:05 A.M., indicated Resident #1 had a new red and purple bruise on the right mid back which measured 3.8 cm (approximately 1.5 inches) centimeters (cm.) in length, by 8 cm. (approximately 3.2 inches) in width. A nurse progress note, dated 8/27/15 and timed at 2:03 P.M. indicated Resident #1 had a second red colored bruise underneath the right eye measuring 0.5 cm. in length by 0.5 cm. in width. physician's orders [REDACTED].M. and at 1:00 P.M. indicated to monitor daily Resident #1's bruise in the lower back and under the right eye daily. The following nurse progress notes indicated there was not change in the eye and back bruises: - Dated on 8/28/15 and timed at 8:05 A.M., dated on 8/28/15 and timed at 2:05 P.M., dated 8/29/15 and timed at 5:05 A.M., dated 8/29/16 at 8:05 A.M., dated 8/30/15 at 3:43 P.M. and 8/30/15 at 9:30 A.M. There was no measurements to monitor if the bruises were gradually worsening (the bleeding was enlarging) for a Resident on anti-coagulant medication. The Unit Manger of the TCU (Transitional Care Unit) said that in order for a bruise to be accurately assessed it should be measured. The Surveyor interviewed the Nurse Practice Educator at 12:05 P.M. on 9/27/16. The Nurse Practice Educator said that measurements should be obtained when a Resident has a hematoma (bleeding into tissue) to determine if the hematoma was enlarging an indicator of active bleeding. The Nurse Practice Educator said she teaches the staff to measure bruises especially if the Resident is on [MEDICATION NAME]. A Clinical Pharmacology report, Drug Interactions for Healthcare Providers, not dated, faxed to the Department of Public Health, on 9/29/16, from the consulting Pharmacist indicated that [MEDICATION NAME] (a corticosteroid) may cause an increase or decrease effect with [MEDICATION NAME]. Corticosteroids should be used cautiously and with appropriate clinical monitoring in patients receiving oral anticoagulants; coagulation indices (e.g. INR - International Normalized Ratio) should be monitored to maintain the desired anticoagulant effect. The written Resident Transfer Form, dated 8/30/15 (for transfer to the hospital), indicated Resident #1 had complained of decreasing back pain for one week. The Hospital Discharge Summary, dated 8/31/15, indicated Resident #1 had an unexpected death, a critical INR (normal 2-3) of 17. Resident #1 had an adverse drug reaction due to the lack of anticoagulant monitoring with laboratory work. The Medical Examiner determined the cause of death was an acute [MEDICAL CONDITION] infarction as a consequence of; cardiogenic shock, blood loss [MEDICAL CONDITION], and a hematoma. 2. The Treatment Administrative Record, dated 6/2015 indicated the weekly skin checks were left blank on 6/8/15, 6/15/15 and 6/22/15. The Surveyor interviewed the Unit Manager at 2:50 P.M. on 9/27/16. The Unit Manager said that weekly skin checks on the Treatment Administration Record, dated 6/2015 were not performed as required.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #1), the Facility failed to: - Ensure Resident #1 was free from unnecessary medications, in the setting of adverse side-effects. Three doses of [MEDICATION NAME] (an anticoagulant medication) 5 milligrams (mg) by mouth were administered between [DATE] and [DATE], after a hematoma (a localized swelling that is filled with blood) and ecchymosis (non raised bleeding into tissue) was found on Resident #1's back and under his/her eye. - On [DATE] Resident #1 was transferred to the Hospital at the insistence of the family, where he/she was found to have a critically elevated INR (International Normalized Ratio) of 17 (normal 2 to 3), low hemoglobin 8.2 (normal 12 to 16 g/dl grams per deciliter) and hematocrit of 24.6 (normal 37 to 47 percent ). Hemoglobin and hematocrit are indicators of the amount of circulating blood volume. Resident #1 was treated with 3 units of fresh frozen plasma (a blood product) and 10 units of vitamin K intravenously (a reversal medication, used to stop active bleeding from medication i.e. [MEDICATION NAME]). - On [DATE] Resident #1 died , cause of death was acute [MEDICAL CONDITION] infarction as a consequence of: cardiogenic shock (a condition in which your body can not pump enough blood to meet your body's needs), blood loss [MEDICAL CONDITION], and a hematoma. Findings include: The Nursing 2014 Drug Handbook, for [MEDICATION NAME] indicated, INR determinations are essential for proper control; recommended INR range is usually 2 to 3; signs and symptoms of overdose include excessive bruising, a black box warning indicated that [MEDICATION NAME] can cause major or fatal bleeding and to regularly monitor INR in all patients. A Clinical Pharmacology report, Drug Interactions for Healthcare Providers, not dated, was faxed to the Department on [DATE], from the consulting Pharmacist indicated that [MEDICATION NAME] (a corticosteroid) may cause an increase or decrease effect with [MEDICATION NAME]. Corticosteroids should be used cautiously and with appropriate clinical monitoring in patients receiving oral anticoagulants; coagulation indices (e.g. INR - International Normalized Ratio) should be monitored to maintain the desired anticoagulant effect. The Facility Policy, Laboratory Monitoring of Drug Therapy, dated [DATE], indicated the purpose was to ensure that residents receive adequate drug laboratory monitoring to assist in decreasing risk of adverse drug reactions. [MEDICATION NAME] is one of the medications that is recommended for laboratory monitoring. Resident #1's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] (an anticoagulant mediation) (dosage per INR results). Laboratory Results, dated [DATE] indicated Resident #1's INR was 2.5 (normal 2 to 3 for [MEDICATION NAME] for venous [MEDICAL CONDITION]). The physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] 20 mg (milligrams) daily by mouth daily) for 5 days for the treatment of [REDACTED]. The Physician's [MEDICATION NAME] order was (dated [DATE]) was 5 mg daily. A nurse progress note, dated [DATE] and timed at 10:05 A.M., indicated Resident #1 had a new red and purple bruise on the right mid back which measured 3.8 cm (approximately 1.5 inches) centimeters (cm.) in length, by 8 cm. (approximately 3.2 inches) in width. A nurse progress note, dated [DATE] and timed at 2:03 P.M. indicated Resident #1 had a new red colored bruise underneath the right eye measuring 0.5 cm. in length by 0.5 cm. in width. A nurse progress note dated [DATE], indicated the Physician was notified on [DATE] at and at 10:00 A.M. and at 2:00 P.M., of Resident #1's bruises on the back and eye. There was no documentation indicating laboratory work or a change in the [MEDICATION NAME] medications dosage ordered. During the survey of [DATE], the Facility was unable to find Resident #1's Medication Administrative Record for [DATE]. On the Hospital faxed copy of Resident #1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].M. The back page of this MAR indicated [REDACTED]. Review of this copied MAR, dated [DATE] indicated there were legible initials (indicating the nurse who administered the [MEDICATION NAME]) written from [DATE] through [DATE]. The initials were not legible for the administration of the [MEDICATION NAME] from [DATE] through [DATE]. The Director of Nurses was interviewed at 3:05 P.M. on [DATE]. The Director of Nursing said that that the [MEDICATION NAME] was scheduled to be given at 5:00 P.M. and the back of the MAR indicated [REDACTED] The Surveyor interviewed Nurse #1 at 1:10 P.M. on [DATE], Nurse #2 at 1:00 P.M. on [DATE], Nurse #3 at 1:38 P.M. on [DATE]. Nurse #1, Nurse #2, and Nurse #3 said that they did not recall if they administered [MEDICATION NAME] 5 mg to Resident #1 on the days they were assigned to care for Resident #1 but said that if it was ordered they would have given it. Nurse #1, Nurse #2, and Nurse #3 said if [MEDICATION NAME] was held then it would be documented in the nurse's progress note and the physician would have been notified, and a physician's orders [REDACTED]. There was no indication that Nurse #1, Nurse #2, or Nurse #3 documented they questioned the administration of the [MEDICATION NAME], or that any changes were made in the plan of care in response the Resident #1 presenting with symptoms of spontaneous bleeding while taking the medication [MEDICATION NAME]. The Surveyor interviewed Nurse #1 at 11:22 A.M. on [DATE]. Nurse #1 said that on [DATE] and [DATE] he was assigned to Resident #1. Nurse #1 said that Resident #1 had a new bruise on [DATE] which was red and purple on Resident #1's right back, and hip. Nurse #1 said Resident #1 had worsening back pain from [DATE] until [DATE]. Nurse #1 said that Physician #1 knew about the bruise on Resident #1's back and the [MEDICATION NAME] continued to be administered, without monitoring laboratory testing for possible bleeding or the INR. Nurse #1 said that the Regional Physician (next in the chain of command for the Physician) or Pharmacy representatives were not notified of Resident #1's spontaneous bleeding (large hematoma and ecchymosis under the eye) and continued the administration of [MEDICATION NAME] when it is contraindicated with bruising (bleeding into tissues). The Surveyor interviewed Physician #1 at 12:54 P.M. on [DATE]. Physician #1 said that she was notified that Resident #1 had a hematoma (bleeding into tissues) and was aware he/she was prescribed [MEDICATION NAME]. Physician #1 said that she did not order laboratory monitoring of Resident #1's INR after the hematoma developed. Physician #1 said that she was not scheduled to come into the Facility to follow up with Resident #1 until the following week. Physician #1 said that when a new medication ([MEDICATION NAME]) was administered with the [MEDICATION NAME], she did not order increased laboratory monitoring of Resident #1's INR. The Surveyor interviewed the Director of Nursing at 3:05 P.M. on [DATE]. The Director of Nursing said that Resident #1's [MEDICATION NAME] was continued daily from [DATE] through [DATE] (3 doses). The Director of Nursing said there was no further monitoring of the INR or the CBC after the new onset of bleeding (large hematoma and ecchymosis under the eye) on [DATE]. On [DATE], Resident #1 was transferred to the Emergency Department at the request of Resident #1's family. The Emergency Department (ED) record, dated [DATE], indicated Resident #1 had a massive right back hematoma (a localized swelling that is filled with blood). The ED Physician's Physical Examination indicated Resident #1 had areas of ecchymosis which was at least a 20 cm (8 inches) wide wrapped around from his/her back to his/her abdomen. The Hospital Computerized Tomography (CT) report of the abdomen, dated [DATE], indicated Resident #1 had a hematoma, which measured 7.9 cm. by 9.7 cm. by 11.9 cm. A Hospital Laboratory report, dated [DATE] indicated Resident #1 had a critically elevated INR of 17 and low hemoglobin 8.2 (normal 12 to 16 g/dl grams per deciliter) and hematocrit of 24.6 (normal 37 to 47 percent- these levels indicate possible acute bleeding). Resident #1 was treated with 3 units of fresh frozen plasma (a blood product) and Vitamin K 10 units intravenously (a reversal medication, used to stop active bleeding from medication i.e. [MEDICATION NAME]). The Hospital Discharge Summary dated, [DATE], indicated the right back ecchymosis hemorrhage on Resident #1 was a large area involving his/her entire right back from breast to pelvis. The Summary included that there was no sign of appreciative trauma. Resident #1 had sustained an acute [MEDICAL CONDITION] infarction, was in the Intensive Care Unit, was made comfort care, and died on [DATE] at 12:02 P.M. The Medical Examiner's report, dated [DATE] indicated Resident #1 died on [DATE], cause of death was acute [MEDICAL CONDITION] infarction as a consequence of; cardiogenic shock, blood loss [MEDICAL CONDITION], and a hematoma.

Based on records reviewed and interviews, for 2 of 7 sampled residents (Resident #1 and #6), the Facility failed to ensure that acceptable standards of practice were followed for [MEDICAL CONDITION] (surgically created artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing), care and suctioning, cardiopulmonary resuscitation and resident abandonment. The facility failed to ensure suction machines were available and operational. -For Resident #6 with a [MEDICAL CONDITION], the facility failed to follow standards of practice by not having a suction machine in the resident's room, when Resident #6 struggled to breathe and required suctioning, it took over an hour to find a functioning suction machine, when staff located a suction machine from another building. - For Resident #1, with a [MEDICAL CONDITION], the facility failed to follow standards of practice to maintain a patent airway through a [MEDICAL CONDITION] by not providing humidification, by not administering physician prescribed respiratory medications, and by not providing [MEDICAL CONDITION] care and suctioning. On [DATE], Resident #1 experienced symptoms of respiratory distress and was later found in [MEDICAL CONDITION], but staff were unable to successfully use the suction machine to attempt to clear his/her airway. Once hospitalized , he/she's [MEDICAL CONDITION] was removed, and a large thick, dry and dense mucus plug was removed. -The facility failed to meet professional standards by not having competently trained staff in [MEDICAL CONDITION] care and suctioning, cardiopulmonary resuscitation, AED, and mock code training. -The facility failed to follow professional standards of conduct by not prohibiting a licensed staff member from abandoning Resident #1, when he/she was in respiratory distress. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Lippincott Manual of Nursing Practice,10th edition, dated 2014 for [MEDICAL CONDITION] Care, indicated that [MEDICAL CONDITION] care removes mucus, crust, and secretions. The goal of airway clearance techniques is to improved clearance of airway secretions thereby decreasing obstruction of the airways. 1. For Resident #6, the facility failed to ensure there was an available suction machine. Resident #6 had a [MEDICAL CONDITION] that required suctioning to maintain a patent airway. Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. Significant Change Minimum Data Set (MDS), dated [DATE], indicated Resident #6 was cognitively intact, had a [MEDICAL CONDITION], and required oxygen therapy. Physician Orders, dated ,[DATE], were to provide: staff may suction as needed and trachestomy care twice daily and as needed. Care Plan, dated ,[DATE], indicated to suction [MEDICAL CONDITION]/airway as needed. [MEDICAL CONDITION] Care Policy, dated [DATE], indicated to gather suction machine with tubing as part of [MEDICAL CONDITION] care at least twice daily and as needed as Physician Ordered. Surveyor #2 interviewed Resident #6 at 1:00 P.M. on [DATE]. Resident #6 said that the first week of admission in [DATE], he/she had a [MEDICAL CONDITION] and developed a mucus plug, which caused him/her to struggle to breathe, and at that time, was unable to clear his/her own airway and required suctioning. Resident #6 said that there was no suction machine in his/her room and that the Nurse took over an hour to find a suction machine and told him/her that the nurse found one in another building across the street. Resident #6 said the nurse had to hit him/her on the back to help dislodge the mucus plug prior to being suctioned. Resident #6 said the suction machine obtained from another facility broke two days later. There was no indication the Facility took corrective action related to the incident involving Resident #6. 2. Resident #1 was admitted in ,[DATE]. Resident # 1's [DIAGNOSES REDACTED]. Resident #1 was readmitted from the Hospital on [DATE] with new [DIAGNOSES REDACTED]. The Facility's Policy on [MEDICAL CONDITION] Suctioning, dated [DATE], indicated that staff members are to establish the need for suctioning by evaluating residents for breath sounds, respiratory rate and pulse oximetry. Review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MAR), dated ,[DATE], indicated this order was not transcribed from the ,[DATE] MAR indicated [REDACTED] Nurse Admission Assessment, dated [DATE] at 2:14 P.M., indicated Resident #1's respiratory rate was 22, and his/her breathing was labored and shallow. The assessment indicated suctioning was checked off as being performed. Nurse #4 was interviewed at 9:50 A.M. on [DATE]. Nurse #4 said that she did not suction Resident #1 during the 3:00 P.M. to 11:00 P.M. shift, but this was not consistent with documentation. Respiratory Therapist #1's progress note, dated [DATE], indicated Resident #1 was short of breath with a nonproductive cough, oxygen saturation level was decreased to 84% (normal greater than 90), and was treated with oxygen being increased from 1 to 4 liters to an oxygen saturation of 92%. The Nurse's Note, dated [DATE] at 11:36 P.M., indicated Resident #1 complained of shortness of breath and had labored breathing, which subsided after repositioning and raising the head of the bed. There was no documentation to indicate Resident #1's oxygen saturation level, vital signs, or lung sounds were assessed. The Treatment Administration Record (TAR), dated [DATE], indicated the initial [MEDICAL CONDITION] care treatment was circled (as not being performed), but the reason was not documented on the back of the TAR. The physician's orders [REDACTED].#1 was prescribed: [MEDICATION NAME] nebulizer (a respiratory medication for treating [MEDICAL CONDITION]) 3 ml four times a day at 8:00 A.M., 12 noon, 4:00 P.M. and 8:00 P.M., [MEDICATION NAME] (a medication for treating [MEDICATION NAME][MEDICATION NAME]) 10 mg at bed time, and [MEDICATION NAME] (an antibiotic) 500 mg daily for 3 days give at 8:00 P.M. The Medication Administration Record [REDACTED].M., [MEDICATION NAME] 10 mg at bed time, and [MEDICATION NAME] 500 mg at 8:00 P.M. The reason for omitting these medications was not documented on the back of MAR. Surveyor #1 interviewed Nurse #4 at 9:50 A.M. on [DATE]. Nurse #4 said that Resident #1 was slightly lethargic during the 3:00 P.M. to 11:00 P.M. shift and she considered this was a change in mental status for Resident #1. Nurse #4 said she did not perform tracheal care or give the scheduled 4:00 P.M. [MEDICATION NAME], and [MEDICATION NAME] 10 mg at bed time because Resident #1 had refused but this refusal was not documented. Nurse #4 stated she had not educated Resident #1 regarding the importance of tracheal care. Nurse #4 said that she did not notify the Physician that she did not administer the [MEDICATION NAME], Singular or tracheotomy care as ordered to Resident #1 and did not document a reason why it was not administered. Review of the medical record during the 11:00 P.M. to 7:00 A.M. shift (Nurse #1's assignment) indicated there was no documentation to indicated Resident #1's vital signs, oxygen saturation were monitored or lungs auscultated. Assessment of the Oxygen saturation, auscultation of lung sounds, and respiratory rates are the three facility's indicators to determine if a resident is in need of suctioning. Resident #1 had a cardiopulmonary arrest on [DATE] at approximately 5:55 A.M., Cardiopulmonary Resuscitation was started and the Emergency Medical Service (EMS) arrived, continued resuscitation, and transferred Resident #1 to the Hospital. The Hospital Report, dated [DATE], indicated EMS found Resident #1 in asystole (no heart conduction activity on the monitor) on arrival and when Resident #1's [MEDICAL CONDITION] was removed a large mucus plug was noted, which was as a large plug, which was significant and noted to be thick, dry and dense (abnormal assessment finding contributing to occluded airway), and with suctioning and manual removal, a portion of the mucus and blood was removed, enabling the patient to be ventilated via the [MEDICAL CONDITION]. After 2 rounds of ACLS, cardiac activity was not re-established; Resident #1 died at 6:09 A.M. on [DATE]. 3. According to the Board of Registration in Nursing; Determination of Compliance with the Standard of Conduct at 244 CMR 9.03 (15) prohibiting abandonment by a licensed nurse. It will be determined whether patient abandonment has occurred based on information demonstrating the licensed nurse: Accepted responsibility for the nursing care of a patient or group of patients; voluntarily withdrew from caring for the patient or patients with any ongoing nursing care need; failed to give reasonable notice to an appropriate person that she or he was withdrawing from caring for the patient or patients so that arrangements could be made for the continuation of safe care and failed to report essential information to an appropriate person. Surveyor #1 interviewed Nurse #1 at 12:39 P.M. on [DATE] and at 7:15 A.M. on [DATE]. Nurse #1 said later in the shift around 1:30 A.M., but she was not sure of the time, Resident #1 had increased chest congestion before and after the breathing treatment (there is no documentation of a breathing treatment given by Nurse #1). Nurse #1 said after Resident #1 experienced the change, she left the unit for 10 to 15 minutes to finish admission paper work on a different unit. Nurse #1 said there was no other licensed Nurse to care for residents, including Resident #1 in her absence. Nurse #1 said upon returning to the Unit Resident #1 was noted to be in [MEDICAL CONDITION]. The Nurse's Note, dated [DATE] at 5:55 A.M., indicated Resident #1 was without pulse or respirations, color pale, CPR (cardiopulmonary resuscitation) was initiated by staff, Code Blue (a facility alert for cardio-pulmonary arrest), called 911 and Resident #1 was transferred to the Community Hospital. Surveyor #1 interviewed Certified Nursing Assistant (CNA) #1 at 2:35 P.M. on [DATE]. CNA #1 said Nurse #1 left the unit. CNA #1 said that there were only 2 CNAs left on the unit. 4. The Facility's policy titled, Cardiac and/or Respiratory Arrest, dated [DATE], stated that Upon discovery of a patient in cardiopulmonary arrest staff will immediately; call for assistance, prepare the patient for CPR/AED (automatic electrical defibrillator) ., a designate an individual to record events on the CPR/AED Flow Sheet. For all cardiac/respiratory arrest document: any significant clinical events preceding the arrest. The American Heart Association, dated 2010, stated that for Cardiopulmonary resuscitation (CPR) and Emergency Cardiovascular Care (ECC) recommend performing CPR on a firm surface. Back boards are commonly used to achieve target depths for chest compressions. Effective compression depth will generate critical blood flow and oxygen and energy and delivery to the heart and lung. Surveyor #1 interviewed Nurse #2 at 3:44 P.M. on [DATE]. Nurse #2 said she responded to a cardiopulmonary arrest over head page on [DATE] during the 11:00 P.M. to 7:00 A.M. shift from the 1st floor. Nurse #2 entered Resident #1's room and saw that Nurse #1 and two CNAs were in the room, with the emergency cart in Resident#1's room. Nurse #2 said that the first thing she noticed was Resident #1 bouncing up and down in bed with each cardiac chest compression. Nurse #1 was performing chest compressions without a cardiac board (which is needed for effective cardiac compressions). Nurse #2 said she asked Nurse #1 where was the back board. Nurse #1 then ran out of the room to get the cardiac board, and Nurse #2 continued chest compressions. 5. Review of the 5 of 6 Nurse's Educational Records (Nurse #1, Nurse #4, Nurse #5, Nurse #6, and Nurse #7), who would be responsible to care for Residents having a cardiopulmonary arrest indicated the nurses failed to have AED and Mock Code training. The AED and Mock code training was offered twice a year from [DATE] through [DATE] but Nurse #1, Nurse #4, Nurse #5, Nurse #6, and Nurse #7 had not attended this training.

Based on records reviewed and interviews for 1 of 7 Residents (Resident #1), out of 4 Residents with tracheotomies (surgically created artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing), the Facility failed to ensure nurses responsible for the care of these Residents were knowledgeable and competent to provide safe care. Further review indicated the lack of availability of operational emergency equipment in case of emergency for suctioning a [MEDICAL CONDITION]. -Resident #6, with a [MEDICAL CONDITION], said within the first week of admission in ,[DATE], struggled to breathe and required suctioning but had no suction machine in his/her room, and it took the Nurse over an hour to find a suction machine. Resident #6 said a suction machine was found in another building across the street. -Resident #1, with a [MEDICAL CONDITION], who was recently hospitalized in ,[DATE], with acute respiratory infections, was not provided tracheal humidification (to liquefy airway secretions) for 21 days, was not provided with tracheal care (to clean the cannula and suction as needed to maintain patency). -The facility failed to provide Resident #1 with two prescribed respiratory medications, [MEDICATION NAME] (a breathing treatment) and [MEDICATION NAME] (a sustained released antibiotic). -The facility failed to notify the Physician of Resident #1 decline in mental status and respiratory distress during night of [DATE] into [DATE]. -The nurses failed to assess and monitor Resident #1 respiratory status and need for suctioning based on the Facility's criteria of: oxygen saturation levels, lung sounds, and respiratory rate. -The nurse abandoned Resident #1 by leaving the unit; leaving no nurse or respiratory therapist to care for and monitor Resident #1, while Resident #1 was in in respiratory distress. When the nurse returned to the unit, Resident #1 was in cardiopulmonary arrest. -The nurse failed to properly announce the location of the cardiopulmonary arrest for Resident #1, delaying the response time of Nurse #2. -The facility failed to provide a functioning suction machine on the emergency cart to maintain Resident #1's airway during the cardiopulmonary arrest. -The nurse failed operate the second suction machine correctly, failed to perform adequate chest compressions on a firm surface, and failed to know how to operate the AED machine correctly, delaying treatment to Resident #1 during a cardiopulmonary arrest. -On [DATE], in the emergency room , Resident #1 was in asystole (no heart conduction activity on the monitor) on arrival. Resident #1's [MEDICAL CONDITION] was removed a large mucus plug was noted, which was significant and noted to be thick, dry and dense and Resident #1 required manual removal and aggressive suctioning to remove a portion of the mucus and blood, enabling the patient to be ventilated via the [MEDICAL CONDITION]. Resident #1 died at 6:09 A.M. on [DATE]. -The surveyor observed that the emergency cart on Resident #1's unit had not been checked for 18 hours after Resident #1's cardiopulmonary arrest. -The surveyor observed four resident's were identified with tracheostomies. One of four units, who had three resident's with tracheostomies, had a non-functioning suction machine on the emergency cart. Findings include: The Facility's Policy on [MEDICAL CONDITION] Suctioning, dated [DATE], stated that staff were to establish the need for suctioning by evaluating residents for breath sounds, respiratory rate and pulse oximetery. The Facility's Policy for Oxygen: Aerosol/[MEDICAL CONDITION] Mask, dated [DATE], stated for nebulizer treatment monitor response to therapy by evaluating the resident for Respiratory rate, heart rate, breathing pattern and color. Perform [MEDICAL CONDITION] care as least twice a day and as needed, as ordered; evaluate the resident's heart rate, respiratory rate, breath sounds, cough effort. Evaluate sputum amount, color and consistency. Suction [MEDICAL CONDITION], if necessary. The Facility's Policy for Medication Administration, dated [DATE], stated for medication refused by the resident, circle your initials in the date and time space where that medication is ordered and document resident's refusal of medication on the back of the Medication Administration Record [REDACTED] Resident #1 was admitted in ,[DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment, dated [DATE], indicated Resident #1 was cognitively intact, received antipsychotic and anti-anxiety medications in the last 7 days, and received [MEDICAL CONDITION] care in the last 14 days. The Pulmonologist consultation of [DATE] indicated Resident #1's [MEDICAL CONDITION] was changed and there was a small amount of thick secretions. Review of the Nurse Practitioner's order, dated [DATE] at 12:02 P.M., indicated that the staff were to increase the tracheal humidification. Review of the Treatment Administration Record (TAR), dated ,[DATE], indicated to increase the tracheal humidification. Review of the Hospital Transfer Note, dated [DATE], indicated Resident #1 had increase tracheal secretions, was short of breath, and had lungs sounds of crackles/rhonchi bilaterally. Oxygen saturation was 86% (normal greater than 90%) on room air, heart rate was 109 (normal 60 to 100), respiratory rate was 22 (normal 12 to 20), and the note stated, vital signs are unstable. Resident #1 was readmitted from the hospital to the facility on [DATE] at 2:14 P.M. with a [DIAGNOSES REDACTED]. Resident #1's Plan of Care indicated Resident #1 had no treatment limitations in place in the event of cardio-pulmonary distress (full code). Review of the TAR, dated from [DATE] to [DATE], and then from [DATE] through [DATE], indicated the increased humidification of Resident #1's [MEDICAL CONDITION] was not transferred to the TAR's of February 2016. Surveyor #1 interviewed Nurse #4, Director of Nursing #2, and Nurse #3 at 9:50 A.M., at 3:25 P.M. and 3:50 P.M. on [DATE], they indicated that the increased humidification was not discontinued by the Physician and should have been carried over to the TARs of ,[DATE], but were not in error. Failure to have humidification could result in increased dry secretions which can contribute to difficulty in breathing. Surveyor #1 interviewed Respiratory Therapist #1 at 2:50 P.M. on [DATE]. Respiratory Therapist #1 said that humidification was not given to Resident #1 for February 2016. The physician's orders [REDACTED].#1, to keep oxygen saturation above 92% and staff were to provide [MEDICAL CONDITION] care twice a day. Nurse Admission Assessment, dated [DATE] at 2:14 P.M., indicated Resident #1's respiratory rate was 22, and his/her breathing was labored and shallow. The assessment indicated suctioning was checked off as being performed. Nurse #4 was interviewed at 9:50 A.M. on [DATE]. Nurse #4 said that she did not suction Resident #1 during the 3:00 P.M. to 11:00 P.M. shift. This was not consistent with the documentation. Respiratory Therapist #1's progress note, dated [DATE], indicated Resident #1 was short of breath, had a nonproductive cough, oxygen saturation level (normal greater than 90%) had decreased to 84% (normal 95 to 100), and was treated with oxygen titration. Resident #1's pulse rate was 111 (normal pulse rate ,[DATE]) beats per minute and the respiratory rate was 24 (normal respiratory rate ,[DATE]). The first [MEDICAL CONDITION] care treatment was scheduled start on the 3:00 P.M. to 11:00 P.M. on [DATE]. There was no orders for humidification of the tracheal secretions. The Treatment Administration Record (TAR), dated [DATE], indicated the initial [MEDICAL CONDITION] care treatment was circled (as not being performed), but the reason was not documented on the back of the TAR. There was no documentation to indicate a physician was informed of [MEDICAL CONDITION] care not being performed. The physician's orders [REDACTED].#1 was prescribed: [MEDICATION NAME] nebulizer (a respiratory medication for treating [MEDICAL CONDITION]) 3 ml four times a day at 8:00 A.M., 12 noon, 4:00 P.M. and 8:00 P.M., [MEDICATION NAME] (a medication for treating [MEDICATION NAME][MEDICATION NAME]) 10 mg at bed time, and [MEDICATION NAME] (an antibiotic) 500 mg daily for 3 days give at 8:00 P.M. The Medication Administration Record [REDACTED].M., [MEDICATION NAME] 10 mg at bed time, and [MEDICATION NAME] 500 mg at 8:00 P.M. The reason for omitting these medications was not documented on the back of MAR. Surveyor #1 interviewed Nurse #4 at 9:50 A.M. on [DATE]. Nurse #4 said that Resident #1 was slightly lethargic during the 3:00 P.M. to 11:00 P.M. shift and she considered this a change in mental status for Resident #1. Nurse #4 said she did not perform tracheal care or give the scheduled 4:00 P.M. [MEDICATION NAME], and [MEDICATION NAME] 10 mg at bed time because Resident #1 had refused but this was not documented. Nurse #4 stated she did not educated Resident #1 regarding the importance of tracheal care in maintaining a patent airway and adequate oxygenation. Nurse #4 said that she did not notify the Physician that she did not administer Resident #1 the [MEDICATION NAME], Singular or perform tracheotomy care as ordered to Resident #1 and did not document a reason and did not assess Resident #1's respiratory status. The Nurse's Note, dated [DATE] at 11:36 P.M., indicated during the evening, there was no documentation of respiratory status including vital signs, oxygen saturation levels, lung sounds or heart sounds. Nurse #4 said Resident #1 received oxygen and the Respiratory Therapy took care of humidification, and she was unsure if Resident #1 received humidification (not consistent with policy ,plan of care, or orders). However there was no documentation that Resident #1 was receiving humidification. Nurse #4 reviewed the physician's orders [REDACTED]. Nurse #4 stated that it should have been carried over to the February physician's orders [REDACTED]. Review of the medical record during the 11:00 P.M. to 7:00 A.M. shift, indicated there was no documentation to indicate Resident #1's vital signs, oxygen saturation were monitored, or lungs auscultated. Assessment of the oxygen saturation, auscultation of lung sounds, and respiratory rates are the three facility's indicators to determine if a resident was in need of suctioning. Surveyor #1 interviewed Nurse #1 at 12:39 P.M. on [DATE]. Nurse #1 said on [DATE] after 1:30 A.M., she left the unit for 10 to 15 minutes and no staff member monitored Resident #1's respiratory status while Nurse #1 was absent from the Unit. When Nurse #1 left the Unit she did not have another Nurse covering the Unit or give report to another Nurse and no nurse was assigned to monitor and care for residents, including Resident #1. The Nurse's Note (written by Nurse #1), dated [DATE] at 5:55 A.M., indicated Resident #1 was found without pulse or respirations, pale (abnormal assessment finding indicative of death), and a Code blue (a cardiac or [MEDICAL CONDITION] arrest staff notification) was called, and CPR (cardiopulmonary resuscitation) was initiated, 911 Emergency Services were activated. Resident #1 was transferred to the Hospital. The Hospital Report, dated [DATE], indicated EMS found Resident #1 in asystole (no heart conduction activity on the monitor) on arrival. When Resident #1's [MEDICAL CONDITION] was removed a large mucus plug was noted. The large plug was significant and noted to be thick, dry and dense. A Q-tip was used in an attempt to remove the plug along with aggressive suctioning. A portion of the mucus and blood was removed, enabling the patient to be ventilated via the [MEDICAL CONDITION]. After 2 rounds of advanced cardiac life supprt, cardiac activity was not re-established. Resident #1 died at 6:09 A.M. on [DATE]. The Facility investigation file, dated [DATE], indicated a written statement by Nurse #1's indicated Resident #1 was given a breathing treatment and the Resident felt better. This was not consistent with the nurses notes or related documentation for the shift. Nurse #1 documented she then left the unit (she was the only licensed staff on the Unit with no replacement) and finished paper work on a second unit. Surveyor #1 interviewed Nurse #1 at 9:50 A.M. on [DATE], stated that on [DATE], she went back to the unit and Resident #1 was dead. Nurse #1 said she called for an emergency assistance for a cardiopulmonary arrest. Nurse #1 said that it was difficult to use the ambu bag, which was fitted over Resident #1's [MEDICAL CONDITION] and when she attempted the suction Resident #1's airway, the suction machine did not work. Nurse #1 said she received shift report from Nurse #4 on [DATE] at 11:30 P.M. Nurse #1 stated she was not informed of Resident #1 having mental status changes but Nurse #4 told her Resident #1 had desaturated (oxygen saturations levels were abnormal less than 90%) at the start of the 3:00 P.M. to 11:00 P.M. shift., but that Resident #1 was stable. Nurse #1 was not informed that Resident #1 did not receive [MEDICAL CONDITION] care during the 3:00 P.M. to 11:00 P.M. shift and she did know if Resident #1 was suctioned during the 3:00 P.M. to 11:00 P.M. shift. Nurse #1 said she first saw Resident #1 on [DATE] at 11:45 P.M., she said Resident #1 was alert and he/she was always congested but Resident #1 could cough his/her own secretions up because she did in the past but not during her shift on [DATE]. When asked what Resident #1's oxygen saturation levels were, she said that at 11:45 P.M. on [DATE] she took the oxygen saturation level but did not document them but Resident #1's oxygen saturation was 90% and respiratory rate was 20 to 22, and she listened to Resident #1's lungs and the lungs were congested (this was not documented). None of these findings were documented in the nurses notes, TARs or witness statements. During survey, it was noted that the emergency cart on Resident #1's unit had not been checked for 18 hours after Resident #1's cardiopulmonary arrest. During the survey on [DATE], the surveyors were informed four residents resided in the Facility with tracheostomies. During tour, on one of four units, where three residents with tracheostomies resided, a non-functioning suction machine on the emergency cart.

Based on records reviewed and interviews, for 3 of 7 Residents (Resident #1, #2, and #4), the facility failed to follow the Physician's orders/the plan of care. - For Resident #1, the facility failed to follow the Physician's order for increased humidification of the [MEDICAL CONDITION] for approximately 21 days in February 2016. In the hospital on [DATE] Resident #1 was found to have a large mucus plug with dried secretion occluding the tracheal airway. - For Resident #1, the facility failed to follow the Physician's order for the prescribed antibiotic. - For Resident #4, the Facility failed to follow the plans of care for monitoring and then increasing oxygen saturations levels. Resident #4 was later hospitalized and found to have significant respiratory acidosis (a sign of [MEDICAL CONDITION]) with hyercarbia (excessive carbon [MEDICATION NAME] in the blood stream). - For Resident #4, the skin care plan for assessment was not followed. Findings include: 1. Resident #1, the facility failed to follow the Physician's order for increased humidification of the [MEDICAL CONDITION] and failed to follow the Physician's order for [MEDICATION NAME] for acute [MEDICAL CONDITION]. Resident #1's [DIAGNOSES REDACTED]. The Physician's order, dated 1/5/16, Resident #1 was prescribed to increase in the tracheal humidification. The Treatment Administration Record (TAR), dated 1/5/16 to 1/31/16, indicated Resident #1 received tracheal humidification. The February 2016 TAR indicated the order for Resident #1 humidification of the [MEDICAL CONDITION] was not transcribed in error. There was no Physician order to discontinue the humidification. On 4/29/16 the Surveyor interviewed Nurse #4 at 9:50 A.M., Director of Nurses #2 at 3:25 P.M., and Nurse #3, at 3:50 P.M. Director of Nurses #2 and Nurse #3 said that Resident #1's ordered tracheal humidification was not discontinued by the Physician and was not transcribed to Resident #1's February 2016 TAR in error. Therefore it was 21 days Resident #1 did not have the tracheal humidification. as prescribed. Hospital Discharge Summary, dated 2/23/16 at 10:59 A.M., indicated Resident #1 had an exacerbation of [MEDICAL CONDITIONS] and coronavirus infection. The Physician's orders, dated 2/23/16, indicated Resident #1 was prescribed [MEDICATION NAME] 500 mg daily for 3 days to be administered at 8:00 P.M. and was scheduled for 2/23/16. The Medication Administration Record, [REDACTED].M. as not being administered. The Surveyor interviewed Nurse #4 at 12:50 P.M. on 5/10/16. Nurse #4 said that she did not administer [MEDICATION NAME] to Resident #1 at 8:00 P.M. on 2/23/16. 2a. Resident #4 was admitted to the facility in 1/2016. Resident #4's [DIAGNOSES REDACTED]. The Physician's order, dated 1/29/16, indicated staff was to increase Resident #4 oxygen via a nasal cannula with 1 to 3 liter flow rate per minute to keep the oxygen saturation level greater than 90% every shift. The Medication Administrative Record (MAR), dated February 2016, indicated the following oxygen saturation levels were circled as not being performed: - During the 7:00 A.M. to 3:00 P.M. shift; on 2/3/16, 2/8/16, 2/11/16 - During the 3:00 P.M. to 11:00 P.M. shift; on 2/2/16, 2/3/16, 2/4/16,and 2/12/16. The Surveyor interviewed Unit Manager (UM) #2 at 2:40 P.M. on 5/3/16. UM #2 said that the Physician's orders for monitoring and titrating the oxygen saturation levels was not performed during the 7:00 A.M. to 3:00 P.M. shift on 2/3/16, 2/8/16, 2/11/16 and during 3:00 P.M. to 11:00 P.M. shift on 2/2/16, 2/3/16, 2/4/16,and 2/12/16. Resident #4 was hosptalized on [DATE] and found to have significant respiratory acidosis (a sign of [MEDICAL CONDITION]) with hyercarbia (excessive carbon [MEDICATION NAME] in the blood stream). Hospital Report, dated 2/13/16, indicated on Resident #4's arrival from the facility he/she had significant respiratory acidosis (a sign of [MEDICAL CONDITION]) with hyercarbia (excessive carbon [MEDICATION NAME] in the blood stream). 2b. The Skin Care Plan, dated 1/30/16, indicated Resident #4 was assessed at risk for skin breakdown due to impaired sensation, limited mobility and incontinence. Intervention included weekly skin assessments to be performed by a licensed Nurse. The Treatment Administration Record, dated 2/2016, indicated the skin assessment were not documented as having been done for 2 weeks, on 2/2/16 and on 2/9/16. The Surveyor interviewed Nurse #8 at 2:05 P.M. on 5/3/16. Nurse #8 said that the skin assessments were not done as care planned. 3. For Resident #2, the facility failed to follow the bed mobility plan of care. Resident #2 admitted in August 2005 with [DIAGNOSES REDACTED]. A Care Plan, dated July 2011, and a Visual /Bedside Kardex Report (utilized by the CNA's), print date of August 2015, indicated Resident #2 was dependent, requiring two staff members for bed mobility. Quarterly Minimum Data Assessment (MDS), dated [DATE], indicated Resident #2 was total dependence with a 2 person physical assist for bed mobility. An Event Summary Report, dated 10/10/15, indicated CNA #4 provided personal care to Resident #2, CNA #4 rolled Resident #2 onto his/her side during personal care without assistance, when he/she started to slide out of bed and had to be lowered to the floor. The Surveyor interviewed CNA #4 at 1:08 P.M. on 4/26/16. CNA #4 said she rolled Resident #2 over to provide care when Resident #2 started to slide out of bed and she had to lower him/her to the floor. CNA #4 said she knew Resident #2 was a 2 person assist with bed mobility; however, she provided Resident #2 personal care by herself and did not ask for help. The Surveyor interviewed Director of Nurses (DON) #1 at 12:56 P.M. on 4/22/16. The DON said that CNA #4 did not follow Resident #4's care plan for bed mobility. Nurse's notes, dated October 2015, indicated Resident #2 did not show any signs of symptoms of pain until 10/12/15, two days after being lowered to the floor on 10/10/15. The Nurse Practitioner (NP) was notified and x-rays were obtained. X-rays, dated 10/12/15, indicated Resident #2 had bilateral leg fractures. The NP was notified and Resident #2 was transferred to the hospital for evaluation.

Based on records reviewed and interviews for 1 of 7 sampled residents (Resident #2), the facility failed to adequately assist Resident #2, who required a 2 person assist with bed mobility, when Certified Nursing Assistant (CNA) #4 rolled Resident #2 in bed independently and Resident #2 began to slide out of bed and had to be lowered to the floor causing Resident #2 to suffer leg fractures in both legs. Findings include: Resident #2 admitted in August 2005 with [DIAGNOSES REDACTED]. A Care Plan, dated July 2011, and a Visual /Bedside Kardex Report (utilized by the CNA's), print date of August 2015, indicated Resident #2 was dependent, requiring two staff members for bed mobility. Quarterly Minimum Data Assessment (MDS), dated [DATE], indicated Resident #2 was total dependence with a 2 person physical assist for bed mobility. An Event Summary Report, dated 10/10/15, indicated CNA #4 provided personal care to Resident #2, CNA #4 rolled Resident #2 onto his/her side during personal care without assistance, when he/she started to slide out of bed and had to be lowered to the floor. The Surveyor interviewed CNA #4 at 1:08 P.M. on 4/26/16. CNA #4 said she rolled Resident #2 over to provide care when Resident #2 started to slide out of bed and she had to lower him/her to the floor. CNA #4 said she knew Resident #2 was a 2 person assist with bed mobility; however, she provided Resident #2 personal care by herself and did not ask for help. The Surveyor interviewed Director of Nurses (DON) #1 at 12:56 P.M. on 4/22/16. The DON said that CNA #4 did not follow Resident #4's care plan for bed mobility. Nurse's notes, dated October 2015, indicated Resident #2 did not show any signs of symptoms of pain until 10/12/15, two days after being lowered to the floor on 10/10/15. The Nurse Practitioner (NP) was notified and x-rays were obtained. X-rays, dated 10/12/15, indicated Resident #2 had bilateral leg fractures. The NP was notified and Resident #2 was transferred to the hospital for evaluation.

Based on observation and staff interview, the Facility failed to ensure that the emergency suction machine on the code cart located on Unit D was in working condition, and failed to ensure that Resident #1's room suction machine was correctly connected and readily available for immediate usage. - On 2/24/16 Resident #1 had a cardiopulmonary arrest. Resident #1's tracheal airway was occluded and needed to be suctioned. Two suction machines were not operational during this emergency. EMS (Emergency Medical Services) was activated and Resident #1 was bought to the hospital. Resident #1 was found to have a large mucus plug with dried secretions occluding the tracheal airway. After Advance Cardiac Support was performed, cardiac activity was not re-established. Resident #1 died at 6:09 A.M. on 2/24/16. - Observations during survey, it was identified that the code cart on Resident #1's unit had not been checked for 18 hours after Resident #1's cardiopulmonary arrest. The emergency code carts on C and D Wing were not checked daily as required per the Facility's Policy. -Observations during survey, on one of four units, who had three resident's with tracheostomies, was identified to have a non-functioning suction machine on the code cart. Findings include: The facility policy on Emergency Medical Response, dated 7/14/14, indicated to Respond to identified emergency, initiate appropriate medical interventions CPR. Obtain an AED (automated external defibrillator) if applicable, and Emergency Cart. -On 2/24/16 Resident #1 had a cardiopulmonary arrest. Resident's tracheal airway was occluded and needed to be suctioned. Two suction machines were not operational during this emergency. EMS (Emergency Medical Services) was activated and Resident #1 was bought to the hospital. Resident #1 was found to have a large mucus plug with dried secretions occluding the tracheal airway. After Advance Cardiac Support was performed, cardiac activity was not re-established. Resident #1 died at 6:09 A.M. on 2/24/16. 1. Review of the Emergency Cart on C Wing which includes the portable emergency suction machine, indicated that the code cart should have been checked daily and signed off during the 11:00 P.M. to 7:00 A.M. shift. The cart was not checked on 7/20/15, 2/17/16, and 2/23/16, as per the facility protocol. 2. Review of the Emergency Code cart checklist (which includes) portable suction (the cart is suppose to be checked daily on the 11:00 P.M. to 7:00 A.M. shift, as per the facility protocol). The following cart checks were not done for D Wing (Resident #1's unit): 2/10/16, 2/18/16, 2/24/16 (approximately 18 hours after Resident #1's cardiopulmonary arrest), 3/8/16, 3/18/16, 3/27/16, and 3/28/16. The Surveyor interviewed The Director of Nurses (DON) #1 at 4:17 P.M. on 4/29/16. DON #1 said that prior to the suction machine not working during Resident #1's cardiopulmonary arrest. The Nurses were instructed only to visually inspect if the suction machine and emergency supplies were present. The Nurses did not ensure that the suction machine had been operationally checked. The Surveyor interviewed Certified Nursing Assistant #1 at 3:27 P.M. on 4/22/16, Certified Nursing Assistant #2 at 5:24 P.M. on 4/27/16, and Nurse #1 at 12:39 on 4/27/16; they said on 2/24/16 the suction machine motor located on the code cart never turned on when they attempted to use it to suction Resident #1, whose airway was not patent, and they were unable to successfully use the ambu bag to ventilate Resident #1's lungs. The staff tried plugging this nonoperational suction machine into 4 different electrical outlets during the code for Resident #1's cardiopulmonary arrest. The suction machine in Resident #1's room was not connected to the canisters to be used for emergency suction, although the staff tried to connect this suction machine without success. The Surveyor interviewed DON #1 on 4/22/16 at 12:35 P.M. and asked if Resident #1's investigation of 2/24/16 at 5:35 A.M. (which had been given to the Surveyor) was the complete investigation. DON #1 said that this was the complete investigation. DON #1 said there were no other witness statements, interventions, or corrective action taken. The Surveyor interviewed DON #1 on 4/29/16 at 4:17 P.M. DON #1 said that there was no problem with the code, but with the competency of the staff. DON #1 said that the suction machine on the code cart did not work, delaying effective CPR because Resident #1 had an airway occlusion. The ambu bag when squeezed met resistance, and the staff tried to suction Resident #1 to relieve the potential secretions occluding his/her airway. On C Wing on 4/29/16 at 12:05 P.M., there were 3 Residents with tracheotomies, the Surveyor tested the suction machine with Nurse #7 and found that the suction machine plugged into the hallway outlet did not work, and the suction machine did not fit into the first outlet on the electric socket. Nurse #7 said that she would report this to Maintenance.

Based on interviews and record review for one of three residents (Resident #1), the Facility failed to ensure the nursing staff followed the plan of care. Resident #1 plan of care included removal of a splint and ace wraps to perform dressing changes and assessment of the incisions daily and as needed. The nursing staff failed to remove the splint to assess the skin under a splint, or perform the dressing changes to the right foot, and failed to ensure weekly foot assessments were completed in accordance with the Facility's Skin Integrity Management policy. Eighteen days after admission, Resident #1 was noted to have leakage (drainage) in the area of the right heel, and when Nurse #3 removed the wraps and splint, she observed Resident #1 had a new unstagable pressure sore. Findings include: The Hospital Discharge Summary, dated 9/24/14, indicated Resident #1's medical history included severe mental [MEDICAL CONDITION], and was nonverbal at baseline, and had a surgically repaired right tibia fracture. The Discharge Summary indicated the Hospital placed a removable fracture boot (splint) on Resident #1's right lower leg so the splint could be removed as needed. The Discharge Summary indicated Resident #1 was transferred to the Facility for short-term rehabilitation. The Hospital's Nursing Discharge Status Report, dated 9/24/14, indicated Resident #1's skin was intact except for two surgical wounds, one on the right knee and one on the right lower leg. The Admission Record indicated in September 2014 the nursing staff admitted Resident #1 to the Facility. The Admission Physician Orders, dated 9/24/14, included a skin assessment weekly and a [MEDICATION NAME] (non-adhering) dressing to the right knee and lower leg wound, covered with wrap, splint, then ace wrap. The orders indicated the dressings were to be changed daily and as needed. The Policy/Procedure titled Skin Integrity Management, revised 1/12/14, indicated the staff performed skin inspections on admission and weekly. The Admission Nursing Assessment, dated 9/24/14, indicated Resident #1's caregiver (from Resident #1's usual residence) was present ,and told the admitting nurse (Nurse #1) not to remove the right lower extremity splint. This was not consistent with the Hospital discharge instructions or the Facility admission orders [REDACTED] The Surveyor interviewed Nurse #1 at 12:25 P.M. on 11/19/14. Nurse #1 said she did not remove Resident #1's right leg splint to inspect Resident #1's right lower leg and foot because Resident #1's caregiver said someone told him the splint could not be removed. Nurse #1 said she did not question the communication and passed on that information during change of shift report. The Medication Record, dated from 9/25/14 to 10/12/14, indicated the nursing staff documented they completed the treatments to Resident #1's right lower leg as ordered. The reverse side of the Medication Record (Medication Nurses Notes), did not indicate staff documented they noted any unusual assessment findings when the nurses performed the treatments. The Surveyor interviewed Nurse #3 at 2:15 P.M. on 11/19/14 and Nurse #5 at 1:34 P.M. on 11/20/14. Nurse #3, and Nurse #5 said although they performed the treatment to Resident #1's right knee, they did not remove Resident #1's wraps or splint to perform the treatment to Resident #1's lower right leg, and therefore did not observe or assess Resident #1's right heel. The Surveyor interviewed Nurse #7 at 5:15 A.M. on 11/21/14. Nurse #7 said when she performed Resident #1's treatment (done 10/8/14 according to the Director of Nurses), she changed the dressing to Resident #1's right knee, took down the wraps, and performed a treatment to an area on the front lower leg, near the top of Resident #1's foot. Nurse #7 said based on her observations, the treatment to the top of the right foot had not been performed for some time, so she cleaned it thoroughly. Nurse #7 said she did not recall observing or assessing Resident #1's heel during the treatment. The Medication Record entries, dated 9/30/14 and 10/7/14, indicated the scheduled skin assessments were not documented as having been performed by the nurses. The Director of Nurses said Nurse #2 and Nurse #8 were assigned to perform Resident #1's skin assessments on 9/30/14 and 10/7/14. The Surveyor interviewed Nurse #2 at 2:00 P.M. on 11/19/14 and Nurse #8 at 9:10 A.M. on 11/21/14. Nurse #2 said he did not work the evening of 9/30/14, however, he never removed Resident #1's right lower leg wrap and splint prior to 10/12/14. Nurse #8 said she performed Resident #1's skin assessment with the assistance of his/her caretaker however, she did not inspect the condition of the skin on Resident #1's right foot and heel. The Progress Notes, dated 10/12/14, indicated Resident #1 had a new pressure sore on his/her right heel. The Progress Notes indicated although Resident #1 was nonverbal, he/she was moaning to indicate pain. Nurse #3 said during the day shift on 10/2/14, she saw strike through (leakage)in the area of Resident #1's right heel and removed the wraps and splint. Nurse #3 said Resident #1 had a large draining sore, which was unable to be staged pressure sore on his/her heel. The Skin Integrity Report, dated 10/2/14, indicated Resident #1 had an unstagable pressure sore on the right heel with necrotic (defined as dead devitalized) tissue and slough (moist, dead tissue), measuring 5 centimeters (cm) x 4 cm x 0.5 cm with serosanguinous (bloody serous) drainage and a Stage II pressure sore on the top of the right foot measuring 2.4 cm x 1.9 cm without drainage. Unit Manager #1 was interviewed at 8:40 A.M. on 11/19/14. Unit Manager #1 said the nursing staff did not follow Resident #1's plan of care.

Based on interviews and record review for one of three residents (Resident #1), the Facility failed to ensure that Resident #1 did not develop an avoidable pressure sore. Resident #1's plan of care included a dressing to Resident #1's right knee and lower leg and use of a removable fracture boot (splint) to Resident #1's right lower leg. Although staff documented they performed the treatments as ordered, the assigned nurses said they did not change the dressing on the lower leg, staff did not remove Resident #1's splint and wraps to inspect or assess Resident #1's right foot and heel. On 10/12/14, Resident #1 was assessed to have a an unstagable pressure sore, which when derided and was determined to be a Stage IV (full thickness loss with extensive destruction involving muscle, bone and supporting structures such as tendons) pressure sore. Findings include: The Hospital's Nursing Discharge Status Report, dated 9/24/14, indicated Resident #1's skin was intact except for two surgical wounds, one on the right knee and one on the right lower leg. The Admission Nursing Assessment, dated 9/24/14, indicated Resident #1's caregiver (from Resident #1's residence) was present and instructed the admitting nurse (Nurse #1) not to remove the right lower extremity splint. The Surveyor interviewed Nurse #1 at 12:25 P.M. on 11/19/14. Nurse #1 said she did not remove Resident #1's right leg splint to inspect Resident #1's right lower leg and foot because Resident #1's caregiver said someone told him the splint could not be removed. Nurse #1 said she did not question the communication and passed on that information during change of shift report. The Admission Physician Orders, dated 9/24/14, included skin assessment weekly on Tuesday and [MEDICATION NAME] dressing to the right knee and lower leg wound, covered with wrap, splint, then ace wrap. The orders indicated the dressings were to be changed daily and as needed. The Plan of Care, dated 9/25/14, indicated Resident #1 was at risk for skin breakdown and interventions included monitor skin for signs and symptoms of skin breakdown. The Physician History and Physical, dated 9/25/14, indicated Resident #1's right knee surgical site was closed and pink, the right lower leg splint was in place, and Resident #1 did not cooperate with the exam. The Surveyor interviewed the Attending Physician at 11:25 A.M. on 11/19/14. The Attending Physician said she did not remove Resident #1's wrap and splint and inspect Resident #1's lower right leg and foot because Resident #1 was so agitated during the examination. The Attending Physician said she did not inspect Resident #1's lower right leg or foot prior to 10/12/14. The Surveyor interviewed the Nurse Practitioner at 11:55 A.M. on 11/19/14. The Nurse Practitioner said she did not examine Resident #1's right lower extremity prior to 10/12/14. The Medication Record, dated from 9/25/14 to 10/12/14, indicated the nursing staff documented they completed the treatments to Resident #1's right lower leg as ordered. The Progress Notes, dated from 9/25/14 to 10/11/14, did not include documentation to indicate staff had any concerns with Resident #1's right lower leg and foot. The Surveyor interviewed Nurse #3 at 2:15 P.M. on 11/19/14, Nurse #5 at 1:34 P.M. on 11/20/14 Nurse #3, and Nurse #5 said although they performed the treatment to Resident #1's right knee, they did not remove Resident #1's wraps or splint to perform the treatment to Resident #1's lower right leg, and did not examine or assess the skin on the right lower leg, including Resident #1's right heel. The Surveyor interviewed Nurse #7 at 5:15 A.M. on 11/21/14. Nurse #7 said when she performed Resident #1's treatment (done 10/8/14 according to the Director of Nurses), she changed the dressing to Resident #1's right knee, took down the wraps, and performed a treatment to an area on the front lower leg near the top of Resident #1's foot. Nurse #7 said based on her observations, the treatment to the top of the right foot had not been performed for some time, so she cleaned it thoroughly. Nurse #7 said the skin on the lower leg was dry so she washed and moistened it then rewrapped the leg. Nurse #7 said she did not recall observing Resident #1's heel during the treatment. The Medication Records, dated 9/30/14 and 10/7/14, indicated the skin assessments were not documented as having been completed. The Director of Nurses said Nurse #2 and Nurse #8 were assigned to perform Resident #1's skin assessments on 9/30/14 and 10/7/14. The Surveyor interviewed Nurse #2 at 2:00 P.M. on 11/19/14 and Nurse #8 at 9:10 A.M. on 11/21/14. Nurse #2 said he did not work the evening of 9/30/14, however, he never removed Resident #1's right lower leg wrap and fracture boot prior to 10/12/14. Nurse #8 said she performed Resident #1's skin assessment with the assistance of his/her caretaker. Nurse #8 said took down the wrap because the right knee dressing was soiled with feces. Nurse #8 said she did not assess Resident #1's right foot or heel at that time. The Progress Notes, dated 10/12/14, indicated Resident #1 had a new pressure sore on his/her right heel. The Progress Notes indicated although Resident #1 was nonverbal, he/she was moaning to indicate pain. Nurse #3 said during the day shift on 10/2/14, she saw strike through (stain of drainage) in the area of Resident #1's right heel and removed the wraps and splint. Nurse #3 said Resident #1 had a large draining sore which was unable to be staged on his/her heel. The Skin Integrity Report, dated 10/2/14, indicated Resident #1 had an unstagable pressure sore on the right heel with necrotic tissue and slough measuring 5 centimeters (cm) x 4 cm x 0.5 cm with serosanguinous drainage and a Stage II pressure sore on the top of the right foot measuring 2.4 cm x 1.9 cm, which was without drainage.

Based on record review and interview, the Facility failed for 4 residents (#2,#4, #13, and #14) out of a total sample of 24 residents, to follow the physician's orders [REDACTED]. Findings include: 1. For Resident #13, the Facility failed to apply the correct treatment to a stage 3 pressure ulcer, failed to follow physician's orders [REDACTED]. Resident #13 was admitted to the facility in March 2007. Review of the physician's orders [REDACTED]. -No brief when in bed, use incontinent pad until healed. -No more than two hours at a time to be up in wheelchair. -Left heel ulcer pressure area spray with wound cleanser, pat dry, apply skin prep to wound edges, [MEDICATION NAME] dressing to wound bed, cover with dry clean dressing, and wrap with Kling every other day and as needed. -Left gluteal/buttock pressure ulcer spray with wound cleanser, pat dry, apply skin prep to edges and a [MEDICATION NAME] dressing over wound bed. -Left dorsal foot apply [MEDICATION NAME] solution to area, cover with [MEDICATION NAME] and wrap with Kling. Observation of the resident on 8/12/13 from 1:00 P.M. to 5:00 P.M.(4 hours), was of the resident sitting in a wheelchair in the dining room. The resident was not placed back in bed after two hours as planned. Observation of the resident, on 8/13/13 at 7:05 A.M., was of the resident in bed. The resident was observed to have a brief in place and not an incontinent pad as ordered. The resident was still in bed with a brief in place at 7:35 A.M. Observations of the resident on 8/13/13 at 7:43 A.M., was of the resident in bed, with a brief on rather than an incontinence pad as ordered by the physician. Review of the 8/13/13 Report of Consultation indicated the resident was seen in the Wound Clinic on 8/13/13. This report indicated that the treatment in place on the heel was not the treatment that was ordered. The resident had Alginate on the heel not [MEDICATION NAME] with Calcium Alginate as ordered. Observation, on 8/14/13 at 11:10 A.M., of the treatment to the resident's wounds was as follows: -The resident was on his/her left side in bed. -Nurse #4 applied [MEDICATION NAME] Solution to the outer edges of the resident's left heel wound ([MEDICATION NAME] was not ordered by the physician for the heel wound). -Surveyor intervened and informed Nurse #4 the left Heel wound did not have an order for [REDACTED]. -Nurse #4 agreed (after checking treatment sheet) that the [MEDICATION NAME] was not ordered to the left heel. Nurse #4 removed the sponges and Kling dressing from the heel wound. -Nurse #4 proceeded to apply the [MEDICATION NAME] to the left heel wound. Nurse #4 did not remove the [MEDICATION NAME] solution that had been applied to the heel edges despite acknowledging that it was the wrong treatment. During interview 8/14/13 at 11:35 A.M., following the treatment observation, Nurse #4 said that the treatment was not done to the heel as ordered by the physician. On 8/14/13 at 12:00 P.M., the resident was observed out of bed. The resident was still observed out of bed at 1:30 P.M., and at 3:00 P.M. (3 hours) During interview 8/14/13 at 3:00 P.M., Unit Manager #1 said that the resident's current physician's orders [REDACTED]. Unit Manager #1 said that the Wound Report (of 8/13/13) indicated the wrong treatment was done to the pressure ulcer. During interview 8/15/13 at 1:00 P.M., the resident's family member said that he/she accompanied the resident to the Wound Clinic (8/13/13), and the physician said the treatment applied to the left heel was incorrect. [MEDICATION NAME] was not on the left heel as ordered. During interview 8/15/13 at 1:30 P.M., the Director of Nurses (DON) said that the resident's wound treatments should have been done as ordered by the physician. Please refer to F314. 2. For Resident #2, the Facility failed to perform the correct treatment to the resident's wound. Resident #2 was admitted in August 2012. Review of the physician's progress note of 7/30/13 indicated the wound was improving but the edges were excoriated and macerated. The note indicated excoriation of the entire area that was covered by the [MEDICATION NAME]. Consequently, the physician changed the treatment from adhesive [MEDICATION NAME] to [MEDICATION NAME] basic (a non-adhesive dressing) with Hypofix (tape). However, review of the Treatment Administration Record (TAR) of 7/31/13 to 8/12/13 indicated the resident continued to receive the [MEDICATION NAME] adhesive dressing in error. Review of the physician's progress note of 8/13/13 indicated the wound was healing but the edges remained white and macerated. During observation on 8/14/13 at 1:10 P.M., Resident #2 was observed lying on the right side. Nurse #5 removed the dressing to the sacral wound. The edges of the wound were observed macerated. During interview 8/14/13 at 1:15 P.M., Nurse #5 said that the treatment change of 7/30/13 was not entered into the TAR (Treatment Administration Record until 8/13/13). Please refer to F314. 3. For Resident #4, the Facility failed to follow the plan of care for Geri (Geriatric)-Sleeves to bilateral lower extremities. Resident #4 was admitted to the Facility in 8/12 and readmitted in 9/12. The Progress Notes of 6/19/13 indicated that the resident sustained [REDACTED]. The 6/2013 Treatment Record indicated that the following was added on 6/19/2013: Geri-Sleeves to be worn on bilateral lower extremities when out of bed. The 7/2013 and 8/2013 Treatment Records included: Geri-Sleeves to be worn on bilateral lower extremities when out of bed. The 8/2013 physician's orders [REDACTED]. On 8/13/13 at 10:20 A.M., Resident #4 was observed sitting in a reclining chair in the hallway. Resident #4 was not wearing Geri-Sleeves on bilateral legs per plan of care. On 8/13/13 at 12:45 P.M., Resident #4 was observed sitting in a reclining chair in the unit dining room. Resident #4 was not wearing Geri-Sleeves on bilateral legs per plan of care. On 8/13/13 at 1:45 P.M., Resident #4 was observed sitting in a reclining chair in the hallway. Resident #4 was not wearing Geri-Sleeves on bilateral legs per plan of care. On 8/14/13 at 2:00 P.M., UM #4 said that Resident #4 should wear Geri-Sleeves to bilateral legs when out of bed per plan of care. 4. For Resident #14, the Facility failed to follow the plan of care for Geri-Sleeves. Resident #14 was admitted to the Facility in 10/2010. The 8/2013 physician's orders [REDACTED]. Remove for care in the morning and in the evening. May wear long sleeves. On 8/13/13 at 10:30 A.M., Resident #14 was observed sitting in a wheelchair in the unit dining room. Resident #14 was wearing a short sleeve shirt. Resident #14 was not wearing Geri-Sleeves as planned On 8/13/13 at 12:30 P.M., Resident #14 was observed sitting in a wheelchair in the unit dining room, feeding self dinner. Resident #14 was wearing a short sleeve shirt. Resident #14 was not wearing Geri-Sleeves as planned. On 8/13/13 at 2:00 P.M., Resident #14 was observed sitting in a wheelchair in the bedroom. Resident #14 was wearing a short sleeve shirt. Resident #14 was not wearing Geri-Sleeves as planned. On 8/14/13 at between 8:00 A.M. and 8:30 A.M., Resident #14 was observed sitting in a wheelchair in the unit dining room. Resident #14 was wearing a short sleeve shirt. Resident #14 was not wearing Geri-Sleeves as planned During interview on 8/14/13 at 8:50 A.M., UM #4 said that Resident #14 should wear Geri-Sleeves per plan of care.

Based on record review, observation and interview, the Facility failed for 2 residents (#2 and #13) of 3 applicable residents, out of a total sample of 24 residents, to insure a resident with a pressure ulcer received appropriate treatment and services to promote healing, prevent infection and prevent new pressure sores from developing. Findings include: 1. For Resident #13 the facility failed to apply the correct treatment to a stage 3 pressure ulcer, failed to use clean technique with a dressing change, and failed to follow physician's orders [REDACTED]. Resident #13 was admitted to the facility in December 2012 with [DIAGNOSES REDACTED]. Review of the admission record of 12/27/12 indicated the resident was admitted to the facility with a deep tissue injury to the left heel. Review of the Skin Integrity Records, physician's and nurses' progress notes (4/10/13 to 6/25/13) indicated that the left heel ulcer was not healing. Review of the Skin Integrity Record of 6/25/13 indicated the wound now was necrotic, contained a moderate amount of serous (thin watery fluid) drainage and now measured 4 cm (centimeters) in length by 4 cm in width and depth could not be determined. The physician monitored the wound and implemented changes as needed to the treatment plan. Review of the quarterly MDS (Minimum Data Set) assessment of 6/25/13 indicated the resident had severe long and short term memory impairment with a Brief Interview of Mental Status (BIMS) score of 3/15. The resident was dependent on staff for positioning, transfers, ambulation, dressing, and eating. The resident was incontinent of bowel and bladder and had a pressure ulcer that was unstageable. Review of the care plan in place 6/26/13 to prevent further breakdown and promote wound healing included: -Float heels. -Reposition frequently. -Dietary consult as needed. -Calozime barrier cream after incontinent episodes. -Incontinent care as needed. -Norton Assessment per policy. -Pressure reduction for bed and chair. -When lying on back place 2 pillows under knee/lower leg area. Place light blue bolster between knees/lower legs. Place soft wedge at left side of resident's body. -Assess skin condition and report abnormalities. -Monitor for changes in nutrition. -Instruct resident on methods of reducing friction and shearing. -Monitor areas from readmission on (12/27/12) and document weekly on Skin Integrity Reports. -Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to physician. -Assess wound weekly including measurements and wound status. -Monitor for new breakdown i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanch. Review of the Skin Integrity Report of 7/2/13 indicated the resident had two new stage 2 pressure ulcers on the left buttock. The wounds were described as inflamed with macerated edges. The wound beds contained slough and granulating tissue. Review of the Skin Integrity Report of 7/11/13 indicated the resident had a new stage 2 pressure ulcer on the left dorsal foot. The wound was described as containing [MEDICATION NAME] tissue (new healthy tissue) with a minimum amount of clear drainage. Review of the physician's progress note of 7/11/13 indicated that the current treatment to the heel ulcer was ineffective and that a new treatment would be implemented. A treatment to the new foot ulcer was also obtained. Review of the physician's note of 7/24/13 indicated the resident would be seen in the Wound Clinic. The resident was diagnosed as having Osteo[DIAGNOSES REDACTED] in the left heel wound and would be starting antibiotic therapy. Review of the physician's progress note of 7/26/13 indicated that the results of an x-ray to the left heel ulcer was "suggestive of osteo[DIAGNOSES REDACTED]". This note indicates the resident was seen in a local hospital wound clinic, and the wound clinic recommendations to treat the osteo[DIAGNOSES REDACTED] with [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) for six weeks would be implemented. Review of the Skin Integrity Report of 8/11/13 indicated the following: Left heel wound bed now measured 5.8 cm in length by 4.1 cm in width with depth not recorded. No undermining was recorded. There was a moderate amount of Serous drainage. The wound was described as having an odor and the surrounding tissue was described as deep purple. The two stage 2 pressure ulcers on the left buttocks were described as containing granulating tissue (pink/red new skin). The first ulcer measured 0.2 cm in length by 0.4 cm in width. The second ulcer measured 0.5 cm in length by 0.4 cm in width. The surrounding tissue was described as inflamed for both ulcers. The wound edges were described as macerated (softening due to exposure to moisture). The stage 2 pressure ulcer on the left dorsal foot measured 0.8 cm in length by 0.6 cm in width with no drainage or odor. There was no documentation of the depth. Review of the physician's orders [REDACTED]. -No brief when in bed, use incontinent pad until healed. -No more than two hours at a time to be up in wheelchair. -Left Heel Ulcer pressure area spray with wound cleanser, pat dry, apply skin prep to wound edges, [MEDICATION NAME] with Calcium Alginate dressing to wound bed, cover with dry clean dressing and wrap with Kling every other day and as needed. -left gluteal/buttock pressure ulcer spray with wound cleanser, pat dry, apply skin prep to edges and a [MEDICATION NAME] over wound bed. -Left dorsal foot apply [MEDICATION NAME] solution to area, cover with [MEDICATION NAME] and wrap with Kling. Observation of the resident on 8/12/13 from 1:00 P.M., to 5:00 P.M. (4 hours), was of the resident up in the dining room sitting in a wheelchair. The resident was not placed back in bed after two hours in the wheelchair as ordered. Review of the Report of Consultation of 8/13/13 indicated the resident was seen in the Wound Clinic on 8/13/13. This report indicated that the treatment in place on the heel was not the treatment that was ordered. The resident had Alginate on the heel not [MEDICATION NAME] with Calcium Alginate. Observation of the resident on 8/13/13 at 7:05 A.M. was of the resident in bed. The resident was observed to have a brief in place and not an incontinent pad as ordered. The resident was still in bed with a brief in place at 7:35 A.M. Observations of the resident on 8/13/13 at 7:43 A.M., was of the resident in bed, with a brief on rather than an incontinence pad as ordered by the physician. Observations of the resident on 8/14/13 at 10:00 A.M., was of the resident in bed with a brief on and not an incontinent pad as ordered by the physician. Observation on 8/14/13 at 11:10 A.M. of the treatment to the resident's wounds was as follows: -Nurse #4 did not set up a clean field, but placed all the resident's treatment supplies, treatment sheets, and a towel on the bedside table. -The resident was on his/her left side in bed. Nurse #4 washed hands, donned gloves and removed the [MEDICATION NAME] dressing to coccyx/buttocks. Nurse #4 removed gloves and donned new gloves without sanitizing her hands. -Nurse #4 cleansed the wound with Wound cleanser as ordered. -Nurse #4 applied skin prep to the area surrounding the coccyx wound as ordered. -Nurse #4 with the same gloves reached into her uniform pocket and retrieved a pair of scissors. Nurse #4 proceeded to cut the [MEDICATION NAME] in half with the scissors that were not disinfected. Nurse #4 placed the scissors on the bedside table. -Nurse #4 applied the [MEDICATION NAME] (that was cut with the scissors that were not cleaned) to the coccyx/buttocks wound. -Nurse #4 changed gloves (did not wash hands) applied new gloves and picked up the dirty scissors. -Nurse #4 cut the Kling dressing off the resident's left heel wound. Nurse #4 removed the dressing (did not change gloves or sanitize hands) and cleansed the wound with Wound Cleanser as ordered. -Nurse #4 applied [MEDICATION NAME] Solution to the outer edges of the resident's left heel wound ([MEDICATION NAME] was not ordered for the heel wound). Nurse #4 then applied a sponge and Kling dressing to the left heel wound. -Surveyor intervened and informed Nurse #4 the left Heel wound did not have an order for [REDACTED]. -Nurse #4 agreed (after checking treatment sheet) that the [MEDICATION NAME] was not ordered to the left heel. Nurse #4 removed the sponges and Kling dressing from the heel wound and placed the sponges and Kling dressing on the bed linens. -Nurse #4 cut the [MEDICATION NAME] with the dirty scissors, applied the [MEDICATION NAME] to the left heel wound. Nurse #4 picked up the sponges and Kling that were on the bed linens (now contaminated) and placed them over the [MEDICATION NAME] on the left heel wound. -Nurse #4 did not remove the [MEDICATION NAME] solution that had been applied to the heel edges despite acknowledging that it was the wrong treatment. -Nurse #4 changed gloves, but did not wash or sanitize hands and proceeded to complete the treatment to the left dorsal foot as ordered by the physician. During interview 8/14/13 at 11:35 A.M., following the treatment observation, Nurse #4 said that the treatment was not done to the heel as ordered, the scissors were not disinfected when removed from her pocket, and she did not cleanse hands between glove changes. On 8/14/13 at 12:00 P.M., the resident was observed out of bed. The resident was still observed out of bed at 1:30 P.M., and at 3:00 P.M. (3 hours). During interview 8/14/13 at 3:00 P.M., Unit Manager #1 said that the resident's current physician's orders [REDACTED]. During interview on 8/15/13 at 1:00 P.M., the resident's family member said that he accompanied the resident to the Wound Clinic (8/13/13) and that the physician said the treatment applied to the left heel was incorrect. [MEDICATION NAME] was not on the left heel as ordered. During interview 8/15/13 at 1:30 P.M., the Director of Nurses (DON) said the treatments should have been done using clean technique. Please refer to F441. 2. For Resident #2, the Facility failed to implement a change in a treatment promptly and failed to perform a dressing change using clean technique. Resident #2 was admitted in August, 2012 with [DIAGNOSES REDACTED]. Review of the Skin Integrity Reports indicated the resident was admitted with a stage 2 pressure area on the sacrum. Review of the physician progress notes [REDACTED]. The resident returned to the facility (3/13/13) with a [DIAGNOSES REDACTED]. A peripherally inserted central line catheter (PICC) line (IV) was placed in the resident's arm and Intravenous antibiotic therapy was started. Review of the Skin Integrity Report of 3/13/13 indicated the wound measured 5.4 centimeters (cm) in length by 3.8 cm in width by 3 cm in depth. The wound bed contained a minimal amount of bloody drainage and contained no odor. Review of the Quarterly MDS assessment of 5/18/13 indicated the resident had long and short term memory loss. The resident was dependent on staff for transfers, ambulation, dressing, eating, bathing and hygiene, was incontinent of bowel and bladder, had a gastrostomy tube and a Foley catheter. The resident had a stage 3 pressure ulcer. Care plan in place 5/15/13 for actual pressure ulcer included the following interventions: -Assist in turning and repositioning. -Evaluate wound daily. -Float heels while in bed. -Monitor for pain and medicate as ordered. -Monitor for additional skin breakdown. -Off load left heel with boot. -[MEDICATION NAME] air bed set at 5. -Pressure redistribution surfaces to chair. -Barrier cream with each cleaning. -Weekly skin assessment. Review of the record of 5/31/13 including the physician orders, progress notes and Treatment Administration Record (TAR) indicated the [DEVICE] was discontinued and a new treatment to the coccyx was started. Further review of the physician, nursing, nurse practitioner notes and the Skin Integrity Reports from 6/1/13 to 7/15/13 indicated the wound continued to improve. Review of the physician's progress note of 7/16/13 indicated the resident's sacral wound was beefy red with granulation tissue, no undermining. However, the wound edges were noted to have a small amount of maceration. Review of the physician's orders [REDACTED]. Apply Skin Prep to wound edges and periphery. Cover with [MEDICATION NAME] Adhesive dressing. Change daily and as needed. Review of the physician's progress note of 7/23/13 indicated the wound was improving but the edges were macerated. The treatment in place was increased from daily to twice a day. Review of the physician's progress note of 7/30/13 indicated the wound was improving but the edges were excoriated and macerated. Mild excoriation of the entire area that is covered by the [MEDICATION NAME] was noted. Consequently, the physician changed the treatment from adhesive [MEDICATION NAME] to [MEDICATION NAME] basic (a non-adhesive dressing) with Hypofix (tape). However, review of the Treatment Administration Record (TAR) of 7/31/13 to 8/12/13 indicated the resident continued to receive the [MEDICATION NAME] adhesive dressing in error. Review of the physician's progress note of 8/13/13 indicated the wound was healing but the edges remained white and macerated. The physician indicated the [MEDICATION NAME] basic (non-adhesive) and Hypofix treatment would be continued. Observation of the resident's treatment on 8/13/13 at 10:15 A.M., was of the resident in bed lying on the right side. The dressing had already been removed from the sacral wound. A package of Skin Prep, an [MEDICATION NAME] dressing and piece of Calcium Alginate were lying on the pillow, in the resident's bed, and not on a clean surface. During interview on 8/13/13 at 10:15 A.M., Nurse #5 said that these were the supplies that were going to be applied to the resident's wound. On 8/13/13 at 10:15 A.M., observation of the treatment to the sacrum was of the above supplies being applied to the sacral ulcer. During observation on 8/14/13 at 1:10 P.M., Resident #2 was observed lying on the right side. Nurse #5 assembled Wound Cleaner, sponges, Skin Prep, Calcium Alginate with silver, [MEDICATION NAME] Basic and Hypofix. Nurse #5 placed the items in the resident's bed on a plastic bag. Nurse #5 washed hands and donned gloves. During positioning of the resident for the treatment, these items rolled off the plastic bag. Nurse #5 removed the dressing and changed gloves but did not sanitize hands. Nurse #5 proceeded with the treatment using the items observed on the bed. During interview 8/14/13 at 1:15 P.M., the surveyor discussed with Nurse #5 the need to establish a clean field when providing treatment to a wound and the need to sanitize hands between glove changes. Nurse #5 said that the treatment change (of 7/30/13), from adhesive [MEDICATION NAME] to basic [MEDICATION NAME], was not entered into the TAR until (8/13/13). During interview 8/14/13 at 2:30 P.M., UM #1 said that the Facility had instructed nurses to set up a clean field on the resident's bedside table and not in the resident's bed. UM #1 said that nurses were instructed to wash or sanitize hands following glove removal. Please refer to F441.

Based on record review, observation and interview, the Facility failed to identify significant weight loss and provide adequate interventions to maintain acceptable parameters of body weight for 1 resident (#19) in a total sample of 24. Findings included: Resident #19 was admitted to the facility in 4/10 with [DIAGNOSES REDACTED]. The Weights and Vitals Summary indicated that Resident #19 weighed 175.6 pounds on 12/3/10. The annual MDS (Minimum Data Set) assessment of 3/17/11 indicated that the Brief Interview for Mental Status (BIMS) indicated a score of 14/15 (intact mental status). Resident #19 required assist of 2 for transfers, was unable to ambulate, required assist with bathing and dressing, required set-up with meals and had no significant weight loss. The Nutrition Assessment of 3/17/11 indicated that Resident #19's weight was 164.5 pounds. Meal intake variable. Average meal intake was 45 percent with extensive assist from staff. Intake appears to be meeting nutritional needs. A Nutrition Progress Note of 5/16/11 indicated that Resident #19 had a a recent weight drop of 14 pounds (8 percent) in 6 months. Suggest continuing with current regular diet with chopped meat and add chocolate milk at lunch and supper meal. The Nutrition Assessment of 6/16/11 indicated that Resident #19's weight was 155.5 pounds (a 7.1 percent weight loss in 6 months). The Nutrition Assessment of 9/9/11 indicated that Resident #19's weight was 158 pounds (a 6.8 percent weight loss in 6 months). The Weights and Vitals Summary indicated that Resident #19's weight was recorded as 136 pounds on 12/2/11 (a 5.4 percent weight loss in 30 days and a 12.5 percent weight loss in 180 days). The December 2011 physician's orders [REDACTED]. The MDS assessment of 12/8/11 indicated that the BIMS indicated a score of 14/15 (intact mental status). Resident #19 required assist of 2 for transfers, was unable to ambulate, required extensive assist with bathing and dressing, was independent with meals and had no significant weight loss (inaccurate coding as Resident #19 had a significant weight loss). The Weights and Vitals Summary indicated that Resident #19's weight was recorded as 144.2 pounds on 12/8/11 but crossed off as incorrect documentation. Resident #19 was re-weighed on 12/9/11, and the weight was recorded as 137.8 pounds (11.38 percent weight loss over 180 days). A Nutrition Progress Note of 12/9/11 indicated that there was no nutritional concerns. Resident #19 with gradual weight loss not significant. Does not eat breakfast per pattern, requesting weekly weight times 4 to assess weight loss trend, has been stable times 30 days. A Nutrition Assessment of 12/9/11 indicated that Resident #19 weighed 144.2 pounds (inaccurate weight). The diet remained appropriate and accepted well. Adequate appetite noted, eats 75 to 100 percent lunch/dinner, continues to refuse breakfast most days per usual history and continues to snack between meals. Staff continue to offer peanut butter and toast daily. Weight loss noted, down 11 pounds in 6 months (7.3 percent) but stable for 30 days. Resident #19 stated, "you shouldn't worry I eat enough." Resident #19 not a breakfast person but will eat small amounts early with encouragement. Enjoys food from home. No new laboratory work. Weight loss not significant. Intake meets needs. Not at significant nutrition risk ( Resident #19 weighed 155.5 pounds on 6/6/11 and 143.7 pounds on 11/7/11. Resident #19 had a 5.4 percent weight loss in 30 days and a 12.5 percent weight loss in 180 days per the 12/2 11 weight of 136 pounds; and 11.38 percent weight loss in 180 days per the 12/9/11 weight of 137.8 pounds). physician progress notes [REDACTED]. Resident #19's weight was incorrectly recorded as 144.2 pounds. Mental status - alert and confused. A recent trial of [MEDICATION NAME] SR (sustained release pain medication) was begun. Resident #19 then developed increased sedation. The dose was held yesterday, and today the lethargy is improved. Review of Resident #19's current Care Plans indicated that there was no plan in place to address the continued significant weight loss. Record review indicated that there were no new dietary interventions implemented. There was no documentation regarding an evaluation to determine if Resident #19 required increased supervision/encouragement at meal times (the MDS indicated that Resident #19 was independent with meals). The Weights and Vitals Summary indicated that Resident #19's weight continued to drop as follows: *136.7 pounds on 12/16/11. *134 pounds on 12/23/11. *128.3 pounds on 12/30/11. *130.8 pounds on 1/7/12. On 1/10/12 at 8:30 A.M., Resident #19 was observed sitting up in bed. The over the bed table was positioned across the bed in front of Resident #19. Resident #19 had a boiled egg and toast cut up, chopped bacon and sausage on a plate. Resident #19 was chewing a mouthful of bacon. At 9:00 A.M., Resident #19 had a piece of toast with peanut butter on the plate. Resident #19 stated that he/she was not going to eat it. On 1/10/12 at 10:20 A.M., the Dietician said that she was not aware that the weight of 144.2 pounds was inaccurate when she completed the quarterly assessment.