Every finding on record at Alliance Health at Rosewood

Based on observation and interview, the facility failed to distribute food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff did not handle ready-to-eat food using bare, ungloved, hands on two of three units. Findings include: Review of the Massachusetts Food Code (105 CMR 590.001) indicated, but was not limited to, the following:-Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.-Food Employee means an individual working with unpackaged food, food equipment or utensils, or food-contact surfaces. In health care facilities, this includes those who set up trays for patients to eat, feed or assist patients in eating, give oral medications or give mouth/denture care. On 1/21/26 at 8:34 A.M., the surveyor observed a staff member, who was providing feeding assistance to a resident in the second-floor dining room, touch her mask with her bare hand; the staff member then, using her bare hands, picked up the Residents toast, buttered it, and placed it back on the Residents' plate. At 8:37 A.M., the surveyor observed the same staff member using her bare hand to pick up the same ready-to-eat toast and handed it to the Resident to eat. On 1/21/26 at 12:55 P.M., the surveyor observed a staff member feeding a resident in the second-floor dining room. The staff member picked up a half of a sandwich with a fork and as she was bringing the sandwich to the Residents mouth the sandwich fell off of the fork and onto the Resident's lap. The staff member then picked up the sandwich using her bare hands and handed it to the Resident to eat. On 1/23/26 at 8:39 A.M., the surveyor observed a staff member providing meal tray set-up assistance for a Resident in the third-floor dining room. The staff member picked up both slices of the Resident's ready-to-eat toast with her bare hands and applied jelly to them; the staff member then placed the jellied toast back onto the Resident's plate. During an interview on 1/23/26 at 9:16 A.M., Nurse #2 said staff should not use their bare hands when handling ready-to-eat food. During an interview on 1/23/26 at 9:44 A.M., the Director of Nursing said staff should not use their bare hands when handling ready-to-eat food. During an interview on 1/23/26 at 9:57 A.M., the Administrator said staff should use gloves, a clean napkin or utensil to pick up ready-to-eat food when providing feeding assistance, not their bare hands.

Based on observations, interviews, and record reviews for two Residents (#77 and #114) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of four nurses observed made 3 errors out of 34 opportunities resulting in a medication error rate of 8.82%. Specifically, 1.) For Resident #77, the nurse administered incorrect doses of vitamin D and polyethylene glycol (a laxative medication).2.) For Resident #114, the nurse administered the incorrect type of eye drops. Findings include:Review of the facility policy titled 'Preparation and General Guidelines', revised December 2019, indicated:-FIVE RIGHTS: Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.-a. Check #1: Select the Medication - label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights.-b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. -c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights.-Administration: 2) Medications are administered in accordance with written orders of the prescriber. 1.) Resident #77 was admitted to the facility in December 2024 with diagnoses including vitamin D deficiency and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 6 out of 15. Review of Resident #77's active physician's orders indicated:-Cholecalciferol (vitamin D3) tablet, 25 micrograms (mcg) (1,000 units), once a day, initiated 1/20/25-Polyethylene glycol 3350 powder, 17 gram/dose, once a day, initiated 3/25/25 On 1/21/26 at 8:11 A.M., the surveyor observed Nurse #4 prepare and administer the following medication to Resident #77:-Cholecalciferol (vitamin D3) tablet, 10 mcg (400 units)-Polyethylene glycol 3350 powder, filled approximately two-thirds to 17 gram (gm) indicator line in the bottle cap (which is used to measure the dose). Instructions on the polyethylene glycol bottle indicate instructions that 17g (cap filled to line). During a follow-up interview on 1/21/26 at 8:35 A.M., Nurse #4 said she administered an insufficient dose of vitamin d because she administered 400 units instead of the physician ordered 1000 units. Nurse #4 further showed the surveyor there was no bottle of vitamin d 1000 units within her medication cart and could not have given the full dose. Nurse #4 said she was unaware that the 17 gram line on the polyethylene glycol bottle cap was where it was. Nurse #4 showed the surveyor an area in the cap below the 17 gram indicator line, which appeared to be a cap thread used to close the bottle, and said that it was the line she filled the polyethylene glycol to. Nurse #4 inspected the bottle closely and said she now sees the 17 gram indicator line is higher and that she administered an insufficient dose of polyethylene glycol. During an interview on 1/21/26 at 10:01 A.M., the Director of Nursing said all medications, including vitamin D and polyethylene glycol, should be administered according to the physician's order. 2.) Resident #114 was admitted to the facility in September 2025 with diagnoses including Alzheimer's dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #114 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 7 out of 15. Review of Resident #114's active physician's orders indicated:-Artificial Teams (PF) (dextran 70-hypromellose (pf)) dropperette, 0.1-0.3%, instill 1 drop into each eye twice a day, initiated 9/4/25. This physician's order pharmacy fill status note indicated that the pharmacy filled this order with a generic equivalent drug and that the dispensed drug was GenTeal Tears Moderate PF 0.1-0.3% solution. On 1/21/26 at 9:33 A.M., the surveyor observed Nurse #1 prepare and administer the following medication to Resident #114:-Systane eye drops (polyethylene glycol 400 0.4%, propylene glycol 0.3%), instilled 1 drop in each eye. During a follow-up interview on 1/21/26 at 9:53 A.M., Nurse #1 said she was unsure if the Systane eye drops were the correct eye drops because the active ingredients in Systane did not match the order. Nurse #1 reviewed the pharmacy fill status note for the physician's order for artificial tears and said she did not administer the GenTeal eye drops as the pharmacy indicated they dispensed for this order. During an interview on 1/21/26 at 10:01 A.M., the Director of Nursing (DON) said all medications, including eye drops, should be administered according to the physician's order. The DON said Nurse #1 should have clarified the physician order before administering the eye drops if the active ingredients did not match the physician's order.

Based on observations, record review and interviews, the facility failed to ensure one Resident (#137) who required respiratory care (continuous oxygen) received care consistent with professional standards of practice out of a total sample of 28 Residents.Specifically, for Resident #137, nursing administered continuous oxygen without a physician's order. Findings include:Review of the undated facility policy titled, Nasal Canula indicated, but was not limited to, the following:Verify physicians' orders. Resident #137 was admitted to the facility in January 2026 with diagnoses of chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and dependence on supplemental oxygen. Review of Resident #137's current active physician's and telephone orders failed to include an order to administer continuous oxygen. Review of the Resident's discontinued physician's orders failed to indicate the Resident had an order for continuous oxygen this admission. On 1/20/26 at 9:02 A.M., the surveyor observed Resident #137 in his/her room. The Resident was receiving oxygen via nasal cannula at three liters per minute. Resident #137 said he/she has recently been utilizing supplemental oxygen. On 1/20/26 at 2:37 P.M., the surveyor observed Resident #137 in his/her room receiving oxygen via nasal cannula. On 1/21/26 at 7:29 A.M., the surveyor observed Resident #137 in his/her room receiving oxygen via nasal cannula. On 1/21/26 at 9:43 A.M. the surveyor observed Resident #137 in his/her room receiving oxygen via nasal cannula at three liters per minute. Review of Resident #137's nurse progress notes, including notes dated 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/19/26 and 1/20/26, indicated Resident #137 was receiving supplemental oxygen. Review of Resident #137's SNF (skilled nursing facility) Initial NP (nurse practitioner) visit progress note, dated 1/16/26, indicated the Resident had a history of COPD and was receiving O2 (oxygen) nightly and as needed during the day. Further review of the progress note indicated the Resident was wearing oxygen as prior to admission. Review of the physical exam portion of the progress note indicated that the oxygen was on. During an interview on 1/21/26 at 9:55 A.M., Certified Nurse Assistant (CNA) #1 said Resident #137 received supplemental oxygen all the time and that the staff frequently checked on the Resident to ensure his/her nasal cannula was on; CNA #1 said the Resident utilized a portable oxygen tank for when he/she left his/her room. During an interview on 1/21/26 at 9:51 A.M., Nurse #2 said Resident #137 was receiving supplemental oxygen and that the Resident had COPD. Nurse #2 said the risk of a Resident who had COPD receiving oxygen at too high of a rate would be that the Resident could retain C02 (carbon dioxide). Nurse #2 said she would expect a physician order to be obtained before the administration of oxygen. Nurse #2 said Resident #137 should have had an active physician's order for the oxygen he/she was receiving but did not. During an interview on 1/21/26 at 9:53 A.M. Unit Manager #2 said Resident #137 had received continuous supplemental oxygen since admission and that the Resident had COPD. Unit Manager #2 said it would not be safe to administer oxygen at too high of a rate for a Resident who had COPD. Unit Manager #2 said she would expect a physician order to be in place prior to administering supplemental oxygen. After reviewing the Residents current, discontinued and telephone orders in the electronic medical record and physical chart Unit Manager #2 said Resident #137 had not had an active order for supplemental oxygen throughout his/her entire admission but should have. During an interview on 1/21/26 at 10:16 A.M., NP #1 said Resident #137 had been receiving supplemental oxygen and should have had an order for the oxygen since admission. NP #1 added that if the order had been missed, an order should have been written on 1/16/26 when she had evaluated the Resident. NP #1 said that oxygen can be administered without an order in emergency situations and that an order would be placed within a business day after the emergency, however, this was not the case for Resident #137 and Resident #137 should have had an order for supplemental oxygen in place, specifying a rate of three liters per minute, prior to administering oxygen. During an interview on 1/21/26 at 10:38 A.M. the Director of Nursing (DON) said she would expect a physician order to be in place for supplemental oxygen prior to administering the oxygen, even if it was on an as-needed basis. The DON said that oxygen could be administered in an emergency and that a physician's order would be placed after the emergency, however, Resident #137's case was not an emergency.

Based on record review and interview, the facility failed to create a baseline plan of care within the required 48 hours of admission for one Resident (#124) out of a total sample of 26 residents.Findings include:Review of the facility policy titled 'Baseline Care Plan', dated 5/15/22, indicated the following but not limited to:A baseline care plan is developed within 48 hours of admission to the facility. The baseline care plan will include the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care. Resident #124 was admitted to the facility in October 2025 with diagnoses including dementia and repeated falls. Review of the progress note dated 11/1/25 at 5:00 A.M., indicated the Resident had been found on the floor. Review of the medical record failed to indicate a baseline care plan. During an interview on 1/21/26 at 12:00 P.M., Unit Manager #2 said a baseline care plan should be completed within 48 hours of admission. She further said the baseline care plan would show what kind of assistance the Resident would require for care. During an interview on 1/21/26 at 1:05 P.M., the Director of Nursing (DON) said that a baseline care plan should have been completed within 48 hours of admission and that the nurses were responsible for initiating the baseline care plan.

Based on observations, interviews and record review, the facility failed to accurately document a peripheral inserted central catheter (PICC) line site assessment for one Resident (#9) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Central Venous Access Device (CVAD) Catheter Dressing Change, dated 1/2022, indicated the following:Dressing changes will occur according to the IV (intravenous) order and when dressing is compromised (drainage/moisture observed, loose, soiled).VAD (venous Access Device) assessments should occur:At least every 2 hours during a continuous infusion.Before and after medication administration.At a minimum of once each shift, when not in use.With each assessment of the VAD, presence of the following, at a minimum, should include drainage. Resident #9 was admitted to the facility in November 2025 with diagnoses including Acute on chronic diastolic congestive heart failure, chronic kidney disease and artificial opening of urinary tract status. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 13 out of a total possible 15 on the Brief Interview for Mental status (BIMS) assessment, which indicated he/she was cognitively intact. During an observation on 1/21/26 at 8:14 A.M., Resident #9 was lying in bed, the surveyor observed his/her PICC line to the right arm. A dressing dated 1/19/26 was in place the insertion site had a bruise and bright red blood that had saturated into the dressing. Review of Resident #9's physician orders indicated the following:PICC: Assess IV site every shift and as needed. Document site condition and patency of the line every shift.PICC: Change dressing as needed if listing, wet, loose or soiled or has gauze or you are unable to inspect insertion site. Review of Resident #9's active care plan date initiated 1/18/26, indicated the Resident was at risk for excessive bleeding and /or bruising due to anticoagulant administration related to atrial fibrillation. Review of Resident #9's January 2026 Medication Administration Record (MAR) indicated Nurse #5 documented the following for PICC line site, (CDI) clean dry intact in response to physician's order to assess the site every shift on 1/21/26 shift one. During an interview and observation on 1/21/26 at 12:00 P.M., the surveyor along with Unit Manager #2 observed Resident #9's PICC line. Unit Manager #2 said the dressing needs to be changed as there was a large amount of bright red blood at the insertion site and on the dressing and would notify the Nurse Practitioner as the Resident was on a blood thinning medication. She further said the nurse should not have documented the PICC site as clean dry and intact. During an interview on 1/21/26 at 3:27 P.M., Nurse #5 said she was a new nurse in training and that she saw the bleeding on the PICC line site and did not think it was a big deal. She said she shouldn't have documented the site as clean dry and intact. During an interview on 1/21/26 at 3:08 P.M., the Director of Nursing (DON) said the PICC site was monitored for swelling, migration of line, and bleeding. If a nurse sees bright red blood at the PICC site, the dressing should be changed and physician notified if the Resident was on an anticoagulant (a blood thinning medication). She further said nurses should also document accurately when they assessed a resident.

Based on observation, interview, and policy review, the facility failed to ensure that infection control and prevention measures were followed during preparation of medication for administration. Specifically, 1.) Nurse #2 contaminated resident medications by touching pills with her bare hand. 2.) Nurse #3 stored an open, coffee cup in the medication cart with bottles of medications directly touching all sides of the cup. Findings include: Review of the facility policy titled 'Medication Administration - General Guidelines', revised 2024, indicated: - Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: prior to handling any medication. - Hands are washed with soap and water or alcohol gel [and examination gloves worn] prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process. 1.) On 1/22/25 at 9:43 A.M., the surveyor observed Nurse #2 prepare medication for Resident #79 on the first floor side a medication cart. The following observations were made by the surveyor: - Nurse #2 touched multiple medication cards, medication bottles, laptop screen, laptop keyboard, and the medication cart drawer handle with her bare hands. The Resident had a physician order for vitamin B 12. When preparing this medication, Nurse #2 accidentally poured an extra vitamin b 12 pill into the medication cup filled with other pills that had previously been prepared. Nurse #2 inserted her bare finger into the medication cup to remove the vitamin B 12, which she then put back into the medication bottle. Nurse #2 did not sanitize her hands or apply a protective barrier to her hand to prevent contaminating the rest of the medications she had already poured for the Resident. - Nurse #2 continued to prepare additional medication without sanitizing her hands. Nurse #2 continued to touch multiple medication cards, medication bottles, laptop screen, laptop keyboard, and the medication cart drawer handle with her bare hands. The Resident had a physician order for a multivitamin. When preparing this medication, Nurse #2 accidentally poured an extra multivitamin pill into the medication cup filled with other pills that had previously been prepared. Nurse #2 inserted her bare finger into the medication cup to remove the multivitamin, which she then put back into the medication bottle. Nurse #2 did not sanitize her hands or apply a protective barrier to her hand to prevent contaminating the rest of the medications she had already poured for the Resident. During an interview on 1/22/25 at 10:23 A.M., Nurse #2 said she should not have touched resident medications with her bare hand and put contaminated pills back into the medication bottles. During an interview on 1/22/25 at 1:50 P.M., the Regional Clinical Specialist said medications should not be touched with a bare hand. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said medications should not be touched with a bare hand. The ADON said the nurse should have used a glove and should have disposed of the pills instead of placing back into the medication bottles. 2.) On 1/22/25 at 8:22 A.M., the surveyor observed Nurse #3 prepare morning medications from the third floor side b medication cart. There was a plastic coffee cup with open drinking spout stored in one of the drawers with bottles of resident medications directly touching all sides of the cup. During an interview on 1/22/25 at 8:23 A.M., Nurse #3 said it was her coffee cup. Nurse #3 said she is not supposed to store her coffee cup inside the medication cart. During an interview on 1/22/25 at 1:50 P.M., the Regional Clinical Specialist said staff members coffee cups should not be stored in medication carts touching medications. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said staff members coffee cups should not be stored in medication carts touching medications because of infection control concerns.

Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on three out of three units. Findings include: During the initial tour of the facility on 1/21/25 the surveyors met with the residents and the following concerns were expressed: - Seven residents on the first floor said that the food was often served cold and tasted bad. - One Resident on the second floor said the quality of the food was terrible and that the food was high in sodium. - Five residents on the first floor said that the food was often cold and tasted bad. During the resident group meeting on 1/22/25 at 10:31 A.M. a Resident said the food was served cold. On 1/23/25 at 12:30 P.M., the 3rd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 12:38 P.M., and the following was recorded and observed: - Meatballs were 132.8 degrees Fahrenheit and tasted lukewarm not hot; the meatballs had good flavor. - Pasta was 137.7 degrees Fahrenheit and tasted lukewarm not hot; the pasta had a metallic flavor and was not palatable. -Green beans were 116 degrees Fahrenheit and tasted cool not hot; the green beans were not palatable. -Soup was 115 degrees Fahrenheit and tasted cool not hot; the soup was not palatable. -Garlic Bread was 104 degrees Fahrenheit and tasted warm. -Raspberry Sherbert was 25 degrees Fahrenheit and tasted cold. -Milk was 38 degrees Fahrenheit and tasted cold. On 1/23/25 at 1:29 P.M., the 2nd floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 1:42 P.M., and the following was recorded and observed: - Meatballs were 124.4 degrees Fahrenheit and tasted warm not hot, the meatballs had good flavor. - Pasta was 124.7 degrees Fahrenheit and tasted warm not hot. -Garlic bread was 123.1 degrees Fahrenheit and had a spongy texture. -Green beans were 97.6 degrees Fahrenheit and tasted warm not hot. -Soup was 137.8 degrees Fahrenheit and tasted warm not hot. -Raspberry Sherbert was 22.2 degrees Fahrenheit but was melting. On 1/23/25 at 1:29 P.M., the 1st floor food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 1:42 P.M., and the following was recorded and observed: - Shrimp was 125 degrees Fahrenheit and tasted warm not hot, the texture of the shrimp was chewy consistent with overcooking. - Pasta was 122.5 degrees Fahrenheit and tasted lukewarm not hot, the pasta was oily. -Garlic bread was 112.2 degrees Fahrenheit and tasted lukewarm, the texture was soggy. -Green beans and carrots were 117 degrees Fahrenheit and tasted lukewarm not hot. -Soup was 131.8 degrees Fahrenheit and tasted warm but was not palatable; the soup had an unpleasantly thick texture and a bitter flavor. -Raspberry Sherbert was 23.4 degrees Fahrenheit but was melting. -Cranberry Juice was 45 degrees Fahrenheit and tasted cold. Review of the Tray Line Check, dated 1/14/2025, indicated that a test tray was conducted, and that the entree and vegetable temperatures at time of service were 130 degrees Fahrenheit. During an interview on 1/22/25 at 3:46 P.M., the Registered Dietitian (RD) said that she would expect hot food to be, at a minimum, 135 degrees Fahrenheit when it arrives to a resident; the RD said she would expect certain foods, such as soups, to be much hotter than 135 degrees Fahrenheit. The Food Service Director (FSD) said it would be the goal for residents to receive hot food around 160 degrees Fahrenheit. The RD said the temperature of the food received by the surveyors was lower than what she would expect.

Based on observation, record review and interview, the facility failed to implement physician's orders related to wound care for one Resident (#64) out of a total of 25 sampled Residents. Specifically, the facility failed to implement would treatments as recommended by the Wound Physician and Wound Clinic. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's Skin Management Program, dated 6/13/19 indicated: Purpose: To minimize the development of any type of ulcers and other skin issues through systematic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. Policy: 2. Residents will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check form in the EHR (electronic health record). 6. If skin breakdown is identified, the physician will be notified, and a treatment will be obtained. 14. The Licensed Nurse responsible for the treatments on each unit will observe each ulcer in conjunction with treatment times and document the observation of the ulcer and or surrounding tissue on the Treatment Sheet in the EHR. Resident #64 was admitted to the facility in October 2023 with diagnoses including cancer and cerebrovascular accident. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #64 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #64 required physical assistance for dressing and bathing and utilized a catheter. During interviews on 1/21/25 at 9:24 A.M., and 1/23/25 at 8:34 A.M., Resident #64 said that he/she has a wound on his/her leg and staff have been taking care of it. Resident #64 said he/she now goes out to the wound clinic instead of seeing the in-house Wound Physician, and that they seem to be more efficient. Resident #64 said it has taken a long time for his/her wound to heal and it still feels sore. Review of Resident #64's Clinical Care Plan indicated: Problem: Resident has a non-pressure wound requiring treatment, initiated 8/15/24 Goal: Resident wound will heal without complications (infection, hemorrhage, dehiscence, etc) Approach: Obtain wound MD consult as indicated. Follow recommendations as directed. Record the amount, type, consistency, color and odor of drainage from the wound. Record the location, size (length, width and depth) color and presence/absence of granulation tissue and epithelization of wound. Review of the Wound Physician's notes dated 8/6/24, 8/13/24 and 8/20/24 indicated: Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury. Dressing treatment plan: Dermablue foam (a highly absorbent vertically-wicking foam primary dressing embedded with three antimicrobials) apply every two days, cut to fit. Gauze island with bdr (border) apply every two days. Review of the August 2024 Treatment Administration Record (TAR) indicated: To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, Dermablue to wound bed cut to fit and cover with allevyn (an alginate dressing utilized for absorbing drainage) foam every two days: Once A Day on Sun, Mon, Thu. (Active 8/3/2024 through 10/2/2024) The wound treatments included the use of allevyn which was not indicated by the Wound Physician and were not completed every two days per the Wound Physician. Review of the Wound Physician Notes dated 8/27/24 and 9/3/24 indicated: Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury Dressing treatment plan: Alginate rope (a dressing used to absorb fluid and prevent contamination) apply once daily, Mupirocin topical 2% (a topical ointment used for infections) apply once daily, Superabsorbent gelling fiber (wound covers that help manage drainage and removal of dead, damaged and infected tissue from the wound), apply once daily. Review of the August 2024 and September 2024 TAR's indicated: To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, dermablue to wound bed cut to fit and cover with allevyn foam every two days: Once A Day on Sun, Mon, Thu. (Active 8/3/2024 through 10/02/2024.) The treatment orders failed to include the use of alginate rope, Mupirocin 2%, Superabsorbent gel fiber, and failed to occur daily per the Wound Physician. Review of Nurse Practitioner #1's note, dated 9/10/24, indicated: Continues with alginate dressing to wound.We will continue with the recommended dressing, monitor for s/sx (signs and symptoms) of infection.He/She will continue to be followed by wound specialist. Review of the Wound Physician's notes dated 9/10/24 and 9/17/24 indicated: Non-pressure wound of the right upper lateral leg. Etiology: Trauma/Injury: Dressing treatment plan: Dermabluefoam apply every two days, Superabsorbent gelling fiber every two days. Review of the September 2024 TAR indicated: To right upper lateral leg non-pressure wound: normal saline wash, skin prep to wound edges, dermablue to wound bed cut to fit and cover with allevyn foam every two days: Once A Day on Sun, Mon, Thu. (8/3/2024 - 10/02/2024) Review of the hospital discharge summary dated 10/1/24 indicated Resident #64 had been hospitalized on [DATE] and recommendations upon discharged included the use of a wound vac (also referred to as negative pressure wound therapy, a method of decreasing air pressure around a wound to assist healing) and for follow up at the wound clinic. Review of the Wound Clinic Note dated 10/31/24 indicated: Wound injury: right lateral leg. Assessment and plan: cleanse wounds with normal saline. Discontinue wound vac. Medihoney to lateral leg wound, cover with gauze and gauze roll, change three times per week or as needed for increased drainage. Review of the November 2024 TAR indicated there were no active treatments in place for Resident right leg wound from 10/31/24 through 11/13/24. During an interview on 1/22/25 at 10:06 A.M., Nurse Practitioner (NP) #1 said that when the Wound Physician makes recommendations, they are communicated to team and then approved by the attending. Nurse Practitioner #1 said that she could not recall a time when she had declined a treatment recommendation made by the Wound Physician. Nurse Practitioner #1 said that Resident #64's wound was being followed by the Wound Physician and the Resident now goes to the Wound Clinic. Nurse Practitioner #1 said she was not aware that Resident #64's treatment orders did not match the orders indicated by the Wound Physician. Nurse Practitioner #1 said that at that time, there had been a different and new Unit Manager who may not have known the process for reviewing orders or inputting them. During an interview on 1/22/25 at 2:21 P.M., the Wound Physician said that when he would round at the facility staff would usually round with him and the treatments were implemented after his notes were uploaded. The Wound Physician said that he was not aware that Resident #64 was not receiving the treatments he indicated during his visits. During an interview on 1/23/25 at 9:36 A.M., the Assistant Director of Nursing (ADON) said that the previous Director of Nursing would round with the Wound Physician, would inform the Nurse Practitioner of the orders and input orders into the record. The ADON said that if the NP does not agree with the orders, it should be documented. The ADON said that other staff would round with the Wound Physician and the orders would be communicated in his report. The ADON was not aware that Resident #64's treatment orders were not implemented as indicated by the wound physician or the wound clinic and that staff were expected to implement the orders after they had been reviewed by the provider.

Based on interview and record review, the facility failed to report an allegation of abuse for one Resident (#101) out of a total of 25 sampled Residents. Findings include: Review of the Abuse Prohibition Policy dated 10/11/22 indicated: All alleged violations of incidents included within the definition of abuses, mistreatment, neglect, involuntary seclusion or misappropriation of resident property shall be reported to the Department of Public Health, upon receipt of the facility's report of basic findings. The facility must then begin an internal investigation of the incident. The Executive Director will be included in the immediate notification of the alleged incident. Resident #101 was admitted to the facility in February 2024 with diagnoses including muscle weakness and aftercare following joint replacement surgery. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #101 was cognitively intact evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam. During an interview on 1/21/25 at 8:06 A.M., Resident #101 said that yesterday (1/20/25) a Certified Nursing Assistant (CNA) yelled at him/her at 2:30 p.m. after he/she rang his/her call light. Resident #101 said that the CNA came into his/her room and asked him/her why he/she was always calling for help and that the CNA was the only one working, was diabetic and needed to eat something and was supposed to be on break. Resident #101 said that it made him/her upset and he/she shouldn't be afraid to use his/her call light. Resident #101 said he told a nurse about it this morning, but could not remember who it was. During an interview on 1/21/25 at approximately 1:00 P.M., Unit Manager #1 said she was not aware of Resident #101's report of being yelled at and she would take care of it. During interviews on 1/22/25 at 7:39 A.M., at 1:18 P.M., the Administrator said she had just learned of Resident #101's allegation and a report was being made to the state agency. The Administrator said that Unit Manager #1 was given education about the two hour requirement for allegations of abuse.

Based on interviews and record reviews, the facility failed to provide assistance with showers for one Resident (#107) out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 1/10/23, indicated the following: -A program of activities of daily living (ADL) is provided to residents by the following method: the ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or members of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Education is provided to resident and family. -Purpose: To prevent disability and return residents to a maximum level of independence. -Process: 1.6 Frequent showers or baths are scheduled, and assistance is provided when required. Resident #107 was admitted to the facility in September 2024 with diagnoses including macular degeneration. Review of Resident #107's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #107 required assistance from staff for bathing tasks. During an interview on 1/21/25 at 8:38 A.M., Resident #107 said he/she is legally blind and needs assistance with bathing tasks. Resident #107 says he/she had not taken a shower in a long time and would love one because he/she feels more clean when given a shower. Review of Resident #107's Activity of Daily Living (ADL) care plan last revised 1/15/25, indicated the following: -Bathing: Assistance level required is substantial maximum assist (assistance) of one. Review of the shower list on the unit indicated Resident #107 is scheduled for a weekly shower on Tuesdays during the 7:00 A.M. and 3:00 P.M. shift. Review of the ADL documentation for the months of December 2024 and January 2025 indicated Resident #107 has been given only one shower in two months. Review of the nursing documentation failed to indicate Resident #107 refused showers in the months of December 2024 and January 2025. During a follow-up interview on 1/23/25 at 7:53 A.M., Resident #107 said he/she did not receive a shower this week on Tuesday and would really like weekly showers. During an interview on 1/23/25 at 7:55 A.M., Certified Nursing Assistants (CNA) #3 and #4 said all residents are scheduled for at least one weekly shower and can have a shower whenever they request one. CNAs #3 and #4 said Resident #107 does not refuse care and requires assistance with all bathing tasks. CNA #3 and #4 could not remember the last time Resident #107 was given a shower. During an interview on 1/23/25 at 8:37 A.M., Unit Manager #3 said all residents are provided with weekly showers and if a resident were to refuse a shower the nursing staff would document the refusal. Unit Manager #3 was unable to say the last time Resident #107 was provided with a shower.

Based on observations, interviews and record review, the facility failed to ensure staff implemented a comprehensive person-centered care plan for one Resident (#25), out of a total sample of 25 residents. Specifically, for Resident #25: a.) The facility failed to ensure nursing implemented a care plan intervention for use of a motion detector alarm for fall prevention. b.) The facility failed to ensure nursing implemented a care plan intervention for seizure pads. Findings include: Resident #25 was admitted to the facility in October 2024 with diagnoses including epilepsy (a seizure disorder), vascular dementia with agitation, and restlessness. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/30/24, indicated Resident #25 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. a.) Review of the facility policy titled 'Fall Management Program', revised 10/13/22, indicated: - Residents identified at high risk for falls (score of 10 or higher of the assessment) will have an appropriate fall prevention care plan developed, implemented, and revised as necessary. Review of Resident #25 assessment titled 'Alliance Fall Risk', dated 12/13/24, indicated the Resident was at high risk for falls as evidenced by a score of 14. Review of Resident #25's active physicians orders, initiated 10/24/24, indicated: - S/P (status post) FALL MONITOR, every shift, initiated 11/8/24. - Fall: Initiate Fall Prevention Program, every shift, initiated 12/11/24. Review of Resident #25's plan of care related to falls, revised 12/26/2024, indicated: - Use a motion detector when Resident #25 is in the room. On 1/21/25 at 1:02 P.M., 1/21/25 at 2:09 P.M., 1/21/25 at 4:22 P.M., 1/22/25 at 6:54 A.M., and 1/22/25 at 7:55 A.M, the surveyor observed Resident #25 alone in his/her room without any staff within view. The motion detector alarm power switch was in the 'off' position. The surveyor waved a hand in front of the motion detector alarm sensor multiple times, and it did not activate any alarm sound. During an interview on 1/22/25 at 7:59 A.M., Certified Nurse Assistant (CNA) #1 said CNAs are expected to check the care plan and ensure interventions, such as motion detector alarms, are put into place. CNA #1 said she was unaware Resident #25 required motion detector alarms and never turned it on. CNA #1 observed the motion detector alarm in Resident #25's room with the surveyor and confirmed it was not on. At this time Resident #25 was in the bed in his/her room. During an interview on 1/22/25 at 8:03 A.M., Nurse #4 said care plan interventions, such as motion detector alarms, should always be implemented as listed in the active care plan. Nurse #4 said she was unaware Resident #25 required motion detector alarms and never turned it on. Nurse #4 reviewed Resident #25's active care plan and said based on the care plan indicating to use a motion detector when Resident #25 is in the room, the motion detector should be turned on and used. Nurse #4 observed the motion detector alarm in Resident #25's room with the surveyor and confirmed it was not on. Nurse #4 turned it on, and said it should have been turned on because Resident #25 was in his/her room alone. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all care plan interventions listed in a resident's care plan should be implemented. The ADON said Resident #25 should have had the motion detector turned on when in his/her room because it was an intervention listed on his/her active care plan. b.) Review of the facility policy titled 'Seizure Precautions', revised 8/5/23, indicated: - Every resident/patient assessed to be at risk for seizures will have protective measures taken to ensure their safety. - Formulate plan of care with interventions focused on prevention of injury and airway maintenance. - Should a resident have a seizure while in bed, pad side rails with pads or bath blankets. Review of Resident #25's active physicians orders, initiated 10/24/24, indicated: -Keppra (a medication used to control seizures) 1250 mg, twice daily. Review of Resident #25's plan of care related his/her seizure disorder, revised 10/24/24, indicated: - PROBLEM: Resident has a seizure disorder. - GOAL: Resident will not injure self secondary to seizure disorder. - APPROACH: Pad siderails. On 1/21/25 at 1:02 P.M., 1/21/25 at 2:09 P.M., 1/21/25 at 4:22 P.M., 1/22/25 at 6:54 A.M., and 1/22/25 at 7:55 A.M., the surveyor observed Resident #25 in bed without seizure pads on bilateral side rails. During an interview on 1/22/25 at 7:59 A.M., CNA #1 said CNAs are expected to check the care plan and ensure interventions, such as seizure pads on side rails, are put into place. CNA #1 said she was unaware Resident #25 required seizure pads on his/her side rails, and they never applied them. CNA #1 observed Resident #25's room with the surveyor and said there were no seizure pads located anywhere in the Resident's room. At this time Resident #25 was in the bed in his/her room with unpadded bilateral side rails. During an interview on 1/22/25 at 8:03 A.M., Nurse #4 said Resident #25 was on seizure precautions because he/she has a seizure disorder. Nurse #4 said care plan interventions, such as seizure pads on side rails, should always be implemented as listed in the active care plan. Nurse #4 said she was unaware Resident #25 required seizure pads on his/her side rails. Nurse #4 reviewed Resident #25's active care plan and said based on the care plan indicating to pad siderails, the side rails should have seizure pads but did not. Nurse #4 observed Resident #25's room with the surveyor and said there were no seizure pads located anywhere in the Resident's room. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all care plan interventions listed in a resident's care plan should be implemented. The ADON said Resident #25 should have had seizure pads on his/her side rails because it was an intervention listed on his/her active care plan.

Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for two Residents (#105 and #71) out of a total sample of 25 residents. Specifically, 1.) For Resident #105, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible. The facility failed to ensure the Resident's urinary catheter drainage system, including the tubing, was not placed directly on the floor. 2.) For Resident #71, the facility failed to ensure physicians orders and care plans related to the use of a catheter were implemented. Findings include: Review of facility policy titled 'Catheter Care of Indwelling Urinary', revised 11/5/23, indicated: - Always keep the drainage bag below the level of the bladder and off the floor. 1.) Resident #105 was admitted to the facility in October 2024 with diagnoses including obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and vascular dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/13/25, indicated that Resident #105 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS also indicated Resident #105 had an indwelling catheter and was dependent on staff for all bed mobility, toileting, and transfer tasks. Review of Resident #105's physician's order, initiated 11/1/24, indicated: - Foley Catheter Care, every shift. Review of Resident #105's plan of care related to his/her indwelling catheter, revised 11/11/24, indicated: - Do not allow tubing or any part of the drainage system to touch the floor. On 1/21/25 at 8:12 A.M., the surveyor observed Resident #105 in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover. This entire urinary catheter drainage system was laying on its side directly touching the floor. The tubing was also directly laying on the floor. The urinary catheter drainage bag was half full of cloudy, yellow urine. Resident #41 was unable to answer questions about his/her urinary catheter. On 1/21/25 at 2:07 P.M., the surveyor observed Resident #105 in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover. This entire urinary catheter drainage system was laying on its side directly touching the floor. The tubing was also directly laying on the floor. During an interview on 2:10 P.M., Resident #105's family member said they visit almost every day, and they are concerned Resident #105 has a urinary tract infection. Resident #105's family member said the urinary catheter drainage system, including the tubing, is almost always directly touching the floor. Resident #105's family member said Resident #105 is unable to adjust the height of the bed or reach the urinary catheter drainage bag on the bed frame without assistance. On 1/23/25 at 7:19 A.M., Unit Manager #1 and Certified Nurse Assistant (CNA) #2 observed Resident #105's urinary catheter drainage bag with the surveyor. Resident #105 was in bed with his/her urinary catheter drainage bag attached to the bed frame by a dignity bag cover and was directly touching the floor. They said the dignity bag straps were not adjusted so urinary catheter drainage system was directly touching the floor but should not be. They said the dignity bag is part of the urinary catheter drainage system and should never touch the floor. During a follow-up interview on 1/23/25 at 7:25 A.M., Unit Manager #1 said Resident #105 was unable to unable to adjust the height of the bed and was dependent on staff for urinary catheter care. During a follow-up interview on 1/23/25 at 7:30 A.M., CNA #2 said CNAs are expected to round shiftly and also throughout the shift to check on Resident #105's urinary catheter drainage system. CNA #2 said this includes checking to make sure it was elevated off the floor. CNA #2 said if it is ever noted to be touching the floor, CNAs are expected to elevate it off the floor. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said the urinary catheter drainage system should never be directly touching the floor, including the dignity bag cover. The ADON said she would expect the straps to be adjusted to ensure the entire urinary catheter drainage system is elevated off the floor. 50338 2.) Resident # 71 was initially admitted to the facility in December 2024 with diagnoses including sepsis, pneumonia, and diabetes. Review of the Minimum Data Set Assessment (MDS) 12/19/24 indicated Resident #71 scored 14 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #71 requires assistance toileting and had occasional urinary incontinence. On 1/21/25 at 8:09 A.M., the surveyor observed Resident #71 resting in bed with a catheter bag hanging off the side of the bed. Review of Resident #71's physician's orders, dated 1/21/25, failed to indicate any orders in place regarding the use or care of a catheter. Review of Resident #71's care plans, dated 1/16/25, indicated: Urinary Incontinence: Interventions: Apply moisture barrier to skin. Check for incontinent episodes at least every two hours. Ensure adequate bowel elimination. Provide incontinence care after each incontinent episode. Report any signs of skin breakdown. Use brief when resident in bed. Use brief when resident is out of bed. Weekly body audit. ADL's (activities of daily living) Functional Status/ Rehabilitation Potential. Interventions: Bladder: Specify level of function: occasionally incontinent. Toileting: assistance level required: substantial maximum assist of one. Resident #71's care plans failed to indicate any plan for use or care of a catheter. Review of Resident #71's hospital discharge summary, dated 1/16/25, indicated Foley placed for acute urinary retention. Failed voiding trial and Foley reinserted on 1/15/25. Review of Resident #71's nursing progress note, dated 1/16/25, indicated Foley catheter noted to be draining clear yellow urine to collection bag. Review of physician's progress note, dated 1/21/25, indicated: Urinary Retention. Foley placed for acute urinary retention. Failed voiding trial and Foley reinserted on 1/15/25. During an interview on 1/22/25 at 10:38 A.M., Unit Manager #2 said that Resident #71 had returned from the hospital with a catheter and that she would expect a resident with a catheter to have physician orders and a plan of care in place to care for the catheter. During an interview on 1/23/24 at 7:58 A.M., the Director of Nursing said that a Resident with catheter should have physician orders and care plan in place for care, management, and monitoring of the catheter.

Based on record review and interviews, the facility failed to ensure the drug regimen for residents was free of unnecessary psychotropic medications one Resident (#1) out of a total sample of 25 residents. Specifically, the facility failed to ensure a PRN (as needed) order for alprazolam (a psychotropic medication) was limited to 14 days, when first ordered on 11/6/24, and failed to include a duration for it's use for Resident #1. Findings include: Review of the facility policy titled 'Psychotropic Medication Management', revised 8/5/23, indicated: - Psychoactive medication management will include behavioral interventions, gradual dose reduction attempts, and adequate monitoring that complies with Federal and State guidelines. - PRN orders for psychotropic drugs are limited to 14 days (except as noted below) if the prescribing MD (physician) or practitioner believes it is appropriate for the PRN order to extend beyond 14 days. The MD will document his/her rational in the resident's medical record and indicate the duration for the PRN order. Resident #1 was admitted to the facility in November 2024 with diagnoses including generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/12/24, indicated that Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #1 received antianxiety medication. Review of Resident #1's physician's order, initiated 11/6/24, indicated: - Alprazolam 0.5 mg (milligram), take one tablet by mouth two times a day as needed for anxiety, without any stop date. Review of Resident #1's January 2025 Medication Administration Record (MAR) indicated the Resident received a PRN dose of alprazolam on 1/1/25, 1/3/25, 1/5/25, 1/9/25, 1/11/25, 1/12/25, 1/14/25, 1/16/25, and 1/20/25. Review of the form titled 'Consultant Pharmacist Recommendation to Prescriber', dated 12/17/24, indicated: - Resident is receiving the following PRN psychotropic medication. Please note these medications are required to be re-evaluated after 14 days. If therapy is to continue, please note medical justification for continued use in Progress Note and specify the # of days the PRN order is to continue. - Alprazolam. - Physician/Prescriber Response: Continue Alprazolam, signed and dated 12/19/24. Review of Resident #1's medical record failed to indicate any stop date, medical justification for continued use, or any other re-evaluation for the use of as needed (PRN) alprazolam since the Resident's admission to the facility. During an interview on 1/21/25 at 1:09 P.M., Unit Manager #1 said PRN psychotropic medication, including alprazolam, should be limited to 14 days when initially ordered and must be re-evaluated by the physician for continued use at that time. Unit Manager #1 said Resident #1's alprazolam was initially ordered on 11/6/24 without any stop date or re-evaluation date but should have. During an interview on 1/23/25 at 7:37 A.M., the Assistant Director of Nursing (ADON) said all PRN psychotropic medications need to have a stop date. The ADON said any PRN psychotropic medication should be limited to 14 days when initially ordered and must be re-evaluated by the physician for continued use at that time. The ADON said after the initial 14 day physician re-evaluation date, the physician may extend it for a longer amount of time, but still requires a stop date. The ADON said the duration of Resident #1's PRN alprazolam should have included a stop date for re-evaluation, with medical justification for continued use documented, but did not.

Based on interviews and record reviews, the facility failed to complete daily documentation for one Resident (#107) out of a total sample of 25 residents. Findings include: Resident #107 was admitted to the facility in September 2024 with diagnoses including macular degeneration. Review of Resident #107's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #107 required assistance from staff for bathing tasks. Review of the ADL documentation for the month of December 2024 indicated the following missing documentation: -60 out of 93 grooming/shower opportunities for documentation were missing. -60 out of 93 dressing/undressing opportunities for documentation were missing. -58 out of 93 bladder care opportunities for documentation were missing. -58 out of 93 bladder care opportunities for documentation were missing. -7 out of 93 for feeding opportunities for documentation were missing. -7 out of 93 for toileting, sit-lying opportunities for documentation were missing. -6 out of 93 for sit to stand opportunities for documentation were missing. -60 out of 93 chair to bed transfer opportunities for documentation were missing. -60 out of 93 for toilet transfer opportunities for documentation were missing. Review of the ADL documentation for the month of January 2025 indicated the following missing documentation: -37 out of 63 grooming/shower opportunities for documentation were missing. -37 out of 63 for dressing/undressing opportunities for documentation were missing. -37 out of 63 for sit-lying opportunities for documentation were missing. -37 out of 63 for sit to stand opportunities for documentation were missing. -37 out of 63 chair to bed opportunities for documentation were missing. -37 out of 63 for toilet transfers opportunities for documentation were missing. -37 out of 63 bladder care opportunities for documentation were missing. -37 out of 63 bladder care opportunities for documentation were missing. -37 out of 63 for feeding opportunities for documentation were missing. -37 out of 63 for toileting opportunities for documentation were missing. During an interview on 1/23/25 at 7:55 A.M., Certified Nursing Assistants (CNA) #3 and #4 said all care provided should be documented on all shifts. During an interview on 1/23/25 at 8:37 A.M., Unit Manager #3 said all care provided should be documented on all shifts. Unit Manager #3 said there was recent education provided to the staff about the need to document on all shifts. During an interview on 1/23/25 at 10:02 A.M., the Assistant Director of Nursing said the facility is using new flow sheets and have done education with staff about needing to document care provided on all shifts.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1's discharge was safe, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when one of the medications (Lisinopril, used to lower blood pressure) sent home with Resident #1 belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. Resident #1 took the Lisinopril, along with all the other medications he/she was sent home with the next morning, he/she experienced mental status changes, required transfer to the Hospital Emergency Department for evaluation, and was admitted to the Intensive Care Unit due to extremely low blood pressure. Findings include: The Facility Policy, titled 72-Hour Discharge Planning/Discharge to Identified Living Arrangements, dated 08/23/23, indicated medications on discharge would be reconciled by nursing. According to MayoClinic.org: - Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. A blood pressure measurement is give in millimeters of mercury (mm Hg). - Ideal blood pressure is usually lower than 120 mm Hg/80 mm Hg. - Low blood pressure is a blood pressure reading lower than 90 mm Hg for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and extreme low blood pressure can lead to a condition called shock, which can be life threatening. Review of the Facility's Medication Error Report Form, dated 01/18/24, indicated Resident #1 was discharged home from the Facility on 01/17/24, and on 01/18/24 the Facility was notified that he/she was sent home with a medication card for Lisinopril which belonged to another resident (later identified as Resident #2). Review of the Photograph provided by the Home Care Agency of the Medication Card indicated it contained Lisinopril, 20 mg, by mouth once daily, and Resident #2's name was clearly indicated on the card. Resident #1 was admitted to the Facility in December 2023, diagnoses included Cerebral Infarction, Alcohol Dependence, Congestive Heart Failure, History of Cardiac Implants, and Atrial Fibrillation. Review of Resident #1's Facility's Vitals Report, for the month of January 2024, indicated that Resident #1's lowest measured blood pressure reading had been 90 mm Hg/60 mm Hg. Review of Resident #1's Physician's Order Summary Report, dated 12/15/23, indicated he/she was admitted to the Facility with physician's orders that included (but not limited to) the following: -Torsemide (diuretic) 20 milligrams (mg), -Atorvastatin (lowers cholesterol) 80 mg, and -Metoprolol (lowers blood pressure) Extended Release, 25 mg. Review of Resident #1's Discharge Medication Release Form, dated 01/17/24, and signed by Nurse #1 and Resident #1, indicated Resident #1 medications upon discharge included (but not limited to) the following: -Torsemide 20 mg, -Atorvastatin 80 mg, and -Metoprolol Extended Release, 25 mg. Further review of the Resident #1's Admission Physician's Orders and Discharge Medication Release Form indicated Resident #1 did not have physician's orders for Lisinopril. Resident #2 was admitted to the Facility in January 2024, diagnoses included hypertension, and aortic valve insufficiency. Review of Resident #2's Physician Order Report indicated he/she had a physician's order, dated 01/13/24 for Lisinopril 20 mg by mouth once daily. During a telephone interview on 03/06/24 at 12:36 P.M., Nurse #1 said that on 01/17/24, she was the nurse assigned to Resident #1, and said she reviewed and prepared his/her medication cards that he/she was taking home. Nurse #1 said she put Resident #1's medication cards in a bag and handed them to Unit Manager #1, who then brought them to the Nurses' Station to discharge Resident #1. Nurse #1 said she did not follow Unit Manager #1 to the Nurses' Station and did not have a second nurse double check the medications before putting them in the bag. Nurse #1 said she was notified the next day that Resident #1 had been accidentally discharged with another resident's medication, and said it was possible that the card could have been stuck to Resident #1's medication cards. During a telephone interview on 03/05/24 at 3:15 P.M., the Home Care Agency (HCA) Nurse said that on 01/18/24 she was the nurse assigned to visit Resident #1 in his/her home. The HCA Nurse said when she reconciled Resident #1's medications she noticed there was a medication card with the Lisinopril 20 mg tablets, and that the card was labeled with another person's name. The HCA Nurse said according to the discharge summary Resident #1 was not prescribed Lisinopril. The HCA Nurse said Resident #1 told her he/she had taken one of each of the medications he/she was sent home with from the Facility, including the Lisinopril earlier that morning. The HCA Nurse said she assessed Resident #1, notified his/her physician of the medication error, and also alerted the HCA Physical Therapist (PT) regarding the medication error because the HCA PT was scheduled to see Resident #1 later that same day. During a telephone interview on 03/07/24 at 12:36 P.M., the HCA Physical Therapist (PT) said that she was assigned to visit Resident #1 in his/her home on 01/18/24, that she arrived at Resident #1's home at 2:15 P.M., and noted he/she was having difficulty focusing on simple tasks, was lethargic, and complained of feeling dizzy. The HCA PT said she checked Resident #1's blood pressure and it was 60 mm Hg/40 mm Hg (very low), so she called 911 and Resident #1 was transferred to the Hospital Emergency Department via ambulance. Review of Resident #1's Hospital Emergency Department History and Physical, (H&P) dated 01/18/24, indicated Resident #1 had been discharged from the Facility with another resident's Lisinopril, and had accidentally taken a dose. The H&P indicated Resident #1's blood pressure was 76 mm Hg/40 mm Hg (very low). Review of Resident #1's Hospital Care Timeline Report indicated he/she diagnosed with hypotension (low blood pressure) as a result of accidental ingestion of Lisinopril, and was admitted to the Hospital's Intensive Care Unit on 01/19/24. During an interview on 03/05/24 at 8:24 A.M., the Director of Nurses (DON) said this incident was an unfortunate mistake, and that Nursing should have been more careful when giving Resident #1 his/her medications on discharge. On 03/05/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 01/18/14, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents would be discharged with the correct medications. B. 01/18/24, The Education Sheet indicated nursing staff were educated by the Director of Nurses and Assistant Director of Nurses to review discharge medications with two nursing staff. C. 01/18/24, A Discharge Medication Accuracy Form was implemented to include review and signatures required by two licensed nurses for all residents discharged with medications. D. 01/22/24, Weekly audits by the Director of Nurses or designee of discharged residents were implemented to ensure discharge process and documentation included that two licensed nurses verified that the correct medications were sent home in the event of a home discharge. E. 02/22/24, The concern area was reviewed by the QAPI committee to determine compliance with the new discharge medication process, and if goals met. F. Weekly audits of discharge medication verifications will be conducted by the Director of Nurses and/or designee indefinitely and compliance reviewed at monthly QAPI meetings. G. The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1 was free from a significant medication error, when the medications provided to him/her upon discharge were not accurately reconciled by nursing. One of the medications, Lisinopril (used to lower blood pressure) was sent home with Resident #1, belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. Resident #1 took the Lisinopril, along with all the other medications he/she was sent home with the next morning, he/she experienced mental status changes, required transfer to the Hospital Emergency Department for evaluation, and was admitted to the Intensive Care Unit due to extremely low blood pressure. Findings include: The Facility Policy, titled 72-Hour Discharge Planning/Discharge to Identified Living Arrangements, dated 08/23/23, indicated medications on discharge would be reconciled by nursing. According to MayoClinic.org: - Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. A blood pressure measurement is give in millimeters of mercury (mm Hg). - Ideal blood pressure is usually lower than 120 mm Hg/80 mm Hg. - Low blood pressure is a blood pressure reading lower than 90 mm Hg for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and extreme low blood pressure can lead to a condition called shock, which can be life threatening. Review of the Facility's Medication Error Report Form, dated 01/18/24, indicated Resident #1 was discharged home from the Facility on 01/17/24, and on 01/18/24 the Facility was notified that he/she was sent home with a medication card for Lisinopril which belonged to another resident (later identified as Resident #2). Review of the Photograph provided by the Home Care Agency of the Medication Card indicated it contained Lisinopril, 20 mg, by mouth once daily, and Resident #2's name was clearly indicated on the card. Resident #1 was admitted to the Facility in December 2023, diagnoses included Cerebral Infarction, Alcohol Dependence, Congestive Heart Failure, History of Cardiac Implants, and Atrial Fibrillation. Review of Resident #1's Facility's Vitals Report, for the month of January 2024, indicated that Resident #1's lowest measured blood pressure reading had been 90 mm Hg/60 mm Hg. Review of Resident #1's Physician's Order Summary Report, dated 12/15/23, indicated he/she was admitted to the Facility with physician's orders that included (but not limited to) the following: -Torsemide (diuretic) 20 milligrams (mg), -Atorvastatin (lowers cholesterol) 80 mg, and -Metoprolol (lowers blood pressure) Extended Release, 25 mg. Review of Resident #1's Discharge Medication Release Form, dated 01/17/24, and signed by Nurse #1 and Resident #1, indicated Resident #1 medications upon discharge included (but not limited to) the following: -Torsemide 20 mg, -Atorvastatin 80 mg, and -Metoprolol Extended Release, 25 mg. Further review of the Resident #1's Admission Physician's Orders and Discharge Medication Release Form indicated Resident #1 did not have physician's orders for Lisinopril. Resident #2 was admitted to the Facility in January 2024, diagnoses included hypertension, and aortic valve insufficiency. Review of Resident #2's Physician Order Report indicated he/she had a physician's order, dated 01/13/24 for Lisinopril 20 mg by mouth once daily. During a telephone interview on 03/06/24 at 12:36 P.M., Nurse #1 said that on 01/17/24, she was the nurse assigned to Resident #1, and said she reviewed and prepared his/her medication cards that he/she was taking home. Nurse #1 said she put Resident #1's medication cards in a bag and handed them to Unit Manager #1, who then brought them to the Nurses' Station to discharge Resident #1. Nurse #1 said she did not follow Unit Manager #1 to the Nurses' Station and did not have a second nurse double check the medications before putting them in the bag. Nurse #1 said she was notified the next day that Resident #1 had been accidentally discharged with another resident's medication, and said it was possible that the card could have been stuck to Resident #1's medication cards. During a telephone interview on 03/05/24 at 3:15 P.M., the Home Care Agency (HCA) Nurse said that on 01/18/24 she was the nurse assigned to visit Resident #1 in his/her home. The HCA Nurse said when she reconciled Resident #1's medications she noticed there was a medication card with the Lisinopril 20 mg tablets, and that the card was labeled with another person's name. The HCA Nurse said according to the discharge summary Resident #1 was not prescribed Lisinopril. The HCA Nurse said Resident #1 told her he/she had taken one of each of the medications he/she was sent home with from the Facility, including the Lisinopril earlier that morning. The HCA Nurse said she assessed Resident #1, notified his/her physician of the medication error, and also alerted the HCA Physical Therapist (PT) regarding the medication error because the HCA PT was scheduled to see Resident #1 later that same day. During a telephone interview on 03/07/24 at 12:36 P.M., the HCA Physical Therapist (PT) said that she was assigned to visit Resident #1 in his/her home on 01/18/24, that she arrived at Resident #1's home at 2:15 P.M., and noted he/she was having difficulty focusing on simple tasks, was lethargic, and complained of feeling dizzy. The HCA PT said she checked Resident #1's blood pressure and it was 60 mm Hg/40 mm Hg (very low), so she called 911 and Resident #1 was transferred to the Hospital Emergency Department via ambulance. Review of Resident #1's Hospital Emergency Department History and Physical, (H&P) dated 01/18/24, indicated Resident #1 had been discharged from the Facility with another resident's Lisinopril, and had accidentally taken a dose. The H&P indicated Resident #1's blood pressure was 76 mm Hg/40 mm Hg (very low). Review of Resident #1's Hospital Care Timeline Report indicated he/she diagnosed with hypotension (low blood pressure) as a result of accidental ingestion of Lisinopril, and was admitted to the Hospital's Intensive Care Unit on 01/19/24. During an interview on 03/05/24 at 8:24 A.M., the Director of Nurses (DON) said this incident was an unfortunate mistake, and that Nursing should have been more careful when giving Resident #1 his/her medications on discharge. On 03/05/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 01/18/14, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents would be discharged with the correct medications. B. 01/18/24, The Education Sheet indicated nursing staff were educated by the Director of Nurses and Assistant Director of Nurses to review discharge medications with two nursing staff. C. 01/18/24, A Discharge Medication Accuracy Form was implemented to include review and signatures required by two licensed nurses for all residents discharged with medications. D. 01/22/24, Weekly audits by the Director of Nurses or designee of discharged residents were implemented to ensure discharge process and documentation included that two licensed nurses verified that the correct medications were sent home in the event of a home discharge. E. 02/22/24, The concern area was reviewed by the QAPI committee to determine compliance with the new discharge medication process, and if goals met. F. Weekly audits of discharge medication verifications will be conducted by the Director of Nurses and/or designee indefinitely and compliance reviewed at monthly QAPI meetings. G. The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1's discharge was safe, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when one of the medications (Lisinopril, used to lower blood pressure) sent home with Resident #1 belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. Resident #1 took the Lisinopril, along with all the other medications he/she was sent home with the next morning, he/she experienced mental status changes, required transfer to the Hospital Emergency Department for evaluation, and was admitted to the Intensive Care Unit due to extremely low blood pressure. Findings include: The Facility Policy, titled 72-Hour Discharge Planning/Discharge to Identified Living Arrangements, dated 08/23/23, indicated medications on discharge would be reconciled by nursing. According to MayoClinic.org: - Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. A blood pressure measurement is give in millimeters of mercury (mm Hg). - Ideal blood pressure is usually lower than 120 mm Hg/80 mm Hg. - Low blood pressure is a blood pressure reading lower than 90 mm Hg for the top number (systolic) or 60 mm Hg for the bottom number (diastolic), and extreme low blood pressure can lead to a condition called shock, which can be life threatening. Review of the Facility's Medication Error Report Form, dated 01/18/24, indicated Resident #1 was discharged home from the Facility on 01/17/24, and on 01/18/24 the Facility was notified that he/she was sent home with a medication card for Lisinopril which belonged to another resident (later identified as Resident #2). Review of the Photograph provided by the Home Care Agency of the Medication Card indicated it contained Lisinopril, 20 mg, by mouth once daily, and Resident #2's name was clearly indicated on the card. Resident #1 was admitted to the Facility in December 2023, diagnoses included Cerebral Infarction, Alcohol Dependence, Congestive Heart Failure, History of Cardiac Implants, and Atrial Fibrillation. Review of Resident #1's Facility's Vitals Report, for the month of January 2024, indicated that Resident #1's lowest measured blood pressure reading had been 90 mm Hg/60 mm Hg. Review of Resident #1's Physician's Order Summary Report, dated 12/15/23, indicated he/she was admitted to the Facility with physician's orders that included (but not limited to) the following: -Torsemide (diuretic) 20 milligrams (mg), -Atorvastatin (lowers cholesterol) 80 mg, and -Metoprolol (lowers blood pressure) Extended Release, 25 mg. Review of Resident #1's Discharge Medication Release Form, dated 01/17/24, and signed by Nurse #1 and Resident #1, indicated Resident #1 medications upon discharge included (but not limited to) the following: -Torsemide 20 mg, -Atorvastatin 80 mg, and -Metoprolol Extended Release, 25 mg. Further review of the Resident #1's Admission Physician's Orders and Discharge Medication Release Form indicated Resident #1 did not have physician's orders for Lisinopril. Resident #2 was admitted to the Facility in January 2024, diagnoses included hypertension, and aortic valve insufficiency. Review of Resident #2's Physician Order Report indicated he/she had a physician's order, dated 01/13/24 for Lisinopril 20 mg by mouth once daily. During a telephone interview on 03/06/24 at 12:36 P.M., Nurse #1 said that on 01/17/24, she was the nurse assigned to Resident #1, and said she reviewed and prepared his/her medication cards that he/she was taking home. Nurse #1 said she put Resident #1's medication cards in a bag and handed them to Unit Manager #1, who then brought them to the Nurses' Station to discharge Resident #1. Nurse #1 said she did not follow Unit Manager #1 to the Nurses' Station and did not have a second nurse double check the medications before putting them in the bag. Nurse #1 said she was notified the next day that Resident #1 had been accidentally discharged with another resident's medication, and said it was possible that the card could have been stuck to Resident #1's medication cards. During a telephone interview on 03/05/24 at 3:15 P.M., the Home Care Agency (HCA) Nurse said that on 01/18/24 she was the nurse assigned to visit Resident #1 in his/her home. The HCA Nurse said when she reconciled Resident #1's medications she noticed there was a medication card with the Lisinopril 20 mg tablets, and that the card was labeled with another person's name. The HCA Nurse said according to the discharge summary Resident #1 was not prescribed Lisinopril. The HCA Nurse said Resident #1 told her he/she had taken one of each of the medications he/she was sent home with from the Facility, including the Lisinopril earlier that morning. The HCA Nurse said she assessed Resident #1, notified his/her physician of the medication error, and also alerted the HCA Physical Therapist (PT) regarding the medication error because the HCA PT was scheduled to see Resident #1 later that same day. During a telephone interview on 03/07/24 at 12:36 P.M., the HCA Physical Therapist (PT) said that she was assigned to visit Resident #1 in his/her home on 01/18/24, that she arrived at Resident #1's home at 2:15 P.M., and noted he/she was having difficulty focusing on simple tasks, was lethargic, and complained of feeling dizzy. The HCA PT said she checked Resident #1's blood pressure and it was 60 mm Hg/40 mm Hg (very low), so she called 911 and Resident #1 was transferred to the Hospital Emergency Department via ambulance. Review of Resident #1's Hospital Emergency Department History and Physical, (H&P) dated 01/18/24, indicated Resident #1 had been discharged from the Facility with another resident's Lisinopril, and had accidentally taken a dose. The H&P indicated Resident #1's blood pressure was 76 mm Hg/40 mm Hg (very low). Review of Resident #1's Hospital Care Timeline Report indicated he/she diagnosed with hypotension (low blood pressure) as a result of accidental ingestion of Lisinopril, and was admitted to the Hospital's Intensive Care Unit on 01/19/24. During an interview on 03/05/24 at 8:24 A.M., the Director of Nurses (DON) said this incident was an unfortunate mistake, and that Nursing should have been more careful when giving Resident #1 his/her medications on discharge. On 03/05/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 01/18/14, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents would be discharged with the correct medications. B. 01/18/24, The Education Sheet indicated nursing staff were educated by the Director of Nurses and Assistant Director of Nurses to review discharge medications with two nursing staff. C. 01/18/24, A Discharge Medication Accuracy Form was implemented to include review and signatures required by two licensed nurses for all residents discharged with medications. D. 01/22/24, Weekly audits by the Director of Nurses or designee of discharged residents were implemented to ensure discharge process and documentation included that two licensed nurses verified that the correct medications were sent home in the event of a home discharge. E. 02/22/24, The concern area was reviewed by the QAPI committee to determine compliance with the new discharge medication process, and if goals met. F. Weekly audits of discharge medication verifications will be conducted by the Director of Nurses and/or designee indefinitely and compliance reviewed at monthly QAPI meetings. G. The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on observations, records reviewed and interviews the facility failed to ensure nursing provided care consistent with professional standards of practice to prevent new pressure ulcers from developing for one Resident (#256) out of 29 sampled residents. Specifically for Resident #256, who was assessed by nursing to be at risk for skin breakdown, the facility failed to ensure nursing consistently implemented his/her physician's ordered prevalon boots (heel protectors that help reduce the risk of pressure ulcers by keeping the heels floated, relieving pressure) Subsequently, Resident #256's right heel pressure ulcer developed and was first observed by nursing, almost 29 hours after the surveyor first observed the wound. Findings include: Review of the facility policy titled, Skin Management Program, dated as revised 6/13/19, indicated to minimize the development of any type of ulcers and other skin issues through the systematic and regular inspection of the skin, and to ensure early detection and intervention for all skin problems. 2. Residents will undergo weekly body check by the licensed nurse. 3. Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the licensed nurse of any skin changes to the resident's skin. Resident #256 was admitted to the facility in December 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and pain in the left knee. Review of the Minimum Data Set (MDS) assessment, dated 12/22/23, indicated Resident #256 had a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15 which indicated moderate cognitive impairment. The MDS indicated he/she did not have any pressure ulcers and was dependent of staff for bed mobility. The MDS indicated a functional limitation in range of motion on both sides of his/her lower extremities. On 1/2/24 at 8:16 A.M., Resident #256 was in bed with his/her heels directly touching the mattress. There were a pair of prevalon boots on the floor next to the nightstand. Resident #256 said that staff do not put on the prevalon boots but said he/she would wear them if staff would put them on. Resident #256 said he/she did not have any skin issues on his/her feet and allowed the surveyor to observe his/her feet. Resident #256 was noted to have an unstageable pressure ulcer on his/her right heel the size of a dime and there was visible slough (moist dead tissue) and eschar (hard dead tissue, appearing like a scab) and the surrounding tissue was red. On 1/2/24 at 3:31 P.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. Resident #256 asked the surveyor to place a pillow under his/her heels because they were sore. On 1/2/24 at 5:02 P.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. On 1/3/24 at 6:32 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. On 1/3/24 at 7:30 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. On 1/3/24 at 9:03 A.M., Resident #256 was in bed and his/her heels were directly touching the mattress. Two prevalon boots were observed on the floor and not applied to the Resident's feet. Review of the Certified Nurse Assistant Care Card (a form indicating the level of care needed and equipment needed for a resident), dated as updated on 12/16/23, indicated: - pressure ulcer prevention: heel protectors. Review of the handwritten physician's order in the medical record, dated 12/16/23 (implemented two days later on 12/18/23), indicated: - Prevalon boots when in bed secondary to pink/ reddened heels. Review of the transcribed physician's order in the electronic medical record, dated 12/18/23, indicated: - Prevalon boots while in bed. Review of the Treatment Administration Record, dated January 2023, indicated the prevalon boots were applied as ordered on 1/2/24 and 1/3/24. Review of the Admission Assessment, dated 12/15/23 indicated: - [NAME] Total Score: 14 which indicated Resident #256 was at risk for skin breakdown. - Feet and heels very dry. Heels pink, intact and blanchable. Review of the Weekly Skin Focused Observation, dated 12/28/23, indicated: - No alterations in skin. Review of the plan of care related to skin breakdown, dated 12/30/23, indicated: - Avoid shearing resident's skin during positioning, transferring, and turning. - Conduct a systematic skin inspection weekly, Pay particular attention to the bony prominences. - Report any signs of skin breakdown (sore, tender, red, or broken areas). - Apply moisture barrier to skin. Review of the nursing practitioner note, dated 1/2/24, indicated: -Reports discomfort to BLE (bilateral lower extremities). -Skin Assessment: Negative. During an interview on 1/3/24 at 10:57 A.M., Certified Nurse Assistant (CNA) #1 said she was assigned for Resident #256 on 1/2/24 and 1/3/24 during the day shift (7:00 A.M. to 3:00 P.M.), CNA #1 said that she completed Resident #256's care around 10:00 A.M., CNA #1 said that during care on 1/2/23 she applied to lotion to Resident #256's legs and feet, CNA #1 said this is part of her usual routine for care. CNA #1 said she looked at Resident #256 during care and did not identify any new open areas on his/her feet or heels. CNA #1 said that Resident #256 wears booties and knows he/she should wear them because the prevalon boots are on his/her care card. During an interview with 1/3/24 at 1:41 P.M., Nurse #1 said that Resident #256 requires prevalon boots on while in bed for pressure ulcer prevention. Nurse #1 said nurses or CNAs will apply the prevalon boots with care. Nurse #1 said that Resident #256 is compliant with wearing the prevalon boots. On 1/3/24 at 1:45 P.M., Nurse #1 and two surveyors went into Resident #256's room. Nurse #1 said that Resident #256 has a new unstageable pressure ulcer to his/her right heel. Nurse #1 said Resident #256 should wear the prevalon boots for pressure ulcer prevention. During an interview on 1/3/24 at 1:49 P.M., Unit Manager #1 said that nurses should follow and implement the physicians order for prevalon boots. Unit Manager #1 said the prevalon boots are for pressure ulcer prevention and nurses and CNAs should ensure they are applied. On 1/3/24 at 1:53 P.M., the Unit Manager #1 and Nurse #1 went into Resident #256's room. Unit Manager said that Resident #256 had a new pressure ulcer to his/her right heel. Resident #256 said to Unit Manager #1 and Nurse #1 that he/she would wear his/her prevalon boots if nursing applied them. During an interview on 1/3/24 at 3:55 P.M., the Nurse Practitioner said she evaluated Resident #256 on 1/3/23 for a new pressure ulcer. Review of the skin check on 1/3/24, indicated: -New 0.5 by 0.5 centimeter (cm) unstageable area noted to right heel. Wound bed 100% eschar. During an interview on 1/3/24 at 4:05 P.M., the Director of Nursing said Resident #256 had developed a new pressure ulcer to his/her left heel. The DON said nursing should have implemented the physician's ordered prevalon boots for pressure ulcer prevention.

Based on records reviewed and interviews for 5 of 29 sampled Residents (#256, #257, #259, #41 and #412), the facility failed to ensure they maintained complete and accurate medical records related to activities of daily living documentation. Findings include: 1.) For Resident #256, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024. Resident #256 was admitted to the facility in December 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction and pain in the left knee. Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #256's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts: -12/16/23, 11:00 P.M.-7:00 A.M. -12/17/23, 11:00 P.M.-7:00 A.M. -12/18/23, 11:00 P.M.-7:00 A.M. -12/19/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/20/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M. -12/21/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/22/23, 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M -12/23/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/24/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/25/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/26/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/29/23, 7:00 A.M.-3:00 P.M., and 3:00 P.M.-11:00 P.M. -12/31/23, 7:00 A.M.-3:00 P.M., and 11:00 P.M.-7:00 A.M. -1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -1/2/24, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M. -1/3/24, 11:00 P.M.-7:00 A.M. 2.) For Resident #257, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024. Resident #257 was admitted to the facility in December 2023 with diagnoses including sepsis, cholecystitis and diabetes. Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #257's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts: -12/26/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/28/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/29/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -1/2/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. 3.) For Resident #259, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024. Resident #259 was admitted to the facility in December 2023 with diagnoses including pulmonary embolism, anxiety, and diabetes. Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #259's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts: -12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -1/2/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. 4.) For Resident #41, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024. Resident #41 was admitted to the facility in December 2023 with diagnoses including hypertension and diabetes. Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #41's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts: -12/1/23, 11:00 P.M.-7:00 A.M. -12/3/23, 11:00 P.M.-7:00 A.M. -12/4/23, 3:00 P.M.-11:00 P.M. -12/6/23, 3:00 P.M.-11:00 P.M. -12/7/23, 3:00 P.M.-11:00 P.M. -12/8/23, 11:00 P.M.-7:00 A.M. -12/9/23, 3:00 P.M.-11:00 P.M. -12/11/23, 3:00 P.M.-11:00 P.M. -12/12/23, 3:00 P.M.-11:00 P.M. -12/14/23, 7:00 A.M.-3:00 P.M. -12/15/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/16/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M. -12/17/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -12/18/23, 3:00 P.M.-11:00 P.M. -12/19/23, 3:00 P.M.-11:00 P.M. -12/20/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/21/23, 7:00 A.M.-3:00 P.M. and 11:00 P.M.-7:00 A.M. -12/22/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/23/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/24/23, 3:00 P.M.-11:00 P.M. -12/25/23, 7:00 A.M.-3:00 P.M. -12/26/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/27/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/29/23, 7:00 A.M.-3:00 P.M. -12/30/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -1/2/24, 11:00 P.M.-7:00 A.M. 5.) For Resident #412, Certified Nurse Aide (CNA) Activity of Daily Living (ADL) documentation was not consistently completed for the months of December 2023 and January 2024. Resident #412 was admitted to the facility in December 2023 with diagnoses including urinary tract infection and sepsis. Review of the CNA ADL documentation dated, December 2023 and January 2024, indicated Resident #412's CNA ADL Flow Sheets for eating, toilet hygiene, grooming, dressing, ambulation, decubitus prevention, bladder care, bowel care and positioning records were left blank on the following dates and shifts: -12/23/23, 11:00 P.M.-7:00 A.M. -12/24/23, 3:00 P.M.-11:00 P.M. -12/25/23, 7:00 A.M.-3:00 P.M. -12/26/23, 7:00 A.M.-3:00 P.M. -12/27/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M. -12/28/23, 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M. -12/29/23, 7:00 A.M.-3:00 P.M. -12/30/23, 7:00 A.M.-3:00 P.M. and 3:00 P.M.-11:00 P.M -12/31/23, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -1/1/24, 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M. -1/2/24, 11:00 P.M.-7:00 A.M. During an interview on 1/3/24 at 1:14 P.M., CNA #1 said that ADL documentation should be completed by the end of the shift. During an interview on 1/4/24 at 1:14 P.M., CNA #4 said that ADL documentation should be completed by the end of the shift. During an interview on 1/3/24 at 1:48 P.M., Unit Manager #1 said ADL documentation needs to be completed by the end of the shift. During an interview on 1/3/24 at 1:55 P.M., the MDS Coordinator said ADL documentation is not being filled out entirely but should be completed by CNAs before the end of the shift. During an interview on 1/3/24 at 2:09 P.M., the Director of Nursing (DON) said ADL documentation needs to be completed by the end of the shift. During a follow up interview on 1/3/24 at 5:30 P.M., the DON said there was no policy on completing ADL documentation. 48990

Based on observation, record review and interview the facility failed to adhere to standards of infection control practices to prevent infection by failing to don and doff personal protective equipment (PPE) as required on two out of three resident care units, failing to ensure potentially contaminated gloves were removed and hand hygiene was performed after being in contact with a resident's environment on 1 out of 3 resident care units. Findings include: Review of the facility's policy entitled, Section I-The infection Prevention Program, dated August 2017 indicated the following: -This facility has developed and maintains an Infection Prevention Program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. The goal of the infection prevention program is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Further review of the policy included but not limited to the following: Hand Hygiene, When to Wash Hands (at a minimum) -Before and after direct patient/resident contact. -After contact with items/surfaces in patient/resident areas. During an interview on 1/2/23 at 7:10 A.M., the surveyors were informed by staff that the facility had residents currently infected with COVID-19 and transmission-based precautions were in effect for those residents. During the survey the following observations were made on the first-floor resident care unit: On 1/2/24 at 8:19 A.M., the Minimum Data Set (MDS) nurse entered a resident room identified as requiring COVID/droplet precautions. The MDS nurse was not wearing an N95 mask and did not put on a gown or eye protection. The MDS nurse adjusted the resident's positioning in bed and turned off the call light. She then left the room and entered another resident's room. During an interview on 1/2/24 at 8:20 A.M., the MDS nurse said she entered the precaution room without wearing the proper PPE. The MDS nurse said she should have put on a gown, eye protection, and an N95 mask. The MDS nurse said she just instinctively entered the room to respond to the call light. On 1/02/24 at 8:28 A.M., Certified Nursing Aid (CNA) entered a resident room with COVID/droplet precautions. The CNA did not put on a gown or eye protection. During an interview on 1/02/24 at 8:29 A.M., CNA #3 said she should have worn a gown and eye protection but forgot. During the survey the following observations were made on the third-floor resident care unit: On 1/03/24 at 11:23 A.M., Nurse #2 was observed in a resident room, identified by a sign on the door as requiring isolation precautions, with instructions of what PPE to don (put on). Nurse #2 was standing near the end of the bed of the resident holding a glucometer in his hand. Nurse #2 was not wearing a gown, an N95 mask, or eye protection. Nurse #2 exited the room. A housekeeper was in the same room, occupied with a resident identified as being positive for Covid-19. The housekeeper was observed to be wearing a surgical mask and no eye protection. The housekeeper with gloved hands, removed a bag of trash, placed the bag in the housekeeping cart located in the doorway, touched the cart, and with the same potentially contaminated gloves, pulled out a mop, using the gloved hands repositioned the pad on the bottom of the mop, entered the room, moved the resident's tray table and walker, and continued to mop. At no time between tasks and encountering the resident's environment did the housekeeper remove her gloves and perform hand hygiene. The housekeeper doffed (removed) the gloves and gown over the threshold, just outside of the room and placed the contaminated PPE in the housekeeping cart trash bin. During an interview on 103/24 at 11:49 A, M, Nurse #2 said he did a blood sugar in a resident's room and that the resident was positive for Covid-19. Nurse #2 said he had removed the gown and did not have eye protection when he did the resident's blood sugar. Nurse #2 said there was no available eye protection in the cart located outside the resident's room. During an interview on 1/4/23 at 10:00 A.M., the surveyor shared the observations made of staff not wearing PPE and not performing hand hygiene with the Infection Preventionist (IP). The IP nurse said all staff should be following the transmission-based precautions, including wearing the appropriate PPE and performing hand hygiene.

Based on interview, record review and observation, the facility failed to: inform the physician of a newly identified pressure injury or conduct weekly skin assessments as ordered by the physician, resulting in the development of a Stage II wound, for one Resident (#163) of 28 sampled residents. Findings include: Review of the facility's policy Skin Management Program, dated 10/12/22, indicated: * Residents at risk for developing and/or who has a PI/PU [pressure injury/pressure ulcer} will be identified. This will be followed by implementation of appropriate individualized interventions to assist with avoiding the development/promoting healing of a PI/PU. * Resident will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check in the EHR [electronic health record]. Resident #163 was admitted to the facility on [DATE] and had diagnoses which included intercranial hemorrhage, expressive and receptive aphasia, right-sided hemiparesis, obesity and right great toe wound. Review of Resident #163's physician orders, dated 5/19/22, indicated weekly skin check (order remained active from prior admission to facility), and apply protective cream to coccyx twice a day. Resident #168's weekly skin assessment, dated 10/20/22, indicated his/her skin was intact. Review of Resident #168's medical record indicated a weekly skin assessment was not done on 10/27/22, or any other date prior to 11/2/22 (date of survey). Resident #168's physician order, dated 10/20/22, indicated an order for an air mattress related to obesity, decreased mobility and a bariatric bed to assist with oxygen status. Resident #163's nurse's note, dated 10/22/22 indicated Resident alert to self, toe dressing completed. New area was found on left buttocks, denies any pain. Resident #163's Skin Incident Report, dated 10/22/22, indicated nursing staff discovered an unstageable wound on his/her right buttock. The wound was described as tear/friction shear. The Report indicated Treatment order obtained: Wound MD to see. Protective cream. The area on the wreport for the date and time of notifying the physician was left blank. Review of Resident #163's nursing, nurse practitioner and physician progress notes, dated 10/22/22 through 10/30/22, indicated there was no reference to nursing staff informing the nurse practitioner or physician that Resident #163 had a new pressure injury on the right buttock, or any new physician orders hich identified the pressure injury. Resident #163's Wound Physician note, dated 10/31/22, indicated he/she had an unstageable deep tissue injury on the coccyx for at least one day duration. The note indicated there was a moderate amount of serosanguinous exudate. The wound measured 3.5 x 5 x 0.3 centimeters (cm). Treatment recommendations indicated alginate calcium apply once daily for 30 days covered by a gauze border dressing. Review of Resident #163's plan of care, start date of 11/1/22, indicated he/she was at risk for pressure ulcers related to decreased mobility, incontinence of bowel and morbid obesity. Interventions to manage this risk included the use of an air mattress, weekly skin inspection, and to report any signs of skin breakdown (sore, tender, red or broken areas). Resident #163's physician order, dated 11/2/22, indicated: * Wound consult *Buttocks stage 2 (superficial). Cleanse with normal saline, pat dry, apply Solosite. Cover with coversite. Change daily and when soiled *Offload buttocks when in and out of bed Resident #163's nurse's note dated 11/2/22, indicated New order for Stage 2 dressing clean with normal saline; apply solosite and coversite; dressing completed, no drainage noted, no pain at site. Measurements are 1.5 x 1 and 1 x 0.5 During an interview with Nurse #3 on 11/2/22 at 11:00 A.M., she said she first noticed Resident #80's pressure injury on 10/22/22, and at that time the wound was red but not open. Nurse #3 said she telephoned the Physician and made him/her aware of the pressure injury. Nurse #3 said the Physician did not provide new orders, and that staff continued to apply barrier cream and use the air mattress to treat the pressure injury. Nurse #3 said she did not document in the medical record that she informed the Physician, or that there were no new orders. Nurse #3 said she first noticed the pressure injury had opened on 10/31/22. Nurse #3 said she then contacted the Wound Physician to examine Resident #80. During an interview with Nurse Manager #1 on 11/2/22 at 1:00 P.M., she said it was expected that staff follow the physician's order and perform weekly skin assessments on Resident #163. Nurse Manager #1 said there was no documentation in the medical record referencing Nurse #3's 10/22/22 conversation with the Physician about Resident #163's new pressure injury.

Based on observation, record review and interview the Facility staff failed to address an unplanned weight loss for 1 Resident (#86), out of a total sample of 24 residents, according to the Facility's weight monitoring policy and procedures and to ensure nutritional parameters are maintained. Findings include: Resident #86 was admitted to the Facility in 02/2019, with [DIAGNOSES REDACTED]. On 3/06/19, at 12:22 P.M., the Surveyor observed Resident #86 eating in her/his room. The Surveyor noticed the Resident had eaten less than 25% of her/his meal and had pushed aside the meal tray. During an interview on 3/06/19, at 12:22 P.M., Resident #86 said she/he was not very hungry and couldn't finish her/his meal. Review of the weight book indicated the following weights: 2/9/29-167 pounds (lbs) 2/14/19-176 lbs. 2/25/29-149.2 lbs. Review of the clincal record indicated that Resident #86 was not weighed again until 3/7/19. On 3/7/19, the Resident's weight was 143.4, a further weight loss of 5.8 lbs. Review of the medication administration records dated for the month of (MONTH) 2019 indicated that during February, Resident #86 ate 50% or less of each meal for 39 out of 60 meals served. Further review indicated that for 25 of those 39 meals, 25% or less of each meal was eaten. Review of the medication administration records dated for the month of (MONTH) 2019 indicated that during March, Resident #86 ate 50% or less of each meal for 15 of the 19 meals served. Further review indicated that for 12 of those 15 meals, 25% or less of each meal was eaten. Review of the weights indicated a weight loss of 10.66% in 16 days from 2/9/19, through 2/25/19 (weight loss is considered significant for a 5% or greater loss in one month). Further review of the weights indicated a minimum total weight loss of 14.13% in 26 days from 2/9/19, until 3/7/19. Review of the doctor's orders dated 2/1/19, through 2/28/19, and 3/1/19, through 3/7/19, indicated there was no order for a diuretic (a medication that removes water from the body and could therefor reduce weight). Further review of the doctor's orders indicated that no intervention to address the significant weight loss was put in place after the significant weight loss was identified on 2/25/19. Review of the nurse's notes dated 2/25/19, through 3/7/19, indicated no documentation regarding the Resident's significant weight loss. Review of the clinical record indicated no discussion by the doctor or Nurse Practitioner (NP) #1 regarding weight loss between the date of 2/25/19, (when the significant weight loss was identified) and 3/7/19, when the Facility notified NP #1. Review of the NP note dated 2/27/19, indicated a weight of 149.3 lbs with no mention that the weight indicated a significant weight loss and no recommended intervention to address the weight loss. Further review indicated that Resident #86's blood sugars in the morning were consistently low and the recommended intervention was to discontinue the medication used to treat her/his diabetes ([MEDICATION NAME]). NP #1 then wrote that the Resident had [MEDICATION NAME] (low protein) due to protein-calorie malnutrition for which she was being treated with the protein supplement drink Juven and the low calorie/high protein drink Glucerna as of 2/20/19. Review of the NP note dated 3/6/19, indicated no mention of a significant weight loss or the potential risk for a significant weight loss due to the Resident's recent medical history. During an interview on 3/7/19, at 10;45 A.M., Nurse #3 said that Resident #86 should have been weighed daily after the 2/25/19, weight was taken and the significant weight loss was identified. During an interview on 3/07/19, at 11:09 A.M., the Dietician said her original note was written on 2/17/19. She said that she had not written any follow up note after the significant weight loss was identified and the last doctor's order to address nutrition was written on 2/24/19, prior to the identification of the significant weight loss. During an interview on 3/07/19, at 12:31 P.M., Resident #86 said that she/he didn't have an appetite since she/he broke her/his leg. Resident #86 also said that she/he rarely eats more than 25% of her/his meals. She/he also said that she/he likes the food served in the Facility but her/his appetite is just gone. Review of the Facility policy titled Weight Policy and Weight Loss Protocol and dated as revised on 10/29/16, indicated that weights will be done weekly unless otherwise determined at the weekly care management meeting. This will be reflected in the residents care plan. Further review indicated that for any significant weight variance the following should occur: -doctor/nurse practitioner, family notification -nursing documentation of changes to plan of care, notifications, resident condition -dietician documentation and care plan revisions and recommendations -resident progress and potential for occurrence of significant change will be discussed at the weekly care management meeting. During an interview on 3/7/19, at 11:00 A.M., the Director of Nursing said that Resident #86 was not discussed at the weekly care management meeting because she was not aware of the significant weight loss.