Every finding on record at Blackstone Valley Health and Rehabilitation

Based on record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for two Residents (#93) and (#74), out of a total sample of 25 residents. Specifically, for Resident's #93 and #74, the facility failed to request a Level II PASARR evaluation when both Residents demonstrated a change in psychosocial condition requiring emergency mental health intervention. Findings include: 1. Resident #93 was admitted to the facility in May 2024 with diagnoses including Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). Review of Resident #93's PASARR Level I screen dated 5/17/24, indicated: -a negative screen -that he/she did not meet criteria for SMI -therefore a Level II PASARR evaluation was not needed Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #93: -was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of a possible score of 15. -had expressed feelings of Depression during the look back period. -was prescribed antipsychotic and antidepressant medications. Review of Resident #93's clinical record indicated: -A Nursing Progress Note dated 7/2/24, that indicated the Physician ordered the Resident to be transferred to the hospital emergency room due to the Resident making a suicidal statement. -A Social Service Progress Note dated 11/12/24, that documented the Resident had expressed feelings of sadness and suicidal ideation to the Consulting Psychiatrist. The facility Physician had been notified and agreed to send the Resident to the Emergency Department for further evaluation. -A Consulting Psychiatrist Note dated 11/12/24, that recommended the Resident be put on one-on-one support and that the Resident agreed to assessment in (hospital) Emergency Department and was sent via medical transport. Further review of the Resident #93's medical record failed to indicate that the Level I PASARR was updated and re-submitted for an additional Resident Review and Level II evaluation following the Resident's change in psychosocial condition requiring emergency mental health interventions in July 2024 and November 2024. During an interview on 4/24/25 at 3:26 P.M., Social Worker (SW) #1 said that an updated Level I should have been submitted to the DMH PASARR office after Resident #93 expressed suicidal ideation (SI) in July 2024 and November 2024, but the Level I screen was not updated and submitted. 2. Resident #74 was admitted in June 2024 with diagnoses including Major Depressive Disorder, Anxiety and Depression. Review of the Resident #74's Level I Preadmission Screening and Resident Review (PASRR) dated 6/12/24, indicated: -he/she had a history of Mood Disorder and Anxiety/Panic Disorder. Review of Resident #74's Level II PASRR determination letter, dated 6/28/24, indicated: -the Resident did not meet criteria for Serious Mental Illness. -no further PASRR involvement was required. Review of Resident #74's Nursing Progress Notes indicated: -On 1/31/25: Resident #74 was agitated and stated to a Certified Nurses Aide (CNA) If I don't get out of here, I will kill myself. When the Resident was approached by the Nurse, the Resident was yelling and agitated and verbalized intentions to kill him/herself. The Nurse Practitioner (NP) was notified, and the Resident was sent out to the hospital for evaluation. -On 2/1/25: a call was placed to the hospital and Resident #74 was admitted for the night for observation. -On 2/1/25: the Resident returned from the hospital with no medication recommendations. Resident #74 started stating to staff he/she wanted to kill him/herself, was yelling and exit seeking. The Physician was notified and ordered Resident #74 be sent out to the hospital for evaluation. -On 2/1/25: Resident #74 returned to facility. Review of the Social Service Progress Notes dated 2/3/25, indicated Resident #74 returned from the hospital and was scheduled to see Behavioral Health Services. The Social Worker followed up with the Resident regarding negative statements that were made by the Resident and indicated that Resident #74 had made no further statements regarding suicidal ideation. Review of the hospital discharge paperwork dated 1/31/25, indicated the Resident was seen for feeling suicidal. Review of Resident #74's Comprehensive Care Plan indicated a focus area initiated on 2/4/25, for a history of suicidal ideation statements. During an interview on 4/24/25 at 3:26 P.M., SW #1 said that the change in status related to the hospitalization for suicidal ideation for Resident #74 should have been reported to the PASRR office, but it had not been.

Based on interview, and record review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care plan process for one Resident (#46), out of a total sample of 25 residents. Specifically, the facility failed to ensure that quarterly care plan meetings were conducted as required for Resident #46. Findings include: Review of the facility policy titled Resident Assessment and Care Planning Policies and Procedures, last revised February 2022, included the following: -Residents and their families .are invited to attend and participate in the resident's assessment and care planning conferences (admission, quarterly, annual, and significant change in status). -A timely advance notice of the care planning conference is provided to the resident and interested family members. -Social services maintain a record of such notices. -Attendance will be taken and kept in the resident's record. -All care plans will be reviewed with the attendees for further input, revisions, and approval by the clinical team and the resident/representative. -If the resident or designated representative cannot attend, they will be contacted by the social services staff or designee either in person, by phone, or by mail to be given a review of the information discussed in the meeting. -This event will be documented in the resident's record. Resident #46 was admitted to the facility in February 2020, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic pain syndrome. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #46 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15. During an interview on 4/23/24 at 8:16 A.M., Resident #46 said that the facility has not had a care plan meeting with him/her recently. Resident #46 further said that he/she was unaware of what his/her plan of care was. Review of the MDS Schedule for Resident #46 indicated that the Resident had care plan meetings scheduled for August 2024 and February 2025. Review of Resident #46's clinical record failed to indicate documented evidence that the Resident/Resident Representative participated in the care planning process or that the interdisciplinary team (IDT) met quarterly to review the plan of care, as required in August 2024 and February 2025. Further review of the clinical record failed to indicate any care plan meetings or refusals to participate in the meetings by the Resident/Resident Representative were documented in August 2024 and February 2025. During an interview on 4/24/24 at 3:23 P.M., Social Worker (SW) #1 said that Resident #46's care plan meeting should have been held in August 2024 and February 2025, but they had not been. SW #1 also said that the meetings should have been added to the MDS care plan meeting schedule but they had not been. During an interview on 4/28/25 at 12:15 P.M., the Assistant Director of Nurses (ADON) said that they were unable to locate evidence or signature pages that the care plan meetings were held for Resident #46 for August 2024 and February 2025.

2. Resident #113 was admitted to the facility in February 2025 with diagnoses including Unspecified Dementia unspecified severity with other behavioral disturbance and Anxiety Disorder Unspecified. Review of the facility policy titled Wandering/Missing Residents, effective 8/2022, included the following: -Purpose: To provide a safe and secure environment to protect residents from elopement. -Policy: It is the policy of (the facility) that the safety and well-being of all residents with the potential for wandering are ensured. -If it is determined, through assessment, that a resident has a potential for wandering, the Resident Care Plan will reflect this behavior with all disciplines aware of the need for his/her monitoring. -A picture of all elopement risk residents is also located on each unit's nursing station and front desk and updated routinely with any changes. Review of the Resident's clinical record included an Elopement Risk Evaluation completed upon admission to the facility in February 2025 which indicated: -the Resident was cognitively impaired with poor decision-making skills. -the Resident had a pertinent diagnosis of Dementia .Anxiety Disorder. -the Resident ambulates independently without the use of an assistive device. -the Resident verbally expressed a desire to go home, has been observed packing his/her belongings up to go home and/or stays near the exit doors/elevators from the unit. -the Resident wanders aimlessly throughout the building. -the Resident had been recently admitted . -the Resident was considered at risk for elopement. Further Review of the Elopement Risk Evaluation failed to indicate whether or not the Resident's picture had been added to the facility's Elopement Risk Book, and no evidence of any further Elopement Risk Evaluations being completed for the Resident. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #113 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 possible points. Further review of the Resident's clinical record indicated: -Physician's order to monitor the Resident for wandering behavior each shift, initiated upon admission to the facility, -Care Plan indicating that the Resident was an elopement risk/wanderer, initiated 2/24/25. Review of the Certified Nursing Assistant (CNA) Behavior/Intervention Monthly Flow Records for the months of February 2025, March 2025, and April 2025, indicated the Resident demonstrated wandering behavior on all days. Further Review of the CNA Behavior/ Intervention Monthly Flow Records indicated there were four days during the three month review period with no CNA documentation noted. Review of the Wandering Resident/Elopement Risk List and Binder with resident pictures located at the facility front desk and unit nurses' station failed to show the Resident's name and photograph to identify Resident #113 for Wandering/Elopement. During an interview on 4/24/25 at 11:44 A.M., Nurse #1 said that the Resident did wander around the unit and that the residents who were evaluated to be at risk for elopement would be included in the Elopement Binder. Nurse #1 said that a resident's risk for elopement was determined by completing an Elopement Risk Evaluation. Nurse #1 said that she had completed the Elopement Risk Evaluation for the Resident on the day the Resident was admitted to the facility. Nurse #1 said that after reviewing the Resident's Elopement Risk Evaluation now, she realized that she should have completed the evaluation to indicate that the Resident would be added to the Red Elopement Risk Binder. Nurse #1 said that she was unsure if the Resident's picture and information were ever added to the Elopement Risk Binder but they should have been. During an interview on 4/24/25 at 12:05 P.M., Receptionist #1 said that the Elopement Binder was located at the front desk. She reviewed the Elopement Binder with the surveyor and confirmed that the Resident was not included in the Elopement Binder. The front page which listed the residents who were considered at risk for elopement did not include the Resident's name, nor was there a photograph of the Resident found in the Elopement Binder. During an interview on 4/24/25 at 3:40 P.M., the Director of Nursing (DON) said that residents were placed in the Elopement Book when they were identified as at risk for elopement per the Elopement Risk Evaluation. She said that Resident #113 was evaluated upon admission to the facility as an elopement risk and his/her name and picture should have been added to the Wandering/Elopement Risk List Red Binder that was located at the front desk and the nurses' stations. Based on record reviews, and interviews, the facility failed to ensure two Residents (#32 and #113) out of a total sample of 25 residents, remained free from accidents and hazards. Specifically, 1. For Resident #32, the facility failed to secure smoking materials at the nurses station after the Resident participated in smoking activities, ensure the Resident disposed of smoking materials safely, and perform one out of three quarterly Safe Smoking Assessments. 2. For Resident #113, the facility failed to include the Resident's name and photograph as part of the Wandering Resident Red Binder located at the facility front desk and unit nurses' stations, when the Resident was evaluated as being at risk for elopement. Findings include: 1. Review of the facility policy titled: Facility Smoking, effective date January 2025, indicated the following: -The purpose of this policy is to protect residents' rights while ensuring the highest level of safety for both residents and staff from the serious consequences that may result from fire and/or smoking activities as well as dangers of exposure to secondhand smoke. -All residents who express the desire to smoke have a Safe Smoking Assessment performed at that time, on admission, readmission, quarterly, and with any change in cognitive or physical function. -The Safe Smoking Assessment evaluates the resident's cognitive abilities, judgement, manual dexterity, and mobility. -Residents are to dispose of smoking materials properly in provided non-combustible smoking receptacles, then when the session is ended these smoking materials will be emptied by the staff into a metal self closing container. -All resident smokers are responsible for following the facility policy and procedures for safe smoking. Resident #32 was admitted to the facility in August 2022 with diagnoses including Major Depressive Disorder and Adult Failure to Thrive. Review of the Minimum Data Set (MDS) assessments, dated 10/24/24 and 1/22/25, indicated Resident #32: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. -was a smoker. On 4/23/25 at 8:20 A.M., the surveyor observed Resident #32 seated on the edge of the bed in his/her room and a rolling walker with a storage compartment positioned next to the bed. The surveyor also observed smoking materials including a cigarette box, a lighter, and multiple used cigarettes inside the storage compartment of the rolling walker. During an interview at the time, Resident #32 said he/she usually gives the smoking materials to the Nurse to be kept at the nurses station but he/she had been out to smoke earlier that morning and was planning to go to out smoke again, so he/she kept the smoking materials in the storage compartment of the rolling walker. Resident #32 also said that he/she likes to save used cigarettes. During an interview on 4/23/25 at 8:22 A.M., Nurse #6 said that Resident #32 should not have any smoking materials in his/her possession. Nurse #6 was then observed to retrieve the smoking materials from Resident #32. During an interview on 4/24/25 at 9:53 A.M., Unit Manager (UM) #1 said that residents are required to adhere to the facility policy regarding smoking. UM #1 said that all smoking materials should have been kept at the nurses station and when the residents want to go and smoke, they come to the desk and get their smoking materials. UM #1 said Resident #32 should not store his/her smoking materials and used cigarettes in the storage compartment of the rolling walker because it was a fire hazard. Review of the MDS submission schedule for Resident #32 indicated the following: -7/27/25: Quarterly MDS submitted and accepted -10/24/24: Annual MDS submitted and accepted -1/22/25: Quarterly MDS submitted and accepted Review of Resident #32's clinical record indicated a facility smoking safety screen was completed 7/22/24 and identified Resident #32 as safe to smoke with supervision. The clinical record further indicated a facility smoking safety screen completed 1/31/25 that identified Resident #32 as safe to smoke independently. Further review of Resident #32's clinical record failed to indicate that a facility smoking safety screen had been completed between the completion of the 7/27/24 facility smoking safety screen and the 1/22/25 facility safe smoking screen. During an interview on 4/28/25 at 11:35 A.M., the Director of Nursing (DON) said that Resident #32 began to smoke about four or five months ago. The DON said that smoking safety screens were completed initially when a Resident indicates wanting to smoke and then quarterly as part of the MDS assessment. During a follow-up interview on 4/28/25 at 3:58 P.M., the DON said Resident #32 had a smoking safety screen completed on 7/22/24 and 1/31/25, but could not provide evidence that a smoking safety screen had been completed quarterly. During an interview and policy review at the same time, the Assistant Director of Nurses (ADON) said that a smoking safety screen should have been completed in October 2024 with the quarterly MDS assessment, but was not completed.

Based on observation, interview, and record review, the facility staff failed to ensure appropriate care and services were provided for one Resident (#45) out of a total sample of 25 residents, when the Resident was identified as being at risk for altered nutrition status. Specifically, for Resident #45, the facility failed to perform a nutritional assessment when the Resident was admitted to the facility and implement interventions thereafter when the Resident was identified as having experienced a significant weight loss. Findings include: Review of the facility policy titled: Nutrition/Weight Policy, effective 12/1/24, indicated the following: -When weights demonstrate undesired trends, or progressive insidious weight change, or significant weight change (gains or losses) the licensed nurse will document the weight change in the EMR (Electronic Medical Record). -The threshold for significant unplanned and undesired weight change (loss/gain) will be based on the following criteria: a. 1 month -5% weight loss/gain is significant; greater than 5% is severe. b. 3 months -7.5% weight loss/gain is significant; greater than 7.5% is severe. c. 6 months -10% weight loss/gain is significant; greater than 10% is severe. -The Dietician is responsible for monitoring residents, making recommendations and documenting in the medical record, including problems, progress, care plan. Resident #45 was admitted to the facility in February 2025 with diagnoses including Multiple Sclerosis, dysphagia, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #45 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total possible score of 15. Review of Resident #45's Care Plan for Nutritional Risk, initiated 2/21/25, indicated: -was at nutritional risk due to chronic medical condition significant for MS (Multiple Sclerosis), impaired self-feeding, and increased caloric needs due to uncontrolled spastic movements. -The care plan interventions included the following: >Regular diet. >Monitor and record meal intake. >Obtain and monitor lab work as ordered. >RD (Registered Dietician) to evaluate and make diet change recommendations, PRN (pro-re nata - as needed). Review of the clinical record failed to indicate any Nutritional Assessments had been completed by the Dietician for Resident #45. Review of the facility Weight Record for Resident #45 indicated the following weight measurements: -2/19/2025: 129.0 lbs. (pounds) -2/25/2025: 125.6 lbs. -3/5/2025: 126.2 lbs. -3/12/2025: 122.6 lbs. -3/28/2025: 118.8 lbs. -4/4/2025: 117.4 lbs. Further review of Resident #45's weight record indicated the Resident experienced a 7.5% weight loss (severe) from 3/5/25 to 4/4/25 and a 9.8% weight loss (severe) from 2/19/25 to 4/4/25. Review of Resident #45's Nursing Progress Note, dated 4/6/25, indicated: -the Physician was in to see the Resident -weights were reviewed -a new order for a dietary consult. Review of Resident #45's Physician Progress Note, dated 4/8/25, indicated weight loss, poor PO (per-os-by mouth) intake, and a dietary evaluation was requested to assess malnutrition. Review of the facility documentation titled At Risk Meeting for Resident #45 indicated: -4/3/25 weight: 118.8 lbs., and no intervention documented. -4/10/25 weight: 117.4 lbs., and no intervention documented. Further review of Resident #45's clinical record failed to indicate that any progress notes or nutritional assessments had been entered by the Dietician. During an interview on 4/28/25 at 10:06 A.M., the Dietician said that when a resident was admitted to the facility, a Nutritional Assessment should be completed within a day or two of the admission. The Dietician said when Resident #45 was admitted to the facility she did not complete a Nutritional Assessment and one should have been completed. The Dietician also said that no Nutritional Assessment had been completed at any time for Resident #45 since he/she has been residing in the facility. The Dietician said she could not recall if nursing had made her aware of Resident #45's weight loss. The Dietician further said she had not reviewed Resident #45's weight record and was not aware that the Resident had experienced a significant weight loss, but she should have reviewed Resident #45's record and been aware of the weight loss. During an interview on 4/28/25 at 10:14 A.M., Unit Manager (UM) #1 said that when resident weights are obtained by the Certified Nurses Aide (CNA), they are reported to the Nurse and the Nurse enters the weight directly into the electronic medical record (EMR). UM #1 said if the Nurse identifies an issue with the resident weight, then the Nurse is expected to notify the Dietician and Physician via phone call of the weight issue and document the notification in the progress notes. UM #1 said the Nurses occasionally make her aware of a weight issue but not all the time. UM #1 further said that Resident #45 had been discussed weekly during the At Risk Meeting where his/her appetite and weights were reviewed. UM #1 said that she was not made aware of Resident #45's weight loss and said that Resident #45 was a picky eater.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#36 and #93) out of a total sample of 25 residents. Specifically, 1. for Resident #36, the facility failed to ensure a clean and sanitary oxygen concentrator (device used to deliver supplemental oxygen) filters in accordance with the manufacturers' guidelines when the air intake gross particle filter was observed with a thick coating of dust, placing the Resident at risk of equipment malfunction and inhaling dust particulate matter. 2. for Resident #93, the facility failed to maintain the Resident's oxygen concentrator filter as required, placing the Resident at risk for impaired oxygen supply delivery and inhaling contaminated oxygen. Findings include: Review of the Invacare Platinum XL II user manual dated, 8/9/06, indicated: -Remove each filter and clean at least once a week depending on environmental conditions. Note: Environmental conditions that may require more frequent cleaning of the filters, include but are not limited to: high dust, air pollutants, etc. -Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. -Dry the filters thoroughly before installation. Caution do not operate the concentrator without the filters installed. Review of the New Life Elite Airsep user manual, last revised February 2014, indicated: -Clean the air inlet gross particle filter with warm soapy water between each patient's use. -Clean this filter at least once per week, depending on the environment, during normal operation. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction for oxygen therapy. -Equipment, maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily . >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Review of facility policy titled Equipment Change/Disinfection, effective April 2022, indicated: -All respiratory equipment, if not disposable, will be sanitized after a patient's use and before storing. -Oxygen concentrators: rinse and dry the external filter weekly and as needed when visibly dusty. Wipe down the concentrator when visibly dusty or soiled. 1. Resident #36 was admitted to the facility in February 2024, with diagnoses including Encephalopathy and Obstructive Sleep Apnea (OSA). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #36: -was severely cognitively impaired as evidence by a Brief Interview for Mental Status (BIMS) score of 0 out of 15 possible points. -was receiving oxygen therapy. -was dependent on staff for activities of daily living (ADL - washing, bathing, grooming) care. Review of Resident #36's April 2025 Physician's orders indicated: -Change or clean oxygen air exchange grid weekly, every night shift, every Tuesday, initiated 12/17/24. -Change oxygen tubing, humidifier bottle and rinse filter weekly on Tuesday 11-7 shift, every night shift every Tuesday, initiated 11/26/24. -Oxygen at 1-5 Liters continuously via nasal cannula (thin, flexible tube that wraps around the head, with two prongs that fit inside the nostrils to provide a steady flow of oxygen from an oxygen supply) to maintain pulse oximeter above 90% (list Physician parameters). -May use portable oxygen when out of room, initiated 11/24/24. Review of Resident #36's April 2025 Treatment Administration Record (TAR) indicated that the Resident's air exchange grid had been changed/cleaned and that the oxygen filter had been rinsed on: -4/1/25 -4/8/25 -4/15/25 -4/22/25 On 4/23/25 at 8:54 A.M., the surveyor observed Resident #36 lying in bed with a nasal cannula in his/her nostrils connected to an oxygen concentrator (New Life Elite Airsep). The surveyor observed a bottle of sterile water on the floor next to the concentrator and the oxygen concentrator was observed to have a thick coating of dark gray dust on the air intake gross particle filter. During an interview at the time, Resident #36 said that he/she was having difficulty breathing. On 4/24/25 at 8:01 A.M., the surveyor observed Resident#36 lying in bed with a nasal cannula in his/her nostrils, that was connected to an oxygen concentrator with a thick coating of dark gray dust on the air intake gross particle filter. During an interview at the time, Resident #36 said that he/she continues to have trouble with his/her breathing. On 4/28/25 at 7:39 A.M., the surveyor and Nurse #4 observed Resident #36's oxygen concentrator. The oxygen concentrator's air intake gross particle filter was observed covered in a thick coating of gray dust. During an interview at the time, Nurse #4 said that the filter on the oxygen concentrator should be cleaned every week, and it had not been. Nurse #4 also said that the bottle of sterile water should not have been on the floor, as the oxygen concentrator has a space for the water bottle to be stored. 2. Resident #93 was admitted to the facility in May 2024, with diagnoses including Chronic Diastolic Heart Failure, unsteadiness on feet and history of falls. Review of the Minimum Data Set (MDS) Assessment, dated 2/18/25, indicated that Resident #93: -was moderately cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 11 out of a total possible score of 15. -was receiving oxygen therapy. -was receiving partial/moderate assistance from staff for activities of daily living (ADL - washing, bathing, grooming) care. Review of Resident #93's April 2025 Physician's orders indicated: -Oxygen at (1-2) Liters as needed via nasal cannula, maintain pulse oximeter above 90%. May use portable oxygen when out of room, start date 11/1/24 -Change or clean oxygen air exchange grid weekly, every night shift every Tuesday, start date 5/21/24 -Change oxygen tubing and rinse filter weekly on Tuesday during the 11-7 shift, every night shift, start date 5/21/24 Review of Resident #93's April 2025 TAR indicated that the Resident's air exchange grid had been changed/cleaned and that the oxygen filter had been rinsed on: -4/1/25 -4/8/25 -4/15/25 -4/22/25 On 4/23/25 at 8:04 A.M., the surveyor observed Resident #93 sitting in a chair next to his/her bed. The surveyor further observed Resident #93's nasal cannula laying on his/her bed, connected to an oxygen concentrator (Invacare Platinum XL II) with a removable filter located on the left side covered with a thick coating of gray dust. During an interview at the time, Resident #93 said that he/she only uses oxygen at night during sleep. On 4/24/25 at 8:41 A.M., the surveyor observed Resident #93 lying in bed with nasal cannula in his/her nostrils and connected to the oxygen concentrator. The surveyor observed the filter on the left side of the oxygen concentrator remained covered in a thick layer of gray dust. During an interview at the time, Resident #93 said while looking at the filter on the concentrator, I don't want to breathe that in. On 4/28/25 at 7:33 A.M., the surveyor and Nurse #4 observed that Resident #93's oxygen concentrator remained with the removable air filter covered in a thick coating of gray dust. During an interview at the time, Nurse #4 said that the filter on the oxygen concentrator should be cleaned weekly, and it appeared to have not been cleaned in a long time as the coating of dust was thick.

Based on interview, and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were responded to and/or implemented timely for one Resident (#34), out of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, for Resident #34, the facility failed to ensure that duplicate recommendations from the Consultant Pharmacist were reviewed and responded to by the Provider and/or nursing staff, and that orders were implemented timely relative to: -obtaining a Vitamin D level made on 5/3/24, 6/2/24, and 7/2/24. -discontinuation of Loratadine (antihistamine medication) made on 10/2/24, 11/4/24, 12/6/24, and 1/2/25. Findings include: Review of the facility policy titled Drug Regimen Review, dated 4/2022, indicated the following: -Consultant Pharmacist reviews the medication regimen of each active resident at least monthly -Findings and recommendations are reported to the Director of Nurses (DON) and the Medical Director. -The Consultant Pharmacist documents the date each medication regimen review is completed in the residents' medical record .and briefly notes the findings. -The Consultant Pharmacist documents all potential or actual significant nursing documentation problems found relating to medications and communicates them in writing to the DON and the Medical Director. -The facility maintains copies of completed reports on file and according to facility policy . Resident #34 was admitted to the facility in May 2024 with diagnoses including Dementia and Chronic Kidney Disease (CKD). Review of the Consultant Pharmacist Progress Notes indicated the following repeated recommendations: -5/3/24: recommend Vitamin D level -6/2/24: recommend Vitamin D level -7/2/24: recommend Vitamin D level Review of the Resident's clinical record failed to indicate documented evidence of the Consultant Pharmacist's recommendation dated 5/3/24, or if the recommendation was reviewed and/or responded by the Provider. Further review of the Resident's clinical record indicated the Provider reviewed and consented to the Consultant Pharmacist's recommendation (dated 6/2/24) on 6/11/24. There was no documented evidence that the Consultant Pharmacist's recommendation to check Resident #34's Vitamin D level was implemented until after the MRR dated 7/2/24 (which was reviewed and consented to by the Provider again on 7/3/24) and a Vitamin D level was obtained on 7/5/24. Review of the Consultant Pharmacist Progress Notes indicated the following repeated recommendations: -10/2/24: to the Medial Doctor (MD) - Recommend continued need for Loratadine medication. -11/4/24: to Nursing - Recommend follow through with Consultant Pharmacist's recommendation to discontinue Loratadine. -12/6/24: to Nursing - Recommend follow through with Consultant Pharmacist's recommendation to discontinue Loratadine. -1/2/25: to Nursing - Recommend follow through with Consultant Pharmacist's recommendation to discontinue Loratadine. Review of Resident #34's clinical record indicated the Consultant Pharmacist's MRR dated 10/2/24 was reviewed and the Provider agreed to discontinue the Resident's Loratadine medication on 10/8/24. There was no documented evidence of the MRRs dated 11/4/24, 12/6/24, and 1/2/25. Further review of the clinical record indicated the Loratadine was not discontinued until 2/4/25. During an interview on 4/25/25 at 3:31 P.M., the surveyor requested evidence from the DON of the Consultant Pharmacist MRRs not located in the Resident's record, dated 5/3/24, 11/4/24, 12/6/24, and 1/2/25. On 4/25/25 at 4:12 P.M., the surveyor and the DON reviewed Resident #34's clinical record. During an interview at the time, the DON said she was unable to find evidence that the Resident's Vitamin D level was drawn sooner than 7/5/24, when the recommendation to draw the Vitamin D level was agreed to by the Provider on 6/11/24 and 7/3/24. The DON said she was unable to find the corresponding MRR request for the Vitamin D level dated 5/3/24. The DON further said she was unable to find the corresponding MRRs dated 11/4/24, 12/6/24, and 1/2/25, for Resident #34. The DON said the Consultant Pharmacist's Recommendations were emailed directly to the Unit Manager (UM), who was currently on vacation, printed out, and put in the Provider's Communication Book. The DON said once the Provider responds to the MRR, the order is implemented if applicable, and the MRR is scanned into the Resident's electronic medical record. The DON said she would expect that there would not be repeated requests made by the Consultant Pharmacist and that recommendations made would be responded to timely by the facility staff. The DON said nursing staff should be checking the Provider's Communication Book every shift for new orders and communication. The DON further said her expectation was when the Provider agreed with the Consultant Pharmacist's Recommendations, nursing would implement those orders immediately. The DON said if the Consultant Pharmacist makes recommendations for Nursing, those recommendations should also be addressed immediately. During a follow-up interview on 4/25/25 at 4:37 P.M., the DON said she was unable to say why the Loratadine medication was not discontinued on 10/18/24 when the Provider agreed to discontinue the medication. Please refer to F757

Based on interview and record review, the facility failed to ensure one Resident (#34) was not administered unnecessary medications, of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, the facility failed to ensure the Consultant Pharmacist Recommendation to discontinue scheduled Loratadine (antihistamine medication), that was approved by the Provider on 10/8/24, was discontinued and Resident #34 continued to receive the scheduled doses of the medication until it was discontinued on 2/4/25 (over three months later). Findings include: Resident #34 was admitted to the facility in May 2024 with diagnoses including Dementia and Chronic Kidney Disease (CKD). Review of the Consultant Pharmacist Progress Notes indicated the following repeated recommendations: -10/2/24: to the Medial Doctor (MD) - Recommend continued need for Loratadine medication -11/4/24: to Nursing - Recommend follow through with Consultant Pharmacist's Recommendation to discontinue Loratadine. -12/6/24: to Nursing - Recommend follow through with Consultant Pharmacist's Recommendation to discontinue Loratadine. -1/2/25: to Nursing- Recommend follow through with Consultant Pharmacist's Recommendation to discontinue Loratadine. Review of Resident #34's clinical record indicated the Consultant Pharmacist's MRR dated 10/2/24 was reviewed and the Provider agreed to discontinue the Resident's Loratadine medication on 10/8/24. Review of a Nurse's Progress Note, dated 10/9/24, indicated the Provider reviewed the Consultant Pharmacist's Recommendation to discontinue Loratadine and was in agreement. Review of October 2024 through February 2025 Medication Administration Records (MARs) indicated Resident #34: -was administered Loratadine 10 milligrams (mg) daily as ordered, with the following exceptions: >10/17/24 >10/21/24 through 10/29/24, due to the Resident being hospitalized . -was discontinued on 2/4/25. On 4/25/25 at 4:12 P.M., the surveyor and the Director of Nursing (DON) reviewed Resident #34's clinical record. During an interview at the time, the DON said the Consultant Pharmacist's Recommendations were emailed directly to the Unit Manager (UM), (who was currently on vacation), printed out, and put in the Provider's Communication Book. The DON said once the Provider responds to the MRR, the order is implemented, if applicable, and the MRR is scanned into the Resident's electronic medical record (EMR). The DON said she would expect that recommendations made by the Consultant Pharmacist would be responded to timely by the facility staff. The DON said nursing staff should be checking the Provider's Communication Book every shift for new orders and communication. The DON further said her expectation was when the Provider agreed with the Consultant Pharmacist's Recommendations, nursing would implement those orders immediately. The DON said if the Consultant Pharmacist makes recommendations for Nursing, those recommendations should also be addressed immediately. During a follow-up interview on 4/25/25 at 4:37 P.M., the DON said she was unable to say why the Loratadine was not discontinued on 10/8/24 when the Provider agreed to discontinue the medication. The DON said she understood the concern relative to unnecessary medication administration.

Based on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#11 and #47), out of five applicable residents, out of 29 medication pass opportunities. The medication error rate was observed to be 6.9%. Specifically, 1. For Resident #11, the Resident was administered the wrong medication dosage form when a Ferrous Sulfate tablet was administered and Ferrous Sulfate Oral Solution was ordered. 2. For Resident #47, the Resident was administered the incorrect dosage of Fish Oil when 2000 mg (milligrams) of Fish Oil was administered and 1000 mg of Fish Oil was ordered. Findings include: Review of the facility policy titled Medication and Treatment Orders, effective June 2022, indicated the following: -Policy: Orders for medications and treatments will be consistent with principles of safe and effective order writing. -Medications shall be administered only upon the written order of physician/NP/PA licensed in MA. Review of the facility policy titled Specific Medication Administration Procedures, effective January 2024, indicated the following: -Policy: To administer medications in a safe and effective manner. -Review the Five (5) Rights of Medication Administration three (3) times: 1) Prior to removing the medication package/container from the cart/drawer. 2) Prior to removing the medication from the container. 3) After the dose has been prepared and before returning the medication to storage. 1. Resident #11 was admitted to the facility in April 2023, with diagnoses including unspecified sequelae of Cerebral Infarction, hemiplegia and hemiparesis following Cerebral Infarction affecting right dominant side, Dysphagia oral phase, and Adult Failure to Thrive. Review of Resident #11's Physician's orders dated 4/24/25, indicated the following: -Ferrous Sulfate Oral Solution 220 ([44 Fe] [Iron]) milligrams (mg)/5 milliliter (ml) (Ferrous Sulfate). Give 7.5 ml via G-Tube (a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) in the morning for supplement. 7.5 ml = 330 mg. Start date 4/10/25. On 4/24/25 at 9:40 A.M., during a medication administration pass, the surveyor observed Nurse #2 prepare (including crushing) and administer the following medication to Resident #11 via G-Tube: -Ferrous Sulfate 325 mg [65] one tablet. Review of Resident #11's April 2025 Medication Administration Record (MAR), indicated: -Nurse #2 electronically signed that he had administered Ferrous Sulfate Solution 220 (44 Fe) mg/5 ml (Ferrous Sulfate) 7.5 ml via G-Tube at 9:00 A.M. on 4/24/25. During an interview on 4/24/25 at 2:14 P.M., Nurse #2 said that the Physician order indicated to administer Ferrous Sulfate Oral Solution 330 mg, and he administered Ferrous Sulfate in tablet form Resident #11 via G-Tube. Nurse #2 said that he should have administered Ferrous Sulfate Oral Solution but had not done so. 2. Resident #47 was admitted to the facility in November 2023, with diagnoses including normal pressure hydrocephalus, Parkinson's Disease without dyskinesia without mention of fluctuations, Atherosclerotic Heart Disease of native coronary artery without Angina Pectoris, presence of Coronary Angioplasty implant and graft, and unspecified Dementia unspecified severity with other behavioral disturbance. Review of Resident #47's Physician's orders dated 4/28/25, indicated the following: -Fish Oil Oral Capsule 500 mg (Omega-3 Fatty Acids). Give 2 capsules [total = 1000 mg] by mouth one time a day for supplement. Start date 1/25/24. On 4/28/25 at 8:40 A.M., during a medication administration pass, the surveyor observed Nurse #3 prepare and administer Fish Oil 1000 mg Oral Capsule, two capsules [total = 2000 mg] administered to Resident #47 by mouth. Review of Resident #47's April 2025 Medication Administration Record (MAR), indicated the following: -Nurse #3 electronically signed that she administered two capsules of Fish Oil Oral Capsule 500 mg (Omega-3 Fatty Acids) by mouth at 8:00 A.M. on 4/28/25. During an interview on 4/28/25 at 10:50 A.M., Nurse #3 said that the Physician order indicated to administer Fish Oil 500 mg, two capsules, and that she administered Fish Oil 1000 mg, two capsules. Nurse #3 said that she should have administered one -1000 mg capsule of Fish Oil, but had instead administered two -1000 mg capsules of Fish Oil.

Based on observation, and interview, the facility failed to follow professional standards of practice for food safety and sanitation in the facility's main kitchen to prevent contamination and the potential spread of foodborne illnesses. Specifically, the facility failed to ensure that food items stored in the walk-in refrigerator in the facility main kitchen area were properly labeled and dated as required. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when Packaging Food using a Reduced Oxygen Packaging method as specified under §3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours: > shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. >The day of [Food] preparation shall be counted as Day 1. Review of the facility policy titled Dietary - Food Storage effective 2/2022 indicated the following: -Refrigerated Storage: Prepared foods will be kept, covered, labeled with contents and dated. -Leftover poultry, fish, eggs, or meat products must not be stored more than 48 hours at refrigerator temperatures. On 4/23/25 at 7:17 A.M., the surveyor and the Food Service Director (FSD) observed the following in the main kitchen walk in refrigerator: -one large stainless steel mixing bowl containing ham salad, that was unlabeled and undated. -one open clear plastic bag containing cubed chicken, that was unlabeled and undated. -one open clear plastic container containing halved tomatoes, that was unlabeled and undated. -one open clear plastic container containing sliced cucumbers, that was unlabeled and undated. -one open clear plastic container containing diced onions, that was unlabeled and undated. During an interview immediately following the observation, the FSD said that all food items in the refrigerator were supposed to be labeled and dated with the date the food item was first opened. The FSD further said that the undated food items in the refrigerator should have been discarded.

Based on record review, and interview, the facility failed to ensure that specialized rehabilitation services were provided to assist in maintaining the highest practicable level functioning for one Resident (#74) out of a total sample size of 25 residents. Specifically, for Resident #74, the facility failed to ensure that Physical Therapy (PT) Evaluations were completed timely as ordered by the Physician for symptoms of bilateral knee pain and stiffness. Findings include: Resident #74 was admitted to the facility in June 2024 with diagnoses including bilateral primary Osteoarthritis of the knees. Review of the Facility Policy titled Scope of Services, Rehabilitation, revised February 2022 indicated: -Residents are screened and/or evaluated by Physical, Occupational and Speech Therapy according to demonstrated need in a specific area -Such therapy encompasses examination and analysis of patients to maximize functional independence: >A therapy screen to assess the need for skilled service >An initial evaluation and assessment of the patient prior to provision of services >A determination and development of treatment goals and plans in accordance with the residents' stated wishes/choices, diagnosis and prognosis with a treatment plan established to meet both the patient and therapist's goals Review of the most recent Minimum Data Set (MDS) Assessment, dated 3/13/25, indicated Resident #74: -received scheduled pain medication. -participated in the pain interview with responses including: >frequently having pain that interferes with sleep. >occasionally having pain that interferes with day-to-day activities. >a pain level of 4/10 (4 out of 10). Review of Resident #74's clinical record indicated the following: -The Resident had a Consultation on 10/8/24 with an Orthopedic Physician. The Orthopedic Physician gave a referral for PT to evaluate and treat for bilateral knee Osteoarthritis, 2-3 times a week for a duration of 6-8 weeks. -no evidence that a PT evaluation had been completed related to the Orthopedic Physician's referral given on 10/8/24. -a request for a rehabilitation screen from the facility nursing department dated 2/10/25, due to increased pain in the Resident's bilateral knees (four months after the initial Physician's referral). -a Physician's order on 2/11/25 to obtain a PT evaluation for bilateral knee stiffness/pain. Review of a Rehabilitation Screen signed and dated by Rehabilitation Staff #1 on 2/24/25, indicated that Resident #74: -was approached on 2/12/25 for a skilled PT evaluation but the Resident was not feeling well due to nausea and diarrhea -Occupational Therapy (OT) evaluation would be completed that week. Review of the Occupational Therapy Evaluation completed for Resident #74 on 2/26/25, indicated: -no assessment of knee pain or stiffness. Review of Resident #74's clinical record failed to indicate evidence the Resident was re-approached by Physical Therapy for a PT evaluation after symptoms of nausea and diarrhea had resolved. During an interview on 4/28/25 at 10:39 A.M., Rehabilitation Staff #1 said she was not aware the Resident had been seen by an Orthopedic Physician in October 2024 or that there had been a PT referral from the Orthopedic Physician. Rehab Staff #1 said she was not in the facility at that time, and she would look for any evidence that Resident #74 had been seen by a PT. Rehab Staff #1 said Resident #74 was not seen by PT in February 2025, the Resident was evaluated by Occupational Therapy for a decline in function even though the order was specified for PT to address knee pain and stiffness. Rehab Staff #1 said that the Rehabilitation Department may have been short staffed at the time the order for PT was written. The surveyor and Rehab Staff #1 reviewed the Occupational Therapy documentation, and Rehab Staff #1 said there was no assessment of knee stiffness or pain on the OT Evaluation as indicated in the Physician's order for Physical Therapy on 2/11/25. During a follow-up interview on 4/28/25 at 10:55 A.M., Rehab Staff #1 said she had no evidence that Resident #74 had been seen by PT in October 2024 to address the referral from the Orthopedic Physician written on 10/8/24. Rehab Staff #1 said Resident #74 should have been seen by a Physical Therapist as ordered by the Physician at that time but had not been seen.

Based on observation, and interview, the facility failed to adhere to infection prevention and control standards of multi-resident use medical equipment to prevent the development and transmission of communicable diseases and infections for one Resident (#108), out of a total sample of 25 residents. Specifically, the facility staff failed to clean and disinfect a blood glucose monitor (BGM- device used to measure the amount of glucose [sugar] in a person's blood) after using the BGM to obtain a blood glucose level for Resident #108 and before storing in the medication cart with clean equipment. Findings Include: Review of the facility policy titled: Disinfecting Shared Resident Equipment indicated the following: -It is the policy of the facility to clean/disinfect shared equipment in order to decrease the risk of infection. -Disinfecting all resident shared equipment with the method recommended depending on the object's intended use and type of contamination will be done routinely. On 4/24/25 at 9:41 A.M., during a medication administration observation, the surveyor observed Nurse #5 obtain a blood glucose level on Resident #108 using a BGM. The surveyor observed Nurse #5 take the BGM back to the medication cart, place the BGM on top of the medication cart and documented the blood glucose level in Resident #108's electronic medical record. Nurse #5 was then observed to place the BGM on top of other equipment inside the drawer of the medication cart. During an interview on 4/24/25 at 9:50 A.M., Nurse #5 said she forgot to clean the BGM after she used the monitor on Resident #108. Nurse #5 said she should have cleaned and disinfected the BGM before putting it back into the medication cart with the other clean equipment. During an interview on 4/24/25 at 9:53 A.M., Unit Manager (UM) #1 said that all shared resident care equipment should be cleaned and disinfected between each resident use. UM #1 said that Nurse #5 should have cleaned and disinfected the BGM after she used it to obtain a blood glucose level on Resident #108, and before placing the BGM into the medication cart. During an interview on 4/29/25 at 9:24 A.M., the Infection Preventionist (IP) said that Nurses were expected to clean and disinfect the BGM with either a purple top disinfectant wipe or a bleach wipe after each use to prevent the spread of infection.

Based on observation, interview, and record review, the facility failed to provide treatment consistent with professional standards of practice, to promote healing and reduce risk for infection, for one Resident (#75) out of a total sample of 24 residents, with a Stage Three (full-thickness loss of skin) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the sacrum (large flat bone in the lower part of the spine). Specifically, the facility staff failed to implement recommendations from the Wound Consultant, made over four consecutive weekly wound consults, with recommendations reviewed and approved by the Physician to apply Skin Prep (water-proof liquid that forms a transparent film over the skin for protection) to the periwound (tissue surrounding a wound) of Resident #75's sacral wound. Findings include: Resident #75 was admitted to the facility in December 2023 with Venous Insufficiency (a condition in which veins fail to return blood efficiently to the heart), Adult Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), and a Stage Three Pressure Ulcer to the sacrum. Review of a Physician's Order, dated 12/6/23, indicated the following for Resident #75: -May have wound team consult. Review of Resident #75's Nursing Admission Skin Assessment, dated 12/7/23, indicated the following: -A pressure ulcer was identified on the Resident's coccyx (tailbone: tiny bones joined with the sacrum). -The Resident's skin was fragile and thin. -Moisture Associated Skin Damage (MASD: caused by prolonged exposure to various sources of moisture) was present on the sacrum and coccyx. -The Wound Team would assess the Resident. Review of Resident #75's Minimum Data Set (MDS) Assessment, dated 12/13/23, indicated the following: -The Resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of 15 total points. -The Resident was always incontinent of urine and bowel. -The Resident was at risk for pressure ulcers. -The Resident had one unstageable deep tissue injury (DTI: Intact skin with localized area of persistent non-blanchable (does not turn white when pressed) deep red, maroon, purple discoloration due to damage of underlying soft tissue which results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) and MASD. Review of Resident #75's Wound Consult, dated 12/13/23, indicated: -The Resident had a DTI of the sacrum. -The recommended wound dressing was for Alginate (type of natural dressing used to absorb wound fluid) and foam to the sacral wound, to be changed daily and as needed. Further review of the 12/13/23 Wound Consult indicated it had been reviewed by the Physician. Review of a Physician's Order, dated 12/13/23, indicated: -Wash with wound cleanser, pat dry, apply cut to fit Alginate followed by foam dressing . Review of Resident #75's Wound Consult, dated 1/3/24, indicated: -The Resident had a cluster of DTI pressure ulcers on the sacrum. -The periwound was moderately macerated (soft, fragile skin resulting from prolonged exposure to moisture). -The Wound Consultant debrided (removal of devitalized tissue and foreign matter from a wound to improve or facilitate the healing process) the Resident's wound. -The post treatment diagnosis was: Stage Three Pressure Ulcer of the Sacrum. -The recommended wound dressing was: 1. Alginate and foam to the sacral wound, to be changed daily and as needed. 2. Skin Prep to the periwound daily. Further review of the Wound Consult indicated the Physician reviewed the Consult and agreed with the Wound Consultant's recommendations for Alginate and foam dressing to the sacral wound and Skin Prep to the periwound. Review of Resident #75's Physician Progress Note, dated 1/7/24 indicated: . sacral decubitus ulcer (bedsore or pressure ulcer) - continue care as per the Wound Consultant. Review of Resident #75's Wound Consults, dated 1/10/24, 1/17/24, and 1/24/24 indicated: -The Resident's wound had moderate serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury). -The periwound had moderate maceration. -Application of Skin Prep to the periwound was recommended. Further review of the 1/10/24, 1/17/24, and 1/24/24 Wound Consults indicated they had been reviewed by the Physician. Review of Resident #75's Physician Progress Note, dated 1/29/24, indicated: . sacral decubitus ulcer - continue care as per the Wound Consultant. On 1/30/24 at 10:17 A.M., the surveyor observed Resident #75 lying in bed, on an air mattress. During an interview at the time, the Resident said he/she had a wound on his/her bottom, that the Wound Consultant came weekly to assess the wound, and that he/she thought it was getting better, but that he/she was not sure. Resident #75 also said he/she was unsure how long the wound had been present on his/her bottom, and was unsure whether it was acquired prior to coming to the facility. Review of Resident #75's Wound Consult, dated 1/31/24, indicated: -The Resident's wound had moderate serous exudate. -The periwound had moderate maceration. -Application of Skin Prep to the periwound was recommended. Review of Resident #75's January 2024 and February 2024 Physician orders included no evidence Skin Prep to the Resident's periwound had been implemented, as recommended by the Wound Consultant, and as reviewed and agreed to by the Physician. On 2/1/24 at 11:34 A.M., the surveyor observed Nurse #6 complete Resident #75's sacral wound treatment dressing change. When the Nurse removed the old dressing, there was no drainage observed from the wound, but the periwound was observed to be macerated. Nurse #6 cleansed the wound with wound cleanser, patted it dry, and applied cut to fit Alginate and a foam dressing. Nurse #6 did not apply any Skin Prep to the periwound. During an interview on 2/2/24 at 12:47 P.M., the Wound Nurse said the Wound Consultant came in weekly for wound rounds with residents that required wound consults and that either the Wound Nurse or one of the other Nurses would accompany the Wound Consultant during wound rounds. The Wound Nurse said the Nurse who accompanied the Wound Consultant would provide a copy of wound consults completed to the residents' Physicians in a binder on the unit, so the Physicians could review the recommendations made. The Wound Nurse said if the Wound Consultant recommendations for treatment changed, the Nurse would be responsible to contact the Physician and alert the Physician the recommendation had changed and to obtain new orders. The Wound Nurse also said the purpose of using Skin Prep on a resident's skin was to protect the skin from breaking down. The surveyor reviewed with the Wound Nurse the Wound Consultant's recommendations from January 2024 to apply Skin Prep to Resident #75's periwound and the Wound Nurse said she could not recall any reason this would not have been implemented for the Resident. During an interview on 2/2/24 at 1:16 P.M., the Physician said the Wound Consultant was very knowledgeable and she always agreed with their recommendations. The Physician said staff at the facility were supposed to call her if the Wound Consultant recommended a change in treatment so that orders for the change could be obtained. The Physician also said staff at the facility left Wound Consultant reports for her in a binder on the units so she could review the Consultant's recommendations. The Physician further said if she initialed the Wound Consult, this meant she agreed with the recommendations made by the Wound Consultant. The Physician reviewed the Wound Consults at this time with the surveyor and said the use of Skin Prep to the periwound of Resident #75's sacral wound should have been implemented when the recommendation was made by the Wound Consultant and the Physician initialed the Consult.

Based on observation, interview, and record review, the facility failed to provide Foley catheter (also known as a urinary catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care related to infection control prevention for one Resident (#64) out of a total sample of 24 residents. Specifically, the facility staff failed to change Resident #64's Foley catheter drainage bag when the Physician ordered weekly catheter drainage bag changes, and the Resident was on Contact Precautions (intended to prevent transmission of infectious agents) for Vancomycin Resistant Enterococcus (VRE- bacterial infection resistant to the Vancomycin antibiotic) in the urine. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter, dated 2/2022, indicated: -Change catheters and drainage bags based on clinical indications such as infection. Resident #64 was admitted to the facility in October 2023 with diagnoses including Retention of Urine (inability to completely empty the bladder of urine) and Obstructive and Reflux Uropathy (this occurs when urine cannot drain through the urinary tract). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #64 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of 15. Further review of the MDS Assessment indicated he/she had an indwelling urinary catheter. Review of Resident #64's January 2024 Physician's orders included the following: -Foley catheter care every shift, dated 10/16/23 -Empty Foley catheter every shift, dated 10/16/23 -Change Foley catheter bag every 7 days on night shift, dated 10/20/23 -Vancomycin HCL (medication used to treat bacterial infection) Oral Capsule 125 milligrams (mg) every 6 hours for 14 days, dated 1/23/24 -Contact Precautions for VRE in the urine, dated 1/23/24 Review of Resident #64's Care Plan indicated: -The Resident had a Urinary Tract Infection related to Proteus Mirabilis (a specific type of bacterial infection in the urine) and VRE in the urine, revised 1/23/24. -The Resident had a Foley Catheter related to large rectal tumor which is blocking/compressing the bladder outlet and preventing urination causing retention, initiated 9/12/23. Review of Resident #64's January 2024 Treatment Administration Record (TAR) indicated that the Foley catheter drainage bag had been changed on 1/19/24 and 1/26/24. On 2/1/24 at 4:08 P.M., the surveyor and Certified Nurses Aide (CNA) #1 observed Resident #64's Foley catheter drainage system. During an interview at the time, CNA #1 said the Resident's Foley catheter drainage bag was last changed on 1/16/24. CNA #1 also said the catheter drainage bag should have been changed weekly but was not. During an interview on 2/1/24 at 4:41 P.M., Unit Manager (UM) #2 said that the Foley catheter drainage bag had not been changed since 1/16/24 and should have been changed as ordered. UM #2 reviewed the January 2024 TAR at this time and said the 1/19/24 and 1/26/24 entries on the TAR were inaccurate. During an interview on 2/1/24 at 5:33 P.M., the Director of Nurses (DON) said the nursing staff were expected to change the catheter drainage bag weekly as ordered by the Physician, but the staff did not change the Foley catheter drainage bag as required.

Based on record and policy review, and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#73) out of a total sample of 24 residents, who required renal dialysis (also known as hemodialysis: a life-saving treatment that filters waste products and excess fluid when the kidneys stop working). Specifically, the facility staff failed to ensure accurate and complete communication with the dialysis facility for Resident #73's dialysis appointments as required. Findings include: Review of the facility policy for Caring for a Hemodialysis Resident, effective January 2023, indicated: -It is the policy of the facility that hemodialysis residents are monitored and assessed following the current professional practices that supports the resident's safety and care unless otherwise ordered by the Physician. -Vital signs should be taken and documented on the dialysis form (and in the resident's record) before the resident goes to dialysis at the floor's regular schedule. Resident #73 was admitted to the facility in November 2020 with a diagnosis of End Stage Renal Disease (ESRD - a condition where the kidneys has reached an advanced state of loss of function). Review of Resident #73's Physician's orders for January 2024 indicated: -Ensure dialysis book is up to date with medication list, any labs, and face sheet before dialysis. -Obtain vital signs and input into electronic medical record (EMR) and on dialysis communication slip before dialysis. Nights (shift staff) to complete for 10 A.M. pick up time, one time every Monday, Wednesday, Friday for dialysis monitoring. -Record Post Dialysis dry weight and vital signs into EMR from Dialysis Communication Book, assess and document for bruit/thrill (bruit - audible sound determined via stethoscope/ thrill - vibration that is felt when palpating the skin over an AV [arteriovenous - surgical connection between an artery and vein] fistula) and the condition of dialysis port upon return from dialysis. Review of Resident #73's Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #73 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated that the Resident was receiving dialysis treatments. During an interview on 1/20/24 at 9:11 A.M., Resident #73 said that he/she attended and received dialysis services every Monday, Wednesday, and Friday. Review of Resident #73's dialysis communication binder did not indicate that the communication forms had been completed as ordered for the following dates that dialysis services had been provided: Monday: 1/1/24, 1/22/24 Wednesday: 1/3/24, 1/10/24, 1/17/24 Friday: 1/26/24 During an interview on 1/31/24 at 1:47 P.M., Nurse #5 said that nursing staff is expected to complete the communication form in Resident #73's dialysis communication book prior to the Resident leaving for dialysis and that the information is clinically important for the dialysis center to be aware of. During an interview on 1/31/24 at 2:29 P.M., the Director of Nurses (DON) said that it is the expectation for nursing staff to complete the dialysis communication form in the dialysis binder prior to the Resident being sent to the dialysis center so that the dialysis center staff can have a baseline (condition taken at an early time point and used for comparison over time to look for changes) on the Resident's medical status. During an interview on 2/1/24 at 10:44 A.M., the DON said that the dialysis communication forms should have been completed for the missing dates identified by the surveyor, and they had not been completed.

Based on record and policy review, and interview, the facility failed to provide mental health services for one Resident (#48) out of a total sample of 24 residents, with a documented history of Depression and Anxiety. Specifically, the facility staff failed to: 1. provide timely Behavioral Health Services for Resident #48 who was expressing psychosocial distress following the death of their roommate. 2. follow the facility suicidal ideation (thinking about or planning suicide) policy when Resident #48 had expressed suicidal ideation to staff members. Findings include: 1. Review of the facility policy for Behavioral Services, effective October 2023, indicated that any resident who identified as exhibiting any behavior or has an order for psychoactive (medication that affects how the brain works) medications is .referred to the facility contracted Behavioral Services vendor for follow-up. Resident #48 was admitted to the facility in June 2013, with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Anxiety (feeling of unease, such as worry or fear, that can be mild or severe). Review of Resident #48's care plan for mood, last revised 11/29/23, indicated an intervention to refer to Psych [sic] if appropriate. Review of Resident #48's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was diagnosed with Depression and Anxiety. Further review of the MDS assessment indicated that Resident #48 was prescribed an antidepressant medication. Review of Resident #48's January 2024 Physician's orders indicated: -Lexapro (antidepressant medication) 5 milligrams (mg) daily for a diagnosis of Major Depressive Disorder, start date 6/25/20 -an order to be seen by psych [sic] services as needed, start date 7/22/20. Review of Resident #48's progress notes indicated that the Resident had been notified on 11/24/23 of their roommate's passing and that the Resident became very upset, requiring comfort and support by staff. During a Resident Council Meeting on 1/31/24 at 10:16 A.M., Resident #48 said that he/she had been grieving the loss of his/her roommate and would appreciate some help with receiving counseling services. Review of Resident #48's clinical record did not indicate that the Resident had been seen by the contracted Behavioral Health Services since 2021. Further review of the clinical record indicated that the Resident was only referred for Behavioral Health Services on 1/31/24, after the surveyor brought the Resident's concern to the facility's attention. During an interview on 1/31/24 at 3:24 P.M., Social Worker (SW) #1 said that the Resident should have been seen by the contracted Behavioral Health Services team following the death of his/her roommate and he/she was not seen. 2. Review of the facility policy for Suicide Precautions, effective November 2022, indicated that when a Resident expressed an intent to commit suicide: -immediately report potential suicidal behavior to the Nursing Supervisor and the attending Physician. -obtain Physician's orders for suicide precautions, psychiatric consultation, and transfer to another facility. Review of Resident #48's progress notes indicated that on 11/17/23, the Resident expressed to nursing staff wanting to take a pill to end it all. Further review of the progress notes indicated that the facility Social Worker (SW) was notified of the Resident's suicidal statement and provided comfort and support, but no further evidence was indicated that the Physician or Nursing Supervisor had been notified, that a psychiatric referral had been made or that the Resident had been transferred out of the facility for evaluation. During an interview on 1/31/24 at 3:24 P.M., SW #1 (identified as the SW on the 11/17/23 progress notes) said that she did not follow the facility policy after Resident #48 had made the suicidal ideation statement. SW #1 also said that she should have contacted the Physician, Nursing Supervisor and the mental health team to determine if the Resident was safe and she did not do so.

Based on interview and record review, the facility failed to ensure that all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure that the facility Infection Preventionist (IP) attended and participated in two out of four quarterly QAPI meetings reviewed. Findings include: Review of the Quarterly QAPI Meeting Attendance Sheet provided by the facility, dated 10/19/23, included no evidence that the IP attended the quarterly meeting. Review of the Quarterly QAPI Meeting Attendance Sheet provided by the facility, dated 1/18/24, included no evidence that the IP attended the quarterly meeting. During an interview on 2/2/24 at 1:50 P.M., the Administrator said the IP was a required QAPI Committee member. The surveyor and the Administrator reviewed the QAPI Meeting Attendance Sheets and the Administrator said the facility did not have an IP in October 2023, so no IP was present for the Quarterly QAPI Meeting held on 10/19/23. The Administrator also said the facility currently had an IP, and that he/she provided a report for the QAPI Committee to review at the Quarterly QAPI Meeting held on 1/18/24, but the IP did not attend the Meeting.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of exit seeking behavior, was assessed as being at increased risk for elopement, and whose care plan interventions included the use of a wander guard bracelet, the Facility failed to ensure his/her safety was maintained to prevent an incident/accident (elopement) resulting in an injury. On 8/05/22, Resident #1 who was in a wheelchair, exited the Facility through an alarmed (wander guard sensor unit) door, the staff member that responded to the exit door alarm sounding, looked out the window in the door, did not search the area to determine the cause of the alarm, canceled the alarm, and went back to work. After going through the alarmed door, Resident #1 proceeded down a hallway annex and exited the Facility through an exterior unalarmed door. Resident #1 was able to make his/her way down a paved walkway on Facility grounds and was found outside by staff lying on his/her back on a set of concrete stairs. Resident #1 was transferred to the Hospital Emergency Department and diagnosed with an acute compression deformity (occurs when the bony block or vertebral body in the spine collapses) of the fourth lumbar spine (vertebra that is level with the summits of the iliac (largest of the bones that make up the pelvis) crest, as well having abrasions and areas of bruising. Findings include: Review of the Facility Policy titled, Missing Resident Procedure, undated, indicated that staff were to do the following when responding to a sounding door alarm: -Respond to alarmed door immediately. -Upon assessment of alarm sounding, you must search the surrounding area including a search in front and beyond the sounding door. The Facility's Policy, titled Wandering/Missing Residents, dated 02/22, indicated the Facility would ensure the safety and well-being of all residents with a potential for wandering. Resident #1 was admitted to the Facility in March 2022, diagnoses included dementia and muscle weakness. Review of Resident #1's Elopement Care Plan, dated 4/25/22, indicated he/she was assessed as being at risk for elopement, and interventions included a wander guard bracelet to his/her left wrist. The Facility's Incident Narrative, dated 8/09/22, indicated that on 8/05/22 Resident #1 was not able to be located on the unit by staff, and a search was initiated. The Narrative indicated Resident #1 was found outside the Facility lying on a set of concrete stairs in a supine position on stairs, and his/her wheelchair was on the grass. Review of Resident #1's Hospital Emergency Department History and Physical, dated 8/05/22, indicated he/she had a skin tear to his/her left forearm, a contusion to the right elbow, bruising to both hands, and abrasions to both knees. Review of Resident #1's Hospital Cat Scan Imaging Report, dated 8/05/22, indicated he/she had an acute appearing compression deformity of the fourth lumbar spine. During interview on 8/22/22 at 9:11 A.M., Activities Aide #1 said that on 8/05/22 at 6:30 P.M., she was conducting an activity in the activities room on the unit, and said she heard the wander guard door alarm located down the hall and around the corner from the main entrance to the activities room sounding. Activities Aide #1 said she turned off the alarm, looked through the window on the door to see if anyone was in that area, but said she did not open the door or go out to search the area to see if anyone (resident or staff member) had gone out the door. Activities Aide #1 said a short time later (about 8 -10 minutes), a nurse asked her if she had seen Resident #1, and said she told the nurse that the wander guard alarm had sounded. Activities Aide #1 said she should have opened the door and gone out to check to see if any residents had gone through the door, but did not. During interview on 8/17/22 at 11:54 A.M., Nurse #1 said that on 8/05/22 at 6:45 P.M., Certified Nurse Aide (CNA) #1 told her that Resident #1 was unable to be located. Nurse #1 said that after searching the Facility and grounds, Resident #1 was found outside the Facility lying on a set of concrete stairs located behind the Facility, and was bleeding from injuries on his/her arms. Nurse #1 said Resident #1 was then transferred to the Hospital Emergency Department via 911. During interview on 8/17/22 at 2:01 P.M., Certified Nurse Aide (CNA) #1 said that on 8/05/22 at 6:45 P.M., she could not locate Resident #1, and notified Nurse #1. CNA #1 said staff searched the Facility and she and another CNA discovered Resident #1 outside, lying on some concrete stairs located behind the Facility, and he/she was bleeding from his/her arms. During interview on 8/17/22 at 1:35 P.M., the Director of Nurses said Activities Aide #1 should have searched the area around the door when the wander guard alarm sounded and should have alerted staff if she did not see any residents outside the door. On 8/17/22, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. Resident #1 was readmitted to the facility on [DATE], and now resides on the Facility's secured unit. B. The Quality Assurance Performance Improvement (QAPI) minutes, dated 8/05/22, indicated the incident of Resident #1's elopement was reviewed, and a plan of correction was implemented. C. The QAPI Performance Improvement Plan minutes, dated 8/05/22, indicated all residents with wander guards or assessed at risk for elopement were accounted for on 8/06/22. D. The Preventative Maintenance Task Sheets, dated 8/05/22 indicated doors with wander guard alarms were tested and in working order. E. The Education Sign in Sheet, dated 8/6/22, indicated staff were re-educated to the Facility's wander guard system and the Facility's Policy, titled, Wandering/Missing Residents. F. The Preventative Maintenance Task Sheet, dated 8/06/22, indicated the wander guard doors were tested and found to be in functioning condition. G. The Elopement Binders Review at Risk Log, dated 8/10/22, indicated Elopement binders were reviewed for any changes, and updated as needed. H. Findings would be reviewed at monthly QAPI meetings for three months. I. The Director of Nurses and/or designee are responsible for ongoing monitoring and overall compliance.

Based on observations and interviews, the facility failed to ensure its staff provided one Resident (#53) with a dignified experience, out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff provided: 1) A clean wheelchair for Resident #53 to use when he/she was out of bed, and 2) When he/she was seated in a common area, where other residents and staff were present. Findings include: On 7/20/22 at 10:47 A.M., the surveyor observed a wheelchair in Resident #53's room, positioned at the foot of the Resident's bed, labeled with the Resident's name. Resident #53 was in bed. The right side of the wheelchair, right wheel, and top of the wheelchair cushion all contained dried, white, spattered, and smeared debris. Underneath the cushion, there was dried food debris and wet milk on the wheelchair seat. The bottom of the cushion had dried food debris adhered to it. On 7/25/22 at 9:33 A.M., the surveyor observed Resident #53 in bed in his/her room and the Resident's wheelchair was positioned at the foot of the bed. The right side of the wheelchair, right wheel, and top of the wheelchair cushion still had dried, white, spattered, and smeared debris on them. Underneath the cushion, there was still dried food debris on the wheelchair seat, and the milk was now dried and adhered to the seat of the chair. The bottom of the cushion still had dried food debris adhered to it. On 7/25/22, during the noon time meal on the Mingen Way Unit, the surveyor observed Resident #53 seated in his/her wheelchair at a table in the common dining area. Other residents and staff were present in the area. The right side of the Resident's wheelchair and chair wheel had dried, white, spattered, and smeared debris on them. On 7/26/22 at 8:45 A.M., the surveyor observed Resident #53 in bed in his/her room and the Resident's wheelchair was positioned at the foot of the bed. The right side of the wheelchair, right wheel, and top of the wheelchair cushion still had dried, white, spattered, and smeared debris on them. Underneath the cushion, there was still dried food debris, and dried milk adhered to the wheelchair seat. The bottom of the cushion still had dried food debris adhered to it. During an interview on 7/26/22 at 9:04 A.M., Certified Nurse Aide (CNA) #5 said that the housekeeping department was responsible for cleaning resident wheelchairs weekly, on Tuesday evenings, for the Mingen Way unit. CNA #5 said that Resident #53's wheelchair would be scheduled to be cleaned that night and that it should have been cleaned on the previous Tuesday evening. She said that if it had been cleaned on the previous Tuesday evening (7/19/22), it should not have debris on the side of the chair or wheelchair wheel, and that food and drink debris should not have been on top of and under the wheelchair seat cushion when the surveyor observed the wheelchair on 7/20/22. CNA #5 also said that if a Resident's wheelchair got dirty between scheduled cleanings, then unit staff should clean the chair. She said that, for dignity, Resident #53's wheelchair should have been cleaned before seating the Resident in it but this was not done. During an interview on 7/26/22 at 11:10 A.M., the Housekeeping Supervisor said resident wheelchairs from the Mingen Way Unit were scheduled to be cleaned that evening. She said that Resident #53's wheelchair would be cleaned then and that it was last cleaned a couple of weeks prior. The Housekeeping Supervisor said that staff should alert housekeeping or maintenance if a resident's wheelchair needed to be cleaned outside of the scheduled timeframe. She also said that she had not been notified by staff, prior to the surveyor inquiry on 7/26/22, about the Resident's wheelchair needing to be cleaned. The Housekeeping Supervisor said that she had observed Resident #53's wheelchair condition and that it was really bad. She said that staff should have notified her or someone in maintenance that it needed to be cleaned. During an interview on 7/26/22 at 11:20 A.M., the Maintenance Director said that if a wheelchair needed cleaning, then the process was for staff to notify someone in housekeeping or maintenance. He said that staff notify maintenance of this need by either completing a request in the maintenance logbook or by calling him on the walkie talkie. The Maintenance Director said that prior to the surveyor inquiring about Resident #53's wheelchair condition, he had not been notified that it needed to be cleaned.

Based on record review and interview, the facility failed to ensure its staff accurately identified advance directives relative to life sustaining treatment for one Resident (#97) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff accurately identified the wishes of the Resident and/or his/her invoked health care proxy (HCP- advanced medical directive in the form of a legal document designating another person to make health care decisions when a person is deemed incapable of making their own decisions) relative to whether or not the Resident wished to be a full code (resuscitated - action taken to revive someone from death, and/or intubated/ventilated - action taken to cause air to enter into one's body when they cannot breathe on their own) in the event that his/her heart stopped and/or he/she was in respiratory distress. Findings include: Review of the facility's policy titled, HCP and Medical Orders for Life Sustaining Treatment (MOLST) Forms, dated February 2022 included the following: - The intent was to support the resident in the continuity of their previous and current decisions related to the determination of whom they have identified as their health care decision maker in the event they were no longer able to speak for themselves as well as for the identification of decisions regarding life sustaining decisions. - The MOLST is a medical order form that converts an individual's wishes regarding life sustaining treatment and resuscitative measures into medical orders. - The MOLST is designed to be a portable, valid, and immediately actionable medical order consistent with the individual's wishes and current medical condition. Resident #97 was admitted to the facility in [DATE]. Review of a Physician Order, dated [DATE], indicated to follow the MOLST for advance directives. Review of the Advance Directives Care Plan, initiated [DATE], included to honor the MOLST. Review of Resident #97's clinical record included no evidence of a completed MOLST form. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:00 P.M., Unit Manager (UM) #1 said that staff were required to refer to residents' MOLST forms relative to life sustaining treatment and resuscitative measures in the event that a resident's heart stopped, and that if a resident did not have a completed MOLST form, then they would be treated as a full code. The UM said that residents' MOLST forms were in the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She then accessed the computer and said that the completed MOLST should have been scanned into the Resident's electronic health record (EHR), but she was unable to locate it there either. UM #1 then said that since there was no MOLST immediately available, the Resident would be treated as a full code if his/her heart stopped. UM #1 then reviewed the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She further said that a completed MOLST form should have been available and that she would have to contact the HCP and Physician to have a MOLST form completed and clarify the Resident's wishes for life sustaining treatment.

Based on observation, record review, and interview, the facility failed to ensure its staff notified the Physician/non Physician Practitioner and health care proxy (HCP) about a non-pressure related change in skin condition for one Resident (#97) out of 22 total sampled residents. Specifically, the facility failed to ensure its staff notified the Physician/non Physician Practitioner and HCP when Resident #97 developed a non-pressure related opening in his/her skin, on the right knee. Findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status and Notification, dated April 2022, included the following: - The facility would promptly notify the resident, his/her attending physician, and resident representative (consistent with their authority) of changes in the residents medical .condition and/or status . - The nurse supervisor/charge nurse shall be notified of a change in the resident's condition .that may serve as an early warning sign of clincal events .including but not limited to .deterioration in the resident's physical .condition . and instructions to notify the physician of changes in the resident's condition. - Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical condition. Resident #97 was admitted to the facility in June 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin Integrity Care Plan, initiated 6/2/22, included that Resident #97 had potential for alteration in skin integrity relative to .PVD. Review of a Physician Order, dated 6/7/22, included that the Resident's health care proxy (HCP) was invoked (made active) as of 6/6/22. Review of the Nursing Admission Assessment, signed 6/27/22, included that Resident #97 presented with redness to his/her skin on the buttocks. No other alteration in skin integrity was included in the assessment, and the assessment indicated that the Resident's skin was otherwise normal in color and turgor (elasticity or firmness), and warm/equal/dry in temperature. Review of Skin Observation Tools, dated 7/1/22, 7/8/22, and 7/15/22, indicated that no new skin injuries or wounds were identified. Previously identified skin injury/wound (s) included that the Resident's bilateral buttocks were red and intact and that there was old scabbing to both knees. On 7/20/22 at 11:37 A.M., the surveyor observed Resident #97 seated on the edge of his/her bed, with a visitor sitting to his/her right side in a chair at the bedside. The Resident's legs were exposed, and a white square adhesive dressing was on the Resident's right knee. The dressing was not dated and there was a dark substance that could be seen through the dressing that appeared to be dried blood. During the observation, the Resident's visitor identified him/herself as one of the Resident's children and said that he/she visited often. The Visitor said that he/she saw the dressing on the Resident's leg but did not know what happened that resulted in the Resident requiring a dressing. The Visitor then told the surveyor that he/she was not the Resident's health care proxy (HCP), but that his/her sibling was, and provided the HCP's contact information. The surveyor exited the Resident's room and called the HCP without any response. Review of the Nurse Notes from time of admission to the facility through 7/21/22 included no evidence that the Physician or HCP had been notified of a change in skin condition for Resident #97. On 7/21/22 at 2:14 P.M., the surveyor observed Resident #97 seated at the Nurses' station, legs exposed, with an open wound, triangular in shape with clear and blood tinged drainage, to the right lateral inferior aspect of the Resident's knee. During an interview on 7/21/22 at 2:15 P.M., Unit Manager (UM) #1 said that if a resident had a change in skin condition, staff were to notify the Nurse/ Nurse supervisor and that the Nurse/ Nurse supervisor was required to assess the skin change. She said that the Nurse/ Nurse supervisor would then report the change to the Physician, obtain new orders for treatment, and notify the HCP of the change, if the HCP was invoked. UM #1 said that she noticed that Resident #97 had a dressing on his/her right knee that day, but that she was not aware of a change in the Resident's skin condition prior to seeing the dressing. UM #1 said that she needed to assess the Resident's skin, then contact the physician and HCP to notify them of the change in condition. She further said that there was no evidence this had been done when the change in skin condition was initially identified as required, but it should have been.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing transcribed orders for medications according to professional standards of practice. On 12/11/21, nursing obtained a physicians' order for [MEDICATION(S)] insulin for Resident #2, however Nurse #2 transcribed the order onto Resident #1's medication administration record, Resident #1 was administered the insulin and experienced a decline in condition. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of [MEDICATION(S)] U-100 Insulin Injection Manufacturer Guideline via the Official Website, dated 2021, indicated [MEDICATION(S)] ([MEDICATION(S)]) is fast-acting insulin used to control high blood sugars in adults and children diabetes. The Guide indicated possible serious side effect of [MEDICATION(S)] insulin is low blood sugar and can cause dizziness, headache, shakiness, irritability, sweating, blurred vision, confusion, hunger, anxiety, mood change and fast heartbeat. The Guide indicated other serious side effects may include severe allergic reaction, low potassium in blood, heart failure and can cause death. Resident #1 was admitted to the Facility in November 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Facility's Investigation, undated, indicated Nurse #2 incorrectly transcribed a physicians' order for [MEDICATION(S)] insulin (obtained for Resident #2) into Resident #1's Medication Administration Record (MAR), and incorrectly reported to Nurse #1 the need for the insulin to be administered to Resident # 1. The Investigation indicated that at 6:30 P.M., Certified Nurse Aide (CNA) #3 requested assistance with Resident #1 who presented with jerky movements. The Investigation indicated Resident #1's blood glucose level when checked by nursing was 70 mg/dl, 911 was called and he/she was transferred to the Hospital Emergency Department at 6:40 P.M. The Investigation indicated the that both Resident #1 and Resident #2 had the same attending physician, and that Nurse #2 incorrectly transcribed the [MEDICATION(S)] that had been obtained for Resident #2 into Resident #1's MAR and incorrectly reported to Nurse #1 the need for insulin to be administered to Resident #1. Review of Resident #1's MAR, dated 12/01/21 through 12/31/21, indicated that Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated that Resident #1's blood glucose levels ranged from 74 to 150 for the three day period. Further review of Resident #1's MAR indicated he/she did not have orders form sliding scale insulin. Review of Resident #1's MAR, dated 12/11/21, indicated that at 4:21 P.M., Nurse #1 administered eight units of [MEDICATION(S)] insulin to Resident #1. Review of Nurse #2's Written Witness Statement submitted via an email, dated 12/15/21, indicated on 12/11/21 the Nurse Practitioner ordered eight units of [MEDICATION(S)] insulin for Resident #2. The Statement indicated she (Nurse #2) opened a new tab on the desktop computer that was being used by Nurse #1 and that she (Nurse #2) was having difficulty entering the new order for Resident #2, because the computer kept prompting her to enter a sliding scale for the [MEDICATION(S)] insulin order. The Statement indicated Nurse #2 closed out the computer screen and reopened it. The Statement indicated that she (Nurse #2) believed that was when she opened the chart of another resident (Resident #1), and documented the [MEDICATION(S)] insulin order in that (Resident #1's) record, instead of Resident #2's. The Statement indicated Nurse #2 explained to Nurse #1 during shift change report that she had taken an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2's MAR. The Statement indicated that Nurse #2 was not aware of the medication transcription error until the Nurse Supervisor called and notified her at 8:40 P.M. The Surveyor was unable to interview Nurse #2. Review of Resident #1's Nurse Progress Note, dated 12/11/21, indicated Nurse #1 assessed Resident #1 at 4:00 P.M. and that his/her vital signs were as follows; blood pressure 106/57, pulse 88, respiration 18, blood glucose level was 223 mg/dl. The Note indicated Resident #1 did not have shortness of breath or respiratory distress at the time. The Note indicated at 5:00 P.M. Nurse #1 fed Resident #1 with some spoonfuls of food, and he/she refused the rest and an alternative meal was offered. Review of Nurse #1's Written Witness Statement, undated, indicated Nurse #1 took over Nurse #2's medication cart at 4:00 P.M. The Statement indicated Nurse #1 assessed Resident #1's blood glucose as 223 mg/dl, and then administered his/her medications including the eight units of [MEDICATION(S)] insulin, per the orders in Resident #1's MAR. The Statement indicated Nurse #1 attempted to feed Resident #1 and that he/she took a spoon sized portion from each item on the tray and refused the rest, stating he/she did not like the food. The Statement indicated that at 6:30 P.M., Nurse #1 was at the Nurses' Station when she heard a call for assistance with Resident #1. The Statement indicated Nurse #1 observed Resident #1 having jerky movements, she immediately called for help, and that his/her blood glucose level was rechecked and was noted to be 70 mg/dl (hypoglycemic, low blood sugar) at the time. The Statement indicated the Nurse Supervisor responded to the call for assistance, 911 was called and Resident #1 was transferred to the Hospital Emergency Department. During an interview on 12/29/21 at 12:00 P.M., Nurse #1 said she worked the 7:00 A.M. to 7:00 P.M. shift on 12/11/21, while Nurse #2 worked 7:00 A.M. to 4:00 P.M. on the same unit. Nurse #1 said between 7:00 A.M. and 3:00 P.M., she covered the desk (answered phone calls and completed skin checks for residents). Nurse #1 said Nurse #2 was responsible for measuring blood glucose levels for residents on the unit. Nurse #1 said around lunch time (noon), Nurse #2 asked her to call the Nurse Practitioner and report that Resident #2's blood glucose level was high. Nurse #1 said she called the Nurse Practitioner who gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2. Nurse #1 said she informed Nurse #2 of the insulin order, but said she did not put the order in Resident #2's eMAR. Nurse #1 said Resident #2 (not Resident #1) had high blood glucose level that morning. Nurse #1 said she did not administer the eight units of [MEDICATION(S)] insulin to Resident #2 because she was covering the nursing station desk when the order was obtained and said Nurse #2 was the Primary Nurse for Resident #2 in the morning. Nurse #1 said when she returned from break at 4:00 P.M, she took over the medication cart because Nurse #2 was leaving at that time. Nurse #1 said Nurse #2 gave a quick report which included the that the order for insulin was recorded in the electronic medical record (eMAR). Nurse #1 said Nurse # 2 did not specify in the shift change report which resident record she put the insulin order in. Nurse #1 said she noticed Resident #1 had a one time order for 8 units of insulin in his/her MAR, but did not really question it. Nurse #1 said she checked Resident #1's blood sugar level at 4:00 P.M., that it was 223 mg/dl, and said she administered the eight units of insulin to Resident #1. Nurse #1 said Resident #1 was alert and at his/her baseline prior to the insulin administration, and that at 6:30 P.M., Certified Nurse Aide (CNA) #1 and CNA #3 requested assistance with Resident #1. Nurse #1 said she observed Resident #1 having jerky movements, she re-checked his/her blood glucose level to be 70 mg/dl, 911 was initiated, emergency medical services (EMS) arrived, and assessed Resident #1's blood sugar to be 30, and he/she was transferred to the Hospital Emergency Department. During an interview on 12/29/21 at 11:00 A.M. and 1:00 P.M., the Administrator said Nurse #2 had indicated in a statement that she was not sure which medical record she had documented Resident #2's [MEDICATION(S)] insulin order.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who both had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #2 who had an elevated blood glucose level of 454 mg/dl ([CONDITION(S)], blood sugar greater than 125 mg/dl), and for whom the one time insulin order was obtained for, was not administered the eight units of [MEDICATION(S)] and his/her hyperglycemic episode was not treated as ordered. Findings include: Review of the Facility's Medication Administration Guide, dated 6/18/2020, indicated, nursing staff must check the medication against the label; label against the electronic medication administration (eMAR) to prevent errors. The Guide indicated nursing must use the lock icon when they perform tasks away from the system to protect residents' privacy and prevent other users from using the system. Review of [MEDICATION(S)] U-100 Insulin Injection Manufacturer Guideline via the Official Website, dated 2021, indicated [MEDICATION(S)] ([MEDICATION(S)]) is fast-acting insulin used to control high blood sugars in adults and children diabetes. The Guide indicated possible serious side effect of [MEDICATION(S)] insulin is low blood sugar and can cause dizziness, headache, shakiness, irritability, sweating, blurred vision, confusion, hunger, anxiety, mood change and fast heartbeat. The Guide indicated other serious side effects may include severe allergic reaction, low potassium in blood, heart failure and can cause death. 1) Resident #1 was admitted to the Facility in November 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Investigation, undated, indicated Nurse #2 incorrectly transcribed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's Medication Administration Record (MAR), and incorrectly reported to Nurse #1 the need for the insulin to be administered to Resident #1. The Investigation indicated that at 6:30 P.M., Certified Nurse Aide (CNA) #3 requested assistance with Resident #1 who presented with jerky movements. The Investigation indicated Resident #1's blood glucose level was 70 milligrams per deciliter (mg/dl), 911 was called and he/she was transferred to the Hospital Emergency Department at 6:40 P.M. The Investigation indicated that both Resident #1 and Resident #2 had the same attending physician, and that Nurse #2 incorrectly transcribed the order for the [MEDICATION(S)] insulin obtained for Resident #2 into Resident #1's MAR and incorrectly reported to Nurse #1 the need for insulin to be administered to Resident #1. Review of Resident #1's MAR, dated 12/01/21 though 12/31/21, indicated that Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated that Resident #1's blood glucose level ranged from 74 to 150 for the three days period. Review of Nurse #2's Written Witness Statement submitted via an email, dated 12/15/21, indicated on 12/11/21 the Nurse Practitioner ordered eight units of [MEDICATION(S)] insulin for Resident #2. The Statement indicated she (Nurse #2) opened a new tab on the desktop computer that was being used by Nurse #1 and that she was having difficulty entering the new order for Resident #2 , because the computer kept prompting her to enter a sliding scale for the [MEDICATION(S)] insulin order. The Statement indicated Nurse #2 closed out the computer screen and reopened it. The Statement indicated that she (Nurse #2) believed that was when she opened the chart of another resident (Resident #1), and transcribed the [MEDICATION(S)] insulin order into that record (Resident #1's), instead of Resident #2's. The Statement indicated Nurse #2 explained to Nurse #1 during shift change report that she had taken an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2's MAR. The Statement indicated that Nurse #2 was not aware of the medication transcription error until the Nurse Supervisor called and notified her at 8:40 P.M. Review of Nurse #1's Written Witness Statement, undated, indicated Nurse #1 took over Nurse #2's medication cart at 4:00 P.M. The Statement indicated Nurse #1 assessed Resident #1's blood glucose as 223 mg/dl, and then administered his/her medications including the eight units of [MEDICATION(S)] insulin, per the orders in Resident #1's MAR. The Statement indicated Nurse #1 attempted to feed Resident #1 and that he/she took a spoon sized portion from each item on the tray and refused the rest, stating he/she did not like the food. The Statement indicated that at 6:30 P.M., she (Nurse #1) was at the Nurses' Station when she heard a call for assistance with Resident #1. The Statement indicated Nurse #1 observed Resident #1 having jerky movements, she immediately called for help, and that his/her blood glucose level was 70 mg/dl. The Statement indicated the Nurse Supervisor responded to the call for assistance with Resident #1, 911 was initiated, and EMS transferred Resident #1 to the Hospital Emergency Department. During an interview on 12/29/21 at 12:00 P.M., Nurse #1 said she worked the 7:00 A.M. to 7:00 P.M. shift on 12/11/21, while Nurse #2 worked 7:00 A.M. to 4:00 P.M. on the same unit. Nurse #1 said between 7:00 A.M. and 3:00 P.M., she covered the desk (answered phone calls and completed skin checks for residents). Nurse #1 said Nurse #2 was responsible of measuring blood glucose levels for residents on the unit. Nurse #1 said around lunch time (noon), Nurse #2 asked her to call the Nurse Practitioner and report that Resident #2's blood glucose level was high. Nurse #1 said she called the Nurse Practitioner who gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2. Nurse #1 said she informed Nurse #2 of this order, and that she (Nurse #1) did not put the order in Resident #2's eMAR. Nurse #2 said Resident #2 (not Resident #1) had high blood glucose level that morning. Nurse #1 said she did not administer the eight units of [MEDICATION(S)] insulin to Resident #2 at that time because she was covering the nursing station desk and said Nurse #2 was the Primary Nurse for Resident #2 in the morning. Nurse #1 said when returned from break at 4:00 P.M, she took over the medication cart because Nurse #2 was leaving at that time. Nurse #1 said Nurse #2 gave a quick report which included that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 said Nurse #2 did not specify in the shift change report which resident record she put the insulin order in. Nurse #1 said she noticed Resident #1 had a one time order for 8 units of insulin on his/her MAR. she checked Resident #1's blood sugar level at 4:00 P.M., that it was 223 mg/dl, administered 4 spoons of his/her meal and that he/she refused the rest, and refused alternative meal offered. Nurse #1 said she administered 8 units of insulin to Resident #1. Nurse #1 said Resident #1 was alert and at his/her baseline prior to the insulin administration, and that at 6:30 P.M., Certified Nurse Aide (CNA) #1 and CNA #3 requested for her assistance with Resident #1. Nurse #1 said she observed Resident #1 having jerky movements, she yelled for assistance, and assessed his/her blood glucose level to be 70 mg/dl. Nurse #1 said the Nurse Supervisor called 911. Nurse #1 said when the emergency medical services (EMS) arrived, they assessed Resident #1's blood sugar to be 30, and he/she was transferred to the Hospital Emergency Department. Review of Resident #1's Medication Administration Record (MAR), dated 12/11/21, indicated that on 12/11/21 at 4:21 P.M., Nurse #1 administered eight units of [MEDICATION(S)] insulin to Resident #1. During an interview on 12/29/21 at 11:00 A.M. and 1:00 P.M., the Administrator said Nurse #2 had indicated in her statement that she was not sure which medical record she had documented Resident #2's [MEDICATION(S)] insulin order. Review of Resident #1's Nurse Progress Note, dated 12/11/21, indicated Nurse #1 assessed Resident #1 at 4:00 P.M. and that his/her vital signs were as follows; blood pressure 106/57, pulse 88, respiration 18, blood glucose 223. The Note indicated Resident #1 did not have shortness of breath or respiratory distress at the time. The Note indicated at 5:00 P.M. Nurse #1 fed Resident #1 with some spoonfuls of food, and he/she refused the rest and an alternative meal was offered. Review of the Nurse Supervisor's Written Witness Statement, dated 12/11/21, indicated that on 12/11/21 at 6:30 P.M., Nurse #1 requested with assistance with Resident #1. The Statement indicated Nurse Supervisor observed Resident #1 having jerky movements and he/she was nonresponsive. The Statement indicated 911 was initiated and Resident #1 was transferred to the Hospital Emergency Department. During an interview on 12/29/21 at 1:30 P.M., the Nurse Supervisor said she was on another unit when a nursing staff called for her /assistance with Resident #1 stating he/she was having [CONDITION(S)] activity. The Nurse Supervisor said she observed Resident #1 having jerky movements with [CONDITION(S)]-like activities, and that she immediately called 911. The Nurse Supervisor said Nurse #1 told her Resident #1's blood glucose level was 70 mg/dl, and that when the emergency response team arrived, they reported Resident #1's blood glucose was in the 30s. The Nurse Supervisor said she knew something was not right, and started an investigation. The Nurse Supervisor said she called Resident #1's family member and was informed he/she did not have any history of a [CONDITION(S)] disorder. The Nurse Supervisor said she reviewed Resident #1's record and saw a one-time order for eight units of [MEDICATION(S)] insulin. Nurse Supervisor said she called Nurse #2 and asked her to come back to the Facility and write a statement for medication transcription error. Review of Resident #1's Nurse Progress Note, dated 12/12/21, indicated the Hospital called to inquire about details leading to Resident #1's need for emergency department evaluation. The Note indicated that insulin was given prior to change in Resident #1's condition. 2) Resident #2 was admitted to the Facility in May 2021, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's MAR, dated 12/01/21 through 12/31/21, indicated he/she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated nursing to update Nurse Practitioner if blood glucose level is below 70 or greater than 350. The MAR indicated that on 12/11/21, Resident #1's blood glucose level at 7:30 A.M. was 360 and 11:00 A.M. was 454 mg/dl. Review of Resident #2's MAR, dated 12/01/21 through 12/31/21, indicated Resident #2 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 units, 200 - 249 = 4 units, 250 - 299 = 6 units, 300 - 349 = 8 units, 350 - 400 = 10 units, over 400, to notify the Physician. Review of Resident #2's MAR, dated 12/01/21 through 12/31/21, indicated Resident #2's physicians' orders also included the administration of four units of [MEDICATION(S)] insulin at 7:30 A.M., 11:00 A.M., and 4:00 P.M. daily. Review of Resident #2's Nurse Progress Notes, dated 12/11/21, indicated that on 12/11/21 at 11:50 A.M., Nurse #1 reported to the Nurse Practitioner that Resident #2's blood glucose level was 454 mg/dl, and that the Nurse Practitioner gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2's blood glucose to be rechecked in two hours (which would have been around 2:00 P.M.). Review of Nurse #2's Written Witness Statement submitted via an email, dated 12/15/21, indicated on 12/11/21 the Nurse Practitioner ordered eight units of [MEDICATION(S)] insulin for Resident #2. The Statement indicated she (Nurse #2 when putting the order in the eMAR) opened a new tab on the desktop computer that was being used by Nurse #1 and that she (Nurse #2) was having difficulty entering the new order for Resident #2, because the computer kept prompting her to enter a sliding scale for the [MEDICATION(S)] insulin order. The Statement indicated Nurse #2 closed out the computer screen and reopened it. The Statement indicated that she (Nurse #2) believed that was when she opened the chart of another resident (Resident #1), and documented the [MEDICATION(S)] insulin order in that residents record (Resident #1's) instead of Resident #2's. The Statement indicated Nurse #2 explained to Nurse #1 during shift change report that she had transcribed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2) could not find the order in Resident #2's MAR. The Statement indicated that Nurse #2 was not aware of the medication transcription error until the Nurse Supervisor called and notified her at 8:40 P.M. Review of Resident #2's medical record indicated there was no documentation to support that Resident #2 was administered the additional eight units [MEDICATION(S)] insulin as ordered by the Nurse Practitioner, or that nursing rechecked his/her blood sugar, as ordered. During an interview on 01/04/21 at 9:30 A.M., the Nurse Practitioner said said per the facility call log registry on 12/11/21, a facility nursing staff paged her at 11:56 A.M. about Resident #2 having high blood glucose levels. The Nurse Practitioner said the second call came in at 12:15 P.M. on Resident #1 who was reported to be having pain and nursing questioning transfer to the Hospital. The Nurse Practitioner said the third page from the facility came in at 3:19 P.M. on Resident #2, nursing had concerns his/her blood glucose level was still high. The Nurse Practitioner said after reviewing the call log, it make sense why Resident #2 was still having high blood glucose even after an order was given to nursing to administer one time dose of additional insulin. The Nurse Practitioner said that meant Resident #2 never got the eight units of [MEDICATION(S)] insulin and therefore his/her hyperglycemic episode went untreated.

Based on records reviewed and interviews, for three of five sampled residents (Resident #1, Resident #3, and Resident #5), who were incontinent and required staff for assistance to meet care needs, the Facility failed to ensure residents were free from neglect when Certified Nurse Aide (CNA) #1 refused to assist Resident #1, Resident #3, and Resident #5 with incontinent care and purposely left the residents in soiled briefs. Resident #1, Resident #3, and Resident #5 said they felt angry and upset after CNA #1 refused to assist them with care. Findings include: The Facility's Investigation, dated 9/27/21, indicated that during the overnight shift (11:00 P.M. to 7:00 A.M.) beginning on 9/24/21, Certified Nurse Aide (CNA) #1 refused to provide toileting and incontinent care for Resident #1, Resident #3, and Resident #5 during her shift. The Investigation indicated the Facility substantiated that the CNA #1 neglected these residents. The Facility Policy titled, Resident Rights and Abuse Program, revised dated July 2021, indicated the Facility defined neglect as the failure of the Facility, its employees or service providers to provide resident goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 1) Resident #1 was admitted to the Facility in April 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care related to Activity of Living Self Care Deficit, dated as initiated 5/07/21, indicated to encourage resident to participate to the fullest extent possible, including encouraging Resident #1 to use the call bell for assistance. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, and required limited assistance from one staff member with transfers, and required extensive assistance from staff for toileting activities. During an interview on 11/04/21 at 3:36 P.M., Resident #1 said that he/she takes medication that makes him/her urinate a lot. Resident #1 said he/she needed staff assistance with transferring from his/her bed to his/her wheelchair and assistance in the bathroom. Resident #1 said CNA #1 came into his/her room and CNA #1 complained about him/her going to bathroom to a lot. Resident #1 said that CNA #1 told him/her that he/she needed to either put on a brief or use the bedpan. Resident #1 said he/she felt upset and requested another staff member to assist him/her with care. During an interview on 11/04/21 at 2:30 P.M., the Staff Development Coordinator (SDC) said she worked as the nurse on call on 9/25/21, and received a call from the Nurse Supervisor who said that Resident #1 and staff reported that CNA #1 had refused to provide care to residents during her shift. The SDC said she told the Nurse Supervisor to call and report that information to the Administrator. During an interview on 11/15/21, at 12:00 P.M., the Nurse Supervisor said Resident #1 said that CNA #1 refused to provide him/her assistance with care during the previous shift (9/24/21). During an interview on 11/03/21, at 2:00 P.M., the Administrator said she received a call from the Nurse Supervisor who said Resident #1 reported that CNA #1 had refused to provide care to him/her during her shift. 2) Resident #3 was admitted to the Facility in July 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact, was incontinent of urine, and required limited assistance from one staff member with mobility activities and transfers. The MDS indicated Resident #3 required limited assistance from staff for toileting activities. Review of Resident #3's Plan of Care, dated as initiated 10/04/2021, indicated he/she has occasional bladder incontinence, required assistance with care, and that interventions included that Resident # 3 should maintain a clean peri-area with each incontinence episode. During an interview on 11/03/21 at 12:45 P.M., Resident #3 said he/she rang the call light for staff because he/she needed assistance with incontinent care. Resident #3 said Certified Nurse Aide (CNA) #1 answered the call light, assisted him/her with care, but said CNA #1 placed two briefs on him/her. Resident #3 said it felt uncomfortable, tight, and painful. Resident #3 said he/she asked CNA #1 why she put two briefs on him/her. Resident #3 said CNA #1 said she did that so she wouldn't have to provide incontinence care for rest of the shift. During an interview on 11/03/21 at 10:30 A.M., CNA #4 said (on 9/25/21) she went to provide care to Resident #3 and found he/she had two briefs on and he/she was soaked with urine. CNA #4 said she asked Resident #3 why he/she had two briefs on, and Resident #3 said CNA #1 put two briefs on him/her and that it was uncomfortable. CNA #4 said Resident #3 said he/she felt upset and his/her pride was hurt. During an interview on 11/15/21 at 8:42 A.M., CNA #1 said she put two briefs on Resident #3 because she did not know what his/her care plan required and said that's what other staff told her to do. CNA #1 said that she was unaware that Resident #3 required only one brief. 3) Resident #5 was admitted to the Facility in September 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact and incontinent of bowel, and required limited assistance from one staff member with mobility activities and transfers. The MDS indicated Resident #5 required total assistance from staff for toileting activities. Review of Resident #5's Plan of Care, dated as initiated on 07/28/2021, indicated he/she has occasional incontinence of bladder and incontinence of bowel. Interventions included that Resident # 5 should maintain a clean peri-area with each incontinence episode, monitor skin and apply moisture barrier as needed. During an interview on 11/03/21 at 1:15 P.M., Resident #5 said he/she had been incontinent of his/her bowel and required staff assistance. Resident #5 said that one morning before 7:00 A.M., he/she needed staff assistance and rang the call light. Resident #5 said CNA #1 came into his/her room to respond to the call light, looked at her watch and said that her shift would be over soon and refused to provide him/her assistance with care. Resident #5 said he/she had to wear a soiled brief for at least 20 minutes (if not longer) until a staff member working the day shift came and assisted him/her with care. During an interview on 11/15/21 at 10:52 A.M., CNA #3 said (on 9/25/21) she saw Resident #5's call light on around 6:40 A.M., and that CNA #1 went to his/her room to respond to the call light. CNA #3 said about 20 minutes later, Resident #5 rang his/her call light again, so she went into his/her room to respond to the call light. CNA #3 said Resident #5 told her that CNA # had refused to provide him/her assistance with care because her shift was almost over. CNA #3 said later that evening (9/25/21) when she was assisting Resident #1 with care, he/she said that CNA #1 had come his/her room the night before, and refused to provide him/her assistance with going to the bathroom. CNA #3 said the CNA #1 told him/her that he/she needed to wear a brief or use a bed pan and refused to provide him/her assistance with care. CNA #3 said she reported this allegation to the Nurse Supervisor. The Nurse Supervisor said that CNA #3 and other staff members reported that CNA #1 had refused to provide care to several residents on the previous night (9/24/21) shift. The Administrator said the Nurse Supervisor also said she received report from staff that CNA #1 has refused to provide care other residents. The Administrator said the Facility Investigation on 9/27/21 concluded that CNA #1 had neglected the residents.

Based on records reviewed and interviews the Facility failed for one of three residents (Resident #1) to ensure that Resident #1's representative was provided a summary of the Base Line Care Plan, which included Admission Physician Orders. On 12/17/18, Resident #1 was admitted to the Facility and documentation indicated Resident #1 was cognitively impaired. Findings include: The Admission Consents, dated 12/17/18, indicated Resident #1 did not sign the consents included in the Admission documents. Resident #1's Health Care Proxy signed all Resident #1's Admission consents. The Facility's Speech Therapy Evaluation, dated 12/19/18, indicated Resident #1 had constant supervision needed 24 hours a day prior to admission. Resident #1's Brief Interview for Mental Status, dated 12/23/18, indicated his/her score was six out of fifteen which indicated Resident #1 cognitive status was severely impaired. The Surveyor interviewed Nurse #1 at 2:05 P.M. on 1/10/19. Nurse #1 said, on 12/17/18, she was Resident #1's Admitting Nurse to the Facility. Nurse #1 said Family Member #1 said she was Resident #1's Health Care Proxy and Family Member #1 was adamant about Resident #1's impaired cognitive status. Nurse #1 said Resident #1 would not be able to sign any Facility documentation because he/she did not have the cognitive capacity to understand what he/she would be signing and wanted Resident #1's Health Care Proxy to be invoked. Nurse #1 said that she communicated this information to the nurses coming on the next shift but was not sure if the physician was aware. Nurse #1 said she did not review Resident #1's Baseline Care Plan with Family Member #1. The Surveyor interviewed Family Member #1 and Family Member #2 at 8:00 P.M. on 1/17/19. Family Member #1 said she was Resident's #1's Health Care Proxy and was not aware the Health Care Proxy was not invoked at the Facility until the Physician invoked it on 12/24/18. Family Member #1 and Family Member #2 said a Baseline Care Plan for Resident #1 was never reviewed with them by the Facility. The Surveyor interviewed the Director of Nursing at 4:52 P.M. on 1/14/19. The Director of Nursing said it was Facility procedure to complete the Baseline Care Plan within 48 hours of a Residents Admission and the documentation should be reviewed with the Resident and the Health Care Proxy. A Plan of Care Note dated 1/11/19 and attached to Resident #1's Baseline Care Plan, dated 12/19/18, was faxed to the Department of Public Health on 1/15/19 and indicated the Baseline Care Plan and Order Summary was provided to Resident #1. The Plan of Care Note indicated Resident #1 was advised to notify any staff member if he/she had any questions about the Baseline Care Plan and Order Summary. There was no documentation to indicate the Baseline Care Plan or Order Summary was reviewed with Family Member #1, who was Resident #1's Health Care Proxy. There was no documentation to indicate Resident #1's Baseline Care Plan was reviewed with Resident #1's Health Care Proxy.

Bases on records reviewed and interviews the Facility failed for one of three residents (Resident #1) to ensure they were free from significant medication errors. Findings Include: On [DATE], Resident #1 was admitted to the Facility from a Hospital and the discharge paperwork provided to the Facility from the hospital included two pages of medications and discharge instructions related to another hospital patient. Based on this erroneous information, Resident #1's Facility admission orders [REDACTED]. As such, Resident #1 received [MEDICATION NAME] XL (betablocker medication: used to treat high blood pressure), [MEDICATION NAME] (antibiotic: used to treat infections), [MEDICATION NAME] (antibiotic: used to treat infection), [MEDICATION NAME] (proton pump inhibitor: medication used to treat heartburn), [MEDICATION NAME] XR (a category of medication used to treat cognitive loss), and Eliquis (anticoagulant: a medication to prevent blood clots, can cause increased risk for bleeding) in error for eight days. The medication error was not identified until Resident #1's physical and medical condition deteriorated, and he/she was observed to hypotensive (low blood pressure), bleeding from his/her mouth and rectum. On [DATE], Resident #1 was emergently transferred to the hospital, admitted to the Intensive Care Unit (ICU), and died . Findings include: The Policy titled, Medication Coordination, dated [DATE], indicated all residents admitted will have the Medication Coordination Form completed by the nurse as part of the admission assessment. The Policy states the nurse will compare the medication history from the admission orders [REDACTED]. The Policy indicated the nurse will review all admission orders [REDACTED]. Resident #1's Discharge Summary from the hospital, dated [DATE], indicated Resident #1's medications included the following; [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (treat enlarged prostate), [MEDICATION NAME] (treat high cholesterol), [MEDICATION NAME] (treat constipation), Dorzolamide (treat [MEDICAL CONDITION]), Hexavitamin (treat or prevent vitamin deficiency), Aspirin (blood thinner/anti-[MEDICAL CONDITION]), Tums (antacid), Lactobacillus Acidophilus (good bacteria), [MEDICATION NAME] (relaxes muscles in airway), [MEDICATION NAME] (nonsteroidal/ anti-[MEDICAL CONDITION]), and [MEDICATION NAME] (treat high blood pressure). Two lists, which included medications, was sent with Resident #1 to the Facility from the hospital. The Patient Summary List, dated [DATE], from the hospital, included a list of medication by name, dose, frequency, and the last time they were administered to Resident #1 by hospital staff. A second list of medications was included within the discharge information and included two pages of medications and discharge instructions intended for another hospital patient (the name of the patient on the two pages was not Resident #1's name). The two lists of medications provided to the Facility were not consistent, and there was no indication the Facility Admitting Nurses identified the inconsistencies between the two medications lists. Resident #1's Patient Summary List, from the hospital, was not the list of medications used by the admitting nurses to generate Resident #1's Facility admission orders [REDACTED] The Surveyor interviewed Nurse #1 at 2:05 P.M. on [DATE]. Nurse #1 said she was the admitting nurse for Resident #1 on [DATE]. Nurse #1 said normally the practice was to review the hospital paperwork, look at the discharge summary and instructions to obtain the resident's medications and then write the information on the Medication Coordination Form. Nurse #1 said the Medication Coordination Form was used to review with the resident and or their representative. Nurse #1 said Resident #1's Family Member had questions about Resident #1's medications, but Nurse #1 did not remember what concerns he/she had, or whether she reviewed the medications with Resident #1's Health Care Proxy. Nurse #1 said she did not document the concerns or whether she reviewed Resident #1's medications on the Medication Coordination Form. The Medication Coordination Form, dated [DATE], included a total of 25 medications that consisted of eye drops and oral, injectable, topical, and rectal medications. The Medication Coordination Form included [MEDICATION NAME] XL (betablocker), [MEDICATION NAME] (antibiotic), Azithromyin (antibiotic), [MEDICATION NAME] (proton pump inhibitor), [MEDICATION NAME] (a category of medication used to treat cognitive loss), and Eliquis (anticoagulant) intended for another hospital patient. The Medication Coordination Form, dated [DATE], included areas for nurses to document last doses the medications were administered at the hospital; however, the last doses for the medications intended for the other hospital patient were not entered onto the form. The Medication Coordination Form, dated [DATE], included areas for nurses to document that the medications were reviewed with the resident or the family; however, this information was not completed by the admitting nurse or any other facility staff member. The Medication Coordination Form, dated [DATE], included areas for nurses to document that medications taken at home were reviewed with the resident or the family member; however, the sections of the form to document that this occurred were not completed. The Medication Coordination Form, dated [DATE], included areas for nurses to document when the Facility staff was unable to obtain home medication history from patient. This section of the form was left blank and was not completed. The Medication Coordination Form, dated [DATE], included areas for nurses to document whether staff contacted a family member to obtain medical history. This section of the form was left blank and was not completed. The Surveyor interviewed Family Member #1 and Family Member #2 at 8:00 P.M. on [DATE]. Family Member #1 said she was Resident's #1's Health Care Proxy. Family Member #1 said Resident #1 was discharged from the hospital to the Facility with [DIAGNOSES REDACTED]. Family Member #1 said she had received a phone call from the Hospital Physician Assistant, on the day of Resident #1's hospital discharge, who informed her that Resident #1's medications stayed the same except Resident #1 was started on a new blood pressure medication ([MEDICATION NAME]), his/her [MEDICATION NAME] (treat [MEDICAL CONDITION]) eye drops were discontinued and replaced with Dorzolamide eye drops. Family Member #1 said Resident #1 had been taking the following medications at home: [MEDICATION NAME], ASA, [MEDICATION NAME], Multi vitamin, Tums and Lactobacillus Acidophilus. Family Member #1 and Family Member #2 said the admitting Nurse at the Facility did not request Resident #1's Home Medication list or review any information in regards to Resident #1's [DIAGNOSES REDACTED]. Family Member #1 said that upon Resident #1's admission she was not asked to, and did not sign, a consent for any of Resident #1's medications. Family Member #2 said during a visit with Resident #1 he saw a copy of a medical consent form which had Resident #1's signature on it and he brought it to Family Member #1's attention. Family Member #1 said she had not been informed by the Facility that Resident #1 had signed the medical consent form. Family #1 said she shared her concern with the Nursing staff about the medical consent form being signed by Resident #1 because he/she did not have the cognitive capacity to understand what he/she would be signing. The Informed Consent for [MEDICAL CONDITION] Administrative Form, dated [DATE], indicated nursing staff witnessed Resident #1 sign the consent form to receive [MEDICATION NAME] XR (medication used to treat dementia). Family Member #1 and Family Member #2 said Resident #1 did not have a [DIAGNOSES REDACTED]. Family #1 and Family #2 said Resident #1 did not have a [DIAGNOSES REDACTED]. Family Member #1 and Family #2 said the only time they spoke to a physician and reviewed Resident #1's medications was on [DATE] and it was identified at that time that Resident #1 was receiving the wrong medications. Resident #1's facility admission physician medications orders, dated [DATE], included the following; [MEDICATION NAME] XL (betablocker), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (proton pump inhibitor), [MEDICATION NAME] XR (a category of medication used to treat cognitive loss), and Eliquis (anticoagulant). The Nurse Practitioner's progress note, dated [DATE], indicated Resident #1's medications were reviewed in the Nursing Home Electronic Medical Record. Nursing Documentation tilted, Capabilities Two Week Prior to hospitalization , dated [DATE], indicated Resident #1 did not prepare and take his/her own medications at home. The Nursing documentation indicated Resident #1's Health Care Proxy assisted with medication preparation and administration for Resident #1. The Nursing documentation indicated Resident #1 did know all his/her medications and the purpose of why he/she was taking them. The form indicated the information provided on this documentation was obtained by nursing staff speaking with the Health Care Proxy by telephone. The Surveyor interviewed the Nurse Practitioner at 10:25 P.M. on [DATE]. The Nurse Practitioner said when a new admission comes to the Facility her admitting practice is to look at the Discharge Summary from the previous hospital, along with the Facility's medication list (Medication Coordination Form), review with the resident (if competent) and if the resident was not competent she would speak to Health Care Proxy/Family and look for any discrepancies. The Nurse Practitioner said she does not recall reviewing the medications with Resident #1 or with the Family. The Nurse Practitioner said when she reviews a new resident's health information, she does not review the name of the resident and his/her date of birth on each individual documentation page she reviews. The Nurse Practitioner said she would hope that all the documentation would be regarding the same (and correct) resident although she has seen this practice happen in the past, where it did not. Resident #1's Medication Administration Records, dated from [DATE] to [DATE], indicated the nursing staff documented they administered [MEDICATION NAME] XL (betablocker), [MEDICATION NAME] (antibiotic), Azithromyin (antibiotic), [MEDICATION NAME] (proton pump inhibitor), [MEDICATION NAME] (a category of medication used to treat cognitive loss), and Eliquis (anticoagulant) to Resident #1 during this time frame. The Surveyor interviewed the Director of Nurses at 4:29 P.M. on [DATE]. The Director of Nurses said it was the Facility policy to verify the medication orders sent with a new admission with the resident's home medication list. The Director of Nurses said the Medication Coordination Form needs to be completed by nursing upon admission and all areas need to be filled out and addressed. The Nurse's note, dated [DATE], indicated on this date family said Resident #1 was not at his/her baseline, he/she was confused and shaking more than usual. The Nurse's note indicated the Certified Nursing Aide said Resident #1 was having a harder time with transferring and she/he observed blood in the toilet after Resident #1's bowel movement. The Nurse's note, dated [DATE], indicated the physician was updated, assess Resident #1, reconciled his/her medications with Resident #1 and Health Care Proxy and identified two medications that were not prescribed for this Resident #1 ([MEDICATION NAME] and Eliquis). (The Records actually included five medications administered in error). Resident #1 was transport to the hospital on [DATE] for further evaluation due to his/her physical and medical condition continued to deteriorate. The Hospital Emergency Department records, dated [DATE], indicated Resident #1 was diagnosed with [REDACTED].#1's medication consumption. The Hospital Emergency Department records and Discharge Summary indicated Resident #1 was critically ill, was transferred to the intensive Care Unit and died on [DATE].

Based on observation and staff interview, facility staff failed to alert the Physician in a timely manner that the resident (#58) had increased pain during a dressing change for 1 (#58) of 24 sampled residents. Findings include: Resident #58 was admitted to the facility in 4/2015. [DIAGNOSES REDACTED]. The resident was admitted to Hospice in 11/2017. On 1/10/18 from 2:30-3:15 P.M., the Surveyor observed Nurse #1 during 3 dressing changes for Resident #58. The resident had 3 wounds that dressings needed to be changed. The right foot had a Stage II pressure sore, the coccyx had a large unstageable pressure sore and the mid back had an infected surgical wound. During the dressing changes, the patient yelled out in pain and swore at Nurse #1 to hurry up. During interview on 1/10/18 at 5:00 P.M., Nurse #1 said that he medicated the resident at 12:00 noon with the narcotic pain medication [MEDICATION NAME] (Concentrate) Solution 0.25 milliliter (5 milligrams). He told the Surveyor that the pain has increased during the dressing changes and the Resident yells frequently. During interview on 1/11/18 at 8:40 A.M., the Director of Nurses (DON) and Administrator said that Nurse #1 did not report that the resident had increased pain during the dressing change on 1/10/18, and that this was the first they had heard of it. The DON said the Physician would be contacted today regarding pain management. The DON told the Surveyor that there was no pain management plan for the dressing changes and that Nurse #1 should have administered the [MEDICATION NAME] closer to the time of dressing change. Please refer to F697 and F880.

Based on observations and record review, the facility staff failed to follow the care plan and/or physician's orders regarding falls, skin checks, dressing changes and positioning of 3 residents (#24,#58 and #97 out of a total sample of 24 residents. Findings include 1. For Resident #97 facility staff failed to ensure the seat alarm on the wheelchair (w/c) was functioning, resulting in a fall from the chair on 1/9/18, and the resident sustained [REDACTED]. Review of the initial Plan of Care addressing falls (initiated 9/26/17) indicated the Resident was identified as a high risk for falls due to falls resulting in a right wrist fracture, mild confusion,[MEDICAL CONDITION] with left sided weakness, gait impairment and need for assist and device. Interventions included: -cues and reminders as needed -On a blood thinning medication (Xarelto) and at risk for bruising and bleeding. -Alarm on chair. Monitor battery and placement -Transfer and walk with gait belt, rolling walker, 1-2 assist -Call light and personal items within reach; bed in low position -Nonskid socks on in bed Review of the Incident Report dated 1/9/18 indicated that at 7:30 P.M., the Resident was found face down on the floor in one of the connecting hallways to another unit. the physician was notified and ordered the Resident be sent to the hospital. Further review of the Incident/Investigation report indicated the w/c alarm was not functioning at the time of the fall, as planned. During interview on 1/16/18 at 10:00 A.M. the Director of Nurses (DON) said that the Resident should have been more closely supervised and the alarm monitored per care plan. Please refer to F 689 2. For Resident #58, facility staff failed to ensure that dressing changes were conducted according to the Physician orders; that the Resident was kept comfortable per the Plan of Care and that the Care Plan for mobility was followed. a. Review of the Plan of Care addressing mobility (revised on 11/20/17) indicated the Resident required assistance of 2 staff members for positioning due to weakness, decreased endurance, [MEDICAL CONDITION] ( nerve pain), and was at risk for further decline. On 1/10/18 at 2:30-3:15 P.M., the Surveyor observed Nurse #1 during a dressing change for Resident #58. The nurse had to reposition the Resident onto his/her left side in order to change the dressings on the coccyx and mid back wounds. Nurse #1 pushed the Resident onto his/her left side by himself, not using 2 staff members as care planned. While holding the Resident onto his/her on their side with one hand Nurse #1 attempted to remove the dressing on the coccyx. Nurse #1 told the Resident to hold onto the siderail despite the Care Plan indicating 2 staff were needed for bed positioning. The Resident yelled out in pain during the entire treatment. b. A physician's order indicated that on 1/10/18 the following treatment should begin: To Right heel, after N/S (Normal Saline) wash, apply Hydrogel ( a gel used in wound care in which the main component is water, to promote wound healing) and cover with a Boarder {sic} (Border) Dressing. Change every 3 days PRN (as needed). During observation on 1/10/18 at 2:30 P.M. Nurse #1 washed the right heel, applied Skin Prep, (a liquid that when applied to the skin forms a protective film and not part of the physician order). Nurse #1 then covered the area with a Border Dressing without applying Hydrogen to the open area as ordered. The Surveyor next observed the coccyx dressing change. The physician order from 10/5/17 was to cleanse the wound gently with N/S and pat dry. Apply [MEDICATION NAME] Cream 1% ( a topical, for the skin, antibiotic cream) to the open wound. Apply Skin Prep to the surrounding tissue. Cover with Border Dressing and apply ZGuard paste (skin protectant) to the surrounding pink skin. Nurse #1 cleansed the wound as ordered but applied [MEDICATION NAME] gel (different from the ordered [MEDICATION NAME] Cream). Nurse #1 said that the [MEDICATION NAME] Cream had not been available for quite some time. Nurse #1 said the wound looked worse for the past three days. The Surveyor next observed the dressing change for the mid-back wound. The wound was a surgical wound. the physician order from 11/2/17 indicated to apply Xeroform dressing (a sterile petroleum gauze dressing on the wound and cover with a gauze dressing. there was no order to cleanse the wound first. The Surveyor observed Nurse #1 cleanse the wound with N/S and apply the Xeroform dressing. He then covered the dressing with 2 Border dressings and not gauze as per the physician orders. During interview on 1/11/18 at 8:45 A.M. the DON said that Nurse #1 did not follow the Resident's Plan of Care or Physician orders for the dressings. The DON said that [MEDICATION NAME] Cream and [MEDICATION NAME] gel are two different medications. Further investigation and interview with the DON revealed that the [MEDICATION NAME] Cream was last ordered 10/4/17. Please Refer to F880 3. for Resident #24, facility staff failed to follow the plan of care/Physician orders regarding conducting weekly skin assessments. Resident #24 was admitted to the facility in 1/2017 and readmitted in 4/2017. [DIAGNOSES REDACTED]. Review of the Facility's policy regarding Weekly Skin Assessments, revised 8/18/15 included: - It is the policy of the facility that every resident will receive a head-to-toe skin assessment by a licensed nurse on a weekly basis. - It is the purpose of this policy to assure any skin impairment is identified, assessed, and treated in a timely manner. - The nurse will assess the skin in a systematic order head-to-toe. If an area exists, the nurse will confirm that documentation and treatments have been established. Review of the Plan of Care (dated 1/26/17) addressing skin impairment included the following interventions: - pressure relieving mattress - cushion in chair - treatments as ordered - Weekly Skin Assessments Review of the Resident's Weekly Skin Assessments indicated: - 9/7/17 Declined shower and weight this P.M. No new skin issues. - 9/14/17 no documented skin assessment. - 9/21/17 Bed bath provided. No new skin issues. - 9/28 and 10/5/17 No documented skin assessments. - 10/12/17 No new skin issues. - 10/19 and 10/26/17 No documented skin assessments. Review of a Nurses' Note dated 10/30/17 indicated the the Certified Nursing Assistant who was providing care to the Resident found new open areas. there was an unstageable pressure area on the coccyx. The right buttock had a deep tissue injury (DTI) which was purple and red, nonblanchable. DTI is a pressure-related injury to subcutaneous tissue under intact skin. The left inner thigh had shearing (pressure area as a result of friction) which measured 3.6 X 0.6 centimeters (cm). during interviews on 1/10/18 at 1:30 P.M. and 10/16/18 at 9:00 A.M., Resident #24 told the Surveyor that he/she did not want the Surveyor to observe the dressing change to his/her coccyx. The Resident was observed on both days to be lying in bed on his/her back in bed. the Resident told the surveyor that he/she was told that They should try to stay of their back as much as possible. Please refer to F686.

Based on observation, record review and staff interview, the facility failed to ensure that 1 of 4 applicable residents (#24) in a total sample of 24 received the care necessary to avoid the development of a pressure ulcer and to identify skin impairment in a timely manner. Findings include: Resident #24 was admitted to the facility in 1/2017 and readmitted in 4/2017. [DIAGNOSES REDACTED]. Review of the facility's policy Weekly Skin Assessments (revised 8/18/15) included: - It is the policy of the facility that every resident will receive a head-to-toe skin assessment by a licensed nurse on a weekly basis. - It is the purpose of this policy to assure any skin impairment is identified, assessed and treated in a timely manner. - The nurse will assess the skin in a systematic order head-to-toe. If an area exists, the nurse will confirm that documentation and treatments have been established. Review of the plan of care (1/26/17) addressing skin impairment included the following interventions: - pressure relieving mattress - cushion in chair - treatments as ordered - Weekly Skin Assessments (also a physician's orders [REDACTED].>Review of the 7/16/17 Quarterly Minimum Data Set (MDS) Assessment indicated the resident: scored 10 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS); required extensive assistance from staff for bed mobility, dressing, toilet use and personal hygiene; required total assistance from staff for transfers (Hoyer lift) and bathing; did not ambulate; had functional limitation in range of motion in both upper and lower extremities; always incontinent of bladder; occasionally incontinent of bowel; weight loss; no pressure ulcers; pressure relieving devices for bed and chair. Review of resident's Weekly Skin assessments indicated: - 9/7/17, Declined shower and weight this P.M. No new skin issues. - 9/14/17, No documented Skin Check. - 9/21/17, Bed bath provided. No new skin issues. - 9/28 and 10/5/17, No documented Skin assessments. - 10/12/17, No new skin issues. Review of the resident's MDS Quarterly Assessment of 10/15/17, indicated the following changes from the previous assessment: BIMS score of 15 out of 15; weight loss (physician prescribed). Review of the Norton Plus Pressure Ulcer Scale dated 10/20/17 scored the resident with a total of 11 (moderate risk of developing a pressure sore.) Review of resident's Weekly Skin assessments indicated: - 10/19 and 10/26/17, No documented Skin assessments. Review of a Nurse's Note dated 10/30/17 indicated that the Certified Nursing Assistant who was providing care to the resident found new open areas. Unstageable pressure area to coccyx noted due to wound bed not being able to be visualized. Area measured 0.3 x 0.2 centimeters (cm) with a copious (a lot) amount of sanguineous (bloody) drainage. The right buttock had a deep tissue injury (DTI) which measured 4.3 x 1.6 cm. The area was described as purple and red, non-blanchable. The left inner thigh had shearing which measured 3.6 x 0.6 cm. A physician's orders [REDACTED].) A physician's orders [REDACTED]. Review of the Wound Consultant Sheet dated 11/6/17 indicated the resident had a history of [REDACTED]. The wound measured 0.5 x 0.5 x 0.9 cm. with moderate serous drainage. During interviews on 1/10/18 at 1:30 P.M. and 1/16/18 at 9:00 A.M., Resident #24 told the Surveyor that he/she did not want the Surveyor to observe the dressing change on the coccyx. The resident was observed on both days lying in bed on his/her back in bed. During an interview on 1/17/18 at 2:00 P.M., the Director of Rehab Services told the Surveyor that prior to the development of the resident's pressure sores (found on 10/30/17), the resident had a standard facility pressure relief mattress (foam) and that he was unable to find any documentation regarding what type of cushion the resident had in the wheelchair (w/c) or when it was issued prior to finding the pressure sores.

Based on observation, interview and record review, the facility staff failed to ensure the resident environment was as free from accident hazards as possible for 3 residents (#3, #51 and #97) in a total sample of 24 residents. Findings include: 1. For Resident #3, the facility staff failed to correctly use a wheelchair and foot rests to transport the resident, causing the resident to fall out of the wheelchair. Resident #3 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of an undated policy entitled Transporting Residents in Wheelchairs indicated the following: -Any resident that is issued a wheelchair will also be issued leg rests and/or foot rests. -If a resident is able to safely self-propel his/her wheelchair using their legs, then the leg rests or foot rests may be removed from the chair while in the building. -If any resident is receiving assistance in propelling his/her wheelchair from anyone (staff, visitor, outside vendor, etc.), the provided leg rests and/or foot rests should be used. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 3/12/17, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 of 15, did not ambulate, required extensive assistance of two for transfers, extensive assistance of one for locomotion on the unit, and used a wheelchair. Review of a Nurse's Note, dated 4/30/17, indicated the resident was status [REDACTED].M. He/she was being pushed down the hall by a Certified Nurses' Aide (CNA). At 7:15 A.M. a 1 centimeter laceration was observed on the bridge of the nose, bruising and swelling on the forehead and the resident complained of hip and ankle pain. The resident was sent to the emergency room . He/she returned at 5:20 P.M. with a nasal fracture, a right ankle fracture and a left distal fibula (leg bone) fracture. Review of the Incident Report, dated 4/30/17, indicated the resident had a fall at 5:45 A.M. and sustained fractures to the nose, lower left extremity and lower right extremity. The CNA wheeled the resident down the hallway to a common area on the unit. The resident, without warning, planted both feet on the floor causing the wheelchair to flip forward and the resident to fall. On further investigation, it was noted that the foot rests were not under the resident's feet. Review of the Significant Change of Status MDS, dated [DATE], indicated the resident had severe cognitive impairment as evidenced by a BIMS score of 4 of 15, required extensive assistance for transfers and locomotion on the unit, did not ambulate, and had a fall with a major injury. On 1/17/18 at 3:40 PM during an interview with the Rehabilitation Director, he said the resident should have had foot rests on the wheelchair. Had the foot rests been used, he felt the accident probably would not have happened. On 1/17/18 at 4:07 P.M. during an interview with CNA #4, she said she was the CNA involved in the accident. She said she was not told the resident wasn't suppose to get up. She thinks she and another staff member working that night put the resident in the wrong wheelchair (w/c). She couldn't remember if the wheelchair had leg rests or not, but remembers the resident's feet were touching the floor. She said the resident flipped forward, but not the chair. She could feel the resident's feet on the floor, then stop suddenly, and the resident flipped forward out of the wheelchair. 2. For Resident #97, facility staff failed to provide supervision and assistive devices to prevent falls and to ensure the w/c seat alarm was functioning. Resident #97 was admitted to the facility in 9/2017. [DIAGNOSES REDACTED]. Review of the Initial MDS assessment dated [DATE] indicated the resident: could make self understood and could usually understand others (misses some part/intent of message); scored a 12/15 on the Brief Interview for Mental Status (BIMS); required extensive assistance from 2 staff members for bed mobility, transfers and toilet use ambulated in the corridor with limited assistance from 2 person physical assist; required extensive assistance from 1 person physical help for dressing, eating, personal hygiene and bathing; balance was unsteady; history of falls with a right wrist fracture (cast on admission) prior to admission; receiving an anticoagulant. Review of the plan of care addressing forgetfulness (9/25/17) indicated the resident sometimes forgets or misses what is said and has a decreased attention span due to being in a new environment and having [MEDICAL CONDITION] 8/2017. Review of a Nurse's Note of 9/25/17 indicated the resident's right wrist cast was removed at an orthopedic appointment and replaced with a splint. Review of an Incident Report of 9/25/17 indicated a visitor reported seeing the resident falling from the wheelchair in an unoccupied room at 4:10 P.M. When staff arrived, the resident was on the floor and told staff that he/she was trying to transfer to another chair. The brakes on the wheelchair (w/c) were not locked. The report indicated that a w/c alarm was added. There were no apparent injuries. Review of the initial plan of care addressing falls (initiated 9/26/17) indicated the resident was identified as a high risk for falls due to falls with a right wrist fracture, mild confusion,[MEDICAL CONDITION] left sided weakness, gait impairment and need for assist and device. Interventions included: - Cues and reminders as needed. - On a blood thinning medication, and at for bleeding or bruising. - Alarm in chair. Monitor battery and placement. - Transfer and walk with gait belt, rolling walker and 1-2 assist. - Call light and personal items within reach; bed in low position. - Nonskid socks on in bed. Review of Nurses' Notes of 10/4/17 and 10/6/17 indicated the resident was self transferring from bed to w/c and into the bathroom, then from the toilet to the w/c. Nurses' Notes of 10/11, 10/12 and 10/15/17 indicated the resident activated the chair alarm when attempting to stand unassisted. Reminders given to resident. A Nurse's Note of 10/18/17 indicated the resident continues to take self to the bathroom. There was no documentation regarding the chair alarm sounding. Resident #97 had subsequent falls on 10/31/17 and 11/30/17 when the Resident was sent out for a CAT scan (due to possibly hitting their head and having increased risk of bleeding due to being on a blood thinner). Review of Nurses' Notes indicated the resident was having increased periods of lethargy and confusion. The resident was seen by a neurologist on 12/11/17 who prescribed [MEDICATION NAME] for depression. Review of the Quarterly MDS assessment dated [DATE], indicated the following changes from the Initial MDS of 9/22/17: A decrease in memory with a BIMS of 9 out of 15; no longer ambulated; frequently incontinent of bladder; falls since admission; received an antidepressant; chair alarm used daily. A Nurse's Note of 12/27/17 indicated the facility attempted a 2 week alarm reduction (w/c) due to setting off the alarm multiple times. The decision was to keep the w/c alarm in place for safety. There were no other Care Plan revisions despite the number of falls. Review of the Incident Report of 1/9/18 indicated that at 7:30 P.M., the resident was found face down on the floor in one of the connecting hallways to another unit (unsupervised). The resident was alert and confused and lying prone with a hoodie over the head. The resident said that he/she just got out of a meeting. Staff observed a large lump on the side of the left forehead. The Physician was notified and ordered the resident be sent to the hospital due to receiving the blood thinning medication Xarelto. Further review of the Incident/Investigation indicated the w/c alarm was not functioning at the time of the fall. The facility planned on replacing the alarm, placing bolsters on the bed, and evaluating the resident for a lap belt. The resident was admitted to the hospital with [REDACTED]. The resident was placed in a hard cervical collar for complaints of pain in the cervical region of the neck and is to remain in this collar continually until seen by orthopedics. The resident returned to the facility on [DATE] with the collar. On 1/16/18 at 8:00 A.M., the Surveyor observed the resident sitting in the w/c outside the nurses' station. The resident had a large black bruise and swelling on and above the left eye and left side of head The left eye was almost closed. The resident had on a hard Cervical Collar, a removable belt, a seat alarm and a personal alarm. During discussion on 1/16/18 at 10:00 A.M., the Administrator and DON told the Surveyor that the resident fell from the w/c on 1/9/18 at 7:30 P.M., was hospitalized and returned on 1/12/18. They said the resident sustained [REDACTED]. They said that a hard Cervical Collar was being worn as a precaution until seen by Orthopedics in approximately 2 weeks. The DON said that the resident should have been more closely supervised and the alarm monitored per care plan. 01/17/18 02:59 P.M., the Surveyor observed that the resident's bed now had 1 bed bolster on each side of the bed near the foot of the bed, and 2 quarter side rails on the sides near the head of the bed. 3. For Resident #51, the facility staff failed to provide supervision and assistive devices to prevent 7 unwitnessed falls. Resident #51 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. Review of the fall care plan, initially dated 12/30/16, included the following interventions: - Assist me to rise and change position slowly, - I use my wheelchair for mobility, - I transfer with a gait belt and 1 or 2 assist, - Keep my environment well lit and clutter free, - Bed in low position, - I need continual supervision while on the patio, (initiated 8/7/17), - Provide frequent safety checks, (initiated 11/8/17), - Monitor my whereabouts, (initiated 11/8/17), and - Safety Checks every hour on 3:00 P.M. - 11:00 P.M. and 11:00 P.M. to 7:00 A.M., (initiated 12/4/17). Review of the Admission MDS Assessment, dated 12/27/16, indicated the resident had severe cognitive impairment as evidenced by a score of 4 out of 15 on the BIMS, needed assistance of one for transfers and ambulation, and had not experienced a fall. Review of the Incident Report, dated 2/22/17, indicated the resident had an unwitnessed fall at 9:35 P.M. in the hallway. The resident was observed in bed before the fall. The bed was in a low position. To prevent further falls staff should continue to anticipate the resident's needs and provide frequent checks while in bed. Review of the Incident Report, dated 3/8/17, indicated the resident had an unwitnessed fall at 1:40 P.M. in the shower room. The resident attempted to self transfer to a shower chair. The resident was incontinent at the time of the fall. To prevent further falls, the report indicated that staff should implement a toileting schedule, although there was already one in place, and put a key pad entry on the shower room door. Review of the Incident Report, dated 3/30/17, indicated the resident had an unwitnessed fall at 3:00 P.M. in the common area. To prevent further falls, the report indicated that staff needed to monitor for the resident's safety, although it did not indicate how the resident's safety was to be monitored. Review of the Quarterly MDS Assessment, dated 5/28/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment, needed assistance of 1 for transfers and ambulation, and had experienced two falls since the last MDS Assessment. Review of the Incident Report, dated 8/6/17, indicated the resident had an unwitnessed fall outside on the patio at 2:50 P.M. To prevent further falls, the report indicated not to leave the resident outside alone. Review of the Incident Reports, dated 9/9/17 and 11/22/17 indicated the resident had an unwitnessed falls and found incontinent. The reports did not indicate the last time the resident was toileted. To prevent further falls the report indicated for staff to anticipate the resident's toileting needs at night, and to continue with safety checks. There was no change to the toileting schedule. Review of the Annual MDS Assessment, dated 11/5/17, indicated the resident had moderately impaired cognition as evidenced by the staff assessment, needed assistance of one for transfers and ambulation, and had experienced two or more falls since the last MDS assessment. Review of the Incident Report, dated 12/1/17, indicated the resident had an unwitnessed fall at 6:30 P.M. in another resident's room. To prevent further falls the report indicated that staff were to anticipate the resident's needs. On 1/12/18 at 7:55 A.M., the surveyor observed Resident #51 in bed, eyes closed, with the bed in low position. On 1/12/18 at 8:41 A.M., the surveyor observed Resident #51 in the common area, seated in a wheelchair. On 1/16/18 at 11:08 A.M. during an interview with the Director of Nurses (DON), she said that the key pad lock was never put on the shower room door. She did not know why. She could not explain how supervision was provided for Resident #51 to prevent falls. She said looking at all of the falls together, it was obvious that something different should have been done to prevent the resident from falling.

Based on observation and staff interview, facility staff failed to ensure that 1 of 24 residents (#58) had a pain management plan in place prior to dressing changes and failed to respond when Resident #58 yelled out in pain during the dressing change and instead continued to precede. Findings include: Resident #58 was admitted to the facility in 4/2015. [DIAGNOSES REDACTED]. The resident was admitted to Hospice on 11/10/17, and at that time had an unavoidable pressure ulcer on the coccyx (unstageable) and developed a pressure ulcer on the right heel (Stage II). Review of the Significant Change in Status Minimum Data (MDS) Assessment (due to being admitted to Hospice) of 11/17/17 indicated the resident required extensive assistance of 2 staff members for bed mobility and had no complaints of pain during the last 5 days. Review of the plan of care addressing mobility (revised on 11/20/17) indicated the resident required assistance of 2 staff members for positioning due to weakness, decreased endurance, [MEDICAL CONDITION] (pain) and at risk for further decline. Review of the plan of care addressing pain (revised 11/30/17) indicated the resident was at risk for pain due to [MEDICAL CONDITION]. The goal was to have a positive effect from any pain relief interventions. Interventions include: - Ensure a position of comfort - Monitor/Record pain characteristics: frequency, quality, severity, location, onset, duration, aggravating factors, relieving factors. - Monitor/record/report any non-verbal signs or symptoms of pain: Vocalizations (moans, yelling out) Mood/behavior (changes, more irritable restless, aggressive) - Notify the Physician if interventions are unsuccessful or if current pain is a change from the previous experience of pain - Provide pain medications as ordered and monitor for side effects. On 1/10/18 at 2:30-3:15 P.M. while observing a dressing change the Surveyor observed that Nurse #1 removed the pressure relieving boot on the resident's right foot and the resident yelled out in pain. Nurse #1 told the Surveyor that the resident has pain whenever the feet and legs are moved. After washing the wound on the right heel, the nurse applied skin prep (protective ointment), on the perimeter of the wound. The resident was yelling out in pain during the whole process. The Surveyor observed a non-blanchable red area on the resident's left heel. There was no treatment in place. The nurse said that he would address it, and then he put the left heel back on the bed. The resident continued to yell out in pain. Nurse #1 told the Surveyor that the resident was medicated 2.5 hours earlier with the pain medication [MEDICATION NAME] (Concentrate) Solution 20 milligrams/milliliter (ml). Give 0.25 ml. by mouth every four hours as needed for pain or distress. Give 5 milligrams (mg)=0.25 ml. every four hours as needed. The resident was turned onto his/her left side by Nurse #1 (care plan indicated to utilize 2 staff for positioning for comfort). The Resident yelled out in pain and the nurse told the resident that he would be done soon. The nurse removed the old dressing from the wound on the coccyx with one hand while trying to hold the resident off the back with the other hand. The nurse told the resident to hold onto the side rail. The resident was yelling and swearing at the nurse, that she/he had a lot of pain and to hurry up. The wound was cleaned using N/S and patted dry. The resident was yelling in pain and swearing, saying, You're hurting the[***]out of me! Nurse #1 continued with the dressing change. Nurse #1 told the Surveyor that the wound looked much worse today. Then Nurse #1 removed the old dressing from the resident's mid back. The Resident was still yelling in pain and saying how much it hurt. During interview on 1/10/18 at 5:00 P.M., Nurse #1 said that he administered the narcotic medication [MEDICATION NAME] 2.5 hours prior to the treatment, and that it was not effective. He said that he should have had the assistance of another staff member to help position the resident during the dressing change. Nurse #1 did not stop the procedure and call the Physician regarding the pain level of the Resident during the dressing change. During interview on 1/11/18 at 8:40 A.M., the Director of Nurses (DON) and Administrator said that Nurse #1 did not report that the resident had increased pain during the dressing change or the reddened nonblanchable area on the left heel, and that this was the first they heard of it. The DON said that he should have had assistance of another staff member during the dressing change. The DON said that the Physician would be contacted today regarding pain management. The DON told the Surveyor that there was no pain management plan for the dressing changes and that Nurse #1 should have administered the [MEDICATION NAME] closer to the time of the dressing change to be more effective. Please refer to F880.

Based on record review and interview for 1 of 3 sampled Residents (Resident #2), the Facility failed to immediately notify a physician or their designee (the Physician Assistant) when Resident #2 presented with symptoms of increased intracranial pressure, following a fall where he/she hit his/her head on the floor. Findings include: Resident #2 was admitted to the Facility in 2/2015 with [DIAGNOSES REDACTED]. The Facility's Change in Resident's Condition policy indicated when there was a change in a resident's condition affecting their current level of care, the nurse caring for the resident will update the physician. The Fall Investigation Report, dated 7/25/15, indicated that on 7/25/15 at 12:22 A.M., Resident #2 sustained an unwitnessed fall and sustained two hematomas (collections of fluid) on the back the head as a result of the fall. The report indicated that after the fall, Resident #2 complained of left arm pain and of a headache. The Nurse's Note written by Nurse #2, an Agency Nurse assigned to care for Resident #2 from 11:00 P.M. on 7/24/15 to 7:00 A.M. on 7/25/15, indicated that Resident #2 had a headache after the fall, and vomited (abnormal assessment finding indicative of possible increased intercranial pressure within the skull) at 12:30 A.M., 8 minutes later. There was no documentation to indicate that Nurse #2 informed a physician or their designee of the symptoms of intracranial pressure. The witness statement from Nursing Supervisor #1 indicated that on 1:20 A.M. on 7/25/15, she spoke with the Physician's Assistant regarding Resident #2's fall. The statement did not indicate the Physician's Assistant was immediately informed that Resident #2 experienced symptoms of a possible head injury following the fall. The Surveyor interviewed Nursing Supervisor #1, a Licensed Practical Nurse at 4:30 P.M. on 10/15/15. Nursing Supervisor #1 said she was called to Resident #2's unit and called the Physician's Assistant at 1:20 A.M. on 7/25/15, 58 minutes after the fall. Nursing Supervisor #1 said she informed the Physician's Assistant that Resident #2 fell , and that Nursing Supervisor #1 was concerned that Resident #2 had a left arm fracture and an abrasion on their head. Nursing Supervisor #1 said she did not inform the Physician's Assistant that Resident #2 vomited 8 minutes after the fall, or that Resident #2 had complaints of a headache because she was not aware of these symptoms. The Surveyor interviewed the Physician's Assistant on 10/16/15 at 4:28 P.M., the Physician's Assistant said that her normal process was to type the details of the call she received from facility staff. The Physician's Assistant said she typed the details of the conversation with Nursing Supervisor #1 at 1:17 A.M. on 7/25/15. The Physician's Assistant reviewed the contents of the note with the Surveyor. The notes indicated that Nursing Supervisor #1 called the Physician's Assistant on 7/25/15 at 1:17 A.M., to report Resident #2 had fallen, was on his/her back, had an abrasion on the head from the fall, was on [MEDICATION NAME], and had left extremity pain. The Physician's Assistant said that Nursing Supervisor #1 did not communicate to her that Resident #1 vomited, complained of headache, had drowsiness and changes in behavior after the fall. The Surveyor interviewed Physician #1 on 10/15/15 at 5:00 P.M., Physician #1 said that for Residents with symptoms of intracranial injuries he would expect the staff to notify him or the Physician Assistant/ Nurse Practitioner,right away.

Based on record review and interviews for 1 of 3 sampled residents sustaining falls while prescribed the anticoagulant medication [MEDICATION NAME] (Resident #2), the Facility failed to ensure Resident #2 was assessed for intracranial bleeding after a trauma. - The Facility failed to ensure nursing staff had the competency to identify emergent symptoms of increasing intracranial pressure in a resident who fell and struck their head. On 7/25/15 at 12:20 A.M., Resident #2 fell and 8 minutes later vomited, complained of a headache, was drowsy, and not behaving in his/her usual manner, but the nurses failed to identify the signs and symptoms as possible increasing intracranial pressure requiring emergent response. - Nurse #2 and Nursing Supervisor #1 failed to immediately inform a physician or their designee of the significant changes in Resident #2 following the fall. Nursing Supervisor #1 informed the Physician's Assistant of Resident #2's fall, 58 minutes after the fall and 50 minutes after Resident #2 first presented with symptoms of possible intercranial hemorrhage. -the nursing staff failed to immediately arrange for Resident #2 to be evaluated following a fall. The ambulance was not called until one hour and 45 minutes after Resident #2 first presented with symptoms of a possible head injury. Once hospitalized , Resident #2 was diagnosed with [REDACTED]. Findings include: Resident #2 was admitted to the Facility in 2/2015 with the [DIAGNOSES REDACTED]. The falls care plan of 4/12/15 indicated Resident #2 was at risk for falls related to decreased safety awareness, decreased mobility, right knee buckling, spinal stenosis and had a history of [REDACTED]. The Lippincott Manual of Nursing Practice, 10th edition, dated 2014, indicated that head injuries commonly occur with falls, which included [MEDICAL CONDITION]; defined as significant bleeding into a space or a potential space between the skull and the brain, which is a serious complication of a head injury and the potential for brain herniation; intracranial pressure is a life threatening medical emergency that required immediate recognition and prompt intervention. The Fall Investigation Report and nurses note, both dated 7/25/15, indicated that on 7/25/15 at 12:22 A.M., Resident #2, sustained an unwitnessed fall in the corridor at the entrance of Resident #2's room. Resident #2 sustained two hematomas (collection of blood) on the back the head after the fall; and, Resident #2 complained of left arm pain and a headache following the fall. The Neurological Nursing Assessment form indicated an assessment of Resident #2's neurological vital signs was first documented as being performed 7 minutes before the fall (at 12:15 A.M.). The form was not accurately filled out, as the the size of the right and left pupils was not documented and instead of sizes, the staff recorded check marks. There was no documentation to indicate that a neurological assessment was performed on Resident #2 after the initial assessment. Nurse #2's and Nursing Supervisor #1's competencies did not include any information to indicate they were determined competent regarding assessing for symptoms of increased intracranial pressure following a fall. The Nurse's Note, dated 7/25/15 at 1:57 A.M., written by Nurse #2, indicated Resident #2 had a headache and eight minutes after the fall (at 12:30 A.M.), vomited (abnormal assessment finding indicative of possible intracranial pressure from bleeding). The Surveyor interviewed CNA #1 at 3:43 P.M. on 10/15/15. CNA #1 was assigned to care for Resident #2 at the time of the fall. CNA #1 said within 5 minutes after the fall, he was told to get Resident #2 back to bed and noticed that Resident #2's level of alertness had changed, he/she was, words to the effect of, out in left field, was not verbal, was out of sorts, was not aware of his/her surroundings; CNA #1 decribed Resident #2 as being the complete opposite of (him/herself), and was drowsy. CNA #1 said he witnessed Resident #2 vomit minutes after the fall and reported the vomiting to Nurse #2 and Nursing Supervisor #1 immediately. CNA #1 said he also reported to Nurse #2 and Nursing Supervisor #1 that Resident #2 had a headache, was drowsy, and was not acting like her/himself immediately after the fall. The Surveyor interviewed Nursing Supervisor #1, a Licensed Practical Nurse, at 4:30 P.M. on 10/15/15. Nursing Supervisor #1 said she was called at 12:22 A.M. on 7/25/15 to Resident #2's floor because of the fall and had not met Resident #2 before 7/25/15. Nursing Supervisor #1 said that Resident #2 was alert and verbal because he/she was talking, so Nursing Supervisor #1 thought Resident #2 was him/herself, but she did not ask anyone about his/her baseline at the time. Nursing Supervisor #1 said that about 5 to 10 minutes after the fall, Resident #2 was in bed and Nurse #2 (an Agency Nurse assigned to Resident #2's care) called Nursing Supervisor #1 to evaluate Resident #2's left arm because of complaints of pain in the arm. Nurse Supervisor #1 said that she looked at the arm, and was concerned of a possible fractured arm and called the Physician Assistant. Nursing Supervisor #1 said she told the Physician's Assistant that Resident #2 fell and she (Nursing Supervisor #1) was concerned that Resident #2's left arm was fracture. Nursing Supervisor #1 said that she did not report to the Physician's Assistant that Resident #2 vomited 8 minutes after the fall, or that Resident #2 had a headache, and was drowsy because she was not informed of these changes. Nursing Supervisor #1 said she thought that normally after a fall, neurological assessments were done at the time of the fall, and then every 4 hours afterwards. The Situation Background Assessment Recommendation (SBAR) sheet, dated 7/25/15, indicated that the situation for Resident #2's change in condition at the time of transfer was left arm pain. The Ambulance trip report indicated at 2:04 A.M. on 7/25/15 , the ambulance was called for transport to the hospital. This was approximately one hour and 34 minutes after Resident #2 first had symptoms of increased intracranial pressure. Resident #2 was transferred to the hospital. The hospital record indicated that the Resident #2 presented with a depressed level of consciousness at arrival. A computerized tomography (CT) scan of the head, dated 7/25/15, indicated Resident #2 sustained multiple acute subdural (bleeding within the brain) hemorrhages.