Every finding on record at Beaumont Rehab & Skilled Nursing CTR - Westboro

Based on interview and record review, the facility failed to ensure that two Residents (#11 and #6), out of a total sample of 30 residents, were free from significant medication errors. Specifically, the staff failed to: 1. For Resident #11, ensure that Seroquel (a medication used to help regulate mood, behaviors and thoughts) was accurately transcribed onto the Medication Administration Record (MAR), resulting in the Resident missing 19 doses of the prescribed medication, and increasing the risk for worsening mood and behavior patterns. 2. For Resident #6, ensure Metoprolol Tartrate (medication used to treat high blood pressure) and Midodrine (medication used to treat low blood pressure) were administered to the Resident in accordance with physician ordered parameters, increasing the Resident's risk for adverse medication reactions. Findings include: 1. Resident #11 was admitted to the facility in November 2023 with diagnoses including Dementia, Parkinson's Disease, and Adjustment disorder with depressed mood. Review of the Resident's written Physician's Order, dated 2/24/26, indicated: -Start Seroquel 12.5 milligrams (mg) by mouth daily at 2:00 P.M. Review of the Resident's February 2026 MAR failed to indicate the physician's order had been transcribed for Seroquel 12.5mg by mouth daily at 2:00 P.M. Review of the Resident's March 2026 MAR indicated that an order for Seroquel 12.5mg by mouth daily had been posted on 3/16/26 (19 days after the Physician order had been written). During an interview on 3/18/26 at 8:04 A.M., Nurse #2 said Resident #11 had a history of behaviors, anxiety, and restlessness. Nurse #2 said that on 3/16/26, Resident #11 had worsening behaviors, and the nursing staff contacted the Nurse Practitioner (NP) who evaluated Resident #11's medications and discovered that the written order from 2/24/26 for Seroquel 12.5mg po at 2:00 P.M., had never been transcribed. Nurse #2 said that the NP instructed the staff to implement the order for Seroquel 12.5mg at 2:00pm. Nurse #2 said it was important for Resident #11 to have received the correct dose of Seroquel to help reduce the Resident's behaviors and increase his/her comfort. During an interview on 3/18/26 at 8:27 A.M., Unit Manager (UM) #2 said the Seroquel medication transcription error was discovered on 3/16/26, when the nursing staff had contacted the NP for Resident #11's worsening behaviors. UM #2 said the NP identified there was an order for Seroquel 12.5mg at 2:00 P.M., that had been written on 2/24/26 but never transcribed onto the Resident's MAR. UM #2 said that the NP had written the order on 2/24/26 due to a pattern of behaviors that Resident #11 had been exhibiting, including agitation and restlessness. UM #2 said that written physician's order should have been transcribed on 2/24/26 but was not transcribed until 3/16/26. During an interview on 3/18/26 at 9:45 A.M., the Director of Nurses (DON) said that when the NP wrote the order for Seroquel 12.5mg to be administered at 2:00 P.M., the order should have been transcribed onto the Resident's MAR on 2/24/26 but was not and resulted in several days of missed doses for the Resident. The DON also said that the 11:00 P.M.-7:00 A.M. nurses were responsible for completing 24-hour chart checks to decrease the likelihood of transcription errors occurring and did not know why this error had not been identified. During an interview on 3/18/26 at 10:27 A.M., Physician #1 said that when the NP prescribed the 2:00 P.M. dose of Seroquel 12.5mg, the order should have been noted and posted onto the MAR the same day but was not. Physician #1 said that Resident #11 would have benefited from receiving the Seroquel as ordered at 2:00 P.M., to treat his/her worsening behaviors. 2. Resident #6 was admitted to the facility in July 2024 with diagnoses including End Stage Renal Disease (ESRD) and Hypertension. Review of Resident #6's Physician Order for Metoprolol Tartrate, dated 8/6/24, indicated the following: -Metoprolol Tartrate tablet; 50 mg oral twice a day. -Special instructions: Hold for systolic blood pressure (SBP: upper number of the blood pressure which shows the highest pressure reached in the arteries) lower than 110 . Review of Resident #6's Physician's Order for Midodrine, dated 12/15/25, indicated the following: -10 mg tablet oral. -Special instructions: . hold medication if SBP greater than 120. Review of Resident #6's MARs for January 2026 through February 2026 indicated the following relative to Metoprolol Tartrate administration: -1/7/26 SBP was 107. Metoprolol Tartrate was administered. -1/9/26 SBP was 101. Metoprolol Tartrate was administered. -1/17/26 SBP was 108. Metoprolol Tartrate was administered. -1/21/26 SBP was 109. Metoprolol Tartrate was administered. -2/22/26 SBP was 110. Metoprolol Tartrate was held. -2/25/26 SBP was 107. Metoprolol Tartrate was administered. Review of Resident #6's March 2026 MAR indicated the following relative to Midodrine administration: -3/2/26 SBP was 123. Midodrine was administered. -3/4/26 SBP was 124. Midodrine was administered. During an interview on 3/13/26 at 11:20 A.M., Nurse #3 said Metoprolol Tartrate was ordered to be held when Resident #6's SBP was lower than 110 and that Midodrine was ordered to be held when Resident #6's SBP was greater than 120. During an interview on 3/13/26 at 11:26 A.M., Unit Manager (UM) #2 said Metoprolol Tartrate and Midodrine were ordered for Resident #6 to treat blood pressure. UM #2 said, for Resident #6, Nurses were required to hold administration of Metoprolol Tartrate when the Resident's SBP was lower than 110 and hold Midodrine when the Resident's SBP was greater than 120. At this time, UM #2 reviewed Resident #6's January 2026 through March 2026 MARs and said Metoprolol Tartrate should have been held, not administered, on 1/7/26, 1/9/26, 1/17/26, 1/21/26, and 2/25/26, and that Metoprolol Tartrate should have been administered, not held on 2/22/26. UM #2 said Midodrine should have been held, not administered to Resident #6 on 3/2/26 and 3/4/26. During an interview on 3/13/26 at 2:26 P.M., the Director of Nursing (DON) said she reviewed Resident #6's Midodrine and Metoprolol Tartrate administration records for January 2026 through March 2026 and that the Midodrine and Metoprolol Tartrate had been administered to the Resident outside of the ordered parameters. The DON said Nurses were required to adhere to the ordered medication parameters set by the physician and that administering Midodrine and Metoprolol Tartrate to Resident #6 outside of the ordered parameters increased risks for adverse medication reactions.

Based on observations, interviews, and records reviewed, the facility failed to provide food at safe and appetizing temperatures to residents from two out of three lunch meal carts on two Units ([NAME] Unit and [NAME] Unit) out of three total resident units.Specifically, the facility failed to provide food at safe and appetizing temperatures for the lunch meal for Residents eating lunch on the [NAME] Unit and [NAME] Unit, increasing residents' risks for reduced food/fluid intake. Findings include:Review of the facility's policy titled Food: Quality and Palatability, revised February 2023, included but was not limited to: -Food will be prepared by methods that conserve nutritive value, flavor and appearance. -Food will be palatable, attractive and served at a safe and appetizing temperature.-Food and liquids are prepared and served in a manner, form and texture to meet resident's needs.-Food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction. Review of the facility's Resident Council Meeting Minutes for 2025-2026, indicated:-May 28, 2025: Cold vegetables; vegetables are crunchy and not cooked well. Ice cream was served melted on Mother's Day, cream of tomato soup and other soups are served cold, French fries are served cold, toast is cold.-June 25, 2025: Cold food discussed, no resolution documented from previous month.-November 24, 2025: Eggs are cold.-December 10, 2025: Old business reviewed, no resolution documented from previous month.-February 11, 2026: Breakfast can be cold at times. On 3/12/26 between 9:26 A.M. through 11:55 A.M., during the initial observations on the [NAME] Unit, multiple residents reported the following concerns to the survey team:-The food arrives cold and sometimes it takes the staff a long time to pass the food trays out.-The food is awful and they will not eat it.-Eggs are usually cold and they do not like the food.-The food does not taste good.-The food for breakfast, lunch and dinner is always cold.-The food is cold and staff offered to heat the food up for them in the microwave. On 3/17/26 at 12:33 P.M., once all resident meals trays were passed, Surveyor #1 completed a lunch meal test tray on the [NAME] Unit which indicated:-corned beef and gravy 105 degrees Fahrenheit (F), not hot.-minced carrots 108 degrees F, not hot.-butterscotch pudding 70 degrees F, not cold. On 3/17/26 at 12:50 P.M., once all resident meal trays were passed, Surveyor #5 completed a lunch meal test tray on the [NAME] Unit which indicated: -corned beef 100 degrees F, not hot.-boiled carrots, 87 degrees F, not hot.-boiled potatoes 90 degrees F, not hot. The two test trays validated the residents' concerns of cold food.During an interview on 3/17/26 at 1:57 P.M., the Food Service Director (FSD) and Surveyor #5 discussed the results of the two lunch meal trays conducted by Surveyor #1 and Surveyor #5. The FSD said that the hot items should have been served at least 120 degrees F and the cold items should have been served below 50 degrees F and they were not.

Based on observations, interviews, and record reviews, the facility failed to provide treatment and services related to an indwelling urinary catheter (thin, flexible tube inserted into the bladder to drain urine outside the body) for two Residents (#93 and #51), out of a total sample of 30 residents.Specifically, the facility failed:1. For Resident #93, to implement the physician's orders relative to the correct indwelling urinary catheter size as ordered by the Physician, increasing the Resident's risk for indwelling urinary catheter complications.2. For Resident #51, to ensure that the urinary catheter drainage bag was not placed directly on the floor, placing the Resident at risk for contamination and infection. Findings include: Review of the facility's policy titled, Reception and Transcription of Physician Orders, revised, 5/16/24, included but limited to:*Is to provide guidelines for the safe and effective means to receive, transcribe and implement physician's orders. -Attending physician (MD-medical doctor), nurse practitioner (NP) or physician assistant (PA) may issue orders for a resident either in writing, verbally, or directly into the electronic health record if available. The order is received and processed by individuals who are qualified by their scope of practice. Orders may also be received from the MD, NP, PA via facsimile (Fax) or encrypted email. -All orders, whether written, verbal or computer entered, are to be noted and posted only by a licensed nurse. -Noting and posting consists of all activities necessary to implement and execute the order. This includes but is not limited to ordering medication, arranging referrals, transcribing orders to the medication administration record (MAR) or treatment administration record (TAR), obtaining consent, notifying interested parties, etc. 1. Resident #93 was admitted to the facility in December 2025 with diagnoses including retention of urine and essential primary hypertension. Review of the Minimum Data Set (MDS) Assessment, dated 2/13/26, indicated Resident #93:-has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of two out of a possible 15 points. -has an indwelling urinary catheter. On 3/13/26 at 7:59 A.M., the surveyor observed Certified Nurse Aide (CNA) #3 standing next to the Resident's bed in his/her bedroom providing activities of daily living care (ADLs- personal care activities including but not limited to, eating, grooming, and personal hygiene) for Resident #93. The surveyor observed the Resident had a urinary catheter in place that was size 16 French (Fr) with a 10 milliliter (mL) [NAME]. Review of Resident #93's March 2026 Physician orders indicated: -Catheter: Silicone (specific type), 14Fr/Balloon size -10 mL. May use leg bag when out of bed, initiated 12/27/25.-Catheter: Silicone (specific type), 14Fr/Balloon size -10 mL. Change monthly once a day on the 25th of the month, 7:00 A.M. - 3:00 P.M., initiated 1/14/26. Review of Resident #93's Care Plan initiated 1/7/26, included but was limited to:-a need for an indwelling urinary catheter due to retention. -intervention to see MD orders for size. Review of Resident #93's Treatment Administration Record (TAR), for January 2026 and February 2026 indicated that the urinary catheter was changed by Nursing staff on the following dates:-1/25/26.-2/25/26. Review of Resident #93's Nursing Progress notes dated 2/21/26, indicated but was not limited to:-urinary catheter was replaced secondary to leaking. -urinary catheter was placed with size 16 Fr with 10 ml balloon. Further review of Resident #93's clinical records failed to indicate a Physician's order for a 16 Fr/ 10 mL urinary catheter. On 3/17/26 at 7:33 A.M., the surveyor and Nurse #4 observed that Resident #93 's urinary catheter size was 16 Fr and 10 mL balloon. On 3/17/26 at 7:37 A.M., the surveyor and Nurse #4 reviewed Resident #93's active Physician orders which indicated the Resident's urinary catheter size was 14Fr with 10 mL balloon. During an interview at the time, Nurse #4 said the size of Resident #93's urinary catheter did not match the Physician orders, and it should match. Nurse #4 said the risk for Resident #93 having an inaccurate urinary catheter size inserted could be increased infection due to leakage of urine. Nurse #4 also said the Nurses should follow the Physician 's orders for urinary catheter size during insertion. Nurse #4 further said Resident #93's urinary catheter was changed monthly in the facility by the Nurses on the 25th of every month. During an interview on 3/17/26 at 10:00 A.M., the Director of Nursing (DON) said the risk of having the wrong size urinary catheter inserted for Resident #93 was trauma and risk of increased infection. During an interview on 3/17/26 at 2:00 P.M., Nurse Consultant #1 said that Nurses should follow the Physician order for Resident #93 when inserting a foley catheter as ordered. During an interview on 3/18/26 at 9:05 A.M., the Infection Preventionist (IP) said she recently had competency training with the Nurses on the process for inserting urinary catheters. The IP said the Nurses should have followed the Physician orders for urinary catheter size when inserting the urinary catheter for Resident #93. 2. Review of the CDC guidelines for the Prevention of Catheter Associate Urinary Tract Infections (CAUTI). Retrieved from: https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, revised 3/25/24, indicated the following: - If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. - Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #51 was admitted to the facility in May 2025 with Acute Kidney Failure and Urinary Retention. Review Resident #51's most recent MDS assessment dated [DATE] indicated that: -The Resident had a severe cognitive impairment as evidenced by a BIMS score of 5 out of a total possible score of 15. -Resident #51 had an indwelling urinary catheter. -Resident #51 required substantial maximal assistance (the helper does 50% or more of the effort to complete the activity) for toileting and personal hygiene. Review of Resident #51's March 2026 Physician's orders included but was not limited to: -Urinary Catheter size: 16 French (5.3 milliliters [ml])/10 ml balloon to drainage bag, every day, start date 3/27/25. -Catheter care every shift, every shift for catheter, with a start date of 3/27/25. -Check catheter every shift for patency. Change as needed for blockage/removal with a start date of 3/27/25. -Document urine output from catheter every shift, with a start date of 3/27/25. -Foley catheter care twice daily and as needed, with a start date of 3/27/25. Review of Resident #51's person-centered Indwelling Urinary Catheter Care Plan, effective date 3/20/25 included but was not limited to: >Goal: Foley catheter will remain patent >Interventions: Maintain enhanced barrier precautions every shift (an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms) On 3/17/26 at 8:02 A.M., the surveyor observed Resident #51 lying in bed with his/her urinary catheter drainage tubing hanging freely over the edge of the bed and the drainage bag system tangled between the Resident's comforter and resting flat on a floor mat on the floor next to his/her bed. During an observation and interview at the same time, Nurse #1 said that the catheter drainage bag should not be on the floor to prevent the risk of infection to the Resident. On 3/18/26 at 7:15 A.M., the surveyor observed Resident #51 lying in bed with his/her urinary catheter drainage tubing hanging freely over the edge of the bed and the drainage bag system resting on the floor next to his/her bed. During an observation and interview at the same time, Unit Manager (UM) #1 said that the catheter drainage bag resting on the floor was an infection control concern, that it should not be on the floor but in a clean basin to prevent infection. During an interview on 3/18/26 at 9:15 A.M., the Infection Control Nurse said that Certified Nursing Assistants (CNAs) and Nurses were educated on the appropriate care of urinary catheters and that urinary catheter drainage bags should not be on the floor to prevent the spread of infections.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#93), out of a total sample of 30 residents. Specifically, for Resident #93, the facility failed to ensure that Enhanced Barrier Precautions (EBPs - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), were appropriately utilized when providing high contact care for the Resident, to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility. Findings include:Review of the facility's policy titled Enhanced Barrier Precautions, dated 4/6/2023, included but was not limited to:*Enhanced Barrier Precautions expand the use of personal protective equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. >The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation of PPE use in nursing homes to prevent spread of MDROs.>Examples of high contact resident care activities requiring gown and gloves use for enhanced barrier precautions include:>dressing>bathing/showering>transferring>providing hygiene>changing linens>changing briefs or assisting with toileting>device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilatorReview of the facility's policy titled Specific Personal Protective Equipment, undated, included but was not limited to:>Hand hygiene is recognized as the most important way to prevent the transmission of infection. All employees are to wash hands after every unprotected contact with blood or other potentially infectious materials and after removing gloves.>Protective clothing, such as aprons, gown, or similar garments, will be provided by the employer to protect employee's clothing as needed. Resident #93 was admitted to the facility in December 2025 with diagnoses including Retention of Urine and Essential Primary Hypertension.Review of Resident #93's Person-Centered Care Plan, initiated 1/28/26, indicated interventions for the following: -on Enhanced Barrier Precautions related to urinary catheter.-PPE for high contact care.-wash hands when entering and exiting room.-Enhanced Barrier precaution sign.Review of the Minimum Data Set (MDS) Assessment, dated 2/13/26, indicated Resident #93:-had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2 out of a possible 15 points.-had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body).Review of Resident #93's March 2026 Physician's Orders indicated: -Maintain Enhanced Barrier Precautions (EBP) every shift related to urinary catheter every shift; Days 7:00 A.M.-3:00 P.M., Evenings 3:00 P.M.-11:00 P.M., Nights 11:00 P.M.-7:00 A.M., initiated 1/28/26.On 3/13/26 at 7:19 A.M., the surveyor observed a sign posted outside of Resident #93's door. The signage indicated:-STOP ENHANCED BARRIER PRECAUTIONS >EVERYONE MUST: -clean their hands including before entering and when leaving the room. > providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: -dressing -bathing/showering -transferring -providing hygiene -changing brief or assisting with toileting -device care or use: central line, urinary catheter, feeding tube, tracheostomy On 3/13/26 at 7:59 A.M., the surveyor observed Certified Nurse Aide (CNA) #3 standing next to Resident #93's bed while providing activities of daily living care (ADLs- personal care activities including but not limited to, eating, grooming, and personal hygiene) to the Resident. CNA #3 was wearing gloves but did not have a gown on during the observation. Resident #93's urinary catheter was draining clear yellow urine, and the catheter tubing was secured on the Resident's left thigh. During an interview on 3/13/26 at 8:12 A.M., CNA #3 said he forgot to wear a gown when providing ADL care for Resident #93. CNA #3 also said it was important for him to wear a gown when providing ADL care for Resident #93 because the Resident has a urinary catheter and that he should wear a gown to protect Resident #93 from infections and to also prevent the potential of transferring germs to other residents. On 3/17/26 at 7:26 A.M., CNA #4 entered Resident #93's room with no hand hygiene observed by the surveyor and closed the door behind him.On 3/17/26 at 7:33 A.M., Nurse #4 and the surveyor together entered Resident #93's room. CNA #4 was observed standing next to the Resident's bed while providing ADL care. CNA #4 was wearing gloves but did not have a gown. During an interview on 3/17/26 at 7:37 A.M., Nurse #4 said that CNA #4 should have worn a gown when caring for Resident #93 because the Resident has a urinary catheter and was on EBP. Nurse #4 said that staff caring for Resident #93 should wear a gown to prevent the transmission of infection to the Resident and to other residents. During an interview on 3/17/26 at 7:41 A.M., CNA #4 said that he should have washed his hands prior to entering the Resident 's room, but he did not. He also said that he should have worn a gown when providing ADL care for Resident #93 because the Resident had a urinary catheter to prevent the transmission of infection from him to the Resident and vice versa, but he did not. CNA #4 said that the sign posted outside the Resident's door informed him of what to do prior to entering the Resident's room, and that he did not follow the sign. During an interview on 3/17/26 at 10:00 A.M., the Director of Nursing (DON) said staff not wearing the required PPE (gown and gloves) when caring for Resident #93 on EBP risked the transference of pathogens from the staff's clothing and hands to the Resident who has an indwelling device as well as to other residents.

Based on observations, interviews, and record review, the facility failed to make prompt efforts to adequately resolve grievances for two Residents (#82 and #7) out of a total sample of 30 residents.Specifically, the facility failed to:1. For Resident #82, -identify steps taken to investigate the Resident's grievance with respect to care not being provided.-summarize pertinent findings or conclusions regarding the Resident's concern with respect to care not being provided.-state whether the Resident's grievance with respect to care not being provided was confirmed or not confirmed.2. For Resident #7, the facility failed to adequately resolve the Resident's grievance for missing dentures in a timely manner when the Resident's lower dentures were missing. Findings include: Review of the facility's Grievance and Complaint Policy, dated October 1998 and revised 7/31/12, indicated the facility has a process that provides residents and families with a means to assure complaints or grievances regarding care or lack of care, lost possessions, . will be heard, investigated promptly, and resolved whenever possible. 1.Resident #82 was admitted to the facility in August 2014 with diagnoses including Multiple Sclerosis (MS), paraplegia, chronic pain, and anxiety disorder. Review of Resident #82's active Care Plan, last reviewed and revised 1/2/26, indicated: -has complaint forms at his/her bedside and has been encouraged to fill them out for care complaints (8/27/15). -Resident is bedbound and uses a trapeze (medical overhead bar designed to help individuals with limited mobility shift positions in bed [1/30/24]). -uses a bed pan and is able to position him/herself on the bed pan (1/30/24). -requires assist with toilet hygiene; dependent at times (1/30/24). -Resident will call for assist with the bed pan (7/5/24). Review of the Minimum Data Set (MDS) Assessment, dated 12/19/25, indicated Resident #82: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment of 15 out of 15 total possible points. -bilateral lower extremity range of motion (ROM) was impaired. -was dependent for toilet hygiene. -required partial/moderate assistance to roll in bed. During an interview on 3/13/26 at 12:00 P.M., Resident #82 said he/she had experienced a problem obtaining assistance from the staff on the overnight (11:00 P.M. through 7:00 A.M.) shift, during the early morning hours of 3/10/26, to place and remove the bed pan. Resident #82 said he/she can place the bed pan under him/herself but that the contents of the bed pan would sometimes spill when he/she did not place it correctly. Resident #82 said the bed pan is positioned better when staff position it for him/her. Resident #82 said he/she called for assistance (on 3/10/26) and waited 30 minutes before positioning the bed pan under his/her body him/herself. The Resident said when he/she was done using the bed pan, he/she waited greater than 30 minutes for staff to respond to his/her request to have the bed pan removed and when staff did not respond, he/she called 911. Resident #82 said he/she felt marginalized. Resident #82 said he/she is familiar with the grievance process at the facility and knows how to file a grievance, and that he/she did not fill out a grievance form for this incident because staff at the facility are never able to substantiate his/her concerns. Review of a Grievance Form, dated 3/13/26, that was filled out and completed by the Administrator, indicated: -Resident #82 stated he/she was on the bed pan for an extended period of time leading him/her to call 911. -The department or person involved was Nrsg [nursing]. -Time of day and location (if applicable) was not filled in [blank]. -The Resident wanted an apology to resolve the problem. -The response of the Social Worker/Administrator/Department head portion of the form was not filled in. -Nsg apologized and the problem was resolved. During an interview on 3/17/26 at 8:54 A.M., the Administrator said she completed a grievance form for Resident #82 on 3/13/26 because Unit Manager (UM) #2 told her that the Resident told the surveyor he/she had been left on the bed pan for an extended period of time. The Administrator said UM #2 told her the Resident wanted an apology and that she (the Administrator) thought UM #2 apologized to the Resident. The Administrator said she did not speak with Resident #82 relative to the Resident's concern and that she did not conduct an investigation regarding the Resident's concern for being left on the bed pan for an extended period of time. During an interview on 3/18/26 at 7:09 A.M., UM #2 said she was aware Resident #82 called 911 during the early morning hours on 3/10/26 relative to personal care concerns and that she discussed this with the Administrator. UM #2 said she was not aware of the Resident wanting an apology to resolve his/her concern and that UM #2 did not provide an apology to the Resident. 2. Resident #7 was admitted to the facility in November 2024 with diagnoses including other sequalae of cerebral infarction, Type Two Diabetes, hemiplegia and hemiparesis. Review of Resident #7's facility clothing list dated 11/16/24 and updated on 11/21/24 indicated that the Resident had both upper and lower dentures. Review of Resident #7's current Physician's orders indicated: -an order for upper and lower dentures, please place on every morning and off at hour of sleep, 8 A.M. and 8 P.M., start date 11/22/24. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of a possible score of 15. -has unclear speech and was rarely/never understood. -has experienced weight loss and was not on a physician weight loss regimen. -was dependent on staff for eating and all other activities of daily living (ADLs). -was receiving a therapeutic and mechanically altered diet. Review of Resident #7's clinical record indicated a Nursing Progress Note dated 11/26/25, which indicated that the Resident's bottom dentures were missing and that the Nursing Supervisor and Resident Representative had been notified. Review of the facility's 2025 Grievance Log indicated that a grievance form was completed on behalf Resident #7 for his/her missing dentures on 11/27/25, and the grievance was resolved by the Administrator on 12/2/25. Review of Resident #7's Treatment Administration Record (TAR) from11/28/25 through March 2026 indicated that the Resident had only their upper denture placed in their mouth by staff daily in the mornings and upper denture removed in the evenings. Further review of Resident #7's clinical record did not indicate that a grievance had been re-filed or that any follow-up had occurred for the Resident's missing lower dentures until it was brought to the facility's attention by the surveyor on 3/16/26. During an interview on 3/17/26 at 10:14 A.M., Unit Manager (UM) #1 said that she did not realize that Resident #7's lower dentures were still missing and that she assumed when her staff informed her that the dentures had been returned, that they were both the upper and lower dentures. UM #1 said she did not inspect the dentures herself and that the documentation had been inaccurate relative to the resolution of the grievance. During an interview on 3/17/26 at 10:53 A.M., the Administrator said that she had resolved Resident #7's grievance and did not specifically ask about the upper and lower dentures. The Administrator also said that she was unaware that the lower dentures remained missing and that another grievance should have been filed once the facility had identified that the lower denture remained missing and had not been.

Based on interviews, and record review, the facility failed to implement the person-centered care plan relative to transfers for one Resident (#70) out of a total sample of 30 residents. Specifically, for Resident #70, the facility failed to ensure that two staff assists were utilized per his/her plan of care when transferring the Resident with the use of a mechanical lift, putting the Resident at risk for injury or falls. Findings include: Review of the facility policy titled, Care Planning, undated with revision date 11/28/18, indicated the following: -Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. -The care plan is based on the resident's comprehensive assessment and developed by a Care Planning/Interdisciplinary team . Review of the facility policy titled Safe Lifting and Movement, dated 3/30/11 with revision date 8/1/18, indicated the following: -This policy describes ways to ensure that employees use safe methods for lifting and moving elders in the nursing facility in order to prevent injury to both employees and elders. -All elders/residents who have any degree of dependency for transfers or movement will be assessed to determine the extent of assistance required and the safest method of assistance including the type of mechanical lifting device that should be used. The recommendation for transfers will be based on the safest technique or device for both caregiver and the elder. >new information and changes will be documented on the elder's/resident's individualized plan of care. >All transfers with lifts should be based on the care plan including level of assistance and number of staff. >Use mechanical lifting devices and other approved lifting or moving aids in accordance with instructions and training. Resident #70 was admitted to the facility in August 2020 with diagnoses including other specified disorders of bone density and structure, osteopenia spine/right upper extremity, dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) Assessment, dated 1/23/26, indicated Resident #70: -rarely/never understood and the Resident was rarely/never understood by others. -should not have a Brief Interview for Mental Status (BIMS) conducted because the Resident was rarely/never understood. -A staff assessment for mental status was conducted which indicated long-term and short-term memory problems as well as severely impaired decision-making regarding tasks of daily life. -was dependent on others for personal hygiene. -was non-ambulatory. -was dependent on others to transfer to and from a chair/bed to chair. Review of Resident #70's person-centered Activities of Daily Living (ADL) Care Plan, dated 2/22/26 included but was not limited to: >Chair to bed to chair transfer - uses Hoyer (specific type on mechanical lift), two (2) assists. Dependent. Review of Resident #70's Profile Care Plan Approaches (Care Kardex) included the following: -Chair to bed to chair transfer; uses Hoyer two (2) assists, Dependent, effective 2/22/26. Review of the medical record indicated that Resident #70 had been transferred to the hospital on 3/6/26 for findings consistent with a fracture of his/her right femur. During an interview on 3/16/26 at 1:11 P.M., the Director of Nursing (DON) said an internal investigation was started immediately relative to the Resident's fractured right femur on 3/6/26. The surveyor and the DON reviewed the investigation records, and it was identified that two Certified Nurse Aides (CNA) #6 and #7 had not transferred Resident #70 in accordance with the Resident's plan of care prior to the injury being identified. The DON said that both CNA #6 and CNA #7 were placed on leave during the investigation then allowed to return to work after education and return demonstration competency. The DON said that CNA #6 and CNA #7 did not follow the Resident's care plan relative to transfers. During an interview 3/17/26 at 1:47 P.M., CNA #6 said he assisted Resident #70 back to bed on 3/3/26 at approximately 7:00 P.M. without using a mechanical lift or another staff member to assist with the transfer. CNA #6 said he knew he should have used the mechanical lift because he had taken care of Resident #70 many times and knows he should follow the Resident's Profile Care Plan. CNA #6 said the Resident was seated in a recliner chair and he reached to hold the back of the Resident's pants, lifted and turned the Resident to the left towards the bed and then sat the Resident on the bed. CNA #6 said he then scooped the Resident with his two arms, one behind the Resident thighs and one behind the Resident's shoulders. CNA #6 said once the Resident was lying in bed, he provided the Resident with incontinence care by rolling the Resident side to side for cleaning without the Resident having any signs of discomfort. CNA #6 said that if the Resident was having pain he would have noticed because the Resident would have moaned louder but the Resident did not. CNA #6 said not using the mechanical lift to transfer Resident #70 put the Resident at risk of getting hurt. During an interview on 3/17/26 at 3:28 P.M., CNA #7 said she had worked with Resident #70 on many occasions and was familiar with the Resident's care needs. CNA #7 said she transferred Resident #70 out of bed and into a recliner chair on 3/2/26, between 5:00 A.M. and 6:00 A.M. after getting the Resident washed and dressed for the day, using a mechanical lift without assistance of another staff member. CNA #7 said she was aware that mechanical lift transfers should be done with two staff members. CNA #7 said the Resident did not exhibit any signs of pain prior to, during or after the transfer. CNA #7 said that by transferring the Resident with the mechanical lift by herself the risk was that the Resident could get hurt.

Based on interviews, and record review, the facility failed to ensure that three Residents (#3, #11, and #15), out of a total sample of 30 residents was provided the right to participate in their care plan process.Specifically, for Residents (#3, #11, and #15), the facility failed to ensure that each Resident was invited to participate in their individual care plan meeting process and the facility also failed to provide rationale as to why the participation of the three Residents was determined not practicable for the development of the care plan.Findings include:Review of the facility policy titled Resident's Rights, dated 11/28/17 and revised 9/5/25, included the following:-The Federal and State laws guarantee basic rights to all residents of this facility:>be informed of, and participate in, his/her care planning and treatment. Review of the facility Patient and Resident Guide, dated 1/4/22, included the following:>We encourage you to participate in the development of your plan of care with our interdisciplinary team. Together we will develop goals based on your needs .>Regular care plan meetings will take place to which you and your family members will be invited for reviewing process and adjusting goals. Review of the facility policy titled Care Planning, revised 11/28/18, included the following:-Our facility's Care Planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.>The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 1.Resident #3 was admitted to the facility in July 2025 with diagnoses including anxiety, Dementia, Heart Failure, and Diabetes. Review of the Minimum Data Set (MDS) Assessment, dated 2/20/26 indicated Resident #3: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 points out of a total possible 15 points. -was able to make him/herself understood and was able to understand others. Review of the Resident's medical record indicated:-Resident #3 had an invoked Health Care Proxy (HCP- person that is delegated to make informed health care decisions for another person when they are unable to do so themselves), effective 7/29/25.Further review of the Resident's medical record indicated that Care Plan meetings were held for Resident #3 on: 10/28/25, 2/3/26, and 3/4/26 without any evidence that the Resident was invited to or present at the care plan meetings. The medical record also did not include any documentation that the participation of the Resident was determined not practicable for the development of the Resident's care plan. During an interview on 3/12/26 at 10:18 A.M., Resident #3 said he/she was unable to recall being invited to attend his/her care plan meetings and would like to go if he/she could. 2.Resident #11 was admitted to the facility in November 2023 with diagnoses including Parkinsons Disease, Dementia, and weakness. Review of the MDS Assessment, dated 2/20/26 indicated Resident #11: -was cognitively intact as evidenced by a BIMS score of 15 points out of a total possible 15 points. -was usually able to make themself understood and was usually able to understand others. Review of the Resident's medical record indicated:-Resident #11 had an invoked HCP, effective 8/26/24.Further review of the Resident's medical record indicated that the Resident's Care Plan meetings were held on: 1/4/25, 4/15/25, 7/22/25, 10/14/25, and 1/13/26 without evidence that the Resident was invited or present at the care plan meetings, or included documentation that the participation of the Resident was determined not practicable for the development of the Resident's care plan. During an interview on 3/12/26 at 10:06 A.M., Resident #11 said he/she knew nothing about care plan meetings and was unable to recall being invited to any care plan meetings. Resident #11 said he/she would probably go if the staff were discussing his/her care. 3. Resident #15 was admitted to the facility in July 2025 with diagnoses including anxiety, weakness, and retention of urine. Review of the MDS Assessment, dated 2/16/26 indicated Resident #15: -was cognitively intact as evidenced by a BIMS score of 14 points out of a total possible 15 points. -was able to make him/herself understood and was able to understand others. Review of the Resident's medical record indicated:-Resident #15 had an invoked HCP, effective 12/15/25.Further review of the Resident's medical record indicated that the Resident's Care Plan meetings were held on: 2/2/26 and 10/28/25 without evidence that the Resident was invited to or present at the care plan meetings. The medical record did not include documentation that the participation of the Resident was determined not practicable for the development of the Resident's care plan. During an interview on 3/12/26 at 8:59 A.M., Resident #15 said he/she was unaware of what a care plan meeting was and was unable to recall being invited to any care plan meetings. During an interview on 3/16/26 at 12:17 P.M., the MDS Nurse said the facility did not have a policy on Care Plan Meetings. The MDS Nurse said the Residents with an invoked HCP did not get invited to their own care plan meetings because the Resident is not considered their own person. The MDS Nurse said it was the responsibility of the HCP to invite the Resident to his/her care plan meetings when the invitations were sent out to the HCP's from the facility staff.During an interview on 3/16/26 at 1:07 P.M., the MDS Nurse said Resident's (#3, #11 and #15) should have been invited to their care plan meetings by the facility staff so the Residents could be made aware of their plan of care and provided opportunity for self-advocacy if they had concerns with the delivery of care and could discuss desired changes. During an interview on 3/16/26 at 2:22 P.M., the Administrator said that the Residents (#3, #11, and #15) should have been invited to their care plan meetings so that they (the Residents) can have a voice in their delivery of care. The Administrator said that if the team thought the Residents should not attend the meetings a reason should be included in the care plan notes.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required set up assistance with meals and beverages, the Facility failed to ensure his/her environment was free from accidents resulting in serious injury, when on 1/16/26, a staff member served Resident #1 a hot cup of coffee that had been reheated in the microwave, however the staff member did not check the temperature of the coffee, in accordance with facility policy, before serving it to him/her. The hot coffee was spilled onto Resident #1, and he/she sustained second degree burns (partial thickness, involves both the first and second layer of skin and appears red, blistered, and maybe swollen or painful) to his/her bilateral upper thighs, which required daily treatment and monitoring by nursing.Findings include:Review of the Facility's protocol titled Microwave Safety for Hot Liquids dated 05/08/2011, indicated any liquids heated in the microwave will have temperature checked and the acceptable serving temperature is between 135-155 degrees Fahrenheit.Review of the American Burn Association Scald Injury Prevention Guide, dated 2017, indicated older adults are in a higher risk for burns and injuries. Older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize the hot liquid is too hot until the injury has occurred.Resident #1 was admitted to the Facility in August 2025, diagnoses included lung cancer, congestive heart failure and chronic respiratory failure. Resident #1 was admitted to hospice services 01/05/26.Review of Resident #1's Annual Minimum Data Set (MDS) assessment, dated 01/20/26, indicated he/she required set up for eating.Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL's), indicated he/she required set up assistance with meals.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/23/26, indicated Resident #1 was sitting in a chair in his/her room at the bedside, had been delivered his/her supper tray on the bedside tray table along with a cup of coffee that CNA #1 had reheated in the microwave, Resident #1 refused the supper tray but requested the coffee. The Report indicated while CNA #1 was removing the supper tray and placing the cup of coffee on the tray table, CNA #1 accidentally bumped the tray table and the contents of the coffee cup spilled onto Resident #1's upper thighs.Review of the Facility's Internal Investigation Report, dated 01/23/26, indicated that the skin on Resident #1's upper thighs were red and blanchable. The Report indicated the Nurse and the Nursing Supervisor assessed Resident #1, saw redness and initiated treatment of cool compresses to both thighs.During an observation on Resident #1's Unit 2/26/26, there were signs clearly posted with the microwave that included reheating instructions along with a thermometer with the microwave, readily accessible for staff use.During an interview on 2/26/26 at 11:35 A.M., Resident #1 said CNA #1 bumped the tray table and the hot coffee spilled onto his/her upper legs and he/she sustained burns and required treatment. Review of Certified Nurse Aide (CNA) #1's written Witness Statement (included in the Investigation Report), dated 01/16/26, indicated she went to hand Resident #1 a cup of hot coffee (that she had reheated in the microwave) and it spilled on his/her upper thighs.CNA #1's Statement did not indicate whether or not she checked the temperature of the coffee with a thermometer, (per facility policy) after she reheated the coffee prior to giving it to the resident.During a telephone interview on 02/26/26 at 2:53 P.M., Certified Nurse Aide (CNA) # 1 said that on 01/16/26, she went into Resident #1's room to deliver his/her supper tray and said she had reheated his/her cup of coffee in the microwave before bringing him/her the tray, because Resident #1 liked his/her coffee hot. CNA #1 said Resident #1 declined his/her supper tray and wanted just the coffee. CNA #1 said when she was removing the supper tray and placing the cup of coffee on the tray table, she accidentally bumped the tray table and the hot coffee spilled onto Resident #1's upper thighs. CNA #1 said she did not use the thermometer to check the temperature after she reheated the coffee.During a telephone interview on 3/02/26 at 2:22 P.M., Nurse #1 said that on 1/16/26 CNA #1 notified her that she bumped into Resident #1's tray table and that hot coffee spilled on Resident #1's upper thighs. Nurse #1 said she assessed Resident #1 and observed red and blanchable skin on his/her upper thighs, applied cool compresses and notified the physician. Nurse #1 said there are signs posted at all microwaves along with thermometers, to remind staff of the facility's Microwave reheating policy.Review of Resident #1's Wound Physician Evaluation, dated 01/22/26, indicated he/she had a cluster of second-degree burns measuring 5.8 centimeters (cm) length x 9.0 cm width on his/her right thigh and a first degree burn measuring 9.0 cm length x 17 cm width x 0.1 depth on his/her right thigh. A second degree burn measuring 2.2 cm x 1.3 cm was located on Resident #1's left thigh. The Wound Evaluation indicated that the primary treatment, as ordered by Physician, was to apply Silver Sulfadiazine cream once daily and as needed liberally to the three burn sites on Resident #1's right and left thighs until healed.During an interview on 2/26/26, at 11:45 A.M., the Wound Care Physician Assistant said Resident #1's burn wounds had healed by the third week of treatment with the Silver Sulfadiazine cream.During an interview on 02/26/26 at 11:59 A. M., the Food Service Director (FSD) said that the temperature guidelines for reheating food and beverages are posted in the kitchenettes on each unit near the microwave and thermometers are kept there as well. The FSD said it has always been the practice of the facility for staff to follow the policy and use thermometers to ensure the food/beverage temperature is reheated to no more than 155 degrees.During an interview on 02/26/26 at 11:49 A.M., the Assistant Director of Nurses (ADON) said CNA #1 reheated Resident #1's coffee in the microwave and did not follow facility policy when she did not use the thermometer to check the temperature after she reheated it. The ADON said it is the Facility's expectations that the CNA's and Nurses follow the reheating policy and check the temperature of beverages with the thermometer before serving it to a resident. The ADON said the policy on Microwave safety is reviewed with all new employees during orientation.During an interview on 02/26/26 at 12:05 P.M., the Director of Nurses (DON) said she interviewed CNA #1, and that she said she had reheated Resident #1's coffee, and that she did not take the temperature with a thermometer after reheating it. The DON said when CNA #1 had not followed facility policy when she did not use a thermometer to check the temperature of the coffee after reheating it in the microwave. The DON said it is the Facility's expectation that the CNA's and Nurses follow reheating guidelines and check the temperature of reheated food and beverage items with the thermometer, before being served to a resident. The DON said the Microwave Safety for Hot Liquids Policy is reviewed during staff orientation.On 02/26/26, the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; with an effective date of 1/23/26, as follows:A. On 01/16/26, Resident #1 was immediately assessed by nursing after the incident. The Physician was notified with orders to use a cover on beverage cups, offer clothing protecters at all meals and monitor burn areas. B. Wound Care Physician consultation was also ordered, and further treatment began on Resident #1 on 1/20/26.C. On 1/29/26, the Silvadene cream was discontinued to the second degree burn on Resident #1's left thigh and the first degree burn on his/her right thigh with treatment continuing for one more week to the second degree burn on his/her right thigh.D. On 01/20/26, a Facility wide audit was completed by the Director of Nursing and the Assistant Director of Nursing to ensure all kitchenettes had the Facility Reheating Guidelines clearly posted and thermometers were available. E. On 1/20/26, an Ad Hoc QAPI meeting was held to develop a plan to address the incident on 1/16/26, assess educational needs with re-education implemented for all nursing staff on the microwave safety policy.F. As of 1/23/26, the Director of Nursing and/or his/her designee had completed the Education of all nursing staff on the facility's reheating meals/beverages policy, and temperature checks.G. Starting effective 01/20/26- the Director of Nursing and/or his/her designee began conducting weekly audits on staff compliance and on staff knowledge of re-education, with reheating food/beverages per facility policy. The audits will continue to be completed weekly until substantial compliance is achieved. The results of the audits will be brought to monthly QAPI meeting.H. The concern area will continue to be reviewed during Quality Assurance Performance Improvement (QAPI) meeting, the Committee will review and discuss the burn incident as well as the results of the Audits completed thus far by the Director of Nursing and/or Designee.I. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observation and interview, the facility failed to accurately and safely provide pharmaceutical services pertaining to the administration of routine medications for one Resident (#40), out of a total of five resident medication administration observations. Specifically, the facility failed to ensure that Resident #40's Furosemide (medication used to treat high blood pressure, heart failure and build-up of fluid in the body) medication: -was dispensed from the pharmacy. -was administered in the correct dose to the Resident when the facility staff used a higher dose medication tablet and broke the higher dose tablet to obtain the ordered dose. Findings include: Review of the facility's policy titled, General Guidelines for Medication Administration, revised August 2020, indicated: -At a minimum, the 5 Rights - right resident, right drug, right dose, right route and the right time should be applied to all medication administration and reviewed at three steps in the process of preparation. -Select the medication, check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the five rights. -Prepare the dose by removing the dose from the container and verifying it against the label and the MAR by reviewing the five rights. -Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. -Splitting of tablets should be avoided and every attempt should be made to obtain an alternate dosage form, medication, or dosing schedule to avoid splitting. -Since unscored tablets may not be accurately broken, their use is discouraged. -Medications supplied for one resident are never administered to another resident. Resident #40 was admitted to the facility in August 2024 with diagnoses of Heart Failure and Hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #40: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #40's December 2024 Physician's orders indicated: -9:00 A.M., Aspirin 81 mg, 1 tablet once a day, started 8/28/24. -8:00 A.M., D- Mannose 2000 mg, 4 tablets once a day, started 11/13/24. -8:00 A.M., Multivitamin tablet, 1 tablet, once a day, started 7/22/24. -8:00 A.M., Vitamin D3, 25 mg, 2 tablets once a day, started 7/22/24. -8:00 A.M., Folate 1 mg, 1 tablet once a day, started 10/23/24. -8:00 A.M., Eliquis 5 mg tablet, 1 tablet twice a day, started 7/22/24. -8:00 A.M., Thera Cran 1 capsule, once a day, started 11/13/24. -8:00 A.M., Furosemide 10 mg tablet, 1 tablet once a day, started 11/20/24. -9:00 A.M., Spironolactone 25 mg tablet, 1 tablet once a day, started 9/4/24. On 12/4/24 at 9:56 A.M., the surveyor observed Nurse #1 prepare and administer the following medications to Resident #40: -Aspirin 81 milligrams (mg), 1 tablet -D-Mannose 2000 mg (4 tablets) -Multivitamins with Minerals, 1 tablet -Vitamin D3 25 microgram (mcg) 2 tablets -Folic Acid 1 mg, 1 tablet -Eliquis 5 mg, 1 tablet -Thera Cran, 1 capsule -Spironolactone 25 mg, 1 tablet Nurse #1 handed the medications to Resident #40, and the Resident asked Nurse #1 where the Furosemide medication was. Nurse #1 said that she would have to locate a dose since the Furosemide medication had not been delivered from the pharmacy. During an interview on 12/4/24 at 10:14 A.M., Nurse #1 said the Furosemide medication was a new order from 11/20/24. Nurse #1 said she was unsure how the medication had been administered to Resident #40, because the Furosemide medication was not available in the medication cart for the Resident. During an interview on 12/4/24 at 10:31 A.M., the Director of Nursing (DON) said there was no indication the Furosemide medication had been removed from the facility Pyxis (automated medication dispensing system). The DON said that the Furosemide medication had not been delivered from the pharmacy since it was ordered on 11/20/24. During an interview on 12/4/24 at 10:38 A.M., Resident #40 said the facility staff would bring a Furosemide 20 mg tablet and break the medication tablet in his/her presence and then administer the Furosemide medication to him/her. During a follow-up interview on 12/4/24 at 10:39 A.M., Nurse #1 said she worked the previous day on 12/3/24, and borrowed the Furosemide 20 mg medication from another resident. Nurse #1 said she had broken the 20 mg tablet of Furosemide medication to administer 10 mg to Resident #40. During an interview on 12/4/24 at 11:03 A.M., the DON said the facility staff should not borrow medication from one resident to administer to another resident. The DON further said the facility staff should not break the Furosemide medication in half to administer to Resident #40, because the Resident could receive an inaccurate amount of the medication. During a follow-up interview on 12/5/24 at 9:32 A.M., the DON showed the surveyor the Resident's Medication Delivery Manifest which indicated that the 20 mg tabs of the Furosemide medication was delivered to the Resident on 12/5/24 at 3:03 A.M. The DON said the order for the 10 mg Furosemide medication never got to the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure that a device utilized for one Resident (#38), was assessed when used as a physical restraint, for one applicable Resident who had nephrostomy tubes (tubes that drain urine from the kidneys into drainage bags), out of a total sample of 27 residents. Specifically, the facility failed to assess Resident #38 for the need of an abdominal binder (wide compression belt that encircles the abdomen) to cover Resident #38's nephrostomy sites to prevent him/her from pulling on the nephrostomy tubes. Findings include: Review of the facility's policy titled Physical Restraints, last revised 10/28/15, indicated: -it is the policy of this facility to use a physical restraint on a resident when alternatives have failed, and it is required by a medical symptom. Every effort will be made to use the least restrictive device with the goal of reducing or eliminating the restraint as soon as possible. -a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Physical restraints may include but are not limited to the following: siderails, clip belts, seat belts, Velcro belts, soft lap bars, waist restraints, cardiac/geri chair (specialized reclining mobility chair for older adults who need extra support and comfort), lap trays, wrist restraints. -When a resident demonstrates consistent medical symptoms with risk for injury, an assessment will be made and alternatives to restraint use will be discussed and tried, and the resident will be monitored by nursing. -if alternatives have failed and a resident remains at risk because of a specific medical system, an assessment will take place with the members of the team to discuss the least restrictive device that can be used for the least amount of time. Resident #38 was admitted to the facility in March 2024 with diagnoses including acute kidney failure (a sudden decline in the functioning of the kidneys which might be reversed), hydronephrosis (condition of increased urine in the kidneys that causes swelling) and Dementia. Review of Resident #38's current Physician's orders for December 2024 included: -May use abdominal binder to hold drain tubes in place as a safety precaution, three times a day: 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., 11:00 P.M. to 7:00 A.M., start date of 10/8/24. Review of Resident #38's Treatment Administration Record (TAR) from October 2024 to December 2024 indicated that the Resident utilized the abdominal binder on the following days: -daily from 10/8/24 to 10/31/24 -daily from 11/1/24 to 11/23/24, and 11/28/24 to 11/30/24 -daily from 12/1/24 to 12/4/24 Review of Resident #38's Activities of Daily Living (ADL) care plan last revised 10/17/24, indicated that the Resident required assistance of one person for both upper body and lower body dressing. Review of the Minimum Data Set (MDS) Assessment, dated 12/2/24, indicated Resident #38: -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. -required substantial/maximal assistance (helper does more than half the effort) for both upper body and lower body dressing. Review of Resident #38's clinical record did not provide any documented evidence of assessment of the abdominal binder restraint until 12/4/24, when the surveyor brought it to the facility's attention. On 12/4/24 at 8:57 A.M., the surveyor observed Nurse #2 attempt to fasten the abdominal binder around the Resident's abdomen. Resident #38 was observed with ace bandages wrapped around his/her abdomen and the nephrostomy bags were loose and had fallen on the Resident's mattress. Resident #38 was observed to be unsteady on his/her feet while attempting to use the rolling walker to steady him/herself. The surveyor then observed Nurse #2 request additional assistance from the Certified Nurses Aide (CNA) to place the abdominal binder on safely and successfully. During an interview at the time, Nurse #2 said that Resident #38 removes his/her restraints frequently and the restraints have gotten lost in the past requiring the need for additional binders. During an interview on 12/4/24 at 2:50 P.M., Nurse #3 said that the abdominal binder is used to prevent Resident #38 from touching the nephrostomy entry sites as he/she has dislodged the tubes in the past and required hospitalization . Nurse #3 also said that an assessment had not been completed for the use of the abdominal restraint, and an assessment should have been completed to determine if the Resident could remove it easily. During an interview on 12/5/24 at 9:10 A.M., the Director of Nursing (DON) said that there was never an assessment for the restraint when the abdominal binder was applied, but there should have been an assessment completed.

Based on interview and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post-Traumatic Stress Disorder (PTSD). Findings include: Review of the facility's policy for Trauma Informed Care, last revised 5/2020, indicated: -acknowledging that trauma is widespread and can affect anyone, and understanding how it can manifest in behaviors and presentations. -care plan will be developed to communicate this history and how it impacts the individualized care of the resident. -all staff members receive comprehensive training in trauma informed care principles and practices. -regularly monitoring the effectiveness of trauma-informed practices and making necessary adjustments. Resident #36 was admitted to the facility in September 2023 with diagnoses including Bipolar Disorder and depressive episodes, Depression, and Anxiety. Review of the Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #36: -was cognitively intact as evidenced by a Brief interview of Mental Status (BIMS) score of 14 out of a possible score of 15. -exhibited verbal behavior symptoms directed at others (e.g., threatening others, screaming at others, cursing at others). -exhibited behaviors were worse when compared to the previous MDS assessment. Review of a Neurological Psychiatric Evaluation Note dated 10/30/24, for Resident #36 indicated: -long complex history of Depression, Anxiety, and panic. -content related to the death of his/her child, functional decline and difficulty with loss of independence. -somatic anxiety complaints with prominent escalation at night where he/she often had bad nightmares or awakened in panic with his/her heart racing. Review of Resident #36's clinical record indicated: -that the Resident had been prescribed Prazosin for nightmares caused by PTSD on 11/1/24. -that the Resident received a new diagnosis of PTSD on 11/15/24 due to experiencing nightmares. -no assessment had been completed relative to the Resident's history or triggers of PTSD after he/she had received the new diagnosis. -that the Resident was started on a new order for Buspar (anti-anxiety medication) on 11/14/24. -the Resident had the prescription for Buspar increased from 10 milligrams (mg) twice a day to 10 mg three times a day on 11/22/24. -that the Resident had been prescribed a PRN (as needed) dose of Buspar for Anxiety from 10/26/24 to 11/19/24. Review of Resident #36's Treatment Administration Record (TAR) for October 2024 and November 2024 indicated that the Resident has utilized the PRN Buspar medication in addition to the standing orders of the Buspar medication on the dates: -10/23/24 -10/25/24 -11/8/24 -11/13/24 -11/14/24 Review of the Resident's Comprehensive Care Plan indicated no documentation that a Trauma Informed Care Plan had been developed for Resident #36. During an interview on 12/4/24 at 3:31 P.M., Social Worker (SW) #1 said that a new Trauma assessment should have been completed once the facility had become aware of the PTSD diagnosis and it was not. SW #1 said that the new diagnosis of PTSD had not been communicated to her. SW #1 also said that a Trauma Informed Care Plan should have been developed with interventions for the Resident's diagnosis of PTSD and it was not. During an interview on 12/5/24 at 10:19 P.M., Nurse Practitioner (NP) #1 said that she had diagnosed Resident #36 with PTSD and prescribed him/her the Prazosin medication to help him/her sleep because he/she had been experiencing nightmares. During a follow-up interview on 12/5/24 at 10:09 A.M., SW #1 said that Resident #36's child had passed away because of an accident, which caused the Resident to have difficulty sleeping at night.

Based on record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility staff failed to request a Level II PASARR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings include: Resident #36 was admitted to the facility in September 2023 with diagnoses including Bipolar Disorder (chronic mood disorder characterized by manic, hypomanic and depressive episodes, Depression and Anxiety. Review of Resident #36's PASARR Level I screen dated 9/18/23, indicated that he/she had a history of a mood disorder and did not meet criteria for SMI, therefore a Level II PASARR evaluation was not needed. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident: -was cognitively intact as evidenced by a Brief interview of Mental Status (BIMS) score of 14 out of a possible score of 15. -had exhibited verbal behavior symptoms directed at others (e.g., threatening others, screaming at others, cursing at others). -the exhibited behaviors were worse when compared to the previous MDS assessment. Review of Resident #36's Psychosocial/Behavioral Care Plan last revised 9/27/24, indicated that the Resident needed monitoring and support for increased Anxiety and depressive symptoms. Review of Resident #36's clinical record indicated: -a Neurological Psychiatric Evaluation note dated 10/30/24, endorsing the Resident's long complex history of Depression, Anxiety, and panic with content related to the death of their child, functional decline and difficulty with loss of independence. The Neurological Psychiatric Evaluation note also references the Resident's somatic anxiety complaints with prominent escalation at night where he/she will often have bad nightmares or wake in panic with his/her heart racing. -that the Resident had been prescribed Prazosin (a medication used to treat high blood pressure and nightmares caused by PTSD - [Post Traumatic Stress Disorder: a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety]) on 11/1/24. -that the Resident has started a new order for Buspar (anti-anxiety medication) on 11/14/24. -that he/she had received a new diagnosis of PTSD on 11/15/24 due to experiencing nightmares. -the Resident had his/her prescription for Buspar increased from 10 milligrams (mg) twice a day to 10 mg three times a day on 11/22/24. -that the Resident had been prescribed an as needed (PRN) dose of Buspar from 10/26/24 to 11/19/24 for Anxiety. Review of Resident #36's Treatment Administration Record (TAR) for October 2024 and November 2024 indicated that the Resident utilized the PRN Buspar medication in addition to the standing orders (three times daily) of the Buspar medication on: -10/23/24 at 1:48 A.M. -10/25/24 at 2:19 A.M. -11/8/24 at 7:32 A.M. -11/13/24 at 10:20 A.M. -11/14/24 at 11:13 A.M. Further review of the Resident's medical record failed to indicate that the Level I PASARR was updated and re-submitted for an additional Resident Review when new mental health diagnoses were identified on 11/15/24. During an interview on 12/4/24 at 2:21 P.M., Social Worker (SW) #1 said that the Level I screen should have been re-submitted when the Resident was diagnosed with PTSD, and it had not been. SW #1 also said that the facility did not have a PASARR policy. During an interview on 12/5/24 at 10:19 P.M., Nurse Practitioner (NP) #1 said that she had diagnosed Resident #36 with PTSD and prescribed him/her the Prazosin to help him/her sleep because he/she had been experiencing nightmares.

Based on record review, and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted within the required timeframe after the completion date for one Resident (#46), out of one applicable resident, out of a total sample of 27 residents. Specifically, for Resident #46, a discharge MDS assessment was not transmitted within 14 days of the MDS assessment completion date as required. Findings include: Review of the Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated [DATE], indicated: -Non-comprehensive MDS assessments (OBRA- required non comprehensive MDS assessments include a select number of MDS items, but not completion of the CAA process [Care Area Assessments- items coded on the MDS to identify problems, needs or strengths] and care planning) must be transmitted to IQIES (Internet Quality Improvement and Evaluation- web based system that is used to transmit data to CMS) no later than 14 calendar days after the MDS completion date. Resident #46 was admitted to the facility in [DATE] with a diagnosis of unspecified Dementia. Review of Resident #46's clinical record indicated: -the Resident expired at the facility on [DATE], while under the care of Hospice services. -a non-comprehensive discharge MDS was completed for Resident #46 on [DATE]. -no evidence was found in the clinical record to indicate that the discharge MDS completed on [DATE] was ever transmitted to IQIES, as required. During an interview on [DATE] at 2:56 P.M., MDS Nurse #1 said the facility followed the RAI Manual to determine when to complete and submit MDS assessments. MDS Nurse #1 further said that Resident #46's discharge MDS assessment was completed on [DATE], and should have been transmitted within 14 days of completion to IQIES, but it had never been transmitted.

Based on observation, policy and record review and interview, the facility failed to adhere to infection control guidelines to prevent contamination and the spread of infection. Specifically, the facility staff failed to: 1.a) don (put on) gloves when handling medications. b) ensure a medical supply bag was placed in a clean area. c) ensure handwashing occurred after doffing (remove) gloves. d) ensure proper COVID-19 (an infectious respiratory illness) staff testing procedure. 2. to perform COVID-19 testing for staff and residents in a manner consistent with infection control standards and perform COVID-19 testing for staff timely as required. Findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 11/28/19, included, but not limited to: -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. a) On 9/27/23 at 7:25 A.M., during a medication administration pass, the surveyor observed Nurse #3 remove a Tums (an antacid) tablet from a container with bare hands and place it into a medication cup for administration. During an interview on 9/27/23 at 7:28 A.M., Nurse #3 said she did not wear gloves prior to removing the Tums from the container as required. b) On 9/27/23 at 8:30 A.M., during an observation on the [NAME] Unit, the surveyor observed a Laboratory Phlebotomist (a medical professional who is trained to perform blood draws) place a large gray insulated bag on the hallway carpeted floor in front of the nurses station. The Phlebotomist then walked away from the nurses station leaving the bag on the floor. Numerous staff members were observed to walk around the bag but did not move it to another location. During an interview on 9/27/23 at 8:35 A.M., Unit Manager (UM) #2 opened the bag and indicated that it contained clean supplies for blood specimen collection. She said the bag should not have been placed and left on the carpeted hallway floor. c) On 9/27/23 at 8:45 A.M., during a medication administration pass, the surveyor observed Nurse #5 exit a COVID-19 positive resident room. Nurse #5 doffed (removed) her Personal Protective Equipment (PPE-specialized clothing worn for protection against infectious materials) which was a gown, eye protection, gloves, mask and discarded them. She did not sanitize her hands after doffing her gloves and before donning new gloves. Nurse #5 donned (put on) a new mask and gloves and wiped down items she used in the resident's room which consisted of a stethoscope, blood pressure cuff, oxygen saturation fingertip monitor (a machine that determines blood oxygen saturation levels) and a thermometer. She placed these items in a clear plastic zippered bag. During an interview at the time, Nurse #5 said she did not sanitize her hands after doffing her gloves and before donning a new pair of gloves as required. On 9/28/23 at 9:15 A.M., during a medication administration pass, the surveyor observed Nurse #4 doffed his gloves after administering medications and did not sanitize or wash his hands. During an interview at the time, Nurse #4 said he did not sanitize his hands after doffing his gloves as required. 44337 d) Review of the Centers for Disease Control Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, updated July 2022, indicated the following: -For healthcare providers collecting specimens or working within six feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves and a gown. -For healthcare providers who are handling specimens, but are not directly involved in collection (e.g. handling self-collected specimens) and not working within six feet of a patient, follow standard precautions. Review of the facility policy titled Hand Hygiene effective 11/28/2019 indicated: -All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. -Hand Hygiene should be performed when hands are soiled or touching a contaminated surface, after coming in contact with body fluids, dressings, mucous membranes, and hands are not visibly soiled (i.e. handling sputum containers, .) On 9/27/23 at 8:09 A.M., the surveyor observed an overbed table in the documentation area of the [NAME] unit with a box of COVID-19 testing devices open on the table, and three used testing devices placed on the bare table. There were no hand hygiene supplies or personal protective equipment observed in the testing area. The surveyor then observed a staff member enter the testing area, retrieve a testing device from the box, open the device and self-swab both nares with ungloved hands. The staff member then closed the testing device and placed it on the bare table with the other used testing devices. The staff member then reached back into the testing device box and retrieved a small white capped bottle of liquid, and then left the testing area. During an interview with the Infection Control Nurse at the time, she said that testing days were Wednesdays and Saturdays. The Infection Control Nurse did not provide an answer when the surveyor asked whether staff should be performing hand hygiene while self-testing for COVID-19. 2. Review of the Massachusetts Department of Public Health (DPH) Guidance titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, Including Visitation Conditions, Communal Dining and Congregate Activities, dated May 10, 2023 indicated the following: -Once a new case (COVID-19) is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. Review of the COVID-19 surveillance documentation provided by the facility indicated the first COVID-19 positive staff member associated with the current outbreak was identified on 9/20/23 on the [NAME] Unit. Further review indicated the first COVID-19 positive resident associated with the current outbreak was identified on 9/23/23 on the [NAME] Unit. The facility did not identify COVID-19 positive residents or staff on any other nursing unit. Review of the timecard documentation provided by the facility indicated that Certified Nurses Assistant (CNA #2) worked the following shifts: -9/20/23 7:00 A.M. to 3:00 P.M. [NAME] Unit -9/21/23 7:00 A.M. to 3:00 P.M. [NAME] Unit -9/23/23 7:00 A.M. to 3:00 P.M. [NAME] Unit -9/24/23 7:00 A.M. to 3:00 P.M. [NAME] Unit -9/25/23 7:00 A.M. to 3:00 P.M. [NAME] Unit -9/26/23 7:00 A.M. to 3:00 P.M. [NAME] Unit Review of the COVID-19 testing log documentation indicated that CNA #2 was tested for COVID-19 on the following date: 9/23/23. During an interview on 9/27/23 at 9:39 A.M., CNA #2 said that he/she worked on the [NAME] Unit last week. He/she said they were tested for COVID-19 on Saturday 9/23/23 because he/she was working on the [NAME] Unit and it was a testing day. He/she said they did not get tested on [DATE] because he/she worked upstairs on the [NAME] Unit. He/she also said that he/she worked again on the [NAME] Unit on 9/26/23 but was told that he/she did not have to test until today (9/27/23) because today is a testing day. During an interview and record review on 9/28/23 at 8:31 A.M., the surveyor, the Administrator and the Infection Control Nurse reviewed the facility timecard punch documentation and the facility COVID-19 testing log documentation for CNA #2. The Infection Control Nurse said that the facility cannot always keep staff working on the same nursing unit all the time. She said that CNA #2 should have been tested for COVID-19 prior to working his/her shift on the [NAME] Unit on 9/25/23, and as part of outbreak testing procedure, but he/she was not tested as required.

Based on record review and interview the facility failed to notify the Physician when medications were not administered for one Resident (#283) out of a total sample of 30 residents. Specifically, the facility staff failed to notify the Physician when medications were not administered as ordered upon the Resident's admission to the facility, and prior to Renal Dialysis treatments. Findings include: Review of the facility policy titled Medication Administration-General Guidelines effective February 2019 indicated the following: -Medications are administered in accordance with written orders of the prescriber. -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. -If an electronic MAR is used, documentation of the unadministered dose is done as instructed by procedures for use of the eMAR system. An explanatory note is entered on the reverse side of the record. -If three consecutive or multiple doses, as established by facility policy, of a vital medication are withheld, refused, or not available the Physician is notified. -Nursing documents the notification and Physician response. Resident #283 was admitted to the facility in September 2023 with diagnoses including Endocarditis (an infection of the heart lining), Renal Cancer, Diabetes Mellitus, and Renal Dialysis (a treatment used when the kidneys no longer function properly to remove waste and extra fluid from the body). Review of the Nursing Clinical Data Admission assessment dated [DATE], indicated Resident #283 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of ten out of a total possible score of 15. Review of the September 2023 Physician's orders indicated the following: -Glipizide tablet, extended release 24 hours, 2.5 milligrams (mg) oral, once a day at 9:00 A.M. -Losartan tablet 100 mg oral, at bedtime, 8:00 P.M. -Minoxidil tablet 2.5 mg oral, at bedtime, 8:00 P.M. -Pravastatin tablet 40 mg oral, once a day, 8:00 A.M. -Reno Caps one capsule oral once a day, 8:00 A.M. -Ropinirole tablet 0.25 mg tablet, give 0.75 mg oral once a day, 9:00 A.M. -Sevelamer Carbonate tablets 800 mg two tablets, 1,600 mg, oral with breakfast and supper twice a day. 8:00 A.M. and 4:00 P.M. -Tamsulosin capsule 0.4 mg oral twice a day 8:00 A.M. and 4:00 P.M -Vitamin D3 capsule 25 mcg (microgram) oral once a day 8:00 A.M. -Zolpidem tablet 10 mg oral at bedtime 8:00 P.M. -Allopurinol 100 mg tablet, give 50 mg, 1/2 tablet, oral once a day, 8:00 A.M. -Miralax Powder 17 grams oral once a day at 9:00 A.M. -Nystatin Suspension 100,000 units per milliliter (ml) 5 mi oral three times a day 8:00 A.M., 2:00 P.M. and 8:00 P.M. -Prilosec tablet, delayed release, 20 mg oral once a day at 9:00 A.M. Review of the September 2023 MAR for Resident #283 indicated the following: -Documentation in the spaces for 9/24/23 on the MAR corresponding to three medications scheduled to be administered at 8:00 P.M. (Losartan, Minoxidil, Zolpidem), reflected three letters encased by parentheses. Further review indicated documentation in the corresponding comment/reason space of the MAR for each of the three medications: the medications were not administered, and the drug/item was not available. -Documentation in the spaces for 9/25/23 on the MAR corresponding to five medications scheduled to be administered at 8:00 A.M. (Allopurinol, Reno Caps, Pravastatin, Sevelamer Carbonate, Tamsulosin), two medications scheduled to be administered at 9:00 A.M. (Glipizide, Ropinirole), and one medication scheduled to be administered at 8:00 P.M. (Minoxidil), reflected three initials encased by parentheses. Further review indicated documentation in the corresponding comment/reason space of the MAR for each medication: that the medications were not administered, and drug/item was not available. -Documentation in the spaces for 9/26/23 on the MAR corresponding to seven medications scheduled to be administered at 8:00 A.M. (Alopurinol, Reno Caps, Pravastatin, Vitamin D3, Nystatin, Sevelamer Carbonate, Tamsulosin) and five medications scheduled to be administered at 9:00 A.M. (Amlodipine, Glipizide, Prilosec, Ropinirole, Miralax), reflected three initials encased by parentheses. Further review indicated documentation in the corresponding comment/reason space of the MAR for each medication: reflecting that the medication was not administered, and the Resident was unavailable, out for dialysis. Review of the September 2023 progress notes provided no evidence that the Physician had been notified that medications were not administered as ordered for Resident #283 on the following consecutive dates: 9/24/23, 9/25/23 and 9/26/23. During an interview and MAR review on 9/28/23 at 9:21 A.M., the surveyor and Unit Manager (UM) #2 reviewed the medication administration documentation on the September 2023 MAR for Resident #283. UM#2 said that when a medication is not administered to a resident the Nurse will document his/her initials encased in a parentheses in the space on the MAR corresponding to the medication. She further said that the Nurse will document the reason the medication is not administered in the comment space corresponding to the medication. UM#2 said that Resident #283 was admitted to the facility in the afternoon on 9/24/23, and that no medications were administered to the Resident because his/her medications were not available from the Pharmacy until some time on 9/25/23. UM #2 said that medications were not administered to Resident #283 on 9/26/23 because the Resident went to Renal Dialysis and was out of the facility. She said if medications are not available or cannot be administered as ordered, the Nurse should notify the Physician and document the communication with the Physician in the progress notes. UM #2 said there was no documentation in the Resident's record that the Physician was notified of the medications that were not administered to Resident #283 for 9/24/23, 9/25/23 or 9/26/23, but there should have been.

Based on observation, policy review and interview, the facility failed to ensure professional standards of quality were maintained during observation of a medication pass for one Resident (#45), out of eight applicable residents, in a total sample of 30 residents. Specifically, -for Resident #45, the facility staff failed to follow professional standards related to crushing enteric coated (EC-special coating that prevent dissolving by stomach acids but allows release of the medication in the intestine) medications prior to administration. Findings include: Review of the facility policy titled, Medication Administration-General Guidelines dated 2/2019, included, but not limited to: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -The Physician order for crushing medications should be included in the Medication Administration Record (MAR) so that all personnel administering medications are aware of this need Review of the Long-Term AdviseERR (Journal for The Institute for Safe Medication Practices), April 2017, Volume 5 Issue 4, indicated the following: -Enteric-coated (EC) tablets should not be crushed or split. The enteric coating prevents the drug inside from being destroyed by stomach acid, delaying the drug's release until it reaches the small intestine. -Crushing or splitting these tablets will release the drug into the stomach, where it may be broken down and not absorbed, or may cause gastric intestine (GI) irritation Resident #45 was admitted to the facility in October 2022 with diagnoses including Gastro-Esophageal Reflux Disease (GERD-a chronic digestive disease in which stomach acid irritates the esophagus/food pipe lining) without Esophagitis (inflammation that damages the tube running from the throat to the stomach). Review of the September 2023 Physician's orders indicated: -Multivitamin (MVI), one tablet daily -Enteric Coated Aspirin (ASA) 81 milligram (mg), one tablet daily On 9/28/23 at 9:15 A.M., during an observation of a medication administration pass, Nurse #4 removed one Enteric Coated ASA 81 mg tablet from a container and one MVI tablet (which had a dark reddish, hard coating) from a container, placed both in a plastic pouch and crushed them. Nurse #4 emptied the contents of the pouch into a medication cup and mixed the contents with applesauce. He then administered the crushed medications with applesauce to Resident #45. During an interview on 9/28/23 at 9:18 A.M., Nurse #4 said that he crushed the enteric coated ASA and MVI tablets. He said he did not see a Physician order in the MAR to crush medications. He further said the ASA was enteric coated and should not have been crushed. The surveyor and Nurse #4 reviewed the label of the MVI container together and found there was no documentation on the label indicating MVI tablets could be crushed. Nurse #4 said the MVI tablet should not have been crushed. During an interview on 9/28/23 at 1:00 P.M., with Unit Manager #1, she said that a Physician order needs to be in place to crush medications.

Based on observations, interviews and record review, the facility failed to provide treatment, care, and services as required for one Resident's (#77), out of a total sample of 30 residents. Specifically, the facility staff failed to respond timely to Resident #77's request to use the bathroom, when the Resident required assistance from staff with activities of daily living (ADLs). Findings include: Resident #77 was admitted to the facility in September 2023 with the following diagnoses: nondisplaced left hip fracture (when broken bones do not separate), subsequent encounter for closed fracture (broken bone with the skin still intact) with routine healing, difficulty walking, unspecified fracture of the lower end of left radius (one of the two bones in the forearm) and unspecified falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated: -Resident #77 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. -required assistance with ADLs including toileting and one physical assistance of staff for toileting. Review of Resident #77's care plan dated 9/6/23, indicated that . -the Resident required assistance with ADLs due to deconditioning (negative psysiological change following a period of inactivity, bedrest or sedentary[inactive] lifestyle), diagnoses of impaired mobility related to left hip fracture, left arm and leg pain. -required toilet assist of one staff member to wheelchair to and from commode over toilet and wall grab bars with a toileting plan every two hours or as needed . On 9/27/23 at 7:36 A.M., the surveyor observed Resident #77 asking Unit Secretary #1(who was in the Resident's room informing him/her that breakfast would be arriving soon) to use the bathroom before he/she ate his/her breakfast. Unit Secretary #1 responded that she could not toilet the Resident but would ask a Certified Nurses Aide (CNA) to come in and provide the care. The surveyor observed Unit Secretary #1 put on the call light for the Resident. On 9/27/23 at 8:15 A.M., the surveyor observed a CNA enter Resident #77's room, deliver the breakfast tray and exit the room while the call light was still on. On 9/27/23 at 8:25 A.M., the surveyor observed Unit Secretary #1 talking to staff members in the hallway who were still passing breakfast trays, asking for one of the staff to toilet Resident #77. The surveyor heard one staff member respond to Unit Secretary #1 and said that they could not toilet the Resident while they were still passing breakfast trays. On 9/27/23 at 8:30 A.M., the surveyor observed a staff member enter the Resident's room and the call light was turned off. During an interview on 9/27/23 at 8:36 A.M., Unit Secretary #1 told the surveyor that Resident #77 had requested to use the bathroom before breakfast. Unit Secretary #1 said she assisted the Resident to put the call light on while she left the Resident's room to find a staff member. Unit Secretary #1 said she located staff members who informed her they could not toilet residents while they were passing breakfast trays. Unit Secretary #1 said she later reminded the assigned CNA (#4) again, who responded that she could not toilet residents until all the breakfast trays are passed. During an interview on 9/27/23 at 8:54 A.M., Unit Manager (UM) #2 said that CNA #4 was assigned to Resident #77, and should have stopped passing the meal trays and toileted the Resident when she was notified that the he/she needed toileting. During an interview on 9/27/23 at 9:54 A.M., Resident #77 said that he/she wears a brief (an incontinent protective pad) for fear of wetting his/herself, due to the delay in staff's response to his/her bathroom needs. Resident #77 further said that a CNA had placed him/her on a bed pan over 45 minutes ago, promised to return, and had not returned. During an interview on 9/27/23 at 9:56 A.M., UM #2 said the assigned CNA #4 had been escorted out of the building and relieved of their shift but the staff was not aware that Resident #77 needed assistance. During an interview on 9/27/23 at 12:01 P.M., the Director of Nursing (DON) and the Administrator said CNA #4 should have assisted Resident #77 when he/she requested assistance, but had not. During an interview on 9/27/23 at 12:39 P.M., the Administrator said she met with Resident #77 and would follow through with the facility grievance protocol. The Administrator said Resident #77 should have received the needed assistance but was not provided with ADL care as requested and required.

Based on observations, record review, and interview the facility failed to assess, provide, and implement activities of the Resident's choice for one Resident (# 77) out of a total sample of 30 residents. Specifically, the facility staff failed to assess Resident #77 for activities preferences, provide meaningful activities designed to meet his/her interests and support his/her physical, mental, and psychosocial well-being. Findings include: Resident #77 was admitted to the facility in September 2023 with the following diagnoses: nondisplaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, difficulty walking, unspecified fracture of the lower end of left radius, unspecified falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/12/23, indicated that Resident #77 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and required assistance with activities of daily living (ADLs). Further reviewof the medical record indicated that the Resident was not interviewed for activity preferences. Review of the clinical record indicated that there was no care plan for activity preferences. On 9/26/23 at 10:35 A.M., the surveyor observed Resident #77 lying in bed, on his/her back looking up at the ceiling. Resident #77 said he/she had never been approached by any Activity Staff to offer meaningful activities of his/her choice, and was very bored. On 9/27/23 at 2:00 P.M., the surveyor observed Resident #77 lying in bed, awake, eyes wide open, and his/her television was off. During an interview on 9/27/23 at 2:15 P.M., the Administrator said the facility does not have Activity Staff to provide services to the residents on the Rehabilitation Unit. During an interview on 9/27/23 at 4:11 P.M., Additional Staff #1 (Nurse Consultant) said there was no indication that Resident #77 had been assessed for preferences in meaningful activities (as required for the completion of the MDS assessment). Additional Staff #1 reviewed the RAI (Resident Assessment Instrument) manual and said that the interview for activity preference should have been completed and was not. During an interview 9/27/23 at 4:33 P.M., the Administrator said Resident #77 should have been assessed for preferences in meaningful activities, but he/she was not. She further said Resident #77 should have been assessed for preferences and provided activities of his/her choice, but he/she was not.

Based on observations, record review, and interviews, the facility failed to provide Behavioral Health Services for one Resident (#91) out of a total sample of 30 residents. Specifically, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for a resident identified with a history of suicidal ideation, and a documented suicide attempt while in the facility resulting in hospitalization . Findings Include: Review of the Facility Policy titled Behavior Management Program, last revised 11/1/2010, indicated the following: -Resident's with behaviors that are problematic and/or dangerous for themselves or others will be identified. -Staff should look for triggers of previous circumstances that lead up to the problematic behavior. -The Interdisciplinary Team can develop a Care Plan for the behavior. The team should review the Minimum Data Set Assessment and psychotropic medications, and use all possible sources to assess and develop the plan of care. -The Interdisciplinary Team should develop specific individualized approaches. -Assessment, planning, intervention, and evaluation are a continuous process. This process must be carefully completed to truly provide a therapeutic approach with behavioral issues. Resident #91 was admitted to the facility in July 2023 with diagnoses including Parkinson's Disease (central nervous system disorder that affects movement, often including tremors), Obsessive-Compulsive Disorder (disorder in which a person experiences uncontrollable and recurring thoughts [obsessions], engages in repetitive behaviors [compulsions] or both), Anxiety Disorder, Depression, and Suicidal Ideations (a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). Review of the Resident Progress Notes indicated the following: -Social Services Note: dated 7/12/23 at 9:43 A.M., the Resident voiced thoughts that he/she would be better off dead. -Nursing Note: dated 7/12/23 at 6:30 P.M., the Resident was transferred to the emergency room (ER) for evaluation. -Nursing Note: dated 8/5/23 at 1:13 P.M., the Resident returned to the facility. -MDS Coordinator Note: dated 8/9/23 at 4:28 P.M., the Resident said to the staff member that he/she had tried to use a blanket to kill him/herself and then wrapped a call light cord around his/her neck in the presence of the staff member. -Nursing Note: dated 8/9/23 at 4:43 P.M., the Resident was transferred to the hospital for evaluation. -Nursing Note: dated 8/31/23 at 8:15 A.M., the Resident returned to the facility. -Social Services Note: on 9/7/23 at 9:50 A.M., documented that the Resident reported ongoing depressive symptoms. Review of Resident #91's Minimum Data Set (MDS) assessment dated [DATE], documented that he/she scored 8 out of 15 points on the Brief Interview for Mental Status (BIMS) assessment indicating that the Resident had moderate cognitive impairment. Further review of the MDS documented he/she reported symptoms of Depression, trouble sleeping, fatigue, trouble concentrating, and experienced hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that was not actually there). Review of the Resident's Comprehensive Care Plan indicated the following: -The Resident has a diagnosis of Depression requiring Psychiatric medication use initiated on 7/11/23, and included an approach to initiate Psychiatric Services as indicated. -The Resident has behaviors related to Parkinson's Disease with possible underlying Dementia initiated on 8/31/23, and included an approach for a Psychiatric Services Consult. -The Resident is at risk for suicide related to decreased functioning secondary to Parkinson's Disease and Depression initiated on 9/26/23, and included the approach if the resident expresses suicidal ideation to obtain a Psychiatric Consult as needed. Further Review of the Medical Record indicated the following: -Resident #91 was trying to get connected with Psychiatric services in the community but that had not occurred at the time of admission to the nursing facility. -No documentation of negative or suicidal thoughts as issues prior to admission to the nursing facility. -No evidence was documented that the Resident was provided with Psychiatric Consults or Behavioral Health Services to support his/her psychosocial well-being upon return to the facility following two hospitalization s for mental health evaluations. No Psychiatric Consult was ordered as indicated in the plan of care for the witnessed suicide attempt. -Review of the Behavioral Health Referral form indicated a request was made on 8/31/23 for a Behavioral Health Consult however the Resident was not seen as there was no Behavioral Health Service consent form in place. -Consent form for Behavioral Health Services was completed on 9/20/23. -No evidence was documented at the time of survey that Resident #91 had received any Psychiatric or Behavioral Health services since his/her admission to the facility. During an interview on 9/28/23 at 11:11 A.M., Social Worker (SW) #2 reviewed the Behavioral Health Referral form with the surveyor and said that the Resident was requested to be seen by the Behavioral Health Service on 8/31/23, but was not evaluated a Behavioral Health practioner due to a lack of a consent form. SW #2 stated she would contact Behavioral Health Service about the status of the consent. During an interview on 9/28/23 at 12:03 P.M., SW #2 said that the Behavioral Health Service did not have a consent form on file for Resident #91, and he/she had not been provided with any Behavioral Health Services.

Based on record review, policy review and interview, the facility failed to implement a Consultant Pharmacist recommendation for one Resident (#86) out of 5 residents reviewed, out of a total sample of 30 residents. Specifically, the facility staff failed to implement a Consultant Pharmacist recommendation, agreed upon by the attending Physician for uric acid serum levels to monitor the results of medication therapy for Resident #86. Findings include: Review of the facility policy titled, Consultant Pharmacists Reports dated February 2019, indicated: - all non-urgent recommendations must be addressed/reviewed within 30 days of the Consultant's monthly visit. Resident #86 was admitted to the facility in July 2022 with diagnoses including: Acute Kidney Failure (when the kidneys suddenly become unable to filter waste from the blood, indicated by increased serum levels of urea and creatinine) and Gout (when urate [normal body waste broken down from uric acid] builds up in the joints, causing pain and swelling). Review of a document titled, Note to Attending Physician/Prescriber dated 4/13/23, indicated: -the Consultant Pharmacist recommended ordering a uric acid serum level (laboratory blood test) to monitor current therapy for the medication Allopurinol (a mediation used to decrease high uric acid levels). Further review of the Note to Attending Physician/Prescriber indicated that the Physician agreed with the Consultant Pharmacist recommendation and signed that they agreed on 6/5/23. Review of Resident #86's clinical record did not indicate that the Consultant Pharmacist recommendation had been implemented. During an interview on 9/27/23 at 3:10 P.M., Unit Manager (UM) #1 said that the Pharmacist recommendation, that had been agreed upon by the Physician, had not been completed and should have been.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when nursing applied a new [MEDICATION NAME] (antihypertensive medication applied to skin via an adhesive patch), without removing the old [MEDICATION NAME], and as a result on 01/15/20 Resident #1 required a hospital transfer and was admitted due to a change in condition including decreased blood pressure and decreased heart rate. Resident #1 was noted by Emergency Department staff to have a total of three [MEDICATION NAME]es on his/her body. Findings include: The Hospital Discharge Summary, dated 01/18/20, indicated that Resident #1 presented with [MEDICAL CONDITION] (low heart rate), lethargy and [MEDICAL CONDITION] (irregular heart rate). The Summary indicated Resident #1's symptoms which were medication induced. The Summary indicated Emergency Department staff noted that upon initial assessment Resident #1 was found with three [MEDICATION NAME]es on his/her body. Review of the Drug Uses, Dosages and Side Effects Guides related to [MEDICATION NAME]es, dated 01/31/20, indicated that [MEDICATION NAME] lowers blood pressure by decreasing the level of certain chemicals in the blood, which allows blood vessels to relax and makes the heart to beat more slowly and easily. The Guide indicated that the old patch must be removed and discarded after one week. The Guide also indicated that patient(s) with [MEDICATION NAME] overdose have developed hypertension (high blood pressure) followed by [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION], apnea (temporary cessation of breathing), hallucinations, semicoma (partial or mild comatose state) and premature ventricular contractions (abnormal heartbeats). The Facility's policy titled Specific Medication Administration Procedures, dated (MONTH) 2019, indicated to administer medication through the skin ([MEDICATION NAME]), the Nurse must identify the location on the body for patch placement and must remove old patch from the body. During an interview on 01/28/20 at 12:05 P.M., the Physician said [MEDICATION NAME] is a strong anti-hypertensive medication and said in addition to the [MEDICATION NAME], Resident #1 was on several other blood pressure medications to manage his/her uncontrolled blood pressure. Review of Resident #1's Physician Orders, dated 01/02/20 through 01/15/20, indicated nursing was to apply one [MEDICATION NAME] once a week on Fridays, and to monitor for placement. Review of Resident #1's Medication Administration Record (MAR), dated (MONTH) 2020, indicated nursing documented that upon re-admission to the facility on [DATE] there was a [MEDICATION NAME] in place on Resident #1's right upper arm (RUA). On Friday 01/03/20 a new patch was placed per physician's orders [REDACTED].#1's right upper back (RUB) and then on Friday 01/10/20 a new patch was applied and documented as being placed on Resident #1's right upper back (RUB). Review of Resident #1's MAR and Nurse Progress notes, dated 01/01/20 through 01/15/20, indicated there was no documentation to support nursing removed the old [MEDICATION NAME]. Review of Resident #1's Nurse Progress Note, dated 01/15/20, indicated that the [MEDICAL TREATMENT] Center called the Facility to inform staff that Resident #1 was transferred to the Hospital Emergency Department due to a decreased pulse rate of 30 beats per minute (bpm, normal range 75 to 130 bpm). During an interview on 01/30/20 at 1:00 P.M., Nurse #2 said she could not find the [MEDICATION NAME] on Resident #1 on 01/03/20, and said that she applied a new patch. Nurse #2 said she only checked Resident #1's back, and said she did not realize [MEDICATION NAME]es could be applied on the arms or elsewhere on the body. During an interview on 01/28/20 at 10:00 [NAME]M., the Director of Nurses (DON) said that the Hospital notified her that three [MEDICATION NAME]es were found on Resident #1's body and said that he/she was admitted for [MEDICAL CONDITION]. The Facility's Investigation, dated 01/19/20, indicated that Resident #1 was re-admitted to the facility on [DATE] and on 1/03/20 a staff Nurse applied a new [MEDICATION NAME] to Resident #1's right upper back. The Investigation indicated that the nurse had not observed that there was already a [MEDICATION NAME] in place and had not removed the old patch. The Investigation indicated that Resident #1 was sent to the hospital on [DATE] due to [MEDICAL CONDITION] and was found by Emergency Department staff to have three [MEDICATION NAME]es on his/her body. On 01/29/20, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) The Facility investigated the Incident and interviewed all Nurses who administered medication to Resident #1 between 01/02/20 and 01/15/20, and the Facility reported the incident to the Department of Public Health immediately. B) The Director of Nurses (DON) completed a Facility wide audit on 01/18/20 and there were no other residents with a [MEDICATION NAME] Patch. C) The Facility audit (1/18/20) identified five residents who used salon pas pain patches and there were no concerns noted. D) The physician's orders [REDACTED]. E) Facility wide education on [MEDICATION NAME] Medications and Monitoring skin checks was initiated on 01/19/20, and by 01/28/20, 100 % of primary nursing staff had received the training while per diem staff will receive training on their next scheduled date to work ongoing until every licensed staff are signed off. F) Supervisors will audit all physician's orders [REDACTED]. G) The Facility's medication test for Nursing Skills Fair and Orientation was updated with [MEDICATION NAME] Medications. H) Medication Pass Competency will be done upon hire, annually and as needed. I) A quality assurance performance improvement (QAPI) meeting was held in 01/19/20 and the medication error involving Resident #1 was reviewed. J) Ongoing weekly internal audits for quality assurance will be done by the Unit Managers and/DON, with results to be reported at QAPI meetings. K) The Administrator and/or designee will be responsible for overall compliance.

Based on interviews and records reviewed, for one of four sampled residents (Resident #1), the Facility failed to prevent a significant medication error, when on 12/11/17 Resident #1 was administered an opioid medication and an anti-[MEDICAL CONDITION] medication that per review of the physician's orders [REDACTED]. Findings include: The Facility Policy titled, General Guidelines for the Administration of Medications, dated 2/2017, indicated; - The Nurse would identify the resident by name and by facility identification system in place, such as an identification bracelet or photograph. The Facility Protocol, titled Medication Checks and The 5 Rights, undated, indicated; - Resident identification would be verified by asking the resident their name and date of birth - Using the photograph in the Medication Administration Record, [REDACTED] - Or confirming identification using familiar staff. - The protocol indicated staff were not to identify a resident by asking them if they were (name). The Event Report, dated 12/11/17, at 7:30 P.M., indicated Resident #1 was administered the following medications in error; [MEDICATION NAME] (opioid [MEDICATION NAME]) Extended Release (designed to slowly release a drug in the body over an extended period of time) 90 milligrams (mg), [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 1200 mg, and [MEDICATION NAME] (antidepressant) 75 mg. The Report indicated the Nurse Practitioner was notified, ordered Resident #1 to be transferred to the Hospital Emergency Department for evaluation, and Resident #1 was transferred to the Hospital at 9:20 P.M. The Hospital Discharge Summary, dated 12/15/17, indicated Resident #1 was admitted with; altered mental status, somnolence, respiratory depression, and low blood oxygen saturation resulting from narcotic overdose as a result of accidentally receiving his/her roommate's medications, including [MEDICATION NAME] Extended Release and [MEDICATION NAME]. The Discharge Summary indicated Resident #1 required two doses of [MEDICATION NAME] with minimal response, and was transferred to the Intensive Care Unit, where [MEDICATION NAME] was administered intravenously (directly into the bloodstream) with good results. Review of Resident #1's Medication Administration Record [REDACTED]. Resident #1's MAR indicated [REDACTED]. Review of Resident #4's MAR, dated 12/2017 indicated he/she had physician's orders [REDACTED]. The Surveyor interviewed Nurse #1 at 11:05 A.M. on 5/29/18. Nurse #1 said that on 12/11/17, she was on orientation as a newly hired nurse, and said Nurse #2 was mentoring her. Nurse #1 said at approximately 7:30 P.M. she prepared Resident #4's prescribed medications, entered Resident #4's room, which he/she shared with Resident #1, addressed Resident #1 using Resident #4's name, and gave Resident #1 the medications she had prepared for Resident #4. Nurse #1 said she did not ask Resident #1 his/her date of birth or identify him/her using familiar staff or photograph identification, and then administered Resident #4's medications to Resident #1 in error. Nurse #1 said she recognized the medication error as soon as she returned to the medication cart, and notified Nurse #2, the Director of Nurses, the Nurse Practitioner, and the Physician. The Surveyor interviewed Nurse #2 at 4:24 P.M. on 5/30/18. Nurse #2 said that on 12/11/17 at approximately 7:30 P.M. he stayed outside the room (shared by Resident #4 and #1) while Nurse #1 entered to administer medications to Resident #4. Nurse #2 said that when Nurse #1 came back to the medication cart, Nurse #1 said she had administered Resident #4's medication to Resident #1 in error. On 5/29/18 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) Resident #1 returned the Facility and has not shown any signs or symptoms long term side effects related to the medications error. B) Nurse #1 and Nurse #2 were immediately re-educated regarding the Facility's Medication Administration Guidelines and Nurse Mentor responsibilities. C) The Training Sign in Sheet, dated 12/12/17 and 12/13/17, indicated all licensed staff were re-educated to the Protocol titled, Medication Checks and The Five Rights. D) On 12/13/17 , the Facility initiated the following additional preventative measure, by ensuring that all Resident Photograph Identification forms ( all resident photographs) were updated by 12/22/17. E) The Nurse Mentor Meeting Record, dated 12/14/17, indicated that all Facility's Nurse Mentors were re-educated regarding orientation of newly hired nurses, and the goals and procedures for medication administration orientation. F) The Facility's Quality Assurance Quarterly Report, titled, Medication Errors by Neighborhood, dated 12/2017, indicated corrective measures were implemented, including education of all licensed staff, and ongoing monitoring of medication error rates. G) Review of The Completion History for the Course titled Medication Administration: Avoiding Common Errors, indicated all licensed staff completed the Course between the dates of 1/31/18 to 5/20/18. H) Review of the Facility's Incident Reports, dated 12/11/17 through 5/30/18, indicated there were no significant medication errors during that time period. I) The Director of Nurses' and/or designee will responsible for overall compliance and Quality Assurance.

Based on record review and observation, for 1 of 5 sampled residents (Resident #1) the Facility failed to ensure Resident #1's falls prevention plan of care to provide a chair alarm for falls prevention was implemented. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated 4/29/2015, indicated Resident #1 was cognitively impaired, required assistance for bathing, dressing, transfers and had a history of [REDACTED]. The Facility's Falls and Accident Prevention Policy, dated 7/29/2014, indicated early detection and recognition of risk factors will reduce the risk of falls among elders, upon identification of those factors, interventions will be identified that will help to reduce that risk, interventions that are identified that could further reduce the risk for falls associated with individual risk factors will be added to the Interdisciplinary Falls Care Plan, those interventions will be added to the CNA Care Plan. An Incident Report, dated 7/29/2015, indicated Resident #1 was found on his/her left side, face down on the floor of his/her room with a laceration to the left forehead and the chair alarm pad was not plugged in. The CNA Care Card (My Personal Care Plan), not dated, indicated Resident #1 was a high fall risk and should have a bed and chair alarm in place as a fall intervention. Resident #1 had a Fall Assessment Log/Intervention Care Plan completed after each fall from 10/26/2014 through 7/29/2015. The Fall Assessment Log/Intervention Care Plan included interventions implemented after each fall. Resident #1 had a second Care Plan for Falls Prevention, revised 3/3/2015, with interventions for falls preventions including a bed/chair alarm. All the interventions on Resident #1's Falls Assessment Log/Intervention Care Plans were not included on Resident #1's Care Plan for Falls Prevention, 3/3/2015. The Surveyor interviewed the Director of Clinical Services at 2:15 P.M. on 12/21/2015. The Director of Clinical Services said the Fall Assessment Log/Intervention Care Plans were utilized for the Facility's At-Risk Falls Meetings. The Director of Clinical Services said it was confusing trying to read and follow two falls care plans which made it difficult to know what interventions were in place and current. The Surveyor interviewed Nurse #1 at 11:50 A.M. on 12/21/2015. Nurse #1 said he worked from 3 P.M. to 11 P.M. on 7/29/2015. Nurse #1 said Resident #1's chair alarm was not on when he/she was found face down on the floor of his/her room at 3:15 P.M. on 7/29/2015. Nurse #1 said he was aware of Resident #1's Care Plan for Falls Prevention, 3/3/15 and the CNA Care Card (My Personal Care Plan) and was not aware of the Facility's Fall Assessment Log/Intervention Care Plans for Resident #1 or any resident. The Surveyor interviewed CNA #1 at 12:50 P.M. on 12/21/2015. CNA #1 said she found Resident #1 face down, on the floor of his/her room at approximately 3:15 P.M. on 7/29/2015. CNA #1 said Resident #1's chair alarm was not on when she found Resident #1 on the floor. The Surveyor interviewed the Unit Manager at 1:36 P.M. on 12/21/2015. The Unit Manager said Resident #1 should have had a chair alarm. The Unit Manager said Resident #1 did not have his/her chair alarm on when he/she was found on the floor on 7/29/2015 and that was one thing the Facility did wrong. The Surveyor interviewed CNA #2 at 2:56 PM. on 12/22/2015. CNA #2 said she knew Resident #1 was a fall risk and should have had a bed and chair alarm in place at all times to help prevent falls CNA #2 said she assisted Resident #1 into his/her personal recliner chair approximately 2 P.M. on 7/29/2015 and forgot to plug in and turn on Resident #1's chair alarm. CNA #2 said she had last observed Resident #1 seated in his/her personal recliner, with eyes closed, at approximately 3 P.M. on 7/29/2015. Resident #1 was sent to the hospital on [DATE], diagnosed with [REDACTED]. The Surveyor interviewed the Facility's Interim Assistant Administrator and Director of Clinical Services at 2:36 P.M. on 12/21/2015. The Facility's Interim Assistant Administrator and Director of Clinical Services said the resident care plans were confusing and had been identified as a problem issue at the Facility. The Interim Assistant Administrator and Director of Clinical Services said any discontinued interventions on the resident care plans should be indicated with a date and highlighted in yellow which was not indicated on Resident #1's Care Plans. The Interim Assistant Administrator and Director of Clinical Services said the CNA Care Card (My Personal Care Plan), would have the updated and active falls interventions for residents, including Resident #1.

Based on record review and interview for 1 of 5 sampled residents (Resident #1), the Facility failed to notify Resident #1's Physician or Nurse Practitioner (NP) of a change in Resident #1's condition after being found face down on the floor of his/her room with a laceration to his/her forehead after the fall at 3:15 P.M. on 7/29/2015. Resident #1 began to complain of soreness to his/her head and continued to complain of head soreness/discomfort for the next 11 hours. In the morning on 7/30/2015, Resident #1 presented with lethargy, unresponsiveness and inability to keep food, liquid or medications in his/her mouth and there was no indication Resident #1's Physician or NP was notified. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated 4/29/2015, indicated Resident #1 was cognitively impaired. The Facility's Notification of Change in Resident's Condition Policy, dated 7/30/2014, indicated the Facility will promptly notify the resident; consult with his or her attending physician, and if known, notify the resident's legal representative of changes in the resident's condition and/or status. A Nursing Note, dated 7/29/2015, indicated Resident #1 was found on the floor at 3:15 P.M. A Neurological Assessment, dated 7/29/2015, indicated staff documented Resident #1 began to complain of soreness to his/her head at 5:15 P.M. on 7/29/2015 and continued to complain of head discomfort for 11 hours, until 4:15 A.M. on 7/30/2015. There was no indication staff notified Resident #1's Physician or Nurse Practitioner. The Surveyor interviewed Nurse #1 at 11:50 A.M. on 12/21/2015. Nurse #1 said Resident #1 was found face down on the floor of his/her room, with a laceration on his/her left forehead, at 3:15 P.M. on 7/29/2015, he completed an assessment and called Resident #1's Physician and family at the time of the fall. Nurse #1 said he did not remember calling Resident #1's Physician or NP when Resident #1 began to complain of soreness to his/her head. Nurse #1 said he would have documented if he had called Resident #1's Physician or NP about complaints of head discomfort. The Surveyor interviewed the Unit Manager at 1:36 P.M. on 12/21/2015. The Unit Manager said he did not work on 7/29/2015 and was not aware Resident #1 began to complain of soreness to his/her head on 7/29/2015. The Unit Manager said Resident #1's complaints of soreness to his/her head would have indicated a change in condition and Resident #1's Physician and/or NP should have been notified. A Nursing Note, dated 7/30/2015, indicated Resident #1 was lethargic, very unresponsive and had great difficulty keeping foods, liquids and medications in his/her mouth during the day on 7/30/2015 and there was no indication Resident #1's Physician or NP were notified. This was not consistent with the Facility's Observation and Reporting of Changes in Resident's Condition or Status Policy. The Surveyor interviewed CNA #2 at 2:56 P.M. on 12/22/2015. CNA #2 said she worked from 7 A.M. to 3 P.M. on 7/30/2015. CNA #2 said Resident #1 seemed to be more sleepy, lethargic, had his/her eyes closed, words to the effect of, a lot, during the day on 7/30/2015 and this was a change for Resident #1. CNA #2 said she did not report Resident #1's change in condition to the nurse because Resident #1's increased lethargy and sleepiness had been reported to her during morning report on 7/30/2015. A Nurse Practitioner's (NP) Note, dated 7/31/2015, indicated Resident #1 had a fall on 7/29/2015, had a hematoma (a collection of blood outside of a blood vessel) above his/her left eye, small amount of bleeding, left eye ecchymosis (bruise), was lethargic and leaning to his/her right side. The NP Note indicated Resident #1's family was concerned about a head injury and wanted an emergency room evaluation. The Surveyor interviewed Resident #1's NP at 2:43 P.M. on 12/22/2015. The NP said she was notified on 7/29/2015 when Resident #1 was found on the floor, but was not notified of any change in Resident #1's condition following the fall. The NP said she was in the Facility on 7/31/2015 and overheard a staff member say Resident #1 was lethargic and she went to assess Resident #1. The NP said, based on her assessment of Resident #1's condition, she was concerned about Resident #1 having a possible head injury, she called Resident #1's daughter, the decision was made to send Resident #1 to the hospital where Resident #1 was diagnosed with [REDACTED].) The NP said she reviewed Resident #1's clinical record which indicated staff had documented Resident #1 complained of soreness to his/her head on 7/29/2015 and inability to keep food, liquid and medication in his/her mouth on 7/30/2015. The NP said she would have expected staff to call her at the time they noted these changes. The NP said she was not informed of any of changes in Resident #1's condition prior to her assessment on 7/31/2015.

Based on record review and interview, the Facility failed to ensure, for 1 of 5 sampled residents (Resident #1), care plan interventions for falls prevention were implemented and followed. Resident #1 was assessed to be a risk for falls by the Facility and a care plan for falls prevention, which included an intervention for a bed and chair alarm, was in place. On 7/29/2015, Resident #1 was found on his/her left side, face down on the floor with a laceration to the left forehead and two days later diagnosed with [REDACTED].#1's bed and chair alarm had not sounded. CNA (Certified Nursing Assistant) #2 told the Surveyor, at 2:56 P.M. on 12/21/2015, she had forgotten to connect Resident #1's chair alarm after she assisted Resident #1 in to his/her personal recliner chair on 7/29/2015. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated 4/29/2015, indicated Resident #1 was cognitively impaired, required assistance for bathing, dressing and transfers and had a history of [REDACTED]. The CNA Care Card (My Personal Care Plan,) not dated, indicated Resident #1 was a high fall risk and should have a bed and chair alarm in place as an intervention to his/her Fall/Safety Plan. An Incident Report, dated 7/29/2015, indicated Resident #1 was found on his/her left side, face down on the floor of his/her room with a laceration to the left forehead, the alarm pad was not plugged in. The Surveyor interviewed CNA #1 at 12:50 P.M. on 12/21/2015. CNA #1 said she found Resident #1 face down, on the floor of his/her room at approximately 3:15 P.M. on 7/29/2015. CNA #1 said Resident #1's chair alarm was not on when she found Resident #1 on the floor. The Surveyor interviewed the Unit Manager at 1:36 P.M. on 12/21/2015. The Unit Manager said Resident #1 should have had a chair alarm. The Unit Manager said Resident #1 did not have his/her chair alarm on when he/she was found on the floor on 7/29/2015 and; said words to the effect of, that was one thing the Facility did wrong. The Surveyor interviewed CNA #2 at 2:56 P.M. on 12/22/2015. CNA #2 said she knew Resident #1 was a fall risk and should have had a bed and chair alarm in place at all times to help prevent falls CNA #2 said she assisted Resident #1 into his/her personal recliner chair at approximately 2 P.M. on 7/29/2015 and forgot to plug in and turn on Resident #1's chair alarm. CNA #2 said she had last observed Resident #1 seated in his/her personal recliner, with eyes closed, at approximately 3 P.M. on 7/29/2015.

Based on record review and interview for 1 of 5 sampled residents (Resident #1), the Facility's Nurses failed to recognize a significant change in Resident #1's condition after being found face down on the floor of his/her room with a laceration to his/her forehead on [DATE] after the fall. Resident #1 complained of head soreness/discomfort two hours after being found on the floor, continued to complain of soreness to his/her head for the next 11 hours and there was no indication Resident #1 was treated for [REDACTED]. In the morning on [DATE], Resident #1 presented with lethargy, unresponsiveness and inability to keep food, liquid or medications in his/her mouth and there was no indication Resident #1's Physician or NP were notified. Resident #1 was sent to the hospital on [DATE] for evaluation for a possible head injury, was diagnosed with [REDACTED].#1 died a week later. Findings include: The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #1 was cognitively impaired. The Facility's Pain Management Policy, not dated, indicated that each resident is afforded appropriate assessment and management of pain and pain will be continually be evaluated, with notification of the attending physician/nurse practitioner of unrelieved pain. The Facility's Observation and Reporting of Changes in Resident's Condition or Status Policy, dated [DATE], indicated the purpose of the policy was to assure any changes in the condition or status of a resident that is observed by any staff member is reported without delay to a nurse who can then assess the resident and make appropriate notifications when necessary to assure a timely response, changes in the resident's condition such as pain, skin changes, unusual loss of appetite, lethargy, mental status changes, etc are to be reported to the nurse in charge of that resident whenever and as soon as those changes are observed. A Nursing Note, dated [DATE], indicated Resident #1 was found on the floor at 3:15 P.M. A Neurological Assessment, dated [DATE] - [DATE], indicated staff documented Resident #1's complaints of soreness to his/her head at 5:15 P.M. on [DATE] and continued to complain of head discomfort for 11 hours. There was no indication staff treated Resident #1's complaints of head soreness or pain and did not notify Resident #1's Physician or Nurse Practitioner. This was not consistent with the Facility's Observation and Reporting of Changes in Resident's Condition or Status Policy. Resident #1's Medication Administration Records (MAR's), dated [DATE], indicated Resident #1 had orders for Tylenol 650 milligrams every 4 hours as needed for pain. There was no indication Resident #1 received Tylenol or any other treatment for [REDACTED]. A Nursing Note, dated [DATE], indicated Resident #1 was lethargic, very unresponsive and had great difficulty keeping foods, liquids and medications in his/her mouth during the day on [DATE] and there was no indication Resident #1's Physician or NP were notified. This was not consistent with the Facility's Observation and Reporting of Changes in Resident's Condition or Status Policy. The Surveyor interviewed Nurse #1 at 11:50 A.M. on [DATE]. Nurse #1 said he worked from 3 P.M. to 11 P.M. on [DATE]. Nurse #1 said Resident #1 was found face down on the floor of his/her room at 3:15 P.M. on [DATE], he completed an assessment and called Resident #1's Physician and family. Nurse #1 said Resident #1 had a laceration on his/her left forehead. Nurse #1 said he did not remember calling Resident #1's Physician or NP when Resident #1 began to complain of head soreness/discomfort at 5:15 P.M. on [DATE] and did not remember administering any medication to treat Resident #1's complaints of head soreness/discomfort. This was not consistent with the Facility's Pain Management Policy and not consistent with the Facility's Observation and Reporting of Changes in Resident's Condition or Status Policy. The Surveyor interviewed the Unit Manager at 1:36 P.M. on [DATE]. The Unit Manager said he did not work on [DATE] and was not aware Resident #1 began to complain of soreness to his/her head on [DATE]. The Unit Manager said he should have been informed of Resident #1's complaints of soreness to his/her head. The Unit Manager said Resident #1's complaints of soreness to his/her head would have indicated a change in condition and Resident #1's Physician and/or NP should have been notified. The Surveyor interviewed CNA #2 at 2:56 PM. on [DATE]. CNA #2 said she worked from 7 A.M. to 3 P.M. on [DATE]. CNA #2 said Resident #1 seemed to be more sleepy, lethargic, had her eyes closed a lot during the day on [DATE] and this was a change for Resident #1. CNA #2 said she did not report Resident #1's change in condition to the nurse because Resident #1's increased lethargy and sleepiness had been reported to her during morning report. The Surveyor interviewed Resident #1's NP at 2:43 P.M. on [DATE]. The NP said she assessed Resident #1 on [DATE] and was concerned about a possible head injury. The NP said she reviewed Resident #1's clinical record which indicated staff had documented Resident #1 complained of soreness to his/her head on [DATE] and inability to keep food, liquid in his/her mouth on [DATE] and she would have expected staff to call her with that information. The NP said she was not informed of any of changes in Resident #1's condition prior to her assessment on [DATE]. The NP said Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. The Surveyor interviewed the Nursing Supervisor at 12:30 P.M. on [DATE]. The Nursing Supervisor said she was not informed Resident #1 complained of soreness to his/her head on [DATE] and was not informed Resident #1 had increased lethargy and inability to keep food, liquids or medication in his/her mouth on [DATE]. The Nursing Supervisor said she the nursing staff should have informed her of Resident #1's complaints of head soreness, lethargy and inability to keep food in her mouth.

Based on interview, record review and observation, for 1 of 11 residents (Resident #1) the Facility failed to prevent Resident #1 from eloping through the unit's exit door, falling down a flight of stairs in his/her wheelchair, and sustaining critical injuries to his/her kidneys. On [DATE], Nurse #2 removed Resident #1's WanderGuard and on [DATE] unknown nursing staff discontinued Resident #1's physician's orders [REDACTED]. On [DATE], Resident #1 opened the service corridor door connected to the unit, but the WanderGuard alarm did not activate because Resident #1 was not wearing a sensor bracelet. Resident #1 wheeled himself/herself down the corridor to a stairwell and fell down the stairs. Staff discovered Resident #1 and transferred him/her to the Hospital and he/she was diagnosed with [REDACTED]. Findings include: Resident #1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she had significant cognitive deficits, required extensive assistance for ambulating on the unit (used a walker or wheelchair), and was diagnosed with [REDACTED].#1's MDS indicated he/she did not exhibit wandering behavior. Review of Resident #1's Plans of Care indicated there were no written interventions developed for wandering. Resident #1's Physician Orders, dated [DATE], indicated he/she required a WanderGuard, for staff to check for functioning on a daily basis and for placement every shift. A WanderGuard is an electronic tracking system designed to prevent persons at risk from leaving a facility unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person. Review of Resident #1's Physician Orders, dated [DATE], indicated the Physician continued the WanderGuard orders, dated [DATE]. Resident #1's Treatment Record, dated [DATE], indicated staff checked his/her WanderGuard for placement every shift until [DATE], ending on the 11:00 P.M. to 7:00 A.M. shift. The order was discontinued on [DATE] during the 7:00 A.M. to 3:00 P.M. shift. Review of the Interim Physician order [REDACTED].#1's original orders for a WanderGuard. The Surveyor interviewed the Unit Manager at 10:50 A.M. on [DATE]. The Unit Manager said he was present on the day of Resident #1's admission to the Facility and that Resident #1 was unsteady on his/her feet, attempted to leave his/her wheelchair and bed and wandered on the unit. The Unit Manager said that Resident #1 required the use of a WanderGuard because of his/her risk for elopement from the unit and one was placed on him/her that first day. The Unit Manager said he was unaware that Resident #1's WanderGuard was removed and only became aware of this until after the [DATE] incident. The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on [DATE]. The DON said that Resident #1 transferred from another facility's secured memory care unit and based on that history and the layout of the unit it was determined that he/she was at risk for elopement. The DON said the Facility did not have a written wandering or elopement assessment tool prior to the [DATE] incident. The DON said the Facility had not developed a written Plan of Care to address Resident #1's wandering or risk for elopement, but that there had been a physician's orders [REDACTED]. The Surveyor interviewed Nurse #1 on [DATE] at 2:50 P.M. Nurse #1 said that at approximately 8:30 P.M. on [DATE], Nurse #2 asked for his help to reposition Resident #1. Nurse #1 said that Nurse #2 indicated that one of Resident #1's legs was swollen and they raised it. Nurse 1 said that Nurse #2 cut the WanderGuard anklet off Resident #1 because she thought it constricted the leg. Nurse #1 said that they initiated fifteen minute checks to monitor Resident #1's whereabouts. The Surveyor interviewed Nurse #2 at 2:25 P.M. on [DATE]. Nurse #2 said that on [DATE] she had signed-out and was leaving work for the night, at approximately 9:00 P.M., when she noticed that Resident #1 was agitated and Nurse #1 was trying to put him/her in bed. Nurse #2 said she entered the bedroom and observed that the WanderGuard band was too tight on Resident #1's ankle, and she cut off the WanderGuard with a pair of scissors. Nurse #2 said she expected that Nurse #1 would document that the WanderGuard was removed. Nurse #2 said she left a note for the Unit Manager that the WanderGuard was removed and she then initiated 15 minute checks for Resident #1. Review of video footage dated [DATE] at 6:07 P.M., showed Resident #1 entering the service corridor from his/her unit and ambulating in his/her wheelchair to the stairwell. At approximately 6:14 P.M., Housekeeper #1 entered the corridor from the staff breakroom and walked to the stairwell, and then appeared to call out for help (there is no audio on the recording). The Surveyor interviewed Housekeeper #1 at 11:30 A.M. on [DATE], with the interpreter assistance of Facility staff. Housekeeper #1 said that on [DATE], he left the staff breakroom and heard a personal alarm sounding from the stairwell. Housekeeper #1 said he saw Resident #1 at the bottom landing lying on his/her back and bleeding from his/her face. Housekeeper #1 said he told Certified Nurse Aide (CNA) #1, who was walking in the service corridor, that a resident fell and needed help. Nurse #2 indicated that CNA #1 told her that a resident fell on the stairs. Nurse #2 said she assessed Resident #1 and emergency services were notified, and he/she was transferred to the Hospital. Review of Resident #1's Hospital history and physical examination [REDACTED]. Resident #1's Pronouncement of Death record indicated he/she died on [DATE].

Based on interview, record review and observation, for 1 of 11 sampled residents (Resident #1), the Facility failed to implement Resident #1's Plan of Care for Wandering. On [DATE], Resident #1 eloped from the unit through a WanderGuard sensor door and was found at the bottom of a stairwell, on the floor. Resident #1's physician's orders [REDACTED]. Resident #1 was diagnosed with [REDACTED]. Failure to implement the Plan of Care occurred when: Findings include: Resident #1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she had significant cognitive deficits, required extensive assistance for ambulating on the unit (used a walker or wheelchair) and was diagnosed with [REDACTED].#1's MDS indicated he/she did not exhibit wandering behavior). Resident #1's Physician Orders, dated [DATE], indicated he/she required a WanderGuard, for staff to check for functioning on a daily basis and for placement every shift. A WanderGuard is an electronic tracking system designed to prevent persons at risk from leaving a supervised area, unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person. The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on [DATE]. The DON said that Resident #1 transferred from another facility's secured memory care unit and based on that history and the layout of the unit it was determined that he/she was at risk for elopement. The Surveyor interviewed the Unit Manager at 10:50 A.M. on [DATE]. The Unit Manager said he was present on the day of Resident #1's admission to the Facility and that Resident #1 was unsteady on his/her feet, attempted to leave his/her wheelchair and bed and wandered on the unit. The Unit Manager said that Resident #1 required the use of a WanderGuard because of his/her risk for elopement from the unit and that first day a physician's orders [REDACTED]. The Surveyor interviewed Nurse #2 at 2:25 P.M. on [DATE]. Nurse #2 said she observed that Resident #1's WanderGuard band was too tight on his/her ankle, and she cut off the WanderGuard with a pair of scissors. Nurse #2 said she left a note for the Unit Manager that the WanderGuard was removed and she then initiated 15 minute checks for Resident #1. Resident #1's Treatment Record, dated [DATE], indicated the physician's orders [REDACTED].M. to 3:00 P.M. shift. Review of video footage dated [DATE] at 6:07 P.M., showed Resident #1 entering the service corridor from his/her unit and ambulating in his/her wheelchair to the stairwell. At approximately 6:14 P.M., Housekeeper #1 entered the corridor from the staff breakroom and walked to the stairwell, and then appeared to call out for help (there is no audio on the recording). The Surveyor interviewed Housekeeper #1 at 11:30 A.M. on [DATE], with the interpreter assistance of Facility staff. Housekeeper #1 said that on [DATE], he found Resident #1 at the bottom of the service corridor stairs, lying on the floor. Housekeeper #1 said that Resident #1's personal chair alarm sounded but that the WanderGuard alarm in the service corridor did not sound. The DON said she did not know who discontinued the physician's orders [REDACTED]. The Unit Manager said he was unaware that staff were not checking Resident #1's WanderGuard for placement and functioning, beginning on [DATE]. Review of Resident #1's Physician Orders, dated [DATE], indicated the Physician continued the original WanderGuard orders. Review of Resident #1's Hospital history and physical examination [REDACTED]. Resident #1's Pronouncement of Death record indicated he/she died on [DATE].

Based on record review and interview for 1 of 11 sampled residents (Residents #1), the Facility failed to follow acceptable standards of practice. On [DATE], Resident #1 eloped from the unit through a WanderGuard sensor door, but he/she was not wearing a WanderGuard anklet at the time. Resident #1 was found at the bottom of a stairwell, on the floor and transferred to the Hospital. Resident #1 was diagnosed with [REDACTED]. Standards of practice were not followed when: - On [DATE], nursing staff removed Resident #1's WanderGuard alarm from his/her leg due to swelling, but did not provide an alternative intervention to manage his/her risk for elopement. - From [DATE] to [DATE], staff documented that Resident #1's WanderGuard was in place and functioning every shift, even though Nurse #1 removed it during the evening of [DATE]. - On [DATE], staff discontinued Resident #1's physician's orders [REDACTED]. - From [DATE] to [DATE], nursing staff failed to determine placement and functioning for Resident #1's WanderGuard, as required by the original physician's orders [REDACTED].>Findings include: Resident #1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she had significant cognitive deficits, required extensive assistance for ambulating on the unit (used a walker or wheelchair) and was diagnosed with [REDACTED].#1's MDS indicated he/she did not exhibit wandering behavior). Resident #1's Physician Orders, dated [DATE], indicated he/she required a WanderGuard, for staff to check for functioning on a daily basis and for placement every shift. A WanderGuard is an electronic tracking system designed to prevent persons at risk from leaving a supervised area, unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person. The Surveyor interviewed the Director of Nurses (DON) at 9:00 A.M. on [DATE]. The DON said that Resident #1 transferred from another facility's secured memory care unit and based on that history and the layout of the unit, it was determined that he/she was at risk for elopement. The DON said the Facility did not have a written wandering or elopement assessment tool prior to the [DATE] incident. The Surveyor interviewed the Unit Manager at 10:50 A.M. on [DATE]. The Unit Manager said he was present on the day of Resident #1's admission to the Facility and that Resident #1 was unsteady on his/her feet, attempted to leave his/her wheelchair and bed and wandered on the unit. The Unit Manager said that Resident #1 required the use of a WanderGuard because of his/her risk for elopement from the unit and one was placed on him/her that first day. The Surveyor interviewed Nurse #1 on [DATE] at 2:50 P.M. Nurse #1 said that at approximately 8:30 P.M. on [DATE], Nurse #2 asked for his help to reposition Resident #1. Nurse #1 said that Nurse #2 indicated that one of Resident #1's legs was swollen and they raised it. Nurse 1 said that Nurse #2 cut the WanderGuard anklet off Resident #1 because she thought it constricted the leg. Nurse #1 said that they initiated fifteen minute checks to monitor Resident #1's whereabouts. Nurse #1 said he did not document the removal of the WanderGuard. The Surveyor interviewed Nurse #2 at 2:25 P.M. on [DATE]. Nurse #2 said she observed that Resident #1's WanderGuard band was too tight on Resident #1's ankle, and she cut off the WanderGuard with a pair of scissors. Nurse #2 said she expected Nurse #1 to document the removal of the WanderGuard. Nurse #2 said she left a note for the Unit Manager that the WanderGuard was removed and she then initiated 15 minute checks for Resident #1. Resident #1's Treatment Record, dated [DATE], indicated staff checked that his/her WanderGuard was present and functioning every shift from [DATE] to [DATE] during the 11:00 P.M. to 7:00 A.M. shift. The order was discontinued on [DATE] during the 7:00 A.M. to 3:00 P.M. shift. Review of the Interim Physician order [REDACTED].#1's original orders for a WanderGuard. Review of video footage dated [DATE] at 6:07 P.M., showed Resident #1 entering the service corridor from his/her unit and ambulating in his/her wheelchair to the stairwell. At approximately 6:14 P.M., Housekeeper #1 entered the corridor from the staff breakroom and walked to the stairwell, and then appeared to call out for help (there is no audio on the recording). The Surveyor interviewed Housekeeper #1 at 11:30 A.M. on [DATE], with the interpreter assistance of Facility staff. Housekeeper #1 said that on [DATE], he found Resident #1 at the bottom of the service corridor stairs, lying on the floor. Housekeeper #1 said Resident #1's personal chair alarm sounded but that the WanderGuard alarm in the service corridor did not sound. The DON said she did not know who discontinued the physician's orders [REDACTED]. The Unit Manager said he was unaware that staff were not checking Resident #1's WanderGuard for placement and functioning, beginning on [DATE]. Review of Resident #1's Physician Orders, dated [DATE], indicated the Physician continued the original WanderGuard orders. Review of Resident #1's Hospital history and physical examination [REDACTED]. Resident #1's Pronouncement of Death record indicated he/she died on [DATE]. The case was assigned to the state Medical Examiner for further investigation.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the staff followed the Facility Diabetic Foot Care Policy and the Facility's Pressure Sore Protocols. Resident #1's, plan of care included diabetic food care, which included an inspection by the nurse of Resident #1's feet every evening. Although the nurses documented they performed the treatments as ordered, the assigned nurses said they did not always inspect Resident #1's feet every evening. On 2/1/15, Resident #1 was admitted without pressure ulcer, had an intact blood blister not documented prior to this date, on the right heel(defined as a stage II pressure sore), a dark area on the right lateral foot, an intact blood blister on the left toe, and a dark area on the plantar (ball) of the foot. Findings include: The Record of Admission indicated the staff admitted Resident #1 to the Facility in January 2015. The Record of Admission indicated Resident #1's [DIAGNOSES REDACTED]. The Physician order, dated 1/14/15, included daily diabetic foot care with an assessment. The Diabetic Foot Care Policy, dated 12/12/08, indicated the nurse was to examine the resident's feet every day for areas of dryness or breaks in the skin. The Surveyor interviewed Nurse #2 at 2:30 P.M. on 3/25/15. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 3/25/15. The Surveyor interviewed Nurse #4 at 3:05 P.M. on 3/25/15. The Surveyor interviewed Nurse #5 at 3:47 P.M. on 3/25/15. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said they were assigned to care for Resident #1 during the evening shift. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said they were assigned to inspect the feet of each diabetic Resident in the evening. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said Resident #1's unit was busy and time did not always allow them to inspect each diabetic Resident's feet every evening. The Treatment Administration Record (TAR), dated 2/1/15, indicated Resident #1 had an intact blood blister on the right heel, a dark area on the right lateral foot, an intact blood blister on the left toe, and a dark area on the plantar (ball) of the right foot. Nurse #5 said on 2/1/15, she observed the skin issues on Resident #1's feet. Nurse #5 said she did not complete measurements of the areas and could not recall the sizes of the skin issues. Nurse #5 said the black area on the plantar area of Resident #1's foot did not appear new. The Physician order, dated 2/1/15, included: Skin Prep to bilateral (both) heels and right great toe twice per day until healed. The TAR, dated from 2/1/15 to 2/9/15, indicated the nurses applied Skin Prep to Resident #1's heels and right great toe on the day and evening shifts. The Surveyor interviewed the Wound Nurse at 1:18 P.M. on 3/26/18. The Wound Nurse said the nurses did not notify her of Resident #1's skin issues, until 2/9/15, 9 days after the areas were identified. This was not consistent with the Facility practice The Pressure Sore Protocols, dated 12/21/11, included a rehabilitation consult when a resident had a stage one pressure ulcer (a persistent area of skin redness, without a break in the skin, that does not disappear within 30 minutes when pressure is relieved) or a stage two pressure ulcer (a partial thickness loss of skin layers either dermis or epidermis that presents clinically as an abrasion, blister, or shallow crater). The Surveyor interviewed the Rehabilitation Manager at 10:38 A.M. on 3/25/15. The Rehabilitation Manager said although Resident #1 received occupational therapy and physical therapy services, the Rehabilitation Team was not aware Resident #1 had skin ulcers or sores on his/her feet. The Surveyor interviewed the Director of Nurses (DON) at 12:40 P.M. on 3/25/15. The DON said the nurses were to assess each diabetic Resident's feet daily. The DON said the nurses assigned to care for Resident #1 did not follow the Diabetic Foot Care Policy.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 did not develop pressure ulcers on the feet. Resident #1's plan of care included diabetic food care, which included an inspection by the nurse of Resident #1's feet every evening. Although the nurses documented they performed the treatments as ordered, the assigned nurses said they did not always inspect Resident #1's feet every evening, which was not consistent with the Plan of Care. -On 1/25/15, Resident #1's right heel was red, but no changes were made in the plan of care and staff did not document any further assessment of the area until 2/1/15. -On 2/1/15, Resident #1 had an intact blood blister on the right heel, a dark area on the right lateral foot, an intact blood blister on the left toe, and a dark area on the plantar (ball) of the foot. Findings include: The Record of Admission indicated the staff admitted Resident #1 to the Facility in January 2015. The Record of Admission indicated Resident #1's [DIAGNOSES REDACTED]. The Physician order, dated 1/14/15, included daily diabetic foot care with an assessment. The Diabetic Foot Care Policy, dated 12/12/08, indicated the nurse was to examine the resident's feet every day for areas of dryness or breaks in the skin. The Surveyor interviewed Nurse #2 at 2:30 P.M. on 3/25/15. The Surveyor interviewed Nurse #3 at 9:30 A.M. on 3/25/15. The Surveyor interviewed Nurse #4 at 3:05 P.M. on 3/25/15. The Surveyor interviewed Nurse #5 at 3:47 P.M. on 3/25/15. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said they were assigned to care for Resident #1 during the evening shift. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said the Certified Nurse Aides (CNAs) washed the feet of diabetic residents and applied lotion during the evening. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said they were to inspect the feet of each diabetic resident during the evening. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said Resident #1's unit was busy and they did not always have time to inspect each diabetic resident's feet every evening. Nurse #2, Nurse #3, Nurse #4, and Nurse #5 said if a Residents' feet had issues, the CNAs reported the information to them and they immediately inspected the resident's feet. The Admission Minimum Data Set Assessment (MDS), completed on 1/20/15, indicated Resident #1 was alert and oriented and had no skin conditions. The day shift Nurse's Note, dated 1/25/15, indicated Resident #1 had a red heel with intact skin (indicative of possible pressure to the heels). The Surveyor interviewed Nurse #1 at 12:50 P.M. on 3/25/15. Nurse #1 said on 1/25/15, the skin on Resident #1's right heel was blanchable and intact. Nurse #1 said although she did not have a physician's orders [REDACTED]. Nurse #1 said she reported the information to the oncoming evening nurse. There was no indication the staff updated Resident #1's Plan of Care in response to the 1/25/15 assessment findings. Nurse #4 said that on 1/25/15, if she was told Resident #1 had a red heel, she would have inspected his/her right heel during the evening shift and documented the findings. Although the Treatment Record, dated from 1/25/15 to 1/31/15, indicated the nurses assessed Resident #1's feet each evening, there was no documentation that indicated the condition of Resident #1's right heel. Nurse #4 said she documented the completion of diabetic foot care on 1/26/15, 1/27/15, 1/29/15, and 1/30/15 but did not always inspect Resident #1's feet each time she was assigned to Resident #1. Nurse #5 said she could not recall if she inspected Resident #1's feet on 1/28/15 and 1/31/15. There was no indication in Resident #1's clinical record, dated from 1/25/15 to 1/31/15, to indicate the condition of Resident #1's feet, prior to the deterioration of Resident #1's feet on 2/1/15. The Treatment Administration Record (TAR), dated 2/1/15, indicated Resident #1 had an intact blood blister on the right heel, a dark area on the right lateral foot, an intact blood blister on the left toe, and a black area on the plantar (ball) of the right foot. Nurse #5 said that on 2/1/15, she observed the skin issues on Resident #1's feet. Nurse #5 said she did not complete measurements of the areas and could not recall the sizes of the skin issues. Nurse #5 said she obtained a treatment to the area. Nurse #5 said the unstageable necrotic area on the plantar area of Resident #1's foot did not appear new. The Physician order, dated 2/1/15, included: Skin Prep to bilateral (both) heels and right great toe twice per day until healed. The TAR, dated from 2/1/15 to 2/9/15, indicated the nurses applied Skin Prep to Resident #1's heels and right great toe on the day and evening shifts. The Surveyor interviewed the Nurse Practitioner (NP) at 2:00 P.M. on 3/25/15. The NP said she was aware Resident #1 had a blister on the right heel and and left great toe and was not aware there was a black area on the plantar area of Resident #1's right foot. The NP said on 2/4/15, although she evaluated Resident #1, the staff reported no concerns with the feet, and she did not evaluate Resident #1's feet. The TAR, dated 2/8/15 and 2/9/15, indicated the blister on the right heel deteriorated to an open ulcer with no drainage and the nurse cleaned the area and applied a protective dressing. The Surveyor interviewed the Wound Nurse at 1:18 P.M. on 3/26/18. The Surveyor interviewed Unit Manager #1 at 10:15 A.M. on 3/30/15. The Wound Nurse and Unit Manager #1 said the nurses did not notify them of Resident #1's skin issues per the Facility practice until 2/9/15. The TAR, dated 2/10/15, indicated Resident #1 had a dark scabbed area on the left toe and bottom of the right foot, an open area on the right heel that had a red wound bed, and above that area, a superficial, macerated, light brown area surrounded by redness. The Wound Nurse said that on 2/10/15, she evaluated Resident #1's feet with the Nurse Practitioner (NP). The Wound Nurse said Resident #1 was scheduled to be discharged on [DATE]. The Wound Nurse said the scabbed areas were not stageable. The Wound Nurse said the right heel had an open stage two pressure ulcer. The Wound Nurse said there was slough (dead tissue) covering the area on the right plantar area of Resident #1's foot. The Wound Nurse said she and the nurses did not complete measurements per the Facility Protocol. The NP said that on 2/10/15, she evaluated Resident #1's feet. The NP said Resident #1 had a small scabbed area on the left great toe and an open area on the right heel from a deflated blister. The NP said Resident #1 also had a scab on the right plantar and an open area on the right plantar that she was not aware of prior to 2/10/15. The Physician order, dated 2/10/15, included: Duragel and a dry clean dressing to the right heel daily, Skin Prep to left great toe tip and right plantar scab daily, and triple antibiotic cream and dry clean dressing to right plantar open area daily. Nurse #1, Nurse #2, Nurse #3, Nurse #4 and Nurse #5 said between 1/14/15 to 2/10/15, they kept Resident #1's feet on a pillow when in bed. The Pressure Sore Protocols, dated 12/21/11) included a rehabilitation consult when a resident had a stage one pressure ulcer or a stage two pressure ulcer. The Surveyor interviewed the Rehabilitation Manager at 10:38 A.M. on 3/25/15. The Rehabilitation Manager said although Resident #1 received occupational therapy and physical therapy services, the Rehabilitation Team was not aware Resident #1 had skin issues on his/her feet. The Surveyor interviewed the Director of Nurses (DON) at 12:40 P.M. on 3/25/15. The DON said the nurses were to assess each diabetic resident's feet daily and were not to rely on the CNAs to report issues. The DON said she was not aware the nurses did not always have time to assess the diabetic residents' feet. The DON said the nurses did not follow the Diabetic Foot Care Policy. The DON said the nurses did not notify the Wound Nurse per the Facility practice to ensure Resident #1 had a timely treatment to his/her feet.

3. For Resident #15, the facility failed to ensure that bilateral hearing aides were placed in the resident's ears according to the physician's order and plan of care. Resident #15 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Admission Minimum Data Set (MDS) of 11/02/11 indicated that Resident #15 had moderately impaired hearing and used a hearing aide. The current physician's orders read, "Hearing Aids, 2 Ears, Daily Times of Administration 8:00 A.M. - 8:00 P.M." Observation of the resident on 6/7/12 at approximately 3:30 P.M. revealed the resident had only one hearing aide in place. Interview with the Medication Nurse at that time indicated that the resident's other hearing aide was in the medication cart but needed to be fixed because it had fallen into the toilet. Interview with the Unit Manager at approximately 4:00 P.M. indicated that the hearing aide had been repaired. The Unit Manager also said this information had not been communicated to the staff. As a result, staff provided the resident with just one hearing aide and not two as per the plan of care. Based on record review, observation and staff interview, the facility failed to ensure that the plan of care for 3 sampled residents (Residents #3, #15 and #19) in a sample of 24 was followed. Findings include: 1. For Resident #19, the facility failed to consistently follow the plan of care for utilizing a chair alarm when the resident was out of bed. On 5/26/12, the resident was found on the floor after having been placed in a recliner chair in his/her room without a chair alarm and sustained a left [MEDICAL CONDITION] that required surgical repair. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/21/12 admission Minimum Data Set (MDS), reviewed on 6/7/12 at 9:50 A.M., indicated the Resident had cognitive impairment and required extensive assistance with ambulation and activities of daily living. Review of the care plan for Falls, written on the day of the Resident's admission on 5/9/12, indicated the resident was at risk for falls due to decreased cognition and safety awareness. The care plan indicated that a pad and clip alarm were to be used in the wheelchair and bed, and a pad alarm was to be used with the recliner chair in the room. According to nursing notes and incident report documentation, on 5/26/12 at 3:30 P.M., a CNA heard someone calling for help. The CNA entered the resident's room and observed Resident #19 on the floor next to the bed. No mobility alarm was sounding. According to the statement of the CNA assigned to the resident on the day shift (7 A.M. - 3 P.M.) on 5/26/12, the CNA had put the resident in the recliner with a clip alarm at 2:30 P.M. According to the nurses notes, there was no clip alarm or pad alarm present on the recliner at the time the 3 P.M. - 11 P.M. staff responded to the resident's room. X-rays were obtained which revealed "left interotrochanteric fracture, [MEDICAL CONDITION] present". The Resident was admitted to the hospital and underwent surgical repair of the left [MEDICAL CONDITION]. On interview 6/7/12 at 11:00 A.M., the unit manager said there was no pad alarm observed on the recliner at the time of the incident. Please see F323. 2. For Resident #3, the facility failed to follow the physician's orders and the written care plan for: a) care of a deep tissue injury to the left heel and b) provide encouragement of meal intake (with a goal of 60% of meals) and fluid intake and output (I&O) with a goal of 1750 cc per day. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a) Review of the current physician's orders and care plan on 6/5/12 indicated that the Resident was to keep the left foot elevated when out of bed, float heels at all times (to relieve pressure), skin prep to heel and monitor closely, non-weight bearing of left leg and knee immobilizer at all times, except for hygiene care. On 6/6/12 at 8:30 A.M. during breakfast, the Surveyor observed Resident #3's heels were resting on the bed and not off-loaded as ordered. The resident was observed to have an inflamed left great toe and an [MEDICAL CONDITION] left foot. At this time the Surveyor showed the Unit Manager the Resident's foot. The Unit Manager said that he/she was not aware of an inflamed toe and did not comment on the heels not being off-loaded while in bed. On 6/6/12 after morning care, the Surveyor observed Resident #3 in his/her wheelchair with a bare left foot against the metal foot rest and the left leg not elevated. On 6/6/12 at 10:00 A.M. the Surveyor interviewed the Nurse Practitioner (NP). Following Surveyor inquiry, the NP said that he/she was not aware of the Resident's reddened left great toe and had just returned from vacation, but would evaluate Resident #3's condition. On 6/6/12 at 11:45 A.M. in the Rehabilitation Room, the Surveyor interviewed the Physical Therapist (PT) about Resident #3's left heel ulcer. The Physical Therapist said that the Resident's heel should be free floating with the use of pillows. The PT also said that the team would re-evaluate possible interventions for off-loading the resident's heel if utilizing a pillow was not practical. On 6/7/12 after morning care, the Surveyor observed the Resident sitting in his/her wheelchair with an elasticized slipper/sock on the left foot with which was observed to have obvious [MEDICAL CONDITION] and the wheelchair leg rest was not elevated. On 6/7/12 at approximately 12:30 P.M., the NP followed-up with the Surveyor and said that he/she was starting Resident #3 back on Keflex (an antibiotic). For Resident #3, the facility failed to follow the care plan for maintaining an elevated left leg and a free floating left heel (off-loading). b) Review of the initial Nutritional assessment dated [DATE] indicated that Resident #3's appetite was not good and the resident may be at risk for fluid volume deficit and weight changes due to [MEDICATION NAME], a diuretic used to prevent fluid retention in patients with [MEDICAL CONDITIONS]. The Nutrition Care Plan for Resident #3 from 5/12 - 6/12 included the following Interventions: - Provide adequate monitoring of hydration with a goal of 1750 cc/day intake of fluid and a goal of 60 % meal intake - Glucerna 6 oz. twice a day - Encourage fluids and by mouth (PO) intake On 6/5/12, during a treatment observation for Resident #3's post-surgical site, the Resident said to the Surveyor, in the presence of the nurse, that he/she did not receive lunch or dinner on the previous day. The Resident said that he/she had been napping and no one woke him/her for his/her meal and that this had happened on other occasions. Review of the Diet Intake Flow Sheet documentation substantiates that Resident #3 did not eat dinner on 6/4/12 and had no lunch on 5/27/12, 5/30/12 and 6/4/12, as follows: 5/27/12: Lunch- no liquids/ no solids 5/30/12: Lunch- no liquids/ no solids 6/04/12: Lunch- no liquids/ no solids 6/04/12: Dinner- no liquids/ no solids In addition, review of the Intake and Output log book from 5/28/12 - 6/4/12 indicated the following documentation: 5/28/12: 24 hr. total=1140cc in/1250 cc out 5/29/12: 24 hr. total= 1100cc in/1180cc out 5/30/12: 24 hr. total= 780cc in/900cc out 5/31/12: 24 hr. total= 1200cc in/1250cc out 6/1/12: unavailable total 6/2/12: 24 hr total=1020cc in/900cc out 6/3/12: 24 hr. total=780cc in/880cc out 6/4/12: 24 hr. total=820cc in/800cc out The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated a Brief Mental Interview for Mental Status at 13 (cognitively intact). On 6/6/12 at 10:00 A.M. the NP said that he/she was not aware of Resident #3's I&O log indicating an overall greater output than input or that the goal of 1750cc/day was consistently not being met. The NP also stated that the Resident needed to remain on [MEDICATION NAME] to prevent [MEDICATION NAME] toxicity and [MEDICAL CONDITION]. On 6/6/12, lab work revealed a Blood/Urea/Nitrogen (BUN) level of 18 (normal range = 7-23) and Creatinine level of 0.57 (normal range = 0.50-1.20) which the NP said did not reflect dehydration at this time. Resident #3's [MEDICATION NAME] level from 5/15/12 was low at 2.8 (normal = 3.5-5.0) and Total Protein was low at 5.4 (normal = 6.0-8.5), which can be indicators for poor wound healing and insufficient intake. The facility failed to correctly follow the plan of care to encourage food and fluid intake to help Resident #3 meet a hydration goal of 1750cc/day and a meal intake goal of 60%.

Based on record review and staff interview, the facility failed to provide adequate assistance devices to prevent accidents for 1 Resident (#19) in a sample of 24 residents. Findings include: For Resident #19, the facility failed to ensure that a clip alarm or pad alarm was applied and funcitioning per physician's orders [REDACTED]. The resident was subsequently found on the floor and sustained a left hip fracture which required surgical repair. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5/21/12 Admission Minimum Data Set (MDS) on 6/7/12 at 9:50 A.M. revealed the Resident had some cognitive impairment and required extensive assistance with ambulation and activities of daily living. Review of the care plan for Falls, written on the day of the Resident's admission on 5/9/12, indicated the resident was at risk for falls due to decreased cognition and safety awareness. Care plan interventions included the use of a pad and clip alarm to the wheelchair and bed, and a pad alarm to the recliner chair in the room. Review of the incident report and the dated and timed nurses notes of 5/26/12 at 3:30 P.M. indicated that a CNA heard someone calling for help. The CNA stated he/she entered the resident's room and observed the resident on the floor next to the bed. No mobility alarm was sounding. The Nurse Practitioner (NP) was notified of the fall and gave orders to obtain left hip, knee and pelvic x-rays. X-ray results revealed a "left interotrochanteric fracture, osteoporosis present" (left hip fracture). The Resident was admitted to the hospital and a left hip ORIF (open reduction internal fixation) was performed. According to the statement of the CNA assigned to the resident on the day shift (7 A.M. - 3 P.M.) on 5/26/12, he/she had put the resident in the recliner with a clip alarm at 2:30 P.M. According to the nurses notes, there was no clip alarm or pad alarm present on the recliner at the time the 3 P.M. - 11 P.M. staff responded to the resident's room. Review of the facility's communication form of 5/26/12, written at 11:00 P.M., indicated the resident was found on the floor and that no alarms were in place. On 6/7/12 at 11:00 A.M., the unit manager said there was no pad alarm observed on the recliner at the time of the incident.