Every finding on record at Berkshire Place

Based on interviews, and record review, the facility failed to ensure Influenza and/or Pneumococcal vaccines were administered when consent was obtained to receive the vaccine for two Residents (#2 and #29), of five applicable residents reviewed for immunizations, out of a total sample of 13 residents. Specifically, the facility failed to: For Resident #2, administer the Influenza Vaccine when consent was obtained for the Resident to receive the vaccine in January 2026. For Resident #29, administer the Pneumococcal Vaccine when consent was obtained to receive the vaccine in June 2024. Findings include:1. Resident #2 was admitted to the facility in January 2026 with diagnoses including chronic kidney disease (CKD) Stage 3, and Cerebral Infarction, and was over the age of 65. Review of the facility policy titled Influenza Immunization, reviewed in January 2026, indicated the following: -Residents/patients will be offered immunization against influenza as recommended by the Centers for Disease Control and Prevention (CDC) and under guidance by the Massachusetts Department of Public Health (MA DPH). -The flu (influenza) vaccine will be offered to Residents/patients between October 1st and March 31st. Review of the Immunization Report indicated Resident #2 last received the Influenza Vaccine on 10/16/24. Review of the CDC Recommended Adult Immunization (www.cdc.gov/vaccines/hcp), dated October 2025, indicated the following for Adults 65 years or older: -Any one of HD-IIV3, RIV3, or aIIV3 (type of Influenza vaccinations) is preferred. If none of these three vaccines is available, then any other age-appropriate influenza vaccine should be used. Review of the Consent for Influenza, Covid-19, Pneumococcal, and/or RSV Vaccine form for Resident #2, indicated: -Written consent by Resident #2's Representative (RR) was obtained for the Influenza Vaccine on 1/6/26. -The consent was for the Influenza Vaccine due now and in the future. Review of the February 2026 Physician's orders indicated: -May have annual Influenza vaccination, initiated 1/5/26 Review of Resident #2's clinical record failed to indicate documented evidence that the annual Influenza Vaccine was offered and/or received to the Resident after consent for the vaccine was obtained from the RR on 1/6/26. On 2/11/26 at 4:18 P.M., the surveyor and Unit Manager (UM) #2 reviewed Resident #2's clinical record. During an interview at the time, UM #2 said Resident #2 received the Influenza Vaccine on 10/16/24. UM #2 said written consent for the Influenza Vaccine was obtained on 1/6/26 for Resident #2 to receive the annual Influenza Vaccine and there was also a Physician's order for the Resident to receive the Influenza Vaccine. UM #2 further said Influenza Vaccines were available in the facility and was not sure why Resident #2 had not received the vaccine, but that the Administrator, Director of Nursing (DON) and Infection Preventionist (IP) would have more information on vaccine tracking. 2. Resident #29 was admitted to the facility in June 2024 with diagnoses including Dysphagia and Acute Kidney Failure and was over the age of 50. Review of the facility policy titled Pneumococcal Immunization, reviewed in January 2026, indicated the following: -To reduce morbidity and mortality associated with pneumococcal disease by ensuring eligible residents/patients receive pneumococcal immunization in accordance with current CDC guidelines. -Residents/patients will be assessed for pneumococcal vaccination status upon admission. -Pneumococcal immunization will be offered to residents/patients who have not previously received the vaccine or who require additional doses based on current CDC recommendations. -Vaccination will be administered unless medically contraindicated or declined by the resident/patient or their authorized representative. -Pneumococcal immunization will be offered at the time of admission to residents/patients who are eligible and have not yet been immunized or who require additional doses per CDC recommendations. Review of Resident #29's Immunization Report indicated: -Prevnar 13 (PCV13) was administered on 11/7/18 (prior to facility admission). Review of the CDC Recommended Adult Immunization (www.cdc.gov/vaccines/hcp), dated October 2025, indicated the following for Adults 50 years or older: -If previously received only PCV13 (Pneumococcal Conjugate Vaccine 13) vaccine, administer 1 dose PCV20 (Pneumococcal Conjugate Vaccine 20) or 1 dose PCV21 (Pneumococcal Conjugate Vaccine 21) at least 1 year after the last PCV13 dose. Review of Resident #29's Pneumococcal Immunization form indicated: -Consent for administration of the Prevnar 20 (PCV20) vaccine was received on 6/28/24. Review of the February 2026 Physician's orders indicated: -May have Pneumonia Vaccine per facility protocol, initiated 6/28/24. Review of Resident #29's clinical record failed to indicate documented evidence that the recommended Pneumococcal Vaccine had been offered and/or administered after consent for the vaccine was obtained on 6/28/24. On 2/11/26 at 9:52 A.M., the surveyor and UM #2 reviewed Resident #29's clinical record. During an interview at the time, UM #2 said consent for the updated Pneumococcal Vaccine had been obtained for Resident #29 in June 2024. UM #2 said there was no evidence in the Resident's clinical record that he/she received the recommended Pneumococcal Vaccine. During interviews on 2/12/26 at 9:03 A.M. and 10:49 A.M., the DON said she was made aware of the concern relative to resident vaccines. The DON said when a consent for Pneumococcal and/or Influenza Vaccines were obtained, the expectation would be that the vaccines would be administered immediately. The DON said when consent for Pneumococcal immunization was obtained, the vaccine would be ordered from the pharmacy and then administered to the resident once received. The DON further said Influenza Vaccines were available in the facility at this time and did not need to be ordered. The DON said Resident #2 received the Influenza Vaccine on 2/11/26 after the surveyor inquired, but the vaccine should have been administered after consent had been obtained. The DON said she would have expected that Resident #29 received the recommended Pneumococcal Vaccine when consent was obtained in June 2024. The DON further said the IP was responsible for tracking resident immunizations. During an interview on 2/12/26 at 12:44 P.M., the IP said he started in the IP position about three to four weeks prior but had assisted with this position previously. The IP said tracking of immunizations was ongoing, and that he started checking for resident Influenza Vaccine status today (2/12/26). The IP said he started auditing the Pneumococcal Vaccines a few days ago, obtained several names of residents who he needed to follow-up on, and thought that resident immunizations were up to date when he started the position. The IP said resident vaccines were reviewed and consents/declinations for vaccines were obtained on admission by the Nurses. The IP said a history of the resident's previous immunization history would also be obtained within a week of the resident's admission and if there was difficulty in obtaining this information, he would contact the resident's previous Primary Care Physician (PCP) in an attempt to retrieve the vaccine information. The IP said Resident #2 should have received the Influenza Vaccine and Resident #29 should have received the updated Pneumococcal Vaccine within a few days after the consents for these immunizations were obtained.

Based on interviews, and record review, the facility failed to ensure that COVID-19 immunization was administered after consent was obtained to administer the vaccine for one Resident (#4), of five applicable residents reviewed for immunizations, out of a total sample of 13 residents. Specifically, for Resident #4, the facility failed to administer the COVID-19 immunization when the Resident was eligible to receive the vaccine and written consent for the vaccine was obtained in October 2025. Findings include: Review of the facility policy titled Resident/Patient COVID-19 Immunization, dated October 2021, included the following: -Residents/patients will be offered immunization against COVID-19 as recommended by the Centers for Disease Control and Prevention (CDC) and under guidance by the Massachusetts Department of Public Health (MA DPH). -The COVID-19 vaccine will be offered unless immunization is medically contraindicated or the resident/patient has already been immunized. -If the COVID-19 immunization requires multiple doses, the resident/patient and/or resident representative, legal guardian, or health care proxy (HCP) will be provided with current information .prior to obtaining consent for the immunization. -COVID-19 immunization will be offered at the time of admission to residents/patients who had not yet been immunized. Review of the CDC Recommended Adult Immunization Schedule 2025 (www.cdc.gov/vaccines/hcp) indicated the following recommendation for Adults 65 years or older: -COVID-19: >two or more doses of the 2025-2026 vaccine. Resident #4 was admitted to the facility in October 2025 with diagnoses including Acute Respiratory Failure with hypoxia, Cerebral Infarction, and was over the age of 65. Review of Resident #4's Immunization Report failed to indicate any evidence of COVID-19 vaccination. Review of the COVID-19 Vaccine Consent Form indicated written consent was obtained for Resident #4 to receive the COVID-19 immunization on 10/21/25. Review of the Resident's clinical record failed to indicate documented evidence that the COVID-19 vaccine was offered and/or administered to Resident #4 after written consent was obtained on 10/21/25. Review of the Resident #4's February 2026 Physician's orders indicated: -May have COVID-19 vaccine according to facility protocol, initiated 10/21/25. During an interview on 2/11/26 at 4:46 P.M., Unit Manager (UM) #1 said she just started her position at the end of January 2026. UM #1 said updated resident vaccinations would be in the clinical record. During an interview on 2/12/26 at 10:49 A.M., the Director of Nursing (DON) said she reviewed the requested COVID-19 vaccination status for Resident #4. The DON said the facility spoke with the Resident's Representative (RR) today (2/12/26) about the Resident's COVID-19 vaccination status and the RR reported Resident #4 had not received the COVID-19 vaccine prior to admission to the facility and the RR had requested that the Resident receive the vaccine. The DON said the Infection Preventionist (IP) was responsible for tracking resident immunizations and that it was her expectation that the Resident would be administered the immunization immediately after consent for the vaccine was obtained. The DON said the facility had COVID-19 vaccines available in the facility at this time. During an interview on 2/12/26 at 12:44 P.M., the IP said he started in the IP position about three to four weeks prior but had assisted with this position previously. The IP said tracking of immunizations was ongoing, and that he started checking for resident covid vaccines status today (2/12/26). The IP said resident vaccines were reviewed and consents/declinations for vaccines were obtained on admission by the Nurses. The IP said a history of the resident's previous immunization history would be obtained within a week of admission and if there was difficulty in obtaining this information, he would contact the resident's previous Primary Care Physician (PCP) in an attempt to retrieve the vaccine information. The IP further said the facility had no difficulty obtaining COVID-19 vaccines and Resident #4 should have been provided the COVID-19 vaccine within a few days of obtaining consent.

Based on interview, and record review, the facility failed to ensure professional standards of care were maintained for diabetic management of one Resident (#23) out of a total sample of 13 residents. Specifically, for Resident #23, the facility failed to ensure that the Medical Doctor (MD) was notified and appropriate assessment conducted when the Resident experienced a period of hyperglycemia (high blood sugar). Findings include: Review of the facility policy titled Diabetes Mellitus (DM- disease in which the body's ability to produce or respond to the hormone insulin [a hormone that helps the body regulate blood sugar] is impaired resulting in variable blood glucose [sugar] levels in the blood), Guidelines For (Nursing Care of Resident With), revised 5/06, indicated the following: -Quickly restore normal cerebral function and prevent hyperglycemia or hypoglycemia. -Recognize, treat or prevent complications commonly associated with diabetes. Resident #23 was admitted to the facility in August 2022, with diagnoses including Type II DM (non-insulin dependent type of diabetes [disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in variable blood glucose [sugar] levels in the blood]). Review of Resident #23's July 2024 Medication Administration Record (MAR) indicated the following: -Call MD for blood sugars over 450 milligrams per deciliter (mg/dL) as needed (PRN) Further Review of the July 2024 MAR indicated: -on 7/5/24 at 9:00 P.M.: the Resident had a blood sugar level of 554 mg/dL -no documentation on the July 2024 MAR to indicate the MD had been made aware of the blood sugar level that was over 450 mg/dL. Review of the Nursing Progress Notes from 7/5/24, indicated no documentation that the MD had been made aware that Resident #23's blood sugar level was over 450 mg/dL on 7/5/24. During an interview on 10/23/24 at 3:06 P.M., Nurse #1 said when Resident #23 had a blood sugar over 450 mg/dL on 7/5/24, the Nurse should have called the MD to find out what type of treatment should be implemented, and documentation should be completed on the MAR and in a Nursing Progress Note. The surveyor and Nurse #1 reviewed the July 2024 MAR and the 7/5/24 Nursing Progress Notes. Nurse #1 said she could find no evidence that the MD had been made aware of Resident #23's high blood sugar on 7/5/24, and she could not be sure what treatment was put into place to lower the Resident's blood sugar.

Based on interview, record and policy review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medication that affect the mind, emotions, and behavior) was limited to 14 days for one Resident (#24), of five applicable residents reviewed, out of a total sample of 13 residents. Specifically, the facility failed to ensure that PRN Ativan (Lorazepam: anti-anxiety medication) was limited to 14 days and if not limited, included a Physician determined duration for continued use of the medication. Findings include: Review of the facility policy titled Psychotropic Medications, dated 8/31/23, indicated the following: -PRN psychotropic medications which are not antipsychotic medications are limited to 14 days. -The Attending Physician/Prescriber may extend the order beyond 14 days if he or she feels it is appropriate. -If the Attending Physician extends the PRN order, the medical record will include documented rationale and determined duration. Resident #24 was admitted to the facility in September 2024, with diagnoses including Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities) and Bipolar Disorder (a mental illness that causes extreme mood swings, from high [mania or hypomania] to low [depression], during which hallucinations or delusions can occur). Review of the October 2024 Physician's orders included the following: -Ativan Oral Tablet 0.5 MG (milligrams). Give 0.5 mg by mouth every 4 hours as needed for Anxiety, agitation related to Anxiety Disorder, start date of 9/26/24. Review of the September 2024 and October 2024 Medication Administration Records (MARs), indicated that the PRN Ativan medication was administered two times during the month of October 2024. Review of the Note to Attending Physician/Prescriber, completed during a monthly Medication Regimen Review (MRR) by the Consultant Pharmacist and dated 10/13/24, indicated the following: -PRN psychotropic orders cannot exceed 14 days with the exception that the Prescriber documents their rationale in the Resident's medical record and indicate the duration of the PRN order. -The Physician/Prescriber responded to the MRR with the following: Disagree, Resident is on Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). No 14 days re-evaluation needed, signed by the Physician/Prescriber on 10/15/24. During an interview on 10/28/24 at 9:48 A.M., the Nursing Administrative Services Nurse said when a Resident was prescribed PRN Ativan it will be reflected in the order to be reviewed every 14 days or the Physician may wish to extend it for longer. The surveyor and the Nursing Administrative Services Nurse reviewed Resident #24's October 2024 Physician orders. The Nursing Administrative Services Nurse said that the Physician order should indicate a review by the Physician date at Day 14 or an explanation as to why the Physician would like to extend the Ativan medication past the required 14-day review date. The Nursing Administrative Services Nurse said that the Physician order did not indicate a stop date, or a review date as required. During a follow-up interview on 10/28/24 at 12:43 P.M., the Nursing Administrative Services Nurse provided the surveyor with a MRR that included the Pharmacist Recommendation and the Physician/Provider response. The Nursing Administrative Services Nurse said that the MRR Physician/Provider response did not include a determined duration for the Ativan medication and should have, as required.

Based on interview, and record review, the facility failed to obtain Physician orders prior to administering a Pneumococcal Vaccination to one Resident (#23) out of five applicable residents reviewed, out of a total sample of 13 residents. Specifically, for Residents #23 the facility failed to obtain a Physician's order prior to administering the Pneumococcal 20-Valent Conjugate Vaccine (PCV20-type of Pneumococcal Vaccination). Findings include: Review of the facility policy titled Resident/Patient Pneumococcal Immunization, reviewed 7/15/22, indicated the following: -A Licensed Nurse will administer the Pneumococcal Vaccine with a standing order from the Medical Director per manufacturer's guidelines for residents/patients. Resident #23 was admitted to the facility in August 2022. Review of Resident #23's immunization record indicated he/she was administered the PCV20 on 5/24/23, while he/she was a Resident in the facility. Further review of the Resident's medical record indicated no documentation a Physician's order was in place prior to or at the time the PCV20 was administered to Resident #23. During an interview on 10/28/24 at 2:56 P.M., the Infection Preventionist (IP) said she was unable to locate a standing Physician's order for Resident #23 to receive the PCV20. The IP said a standing Physician's order should have been placed in the Resident's electronic medical record (EMR) prior to or at the time of the PCV20 being administered and this was not done.

Based on record review and interviews for one resident (Resident #199) out of a total sample of 12 residents, the facility failed to notify the Attending Physician of a significant change in the Resident's medical status. Specifically, for Resident #199 the facility staff failed to contact the Physician when the Resident began to first exhibit signs and symptoms of a significant decline, resulting in a delayed transfer to the hospital. The Resident was diagnosed with sepsis and admitted to the Critical Care Unit when finally transferred to the hospital. Findings include: Resident #199 was admitted to the facility in June 2023 with the following diagnoses: surgical aftercare following surgery of the nervous system, and history of urinary retention (a condition where a person is unable to fully empty the contents of the bladder that may lead to other health problems such as Urinary Tract Infection [UTI] and kidney failure). Review of the facility's policy titled Physician Notification, reviewed 8/15/22, included but was not limited to: -Upon the identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection and update the physician. -Urgent notification will occur by the licensed nurse calling the physician, nurse practitioner or covering physician by phone if: clinical status and findings indicate need to transfer to the hospital, a significant change in the resident's physical, mental or psychosocial status and abnormal diagnostic results. Review of the Resident's June 2023 Vitals and Weights Summary indicated the following: -Blood Pressure (BP) ranged from a low of 106/85 to a high of 140/76. -Temperature ranged from a low of 97.5 degrees to a high of 98.2 degrees. -Pulse ranged from a low of 68 beats per minute (bpm) to a high of 82 beats per minute. -Oxygen saturation (the amount of oxygen circulating in the bloodstream) from a low of 91 percent (%) to a high of 96%. Review of a Nursing a Progress Note dated 7/11/23 at 7:26 A.M. indicated the following: -The Resident was calling out and moaning which was atypical behavior. -The Resident had dry lips, teeth and mouth, was confused and exhibited body twitching which was not previously noted. -The note further indicated that his/her temperature was 90.5 degrees (normal is approximately 98.6 degrees), BP was 84/40 (normal is between 90/60 and 120/80) and his/her oxygen saturation was 90% (normal is between 95-100%). Further review of the Nursing Progress Notes did not indicate any evidence that the Attending Physician had been notified of the abnormal assessment. Review of the SBAR (situation, background, assessment, recommendations) Communication Form (a technique that provides framework for communication between members of the health care team about a patient's condition) dated 7/11/23, indicated the Attending Physician was notified of the Resident's condition at 11:15 A.M., and his recommendation was to transfer the Resident to the ER for evaluation. Review of the Emergency Department Note dated 7/11/23, indicated the Resident was initially seen by the Emergency Department Physician at 12:33 P.M. During an interview on 8/16/23 at 2:29 P.M., Unit Manager (UM) #1 said the Resident's vital signs and his/her multiple changes in his/her baseline (usual state) were concerning, that the Physician should have been notified immediately and was not, resulting in a delay in transferring the Resident to the emergency room , where he/she was later admitted to the Critical Care Unit. During a telephone interview on 8/17/23 at 9:18 A.M., the Attending Physician said that if a Resident's temperature was 90 degrees and BP was 84/40, he would expect to be notified and did not recall being notified about the change in status for Resident #199. During an interview on 8/17/23 at 2:10 P.M., the Director of Nursing (DON) said the Nurse should have alerted the UM, and contacted the Attending Physician immediately when she discovered the Resident's vital signs were abnormal and his/her assessment indicated changes in his/her status and she did not, as required. see F684

Based on record review and interviews for one Resident (#199) out of a total sample of 12 residents, the facility failed to ensure standards of quality of care were provided to the Resident. Specifically, the facility failed to: 1. Recognize a significant decline in the Resident's status and notify the Attending Physician timely resulting in delay in transferring the critically ill Resident to the hospital. 2. Appropriately document and monitor areas of concern on the Resident's skin which was ultimately diagnosed as a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings include: Resident #199 was admitted to the facility in June 2023 with the following diagnoses: encounter for surgical aftercare following surgery on the nervous system (tumor removal from the spinal cord), history of urinary retention (the inability to fully empty the contents of the bladder) with a Foley catheter (a thin flexible tube inserted into the bladder to drain urine outside the body) and muscle weakness. Review of the facility's policy titled Physician Notification, reviewed 8/15/22, included but was not limited to: -Upon the identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection and update the physician. -Urgent notification will occur by the licensed nurse calling the physician, nurse practitioner or covering physician by phone if: >clinical status and findings indicate need to transfer to the hospital, >a significant change in the resident's physical, mental or psychosocial status and abnormal diagnostic results. Review of the National Library of Medicine website, www.ncbi.nlm.nih.gov, dated 4/5/18, indicated: The urinary bladder can store up to 700 milliliters (ml) in some cases. Review of Admit/Readmit Screener (Nursing Admission Assessment) dated 6/21/23, indicated: - The Resident was admitted from the hospital, post spinal surgery for removal of a mass. - The Resident possessed no open areas on his/her skin other than a surgical wound on the back of his/her neck. - The Resident was alert and oriented times four (knows who he/she is, where he/she is, the date and what is happening to them) and was verbally appropriate. - The Resident possessed an irregular heartbeat, pulses could be palpated (felt) and were equal on both sides with no edema (swelling caused by fluid collecting within the tissues). - The Resident had normal bowel sounds with a round, firm abdomen. - The Resident had not been up walking and had not wheeled himself/herself in a wheelchair. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15, -required extensive assistance of two plus persons for bed mobility, -utilized a Foley catheter, -and was at risk for developing a pressure injury however had no pressure injuries at the time of the assessment. Review of the Resident's June 2023 Vitals and Weights Summary indicated the following: -Blood Pressure (BP) ranged from a low of 106/85 to a high of 140/76. -Temperature ranged from a low of 97.5 degrees to a high of 98.2 degrees. -Pulse ranged from a low of 68 beats per minute to a high of 82 beats per minute. -Oxygen saturation (the amount of oxygen circulating in the bloodstream) from a low of 91 percent (%) to a high of 96%. Review of the Nursing Home to Hospital Transfer Form dated 7/11/23 at 11:30 A.M., indicated the Resident was being transferred to the hospital due to altered mental status (AMS) and left-sided twitching with the following vital signs recorded: BP 84/46 and pulse 53. In addition, the transfer form indicated a shearing injury (separation of skin from underlying tissue) to the buttocks. 1. Review of Nursing Progress Notes authored by Nurse #1 indicated the following: *On 7/11/23 at 7:26 A.M., the Resident was calling out and moaning which was atypical behavior. -The Resident had dry lips, teeth and mouth, was confused and exhibited body twitching which was not previously noted. -The note further indicated that his/her temperature was 90.5 degrees (normal is approximately 98.6 degrees), BP was 84/40 (normal is between 90/60 and 120/80) and his/her oxygen saturation was 90% (normal is between 95-100%). Further review of the Nursing Progress Notes did not indicate any evidence that the Attending Physician had been notified of the abnormal assessment. *On 7/11/23 at 11:18 A.M., the Occupational Therapist (OT) requested the Nurse to re-assess the Resident at 10:15 A.M. because he/she seemed like he/she had a stroke (a medical event when the blood flow to the brain is blocked or there is sudden bleeding in the brain). Nurse #1's assessment of the Resident indicated: his/her skin was warm, pale and dry and he/she did not appear at his/her baseline (usual state) as evidenced by confusion, inattentiveness, oriented to person only, did not know which body part underwent surgery, hypoactive bowel sounds (indicating intestinal activity has slowed), abnormal lung sounds, swelling to his/her left toes, and not reacting to painful stimuli that he/she usually reacted to. The note further indicated that his/her temperature was 95.4 degrees, BP was 74/40 and oxygen saturation was 92%. At this time the Unit Manager (UM) and Attending Physician were notified, and an order was initiated to send the Resident to the emergency room (ER) for evaluation. Review of Occupational Therapy Notes indicated the following: -7/10/23 - Upon therapist entering, the Resident's spouse verbalized they were fearful the Resident is going to die here and was also concerned about the Resident's mental status (signed at 4:45 P.M.). - 7/11/23 - Attempted to engage in therapy however the Resident presented with increased confusion and increased lower extremity edema. BP 78/40 and oxygen saturation 92%. Therapy halted due to medical concerns (signed at 12:10 P.M.). Review of the receiving hospital Admission History and Physical Report dated 7/11/23, indicated the following: - Resident was admitted to the hospital and found to be in septic shock (a serious medical condition that can occur when an infection in the body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment, it is the most severe stage of sepsis) secondary to a urinary tract infection (UTI-an infection in the urinary system), requiring vasopressors (a drug that is used to make the blood vessels constrict (narrow) and used for people in shock who are unable to get enough blood to their vital organs) and was admitted to the Critical Care Unit for further management. - Upon arrival to the ER, the Resident had a Foley catheter placed with 1600 ml of urine output obtained, was noted to be hypothermic (low body temperature) requiring a [NAME] (a device designed to manage hypothermia by warming and stabilizing a person's body temperature) and acute kidney injury likely due to obstructive uropathy (when kidneys suddenly stop working properly due to obstructed urine flow). During an interview on 8/16/23 at 12:59 P.M., with Nurse #1 who provided care for Resident #199 on 7/11/23, Nurse #1 said it was uncharacteristic of the Resident to be calling out for help. She further said she was not concerned about the Resident's temperature because the fan was blowing on him/her and she thought that the upper extremity twitching was because the Resident was trying to pull his/her leg back into the bed. When the surveyor asked Nurse #1 about the Resident's low blood pressure, she said she was unsure if that blood pressure was low for him/her and would have to go back and check his/her usual readings. She further said she did not see a reason to alert the Attending Physician or reassess the Resident until the OT voiced her concerns. At that time, she and the UM assessed the Resident and the Unit Manager (UM) #1 initiated contact with the Attending Physician, who then ordered the facility to transfer the Resident to the hospital. During an interview on 8/16/23 at 2:29 P.M., UM #1 said the Resident's vital signs and the multiple changes in his/her baseline (usual state) on 7/11/23 at 7:26 A.M. were concerning, that the Physician should have been notified immediately and was not, resulting in a delay in transferring the Resident to the emergency room . During a telephone interview on 8/17/23 at 9:18 A.M., the Attending Physician said that if a Resident's temperature was 90 degrees and the BP was 84/40, he would expect to be notified and did not recall being notified about the change in status and at that time of the telephone interview, he had no personal knowledge that the Resident had been hospitalized . Review of the SBAR (situation, background, assessment, recommendations) Communication Form (a technique that provides framework for communication between members of the health care team about a patient's condition) dated 7/11/23, indicated the Attending Physician was notified of the Resident's condition at 11:15 A.M., and his recommendation was to transfer the Resident to the ER for evaluation. During a follow up interview on 8/17/23 at 11:22 A.M., Nurse #1 said Resident #199 was the most complicated case she ever had on her unit (the Long-Term Care Unit), and she had worked at the facility for many years. Nurse #1 further said, we don't often get complicated cases up here. Additionally she said that the Resident's temperature was regularly 90 in the morning and that the staff routinely used forehead thermometers. Review of the Resident's Medical Record indicated the vital signs obtained during the morning of 7/11/23 were not the Resident's baseline. In addition, there was no documented evidence in the Medical Record the Resident's body temperature was ever 90 degrees. During a follow up interview on 8/17/23 at 12:22 P.M., UM #1 said if she were caring for the Resident on 7/11/22 at 7:26 A.M., she would have taken a second set of vital signs and if they remained abnormal, she would have called the Attending Physician right away. She further said the Resident should have been reassessed by Nurse #1 prior to the OT alerting the Nurse of her concerns at 10:15 A.M., that three hours was too long to wait given the Resident's status. During an interview on 8/17/23 at 2:10 P.M., the Director of Nursing (DON) said Nurse #1 did not notify the Attending Physician as soon as she assessed the Resident's vital signs to be abnormal on 7/11/22 at 7:26 A.M., and she should have. 2. Review of the facility's policy titled, Proper Wound Documentation and Measuring of Wounds, undated, indicated the following: -All wounds should be documented with every dressing change and measured weekly. The person doing the weekly measurements will be required to fill out the Skin Assessment in the Electronic Medical Record (EMR). -The following should be included in the documentation: >location of wound >any odor >ulcer category-stage for pressure (determine the severity), necrotic (dead) tissue, dimension (shape, length and width in centimeters (cm) >pain >describe the surrounding tissue, color of the wound bed, tunneling (when wound extends deeper than the surface) and undermining (separation of wound edges from surrounding tissue, creating a pocket), redness or other discoloration in the surrounding skin, and whether the surrounding skin is loose, tightly adhered, flat or rolled under. Review of Norton Scale for Predicting Risk of Pressure Ulcer (a tool used to assess risk for developing pressure injuries or ulcers), dated 6/21/23 indicated the Resident was at moderate risk for developing a pressure injury. Review of the Nursing Progress Notes indicated the Resident's Foley catheter had been removed on 6/1/23, he/she remained mostly bed bound and was incontinent of bladder and bowel, increasing the Resident's risk, along with his/her immobility for developing a pressure injury. Review of the Resident's Care Plan indicated the following: - Resident at risk for skin breakdown related to recent surgery and immobility (initiated 6/27/23). - Resident needs an alternating pressure mattress set between soft and firm to protect skin while in bed (initiated 6/27/23). - Follow facility protocols for treatment of injury (initiated 6/27/23). Review of Weekly Skin Assessments indicated the following: -6/30/23: Skin intact, limited assessment related to pain and limited mobility, no concerning areas visualized. -7/7/23: Skin intact, no concerns. Review of the Nursing Progress Notes indicated the following: -7/1/23: 10:57 A.M., Bilateral inner buttocks with reddened irritation, has denuded area (loss of outer layer of skin due to exposure of urine, feces, body fluids or friction) measuring 2 centimeters (cm) by (x) 0.75 cm between the butt cheeks at the coccyx area (area at the base of the tailbone). Skin intact except for the right inner buttock cheek. Calmoseptine (an ointment intended as a moisture barrier that protects and helps heal skin irritations) applied to denuded area and inner bilateral buttocks. -7/1/23: 9:27 P.M., Calmoseptine to open areas and buttocks. -7/2/23: 10:24 A.M., Bilateral inner buttocks nearly healed, coccyx denuded slit improved. -7/6/23: 10:57 A.M., Denuded slit above rectal area healed, new slit noted today measuring 1 cm x 0.25 cm in the sacral area (area above the tailbone and below the spine). Bilateral inner buttocks with scattered discolored purplish irritated areas, Calmoseptine applied. -7/6/23: 2:51 P.M., Resident complained of pain in right butt cheek after transfer by mechanical lift. -7/7/23: 11:36 A.M., Slit in sacral area noted, Calmoseptine applied per orders. -7/7/23: 9:02 P.M., Nursing Assistant requested for Nurse to assess slit between coccyx. Right buttocks is purple in color with three blisters 2-3 cm round. When Calmoseptine was applied, blisters slid off buttocks and there are now three open areas measuring 2-3 cm round. -7/8/23: 15:35 P.M., Right buttocks continue to be purple in color with three open areas 2-3 cm round. The Resident complained of pain to the buttocks, Calmoseptine applied. Review of the Hospital Admission History and Physical dated 7/11/23, indicated the Resident was noted to have a wound on the buttocks that appeared infected. Review of the Hospital Wound Care Consultation dated 7/15/23, indicated a Wound Specialist was consulted to assess and treat a Deep Tissue Pressure Injury (DTPI- a persistent non-blanchable (does not turn white when pressed) deep red, maroon or purple discoloration due to damage of underlying soft tissue) present on arrival to the hospital to the sacrococcygeal area (base of the spine by the tailbone) region extending to the soft tissue of the bilateral buttocks. Further review of the Wound Care Consultation notes indicated the Resident required sharp debridement (removal of dead tissue using a sharp instrument such as a scalpel) on 7/18/23. During an interview on 8/16/23 at 9:41 A.M., UM #1 said Resident #199 came in with no skin issues other than his/her surgical incision and when a skin issue occurs our policy is to complete an incident report. She further said the facility did not contract with an outside wound specialist, their Minimum Data Set (MDS) Nurse acts as the wound specialist, and if a skin issue arises, we request her to assess the Resident. UM #1 said she did not know if an incident report was completed for Resident #199 because the area was not truly open when it was first identified as a slit. She further said the Weekly Skin Assessment recorded on 7/7/23 was inaccurate because the same Nurse indicated the Resident had an open area in a progress note on the same day. In addition, UM #1 said purple skin could indicate a DTPI and should have been fully assessed, measured and monitored in order to determine whether the area was improving or worsening. She also said there was no evidence in the medical record that the purple areas on the Resident's buttocks were monitored or determined to be a DTPI. During an interview on 8/16/23 at 12:59 P.M., Nurse #1 said Resident #199 had scattered purple areas located in his/her inner buttocks that seemed to be there one day then gone the next, and she did not feel the need to report this on an incident report. She further said that if she suspected a pressure injury, she would let the UM know and she would contact the Attending Physician. In addition, Nurse #1 said she did not know if she had to complete incident reports for a pressure injury. She said she did not measure the Resident's purple area, and the measuring is usually left up to the UM and the MDS nurse who seemed to be the designated wound specialist in the facility. During an interview on 8/17/23 at 1:20 P.M., the MDS Nurse said she did not have any official wound care credentials, her wound care experience came from working with wound specialists and she had served as the dedicated wound nurse in a different facility in the past. She further said she remembered seeing the Resident's wound early on, however she did not normally document her findings in the progress notes. The MDS Nurse said she visits the Residents along with the UM and will recommend a treatment for the UM, who would then obtain a Physician's order for the treatment. In addition, she said the facility policy was to perform weekly skin assessments and document in the EMR, and even small areas, including those described as slits should be assessed daily, however they are not always entered into the Weekly Skin Assessment. She said that anything purple in color on an area that is subject to pressure (such as a buttock) is concerning for a DTPI. She further said that a DTPI or unstageable wound should be recognized as a pressure injury, measured and tracked in the Weekly Skin Assessment. During an interview on 8/17/23 at 2:10 P.M., the DON said when there was skin breakdown, an incident report should be completed and for Resident #199 she confirmed there were no incident reports or Skin Assessments related to the purple area on his/her buttocks. She further said the areas should have been monitored and measured to determine whether they were getting better or worse and for Resident #199 this was not done, as required.

Based on interview and records reviewed for one resident (Resident #27) out of a total sample of 12 residents, the facility failed to complete a significant change of status (SCOS) Minimum Data Set (MDS) Assessment within the required 14 days. Findings include: Resident #27 was admitted to the facility in May 2023. Review of the Resident's Medical Record indicated the Resident signed onto Hospice Services on 7/31/23. On 8/16/23 at 9:13 A.M., the surveyor reviewed the SCOS MDS Assessment with an Assessment Reference Date (ARD) of 8/9/23 and noted that it was marked in progress. On 8/16/23 at 12:28 P.M., the surveyor and the MDS Nurse reviewed the Resident's SCOS MDS Assessment with an ARD date of 8/9/23. The MDS Nurse said the date the Resident signed onto Hospice Services started the count down for when the SCOS MDS Assessment should have been completed, and the SCOS MDS Assessment should have been completed within 14 calendar days after 7/31/23, the date the Resident signed onto Hospice Services, and it was not, as required.

Based on record review and interview for one Resident (#199) out of a total sample of 12 residents, the facility failed to implement the plan of care. Specifically, for Resident #199 the facility staff failed to ensure that lab work ordered by the Physician was obtained, resulting in incomplete diagnostic information available for the Attending Physician to make treatment decisions. Findings include: Resident #199 was admitted to the facility in June 2023. Review of the Physician's History and Physical Exam Form signed and dated by the Physician on 6/23/23, indicated to repeat Lytes (also known as an Electrolyte panel, a blood test that measures levels of the body's Sodium (helps control the amount of fluid in the body and helps nerves and muscles work properly), Chloride (helps control the fluid in the body and helps maintain healthy blood volume and blood pressure), Potassium (helps heart and muscles work properly) and Bicarbonate (helps maintain the body's acid and base balance and plays an important role of moving carbon dioxide through the bloodstream). Review of the Resident's Medical Record did not indicate evidence the lab work was completed. During an interview on 8/16/23 at 9:41 A.M., Unit Manager (UM) #1 said the lab work was never obtained as ordered by the Physician, but it should have been. She further said that she must have missed that on the History and Physician Form when she reviewed it.

Based on observations, interview and records reviewed for one Resident (#27) out of a total sample of 12 residents, the facility failed to provide care and services for the use of Oxygen. Specifically, for Resident #27 the facility failed to ensure that Physician's orders were in place for the accurate amount of Oxygen being utilized by the Resident, and care and services of the oxygen tubing. Findings include: Review of the facility policy titled Oxygen, reviewed 7/15/22, indicated the following: -Obtain specific physician order for oxygen therapy. -Change oxygen tubing weekly. Date and initial on tape when changed and apply to tubing. Resident #27 was admitted to the facility in May 2023 with the following diagnoses: Pneumonia (an infection that affects the lungs) and Respiratory Failure (when the lungs are unable to get adequate oxygen to the blood/ body and get rid of carbon dioxide from the body) condition that makes it difficult to breathe on your own). On 8/15/23 at 4:58 P.M., the surveyor observed Resident #27 resting in bed. He/she was receiving Oxygen via nasal cannula (a device used to deliver supplemental Oxygen through the nose) and his/her oxygen concentrator (a device that concentrates oxygen to provide supplemental Oxygen) was set to 3 liters per minute (LPM: the flow at which the body receives supplemental oxygen). Review of the August 2023 Physician's Orders indicated the following order: -Oxygen at 2 LPM PRN (as needed) for Shortness of Breath/oxygen saturations (the amount of oxygen carried by the red blood cells) below 89%, with a start date of 5/12/23. Further review of the medical record indicated no other additional orders for the care and services of the oxygen equipment or to apply Oxygen at a higher LPM. According to the American Association of Respiratory Care (AARC) (2014): https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf, undesirable results or events may result from non-compliance with Physician's orders for Oxygen use and not measuring oxygen saturation levels to determine the appropriate Oxygen flow. Review of the following Nursing Notes indicated the Resident had utilized Oxygen at higher than 2 LPM on multiple days: -On 8/10/23 the Resident was using oxygen at 3 LPM -On 8/12/23 the Resident was using oxygen at 3.5 LPM -On 8/13/23 the Resident was using oxygen at 2 LPM to 3.5 LPM -On 8/15/23 the Resident was using oxygen at 3 LPM On 8/16/23 at 9:30 A.M., the surveyor observed Resident #27 resting in bed. He/she was receiving Oxygen via nasal cannula, his/her oxygen concentrator was set to 3 LPM, and his/her tubing remained undated. During an interview on 8/16/23 at 10:32 A.M., Nurse #1 said the Resident was currently on Oxygen and the concentrator was set at 3 LPM. She further said the Resident had been using the Oxygen continuously since he/she had returned from the hospital on 8/9/23 and a new Physician's order should have been obtained when staff realized the Resident was utilizing more than his/her current order of 2 LPM PRN, and this was not done as required. Nurse #1 further said the Resident's oxygen tubing should have been dated with the last time it was changed and there should have been a Physician's order in place to change oxygen tubing weekly. She said since neither of these were in place, she was unable to tell when the oxygen tubing was last changed.

Based on record review and interviews for one Resident (#199) out of a total sample of 12 residents, the facility failed to maintain accurate medical records. Specifically, for Resident #199 the facility failed to: 1. Ensure that staff accurately documented Nursing Progress Notes pertaining to the status of the Resident's Foley catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). 2. Ensure that staff accurately documented the findings of the Resident's skin condition on a Weekly Skin Assessment and Nursing Progress note. Findings include: Resident #199 was admitted to the facility in June 2023 with a Foley catheter. 1. Review of the June 2023 Physician's orders indicated an order to discontinue the Resident's Foley catheter on 6/30/23. Review of a Nursing Progress Note dated 6/30/23 indicated the following: Resident's Foley catheter was removed early this morning. Review of a Nursing Progress Note dated 7/7/23 indicated the following: Resident's Foley patent (not clogged) and draining. Review of the Medical Record indicated no evidence that the Foley catheter was reinserted. 2. Review of the Weekly Skin assessment dated [DATE] at 11:30 A.M., indicated the Resident's skin was intact with no concerns. Review of a Nursing Progress Note dated 7/7/23 at 11:36 A.M., completed by the same Nurse who completed the Weekly Skin Assessment on 7/7/23, indicated: Resident has a slit (a small open area) in the sacral area (area located at the base of the spine) noted, Calmoseptine ointment (an ointment that creates a moisture barrier that protects and helps heal skin irritations) applied per orders. During an interview on 8/16/23 at 9:41 A.M., Unit Manager (UM #1) said the Resident's Medical Record was inaccurate because the Resident's Foley catheter was discontinued on 6/30/23 and never reinserted. She further said that the skin assessment was also incorrect because the Resident's skin was not intact on the day the assessment was completed.

Based on record review and interview the facility failed to ensure its staff educated and offered COVID-19 vaccinations to four Residents (#1, #2, #3, and #4) out of a sample of five residents, to stop the spread of infection. Findings include: Review of the facility policy titled Resident/Patient COVID-19 Immunization, dated 10/2021, indicated the following: -Resident/patients of Berkshire Place will be offered immunization against COVID-19 as recommended by the Centers for Disease Control and Prevention (CDC) . -The COVID-19 vaccine will be offered unless immunization is medically contraindicated or the resident/patient has already been immunized. -Before being offered COVID-19 immunization, the resident/patient and/or the resident representative, legal guardian or Health Care agent (HCP) will receive education regarding the benefits and potential side effects of the COVID-19 vaccination . -COVID-19 immunization will be offered at the time of admission to the residents/patients who have not yet been immunized. -The resident/patient and/or the resident representative, legal guardian or HCP has the opportunity to decline immunization and will sign and date a declination statement. -Documentation of the administered COVID-19 vaccine will occur in the E-MAR (electronic Medication Administration Record) for residents/patients who receive the vaccine. The medical record will include documentation of education provided as well as indication if the COVID-19 immunization was not received due to medical contraindication or declination. Review of the CDC website www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, last updated June 7, 2023 recommends the following: -Everyone aged 6 years and older: You are up to date when you get 1 updated Pfizer-BioNTech or Moderna COVID-19 vaccine. Updated (Bivalent) and Original (Monovalent) COVID-19 Vaccines. -Updated vaccines, sometimes called bivalent vaccines: [The updated vaccines are called updated because they protect against both the original virus that causes COVID-19 and the Omicron variant BA.4 and BA.5. Two COVID-19 vaccine manufacturers, Pfizer-BioNTech and Moderna, have developed updated COVID-19 vaccines]. 1. Resident #1 was admitted to the facility in April 2023. Review of the Resident's immunization record indicated he/she had an initial COVID-19 immunization series of the Moderna vaccination with dose one being administered on 2/9/21 and dose two being administered on 3/9/21. Further review indicated the Resident also received a booster dose of the Moderna vaccination on 12/8/21. Additional review of the Resident's medical record indicated no documentation the Resident had been educated on or offered the Bivalent vaccination as recommended. 2. Resident #2 was admitted to the facility in January 2023. Review of the Resident's immunization record indicated he/she had an initial COVID-19 immunization series of the Moderna vaccination with dose one being administered on 1/23/21 and dose two being administered on 2/20/21. Further review indicated the Resident also received a booster dose of the Moderna vaccination on 8/27/21. Additional review of the Resident's medical record indicated no documentation the Resident had been educated on or offered the Bivalent vaccination as recommended. 3. Resident #3 was admitted to the facility in May 2023. Review of the Resident's immunization record indicated he/she had an initial COVID-19 immunization of the Pfizer vaccine administered on 2/16/21 and had refused the recommended second dose on 3/11/21. Further review of the Resident's medical record indicated no documentation the Resident had been educated on or offered the Bivalent vaccination as recommended. 4. Resident #4 was admitted to the facility in May 2023. Review of the Resident's immunization record indicated he/she had an initial COVID-19 immunization of the Johnson & Johnson vaccination on 12/21/21. Further review of the Resident's medical record indicated no documentation the Resident had been educated on or offered the Bivalent vaccination as recommended. During an interview on 6/6/23 at 12:26 P.M., the Infection Preventionist (IP) said Residents #1, #2, #3, and #4 had not been educated on or offered the recommended Bivalent COVID-19 vaccination at the time of their admissions. She further said she followed up with Resident's #1, #2, and #4 today 6/6/23 and the Resident's provided consent to receive the recommended Bivalent COVID-19 vaccinations and that Resident #3 had also just been offered today but he/she had declined the vaccination. The IP said Residents #1, #2, #3, and #4 should have all been asked at the time of their admission and this did not happen, as required.

Based on record review and interview the facility failed to obtain the necessary Physician's Orders prior to the administration of a vaccination for two Residents (#1 and #5) out of a total sample of five residents. Specifically, 1. For Resident #1, the facility failed to ensure staff acquired the necessary Physician's order to provide a Pneumococcal Vaccination. 2. For Resident #5, the facility failed to ensure staff acquired the necessary Physician's order to provide an Influenza Vaccination. Findings include: 1. Review of the facility policy titled Resident/Patient Pneumococcal Immunization, revised 7/15/22, indicated the following: -Resident/patients of Berkshire Place will be offered immunization against pneumococcal disease as recommended by the Centers for Disease Control and Prevention (CDC) and under the guidance by the Massachusetts Department of Public Health (DPH) . Review of the CDC website www.cdc.gov/vaccines/hcp/adults/for-practice/standards/referral.html, titled Standards for Practice: Vaccine Administration & Referral, last reviewed May 2, 2016, indicated the following: Use standing orders (written protocols approved by a physician or other authorized practitioner that allow qualified health care professionals to assess the need for and administer vaccines) or protocols (where allowed by state law) for vaccine administration. Authorizing nurses, pharmacists, and other healthcare professionals to assess patient vaccine status and administer needed vaccinations without examination or direct order from the attending provider can save time and reduce missed opportunities for vaccination. Resident #1 was admitted to the facility in April 2023. Review of the Resident's immunization record indicated the Resident had been administered the Prevnar 20 (PCV20-a Pneumococcal Vaccination) on 5/24/23. Further Review of the Resident's medical record indicated no standing Physician's order to administer the PCV20 vaccination to the Resident. 2. Review of the facility policy titled Resident/Patient/Facility Personnel Influenza Immunization, reviewed 7/15/22, indicated the following: -Resident/patients and facility personnel of Berkshire Place will be offered immunization against pneumococcal disease as recommended by the Centers for Disease Control and Prevention (CDC) and under the guidance by the Massachusetts Department of Public Health (DPH) . Review of the DPH Memo titled COVID-19 and Influenza Vaccination Guidance, dated November 2, 2022, indicated the following: Long term care facilities that receive and possess COVID-19 and influenza vaccine must: -Administer the vaccine pursuant to a valid practitioner's order Resident #5 was admitted to the facility in April 2022. Review of the Resident's immunization record indicated the Resident had been administered the Influenza Vaccination on 10/4/22. Further review of the Resident's medical record indicated no standing Physician's order to administer the Influenza Vaccination to the Resident. During an interview on 6/6/23 at 12:49 P.M., the Infection Preventionist (IP) said Physician's orders need to be in place for a vaccination to be administered. She reviewed Resident #1 and Resident #5's medical records and said neither Resident had Physician's orders in place for the vaccinations in question. She further said the facility utilized standing orders that were put into the resident records in the electronic medical record (EMR) at the time of admission and Resident #1 did not have a standing order in place for Pneumococcal Vaccination and Resident #5 did not have a standing order in place for Influenza Vaccination, as required.

Based on record review and interview, the facility failed to ensure its staff assessed for eligibility, provided education on, and obtained consent or refusal for the administration of recommended Pneumococcal immunization for one Resident (#2) out of a sample of five residents. Findings include: Review of the facility policy titled Resident/Patient Pneumococcal Immunization, revised 7/15/22, indicated the following: -Resident/patients of Berkshire Place will be offered immunization against pneumococcal disease as recommended by the Centers for Disease Control and Prevention (CDC) . -Before being offered pneumococcal immunization, the resident/patient and/or the resident representative, legal guardian or Health Care agent will receive education regarding the benefits and potential side effects of the pneumococcal vaccine from a licensed nurse using the current Vaccine Information Statement (VIS). A copy of the VIS is provided to the resident/patient and/or their resident representative, legal guardian or Health Care agent. -Pneumococcal immunization will be offered at the time of admission . -The resident/patient and/or the resident representative, legal guardian or Health Care agent has the opportunity to decline immunization and will sign and date a declination statement . Review of the CDC website www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed February 13, 2023 indicated the following: For adults 65 and over who have only received Pneumococcal Polysaccharide Vaccine (PPSV23), CDC recommends you: -Give 1 dose of Pneumococcal Conjugate Vaccine 15 (PCV15) or PCV20. -The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. -Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. Resident #2 was admitted to the facility in January 2023 and was above the age of 65. Review of the Resident's document Pneumococcal Immunization dated 1/9/23 indicated the Resident received a Pneumococcal immunization but the document did not indicate which Pneumococcal immunization the Resident had received. Review of the Resident's immunization record in the electronic medical record (EMR) indicated the Resident received the PPSV23 on 10/2/2017. Further review indicated no additional documentation the Resident had been offered any additional recommended Pneumococcal vaccination at the time of admission. During an interview on 6/6/23 at 12:26 P.M., the Infection Preventionist said the Resident should have been offered and educated on the PCV20 at the time of admission and this was not done.

Based on observation, interview, and policy review the facility failed to: 1. properly store perishables needing refrigeration in two of two facility kitchens (Unit 2 and Unit 3), 2. label and date open dry good items stored in two out of two facility kitchens (Unit 2 and Unit 3), 3. discard food that had been stored over three days in one out of two facility kitchens (Unit 3), 4. date opened food items in the refrigerator in two of two facility kitchens (Unit 2 and Unit 3), and 5. date opened food items in the freezer in one out of two facility kitchens (Unit 3). Findings Include: Review of the facility policy titled Food Storage, Revised 7/2017, indicated the following: -All containers and food products shall be legibly and accurately labeled no matter how obvious a product may be to an individual and dated as to when the product was received and/or prepared. -Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. -Leftover food is used within three days from preparation or is discarded. 1. On 4/20/22 at 7:15 A.M., during the initial tour of the kitchen on Unit 2 an open and partially used bottle of ketchup and an open and partially used bottle of soy sauce were observed being stored on the dry storage shelf. Both bottles had manufacturer's instructions to refrigerate after opening printed on the bottles. Neither bottle was dated as to when it was opened. On the dry storage shelf an open and partially used bag of pasta and an open and partially used bag of lentils were noted to be unlabeled and undated. In the Unit 2 freezer a quarter of wrapped up coffee cake was observed unlabeled and undated, and an open bag of corn was observed undated. During an interview at the time of the Unit 2 kitchen initial tour, Dietary Staff Member #1 said the ketchup and the soy sauce were open, should have been dated with the date they were opened, and stored in the refrigerator, and they had not been, as required. She further said the bag of pasta, bag of lentils, frozen coffee cake, and frozen corn should have all been labeled and dated, and they were not, as required. On 4/20/22 at 7:30 A.M., during the initial tour of the kitchen on Unit 3 an open and partially used bottle of ketchup was observed being stored on the dry storage shelf. The bottle had manufacturer's instructions to refrigerate after opening printed on the bottle. In the Unit 3 freezer the surveyor observed a plastic container labeled baked beans with a date of 3/25, which had freezer burn on the top of the container. On the dry storage shelf an open bag of couscous was noted to be unlabeled and undated. During an interview at the time of the initial tour of the Unit 3 kitchen the Food Service Director (FSD) said the ketchup should have been stored in the refrigerator, and it had not been, as required. She said the baked beans in the refrigerator should be used soon. She further said when dry goods are opened, they should be labeled and dated and the couscous had not been, as required. 2. During a follow up visit to the Unit 2 Kitchen on 4/22/22 at 9:05 A.M., the surveyor observed the following: - two packages of corned beef in plastic wrap with freezer burn dated 2/25/22 and 3/20/22 in the reach in freezer - a half of an onion, wrapped in plastic wrap, undated. On 4/22/22 at 9:26 A.M Dietary Staff #1 said the corned beef should not be served and the onion should have been dated, and then discarded the items. During a follow up visit to the Unit 3 Kitchen on 4/22/22 at 10:00 A.M., the surveyor observed the following: - The reach in freezer included a large, undated, opened box of unwrapped bacon and an undated, opened plastic package of hot dogs - the dry goods storage shelf included opened, undated packages of stuffing mix and cheese Danish. During an interview on 4/22/22 at 10:10 A.M., the FSD said that all opened food should have been dated, as required.

Based on record review and interview, the facility failed to ensure seven out of sixty staff members were tested in one specific week for the COVID-19 (a contagious respiratory illness) virus. Findings include: Review of the Department of Health (DPH) guidelines titled, Updates to Long Term Care Surveillance Testing, dated 9/24/2021, included, but was not limited to: -Surveillance Testing Program: Long term care facilities must conduct weekly testing of all staff. Review of the facility policy titled, Testing Policy related to COVID-19, dated 3/2022, included, but was not limited to: Weekly surveillance testing of all staff will be done in accordance with Department of Health (DPH) guidelines. Review of the facility COVID-19 Testing schedules indicated testing takes place weekly on Monday and Thursday. If a staff member cannot make it for these days, the staff member must see the Director of Nurses (DON) to make arrangements for the testing to be completed. Review of the list of 60 staff members that were required to be tested during the week of 4/7/22 thru 4/13/22 indicated seven staff members who regularly worked in the facility were not tested . During an interview on 4/7/22 at 1:20 P.M., the DON said seven staff members were not tested during the week of 4/7/22 thru 4/13/22, as required.

Based on observation, record review, and interview, the facility failed to ensure their staff developed an individualized plan of care relative to a Stage 4 pressure ulcer (a deep wound with full thickness skin loss and exposed bone, tendon, or muscle) to the sacral (located at the very end of the back) area, for one sampled Resident (#23), out of a total sample of 12 residents. Findings include: Review of the facility policy titled, Decubitus Ulcer Prevention and Treatment, undated, included but was not limited to: -Once it has been determined that a resident may benefit from certain treatment or revision to existing treatment, the attending physician will be contacted for appropriate orders. An individualized skin care plan will be written and placed in chart. Nursing staff will revise and update. All other residents will be reviewed quarterly. Resident #23 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 2/28/22, indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment and had a Stage 4 pressure ulcer. On 4/21/22 at 1:58 P.M., the surveyor observed Resident #23 resting in bed on a low air loss (LAL-a mattress designed to distribute a patient's weight over a broad surface area and help prevent skin breakdown) mattress. Review of the medical record did not indicate that an individualized care plan relative to the Resident's Stage 4 pressure ulcer had been initiated. During an interview on 4/21/22 at 3:28 P.M., the Director of Nurses (DON) said there was no individualized care plan in place specifically addressing Resident #23's Stage 4 pressure ulcer, as required.

Based on observation, record review, and interview, the facility failed to ensure the staff provided necessary care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A. ensure correct setting and monitoring for a low air loss (LAL-a mattress designed to distribute a patient's weight over a broad surface area and help prevent skin breakdown) and, B. availability of weekly wound measurements to monitor the progress of the Stage 4 pressure ulcer, for one sampled Resident (#23), out of three applicable residents, in a total sample of 12 residents. Findings include: Resident #23 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 2/28/22, indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment and had a Stage 4 pressure ulcer. A. The facility failed to ensure the Resident's LAL mattress setting was correct and failed to monitor the settings for accuracy. On 4/20/22 at 7:55 A.M., the surveyor observed the Resident in bed resting on a LAL mattress set at 350 pounds. On 4/21/22 at 1:58 P.M., the surveyor observed the Resident in bed resting on a LAL mattress set at 350 pounds. Review of the medical record documentation indicated that the Resident's most current weight was 230 pounds. Further review of the medical record did not contain any documentation as to the monitoring or required setting of the LAL mattress. Review of the LAL mattress manufacturer's guidelines indicated users can easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. During an interview on 4/21/22 at 1:58 P.M., Unit Manager (UM) #1 said the Resident's recorded weight was 230 pounds. She further said the LAL mattress setting was incorrect as it did not reflect the Resident's documented weight. During an interview on 4/21/22 at 3:01 P.M., the Director of Nurses (DON) said there should be a physician order in place for the LAL mattress. She said there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . B. The facility failed to ensure the completed weekly wound measurements were done and readily available in the medical record to monitor the healing or decline of the Resident's Stage 4 pressure ulcer. Review of the facility policy titled, Decubitus Ulcer Prevention and Treatment, undated, included but was not limited to: -After a treatment has been initiated for an abnormal skin condition, nursing will reassess, measure and document weekly. Review of Wound Care Essentials Practice Principles, 5th edition indicated: Documentation is an essential component of wound assessment. Every wound assessment should be documented thoroughly, accurately, and legibly, with an accompanying signature as well as date and time of assessment. Wounds should be documented on admission, weekly, with each dressing change, upon significant change in the wound, and upon discharge. During an interview on 4/22/22 at 1:35 P.M., the DON said wounds are to be measured weekly. If the Resident goes to the wound clinic, the facility does not measure the wound and the wound clinic measurements are a source which are included in the medical record. If the Resident does not go to the wound clinic weekly, the facility nursing staff should measure the wound and record the measurements on the Weekly Skin Assessment form. Review of the medical record indicated the Resident was transferred to the wound clinic on 2/23/22, 3/2/22, 3/9/22, 3/26/22 and 4/6/22 for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/22/22 at 1:45 P.M., UM #1 reviewed the weekly wound assessments with the surveyor. She said Resident #23 went to the wound clinic on 2/23/22, 3/2/22, 3/9/22, 3/26/22 and 4/6/22. She said the facility was responsible for the wound measurements to be done on 3/22/22, 4/12/22 and 4/19/22. She further said there were no recorded measurements on any of those days, as required. During an interview on 4/22/22 at 3:30 P.M., UM #1 said the wound clinic documentation, after a visit, consists of two pages. She said the first page comes back with the Resident and describes the treatment that the clinic provides to the Resident. The second page includes the progress notes and wound measurements and page two does not return with the Resident. She said she has to call the wound clinic to obtain this page. She said she called the clinic and showed the surveyor the clinic wound measurements and progress notes from the visits of 2/23/22, 3/2/22, 3/9/22 and 4/6/22 that were faxed to the facility upon request. She further said the wound measurements were not readily available in the medical record, as required.

Based on record review and interview the facility failed to ensure the staff provided a safe environment, free of accident hazards for one Resident (#27), out of a total sample of 12 residents. Specifically, the nurse left medication in the resident's room with the Resident without ensuring that Resident #27 took the medication and walked away. Findings include: Resident #27 was admitted to the facility in May 2015 with a diagnosis of adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) Assessment, dated 9/1/21, indicated that the Resident was moderately cognitively impaired as evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS). Review of the nurse's note, dated 10/16/21, indicated that the Resident snatched the cup containing the Resident's medications from the nurse. The nurse asked the Resident if he/she was going to take the medications and the Resident replied, I'll take them whenever the hell I feel like, now get the hell out. The calmly reminded the Resident that the way he/she was speaking was rude and disrespectful, and the Resident then started mumbling and replied that's you, you sound stupid, shut up I don't care if I'm being rude The nurse left the room before the Resident took his/her medication. During an interview with the Director of Nursing (DON) on 4/21/22 at 1:40 P.M. She said that the nurse should not have walked away and left the medication in the room with the Resident.

Based on interview, record review, and policy review the facility failed to limit the timeframe for a PRN (as needed) [CONDITION(S)] medication (a medication that alters mood/behavior) to 14 days and failed to have the physician document the rationale for the continuation of a PRN antipsychotic for one Resident (#23), out of 12 total residents sampled. Findings include: Review of the facility policy titled [CONDITION(S)] Medications, undated, indicated the following: -PRN [CONDITION(S)] medications which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she feels it is appropriate. If the attending physician extends the PRN order the medical record will include documented rationale and determined duration. Resident #23 was admitted to the facility in February 2022 with a diagnosis of Depression. Review of the April 2022 Physicians' orders indicated the following order: [MEDICATION(S)] (a [CONDITION(S)] medication used to reduce anxiety) Tablet 0.5 milligram (MG) Give 1 tablet by mouth every eight hours as needed for agitation. Further review of the order indicated a start date of 2/22/22 and no stop date. Review of the February 2022 Medication Administration Record (MAR) indicated Resident #23 had received the PRN [MEDICATION(S)] four times in the month of February. Review of the March 2022 MAR indicated the Resident had received the PRN [MEDICATION(S)] 11 times in the month of March. Review of the April 2022 MAR indicated the Resident had received the PRN [MEDICATION(S)] four times in the month of April. Review of the Pharmacy Consultation Report dated 4/7/22 indicated the following recommendation: Resident #23 has a PRN order for an anxiolytic (drug used to reduce anxiety), without a stop date: [MEDICATION(S)] 0.5 MG every eight hours as needed for agitation. Please discontinue PRN [MEDICATION(S)]. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Further review of the Pharmacy Consultation Report indicated the Physician declined the recommendation but did not provide rationale for continuing the use of the [MEDICATION(S)] and did not provide an intended duration for the use of [MEDICATION(S)]. During an interview on 4/20/22 at 3:11 P.M., Unit Manager (UM) #1 said PRN psychotropics should be reevaluated every 14 days for continuation of the medication, unless the physician documented a recommendation to continue the medication for a specific time frame. During an interview on 4/20/22 at 4:31 P.M., UM #1 said Resident #23 did not have an end date to his/her PRN [MEDICATION(S)] and it had not been reviewed every 14 days, as required.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was lethargic, unable to bear weight, was unable to participate physically and required the use of a mechanical lift for transfers, the Facility failed to ensure he/she was provided with the necessary assistive equipment required to safely transfer him/her. When on 2/15/20, when Resident #1's new air mattress was delivered and needed to placed on his/her bed, a mechanical lift was not available on the rehabilitation unit for staff to transfer him/her in/out of bed. Resident #1 was transferred in and out of his/her bed to a chair and then back again, by staff members using a firemen's carry (completely lifting the resident with a two person assist, with staff members holding the resident up on each side, under the thighs and arms) and during the transfer Resident #1 sustained a 3 centimeter (cm) by 2 cm skin tear to his/her left upper arm, which required treatment. Findings include: The Facility Policy, titled Resident Movement and Transfer Guidelines, dated 10/2017, indicated that: - The staff need to know the equipment they need. - When transferring the resident do not grab the person under arms. - Do not let the person hold or grasp you around the neck. - For mechanical lifts determine how the resident transfers, the type and size of the sling, and attach the motor control to the ceiling. Review of Resident #1's Admission Evaluation, dated 2/13/20, indicated that on his/her arms were scattered bruises due to previous intravenous needle insertions, and that his/her skin was intact. Review of Resident #1's Plan of Care related to risk for skin breakdown due to end stage disease processes, dated 2/13/20, indicated to maintain his/her skin as issues arises as he/she transitions to the end of life. Review of Resident #1's Plan of Care related to assistance with activities of living, dated 2/13/20, indicated to assist with transfers as needed. Review of the Facility's Internal Investigation Report, dated 2/15/20, indicated that Resident #1 was transferred out of bed (at approximately 5:00 P.M.) due to the need to put a new air mattress on his/her bed. Resident #1's arm was bumped during this transfer, he/she sustained a 3 centimeter (cm) by 2 cm skin tear (to his/her left upper arm), the area was cleansed with normal saline, a topical antibiotic, a non-stick dressing and Kling bandage were applied. During an interview on 11/6/20 at 4:00 P.M., Witness #1 said on 2/15/20, at approximately 6:00 P.M., while visiting with Resident #1, she witnessed staff members transfer him/her from a chair back into bed. Witness #1 said that Resident #1 was unresponsive, was dead weight, and said the transfer was unsafe, ugly to watch, and that there was a complete disregard for his/her safety. Witness #1 said Certified Nurse Aide (CNA) #1 and CNA #2 manually lifted Resident #1 up from the chair, that CNA #1 and CNA #2 were positioned on opposite sides of the resident, with Resident #1 seated in between them in the chair. Witness #1 said the two CNA's lifted Resident #1 up a few inches off the chair then dropped Resident #1 back into the chair, because CNA #1 was struggling holding Resident #1 up on her side. Witness #1 said CNA #2 then said to CNA #1, get out of my way, and that CNA #2 stood in front of Resident #1, picked Resident #1 up under his/her arms in a bear hug, swung Resident #1 around by herself and then dropped Resident #1 onto the bed. Witness #1 said that CNA #1 stated that Resident #1 had been difficult for them to transfer when they transferred him/her out of bed earlier and put him/her the chair, and that CNA #1 said they needed a Hoyer (mechanical ) lift to transfer him/her, but one was not available. Review of Certified Nurse Aide (CNA) #2's written witness statement indicated Nurse #1 and CNA #1 were having difficulty transferring Resident #1 from the chair to bed, and CNA #1 told her she needed to assist them with the transfer. During an interview on 11/13/20 at 12:20 P.M., CNA #1 said that although Resident #1 required a mechanical lift for transfers, a mechanical lift was not available on the rehabilitation unit. CNA #1 said she attempted to obtain a mechanical lift from another unit but was told it was not available. During an interview on 11/13/20 at 12:08 P.M., Nurse #1 said Resident #1 required a mechanical lift with all transfers due to weakness, that he/she was dead weight, and was unable to bear weight. Nurse #1 said Resident #1 could not participate with the transfer because he/she was lethargic and unresponsive. Nurse #1 said since a mechanical could not be obtained by the staff at the time of the transfer, Resident #1 was transferred in and out of his/her bed to a chair and back again, by staff members using a firemen's carry. Nurse #1 said that Resident #1 sustained the skin tear during the transfer. During an interview on 11/13/20 at 10:40 A.M., the Director of Nurses said her expectations were that Resident #1 would be transferred with a mechanical lift.

Based on staff interviews, record and policy review, the facility staff failed to ensure the Physician was updated relative to a resident's change in condition, for 1 sampled resident (#2), in a total sample of 13 residents. Findings include: Review of the undated facility policy for Physician Notification indicated the following: - Upon identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection, and update the Physician. -Urgent notification will occur by licensed nurse calling the Physician, Nurse Practitioner or covering Physician by phone if: -the clinical status and findings indicate the need for a transfer to the hospital -a significant change in the resident's physical, mental or psychosocial status occurs Resident #2 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/14/16, indicated that the resident was rarely/never understood/understands, had severe cognitive impairment, was dependent on staff for Activities of Daily Living (ADLs), and received 7 days of anticoagulant medication. Review of the nurse's note, dated 2/25/17, indicated that at 10:30 P.M., a Certified Nursing Assistant (CNA) observed that Resident #2 had a moderate amount of blood in his/her brief and notified the nurse. The nurse notified the Physician. An order was obtained to check the INR (International Normalized Ratio-measures clotting of the blood) and PT ([MEDICATION NAME] Time-measures blood clotting time) on 2/26/17 in the morning. Review of the nurse's note, dated 2/26/17 at 3:28 A.M., indicated the resident had moderate to large amounts of vaginal bleeding and was restless during the shift. There was no indication that the Physician had been updated regarding the additional episode of bleeding. Review of a nurse's note, dated 6/26/17 at 6:27 A.M., indicated the resident's gums were bleeding. Mouth care was provided. There was no indication that the Physician was updated regarding the additional episode of bleeding. Review of a Situation Background Assessment and Recommendation Form (SBAR), indicated that on 2/26/17 at 10:40 A.M. the Physician was contacted and had the resident sent to the hospital. The resident was to have a PT/INR blood test done that morning. The blood draw was not done-lab didn't arrive. The resident had 3 full briefs of blood overnight and one that day. Color was pale, white, gray. Review of the nurse's note, dated 2/26/17 at 11:19 A.M., indicated that during care the staff observed that the resident had a full brief of blood. The nurse's note indicated the resident's color was pale, white, gray. He/she was cool to the touch and slow to respond to verbal stimuli. The Physician and responsible party were notified of the resident's condition. A physician's orders [REDACTED]. Review of the nurse's note, dated 2/26/17 at 6:00 P.M., indicated the resident was admitted to the hospital with [REDACTED]. During a telephone interview on 6/6/17 at 9:40 A.M., Nurse #2 said she was working during the 11:00 P.M. to 7:00 A.M. shift starting on 2/25/17 and ending on 2/26/17. She said Resident #2 was monitored during her shift and medicated for restlessness with Tylenol. She said that she did not inform the Physician about the episodes of bleeding during her shift. She said the Physician was already updated on the previous shift, and an order had been obtained to check lab work in the morning. During an interview on 6/6/17 at 1:30 P.M., the Director of Nurses (DON) said the Physician should have been notified of the continued change in the resident's condition. Refer to F309

Based on staff interviews, record and policy review, the facility staff failed to ensure the necessary care and services were provided to maintain the highest practicable physical well being when the resident had a change in condition for 1 sampled resident (#2), in a total sample of 13 residents. Findings include: Review of the undated facility policy for Physician Notification indicated the following: - Upon identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection, and update the Physician. -Urgent notification will occur by licensed nurse calling the Physician, Nurse Practitioner or covering Physician by phone if: -the clinical status and findings indicate the need for a transfer to the hospital -a significant change in the resident's physical, mental or psychosocial status occurs Review of the facility policy for Incident/Accident/Medication Error Reporting, revised 3/2013, indicated the following: - Document the events of a resident incident - Identify any injuries or adverse reaction - Examine the entire skin surface, measure all vital signs, assess pain - Assess any changes in mental and cognitive status - Observe and assess all neurological signs - Notify the resident's attending Physician of the change of condition or any concerns that have been identified -Notify the resident's legal representative Resident #2 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of the resident care plan, initiated 11/18/14, indicated an increased risk of bleeding related to anticoagulation (blood thinning) therapy. Interventions included the following: assess for bone, joint and abdominal pain, monitor for acute bleeding (hematuria-blood in the urine, bruising, positive occult blood in the stools, bleeding gums), and monitor for pallor and cyanosis (bluish or grayish color of the skin, nails, lips or around the eyes). Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/14/16, indicated that the resident was rarely/never understood/understands, had severe cognitive impairment, was dependent on staff for Activities of Daily Living (ADLs), and received 7 days of anticoagulant medication. Review of the 2/2017 Weights and Vital Signs (blood pressure, pulse, respirations, temperature and Oxygen saturation level) Summary indicated no vitals signs were documented after 2/22/17. Review of a laboratory report for an INR (International Normalized Ratio-measures clotting of the blood), dated 2/9/17, indicated the results were 2.3. Normal range was 2 to 3. In addition, the [MEDICATION NAME] Time (PT-measures blood clotting time) was also measured and was 24.1 seconds. The normal range was 9 to 14 seconds. Review of the Physician's Interim/Telephone Orders, dated 2/9/17, indicated an order to increase the dosage of [MEDICATION NAME] (an anticoagulant medication) from 3.0 milligrams (mg.) to 3.5 mg. daily. Review of the nurse's note, dated 2/25/17, indicated that at 10:30 P.M., a Certified Nursing Assistant (CNA) observed that Resident #2 had a moderate amount of blood in his/her brief and notified the nurse. The nurse notified the Physician. An order was obtained to check the INR and PT on 2/26/17 in the morning. No clinical assessment was documented. Review of the nurse's note, dated 2/26/17 at 3:16 A.M., indicated the resident was administered 2 tablets of Tylenol (a pain reliever) 650 mg. for restlessness related to moderate amounts of bleeding. No clinical assessment was documented. Review of the nurse's note, dated 2/26/17 at 3:28 A.M., indicated the resident had moderate to large amounts of vaginal bleeding. He/she was restless during the shift. A pain assessment was completed. No other clinical assessment was documented. Review of the nurse's note, dated 2/26/17 at 5:04 A.M., indicated that the resident was administered Tylenol 650 mg. for pain. Review of a nurse's note, dated 6/26/17 at 6:27 A.M., indicated the resident's gums were bleeding. Mouth care was provided. No clinical assessment was documented. Review of the nurse's note, dated 2/26/17 at 9:30 A.M., indicated that the resident was administered 2 tablets of Tylenol 650 mg. for pain. Review of the Physician's Interim/Telephone Orders, dated 2/26/17 at 10:30 A.M., indicated an order to send the resident to the Emergency Department for evaluation. Review of a Situation Background Assessment and Recommendation Form (SBAR), indicated that on 2/26/17 at 10:40 A.M. the Physician was contacted and gave an order for [REDACTED]. The blood draw was not done-lab didn't arrive. The resident had 3 full briefs of blood overnight and one that day. Color was pale, white, gray. Review of the nurse's note, dated 2/26/17 at 11:19 A.M., indicated that during care the staff observed that the resident had a full brief of blood. The nurse's note said the resident's color was pale, white, gray. He/she was cool to the touch and slow to respond to verbal stimuli. Further review of the nurse's note indicated that vital signs were obtained. The Physician and responsible party were notified of the resident's condition. An order was obtained to send the resident to the hospital for evaluation. Review of the nurse's note, dated 2/26/17 at 6:00 P.M., indicated the resident was admitted to the hospital with [REDACTED]. Review of the Hospital Discharge Summary, dated 2/28/17, indicated the resident was admitted to the hospital with [REDACTED]. In addition, the resident received intravenous fluids for acute [MEDICAL CONDITION] (elevated sodium levels) and antibiotics for a urinary tract infection. The PT clotting time on admission to the hospital was initially greater than 150. During an interview on 6/2/17 at 1:20 P.M., Nurse #1 said she was working during the 7:00 A.M. to 3:00 P.M. shift on 2/26/17. She said she had received a report that the resident had bleeding during the previous shifts. Sometime after breakfast when the resident was being changed, blood was again observed in the resident's brief. Nurse #1 did a clinical assessment, including vital signs, and called the Physician. She could not remember if she had received a report about vital signs being monitored during the night. During a telephone interview on 6/6/17 at 9:40 A.M., Nurse #2 said she was working during the 11:00 P.M. to 7:00 A.M. shift starting on 2/25/17 and ending on 2/26/17. She said Resident #2 was monitored during her shift and medicated for restlessness with Tylenol. She said she did not inform the Physician about the episodes of bleeding during her shift. In addition, she said if vital signs had been assessed, they would be in the progress notes or in vital signs section of the clinical record. She said the Physician was already updated on the previous shift and an order had been obtained to check lab work in the morning. During an interview on 6/6/17 at 1:30 P.M., the Director of Nurses (DON) said that an assessment, including obtaining vital signs like blood pressure and assessing other orifices for bleeding, should have been completed when the resident had further bleeding. She also said the Physician should have been notified of the continued change in the resident's condition.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that nursing staff transferred Resident #1 with two assist, per plan of care. On 1/5/14, Certified Nurse Aide (CNA) #1, transferred Resident #1 wilthout the assistance of two people from the the toilet to the wheelchair. During the transfer Resident #1's legs buckled and he/she had to be lowered to the floor. Resident #1 sustained a right humerus fracture. Findings include: The Admission Record indicated Resident #1 was admitted to the Facility in October, 2001 with [DIAGNOSES REDACTED]. The Fall Risk assessment, dated 12/4/13, indicated Resident #1 was at a moderate risk for falls. The Fall Risk Care Plan, dated 12/9/12, indicated Resident #1 required the assistance of two people for all transfers. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required the assistance of two people for all transfers. The MDS indicated Resident #1 exhibited poor balance when standing. The CNA assignment sheet indicated Resident #1 was a two person assist for a stand-pivot transfer. The Nurse's Note, dated 1/5/14, and written by Nurse #1, indicated that at approximately 7:40 A.M., CNA #1 was heard calling for help from Resident #1's bathroom. The note indicated that when Nurse #1 responded to the room she saw CNA #1 lowering Resident #1 to the floor. The note indicated that CNA #1 said that Resident #1's legs buckled when she tried to transfer him/her from the toilet to the wheelchair. The note indicated that Resident #1 complained of pain in the right arm, an X-ray was done, and Resident #1 sustained a fracture of the right humerus. The note indicated Resident #1 was transferred to the Hospital for treatment. The Surveyor interviewed CNA #1 at 10:00 A.M on 2/12/14.. CNA #1 said that Resident #1 was assigned to her care on 1/5/14. She said she took Resident #1 to the bathroom and transferred Resident #1 from the wheelchair to the toilet, by herself, without a gait belt. She said she provided morning care to him/her. CNA #1 said when she began to transfer Resident #1 back to the wheelchair, from the toilet, by herself and without a gait belt, Resident #1's legs buckled and she was unable to get him/her back onto the wheelchair. She said she could only get him/her to the edge of the wheelchair, she called for help, but when she could not hold onto Resident #1 any longer, she lowered him/her to the floor. CNA #1 said she did not request help from anyone else, she did not use a gait belt, and she performed the transfers by herself. She said she was aware of the gait belt policy and Resident #1's need to be transferred with two people. She said she did the transfer alone, the way she always did. The Surveyor interviewed CNA #2 at 3:45 P.M. on 2/12/14. She said she was working with another resident in the same room when CNA #1 had Resident #1 in the bathroom. She said CNA #1 did not ask her for help and when she offered to help CNA #1, she said she was all set and did not need help. The Surveyor interviewed Nurse #1 at 11:30 A.M. on 2/12/14. She said that when she heard CNA #1 calling for help and went to Resident #1's room, she saw Resident #1 being lowered to the floor in the bathroom, in front of the wheelchair. She said she reminded CNA #1 that Resident #1 required the assistance of two people for transfers and a gait belt. She said CNA #1 said she knew that, but she was busy. The Facility policy relative to Gait Belts indicated that gait belts were part of the uniform for CNAs and were to be used with any resident who required the assistance of one to two people for transfer or ambulation.