Every finding on record at Bedford Nursing & Rehabilitation Center

Based on interview and record review, it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR) in accordance with the American Heart Association (AHA) guidelines and/or the facility's policy for 1 of 3 closed records reviewed. (Resident identifier is #119.)Findings include:Review on [DATE] of Resident #119's progress notes revealed the following nurse's note dated [DATE] at 6:43 a.m., written by Staff A (Registered Nurse), This writer told by 11-7 nurse [Staff B, Licensed Practical Nurse] that resident had passed away and needed to be pronounced. This writer found no bp [blood pressure], no apical [apical pulse], no respirations present, pupils fixed. Pronounced by this writer at 0640 [6:40 a.m.]. A nurse's note dated, [DATE] at 7:08 a.m., written by Staff A, revealed Immediately after pronouncing this writer learned resident full code CPR initiated,911 called. Further review of nursing progress notes revealed no notes from Staff B about Resident #119 passing away. Review on [DATE] of Resident #119's physician orders revealed an order, dated [DATE], for a full code, indicating Cardiopulmonary Resuscitation (CPR) is to be initiated in the event their heart or breathing stops.Interview on [DATE] at approximately 11:50 a.m. with Staff A revealed that on the morning of [DATE] they arrived at work around 6:30 a.m. Staff A was informed by Staff B that Resident #119 had passed away and needed to be pronounced. Staff A stated that while writing the pronouncement note in Resident #119's medical record they realized they were a full code. During a second interview on [DATE] at approximately 10:50 a.m., Staff A revealed that when they went to pronounce Resident #119, they found them with no vital signs and fixed pupils. Staff A stated Resident #119 did not have rigidity noted on their assessment.Interview on [DATE] at approximately 10:30 a.m. with Staff B revealed that on [DATE] they entered Resident #119's room to administer their morning medication between 5:00 a.m. and 5:30 a.m. Staff B observed that Resident #119 was not responsive, had no vital signs and was cold to touch and stiff. Staff B stated they went to the chart to check Resident #119's code status and noted they were a full code. Staff B proceeded to do an internet search to see when not to start CPR on someone. Staff B stated that after the internet search they called the on-call nurse, Staff C (Assistant Director of Nursing), to inform them that Resident #119 had passed away and needed to be pronounced. Interview on [DATE] at approximately 10:40 a.m. with Staff C revealed that they were the registered nurse on call for [DATE]. Staff C stated that on [DATE] they received a call from Staff B early in the morning informing them that Resident #119 had passed away and needed to be pronounced. Staff C stated they were not aware that Resident #119 was a full code at the time of the call.Review on [DATE] of facility policy titled Cardiopulmonary Resuscitation (CPR), revised on [DATE], revealed .1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advanced directive. B. In the absence of advanced directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition).Review on [DATE] of the American Heart Association Journals: Circulation, [DATE], Volume 122. Number 18 supply 3, retrieved from https://doi.org/10.1161/CIRCULATIONAHA.110.970905 Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Withholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital Cardiac Arrest (OHCA), Criteria for Not Starting CPR in All OHCA revealed the following: .Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of cardiac arrest, there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNR order.

Based on interview and record review, it was determined that the facility failed to ensure that resident's advance directives were accurately reflected for 3 residents in a final sample of 32 residents. (Resident identifiers are #18, #70 and #92.)Findings include:Interview on [DATE] with Staff E (Regional Clinical Nurse) revealed that the facility places a green dot on the spine of paper charts to indicate a Full Code status (meaning perform CPR (Cardiopulmonary resuscitation)). Resident #70 Review on [DATE] of Resident #70's electronic medical record revealed a resident demographic banner that indicated a code status of Full Code. Further review revealed a physician's order dated [DATE] for a Full Code. Review on [DATE] of Resident #70's paper chart revealed there was a green dot on the outside spine of the book. Further review revealed a green Full Code sheet and a Portable Do Not Attempt Resuscitation (P-DNR) Order form that was signed and dated by the provider on [DATE]. Review on [DATE] of Resident #70's care plan revealed that the Resident had a code status of Full Code dated [DATE]. Further review revealed this care plan had a goal with a target date of [DATE] that the resident and/or representative will make healthcare decisions known and will be updated in any change of status. Interview on [DATE] at 12:51 p.m. with Staff A (Registered Nurse) confirmed the above and revealed that based on the electronic record he/she would perform CPR on the resident. Interview on [DATE] at 2:28 p.m. with Staff F (Unit Manager) confirmed that Resident #70's code status was DNR and that the physician's order wasn't updated. Resident #18 Review on [DATE] of Resident #18's electronic medical record revealed a physician's order, dated [DATE], for a DNR. Further review revealed a resident demographic banner, at the top of the screen, that indicated a code status of DNR. Review on [DATE] of Resident #18's care plan revealed that the Resident had a code status of Full Code dated [DATE]. Interview on [DATE] at 12:00 p.m. with Staff I (Licensed Practical Nurse) confirmed the above findings for Resident #18. Resident #92 Review on [DATE] of Resident #92's electronic medical record revealed a physician's order, dated [DATE], for a DNR. Further review revealed a resident banner, at the top of the screen, that indicated a code status of DNR. Review on [DATE] of Resident #92's care plan revealed that Resident #92 had a code status of Full Code dated [DATE]. Interview on [DATE] at 12:00 p.m. with Staff I confirmed the above findings for Resident #92. Review on [DATE] of the facility's policy titled Resident's Rights Regarding Treatment and Advance Directives revised on [DATE] revealed, .It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive . 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .

Based on interview and record review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for individuals who required greater than 30 days of facilities services for 2 of 3 residents reviewed for PASARR in a final survey sample of 24. (Resident identifiers are #20 and #48.)Findings include:Resident #48 Review on 12/15/25 of Resident #48's medical record revealed an admission date of 1/10/25 and a diagnosis of Traumatic Brain Injury. Review on 12/15/25 of Resident #48's PASARR Level 1 screen form, dated 1/8/25, revealed Section 6. Exemption/Exclusion, Hospital Discharge Exemption was signed by a provider on 1/24/25. Further review of this section revealed .If the NF [Nursing Facility] stay is 30 days or longer, a new PASARR screen and resident review must be performed with in 40 calendar days of admission . Interview on 12/17/25 at approximately 8:23 a.m. with Staff J (Social Services) confirmed that Resident #48 had remained at the nursing facility past 30 days and a PASARR Level 1 screen had not been done within 40 calendar days of admission. Resident #20 Review on 12/17/25 of Resident #20's was admitted to the facility 1/24/25 with a diagnosis of unspecific psychosis not due to a substance or known physiological condition. A new diagnosis of Mild Dementia, with mood disturbance was added to Resident #20's diagnosis list on 4/16/25. Review on 12/17/25 of Resident #20's PASARR Level I screen form dated 1/24/25 revealed under Section 2A: Suspected Diagnosis of Mental Illness was checked no, Section 3A: Screening for Intellectual Disability/Developmental Disability (ID/DD) was checked no, Section 4A: Screening for related Condition (RC) was checked no, and Section 5 Undiagnosed Condition was checked no. Further review of this form revealed hospital discharge was not checked and signed by a physician on 1/24/25 certifying that Resident #20 would require less than 30 days of nursing facility services. Further review revealed a note .Note: If the [nursing facility name omitted] stay is 30 days or longer, a new [PASARR] screen and resident review must be performed within 40 calendar days of admission. Interview on 12/17/25 at 2:00 p.m. with Staff D (Administrator) confirmed that Resident #20 did not have a Level I PASARR completed within 40 days of admission.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and standards for 1 of 1 resident reviewed for Transmission Based Precautions (TBP) and 1 of 1 resident reviewed for catheters. (Resident identifier are #2 and #114.)Findings include:Resident #114Observation on 12/15/25 at 9:57 a.m. at the 300's hallway revealed that Resident #114 had a contact precaution sign posted outside of the door.Interview on 12/15/25 at 9:57 a.m. with Staff H (Registered Nurse (RN)) revealed that Resident #114 was on contact precaution for a Clostridium Difficile (C-diff) infection. Review on 12/15/25 of Resident #114's care plan revealed a contact precautions for C-diff infection care plan, dated 12/15/25, with the following interventions: Place resident in a private room with contact precautions. Care equipment should be appropriately cleaned, disinfected or sterilized according to facility protocol. Further review revealed a C-diff infection care plan, dated 12/15/25, with an intervention to disinfect all equipment used before it leaves the room. Observation on 12/16/25 at approximately 8:30 a.m. in Resident #114's room revealed that Staff G (RN) was wearing personal protective equipment (PPE), including a protective gown and gloves, while performing a fingerstick blood glucose (FSBG) test on Resident #114 using a glucometer. Staff G exited the room wearing the protective gown and gloves while carrying a tray containing the glucometer and Resident #114's inhaler. Further observation revealed that Staff G disinfected the glucometer at the medication cart in the 300's hallway using a Super Sani-Cloth Germicidal Wipe and stored it in the medication cart. Resident #114's inhaler was stored in the medication cart without being disinfected.Interview on 12/16/25 at approximately 8:38 a.m. with Staff G confirmed the above observation. Staff G stated that he/she was in Resident #114's room to perform an FSBG test and administer Resident #114's inhaler.Review on 12/16/25 at approximately 1:45 p.m. with Staff C (Infection Preventionist) of the manufacturer's instructions for the Super Sani-Cloth Germicidal Wipe revealed that the product did not indicate efficacy against C-diff (meaning it does not disinfect against C-diff). Review on 12/16/25 of the facility's policy titled, Transmission-Based (Isolation) Precautions, review date of 6/4/24, revealed .Initiation of Transmission-Based Precautions ( Isolation Precautions) .use disposable or dedicated noncritical resident-care equipment (e.g., blood pressure cuff, bedside commode). If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA [Environmental Protection Agency]-registered disinfectant after use.Review on 12/16/25 of the CDC website titled, Guidelines for Environmental Infection Control in Health-Care Facilities, update date of 7/2019, revealed .Environmental Services .Cleaning of Medical Equipment Manufacturers of medical equipment should provide care and maintenance instructions specific to their equipment. These instructions should include information about a. the equipments' compatibility with chemical germicides, b. whether the equipment is water-resistant or can be safely immersed for cleaning, and c. how the equipment should be decontaminated if servicing is required. In the absence of manufacturers' instructions, non-critical medical equipment (e.g., stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination .Special Pathogen Concerns .b. Clostridium difficile .The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using EPA-registered products specific for inactivating C. difficile spores as appropirate [sic]. Thus, combined use of appropriate hand hygiene, barrier precautions, and meticulous environmental cleaning, and use of an EPA-registered product that is appropriate for the level of risk, should effectively prevent spread of the organism .Review on 12/16/25 of the CDC website titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), update date of 9/2024, revealed .Contact Precautions .Patient-care equipment and instruments/devices .In acute care hospitals and long-term care and other residential settings, use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean, and disinfect such equipment before use on another patient .Resident #2Observation on 12/15/25 at 9:29 a.m., 10:04 a.m., and 2:50 p.m. in Resident #2's room revealed that Resident #2's urinary drainage bag, filled with yellow, urine-like fluid, was resting on the floor. Review on 12/15/25 of Resident #2's medical record revealed that Resident #2 has an indwelling urinary catheter for a medical diagnosis of obstructive and reflux uropathy. Observation on 12/16/25 at 9:21 a.m. with Staff G revealed that Resident #2's urinary drainage bag was resting on the floor.Interview on 12/16/25 at approximately 9:21 a.m. with Staff G confirmed the above observation on 12/16/25. Interview on 12/17/25 at approximately 10:30 a.m. with Staff C revealed that urinary drainage bag should not be on the floor. Review on 12/17/25 of the facility's policy titled, Indwelling Catheter Use and Removal, review date of 11/27/23, revealed .If an indwelling catheter is in use, the facility will provide appropriate care in accordance with current professional standards of practice and resident care policies.References:.Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) .Review on 12/17/25 of the CDC website titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), dated 3/25/24, retrieved from: https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, revealed .III. Proper Techniques for Urinary Catheter Maintenance.Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, interview, and record review, it was determined that the facility failed to store medications securely in accordance with professional standards for 1 of 2 units observed.Findings include:Observation on 12/15/25 at approximately 8:00 a.m. of the first floor nurses' station revealed the following medication cards laying on the counter for Resident #119:Diltiazem HCI Coated Beads 240 Milligrams (MG) with 6 capsules remaining.Eliquis Oral Tablet 5 MG with 14 tablets remaining.Lasix Oral Tablet 40 MG with 8 tablets remaining.Lasix Oral Tablet 40 MG with 1 tablet remaining.Lasix Oral Tablet 20 MG with 12 tablets remaining.Letrozole Oral tablets 2.5 MG with 6 tablets remaining.Pantoprazole Sodium Oral Tablet Delayed Release 40 MG with 6 capsules remaining.Potassium Chloride Extended Release Tablet 20 Milliequivalent (MEQ) with 13 tablets remaining.Potassium Chloride Extended Release Tablet 20 Milliequivalent (MEQ) with 12 tablets remaining.Sotalol HCI Oral Tablet 120 MG with 18 tablets remaining.Further observation revealed the following the nurses' station entrance did not have a door and was open to the adjacent common area where residents were sitting. There were no staff in or near the nurses' station. Review on 12/15/25 of the facility's policy titled Medication Storage, revised 4/9/23 revealed, .1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments.Interview on 12/15/25 at approximately 8:10 a.m. with Staff I (Licensed Practical Nurse) confirmed the above findings and that all medications should be locked in a medication cart or in the medication room.

Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 3 closed records reviewed. (Resident identifier is #119.)Findings include:Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .Review on 12/16/25 of Resident #119's physician orders, revealed the following insulin orders:Insulin Lispro to inject per sliding scale: if 71-150=0 units; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-999=10 units Notify Provider if CBG [capillary blood glucose] over 351 with an order date of 11/18/25;Insulin Lispro to inject 15 units at 4:30 p.m. with an order date of 11/26/25.Review on 12/16/25 of Resident #119's November 2025 Medication Administration Record (MAR) revealed the following insulin administrations on 11/30/25:Insulin Lispro (sliding scale) 10 units were given at 11:30 a.m. for a CBG of 363 by Staff L (Licensed Practical Nurse (LPN)), Insulin Lispro 15 units scheduled for 4:30 p.m. was documented held (not administered) by Staff L;Insulin Lispro (sliding scale) 0 unit was given at 4:30 p.m. for a BS (blood sugar) of 121 by Staff L, and Insulin Lispro (sliding scale) 10 units were given at 9:00 p.m. for BS of 469 by Staff B (LPN). Review on 12/16/25 of Resident #119's progress notes revealed the following:On 11/30/25, at 5:31 p.m., written by Staff L, Insulin Lispro 15 units held per nursing judgement for CBG of 80 and none of meal consumed. On 11/30/25, at 7:46 p.m. written by Staff L, pt [patient] drowsy this shift and spends majority of day resting in bed, refused any lunch or substitute offered. CBG's vary from hi [high] end of normal to 60 when most recently checked. pt alert and verbal and willing to drink a cup of milk but again refuses any food. oncoming sure aware wand [sic] will monitor CBG's closely. provider book updated with request to assess. Further review of Resident #119's progress notes revealed no other documentation regarding physician notification of Resident #119's CBG over 351 per Insulin Lispro (sliding scale) order, not administering the Insulin Lispro 15 units at 4:30 p.m., and monitoring of Resident #119's CBG. Interview on 12/16/25 at approximately 10:30 a.m. with Staff B confirmed that they gave Resident #119 10 units of Insulin Lispro (sliding scale) on 11/30/25 at 9:00 p.m. and did not notify a provider. Review on 12/17/25 of the provider communication book with Staff F (Unit Manager) revealed no entries for Resident #119's CBGs on 11/30/25.Interview on 12/17/25 at approximately 8:52 a.m. with Staff F confirmed the above mentioned progress note for holding the 4:30 p.m. scheduled Insulin Lispro 15 units on 11/30/25, there were no notes for the provider of Resident #119's CBGs on 11/30/25 in the provider communication book, and the Insulin Lispro (sliding scale) order indicated to notify the provider for a CBG above 351. Staff F stated that the provider communication book was for issues that do not require immediate attention. Review on 12/17/25 of facility's policy titled Medication Administration, revised on 4/9/25, revealed .17. Administer medications as ordered .22. Report and document any adverse side effects, refusals or holding of medications .

Based on observation and interview, it was determined that the facility failed to ensure that food and dishware were stored in accordance to professional standards for food service safety for 1 of 1 kitchen observed. Findings include: Observation on 10/1/24 at approximately 8:30 a.m. with Staff H (Food Service Director) of the facility kitchen revealed a box of zucchini and yellow squash that were soft, covered with a clear slime-like substance, clusters of white fuzzy substance, and black discoloration that were stored in the kitchen walk-in refrigerator. Further observation revealed a stack of pre-sliced hard yellow cheese half covered with saran wrap with no date. Interview on 10/1/24 at approximately 8:30 a.m. with Staff H confirmed the above finding. Observation on 10/2/24 at approximately 8:40 a.m. with Staff H in the kitchen revealed a dietary aide stacked wet cups and stored them in a bin to air-dry. A few minutes later, another dietary aide took the same stack of wet cups and moved them to the main dining room for use. Interview on 10/2/24 at approximately 8:40 a.m. with Staff H confirmed the above finding and that they stacked wet cups to air dry. Staff H was unable to provide a facility policy on storage and drying of dishware. Review on 10/2/24 of the facility policy titled, Food Safety Requirements, dated 4/9/24, revealed: .Facility staff shall inspect all food, food products, and beverages for safe transport and quality .and ensure timely and proper storage .Practices to maintain safe refrigerated storage include: .labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers . Review on 10/2/24 of the FDA 2017 Food Code, retrieved from:https://www.fda.gov/media/110822/download, revealed: .Preventing Food and Ingredient Contamination 3-302.11Packaged and Unpackaged Food - Separation, Packaging, and Segregation .FOOD shall be protected from cross contamination by .storing the FOOD in packages, covered containers, or wrappings; Preventing Contamination from the Premises 3-305.11 Food Storage .(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location (2) Where it is not exposed to splash, dust, or other contamination; .Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining .before contact with FOOD .4-901.12 Wiping Cloths, Air-Drying Locations . shall be air-dried in a location and in a manner that prevents contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from a medication cart in 1 of 3 medication carts observed. Findings include: Observation on 10/1/24 at approximately 8:20 a.m. revealed a bottle of Latanoprost Ophthalmic Solution 0.005% with an open date of 8/9/24. Review on 10/1/24 of manufacturers instructions on package revealed: .Opened bottle may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks . Interview on 10/1/24 at approximately 8:25 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings and that the above medication was expired and currently in use. Review on 10/3/2024 of facility policy titled, Medication Storage, revised 4/16/24 revealed: . 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on interview and record review it was determined that the facility failed to employ, at least on a part time basis, an Infection Prevetionist who completed specialized training in infection prevention and control for a facility census of 86 residents. Findings include: Review on 10/2/24 of infection control line listing and antibiotic stewardship records indicated that Staff D (Infection Preventionist) was responsbile for the infection prevention and control program. Interview on 10/2/2024 at approximately 1:10 p.m. with Staff A (Director of Nursing) revealed that Staff D had been the full time Infection Preventionist since January 2024. Review on 10/2/24 of Staff D's training revealed that Staff D had started specialized Infection Prevention Training in September 2023 but had not completed it. Interview on 10/2/2024 at approximately 1:00 p.m. with Staff E (Registered Nurse) revealed that Staff E assisted Staff D with the infection control and prevention program. Staff E revealed that they had not completed specialized education in Infection Prevention.

Based on interview and record review, it was determined that the facility failed to secure a communication process was implemented that ensures that the needs of the resident were addressed for hospice services for 1 resident in a closed record sample of 4 residents (Resident identifier is #228). Findings include: Review on 12/14/23 of Resident #228's hospice notes, dated 10/19/23, revealed that there was a recommendation to increase the morning dose of methadone to 5 milligrams (mg) and this was reviewed with the facility unit manager. Review on 12/14/23 of Resident #228's hospice recommendation forms revealed the following: On 10/9/23, there was a hospice recommendation for Methadone [Opioid] 10 mg/ml [milligram/milliliter] to give 0.25 ml [2.5 mg] by mouth every 12 hours. Further review of the 10/9/23 hospice recommendation revealed the facility nurse and provider had signed the hospice recommendation. On 10/19/23, there was a hospice recommendation to increase Methadone 10 mg/ml to 5 mg (0.5 ml) by mouth every morning and keep same dose of 2.5 mg (0.25 ml) by mouth every evening. Further review of the 10/19/23 hospice recommendation revealed that the Durable Power of Attorney (DPOA) was in agreement of the hospice recommendation. Review also revealed that there was no signature from a provider or facility nurse in the hospice recommendation form. Review on 12/13/23 of Resident #228 revealed the following physician's orders: On 10/19/23, there was an order change for Methadone 10 mg/ml to give 0.25 ml by mouth twice a day with a start date of 10/19/23 and discontinued date of 10/25/23. There was no order for an increase morning dose of Methadone 10 mg/ml as recommended by hospice on 10/19/23. On 10/25/23, there was an order to increase the Methadone 10 mg/ml to give 0.25 ml by mouth once a day [scheduled for 8:00 p.m.] and 0.5 ml [5 mg] by mouth once a day [scheduled for 7:00 a.m.] with a start date of 10/25/23. Interview on 12/14/23 at approximately 9:56 a.m. with Staff B (Nurse Unit Manager) revealed that the hospice recommendations were communicated to the facility provider. Staff B stated that he/she worked as the unit manager on 10/19/23. Further interview with Staff B revealed that he/she was unable to recall any hospice recommendation for Resident #228 on 10/19/23. Review on 12/14/23 of Resident #228's medical record revealed that Resident #228 received hospice services from 10/7/23 to 12/1/23. Further review revealed that Resident #228's attending physician was Staff K (Medical Director). Review also revealed no documentation of the 10/19/23 hospice recommendations being addressed with Staff K or any other facility provider. Further review also revealed no documented communication between hospice and the facility regarding the physician's order for an increased dose of Methadone on 10/25/23, as mentioned in the above findings. Interview on 12/14/23 at approximately 3:30 p.m. with Staff J (Regional Nurse) confirmed the above findings. Interview on 12/15/23 at approximately 11:30 p.m. with Staff K revealed that he/she defers to hospice recommendations for residents receiving hospice services, if the DPOA is in agreement. Staff K does not recall any hospice recommendation for Resident #228. Review on 12/15/23 of the facility's policy titled, Coordination of Hospice Services, review date of 11/28/23, revealed .The facility and hospice provider will coordinator a plan of care and will implement interventions in accordance with resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible .The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility .The facility will maintain communication with hospice as it related to the resident's plan of care, services to ensure each entity is aware of their responsibilities .

Based on observation, interview, and policy review it was determined that the facility failed to maintain a clean environment in the dishwashing area. Findings include: Main Kitchen Observation on 12/13/23 at 8:00 a.m. in the kitchen dishwashing area with Staff L (Dietary Director) revealed two fans that were on and one ceiling vent that had accumulated gray dust and grease debris. Interview on 12/13/23 at 8:05 a.m. with Staff L confirmed the above finding. Review on 12/15/23 of the FDA [Food and Drug Administration] Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed . 4-602.13 Nonfood Contact Surfaces Nonfood contact surfaces or equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues . Review on 12/15/23 of facility policy titled, Sanitization, last revised November 2022, revealed: The food services area is maintained in a clean and sanitary manner.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secured for 2 of 3 medication carts observed and the facility failed to ensure that medications were labeled with open expiration dates for 1 of 3 medication carts and 1 of 1 medication room observed. Findings include: Overflow Medication Cart Observation on 12/13/23 at 8:15 a.m. with Staff G (Nurse Unit Manager) revealed that the nurse's station door was open. The Overflow Medication Cart was unlocked in the nurse's station. Further observation also revealed that the Overflow Medication Cart had resident's oral prescription medications, resident's prescription inhalers and Over-The-Counter (OTC) medications. Interview on 12/13/23 at approximately 8:15 a.m. with Staff G confirmed the above finding. Staff G stated that only nurses and Medication Nursing Assistants (MNAs) should have access to medications. Staff G also stated that staff other than the nurses and MNAs, such as providers, Licensed Nursing Assistants, and therapists have access to the nurse's station. Review on 12/14/23 of the facility's policy titled, Medication Storage, review date of 5/23/23, revealed .General Guidelines . All drugs and biological will be stored in locked compartments . West Odd Medication Cart Observation 12/13/23 at 8:28 a.m. with Staff H (MNA) of the [NAME] Odd Medication Cart revealed that Resident #62's Advair Diskus 500 microgram (mcg)/50 mcg had no open expiration date. Interview on 12/13/23 at approximately 8:28 a.m. with Staff H confirmed the above finding of the [NAME] Odd Medication Cart. Review on 12/13/23 of the Advair 500/50 manufacturer's instruction revealed .How should I store Advair Diskus? .Safely throw away ADVAIR DISKUS in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first . Observation on 12/13/23 at approximately 3:52 p.m. of the [NAME] Odd Medication Cart revealed that the cart was unlocked and unsupervised by nursing staff and stationed at the west wing hallway. Further observation revealed that the cart had resident's prescription medications and OTC medications. Interview on 12/13/23 at approximately 3:52 p.m. with Staff I (MNA) confirmed the above observation. Staff I stated that he/she was assigned to the [NAME] Odd Medication Cart. Medication Room Observation on 12/13/23 at approximately 8:35 a.m. with Staff J (Regional Nurse) of the medication room revealed an open tuberculin vial with no open expiration date. Interview on 12/13/23 at approximately 8:35 a.m. with Staff J confirmed the above finding of the medication room. Review on 12/13/23 of the tuberculin manufacturer's instruction revealed Storage .vial in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 12/14/23 of the facility's policy titled, Labeling of Medications and Biologicals, review date of 5/3/22, revealed .All medications and biologicals will be labeled in accordance with applicable federal and state requirement and current accepted pharmaceutical principles and practices .Any medication label that is soiled, incomplete, illegible, work, or makeshift must be returned and replaced by the issuing pharmacy, not merely covered .Labels for mutli-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured) .

Based on observation, interview, and record review the facility failed to follow physicians orders for 1 of 1 residents reviewed for general skin conditions in a final sample of 18 residents (Resident identifier is #6). Findings Include: Observation on 12/13/23 at approximately 9:30 a.m. of Resident #6's right hand revealed a mepiplex dressing dated 12/8/23. Review on 12/13/23 of Resident #6's medical record revealed the following physician's order: Skin tear top of right hand, cleanse with NS [normal saline] apply Vaseline, gauze, assure steri strips are intact then cover with Tegaderm, change QOD [every other day] and prn [as needed] every evening shift every other day, Start Date 12/3/23. Interview on 12/14/23 at approximately 1:15 p.m with Staff B (Nurse Unit Manager) confirmed the above findings. Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary .

Based on interview, record review, and policy review, it was determined that the facility failed to notify the resident's physician when medications were unavailable for 1 resident in a final sample of 18 residents (Resident identifier is #281). Findings include: Resident #281 Review on 12/14/2023 of Resident #281 hospital discharge medication list, dated 12/6/2023, revealed an order for Clobazam (used for the treatment of seizures) 10 milligrams (mg) 1 tablet by mouth two times per day. Further review revealed that Resident #281 received Clobazam prior to leaving the hospital at 8:46 a.m. on 12/6/2023. Review on 12/14/2023 of Resident #281's December Medication Administration Record (MAR) revealed that Resident #281 did not receive a second dose of Clobazam on 12/6/23 and received one dose on 12/7/23 at 8:00 p.m. Review on 12/14/2023 of Resident #281's progress note, dated 12/6/2023, revealed that Clobazam had not been received from the pharmacy. Interview on 12/14/2023 at approximately 12:30 p.m. with Staff D (Director of Nursing) revealed that when a medication is unavailable, it is the facility's policy to inform the provider and obtain an order to either hold that medication until it's available or obtain an order for another medication/treatment. Review on 12/14/2023 of Resident #281 medical record revealed no documentation that the provider was notified that Clobazam was unavailable and Resident #281 had not received two doses. Interview on 12/14/2023 at approximately 2:00 p.m. with Staff D confirmed there was documentation of notification to the provider for the above missed doses. Review on 12/14/2023 of facility policy titled Unavailable medications, dated 5/30/2023 revealed: .b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternate treatment orders and/or specific orders for monitoring resident while medication is on hold .

Based on observation, interview, and policy review, the facility failed to ensure dignity was maintained for 1 of 1 residents reviewed for dressing changes in a final sample of 18 residents (Resident identifier is #37). Findings include: Observation on 12/15/23 at approximately 10:10 a.m. of Resident #37's pressure ulcer dressing changes in his/her room with Staff B (Nurse Unit Manager) revealed that during the dressing change both the door and curtain remained open. A housekeeper entered the room during the dressing change. Interview on 12/15/23 at approximately 10:15 a.m. with Staff B confirmed the above findings. Review on 12/15/23 of the facility policy titled, Promoting/Maintaining Resident Dignity, Revised on 11/23/23 revealed: Compliance Guidance 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights 12. Maintain resident privacy

Based on interview, observation, and record review, it was determined that the facility failed to assess a residents ability to self-administer medications for 2 of 2 residents reviewed for self-administration of medication in a final sample of 21 residents. (Resident identifiers are #29 and #72.) Findings include: Resident #29 Observation on 11/1/22 at approximately 10:18 a.m. of Resident #29 revealed an unused [MEDICATION(S)] on Resident #29's side table. Further observation of Resident #29 revealed Resident #29 to remove the backing of the [MEDICATION(S)] and place the [MEDICATION(S)] on their right deltoid. Interview on 11/1/22 at approximately 10:18 a.m. with Resident #29 revealed that the nurse will leave the [MEDICATION(S)] with them to put on whichever arm they need it on that day. Review on 11/2/22 at approximately 12:18 p.m. of Resident #29's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 11/2/22 at approximately 12:18 p.m. of Resident #29's medical record revealed no current order to self-administer [MEDICATION(S)]. Further review of Resident #29's medical record revealed no assessment for self-administration of medication. Interview on 11/3/22 at approximately 10:30 a.m. with Staff B (Director of Nursing) confirmed that Resident #29 did not have an assessment or order for self-administration of medication. Resident #72 Observation on 11/1/22 at approximately 12:55 p.m. of Resident #72 revealed an open tube of [MEDICATION(S)] gel on Resident #72's side table. Interview on 11/1/22 at approximately 12:55 p.m. with Resident #72 revealed that they apply the [MEDICATION(S)] gel to their shoulder as needed for pain. Review on 11/2/22 at approximately 1:30 p.m. of Resident #72's medical record revealed no current order to self-administer [MEDICATION(S)] gel. Further review of Resident #72's medical record revealed no assessment for self-administration of medication. Interview on 11/3/22 at approximately 10:30 a.m. with Staff B confirmed that Resident #72 did not have an assessment or order for self-administration of medication. Staff B stated that they were unaware that Resident #72 had the [MEDICATION(S)] gel at their bedside. Review on 11/3/22 of the facility policy titled Self-Administration of Medication, revised on February 2021, revealed .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so .As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive an physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan .

Based on interview, observation, and policy review, the facility failed to maintain infection control practices according to accepted national standards during a facility COVID-19 outbreak on 2 of 2 units observed for staff infection control practices (Resident identifier is #23). West Wing Unit Observation on 11/3/22 at approximately 10:00 a.m. of medication administration for Resident #23 with Staff D (Registered Nurse) revealed a droplet precaution sign on the outside of Resident #23's room. Further observation revealed Staff D to enter Resident #23's room wearing only a gown, gloves, glasses and a surgical mask. Further observation of Staff D revealed them to not change the surgical mask after leaving Resident #23's room and proceeding to pass medications to other residents. Interview on 11/3/22 at approximately 10:05 a.m. with Staff D revealed that Resident #23 is on droplet precautions for a positive COVID-19 test. Staff D stated that the facility did not require an N95 mask to be worn when going into the room of COVID-19 positive residents. Interview on 11/3/22 at approximately 10:30 a.m. with Staff B (Director of Nursing) confirmed that the facility did not requie a N95 mask when staff enter a COVID-19 positive room. Staff D stated that N95 masks are available if they chose to wear one but a surgical mask is acceptable. Review on 11/3/22 of the facility policy titled Transmission-Based Precautions When Caring for Patients with Confirmed or Suspected COVID-19, revised on 9/36/22, revealed .When caring for patients with confirmed or suspected COVID-19, [facility name omitted] will follow guidance put forth by the Centers for Disease Control and Prevention (CDC) to prevent the transmission of the virus. Personal Protective Equipment HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and Transmission Based Droplet Precautions which include: Gown, Gloves, Eye protection, NIOSH-approved particulate respirator with N95 filters or higher. While N95 or higher respirators are preferred, facemasks are an acceptable alternative . Review on 11/3/22 of the Centers for Disease Control (CDC) website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/23/22, revealed .Implement Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection .Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . North Wing Unit Observation on 11/2/22 approximately between 9:04 a.m. to 9:20 a.m. revealed that Staff F (Licensed Nursing Assistant (LNA)) was wearing a surgical mask below their nose while transporting a resident from the dining room to the resident's room with approximately 4 other residents in the hallway, 2 residents did not have surgical masks on. Observation also revealed that Staff F was observed to have their surgical mask below the nose after coming out of a resident's room. Interview on 11/2/22 at approximately 9:15 a.m. with Staff F confirmed the above findings. Staff stated that their surgical mask should cover the nose. Observation on 11/2/22 approximately between 9:15 a.m. to 9:30 a.m. revealed that Staff G (LNA) was wearing their surgical mask below their nose near the elevator. Further observation revealed that Staff G was wearing their surgical mask below their nose while assisting a resident in bed. Staff G was observed to have their surgical mask below their nose while in a resident's room and exiting a resident's room. Interview on 11/2/22 at approximately 9:20 a.m. with Staff G confirmed the above finding. Staff G stated that their surgical mask does not fit appropriately and kept falling off. Staff also stated that the surgical mask should cover the nose. Review on 11/3/22 of the CDC website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated date of 9/23/22, retrieved from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed that .Implement Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .When [CONDITION(S)]-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients . Review on 11/3/22 of the facility's community transmission rate logs revealed that the community transmission rate dated 10/31/22 was high.

Based on observation, interview and record review, it was determined that the facility failed to ensure medication error rate was not greater than 5 percent (%) during medication administration observations with 28 medication opportunities (Resident identifier is #4). Findings include: Observation on 11/2/22 at approximately 8:50 a.m. of Resident #4's medication administration with Staff E (Licensed Practical Nurse) revealed Staff E to dispense [MEDICATION(S)] 100 milligrams (mg). Review on 11/2/22 at approximately 8:50 a.m. of Resident #4's November Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50 mg one time a day, with a start date of 10/28/22. Interview on 11/2/22 at approximately 8:50 a.m. with Staff E confirmed they had dispensed the wrong dose of [MEDICATION(S)] for Resident #4. Observation on 11/2/22 at approximately 8:55 a.m. of Resident #4's medication administration with Staff E revealed a small white tablet to have fallen to the bottom of Resident #4's water cup while taking their medications. Further observation revealed the small white tablet to have dissolved in the remainder of water in Resident #4's cup. Resident #4 returned the water cup to Staff E who then disposed of the cup in the garbage. Interview on 11/2/22 at approximately 8:55 a.m. with Staff E confirmed there was a small lump of a white substance remaining Resident #4's water cup when it was disposed of. Review on 11/3/22 of facility policy titled Administering Medications, revised on April 2019, revealed . The individual administering the medication checked the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . There were 2 medication errors out of a total 28 medication opportunities resulting in 7.14% medication error rate.

Based on interview and record review, it was determined that the facility failed to ensure that the resident (and/or the resident representative) was informed of the Notice of Medicare Non-coverage (NOMNC) for 3 out of 3 residents reviewed for Beneficiary Notices (Resident identifiers are #23, #58, and #83). Findings include: Resident #23 Review on 11/1/22 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #23 was discharged from Medicare Part A Services on 10/22/22 and remained at the facility. Review on 11/1/22 of Resident #23's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility, revealed that Resident #23's last covered day of Medicare Part A skilled services was 10/22/22 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review of this form revealed under question 2 Was the NOMNC . provided to the resident? was checked No. Resident #58 Review on 11/1/22 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #58 was discharged from Medicare Part A on 7/8/22 and remained at the facility. Review on 11/1/22 of Resident #58's SNF Beneficiary Protection Notification Review form, completed by the facility, revealed that Resident #58's last covered day of Medicare Part A skilled services was 7/8/22 and that the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. Further review of this form revealed under question 2. Was the NOMNC . provided to the resident? was checked No. Resident #83 Review on 11/1/22 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #83 was discharged from Medicare Part A on 8/12/22 and discharged home or to lesser care. Review on 11/1/22 of Resident #83's SNF Beneficiary Protection Notification Review form, completed by the facility, revealed that Resident #83's last covered day of Medicare Part A skilled services was 8/12/22 and that the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. Further review of this form revealed under question 2. Was the NOMNC . provided to the resident? was checked No. Interview on 11/1/22 at 11:20 a.m. with Staff C (Clinical Reimbursement Coordinator) confirmed that the NOMNC form was not issued to Residents #23, #58, or #83. Staff C stated the facility did not know that they needed to complete this form when the facility initiated a discharge from Medicare Part A Services when benefit days were not exhausted. Staff C revealed that the facility had only been issuing the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Centers for Medicare & Medicaid Services (CMS) Form- . Review on 11/2/22 of the facility's policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, revealed .Residents are informed in advance when changes will occur to their bills . Notice of Medicare Non-Coverage (CMS form ) 1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form ) is issued to the resident at least two calendar days before benefits end. 2. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review by a Quality Improvement Organization .

Based on interview and record review, it was determined that the facility failed to ensure that a Significant Change in Status Minimum Data Set (MDS) was completed timely by the 14th calendar day of a resident being admitted to hospice services for 2 of 2 residents reviewed for hospice in a final sample of 21 residents. (Resident identifiers are #10 and #14). Findings include: Resident #14 Review on 11/1/22 of Resident #14's care plan revealed that the resident admitted to hospice services on 10/15/22. Review on 11/1/22 of Resident #14's Hospice Charts/Clinical Notes revealed that Resident #14 was admitted to routine hospice services with an effective date of 10/15/22. Review on 11/1/22 and 11/2/22 of Resident #14's MDS record in the electronic medical record revealed that there was an Significant Change MDS in progress, but it had not yet been completed. Interview on 11/2/22 at 1:39 p.m. with Staff A (MDS Coordinator) confirmed that Resident #14 admitted to hospice services on 10/15/22 and that the Significant Change MDS was not yet completed. Resident #10 Review on 11/2/22 of Resident #10's hospice record revealed that Resident #10 hospice services start date was 7/20/22. Review on 11/1/22 of Resident #14's Hospice notes revealed that Resident #10 was admitted to routine hospice services with an effective date of 7/20/22. Review on 11/2/22 of Resident #10's significant change MDS record dated 7/28/22 revealed that it was completed on 8/10/22, 8 days past the 14th day required completion date of 8/3/22. Interview on 11/2//22 at approximately 1:40 p.m. with Staff A confirmed the above findings for Resident #10.

Based upon a facility investigation the facility failed to keep a resident from being verbally and emotionally abused resulting in the resident being agitated and falling resulting in a facial fracture for 1 out of sample resident in a standard survey sample of 18. (Resident identifier is #19.) Findings include: Review of the Resident #19's medical record revealed a nurse's note written by Staff H(LPN), on 3/29/15 revealed, .Resident fell at approximately 2145. (Resident) was sitting outside (pronoun omitted) room .and saw a staff member who (Resident) had been upset with earlier in the shift. (Resident) quickly stood and began yelling at (staff member), and started to turn towards .room, when .lost .balance, falling face forward into .room.face smashed into the floor with an audible crack Resident continued to be agitated at the sight of LNA, so prn (as needed) ABH ([MEDICATION NAME] and [MEDICATION NAME]) gel given at 2245 with little effect. Continue to monitor. Review of the X-ray reports with a triage date of [DATE] revealed a comminuted right hygrometric fractures with hemorrhage involving the right maxillary sinus as described. Review of the written synopsis by Staff J, (Former DON) revealed that on late Saturday March 28, 2015, Staff I, LNA helped Resident #19 to the bathroom when other staff heard Staff I yelling at the Resident #19. Two nurses went to investigate and instructed Staff I not to go near Resident #19. Staff I continued to to be visible to Resident #19. Observation at this time revealed that Resident #19 was upset and agitated. Staff I was instructed several more times to not be visible at the nurses' desk due to the fact this was upsetting and agitating Resident #19. Staff I failed to follow these instructions. Resident #19 saw Staff I became agitated and stood up from chair falling face first onto the floor. On March 30, 2015 call was placed to Staff I for immediate suspension pending investigation for abuse. Review of written warning dated 3/31/15 by Staff J revealed that the Resident was upset and agitated with (Staff I) 2 nurses heard (Staff I) yell at resident. Every time resident saw (Staff I) (Resident #19) became agitated , yelling and tried to get up out of w/c (wheel chair) to get to this LNA. (Resident #19) stated (pronoun omitted) 'was afraid of (Staff I) and wanted a restraining order' (Staff I) was told multiple times to keep away + out of sight + (Staff I) would not. (Resident #19) finally fell sustaining injury. The facility failed to protect the resident from verbal and emotional abuse.

Based on medical record review, staff interview, and review of the facility incident report the facility failed to ensure that a resident who is fed by a gastrostomy tube received the appropriate treatment, monitoring, and services resulting in hospitalization for Aspiration Pneumonitis resulting in Hospice Placement. The facility failed to implement effective monitoring of the resident's positioning following a previous episode of suspected aspiration and a recent history of aspiration risk. (Resident identifier is #12.) Findings include: Medical record review for this resident was conducted 2/4/14, and 2/6/14 - 2/7/14. Review of physician orders [REDACTED]." Review of Resident #12's January 2014 active care plan revealed under the care plan concern for "Feeding Tube" that the facility was to "Keep the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed." Review of nursing notes for January 2014 reveals a note dated 1/15/14 at 08:01 which reads "Res yelling out, went to assess. VS (vital signs) 123/99, 158, 98.6, 93% ra (room air) 18. Res gurgling, res boosted up and HOB at 90 degrees, shut [MEDICATION NAME] off for one hour. Had...PA assess, LS (lung sounds) clear. Gurgling improved, meds given. reckd (recorded) vs 116/78, p (pulse) 115, T (temperature) 98.0, O2 94% ra. Gtube patent, positive placement, flushed with 220 cc (cubic centimeters) h2o (water). Will monitor." Review of nursing notes dated 1/19/14 (5 days later) at 08:26 documents "At approx. 0740 this nurse was alerted by 2 LNA's...that resident 'was acting weird and having trouble breathing' (.) Went to assess resident. Res was lying diagonally with HOB (head of bed) at 20 degrees, foaming at the mouth and diaphoretic. Immediately shut feed off and assisted res to sitting position. Two LNA's stayed with resident while I retrieved suction machine...Attempted to suction, res was clenching teeth, Lnas (LNA's) able to pry jaw open enough to suction with some success. O2 saturation obtained was 75% ra (room air), NC (nasal cannula) applied at 4 L (liters). Res was sob (short of breath), using accessory muscles to breathe, audible wheezing and crackles in bases. Res had irregular pulse from 127-155 bpm (beats per minute). Saturation at this time increased to 78%, O2 mask at 6 L applied,...Non re-breather mask applied, O2 saturation increased to 82%....nurse left to call PA (physician assistant)...New order to send res. to...hospital for evaluation...Called DPOA...message left." Review of the hospital admission history and physical dated 1/19/14 read, "This is a [AGE] year old female who presented with respiratory distress on [MEDICAL CONDITIONS] after being seen to aspirate tube feeds at her nursing home. She likely has an aspiration pnemonitis and is at risk of developing an aspiration PNA (pneumonia)." Review of the Hospice documentation dated 2/4/14 revealed, "...pt(patient) aspirated on her tube feeding w(with) Massive Pneumonitis..." During an interview with Staff B (DON) on 2/6/14 in the afternoon both nursing notes as well as the facility incident report were reviewed. Staff B was asked what did the facility do after the 1/15/14 incident to prevent any further occurrences from happening to this resident. Staff B stated this was a resident who was constantly wiggling in bed and would often move around. Staff B said staff often passed her room and would check on her but there was no set or documented checks like 15 minute checks instituted after this incident. Staff just knew to check on her often. Nurses notes and progress notes revealed no documented evidence that any frequent time checks were completed in the 24-48 hours following the above incident. During this same interview Staff B was asked about the nursing documentation on 1/19/14 indicating the head of the bed was at a 20 degree angle. Staff B said they were aware of what had been documented but during the interviews done as part of the investigation the facility could not confirm definitively that the head of the bed was at 20 degrees since it is so difficult to determine the actual elevation difference of 10 degrees. Staff B stated Resident #12 had been admitted to the hospital and was expected to return but the facility had just been notified that this resident had been discharged to another facility and would not be returning.