Every finding on record at Blueberry Hill Rehabilitation and Healthcare CTR

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, 1. For Resident #134 who was diagnosed with Influenza Type A, the facility failed to ensure staff implemented precautions after entering and exiting a room identified as being on contact precautions.2. Failed to, ensure nursing staff disinfected a blood glucose monitor after use.3. Failed to, ensure nursing staff performed hand hygiene appropriately during the medication administration task.Findings include:Review of the facility policy titled Influenza, Prevention and Control of Seasonal, dated March 2022, indicated the following: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza.-The prevention of seasonal flu outbreaks is a coordinated effort which is organized by the infection preventionist and overseen by the medical director.Infection Precautions-Visual alerts (e.g., signs, posters) are posted at the entrance to and in common areas of the facility to provide residents, visitors and staff with instructions about respiratory hygiene and cough etiquette. Instructions include:a. how to use facemask or tissues to cover nose and mouth when coughing or sneezing and to dispose of contaminated items in waste receptacles; andb. how and when to perform hand hygiene.-Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement. Review of the facility policy titled Enhanced Barrier Precautions, dated as revised April 2025, indicate the following:-Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents.-Example of high contact resident care activities requiring he use of gown and gloves for EBP's include:h. prolonged, high-contact with items in the residents' room, with resident equipment, or with resident's clothing or skin.-Signs are posted at the door or wall outside the residents room which communicate the type of precautions and PPE required. Review of the facility policy titled Personal Protective Equipment', dated as revised July 2009, indicated the following:-Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin.-Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed.-The use of gloves will vary according to the procedure involved. The use of disposable gloves in indicated:a. when it is likely that the employee's hand will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure;d. when handling soiled linen or items that may be contaminated;g. during invasive procedures;-Wash your hands after removing gloves.1. Resident #134 was admitted to the facility in December 2025 has diagnosis including Influenza due to identified novel influenza A, a virus with other respiratory manifestations (a contagious respiratory illness), acute respiratory failure with hypoxia, congestive heart failure, and type two diabetes mellitus.Review of the medical record indicated Minimum Data Set assessment had not been completed as of the date of this survey as the Resident was a new admission.Review of the hospital Discharge summary dated [DATE] indicated Resident #134 tested positive for Influenza Type A on 12/5/25.Review of Resident #134's medical record indicated physician's orders indicated the following:-Droplet Precautions for flu every shift, dated 12/10/25.-Contact Precautions for flu, dated 12/11/25.On 12/10/25 at 11:10 A.M., the surveyor observed Resident #134 sitting up in bed, the Resident could be heard coughing, the Resident's door was open, there was a sign on the door indicating droplet precautions, and a cart containing Personal Protective Equipment (PPE) was located outside the door.On 12/10/25 at 11:27 A.M., the surveyor observed the Admissions Director enter Resident #134's room without wearing gloves and was wearing a regular facemask. The Admissions Director was observed touching Resident #134's personal items located on his/her overbed table and picked up a pile of soiled linens off the bed with her bare hands and placed them on the floor. The admissions director then obtained gloves from a box inside of the room and was observed donning (apply) gloves, without performing hand hygiene. The Admissions Director was observed picking up a folder with her contaminated gloved hands and placing it on the empty bed located in the room and then picked up the soiled linen off the floor and placed the linen into a trash bag and proceeded to touch the outside of the bag with her contaminated gloves. The Admissions Director was observed removing her contaminated gloves by touching the inside of the gloves with her contaminated hands and did not perform hand hygiene after removing her gloves. The surveyor then observed the Admissions Director touch Resident #134's overbed table and call light with her bare contaminated hands. The Admissions Director then picked up a folder with her bare hands and walked out of Resident #134's room wearing a gown and regular face mask and was observed removing her gown and facemask as she walked down the hall. Pieces of the plastic blue gown had fallen to the ground as she tore off the waist ties.On 12/10/25 at 11:27 A.M., the surveyor observed the Admissions Director walking back into Resident #134's room without donning PPE and was observed obtaining a folder from the second bed located in the Resident's room. The Admissions Director walked out of the room and did not perform hand hygiene.During an interview on 12/10/25 at 11:31 Certified Nursing Assistant (CNA) #3 and said Resident #134 is a new admission who just came in and is positive for Influenza and is on isolation precautions.During an interview on 12/10/25 at 11:38 A.M., the Infection Preventionist (IP) said she doesn't know much about Resident #134 because he/she is a new admission and said the admission Director should have worn PPE as the Resident is on precautions because he/she is positive for influenza and is on isolation precautions. The IP said staff can wear a regular face mask and do not need an N95 mask (fitted filtered mask that reduces the spread of viruses). During an interview on 12/11/25 at 8:32 A.M. the Admissions Director said she knew Resident #134 was positive for the flu and should have followed the sign for precautions when entering the room and put on gloves and removed PPE before leaving the room. The Admissions Director said she should have performed hand hygiene before putting on and after removing her gloves.During an interview on 12/11/25 at 9:15 A.M., the Director of Nurses said we would want Resident #134 on droplet precautions as he/she is symptomatic and requires additional doses Tamiflu (medication to treat influenza), and staff must always follow infection control guidelines for hand hygiene and PPE precautions. The DON said staff can keep the door open and said staff can wear a regular face mask and do not need to wear an N95 mask when caring for Residents who are positive for Influenza.1b. On 12/12/25 at 6:41 A.M., the surveyor observed Resident #134 in bed, the Resident could be heard coughing, the door to the Resident room was open and a new sign was hanging on the outside door and was changed to Isolation Precautions indicating N95 mask must be worn.On 12/12/25 at 8:43 A.M. the surveyor observed Resident #134's door open. Certified Nursing Assistant (CNA) #2 was observed entering Resident #134's room wearing a gown, face shield, and a regular facemask that was covering her chin leaving her mouth exposed and entered Resident #134's room touching the overbed table with her ungloved bare hand. CNA #2 was not wearing gloves. CNA #2 could be seen talking with Resident #134 and Resident #134 could be heard coughing from the hallway and the Resident was not wearing a facemask. CNA #2 was observed walking out of the resident's room wearing PPE and used her ungloved potentially contaminated hand, to open the PPE cart located outside of the room in the hall and obtained an N95 facemask. CNA #2 was observed removing the potentially contaminated face shield with her bare hand, and donned the N95 mask, placing it over the regular facemask that was still applied to her face covering her chin. The N95 mask was applied directly over the regular facemask and did not contain a tight seal. CNA #2 then picked up the potentially contaminated face shield with her bare hands and placed it over her head. Without performing hand hygiene CNA #2 then donned gloves and re-entered Resident #134's room and was observed touching items on Resident #134's bed and overbed table. CNA #2 was then observed removing her gown, gloves, face shield and N95 mask in the doorway and exited the room still wearing the regular facemask that was applied to her chin exposing her mouth and proceeded to walk down the hall.During an interview on 12/12/25 at 9:04 A.M., CNA #2 said the resident was on precautions and the sign said to use an N95 mask. CNA #2 said she was not sure why the resident was on precautions, but she put on an N95 mask to follow the instructions.During an interview on 12/12/25 at 10:31 A.M., the Director of Nurses (DON) said staff must follow the guidelines for infection control and said the CNA should not have worn the N95 mask over the regular mask. During an interview on 12/17/25 at 2:13 P.M., Physician #2 said infection control guidelines are to be followed to reduce the spread of infection and said staff must follow enhanced barrier precautions and contact precautions when providing care. Physician #2 said he expects all staff to wear appropriate PPE including an N95 mask appropriately when caring for a resident with influenza. 2. The facility failed to ensure nursing staff disinfected a blood glucose monitor after use.-On 12/17/25 at 7:52 A.M., the surveyor observed Nurse #4 remove a black bag from a drawer located in the medication cart, containing a glucometer, several lancets, and alcohol prep pads. Nurse #4 placed the black bag on top of a cart containing Personal Protective Equipment (PPE) located in the hall outside the Resident's door. There was a sign located outside the door indicating the Resident was on Enhanced Barrier Precautions. Nurse #4 put on a gown, facemask and gloves, picked up the black bag and entered the Resident's room and placed the black bag directly on top of his/her uncleaned overbed table. Nurse #4 obtained the Resident's blood sugar and immediately put the glucometer back into the black bag without cleaning it and potentially contaminating the contents of the bag. Nurse #4 used her contaminated gloved hand to zip up the black bag and then proceeded to use her contaminated gloved hand to remove her personal cell phone from her pocket to check the time on her phone and place the phone back into her pocket. Nurse #4 then removed her gloves, did not perform hand hygiene, and picked up the black bag with her ungloved potentially contaminated hands and proceeded to walk toward the Resident's door. Nurse #4 used one hand to remove gown and mask while holding on to the black bag and proceeded to exit the room without performing hand hygiene. Nurse #4 walked out of the room and returned to the medication cart. Using her potentially contaminated hands Nurse #4 touched the keys to the medication cart and used her bare hands to open the drawer to the cart and placed the black bag back into the drawer of the medication cart.3. The facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task.On 12/17/25 8:03 A.M., Nurse #4 placed an insulin pen on top of a cart containing (PPE) located in the hall outside the Resident's door. There was a sign located outside the door indicating the Resident was on Enhanced Barrier Precautions. Nurse #4 was observed donning (applying) a pair of gloves only and entered the Resident's room without wearing a gown or mask. Nurse #4 then touched the Residents' blankets, clothing and skin area to expose the injection site, cleansed the area with alcohol and administered the insulin injection. Nurse #4 then touched the Resident's clothing covering up the injection area and removed her gloves by touching the contaminated glove with her bare hand, and without performing hand hygiene after discarding the contaminated gloves. Nurse #4 then carried the insulin pen into the hallway with her bare hand. Nurse #4 placed the insulin pen on top of the medication cart. Nurse #4 did not perform hand hygiene during this observation.On 12/17/25 at 8:09 A.M., Nurse #4 was observed donning (applying) a pair of gloves and administered an insulin injection. Nurse #4 then touched the Resident's clothing covering up the injection area and removed her gloves by touching the contaminated glove with her bare hand, and without performing hand hygiene after discarding the contaminated gloves. Nurse #4 then carried the insulin pen into the hallway with her bare hand. Nurse #4 placed the insulin pen on top of the medication cart. Nurse #4 did not perform hand hygiene during this observation.During a medication observation on 12/17/25 at 8:39 A.M., the surveyor observed Nurse #4 administer insulin to a Resident then doffing (removing) her gloves, touching the contaminated glove with her bare hand, and without performing hand hygiene after discarding the contaminated gloves. Nurse #4 then used her ungloved hands to touch the Resident's clothing and personal items on the over bed table and exited the Resident's room carrying the insulin syringe with her bare hands. Nurse #4 was observed placing the insulin syringe directly on top of the medication cart, performed hand hygiene, then picked up the contaminated insulin syringe and needle with her bare hands and discarded them in the sharp's container located on the side of the medication cart. Nurse #4 then touched her computer and keyboard and did not perform hand hygiene.During an interview on 12/17/25 at 8:54 A.M., Nurse #4 said she cleans the glucometer after she is finished obtaining blood sugars and administering insulin to residents. Nurse #4 said she should have cleaned the glucometer with the bleach wipes and said she should have performed hand hygiene before and after removing her gloves and should not have touched items with her bare hands.During an interview on 12/17/25 at 8:59 A.M., Unit Manager #1 said staff must ensure the glucometer is cleaned before and after each use with bleach wipes and said staff must perform hand hygiene before and after glove removal and not touch items with their contaminated hands.During an interview on 12/17/25 at 11:18 A.M., the Infection Preventionist (IP) said she expects staff to follow all infection control guidelines when administering insulin and performing proper hand hygiene and when putting on or taking off gloves. The IP said staff must clean the glucometer between each use with the proper bleach wipes to reduce the risk of cross contamination.During an interview on 12/17/25 at 10:45 A.M., the Director of Nurses (DON) said staff must follow infection control guidelines and clean the glucometer before and after use and said hand hygiene must be performed before and after glove use. The DON said staff should not be placing items on residents' overbed tables and should not be touching items with contaminated gloves.During an interview on 12/17/25 at 10:49 A.M., the Regional Clinical Director said the glucometer bag should not have been brought into the room and placed on the Resident's overbed table and said staff must use approved bleach wipes to clean and disinfect shared equipment. She expects all staff to follow infection control guidelines for proper cleaning and disinfection and said not following recommendations could increase the risk of blood borne pathogens between residents if equipment is not properly cleaned in between use.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to 1.ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, when two insulin pens were observed unlabeled during the medication pass observation and 2. failed to ensure staff secured medications as evidenced by leaving a syringe with insulin unattended on top of a medication cart on the [NAME] unit. Findings include:Review of the facility policy titled Medication Labeling and Storage, dated as revised February 2023, indicated the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. -Medications are stored separately from food and are labeled accordingly. -Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. -The medication label includes, at a minimum: a. medication name (generic and/or brand b. prescribed dose; c. strength; d. expiration date; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. -If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. Review of the facility policy titled Administering Medications, dated as revised April 2019, indicated the following: -Insulin Pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verified that the correct pen is used for that resident. 1.During the medication pass observation Nurse #3 was observed drawing up insulin to administer during the morning medication pass. Nurse #3 removed a clear bag from the medication cart, and the following medications were inside: -One Novalog Insulin Aspart Injection FlexPen. The medication was open, dated and unlabeled. There was no resident name identified. -One Lantus SoloStar (insulin glargine) Injection Pen. The medication was open, dated and unlabeled. There was no resident name identified. During an observation and interview on 12/17/25 at 8:29 A.M., the surveyor asked Nurse #3 how she identifies the two insulin pens belonging to Resident #34 and she said because his/her name is written on the plastic bag. Upon inspection of the plastic bag, the surveyor and Nurse #3 observed partial letters of Resident #9's last name handwritten in faded black ink. The bag did not contain the residents' full name or any other identifying information. Nurse #3 observed each insulin pen and said there should be resident labels on each pen, but they are missing. During an interview on 12/17/25 at 8:42 A.M., the Unit Manager said she would expect the medications to labeled appropriately with the Residents information. During an interview on 12/17/25 at 11:45 A.M., the Director of Nurses said medications must be dated and labeled appropriately to identify the correct medication for each Resident. 2. On 12/15/2025 at12:09 P.M., the surveyor observed a syringe filled with liquid on top of a medication cart on the [NAME] unit. There were multiple staff walking by and residents in the area as the lunch trays were being passed. The surveyor moved the syringe to read how full of fluid it was, (1.2 ml), and the orange cap rolled away exposing the sharp. The surveyor then called over Nurse #2 who was down at the end of the hallway. Nurse #2 said it was her medication cart, and she needed to waste the contents of the syringe. Nurse #2 said that syringe was filled with insulin and she should not have left the sharp on the top of the medication cart unattended. During an interview on 12/15/2025 at 12:20 P.M., the Director of Nursing (DON) said that nurses should not leave medications and sharps unattended.

Based on observation, record review and interview, the facility failed to ensure follow-up dental services were provided for one Resident (#121) out of a total of 36 sampled residents. Specifically, the facility failed to ensure Resident #121 received dental exams every six months as recommended by the dentist. Findings include:Resident #121 was admitted to the facility in September 2023 with diagnoses including Alzheimer's Disease, anemia and asthma.Review of the Minimum Data Set (MDS) assessment, dated 9/15/25, indicated Resident #121 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS also indicated that Resident #121 required partial to moderate assistance with functional daily tasks and had not exhibited any behaviors related to rejection of care. On 12/10/25 at 9:48 A.M., the surveyor observed a moderate amount of white substance on Resident #121's bottom teeth. Resident #121 stated to the surveyor that he/she had seen the dentist since being admitted to the facility but had not seen the dentist in a long time and would like to see the dentist again. Review of Resident #121's oral health care plan dated 9/21/23, indicated the following interventions:-Coordinate arrangements for dental care as ordered and as needed.-Monitor/document/report to physician as needed signs/symptoms of oral/dental problems needing attention such as eroded, decayed and debris in mouth. Review of Resident #121's medical record indicated a consent dated 8/9/25 indicating the Resident wanted to receive contracted dental services. Review of Resident #121's medical record indicated the Resident was seen by the dentist on 12/22/23 indicating the following: -Poor condition of teeth.-Moderate soft plaque/food debris buildup.-light hard calculus deposits.-Recommended treatment: annual exam dated 12/22/24 and follow up exams every 6 months. Further review of the medical record failed to indicate the following:-Recommended exams every 6 months from initial exam on 12/22/23.-Scheduled annual exam dated 12/22/24.-Refusals of dental services by Resident #121. During an interview on 12/15/25 at 1:34 P.M., the Building Clerk said when a resident is admitted , consent for contracted services is signed and the resident is added on a list to be seen by the selected discipline. She stated that visits from all services provided are automatically uploaded to the medical record for the residents who have been seen. She said that an email is sent out 3 weeks to a month indicating the scheduled discipline and the residents scheduled to be seen. During a follow up interview on 12/16/25 at 1:43 P.M., the Building Clerk said the contracted service provider keeps track of how many visits the residents require. She stated the facility went paperless and she did not have consents to reference services selected for the residents who have been in the facility for a long time. She stated that the family for Resident #121 had requested him/her to be seen by the dentist in August 2025 and a new consent for the contracted services were signed at that time. The Building Clerk was unable to articulate her tracking methods for follow up recommendations by the dentist for the residents who have been in the facility long-term. During an interview on 12/16/25 at 2:43 P.M., the Director of Nurses (DON) said she expects the facility to keep track of services provided to the residents by the contractors and follow up with their recommendations.

Based on observation, record review and interview, the facility failed to provide behavioral health services for one Resident (#35) out of a total of 36 sampled Residents. Specifically, for Resident #35, the facility failed to a. ensure Resident #35 was seen by behavioral health services timely, and b. failed to implement medication change recommendations by the psychiatric Nurse Practitioner timely. Findings include:Review of the facility's Behavioral Health Services Policy dated as revised February 2019 indicated:Policy Statement: 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation: 1. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. Resident #35 was admitted to the facility in July 2025 with diagnoses including unspecified dementia and major depressive disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #35 scored 5 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired. The MDS also indicated that Resident #35 experienced hallucinations and verbal behaviors. The MDS also indicated Resident #35 receives antipsychotic medications and antidepressant medications. a. Review of the Hospital Discharge paperwork dated 7/24/25 indicated: Discharging to [facility] where he/she will be followed psychiatrically DX: Major neurocognitive disorder with behavioral disturbance. Target symptoms: physical and verbal agitation, combativeness, anxiety, change in mental status and increased confusion. Review of the Nurse Practitioner's note dated 7/28/25 indicated: admitted to [facility] for long term care placement s/p (status post) lengthy geri-psychiatric hospitalization. Staff reporting appetite is poor. Not sleeping at night, sleeps during the day. Aggressive with redirection. Plan: Follow up with behavioral health. Review of Resident #35's physicians orders indicated: Consult psychiatric and/or psychology services as needed, 7/25/25.Review of Resident #35's care plan dated 7/28/25 indicated: Focus: I have mood problem r/t dementia. I scream, yell out, curse, I have delusions, I can get teary, anxious, continuously try to stand from wheelchair - staff have to provide continuous supervision because I am not aware of safety precautions. Interventions: Behavioral health consults as needed (psychiatry, psychology and/or Spiritual services). Review of the Consultant Pharmacist MRR (Monthly Record Review) Recommendation to Prescriber form dated 9/9/25 indicated: This resident receives Haloperidol, Sertraline and Trazodone. Please consider a psych consult for review of appropriateness of medications and/or possible decrease in dosage if you feel warranted at this time. Please indicate rationale if you feel not needed below.The 9/9/25 form failed to indicate the physician reviewed the recommendation and had handwritten note indicating: Conservator granted 5/2025. Conservator applied for MassHealth/Medicaid pending. Will sign consent for HD/psych (HCP) when approved. Review of the Consultant Pharmacist MRR (Monthly Record Review) Recommendation to Prescriber form dated 10/10/25 indicated: This resident receives Haloperidol, Sertraline and Trazodone. Please consider a psych consult for review of appropriateness of medications and/or possible decrease in dosage if you feel warranted at this time. Please indicate rationale if you feel not needed below.The 10/10/25 form indicated a psych referral was requested. Review of the clinical record indicated Resident #35 was not seen by Behavioral Health Services until 11/6/25; approximately 104 days after Resident #35's admission to the facility. During an interview on 12/15/2025 at 11:31 A.M., The Director of Nursing (DON) said she was unsure why there was a delay in behavioral health services seeing Resident #35, but it may have been related to Resident #35 being private pay at the time or obtaining consents from the Resident's conservator. During an interview on 12/15/2025 at 11:59 A.M., the Assistant Director of Nursing (ADON) said that Resident #35 could not be seen by behavioral health services until he/she was covered by MassHealth and she called Resident #35's appointed health care proxy to obtain verbal consent for behavioral health services.During an interview on 12/15/2025 at 12:46 P.M., Physician #1 said that he would expect residents with a psych history and recent psychiatric hospitalization to be involved with behavioral health services upon admission to the facility. During an interview on 12/15/2025 at 1:38 P.M., Social Worker #1 said that residents with a psychiatric history are signed upon admission to be seen by behavioral health services. Social Worker #1 said that consent forms need to be signed and once the forms are signed, they are automatically added to the list to be seen by behavioral health services. Social Worker #1 said that Resident #35's daughter is his/her activated healthcare proxy visits the facility and is involved in his/her care. Social Worker #1 said she was not aware that Resident #35 was not seen by behavioral health services until November 2025 when he/she was admitted to the facility in July 2025. On 12/15/2025 at 2:13 P.M., Resident #35 was observed seated in the activity room away from the large group and fidgeting with items on the table in front of him/her. Resident #35 was unable to engage in the interview process. Certified nurse aide (CNA) #1 and Nurse #1 were present. CNA #1 said that Resident #35 is very behavioral and often panics or goes to stand up from his/her chair constantly. Nurse #1 said that Resident #35 was having a good day today and that he/she has been slightly better since behavioral health services became involved in his/her care. During an interview on 12/16/2025 at 4:15 P.M., Family Member #1 said that she is Resident #35's activated health care proxy and was not aware that Resident #35 had not been seen behavioral health services until November 2025. Family Member #1 said that when Resident #35 was hospitalized he/she had a lot of communication with the psychiatrist at the hospital but felt that she did not receive a lot of communication from the facility unless it was to change Resident #35's medications or if something like a fall occurred. During an interview on 12/16/2025 at 8:33 A.M., Social Worker #1 said that Resident #35 had a delay in behavioral health services because the facility was waiting on a consent form from the health care proxy. The Social Worker and Director of Nursing (DON) said that staff should be documenting attempts to reach families regarding signed consents, and she believed the ADON called and received verbal consent for behavioral health services from the health care proxy on 10/30/25. Review of the clinical record failed to indicate any attempts were made by staff to alert Family Member #1 of the need to obtain consent to receive behavioral health services.During an interview on 12/17/2025 at 8:19 A.M., Nurse Practitioner #1 said that she believed all residents, especially residents on antipsychotic medications are involved in Behavioral Health services upon admission to the facility. Nurse Practitioner #1 said she assumed Resident #35 was being seen by Behavioral Health Services upon admission and was not aware that he/she had not been seen until November 2025. b. Review of the Behavioral Health Service note dated 11/13/25 indicated: Problem: Requested to be seen by staff due to increased anxiety and agitation. [Resident] states his/her name, then says I don't know to all other questions regarding mood, anxiety, sleep. Staff endorse worsening restlessness. Plan/Recommendations: Trazadone Hydrochloride, add as needed trazodone 25 mg twice daily for 14 days for anxiety (continue standing order for trazodone). Sertraline Hydrochloride, increase sertraline to 100 mg daily for depression and anxiety. Review of the Behavioral Health Service Note dated 11/20/25 indicated: Problem: Requested to be seen by staff for increased anxiety, agitation, and combative behaviors, (combative behaviors were not documented on the previous behavioral health visit). [Resident] states I'm okay denies depression and anxiety at this time. Staff endorse worsening restlessness. Plans/recommendations: Sertraline Hydrochloride, increase sertraline to 100 mg daily for depression and anxiety. Trazodone Hydrocholoride, initiated as needed trazodone 50 mg twice daily for 14 days, (the same recommendations as the previous visit with an increase in the dosage of the trazodone.) Review of the physician orders failed to indicate the recommendations for a PRN dose of trazadone or the increase of the Sertraline per the behavioral health nurse practitioner until 11/20/25. Review of the clinical record indicated Family Member #1 had signed consent forms dated 7/25/25 indicated Resident #35's healthcare proxy agreed to the use of 25-200 MG of Sertraline and 12.5-400 mg of Trazodone daily.During an interview on 12/16/2025 at 8:04 A.M., Nurse #1 said that when psych services make medication change recommendations, they write it in their notes, and the DON inputs it in the system. Nurse #1 said staff also have to alert the family and obtain a new consent form if needed. Nurse #1 said that the process is usually very quick and the orders for medication changes are usually ready by the next medication pass. During an interview on 12/16/2025 at 8:33 A.M., the Director of Nursing (DON) said that medication recommendations from behavioral health services are communicated to nursing staff, families are notified and orders are verified with the attending physician. The DON said after orders are verified a consent is obtained and the order is implemented. The DON said that the timing can be variable when the medication changes are fully implemented.

Based on observation, interviews, and records reviewed, the facility failed to meet professional standards of practice for three Residents (#7, #8, and #34) out of a total sample of 36 residents. Specifically: the facility failed to implement physician orders for insulin administration prior to the breakfast meal. Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Review of the facility policy titled Administering Medications, dated as revised March 2025, indicated the following:-Medications are administered in a safe and timely manner, and as prescribed.-Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.-Medications are administered in accordance with prescriber orders, including any required time frame.-Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).-The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next one. 1.Resident #7 was admitted to the facility in February 2025 with diagnoses including type two diabetes, chronic kidney disease stage three, heart failure, and vascular dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/10/25, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicting severe cognitive impairment.On 12/11/25 at approximately 7:45 A.M., the surveyor reviewed physician orders for blood sugar checks and insulin administration on the [NAME] unit. On 12/11/25 the following observations were made on the [NAME] Unit:-At 7:45 A.M., the surveyor observed Unit Manager #1 on the [NAME] unit medication cart obtaining report from the overnight nurse. -At 8:12 A.M. the surveyor observed Unit Manager #1 assisting with the breakfast cart passing out trays.-At 8:49 A.M., breakfast carts had arrived, and all breakfast meal trays were delivered and set up was completed. Residents on the unit were observed eating breakfast in their rooms and in the dining room.-On 12/11/25 at 8:15 A.M., the surveyor observed Resident #7 sitting up in bed eating his/her breakfast meal while being assisted by a staff member. Review of the active physician orders for Resident #7 indicated the following:NovoLOG Injection Solution Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 under 70 or over 400 CALL NP/MD (Nurse Practitioner/Medical Doctor), subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Nephropathy. Start Date: 8/14/25. Scheduled for 8:00 A.M., 11:00 A.M., and 4:00 P.M.Review of Resident #7's Electronic Medical Record (EMAR) at 8:40 A.M., failed to indicate the blood sugar was completed and contained no documentation.Review of the administration history report indicated the medication was not documented as administered until 9:14 A.M., after the breakfast meal. 2.Resident #8 was admitted to the facility in May 2022 with diagnoses including type two diabetes, chronic kidney disease, asthma and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 10/6/25, indicated Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition.On 12/11/25 at 8:50A.M., Resident #8 was observed sitting up in bed eating his/her breakfast meal. Resident #8 said he/she has not received any morning medications including insulin.Review of the active physician orders for Resident #8 indicated the following:-NovoLOG FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart). Inject 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold Novolog insulin 5 units with meals if fasting blood sugar is less than 100 and notify provider. Start Date: 6/6/25. Scheduled for 8:00 A.M., 11:00 A.M., and 4:00 P.M.Review of Resident #8's Electronic Medical Record (EMAR) at 10:04 A.M., failed to indicate the blood sugar was completed and contained no documentation.Review of the administration history report indicated the medication was not documented as administered until 11:08 A.M., after the breakfast meal.During an interview on 12/11/25 at 9:04 A.M., the Medical Director said nurses must ensure blood sugar checks and insulin orders are to be administered as ordered and said he expects residents to have blood sugars and insulin administered prior to meals as indicated per the physician orders. During an interview on 12/11/25 at 8:57 A.M., Unit Manager #1 who was assigned to work on the medication cart, said she had not administered any medications and had not obtained any blood sugar checks. Unit Manager #1 said she does not know which residents need to have blood sugars checked and has not reviewed the lab values in the electronic medical record yet as she obtained report from the overnight nurse around 7:45 A.M. During an interview on 12/12/25 at 10:35 A.M., Unit Manager #1 said she did not administer the insulins before the breakfast meals.During an interview on 12/12/25 at 10:37 A.M., the Director of Nurses said she expects orders to be followed and said she expects staff to obtain blood sugar levels when they are ordered and insulin to be administered prior to meals being served.3. Resident #34 was admitted to the facility in August 2024 with diagnoses including type two diabetes, chronic kidney disease stage three, hypertension and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 11/7/25, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition.On 12/17/25 at 8:28A.M., Resident #34 was observed sitting up in bed eating his/her breakfast meal. Resident #34 said he/she has not received any morning medications including insulin.Review of the active physician orders for Resident #34 indicated the following:-NovoLOG Injection Solution 100 UNIT/ML Inject 3 unit subcutaneously before meals for Type 2 Diabetes. Notify MD if glucose is over 200. Hold if no starch/carbs with meals. Start Date: 9/9/25. Scheduled for 8:00 A.M., 11:30 A.M., and 4:00 P.M.-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ Call NP/MD, subcutaneously before meals for DMII (Diabetes Mellitus type two) Notify MD of glucose greater than 400. Start Date: 3/11/25. Scheduled for 8:00 A.M., 12:00 P.M., and 4:00 P.M.During a medication pass observation on 12/17/25 at 8:58 A.M., Nurse #3 prepared to administer Insulin to Resident #34. Resident #34 was sitting up in bed eating the breakfast meal.During an interview on 12/17/25 at 9:00 A.M., Nurse #3 said she should have administered the insulin prior to the breakfast meal as ordered.During an interview on 12/17/25 at 11:45 A.M., the Director of Nurses said insulin must be administered prior to the breakfast meal and said she expects nurses to follow physician orders to ensure medications are given on time as ordered.

Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for one Resident (#9) out of a total sample of 36 residents. Specifically, for Resident #9, the facility failed to develop a psychotropic medication care plan. Findings include:Review of the facility policy titled Care Plans, Comprehensive Person-Centered', indicated but was not limited to the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care play for each resident.-The comprehensive, person-centered care plan is developed withing seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.-The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.e. reflects currently recognized standards of practice for problem areas and conditions.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition b. when the desired outcome is not met c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. Resident #9 was admitted to the facility in January 2024 with diagnoses including type two diabetes mellitus, hypertension, and depression. Review of Resident #9's most recent Minimum Data Set (MDS) assessment, dated 11/11/25, indicated Resident #9 had no cognitive impairment as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Further review of the MDS indicated the use of antipsychotic medications daily.Review of Resident #9's physician orders indicated the following:*Aripiprazole (an antipsychotic medication) 7.5 MG (milligrams) at bedtime for anxiety and depression. Start Date 10/16/25.Review of October 2025 through December 2025 Medication Administration Records (MAR) indicated Aripiprazole was administered as ordered by the physician.Review of Resident #9's comprehensive care plans failed to indicate a care plan had been developed for the use of Aripiprazole that identified resident-specific symptoms or targeted behaviors, resident-specific interventions, including non-pharmacological approaches, and measurable goals of treatment to meet the Resident's needs.During an interview on 12/16/25 at 8:39 A.M., the Director of Nursing said the care plans should include the use of antipsychotic medications and should be personalized and individualized to meet the residents' needs and keep them safe.

Based on record review and interview, the facility failed to ensure it reported an allegation of abuse to the state agency for one Resident (#18) of 36 sampled residents. Findings include:Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, indicated, but was not limited to:Investigate and report any allegations within timeframes required by federal requirements.Resident #18 was admitted to the facility in October 2022 and has active diagnoses which include schizoaffective disorder, major depressive disorder, recurrent, severe with psychotic features, anxiety disorder, and urinary incontinence.Review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE] indicated he/she was incontinent of bowel and bladder, exhibited behavioral disturbances, and a Brief Interview for Mental Status exam score of 10, signifying moderate cognitive impairment.Review of Resident #18's care plan dated 3/11/24 indicated he/she exhibits paranoia, makes accusatory statements and reports false information. The care plan (dated 10/29/22) indicated the Resident has bowel and urinary incontinence and he/she obsesses over wipes and stays on the toilet for long periods of time.During an interview on 12/10/25 at 9:23 A.M., Resident #18 said that yesterday and this morning, during the 11:00 P.M. to 7:00 A.M. shift, an unidentified member of the nursing staff turned the bathroom lights on and off while she was using the toilet and tried to rush him/her. Resident #18 said the staff member entered the bathroom and pushed him/her off the toilet. Resident #18 said the staff member wanted him/her to stop using the wipes and physically struggled with him/her over the wipes.Following the interview, on 12/10/25 at approximately 9:30 A.M., the surveyor told Nurse #3 (nurse assigned to the Resident) that Resident #18 alleged that yesterday and this morning a staff member pushed him/her off the toilet and they struggled over toilet wipes. Nurse #3 said he would immediately interview Resident #18 and inform management of the alleged incident.During an interview on 12/10/25 at 12:15 P.M., Nurse #3 said Resident #18 told him that for the past couple of days during the 11:00 P.M. to 7:00 A.M. shift, an aide was rough with him/her while in the bathroom. Nurse #3 said Resident #18 told him that the aide was fighting over placing used wipes in a bag. Nurse #3 said Resident #18 told him the aide pushed him/her while still sitting on the toilet and that the aide grabbed the bag from him/her. Nurse #3 said he told management about the alleged incident. Review of the Facility's grievance binder and the state agency's Health Care Reporting System on 12/15/25 at 10:01 A.M. indicated there was no report of the alleged incident. During an interview on 12/15/25 at 10:39 A.M., Resident #18 said he/she did not recall the alleged incident, or reporting to staff of an incident.On 12/15/25 at 10:45 A.M., the Director of Nurses and Administrator said no one reported that Resident #18 alleged a staff person pushed him/her off the toilet. The DON said that pushing a resident off the toilet rose to the level of an allegation of abuse. The DON and Administrator said they would begin an abuse investigation immediately and report the incident to the state agency. The DON said it was the facility's policy for all allegations of abuse to be immediately reported to administration and the state agency.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 12/25/24, Resident #1 was administered his/her scheduled medications in the morning by his/her assigned nurse and then Nurse #1, administered another resident's medications to Resident #1 in error. Several hours later Resident #1 experienced a significant change in condition, was disoriented and became lethargic, was transferred to the Hospital Emergency Department (ED), and was admitted to the Hospital for four days due to an accidental drug overdose. Findings include: The Facility Policy, titled Medication Errors, dated 09/2021, indicated all medication errors would be immediately reported to the resident, the resident's responsible party, and the prescriber, and also indicated medication errors were defined as one of the following: -Failure to administer a medication -Administration of the wrong medication -Administration of the wrong amount of medication -Failure to administer a medication at the prescribed time -Administration to the wrong resident -Administration through the wrong route. The Facility Policy, titled Administering Medications, dated 2001, indicated: - Medications would be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed times. - The nurse administering the medications would verify the resident's identity before giving the medication to him/her, and methods of identifying the resident included checking his/her identification wrist band, checking the photograph attached to his/her medical record, and if necessary, verifying the resident identification with other Facility personnel. Resident #1 was admitted to the Facility in December 2023, diagnoses included hypertension (high blood pressure), altered mental status, paranoid personality disorder, and mild neuro-cognitive disorder. Review of Resident #1's Medication Administration Record (MAR), dated 12/25/24, indicated he/she was administered the following scheduled medications between 09:00 A.M., and 10:00 A.M.: -Amlodipine (antihypertensive), 5 milligrams (mg) tablet. -Aspirin (anti platelet), 81 mg chewable tablet. -Finasteride (genitourinary agent), 5 mg tablet. -Sennosides (stool softener), 8.6 mg tablet. -Depakote (for mood regulation), 250 mg delayed release tablets, two tablets (500 mg) -Quetiapine Fumarate (antipsychotic), 25 mg tablet. Resident #2 was admitted to the Facility in July 2024, diagnoses included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) , hypertension, chronic kidney disease, and dysphagia (difficulty swallowing). Resident #2's MAR, dated 12/25/24 indicated he/she was scheduled to have the following medications administered: -Aspirin, 81 mg capsule. -Famotidine (treats heartburn), 20 mg tablet. -Invega (antipsychotic), 9 mg extended release tablet. -MagOx (magnesium oxide supplement, also used as a laxative), 400 mg tablet. -MiraLax (laxative) oral packet, 17 grams (GM). -Olanzapine (antipsychotic) 5 mg tablet. -Depakote Sprinkles 125 mg delayed release capsule, administer four capsules (500 mg). -Sennosides-Docusate Sodium (combination stool softener and laxative) tablet 8.6-50 mg. -Clonazepam (antipsychotic) 1 mg tablet. Resident #1 and Resident #2 both resided on the Hale unit of the Facility and shared a common first name, however Resident #1 used a nickname. Review of the Facility's internal investigation synopsis, undated, completed by the Director of Nurses, indicated that on 12/25/24 at 11:00 A.M., Nurse #1 administered Resident #2's morning medications to Resident #1, in error. The Synopsis indicated that on that same day at 01:00 P.M., Resident #1 was assessed as having had a change in condition, was lethargic and disoriented, and when Nurse #1 heard Nurse #2 refer to Resident #1 by another name (his/her nickname), Nurse #1 recognized that a medication error had occurred. The Synopsis indicated Resident #1 was transferred to the Hospital ED for evaluation. Review of Resident #1's Hospital ED History and Physical, dated 12/25/24, indicated he/she was transferred to the ED via 911, was somnolent and mumbling, his/her heart rate was 43 beats per minute (slow, normal heart rate range is between 60 to 100 beats per minute), and was admitted to the Hospital with diagnosis of accidental drug overdose. During a telephone interview on 02/19/25 at 10:10 A.M., Nurse #1 said that on 12/25/24 he was Resident #2's assigned nurse. Nurse #1 said that on 12/25/24 around 11:00 A.M., he prepared Resident #2's morning medication, and went to the unit dining room where several residents were in an activity, and called out Resident #2's name. Nurse #1 said a resident (later identified as Resident #1) responded to Resident #2's name. Nurse #2 said the resident resembled the picture that was in Resident #2's medical record, so he administered the medications to him/her, as he believed that he/she was Resident #2. However, Nurse #1 had actually administered Resident #2's morning medications to Resident #1, who had already been administered his/her own scheduled morning medications early that day by Nurse #2. Nurse #1 said he was not familiar with the residents on the unit, and said he did not look for an identification bracelet, because at the time, most residents did not have one anyway. Nurse #1 also said he did not ask any other staff members working on the unit to help him identify Resident #2. Nurse #1 said around 01:00 P.M. (on 12/25/24), Resident #1 was returned from the main dining room by Activities Aide #1, and that he/she was sleepy and dizzy. Nurse #1 said he heard Nurse #2 call Resident #1 by his/her nickname, said he asked Nurse #2 to clarify who Resident #1 was, and said that was when he realized he had administered Resident #2's medications to Resident #1, in error. During an interview on 02/19/25 at 10:57 A.M., Nurse #2 said that on 12/25/24 she was Resident #1's assigned nurse. Nurse #2 said she had administered Resident #1's scheduled morning medications between 09:00 A.M., and 10:00 A.M., that morning. Nurse #2 said Resident #1 had been at his/her baseline and that he/she was his/her normal self until around 01:00 P.M., when Activities Aide #1 brought Resident #1, who normally ambulated, back to the unit in a wheelchair from the main dining room. Nurse #2 said Resident #1 had a change in mental status, was lethargic and unsteady on his/her feet. Nurse #2 said when she assessed Resident #1, she called him/her by his/her preferred nickname, and that Nurse #1 then asked her to clarify who Resident #1 was. Nurse #2 said Nurse #1 then told her that he had administered Resident #2's morning medications to Resident #1 in error. Review of Resident #1's Nurse Progress Note, dated 12/25/24, indicated Resident #1 was accidentally administered Resident #2's morning medications, and later had a change in condition, became disoriented, and his/her speech was unclear. The Note indicated that Nurse Practitioner #1 was notified of the medication error, Resident #1's change in condition, and an order was obtained to transfer Resident #1 to the Hospital ED. During an interview on 02/19/25 at 08:35 A.M., the Director of Nurses (DON) said Nurse #1 should have identified Resident #2 before administering his/her medications, but had not, and instead administered Resident #2's medications to Resident #1 in error.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure they notified his/her medical provider of a medication incident, when on 12/25/24, his/her morning medications were administered well over one hour later than the prescribed times, and his/her scheduled morning and afternoon Clonazepam (antipsychotic) doses were administered at the same time. Findings include: The Facility's Policy, titled Change in a Resident's Condition or Status, dated as revised 02/2021, indicated the Facility would notify the resident's physician when there had been an accident involving the resident. The Facility Policy, titled Medication Errors, dated 09/2021, indicated all medication errors would be immediately reported to the resident, the resident's responsible party, and the prescriber, and also indicated medication errors included failure to administer a medication, administration of the wrong amount of medication, and failure to administer a medication at the prescribed time The Facility Policy, titled Administering Medications, dated 2001, indicated medications would be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed times. Resident #2 was admitted to the Facility in July 2024, diagnoses included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), hypertension, chronic kidney disease, and dysphagia (difficulty swallowing). Resident #2's Medication Administration Record (MAR), dated 12/25/24 indicated he/she was scheduled to have the following medications administered between 09:00 A.M., and 10:00 A.M.: -Aspirin, 81 milligram (mg) capsule -Famotidine (treats heartburn), 20 mg tablet -Invega (antipsychotic), 9 mg extended release tablet -MagOx (magnesium oxide supplement, also used as a laxative), 400 mg tablet -MiraLax (laxative) oral packet, 17 grams (GM) -Olanzapine (antipsychotic) 5 mg tablet -Depakote Sprinkles 125 mg delayed release capsule, administer 500 mg (four capsules) -Sennosides-Docusate Sodium (combination stool softener and laxative) tablet 8.6-50 mg -Clonazepam (antipsychotic) 1 mg tablet, administer one tablet by mouth three times daily, scheduled for 10:00 A.M., 02:00 P.M., and 06:00 P.M. During an interview on 02/19/25 at 10:10 A.M., Nurse #1 said that on 12/25/24, around 01:00 P.M., he and Nurse #2 identified a medication error, and that they had discovered that he (Nurse #1) had administered Resident #2's morning medications to another resident, in error. Nurse #1 said he then prepared Resident #2's morning medications again around 01:30 P.M., and administered Resident #2's scheduled morning medications to him/her. Nurse #1 said he also administered Resident #2's scheduled 02:00 P.M., Clonazepam 1 mg, to him/her at the same time. Nurse #1 said he did not notify Resident #2's on call medical provider of the late administration of the morning medications or that he had administered both the morning and afternoon Clonazepam doses at the same time. During a telephone interview on 02/19/25 at 12:35 P.M., Physician #1 said he would not have given Resident #2 his/her morning and afternoon medications all at one time, especially his/her two doses of Clonazepam, as the increased dose could have caused him/her to develop lethargy and to become unresponsive. Physician #1 said he would expect nursing staff to report late medication administration to the on-call medical provider to obtain new orders. During an interview on 12/19/25 at 08:35 A.M., The Director of Nurses said that on 12/25/24 Nurse #1 should have notified Resident #2's on-call medical provider of the late medication administration before administering his/her morning medications, but had not.

Based on observation, record review, and interview, the facility failed to ensure treatment and care in accordance with professional standards for 4 Residents (#323, #24, #70, and #2) out of a total sample of 39 residents. Specifically; 1. For Resident #323, the facility failed to follow up on abnormal labs that were drawn for a Resident with a known history of Chronic Kidney Disease, resulting in a subsequent panel of critically high labs, which required emergency hospitalization and resulted in death. 2. For Resident #24, the facility failed to ensure that a significant change in condition was monitored, assessed and reported timely to the physician for one resident who exhibited coffee ground emesis and continuous stooling of black liquid feces. 3. For Resident #70, the facility failed to obtain a physician's order for a wound dressing that was in place. 4. For Resident #2, the facility failed to implement orders for a known rash and failed to monitor his/her skin for further condition change, resulting in unidentified red, scaly, open wound on his/her left lower leg, requiring treatment for cellulitis and wound dressing two times a day. Findings include: 1. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - A physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. - The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. - When test results are reported to the facility, a nurse will first review the results. - If staff who receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - Nursing will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: * Whether the physician has requested to be notified soon as a result is received. * Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) * Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. * A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. * If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS also indicated Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's advanced directive care plan indicated Resident #323 was not capable of making his/her informed consent regarding his/her health care decisions. Review of the hospital admission paperwork for Resident #323, dated 6/7/24, indicated Resident #323 was admitted to the hospital with a Covid infection and family inability to care for him/her at home. Review of the lab results on the hospital admission paperwork, dated 6/7/24, indicated Resident #323 had the following lab results: -BUN: 31 -Creatinine: 1.87 -Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are 6-24 milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0.7-1.3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is 90-120 milliliters per minute.) Review of the progress notes, since admission, indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On 8/14/24, a urine culture was obtained. Review of the medical record failed to indicate why a urine culture was obtained for Resident #323. Review of the lab results, dated 8/14/24, indicated the following: - Culture 10,000-50,000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the progress note, dated 8/16/24, indicated the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the record failed to indicate if a urine sample or lab was ever obtained after 8/14/24 or any follow up documentation from the Nurse Practitioner or Physician. Review of the progress note, dated 8/24/24, indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values, specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23. The note indicated that the Director of Nursing was made aware, and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated 8/25/24, the day after the abnormal labs were obtained, indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD (chronic kidney disease): Encourage po fluids, monitor renal, monitor retention Review the record failed to indicate that any further review or action of the abnormal labs took place. Review of the progress note, dated 9/20/24, indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital summary, dated 9/19/24, indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). During an interview on 11/5/24 at 8:30 A.M., the Nurse Practitioner said she doesn't remember the Resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner could not recall if she had been notified. The Nurse Practitioner said that if a family member refuses any treatment, then that should be documented. Review of the record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on 11/5/24 at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated with intravenous fluids because his/her labs reflected dehydration. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the facility obtained Resident #323's urine for testing because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample) but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner. During an interview on 11/4/24 at 1:32 P.M., Resident #323's health care proxy said the family did not feel heard by the facility and feel that Resident #323's death could have been prevented. The health care proxy said that his/her death certificate said the cause of death was sepsis, but also felt the facility was overmedicating Resident #323. The healthcare proxy said she notified the facility to be careful with medication because of the Resident's Chronic Kidney Disease. The healthcare proxy said she felt the Resident was severely neglected. 49880 2. Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: - Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/ mental condition and or status (e.g. changes in level of care, billing/ payments, resident rights etc.) - 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (situation, background, assessment, recommendation) Communication Form. - 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status. Resident #24 was admitted to the facility in December 2014 with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On 11/4/24 at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending out Resident #24. During an interview on 11/4/24 at 8:45 A.M., Nurse #3 said that she arrived at the facility around 7:20 A.M. and was told in report that the Resident had coffee ground emesis (vomiting) during the night. She said she went right into the Resident when she got there, and he/she said they wanted to go to the hospital. At this time the ambulance company was picking up the Resident for transport to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M., when she saw him/her. During an interview and observation on 11/4/24 at 8:48 A.M., a surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go. Review of a progress note written 11/4/24 at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do lab. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] 107/77, pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP (health care proxy) was called and left a message. Review of the Patient Care Report for Resident #24 from the Ambulance service dated 11/4/24 indicated that dispatched received the call from the facility for transfer to the hospital at 8:01 A.M. on 11/4/24. The Patient Care Report indicated that the chief complaint was general illness- GI bleed for 7 hours with a primary symptom of abdominal distension. The Patient care report further indicated that the ambulance was dispatched to the facility for a patient with incontractible vomiting. (sic) The BLS (basic life support) crew arrived at the patient at 8:39 A.M. and patient found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel .Skin is pale, warm and dry. Significant distension noted on initial impression. The report further indicated, Nursing staff reported coffee ground emesis began at 1:00 A.M. that morning with 3 episodes . No vitals or assessments taken to provide EMS (emergency medical service) staff. Vital signs revealed hypotension with a blood pressure of 80/60 and weakened radial pulses. BLS crew called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI (gastrointestinal) bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. Review of Resident #24's active risk for constipation care plan, dated 12/8/2014 indicated the following interventions: - Monitor/ document/ report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low pulse) abdominal distension, vomiting, small loose stools, fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding, rigidity, fecal compaction. - I have constipation related to decreased mobility, Hx (history) of bowel obstruction, dated 2/26/24. Further review of the nursing progress note written on 11/4/24 failed to indicate a comprehensive GI (gastrointestinal) assessment or abdominal assessment. Review of the Electronic Medical Record (EMR) for Resident #24 indicated special instructions as follows: -Please document on every shift on GI (Gastrointestinal) status- appearance: distended, tenderness, flatus, BMs (bowel movements) and size, N/V (nausea and vomiting), GS/ bloating; anything clinically pertinent; behaviors- refusal of care; GU (genitourinary)- signs or symptoms of UTIs (urinary tract infections); always add effects of any PRN (as needed) medications administered during shift. Review of the medical record failed to indicate documentation regarding the resident's GI status over the last month. Review of Resident #24's progress notes indicated a note dated 11/3/24 at 4:56 P.M. which indicated that the Resident was awake and alert, able to make needs know. During an interview on 11/5/24 at 12:08 P.M., CNA #9 said that on 11/3/24 she worked the 3:00 P.M. to 11:00 P.M. shift and took care of Resident #24. She said that he/she was their usual self, ate dinner, and had no issues. She said he/she had no vomiting on her shift. During an interview on 11/4/24 at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history, Nurse #4 said that he/she does have a history of a bowel obstruction as well as a recent fall on 11/1/24. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation, that the Resident was vomiting. During a follow up interview on 11/4/24 at 9:21 A.M., Nurse #4 said Resident #24 started vomiting between 1:00 A.M., and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the emergency room . Nurse #4 said Resident #24 was not agreeable to go to the hospital earlier in the morning, however said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport between 6:00 and 7:00 A.M. and was told that it would be about one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on 11/4/24 at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During a phone interview on 11/6/24 at 9:00 A.M. the surveyor spoke to Nurse Practitioner (NP) #1 who returned a phone call regarding when phone calls were placed into the call service to report the change in condition on Resident #24. NP #1 said that she was not the one that responded to the call, but the service got one call at 1:13 A.M. with a message stating the Resident was vomiting a lot. She said this is the only call that came into the service on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 11/6/24 at 9:42 A.M., Nurse Practitioner (NP)#2 said she was the covering NP for the night of 11/3/24 into 11/4/24 and the only page she got from the facility for this Resident was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on 11/4/24 at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. During a follow up interview on 11/6/24 at 7:45 A.M., Nurse #4 said that on the night before Resident #24 was sent out it was around 1:00 A.M. that the Resident began vomiting. She said that it was coffee ground. She said that as soon as she could, she called the NP. She said that she told the NP the Resident was vomiting but could not remember if she told her that it was coffee ground. She said she did not tell the NP about the history of obstructions or GI bleeding. Nurse #4 said she only discussed the current situation. She said that the NP ordered labs and Zofran for nausea. Nurse #4 said that she gave the Resident a dose of Zofran and that he/she slept until vomiting began again around 6:00 A.M. Nurse #4 said she called the NP again at this time and an order was given to send the Resident to the hospital. Nurse #4 said the Resident agreed to go to the hospital. Nurse #4 said that she called the ambulance company and was told it would be a one to two hour wait for the transport. Nurse #4 said the Resident's vital signs were stable, so she was ok with the one to two hours wait. Nurse #4 said nurses can use their judgement and call 911 for an emergent transfer but she did not think it was necessary and said the Resident was stable. Nurse #4 said that coffee ground emesis is a change in condition and could indicate GI bleeding. During a phone interview on 11/6/24 at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on 11/3/24 into 11/4/24. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long and that both the vomit and stool was liquid and black. CNA #7 said that she provided incontinence care at least five times over night for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said she told the nurse. CNA #7 said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital and after getting the Resident cleaned and changed again at that time, she told the nurse (Nurse #4) that the Resident wanted to go to the hospital. CNA #7 said that when her shift ended, and she left the facility around 7:15 A.M. and Resident #24 was still at the facility. During an interview on 11/6/24 at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on 11/6/24 at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. She said she would not have called the covering again at any point during the shift and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical, she would have called again, but she said she did not take this as a critical situation. She said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times. She said however, she had not spoken to CNA #7, who reported to the surveyor ongoing black vomiting and black stooling throughout the night. Review of Resident #24's discharge summary from the hospital, dated 11/4/24 at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and 1600-2000 milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in May 2023, February 2024, May 2024, June 2024 and November 2024. Further, the report indicated that Resident #24 presented to the emergency department from his extended care facility with coffee ground emesis x3 and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. The discharge summary also indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. After lengthy conversation with patient and nursing at the bedside patient seems for comfort measures at end of life. He/she was requesting narcotics for abdominal discomfort . Patient was cognizant and fully intact to make this decision. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Nursing progress notes indicated the following: - A progress note dated 11/5/24 at 1:27 A.M., indicating, Patient came back from hospital on a 3-11p shift, earlier this nurse took report from the ED [emergency department] nurse stating that,' Patient had a bowel obstruction', this nurse asked the ED Nurse if patient had any surgeries to correct the obstruction, she said No, patient is coming back to the facility for comfort care admitted to Hospice. however, it is not stated in the Hospital visit, paperwork. Will F/u [follow up] with facility MD. Review of the medical record failed to indicate a comprehensive assessment was completed on Resident #24 when he/she arrived back at the facility with a diagnosis of bowel obstruction. Review of the nursing progress note dated 11/5/24 at 12:03 P.M., indicated the following: - At approximately 8:28 A.M., the resident was noted to be unresponsive. Resident did not respond to verbal or physical stimuli. There was no palpable pulse or visual chest rise/fall and no audible breath sounds. Time of death 8:29 A.M. Health care proxy notified, and body released to funeral home at 10:30 A.M. 3. Review of the facility policy titled Wound Care, dated as revised October 2010 indicated the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -1. Verify that there is a physician's order for this procedure. #70 was admitted to the facility in August 2021 with diagnoses that include type 2 diabetes mellitus with diabetic neuropathy and acquired absence of other left toe(s) Review of Resident #70's most recent Minimum Data Set (MDS) Assessment, dated 8/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #70 is cognitively intact. The MDS further indicated intact skin. During the survey the surveyor made the following observations: -On 11/3/24 at 7:39 A.M. and 11:45 A.M., Resident #70 was observed in bed, an undated dressing was observed over the left foot with staining on the dressing. At 11:45 A.M., the Resident said that she had asked for the dressing to be placed about a week ago to cover an open skin area and it has not been changed since. -On 11/4/24 at 7:58 A.M. and 11:09 A.M., Resident #70 was observed in bed with the same undated and stained dressing covering his/her left foot. -On 11/5/24 at 7:10 A.M. and 12:12 P.M. Resident #70 was observed in bed with the same undated and stained dressing covering his/her left foot. Review of Resident #70's physician's orders failed to indicate an order for a dressing change to the left foot. Review of Resident #70's most recent weekly skin check which was completed 10/4/24 indicated no skin issues noted. Review of Resident #70's progress notes failed to indicate when the dressing was applied to the left foot and why. Review of Resident #70's physician's orders indicated the following orders: -Skin Checks weekly on Monday 3-11 one time a day every Mon, 8/9/2021. -Skin Checks weekly on Tuesday 3-11 every evening shift every Tue, 4/30/2024. During an interview on 11/4/24 at 11:19 A.M., Nurse #3 said that there should be a physician's order to put a dressing on a resident. During a follow up interview and observation on 11/5/24 at 12:46 P.M., the surveyor and Nurse #3 observed Resident #70's foot and dressing. Nurse #3 said she did not know there was a dressing on Resident #70's foot. Nurse #3 said there was no order for this dressing in the medical record. Nurse #3 removed the dressing and Resident #70 said the dry scabbed area was much bigger than it was when the dressing was placed. Nurse #3 said there should have been a physician's order to apply the dressing initially and monitor the area but there was not. During an interview on 11/6/24 at 9:31 A.M., the Director of Nurses said that there should be a physician's order to apply and monitor a dressing on a resident. 36431 4. For Resident #2, the facility failed to implement orders for a known rash and failed to monitor his/her skin for further condition change, resulting in unidentified red, scaly, open wound on his/her left lower leg, requiring treatment for cellulitis and wound dressing two times a day. Resident #2 was admitted to the facility in May 2024 and has diagnoses that include chronic obstructive pulmonary disease, weakness, ventricular fibrillation, peripheral vascular disease and unspecified dementia. Review of the Minimum Data Set (MDS) assessment, dated 8/21/24, indicated Resident #2 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment. The MDS further indicated that the Resident requires partial to moderate assistance from staff for toileting, and bathing. During an observation and interview on 11/3/24 at 8:00 A.M., Resident #2's right forearm had multiple scabbed areas the size of pencil erasers and smaller reddened areas. Resident #2 said his/her feet looked worse and proceeded to take off his/her left sock revealing a scaly, red, discolored left lower extremity from the calf down. Review of Resident #2's care plans indicated the following: A care plan focus: I have potential for impaired skin integrity r/t (related to) . was blank, dated 5/22/24. Interventions included, Administer treatments as ordered and monitor effectiveness, Monitor for new or worsening s/sx (signs and symptoms) of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness fever, chills, etc. Report to physician if noted and follow-up as indicated, date initiated 5/22/24. Review of Resident #2's physician's order failed to indicate any treatment or monitoring of the Resident's lower extremity for possible worsening conditions. Review of Resident #2's medical record indicated the following: -A health status progress note dated 10/29/24 entered by nursing, Note text: Resident noted with rash, bilateral arms, feet, groin, new order to wash areas with soap and water, dry and apply antifungal cream twice daily. -A weekly skin check dated 10/30/24, are there any skin impairments noted? yes, type of skin impairment rash site 1d. groin, 2d. other specify feet, and 3d. other both hands. The weekly skin check did not indicate any areas on Resident #2's lower left leg. -The skin check dated 11/6/24 was incomplete and not signed off on the Treatment Administration Record. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 10/29/24 through 10/31/24 failed to indicate that the treatment order to wash areas with soap and water, dry and apply antifungal cream twice daily for Resident #2 were implemented. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 11/1/24 through 11/5/24 failed to indicate that the treatment order to wash areas with soap and water, dry and apply antifung[TRUNCATED]

Based on record review and interview, the facility failed to protect two Residents (#24 and #323), from neglect, out of a total sample of 39 residents. Specifically, 1. For Resident #24, the facility neglected to monitor, assess and notify the physician timely for the Resident who was found to be vomiting coffee ground emesis and exhibiting continuous stooling of black liquid. 2. For Resident #323, the facility neglected to a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss. Findings include: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The American Nurses Association (ANA), Scope of Nursing Practice, Third Edition, indicated Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misapporpriation Prevention Program, revised [DATE], indicated the following: - Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. - Develop and implement policies and protocols that prevent and identify abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. 1. Resident #24 was admitted to the facility in [DATE] with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On [DATE] at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending out Resident #24. During an interview on [DATE] at 8:38 A.M., Nurse #4 said she is sending Resident #24 to the hospital as he/she was vomiting a lot over night that was coffee ground in color and has a history of bowel obstructions. Nurse #4 said the Resident started vomiting around 1:00 A.M. Nurse #4 said she called the on-call service Nurse Practitioner (NP) and the NP ordered labs because the Resident did not want to go to the hospital. Nurse #4 said the Resident only vomited a few times around 1:00 A.M. but then the Resident was okay and was asleep until 6:00 A.M. Nurse #4 said she then called the on-call service around 6:00 A.M. as the Resident again vomited dark coffee ground substances and wanted to go to the hospital at that time. During a follow up interview on [DATE] at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history Nurse #4 told the surveyors that he/she does have a history of a bowel obstruction as well as a recent fall on [DATE]. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation; that the Resident was vomiting. During an interview on [DATE] at 8:45 A.M., Nurse #3 said that she arrived to the facility around 7:20 A.M. and was told in report that the Resident had coffee ground emesis (vomiting) during the night. She said when she got there Resident #24 said he/she wanted to go to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M. when she saw him/her. During an interview and observation on [DATE] at 8:48 A.M., the surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go. Review of Resident #24's nursing progress note, dated [DATE] at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do lab. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] ,d+[DATE], pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP [health care proxy] was called and left a message. Review of the Electronic Medical Record (EMR) for Resident #24 indicated special instructions as follows: -Please document on every shift on GI (Gastrointestinal) status- appearance: distended, tenderness, flatus, BMs (bowel movements) and size, N/V (nausea and vomiting), GS/ bloating; anything clinically pertinent; behaviors- refusal of care; GU (genitourinary)- signs or symptoms of UTIs (urinary tract infections); always add effects of any PRN (as needed) medications administered during shift. Review of Resident #24's medical record failed to indicate that any assessments or other vitals were taken on [DATE]. During a follow up interview on [DATE] at 9:21 A.M., Nurse #4 said the vomiting started between 1:00 and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said that she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the emergency room . She said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport, not 911 emergency services, between 6:00 and 7:00 A.M. and was told that it would be one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on [DATE] at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During an interview on [DATE] at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said she was told he vomited around 1:00 A.M. and then again prior to the page at 7:56 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. During an interview on [DATE] at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on [DATE] into [DATE]. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long. She said that both the vomit and stool was liquid and black. She said that she provided incontinence care at least five times overnight for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said that she told the nurse. She said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital, and she told the nurse (Nurse #4) that he/she wanted to go to the hospital. CNA #7 said that her shift ended, and she left the facility around 7:15 A.M., and Resident #24 was still at the facility. During an interview on [DATE] at 9:42 A.M., NP #2 said the only page she got from the facility for Resident #24 was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on [DATE] at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on [DATE] at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. When asked if she was aware that the CNA #7 said that Resident #24 said he/she wanted to go to the hospital at 3:00 A.M., the DON said that after CNA #7 notified Nurse #4, Nurse #4 went into the room and the Resident said he/she didn't want to go. She said she would not have called the covering again at that point and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical she would have called again, but she said she did not take this as a critical situation. The DON said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times and denied the Resident was having coffee ground emesis. The DON said she had not spoken to CNA #7 who reported to the surveyor the Resident had ongoing black vomiting and black stooling throughout the night. Review of Resident #24's Ambulance Patient Care Report, dated [DATE], indicated dispatched at 8:01 A.M. to the facility for chief complaint of incontractable [sic] vomiting. Pt (patient) found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel. Skin is pale, warm and dry. Significant distension noted on initial impression. Nursing staff reported coffee ground emesis began at 0100 (1:00 A.M.) that morning with 3 episodes. No vitals or assessments taken to provide EMS (emergency medical services) staff. Vitals revealed hypotension (,d+[DATE]) and weakened radial pulses. Regrouped in patient room and called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. Review of Resident #24's discharge summary from the hospital, dated [DATE] at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and ,d+[DATE] milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in [DATE], February 2024, [DATE], [DATE] and [DATE]. The discharge summary indicated that Resident #24 presented to the emergency department from his/her extended care facility with coffee ground emesis times three and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. Further the discharge summary indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. After lengthy conversation with patient and nursing at the bedside patient seems for comfort measures at end of life. He/she was requesting narcotics for abdominal discomfort . Patient was cognizant and fully intact to make this decision. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Resident #24's medical record indicated the Resident returned to the facility on [DATE] on the 3:00 P.M. to 11:00 P.M. shift and was readmitted on care and comfort measures. Further review of the medical record indicated that Resident #24 died at the facility on [DATE] at approximately 8:28 A.M. 41019 2. For Resident #323, the facility neglected to: a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss. Resident #323 was admitted to the facility in [DATE] with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS further indicated Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing and walking. Review of the record indicated that effective [DATE] Resident #323 had an activated Health Care Proxy (deemed incapable of making medical decisions for self). The Health Care Proxy was Resident #323's daughter. During an interview on [DATE] at 1:32 P.M., Resident #323's daughter said she felt the facility did not listen to any of her concerns. Resident #323's daughter said her parent died and she believed it was the direct result of the facility's mistreatment and neglect. Resident #323's daughter said at the time of the Resident's death, he/she had significant wounds on his/her feet and had lost a significant amount of weight. Resident #323's daughter said she believes Resident #323 was overmedicated and said she was never made aware of medication changes and was never asked to sign consents for changes to Resident #323's medications. She said prior to passing Resident #323 could not get out of bed like he/she used to due to being overmedicated and was left in bed a lot of the day, creating wounds on the Resident's heels. Resident #323's daughter said that when the wounds were discovered on his/her heels that she was horrified. She said that the condition of Resident #323's heels were due to severe neglect by the facility. The Resident's daughter also said the Resident required assistance with chewing and swallowing and his/her meals were often left by the bed side, which likely contributed to the Resident's weight loss. The daughter said she believes that the Resident's death could have been prevented. 2 a. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised [DATE], indicates the following: - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. o A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. o If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Review of the hospital admission paperwork, prior to admission, for Resident #323, dated [DATE], indicated Resident #323 was admitted to the hospital with a Covid infection and the family's inability to care for him/her at home. Review of the lab results on the hospital admission paperwork, dated [DATE], indicated Resident #323 had the following lab results: - BUN: 31 - Creatinine: 1.87 - Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are ,d+[DATE] milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0XXX,d+[DATE].3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is ,d+[DATE] milliliters per minute.) Review of multiple nursing progress notes since admission indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On [DATE], a urine culture was obtained. Review of the medical record failed to indicate why a urine culture was obtained for Resident #323. Review of the laboratory results, dated [DATE], indicated the following: - Culture 10,,d+[DATE],000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the record failed to indicate if a urine sample or lab was ever obtained after [DATE]. Review of the record failed to indicate any follow up documentation from the Nurse Practitioner or Physician or if the laboratory results were ever reported to the physician or nurse practitioner from [DATE]-[DATE]. Review of the nursing progress note, dated [DATE], indicated that the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the medical record failed to indicate any follow up documentation from the Nurse Practitioner or Physician following the [DATE] progress note or if a urine sample was obtained after [DATE]. Review of the nursing progress note, dated [DATE], indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values. Specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23, which are considered abnormally high. The nursing progress note indicated that the Director of Nursing was made aware, and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated [DATE], indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD: Encourage po fluids, monitor renal, monitor retention Review the medical record failed to indicate that any further review or action of the abnormal labs from [DATE] through [DATE] a total of 27 days. Review of the labs draw on [DATE] indicated the following: - BUN 172 - Creatinine 5.6 - GFR 10 Review of the progress note, dated [DATE], indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital discharge summary, dated [DATE], indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). Resident #323 expired shortly after arrival to the hospital. During an interview on [DATE] at 8:30 A.M., the Nurse Practitioner said that she doesn't remember the resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner said that if a family member refuses any treatment then that should be documented. Review of the medical record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on [DATE] at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated him/her with intravenous fluids because the labs reflected dehydration. During an interview on [DATE] at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the urine was done because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample) but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why the additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner. During an interview on [DATE] at 9:47 A.M., the Physician said that most of the time the Nurse Practitioner makes the decision on what to do with abnormal labs. He said the Nurse Practitioner has been here for 7 years and is usually on top of these things. He said he was upset when they told him about Resident #323 and that this was a big concern. 2 b. Review of Resident #323's care plan for skin indicated the following: - Focus: I have the potential for skin breakdown r/t (related to) impaired mobility (initiated [DATE]) - Interventions: o Apply barrier cream after incontinence care (initiated [DATE]) o Document skin checks weekly and PRN (as needed). Notify physician and resident/RP (representative) of new areas if observed. Follow up as indicated (initiated [DATE]). Review of the weekly skin check, dated [DATE], indicated Resident #323 had no open areas. Review of the medical record failed to indicate weekly skin checks were being completed per the Reisdent's care plan from [DATE] until [DATE]. The weekly skin check, dated [DATE], indicated Resident #323 had a new open area on his/her right heel and his/her left heel due to pressure. The skin check failed to indicate any measurements for the wounds. Review of the Nurse Practitioner's progress note, dated [DATE], four days after the weekly skin check was completed, indicated the following: -Skin: no lesions or rashes noted in b/l (bilateral) UE (upper extremity) or LE (lower extremity). Review of the medical record failed to indicate if the Nurse Practitioner or Physician were notified of the new open pressure wounds. Review of the physician's orders indicated that a treatment order was implemented on [DATE], 8 days after the initial wound was identified and 4 days since he/she was last seen by the Nurse Practitioner, for both heels to cleanse with normal saline, apply Xerofoam gauze, to wound perimeter cover with ABD pad, wrap with kerlix. Review of the Initial Wound Evaluation and Management Summary, dated [DATE], 15 days after the wound was initially identified, indicated Resident #323 had the following: - an unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. - An unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. During an interview on [DATE] at 9:37 A.M., the Wound Physician said when she met with Resident #323, he/she had bad DTI's (deep tissue injuries) and that the treatment for a DTI is to offload the wound. The wound doctor said that in her assessment note she documents duration of the wound. She said the duration is her professional opinion of how long the wounds existed prior to her evaluation. For Resident #323 she said that she believes the wounds were due to pressure, indicating the heels were not offloaded. Review of the medical record failed to indicate any intervention to offload Resident #323's heels after the wounds were first identified. During an interview on [DATE] at 10:47 A.M., the Director of Nursing said if a wound is identified then she would have expected the skin prep (a liquid applied to the skin to provide a barrier) to go in earlier, but depends on what the doctor says. 2 c. Review of Resident #323's nutrition care plan indicated the following: Focus: I have a nutritional problem or potential nutritional problem related to significant weight changes, suspected malnutrition, past medical history significant for dementia, anemia pressure ulcers, and GERD (Gastroesophageal reflux disease). Review of the weight report for Resident #323 indicated the following weights: [DATE]: 158.2 lbs (pounds) [DATE]: 135 lbs [DATE]: 120 lbs Review of the nutrition risk assessment, dated [DATE], indicated Resident #323 had an ideal body weight of 153 lbs. Review of the weights indicated Resident #323 lost 23.2 lbs in one month from [DATE] to [DATE], which is a 14.6% significant weight loss. Review of the progress note, dated [DATE], indicated the following: RD (registered dietitian) suspects pt (patient) meets criteria for protein calorie malnutrition. Malnutrition in the context of chronic illness r/t (related to) dementia AEB (as evidenced by) significant weight loss with NFPE (nutrition focused physical exam) finding indicating fat and muscle loss. Review of the weight warning note, dated [DATE], indicated the dietitian recommended a re-weight and to start weekly weights, as well as, a nutritional drink BID (twice per day) and fortified foods. Review of the medical record failed to indicate that weekly weights were implemented as recommended. Review of the weights indicated Resident #323 lost an additional 15 lbs from [DATE] to [DATE], which is an 11% significant weight loss in one month. Review of the clinical record failed to indicate that the significant weight loss was addressed, the care plan was reviewed, or any new interventions were implemented. During an interview on [DATE] at 9:00 A.M., the Dietitian said that after the initial significant weight loss, she recommended weekly weights, but said they were not being done. The dietitian said she was not notified of the weight loss that occurred on [DATE] and would have expected to be notified so that she could address the weight loss.

Based on record review and interview, the facility failed to ensure physician and/or delegate supervision after a change in medical status for one Resident (#323) of a total sample of 39 residents. Specifically, the facility failed to follow up on abnormal labs that were drawn, for a Resident with a known history of Chronic Kidney Disease, resulting in critically high labs, which required emergency hospitalization and death. Findings include: Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - A physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. - The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. - When test results are reported to the facility, a nurse will first review the results. - If staff who receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - Nursing will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: * Whether the physician has requested to be notified soon as a result is received. * Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) * Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. * A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. * If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicates Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's care plan indicated Resident #323 was not capable of making his/her informed consent regarding his/her health care decisions. Review of the hospital admission paperwork for Resident #323, dated 6/7/24, indicated Resident #323 was admitted to the hospital with a Covid infection and family inability to care for at home. Review of the lab results on the hospital admission paperwork, dated 6/7/24, indicated Resident #323 had the following lab results: - BUN: 31 - Creatinine: 1.87 - Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are 6-24 milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0.7-1.3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is 90-120 milliliters per minute.) Review of the progress notes indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On 8/14/24, a urine culture was obtained. Review of the record failed to indicate why a urine culture was obtained for Resident #323. Review of the lab results, dated 8/14/24, indicated the following: -Culture 10,000-50,000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the progress note, dated 8/16/24, indicated that the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the record failed to indicate if a urine sample or lab was ever obtained after 8/14/24. Review of the record failed to indicate any follow up documentation from the Nurse Practitioner or Physician. Review of the progress note, dated 8/24/24, indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values, specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23. The note indicated that the Director of Nursing was made aware and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated 8/25/24, indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD: Encourage po fluids, monitor renal, monitor retention Review the record failed to indicate that any further review or action of the abnormal labs took place. Review of the progress note, dated 9/20/24, indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital summary, dated 9/19/24, indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). During an interview on 11/5/24 at 8:30 A.M., the Nurse Practitioner said that she doesn't remember the resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner said that if a family member refuses any treatment then that should be documented. Review of the record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on 11/5/24 at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated with intravenous fluids because his/her labs reflected dehydration. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the urine was done because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample), but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner.

Based on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant change in a resident's status for one Resident (#24) out of a total sample of 39 residents. Specifically, for Resident #24, the facility failed to provide a covering Nurse Practitioner (NP) with complete and accurate information about a resident with coffee ground emesis and ongoing black stools, including but not limited to the Resident's significant history of bowel obstructions and Gastrointestinal (GI) bleeding, resulting in hospitalization and subsequent death. Findings Include: Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: -Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/ mental condition and or status. -The nurse will notify the resident's attending physician or physician on call when there has been a(an) significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/ treatment center. -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (situation, background, assessment, recommendation) Communication Form. Resident #24 was admitted to the facility in December 2014 with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) Assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On 11/4/24 at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending Resident #24 to the hospital. During an interview on 11/4/24 at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history, Nurse #4 said that he/she does have a history of a bowel obstruction as well as a recent fall on 11/1/24. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation, that the Resident was vomiting. During a follow up interview on 11/4/24 at 9:21 A.M., Nurse #4 said Resident #24 started vomiting between 1:00 A.M., and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the emergency room . Nurse #4 said Resident #24 was not agreeable to go to the hospital earlier in the morning, however said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport between 6:00 and 7:00 A.M. and was told that it would be about one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on 11/6/24 at 7:45 A.M., Nurse #4 said that on the night before Resident #24 was sent out it was around 1:00 A.M. that the Resident began vomiting. She said that it was coffee ground. She said that as soon as she could, she called the NP. She said that she told the NP the Resident was vomiting but could not remember if she told her that it was coffee ground. She said she did not tell the NP about the history of obstructions or GI bleeding. She said that the NP ordered labs and Zofran for nausea. Nurse #4 said she called the NP again at 6:00 A.M., and an order was given to send the Resident to the hospital. During an interview on 11/4/24 at 8:45 A.M., Nurse #3 said that she arrived at the facility around 7:20 A.M. and was told in report that the resident had coffee ground emesis (vomiting) during the night. She said she went right into Resident #24's room when she got there, and he/she said they wanted to go to the hospital. At the time of the interview the ambulance company was picking up the Resident for transport to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M. when she saw him/her. During an interview and observation on 11/4/24 at 8:48 A.M., the surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go earlier in the morning when the vomiting started. During a phone interview on 11/6/24 at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on 11/3/24 into 11/4/24. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long and that both the vomit and stool was liquid and black. CNA #7 said that she provided incontinence care at least five times over night for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said that she told the nurse. CNA #7 said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital and after getting the Resident cleaned and changed again at that time, she told the nurse (Nurse #4) that the Resident wanted to go to the hospital. CNA #7 said that when her shift ended, and she left the facility around 7:15 A.M. and Resident #24 was still at the facility. Review of a progress note written by Nurse #4 on 11/4/24 at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do labs. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] 107/77, pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP (health care proxy) was called and left a message. Further review of the nursing progress note written on 11/4/24 failed to indicate a comprehensive GI (gastrointestinal) assessment or abdominal assessment. Review of the Patient Care Report for Resident #24 from the Ambulance service dated 11/4/24 indicated that dispatched received the call from the facility for transfer to the hospital at 8:01 A.M. on 11/4/24. The Patient Care Report indicated that the chief complaint was general illness- GI bleed for 7 hours with a primary symptom of abdominal distension. The Patient care report further indicated that the ambulance was dispatched to the facility for a patient with incontractible vomiting. (sic) The BLS (basic life support) crew arrived at the patient at 8:39 A.M. and patient found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel .Skin is pale, warm and dry. Significant distension noted on initial impression. The report further indicated, Nursing staff reported coffee ground emesis began at 1:00 A.M. that morning with 3 episodes . No vitals or assessments taken to provide EMS (emergency medical service) staff. Vital signs revealed hypotension with a blood pressure of 80/60 and weakened radial pulses. BLS crew called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI (gastrointestinal) bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. During a follow up interview on 11/4/24 at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During a phone interview on 11/6/24 at 9:00 A.M., the surveyor spoke to Nurse Practitioner (NP) #1 who returned a phone call to the surveyor regarding when phone calls were placed into the call service to report the change in condition on Resident #24. NP #1 said that she was not the one who responded to the call, but the service got one call at 1:13 A.M. with a message stating the Resident was vomiting a lot. She said this is the only call that came into the service on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 11/6/24 at 9:42 A.M., Nurse Practitioner (NP)#2 said she was the covering NP for the night of 11/3/24 into 11/4/24 and the only page she got from the facility for this Resident was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on 11/4/24 at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. Review of Resident #24's discharge summary from the hospital, dated 11/4/24 at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and 1600-2000 milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in May 2023, February 2024, May 2024, June 2024 and November 2024. Further, the report indicated that Resident #24 presented to the emergency department from his extended care facility with coffee ground emesis x3 and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. The discharge summary also indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Nursing progress notes indicated the following: - A progress note dated 11/5/24 at 1:27 A.M., indicating, Patient came back from hospital on a 3-11p shift, earlier this nurse took report from the ED [emergency department] nurse stating that,' Patient had a bowel obstruction', this nurse asked the ED Nurse if patient had any surgeries to correct the obstruction, she said No, patient is coming back to the facility for comfort care admitted to Hospice. however, it is not stated in the Hospital visit, paperwork. Will F/u [follow up] with facility MD. Review of the nursing progress note dated 11/5/24 at 12:03 P.M., indicated the following: - At approximately 8:28 A.M., the resident was noted to be unresponsive. Resident did not respond to verbal or physical stimuli. There was no palpable pulse or visual chest rise/fall and no audible breath sounds. Time of death 8:29 A.M. Health care proxy notified, and body released to funeral home at 10:30 A.M. During an interview on 11/6/24 at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on 11/6/24 at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. She said she would not have called the covering again at any point during the shift and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical, she would have called again, but she said she did not take this as a critical situation. The DON said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times. The DON said however, she had not spoken to CNA #7, who reported to the surveyor ongoing black vomiting and black stooling throughout the night.

Based on observation, record review and interview, the facility failed to ensure staff identified and implemented interventions related to pressure ulcers for three Residents (#48, #110, and #323), out of a total of 39 sampled Residents. Specifically, 1. For Resident #48, the facility failed to identify a deep tissue injury (DTI) upon admission and implement interventions. Additionally, the facility failed to initiate treatments recommended by the Wound Physician timely. 2. For Resident #110, the facility failed to implement a treatment for a pressure wound timely. 3. For Resident #323, the facility failed to implement treatment for a wound timely. Findings include: Review of the Prevention of Pressure Injuries, dated 2001, indicated: Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Risk Assessment: Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Use a standardized pressure injury screening tools to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. Prevention: Use a barrier product to protect skin from moisture. Mobility/repositioning: Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team. Monitoring: Evaluate, report and document potential changes in skin. Review the interventions and strategies for effectiveness on an ongoing basis. Review the interventions and strategies for effectiveness on an ongoing basis. 1. Resident #48 was admitted to the facility in May 2024 with diagnoses including cerebral infarction, dysphagia, and contractures of the lower extremity. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is severely cognitively impaired evidence by a score of six out of a possible 15 on the Brief Interview for Mental Status exam. On 11/4/24 at 7:27 A.M., the surveyor observed Resident #48 resting on an air mattress (a specialty mattress utilized to reduce pressure on the body). Due to his/her cognition, Resident #48 was unable to engage in the interview process. During an interview on 11/4/24 at 7:21 A.M., Certified Nursing Aide #1 said that Resident #48 has wounds and requires two staff to reposition him/her in bed. Review of Resident #48's Hospital discharge paperwork dated 5/10/24 indicated that Resident #48 developed DTPI (deep tissue pressure injury) on the right heel during his/her hospitalization . The paperwork indicated: Wound bed site assessment: (pink;purple) Structure exposed: None Peri-Wound assessment: Fragile; intact. Cover dressings: Bordered foam. Dressing complexity: Routine. Dressing status: Clean, dry, intact. The discharge forms did not provide instructions related to monitoring or care for Resident #48's DTI. Review of the Nurse Progress note 5/10/24: Skin clean dry and intact. Right heel large black discoloration covering most of the heel. covered with protective dressing. There were no measurements or further description of the DTI or evidence that the physician was notified. Review of the MDS dated [DATE] indicated Resident #48 had no areas of skin breakdown and was not at risk for the development of pressure injuries. Review of Resident #48's physicians orders for May 2024 failed to indicate any treatments or interventions related to his/her DTI. Review of the Nursing Admission Evaluation dated 5/10/24 failed to include an assessment of Resident #48's skin or an assessment of Resident #48's risk of skin breakdown. Review of Resident #48's skin care plan effective 5/10/24 through 7/30/24 indicated: Focus: I have skin breakdown and/or potential for skin breakdown, Initiated: 5/10/2024 Interventions: Document skin checks weekly and PRN (as needed). Notify the physician and resident/RP of new areas if observed. Follow-up as indicated. I need moisturizer applied to my skin as needed. Do not massage over bony prominences. I need reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. The care plan failed to identify and include interventions related to Resident #48's DTI on his/her heel. Review of Resident #48's skin checks indicated no skin check was completed on 5/12/24. The skin check completed 5/21/24 indicated that Resident had no open areas and failed to indicate Resident #48's right heel DTI. Review of the nurse progress note dated 5/27/2024 (17 days after Resident #48's DTI was first documented upon admission): Pressure injury observed to right heel, measures approximately 3''x 3''. DON (Director of Nursing) and on call NP (Nurse Practitioner) notified. Review of the Wound Physician's note dated 5/28/24 indicated: Unstageable (due to necrosis) of the right heel full thickness. Etiology: Pressure. Wound Size: 10 CM X 8 CM X Not measurable due to presence of non-viable tissue and necrosis (dead tissue). Exudate (drainage): light serous. Thick adherent devitalized necrotic tissue: 100%. Dressing treatment plan: Betadine apply once daily for 30 days: ABD pad apply once daily for 30 days, gauze roll apply once daily for 30 days. Debridement Procedure (a surgical procedure utilized to remove dead tissue from wounds): The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 16 CM of devitalized tissue and necrotic subcutaneous level tissues.The wound bed was decreased from 100 percent to 80 percent. Review of the physician's orders, and May 2024 and June 2024 Treatment Administration Records (TAR) indicated that no treatments were implemented for Resident #48's heel until 6/8/24. Review of the Nurse Practitioners note dated 5/29/24 indicated: He/she is contracted and is putting pressure on his/her right lateral ankle and heel in the position that he/she prefers to be in, upright and facing the doorway to her room (right side).I have reviewed [the wound physician's] detailed note from yesterdays consult and agree with plan of care. Review of the Wound Physician's note dated 6/4/24 indicated: Unstageable (due to necrosis) of the right heel full thickness. Etiology: Pressure. Wound Size: 10 X 8 X Not measurable due to presence of non-viable tissue and necrosis. Exudate: light serous. Thick adherent devitalized necrotic tissue: 100%. Dressing treatment plan: Betadine apply once daily for 23 days. ABD pad apply once daily for 23 days, gauze roll apply once daily for 23 days. Debridement Procedure: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 8 CM of devitalized tissue and necrotic subcutaneous level tissues.The wound bed was decreased from 100 percent to 90 percent. Review of the physicians orders and June 2024 TAR indicated that the treatment was not implemented for Resident #48's heel until 6/8/24. During an interview on 11/4/24 at 8:53 A.M., Nurse #7 said that every time a resident is admitted , a full skin check is done. Nurse #7 said that if a resident is admitted with wounds, the physician is notified and treatment is implemented and the Wound Physician becomes involved in resident care. Nurse #7 said that Resident #48 has wounds and due to his/her contractures, treatments can be difficult to apply. During an interview on 11/4/24 at 10:49 A.M., the Director of Nursing (DON) said that staff perform a full skin check on residents upon admission and if there are wounds identified upon admission staff would alert the physician and implement a treatment and involve the Wound Physician. The DON said that the Wound Physician rounds the facility weekly and her treatment recommendations are implemented within the week. The DON said she was not aware of any delay in treatment or that Resident #48 was identified as having a DTI upon admission. During an interview on 11/4/24 at 3:50 P.M., the Wound Physician said that she rounds the facility once a week with a nurse who then inputs treatment recommendations. The Wound Physician said that treatments for residents with deep tissue injuries include offloading and the use of skin prep. The Wound Physician said she could not comment on Resident #48's wounds upon admission as she was not assigned to the facility at that time. During an interview on 11/5/24 at 12:32 P.M., the Regional Nurse and DON said that they were not aware that Resident #48 had a DTI upon admission and there was no monitoring or interventions initiated. The Regional Nurse and DON said the nurse who performed the initial assessment and documented the DTI on 5/10/24 was an agency nurse and she should have communicated the DTI to the team. The Regional Nurse and DON said that there should not have been a delay in the documented initiation of the betadine treatment for Resident #48's heel until 6/8/24. 36431 2. For Resident #110 the facility failed to implement a treatment for a pressure ulcer identified on 10/18/24. Resident #110 was admitted to the facility in April 2024 with diagnoses including unspecified dementia, muscle wasting and atrophy, and moderate-protein calorie malnutrition, Review of the Minimum Data Set assessment, dated 10/23/24, indicated a staff assessment for mental status was completed and indicated Resident #110 as having severely impaired cognition. Further the MDS indicated Resident #110 is dependent on staff for toileting and bathing, is at risk for developing pressure ulcers and had one stage 2 pressure ulcer not present on admission or reentry. The MDS indicated a stage 2 pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough, may also present as an intact or open/ruptured serum-filled blister. Review of the MDS assessments indicated Resident #110 was in the hospital from 10/11/24 through 10/17/24. Review of the hospital discharge summary dated 10/17/24 indicated Resident #110 had a pressure injury present on original admission, on the coccyx with the initial staging: stage 2. Further, the discharge summary indicated on 10/16/24 the pressure injury on the coccyx was U (unstageable), had the wound length of 1.5 cm (centimeters), wound width of 1 cm and wound depth of 0.1 cm, wound bed site with slough (dead skin or tissue that separates from healthy skin or tissue), margins distinct, treatments soap and water and Triad cream (A sterile coating that can be applied to a wound to facilitate healing and debridement). Review of Resident #110 admission orders failed to indicate a treatment for the stage 2 coccyx pressure ulcer upon readmission to the facility. Review of Resident #110's medical record indicated the following: -A skin check dated 10/18/24 indicated, are there any new skin impairments? which was documented as yes, type was documented as pressure injury site was documented as coccyx and description was documented as stage 2, no further description or assessment of the pressure injury was included. Review of Resident #110's medical record failed to indicate a physician's order for the treatment of the stage 2 pressure ulcer on the Resident's coccyx was implemented. Review of the progress notes dated 10/18/24 failed to indicate that the Physician or Nurse Practitioner were notified of Resident #110's pressure injury and that a treatment order was obtained. During an interview on 11/6/24 at 5:01 A.M., Nurse #10 said Resident #110 was sent to the hospital recently and returned with a wound on his/her coccyx. Nurse #10 said she did the skin assessment for Resident #110 on 10/18/24 as part of the readmission assessment. Nurse #10 said the Resident had an open area on the coccyx and documented it as a stage 2 pressure injury. Nurse #10 said the hospital discharge summary included a picture of the Resident's pressure area on his/her coccyx. Nurse #10 said she did not notify the NP/MD (nurse practitioner/Medical doctor) or obtain an order for a treatment for the coccyx and said that Unit Manager #1 was aware, and Nurse #3 also reviewed the hospital discharge summary on 10/17/24 when the Resident returned from the hospital. Nurse #10 said when a pressure area is identified they do not wait to get an order for a treatment. Review of the nurse progress note dated 10/22/24 at 20:49 (8:49 P.M.) indicated, I was notified by the CNA (certified nursing assistant) caring for this resident that there was a new skin issue found. I went to assess the resident. Red raw area noted on his/her buttox (sic), and open area found on his/her coccyx to be a stage 2 pressure injury 1.1 cm by 0.9 cm. NP (nurse practitioner) notified, DON notified, HCP (health care proxy) notified. Treatment to apply Triad dressing/paste twice daily and as needed. Review of the Treatment Administration Record indicated the following orders: -Stage 2 Gluteal Cleft: Cleanse with normal saline, apply Triad dressing/paste twice daily, and as needed. Every day and evening shift Start date 10/22/24 D/C (discharge) date 10/31/24. This order does not indicate a treatment for the coccyx which was documented as present on the 10/18/24 skin check, and the 10/22/24 nurse's progress note. -Stage 3 (Indicated by the MDS as full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure wound coccyx: cleanse with normal saline, apply mesalt sheet (an impregnated gauze used for wounds with moderate to heavy drainage,) cover with border gauze island dressing. Change daily and as needed. Start date 10/31/24. Review of the document titled 'Specialty Physician Wound Evaluation and Management Summary' dated 10/29/24 (eleven days after the 10/18/24 skin evaluation which indicated a coccyx pressure injury) indicated chief complaint, Patient has wounds on his/her coccyx. Focused wound exam (site 5) Stage 3 Pressure Wound Coccyx Full Thickness, Etiology: Pressure Duration greater than 5 days, wound size Length 1 x width 0.5 x depth 0.2. During an interview on 11/6/24 at 7:34 A.M., the Director of Nursing (DON) said when nurses do a skin evaluation and identify any new skin areas, they are to document the location, describe what they are seeing, give an estimate of the size, notify the doctor or nurse practitioner and obtain a treatment. The DON said staff should not be staging the wounds. The DON said nursing staff are to notify her of any wounds identified and complete a risk reporter (incident report). The DON said a resident with a new wound would be evaluated by the wound doctor on her next weekly visit. The DON said she was not aware that Resident #110 was readmitted from the hospital with a stage 2 coccyx pressure ulcer that was documented in the hospital discharge summary and documented on the skin evaluation dated 10/18/24. The DON said an order should have been put in place when it was identified by the nurse. Further, the DON said an area was identified on 10/22/24 by a CNA (certified nursing assistant) and a treatment was implemented for the gluteal cleft and documented as a stage 2 pressure area. The DON said the wound physician saw Resident #110 and documented the wound as a stage 3 coccyx wound. 41019 3. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS also indicated Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's care plan for skin indicated the following: - Focus: I have the potential for skin breakdown r/t (related to) impaired mobility (initiated 7/5/24) -Interventions: * Apply barrier cream after incontinence care (initiated 7/5/24) * Document skin checks weekly and PRN (as needed). Notify physician and resident/RP (representative) of new areas if observed. Follow up as indicated (initiated 7/5/24). Review of the weekly skin check, dated 6/25/24, indicated Resident #323 had no open areas. Review of the record failed to indicate weekly skin checks were being done until 7/25/24. The weekly skin check, dated 7/25/24, indicated Resident #323 had a new open area on his/her right heel and his/her left heel due to pressure. The skin check failed to indicate any measurements for the wounds. Review of the Nurse Practitioner note, dated 7/29/24, indicated the following: -Skin: no lesions or rashes noted in b/l (bilateral) UE (upper extremity) or LE (lower extremity). Review of the record failed to indicate if the Nurse Practitioner or physician was made aware of the new open wounds. Review of the physicians orders indicated an order for right heel area skin prep every shift, monitor for changes, which was initiated on 7/31/24, six days after the wound was identified. Review of the physician's orders indicated that a treatment order went in place on 8/2/24, 8 days after the initial wound was identified, for both heels to cleanse with normal saline, apply Xerofoam gauze, to wound perimeter cover with ABD pad, wrap with kerlix. Review of the Initial Wound Evaluation and Management Summary, dated 8/6/24, 15 days after the wound was initially identified, indicated Resident #323 had the following: - an unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. - An unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. During an interview on 11/5/24 at 9:37 A.M., the Wound Physician said when she met with Resident #323, he/she had bad DTI's (deep tissue injuries) and that the treatment for a DTI is to offload the wound. The wound doctor said that the duration of the wound she documents is how long she expected the wound to be there prior to her evaluation and believes his/her wounds were due to pressure. Review of the clinical record failed to indicate any intervention to offload Resident #323's heels after the wounds were identified. During an interview on 11/4/24 at 10:49 A.M., the Director of Nursing (DON) said that staff perform a full skin check on residents upon admission and if there are wound identified upon admission staff would alert the physician and implement a treatment and involve the Wound Physician. The DON said that the Wound Physician rounds the facility weekly and her treatment recommendations are implemented within the week. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said if a wound is identified then she would have expected the skin prep to go in earlier for Resident #323, but depends on what the doctor says.

Based on observations, record review and interviews the facility failed to maintain acceptable nutrition status for three Residents (#114, #323, and #74) out of a total sample of 39 residents. Specifically, 1. For Resident #114 the facility failed to; a. failed to identify and address significant weight loss and b. failed to provide fortified foods in accordance with physician's orders following a significant weight loss. 2. For Resident #323, the facility failed to identify and address a significant weight loss. 3. For Resident #74, the facility failed to identify and address a significant weight loss timely. Findings Include: Review of facility policy titled Weight Assessment and Intervention, undated, indicated the following: -Resident weights are monitored for undesirable or unintended weight loss or gain. -1. Weights are recorded in each unit's weight record chart and in the individual's medical record. -3. Any weight change of 5% or more since the last weight assessment, nursing will notify the dietitian. -5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight = (usual weight- actual weight)/(usual weight) x 100]: a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months 10% weight loss is significant; greater than 10% is severe. Review of facility policy titled Nutrition (Impaired)/ unplanned weight loss- Clinical Protocol, dated as revised September 2017 indicated the following: -The Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. -Treatment/ Management: The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. 1. Resident #114 was admitted to the facility in June 2024 with diagnoses including syncope and collapse, obesity, and atrial fibrillation. Review of Resident #114's most recent Minimum Data Set (MDS) Assessment, dated 8/7/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident was cognitively intact. The MDS failed to indicate behaviors, including behaviors of refusal. a. Review of Resident #114's weights indicated the following: 6/21/24: 238.1 lbs. (pounds). 7/8/24: 224.6 lbs. 7/17/24: 222.0 lbs. 8/30/24: 221.6 lbs. 9/10/24: 204.5 lbs. 10/4/24: 198.4 lbs. 10/28/24: 189.4 lbs. 11/3/24: 191.2 lbs. - On 6/21/24, the Resident weighed 238.1 lbs. On 11/3/24, the Resident weighed 191.2 lbs., which is a -19.70 % loss in 4 months and 13 days. - On 8/30/24, the Resident weighed 221.6 lbs. On 9/10/24, the Resident weighed 204.5 lbs., which is a -7.72 % loss in 11 days. Review of the Nutrition Assessment, dated 9/11/24, indicated completion on 10/7/24, 27 days after a 7.72% weight loss from 8/30/24 to 9/10/24. The assessment indicated Rt (Resident) being reviewed for quarterly nutrition assessment and this quarter weights have ranged from 204.5# (pounds) to 222#, with significant weight changes. At this time recommendations were made for fortified foods and weekly weight as ordered. Review of physician's orders, dated 10/7/24, indicated the following: - CCHO (consistent or controlled carbohydrate) diet, regular texture, thin consistency- fortified foods related to hyperglycemia, dated 10/7/24. - Weekly weights one time a day every Tuesday, dated 10/7/24. - Glucerna every day and evening shift 237 ml (milliliters) via PO (by mouth), dated 10/28/24. Review of the October 2024 Medication Administration Record indicated that Resident #114 refused to be weighed on 10/8 and 10/15. On 10/22 there is no indication that a weight was obtained or that the Resident refused. Review of progress notes failed to indicate ongoing attempts to weigh the Resident after refusal or education provided to the Resident regarding weights. During an interview on 11/6/24 at 9:33 A.M., the Director of Nurses (DON) said there is no one person who enters the weights into the electronic health record and evaluates them, but generally the weights are evaluated by the Dietitian. She said she would not reweigh a resident unless the Dietitian asks for a reweight of the resident. (contrary to the facility policy) During an interview on 11/6/23 at 10:06 A.M., Nurse Practitioner #3 said that she was not notified of weight loss until 10/28/24 and said the weight loss is concerning because Resident #114 has had a lot of recent illness. During an interview on 10/6/24 at 10:12 A.M., the Dietitian said that the facility does not meet regularly for risk meetings to discuss things like weight loss, but they are trying to do it more regularly, and that she reviews resident weights outside of risk meeting as well. She said she works at a regional level, and it varies how often she is in the facility to review weights. She said that she would have expected staff to report the weight change between 8/30/24 and 9/10/24 to her and a physician, and she would have expected a reweight to be done as well to confirm the weight loss. She said both nursing and the Dietitian enter weights into the electronic health record, but they should be reviewed and compared to previous weights when entered. b. Review of physician's orders indicated the following orders: - CCHO (consistent or controlled carbohydrate) diet, regular texture, thin consistency- fortified foods related to hyperglycemia, dated 10/7/24. - Weekly weights one time a day every Tuesday, dated 10/7/24 During the survey, the surveyor made the following observations: - On 11/4/24 at 8:17 A.M., the surveyor observed Resident #114's breakfast tray. The meal ticket on the tray did not indicate that the Resident was to receive fortified foods and there were not fortified foods present on the tray. The tray contained juice, milk, eggs, and toast. - On 11/4/24 at 12:10 P.M., the surveyor observed staff bring the lunch meal tray into Resident #114. Resident #114 received milk and juice to drink along with pork, gravy, macaroni and cheese and spinach, which was the indicated meal on the menu. There were no fortified foods provided and Resident #114's meal ticket did not indicate for the Resident to receive fortified foods. - On 11/5/24 at 8:19 A.M., the surveyor observed staff bring the breakfast tray into Resident #114. Resident #114 received one piece of french toast and one piece of ham along with milk, juice, and coffee to drink. There were no fortified foods provided and the meal ticket on the tray did not indicate for the Resident to receive fortified foods. Review of the Nutrition assessment dated [DATE] indicated completion on 10/7/24 indicated the following: - This quarter weights have ranged from 204.5# (pounds) to 222#, with significant weight changed. - Recommend fortified foods. During an interview on 11/5/24 at 12:19 P.M., the Staff Development coordinator, who was present on the unit, said that fortified foods are foods that are supplemented by the kitchen. She said for breakfast it could mean fortified cereal which may have extra cream and sugar in the cereal to add more calories to it. She said the dietitian would arrange for those foods to come from the kitchen but was not sure if it would be reflected on the meal ticket that comes on the trays. During an interview on 11/5/24 at 12:19 P.M., Nurse #3 said that she doesn't know what fortified foods means. She said that any special diet order or recommendation should be on the meal ticket such as likes/ dislikes and allergies. During an interview on 11/6/24 at 9:33 A.M., the Director of Nurses (DON) said that fortified foods include super cereal and super potatoes that may have cream and butter added to them for added calories. The DON said that an order for fortified foods should be on the meal ticket. During an interview on 11/6/24 at 10:06 A.M., Nurse Practitioner #3 said she would expect that interventions put into place because of weight loss would be implemented and that she did not know the Resident was not receiving fortified foods with meals. During an interview on 11/6/24 at 10:12 A.M., the Dietitian said that orders for fortified foods should be on the meal ticket and is generally communicated to the kitchen on dietary communication forms. She said that fortified foods would include super cereal at breakfast and potatoes or pudding at lunch or dinner depending on the resident's preferences. She said Resident #114 should have been receiving fortified foods with all meals. 41019 2. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Further, the MDS indicates Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's nutrition care plan indicated the following: Focus: I have a nutritional problem or potential nutritional problem related to significant weight changes, suspected malnutrition, past medical history significant for dementia, anemia, pressure ulcers, and GERD (Gastroesophageal reflux disease). Review of the weight report for Resident #323 indicated the following weights: 7/5/24: 158.2 lbs (pounds) 8/5/24: 135 lbs 9/7/24: 120 lbs Review of the nutrition risk assessment, dated 7/10/24, indicated Resident #323 had an ideal body weight of 153 lbs. Review of the weights indicated Resident #323 lost 23.2 lbs in one month from July 2024 to August 2024, which is a 14.6% significant weight loss. Review of the progress note, dated 8/6/24, indicated the following: RD suspects pt meets criteria for protein calorie malnutrition. Malnutrition in the context of chronic illness r/t dementia AEB (as evidenced by) significant weight loss with NFPE (nutrition focused physical exam) finding indicating fat and muscle loss. Review of the weight warning note, dated 8/6/24, indicated the dietitian recommended a re-weight and weekly weights, as well as, a nutritional drink BID (twice per day) and fortified foods. Review of the physician orders indicated an order for weekly weights, started on 8/6/24. Review of the weight record failed to indicate weekly weights were done. Review of the weights indicated Resident #323 lost an additional 15 lbs from August 2024 to September 2024, which is an 11% significant weight loss in one month. Review of the clinical record failed to indicate that the significant weight loss was addressed, the care plan was reviewed, or any interventions were implemented. During an interview on 11/5/24 at 9:00 A.M., the Dietitian said that after the initial significant weight loss, she recommended weekly weights, but said they were not being done. The Dietitian said she was not notified of the weight loss that occurred on 9/7/24 and would have expected to be notified. 3. Resident #74 was admitted in April 2024 with diagnoses including unspecified protein-calorie malnutrition, dysphagia, and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #74 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of Resident #74's nutrition care plan indicated the following: Focus: I have a nutritional problem or potential nutritional problem related to significant weight changes, past medical history significant for COPD (chronic obstructive pulmonary disorder), dysphagia, and malnutrition. Review of the weight and vitals summary for Resident #74 indicated the following: 6/2/24: 155.7 lbs (pounds) 7/1/24: 155.8 lbs 7/2/24: 149 lbs 7/5/24: 149 lbs 8/7/24: 141.6 lbs 9/3/24: 141.8 lbs Review of the weights indicate Resident #74 lost 14.1 pounds between June 2024 and August 2024, which is a 9% significant weight loss in 2 months. Review of the clinical record failed to indicate that the care plan was reviewed or interventions were put in place until 9/10/24, which is one month after the significant weight loss was identified, when the Dietitian recommends Ensure (a nutrition supplement) every day. During an interview on 11/5/24 at 9:00 A.M., the Dietitian said she put a note in on 9/10/24 acknowledging the weight loss, but ideally she would review the weights each week and see them shortly after a weight loss is identified. The Dietitian said there has been an issue with nurses notifying her of weight losses, but it has improved.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring with measurable outcomes for a pressure ulcer QAPI project. Findings Include: During the survey period, multiple residents were identified as having facility acquired pressure ulcers with delayed treatment. During an interview on 11/7/24 at 10:41 A.M., the Administrator and Director of Nursing said they had recently developed a QAPI project for skin as it was identified as an area of concern for the building. The Administrator and Director of Nursing said the project's goal was to lessen the frequency of facility acquired pressure ulcers and the facility used reports to measure the progress of the project. When asked specifics about the reports used, the Director of Nursing said the regional support team uses the KPI (Key Performance Indicator) reports and tells the facility what changes to make based on that. Neither the Director of Nursing or Administrator could list specific tools or strategies used at the facility level that monitor and measure the progress or success of the project. The Director of Nursing also said it was hard to implement strategies for skin management due to staff turn over and that the skin QAPI project was definitely not successful and we failed at that project and will have to do it again.

Based on observations, record reviews and interviews, the facility failed to provide a person-centered activity program for four Residents (#25, #103, #87, and #28) out of a total sample of 39 residents. Finding include: 1. Resident #25 was admitted in June 2023 with diagnoses including bipolar disorder and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #25 scored a 12 out of a possible 15 on the Brief Interview of Mental Status (BIMS), indicating moderate cognitive impairment. Review of the MDS indicated that Resident #25 scored a 10 out of a possible 27 points on the Patient Health Questionnaire (PH-Q9), indicating moderate depression. During observations throughout survey, Resident #25 did not get out of bed and was in his/her room in bed. Resident #25 did not have any entertainment materials provided, outside of the television, which was on one time during observation. Review of Resident #25's care plan indicated the following: Focus: I am independent in filling my leisure time as I prefer to spend time alone in my room . (initiated 4/6/23) Goal: I am no longer able to participate in meaningful group activities d/t progress dementia. I am unable to follow directions and am not aware of my surroundings during programs. Visits with Resident #25 are soft hand massages and some conversation (updated 10/31/24) Interventions: - Check on me often to ensure I am content with items provided to me for my self directed independent leisure (initiated 11/2/22) - Encourage me to utilize community areas within the facility to promote socialization (initiated 11/2/22) - Encourage my family to bring in familiar items for home to engage me in leisure activity (initiated 11/2/22) - I can be verbally inappropriate at times. Please offer gentle redirection during these times. (initiated 11/2/22) - I have a personal cell phone that I enjoy independently (initiated 11/2/22) - Provide me with independent leisure materials. I like to be supplied with magazines, history articles, coloring pages and friendly conversation (initiated 11/2/22) - Provide me with the monthly activity calendar and continue to invite me to activities (initiated 11/2/22) - Remind me I may come an leave an activity at any time I please and I do not have to stay for the duration of the program (initiated 11/2/22) - Some of my preferred activities are talking with peers, outside socials, parties, food events, music programs and relaxing in the comfort of my own room watching TV or movies. (initiated 11/2/22) During an interview on 11/7/24 at 8:43 A.M., the Activities Director said that Resident #25 likes room visits, but sometimes refuses those. The Activities Director said that if there is refusal of room visits, then that should be documented in the record. The Activities Director said Resident #25 only likes to talk and does not like crosswords or magazines like his/her care plan says. The Activities Director said Resident #25's care plan should have been updated after 2022. Review of the activity log sheets for November 2024 indicated Resident #25 did not receive room visits for November. Review of the activity log sheets for October 2024 indicated Resident #25 did not receive any room visits for October and was unavailable on October 27th and 28th. Review of the activity log sheets for September 2024 indicated Resident #25 did not receive any room visits for September. 41456 2. Resident #103 was admitted in January 2024 with diagnoses including dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #103 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 11/03/24 at 8:04 A.M., Resident #103 said he/she loves listening to music and would love a radio in his/her room. Resident #103 said he/she chooses not get out of bed, so does not join group activities, and a radio would be a blessing and a radio would be so nice to help pass the time. Throughout the survey, Resident #103 was never seen out of bed and was observed lying in bed, without the light to his/her room on, without television on and without a radio. There were no independent activities materials observed in his/her room. Review of Resident #103's activity care plan indicated the following interventions: -Provide resident with independent leisure materials. Resident wants to be supplied with reading materials and an occasional visit to talk about my past rolls and family. Review of Resident #103's last quarterly activity assessment dated [DATE], indicated the following: -I am independent/dependent in fulfill my activity pursuits. I enjoy being out in the neighborhood with my peers. I will join programs of special events, entertainment. I will choose which programs to join -I enjoy being with staff and peers. Review of Resident #103's medical record failed to indicate an updated activity assessment with Resident #103's choice to stay in bed. Review of Resident #103's Kardex (a form indicating the level of care each resident requires) failed to indicate any activity information. Review of the Documentation Survey Report, a report that shows participation in activities, indicated the following: - Out of 30 days in September 2024, Resident #103 had only 4 room visits and one-on-one activities. -Out of 31 days in October 2024, Resident #103 had only 4 room visits and 6 one-on-one activities. During an interview on 11/7/24 at 8:29 A.M., the Activities Director said the activities calendar is made to the Residents' preferences. The Activities Director said the activity staff should be going room to room each morning to pass out materials and to inform the residents what the activities are for the day. She said there are both group activities on the floor and room visits offered daily. The Activities Director said the staff should be documenting all participation of activities and one-to-one room visits. The Activities Director said residents often refuse activities, and this should also be documented. The Activities Director said Resident #103 only enjoys room visits and enjoys watching television. The Activities Director was unaware Resident #103 liked to listen to music and would like a radio in his/her room. She said she was unaware Resident #103 did not have his/her television on throughout survey and was unaware he/she had so few room visits. 3. Resident #87 was admitted to the facility in April 2023 with diagnoses including heart failure. Review of Resident #87's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she was cognitively intact. During an interview on 11/3/24 at 8:10 A.M., Resident #87 said there were not a lot of activities, except for Bingo, at the facility and that he/she is extremely bored in the facility. Resident #87 had no independent activity materials in his/her room for independent leisure. Throughout survey, Resident #87 was not observed in any group activities and was not observed to have any one-on-one activity visits. Review of Resident #87's activity care plan indicated the following interventions: -Modify my daily schedule, treatment plan PRN (as needed) to accommodate activity participation. -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Review of Resident #87's last quarterly activity assessment dated [DATE], indicated the following: -I am independent/dependent in my activity pursuits. Staff will invite me to programs of my choosing. My pursuits are bingo, entertainment and special events, going outside. -I enjoy being out in the neighborhood and chatting with staff and my peers. I enjoy hanging out with the men in my neighborhood. Review of Resident #87's Kardex (a form indicating the level of care each resident requires) indicated: -Ensure appropriate visual aids are available to support my participation in activities. I wear glasses for distance and reading. -Modify my daily schedule, treatment plan PRN (as needed) to accommodate activity participation. Review of the Documentation Survey Report, a report that shows participation in activities, indicated the following: - Out of 30 days in September 2024, Resident #87 had only 3 one-on-one activity visits, participated in Bingo 7 times, and participated in other activities only 12 times. -Out of 31 days in October 2024, Resident #87 had only 8 one-on-one activity visits, participated in Bingo 7 times, and participated in other activities only 11 times. During an interview on 11/7/24 at 8:29 A.M., the Activities Director said the activities calendar is made to the Residents' preferences. The Activities Director said the activity staff should be going room to room each morning to pass out materials and to inform the residents what the activities are for the day. She said there are both group activities on the floor and room visits offered daily. The Activities Director said the staff should be documenting all participation of activities and one-to-one room visits. The Activities Director said residents often refuse activities, and this should also be documented. The Activities Director said Resident #87 likes to play Bingo, likes room visits and likes to sit in the hallway to converse with other residents. She was unable to list any other activities that the Resident prefers to participate in and was unaware Resident #87 often felt bored and had not been observed in any activities during the survey period. 4. Resident #28 was admitted to the facility in September 2020 with diagnoses including chronic obstructive pulmonary disease and paranoid schizophrenia. Review of Resident #28's most recent Minimum Data Set (MDS) dated [DATE] indicated he/she had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. During an interview on 11/3/24 at 8:37 A.M., Resident #28 said there were not a lot of activities, except for Bingo, at the facility and that he/she is often bored. Resident #28 had minimal materials in his/her room for independent leisure. Throughout survey, Resident #28 was not observed in any group activities and was not observed to have any one-on-one activity visits. Review of Resident #28's activity care plan indicated the following interventions: -I enjoy live entertainment, invite me and remind me of these type of events. -I enjoy playing pool, art and painting, music and outside socials. -Remind me of the importance of remaining social and provide opportunities for me to socialize with others that have similar interests. -Check with me often to assess needs for independent materials and satisfaction with provided supplies. Review of Resident #28's cognition care plan indicated the following intervention: -Provide a program of activities that accommodate my abilities. I benefit from encouragement to attend activities and require getting assist getting to activities on/off unit. Review of Resident #28's quarterly activity assessment dated [DATE], indicated the following: -I enjoy watching TV, not very social but will occasionally chat with the men and staff in the neighborhood. Entertainment, gatherings, and special events are my choices of my choice. Review of Resident #28's Kardex (a form indicating the level of care each resident requires) indicated: -Psychosocial well-being: Provide a program of activities that accommodate my abilities. I benefit from encouragement to attend activities and require getting assist getting to activities on/off unit. Review of the Documentation Survey Report, a report that shows participation in activities, indicated the following: - Out of 30 days in September 2024, Resident #28 had only 3 one-on-one activity visits, participated in Bingo 8 times, and participated in other activities only 7 times. -Out of 31 days in October 2024, Resident #28 had only 6 one-on-one activity visits, participated in Bingo 8 times, and participated in other activities only on 11 days. -There were no refusals to participate documented. During an interview on 11/7/24 at 8:29 A.M., the Activities Director said the activities calendar is made to the Residents' preferences. The Activities Director said the activity staff should be going room to room each morning to pass out materials and to inform the residents what the activities are for the day. She said there are both group activities on the floor and room visits offered daily. The Activities Director said the staff should be documenting all participation of activities and one-to-one room visits. The Activities Director said residents often refuse activities, and this should also be documented. The Activities Director said Resident #28 likes to sit in the hallway and converse with other residents and could not list any other activities that the Resident prefers to participate in. The Activities Director was unaware Resident #28 often felt bored and had not been observed in any activities during the survey period.

Based on record review and interviews, the facility failed to develop and implement personalized care plans for four Residents (#91, #106, #117, and #323), out of a total sample of 39 residents. Specifically: 1. For Resident #91, the facility failed to develop a care plan for suicide ideation, 2. For Resident #106, the facility failed to develop a skin at risk care plan, 3. For Resident #117, the facility failed to implement a care plan for a pacemaker. 4. For Resident #323, the facility failed to implement a plan of care for skin checks. Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered, dated 2001, indicated the following: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive person-centered care plan: a. Includes measurable, objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. Includes the resident's stated goals upon admission and desired outcomes; d. Builds on the resident's strengths; e. Reflects currently recognized standards of practice for problem areas and conditions. - Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident problem areas and their causes, and relevant clinical decision making. - When possible, interventions address the underlining source(s) of the problem area(s), not just symptoms or triggers. 1. Resident #91 was admitted to the facility in May 2023 with diagnoses including bipolar disorder, major depression, anxiety, and suicidal ideations. Review of Resident #91's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she had a Brief Interview for Mental Status score of 12 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated Resident #91 required supervision for functional daily tasks. Review of Resident #91's diagnosis list includes suicidal ideation as an admitting diagnosis to the facility. Review of the Psychiatric Nurse Practitioner note, dated 10/22/24, indicated the following: - Problem: 60 yo (year old) (Male/Female) with dementia, OCD (obsessive compulsive disorder), anxiety, depression, bipolar d/o (disorder) and prior suicidal ideation is seen for a follow up. - History of SI/SA/SIB (Suicidal Ideation/Suicide Attempt/Self-Injurious Behavior): Yes Review of Resident #91's care plans failed to indicate a care plan for suicidal ideation had been developed. During an interview on 11/4/24 and 8:10 A.M., Nurse #1 and Nurse #2 said both the nurses and social worker are responsible for creating care plans upon admission and throughout a resident's stay and the care plans should address all major care areas. Nurse #1 and Nurse #2 said a suicide ideation care plan should be developed for anyone with a history of suicide ideation and if known at the time of admission, that type of care plan should be developed upon admit to the facility. Nurse #1 and Nurse #2 said they were both unaware of Resident #91's history and diagnosis of suicidal ideation. During an interview on 11/4/24 at 8:32 A.M., the Social Worker (SW) said when a new resident is admitted to the facility, she reads the discharge summary from the hospital and will develop any pertinent care plans based on the resident's diagnoses and history. The SW said this would include any psychosocial care plans. The SW said if a new resident is admitted with a history of suicidal ideation, she would expect a suicide ideation care plan to be developed upon admission. The SW said she was unaware of Resident #91's history and diagnosis of suicidal ideation. During an interview on 11/4/24 at 8:44 A.M., the Director of Nursing (DON) said she would expect any resident with a history of suicidal ideation to have a care plan developed for that diagnosis. 49880 2. Resident #106 was admitted to the facility in May 2024 with diagnoses that include protein calorie malnutrition, non-pressure chronic ulcer of the skin and lack of coordination. Review of Resident #106's most recent Minimum Data Set (MDS) Assessment, dated 8/30/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the Resident is cognitively intact. The MDS further indicates that the Resident is at risk for the development of pressure areas. Review of Resident #106's initial Norton Assessment (an assessment to determine risk for pressure ulcer development), completed 5/23/24, indicated a score of 6, which indicates high risk for skin breakdown. Review of Resident #106's Norton Assessment, completed 8/13/24, indicated a score of 14, which indicates moderate risk for skin breakdown. Review of Resident #106's active care plan failed to indicate a risk for skin breakdown care plan. During an interview on 11/6/24 at 9:32 A.M., the Director of Nursing said that if the Norton Assessment indicates risk for skin breakdown, then there should be a plan of care around risk for skin breakdown. 43846 3. Review of the facility policy titled Pacemaker, dated December 2015, indicated: - Monitoring: the pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. Resident #117 was admitted to the facility in September 2024 with diagnoses that included cardiac pacemaker, cardiac defibrillator, depression and dementia. Review of Resident #117's most recent Minimum Data Set Assessment (MDS), dated [DATE] , scored a nine out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. Review of Resident #117's Psychiatric Nurse Practitioner (NP) note, dated 9/30/24, indicated cardiac defibrillator placement and pacemaker. Review of Resident #117's pacemaker care plan, dated 10/8/24, indicated pacemaker checks as ordered. Review of Resident #117's physician orders failed to indicate pacemaker checks. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said the Resident admitted without a monitoring device for their pacemaker. Nurse #3 said she admitted Resident #61 and was not aware of when or how the Resident's pacemaker should be checked. During an interview on 11/6/24 at 10:26 A.M., Director of Nurse said pacemaker checks should have orders. 41019 4. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicates Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's care plan for skin indicated the following: Intervention: Document skin checks weekly and PRN (as needed). Notify the physician and resident/RP (representative) of new areas if observed. Follow-up as indicated. (initiated 7/5/24). Review of the weekly skin check reports failed to indicate that skin checks were being completed between 7/5/24 and 7/25/24, which was when a new wound was identified. During an interview on 11/4/24 at 4:00 P.M., Nurse #11 said that all residents have weekly skin checks. During an interview on 11/6/24 at 10:22 A.M., the Director of Nurses (DON) said skin checks should be completed weekly as ordered and said she knows it is an issue in the building.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for 12 Residents (#40, #47, #41, #92, #108, #4, #55, #12, #19, #106, #2 and #75) out of a total of 39 sampled residents. Specifically: 1. For Resident #40, the facility failed to a.) obtain a physicians order for the treatment of a skin tear and b.) failed to complete weekly skin checks as ordered. 2. For Resident #47, the facility failed to complete weekly skin checks as ordered. 3. For Resident #41, the facility failed to complete weekly skin checks as ordered. 4. For Resident #92, the facility failed to complete weekly skin checks as ordered. 5. For Resident #108, the facility failed to complete weekly skin checks as ordered. 6. For Resident #4, the facility failed to to complete weekly skin checks as ordered. 7. For Resident #55, the facility failed to a.) to complete weekly skin checks as ordered and b.) obtain weights as ordered. 8. For Resident #12, the facility failed to obtain weights as ordered. 9. For Resident #19, the facility failed to complete weekly skin checks as ordered. 10. For Resident #106, the facility failed to complete weekly skin checks as ordered. 11. For Resident #2 the facility failed to a.) implement the physician's order for an identified skin impairment, and b.) failed to provide skin checks. 12. For Resident #75 the facility failed to a.) implement the physician's order to hold insulin for a blood sugar below 100 and to notify the Medical Doctor/Nurse Practitioner his/her blood sugar was less than 100 and b.) failed to ensure weekly skin checks were implemented in accordance with the physician's order. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the American Nursing Associations Scope and Standards of Nursing Practice, 2010, pg 32, indicated the following: Standard 1. Assessment: The Registered Nurse (RN) collects comprehensive data pertinent to the consumer's health and/or the situation. Competencies: Collects comprehensive data including but not limited to physical functional, psychosocial, emotional, cognitive, age related, environmental, spiritual/transpersonal and economic assessments in a systemic and ongoing process while honoring the uniqueness of the person. Review of the Facility's Assessment of Skin Condition and Integrity policy, dated March 2021, indicated: Purpose: The purpose of this policy is to provide information regarding the routine assessment of skin integrity. Skin Assessment: Conduct a comprehensive head to toe skin assessment upon admission, weekly, prior to discharge, and as needed. Inspect the skin daily when performing or assisting with personal care or ADL's. Review of the facility policy titled Weight Assessment and Intervention, not dated, indicated Residents are weighed upon admission and at intervals established by the interdisciplinary team. 1. Resident #40 was admitted to the facility in December 2020 with diagnoses including dementia and schizophrenia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is severely cognitively impaired evidenced by a score of 3 out of a possible 15 on the Brief Interview for Mental Status exam. a). Review of the Skin Tears - Abrasions and Minor Breaks policy, dated September 2013, indicated: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears and minor breaks in the skin. Preparation: 1. Obtain a physicians order as needed. Document physician notification in medical record. On 11/3/24 at 8:05 A.M., the surveyor observed Resident #40 eating breakfast with a visible bandage on his/her lower right arm. Review of physician's orders on 11/3/24 at 10:00 A.M., indicated there were no active orders for Resident #40's right arm. Review of the Interim Skin Check dated 11/1/24 indicated Resident #40 had a sustained a skin tear on his/her right lower forearm. On 11/3/24 at 11:58 A.M., the surveyor observed Resident #40 eating lunch in dining room with his/her right forearm covered in a bandage. The Resident said he/she had banged his/her arm and the nurse covered it. The bandage had no date indicating when it was applied. During an interview on 11/3/24 at 12:02 P.M., Nurse #6, who worked yesterday, said that Resident #40 had an old scab that opened up and the hospice nurse applied the treatment dressing yesterday. Nurse #6 said the dressing should have been dated. Review of the physician's orders on 11/3/24 at 1:00 P.M., indicated the following treatment order was initiated on 11/3/24 at 12:15 P.M.: Right lower arm skin tear: cleanse with normal saline/wound cleanser, apply xeroform, cover with protective dressing. During an interview on 11/5/24 at 9:05 A.M., the Director of Nursing (DON) said that Resident #40 sustained the skin tear on 11/1/24 during a behavioral issue while he/she was thrashing around. She said Resident #40 should have had physician orders for wound treatment in place. b). Review of the physician's orders indicated: Weekly Skin Check, initiated 4/8/24. Review of Resident #40's Weekly Skin Check and Interim Skin Evaluations Assessments indicated: September 2024: A skin check was completed on 9/6/24. There were no other skin checks completed. October 2024: A skin check was completed on 10/25/24. There were no other skin checks completed. During an interview on 11/6/24 at 8:26 A.M., the Regional Nurse said orders for weekly skin checks should be completed as ordered. 2. Resident #47 was admitted to the facility in February 2024 with diagnoses including chronic obstructive pulmonary disease, Parkinson's disease and bipolar disorder. Review of Resident #47's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is severely cognitively impaired as evidenced by a score of 9 out of a possible 15 on the Brief Interview for Mental Status exam (BIMS). Additional review of the MDS dated [DATE], 5/16/24, and 7/9/24 all indicated Resident #47 scored a 9 out of a possible 15 on the BIMS. Review of Resident #47's physician's orders indicated: Skin Check Weekly, initiated 2/16/24. Review of Resident #47's Weekly Skin Check and Interim Skin Checks Assessments indicated: September 2024: Skin checks were completed on 9/1/24 and 9/21/24. No other skin checks were completed. October 2024: A skin check was completed on 10/10/24. No other skin checks were completed. November 2024: A skin check were completed on 11/1/24. No other skin checks were completed. During an interview on 11/6/24 at 8:26 A.M., the Regional Nurse said that weekly skin checks should be completed as ordered. 3. Resident #41 was admitted to the facility in July 2020 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and schizophrenia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #41 was moderately cognitively impaired evidenced by a score of 9 out of a possible 15 on the Brief Interview for Mental Status Exam. Review of Resident #41's current physician's orders indicated: Skin Check Weekly. Review of Resident #41's Weekly Skin Checks and Interim Skin Check Assessments indicated: August 2024: A skin check was completed on 8/12/24. No other skin checks were completed. September 2024: A skin check was completed on 9/2/24. No other skin checks were completed. October 2024: No skin checks completed. November 2024: No skin check completed. During an interview on 11/6/24 at 8:26 A.M., the Regional Nurse said that weekly skin checks should be completed as ordered. 4. Resident #92 was admitted to the facility in October 2022 with diagnoses including schizophrenia and repeated falls. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #92 is severely cognitively impaired and requires assistance with transfers and bathing. Review of the physicians orders indicated: Skin check weekly, initiated 4/8/24. Review of Resident #92's Weekly Skin Checks and Interim Skin Assessment Evaluations indicated no skin checks had been completed for October 2024 and November 2024. During an interview on 11/6/24 at 8:26 A.M., the Regional Nurse said that weekly skin checks should be completed as ordered. 43846 5. Resident #108 was admitted to the facility in October 2024 with diagnoses that included protein-calorie malnutrition, adult failure to thrive, and mood disorder. Review of Resident #108's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored a 15 out of a 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Further review of the MDS indicated the Resident has an unhealed pressure ulcer and is at risk for developing pressure ulcers. Review of Resident #108's physician's order, dated 10/16/24, indicated Weekly Skin Check on: Day: Shift: every evening shift every Wednesday. Review of Resident #108's evaluation tab indicated the only skin check completed was on 10/9/24. Review of Resident #108's October 2024 Medication Administration Record (MAR) indicated 10/16/24, 10/23/24, 10/30/24 was signed off by nursing staff as completed as ordered. Review of Resident #108's skin breakdown care plan, dated 10/20/2024, indicated Document skin checks weekly and PRN. Notify the physician and resident/RP (representative) of new areas if observed. Follow-up as indicated. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said skin checks should be completed weekly as ordered and they would be completed in the evaluation section of the medical record. During an interview on 11/6/24 at 10:22 A.M., the Director of Nurses (DON) said skin checks should be completed weekly as ordered and said she knows it is an issue in the building. 6. Resident #4 was admitted to the facility in September 2023 with diagnoses that included Post Traumatic Stress Disorder (PTSD) hemiplegia and hemiparesis, bipolar disorder, anxiety and depression. Review of Resident #4's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored a 14 out of a possible 15 on the Brief Interview for mental status indicating intact cognition. Further review of the MDS indicated the Resident does not reject care. Further review of the MDS indicated that the Resident is at risk for developing pressure ulcers. Review of Resident #4's physician order, dated 4/24/24, indicated Skin Checks weekly on Monday 7-3 (7:00 A.M. to 3:00 P.M.). Review of Resident #4's evaluation tab, indicated the last skin check completed was 9/22/24 and prior to that was 8/3/24. Review of Resident #4's nursing progress notes from 8/1/24 through 11/4/24 failed to indicate that the Resident refused skin checks. Review of Resident #4's skin breakdown care plan, dated 10/5/2023, indicated Document skin checks weekly and PRN. Notify the physician and resident/RP of new areas if observed. Follow-up as indicated. Review of Resident #4's October and November 2024 Treatment Administration Record (TAR), indicated on 10/7/24, 10/14/24, 10/21/24, 10/28/24, 11/4/24 that skin checks were completed as ordered. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said skin checks should be completed weekly as ordered and they would be completed in the evaluation section of the medical record. During an interview on 11/6/24 at 10:22 A.M., the Director of Nurses (DON) said skin checks should be completed weekly as ordered and said she knows it is an issue in the building. 7. Resident #55 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes, cellulitis of right and left lower limb, protein-calorie malnutrition, anxiety and major depressive disorder. Review of Resident #55's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairments. Further review of the MDS indicated the Resident is at risk for developing pressure ulcers and has three unhealed pressure ulcers. a. Review of Resident #55's physician order, dated 10/7/24, indicated Weekly Skin Check on: every evening shift every Monday. Review of Resident #55's evaluation tab, indicated the only skin check that was completed by facility nursing staff was on 10/7/24. Review of Resident #55's October and November 2024 Medication Administration Record (MAR), indicated on 10/14/24, 10/21/24, 10/28/24, and 11/4/24 were signed off by nursing as completed as ordered. Review of Resident #55's nursing progress notes from 10/14/24 through 11/4/24 failed to indicate the Resident refused the skin checks or weights. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said skin checks should be completed weekly as ordered and they would be completed in the evaluation section of the medical record. During an interview on 11/6/24 at 10:22 A.M., the Director of Nurses (DON) said skin checks should be completed weekly as ordered and said she knows it is an issue in the building. b. Review of Resident #55's physician order, dated 10/15/24, indicated Weights Weekly one time a day every Wednesday. Review of Resident #55's nutrition care plan, dated 10/16/24, indicated Obtain weights at ordered intervals. Review of Resident #55's nutritional risk assessment, dated 10/21/24, indicated Re-weight pending d/t weight discrepancies. Weekly wt's x 4 weeks (weights times four weeks) from admission. Review of Resident #55's Nurse Practitioner (NP) progress note, dated 10/23/24, indicated Protein-calorie malnutrition: Monitor weights. Review of Resident #55's weight tab indicated the only weight taken was on 10/9/24. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said weights should be completed as ordered. During an interview on 11/6/24 at 10:23 A.M., the Director of Nurses (DON) said weights should be obtained as ordered and documented in the medical record. During an interview on 11/6/24 at 10:50 A.M., the Dietitian said weights should be obtained as ordered and said she is aware that Resident #55 is not being weighed as ordered. 8. Resident #12 was admitted to the facility in August 2023 with diagnoses that included cirrhosis of the liver, anxiety, portal vein thrombosis, and pancytopenia. Review of Resident #12's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Review of Resident #12's nutrition note, dated 10/15/24, indicated Resident d/w (discussed with) IDT (interdisciplinary team) at At Risk Meeting d/t (due to) significant weight changes. Chart reviewed. Weights changed to 2x/w (two times a week). RD (Registered Dietitian) believes weight on 9/24 is inaccurate. Review of Resident #12's nursing progress note, dated 10/15/24, indicated Resident daily weights changed to 2x/week per NP (Nurse Practitioner) scheduled Mondays and Thursdays. Review of Resident #12's October and November 2024 Medication Administration Record (MAR), indicated 10/21/24, 10/24/24, 10/28/24, and 10/31/24 that weights were not obtained as ordered. During an interview on 11/6/24 at 10:00 A.M., Nurse #3 said weights should be completed as ordered. During an interview on 11/6/24 at 10:23 A.M., the Director of Nurses (DON) said weights should be obtained as ordered and documented in the medical record. During an interview on 11/6/24 at 10:50 A.M., the Dietitian said weights should be obtained as ordered and said she is aware that Resident #12 is not being weighed as ordered. 49880 9. Resident #19 was admitted to the facility September 2024 with diagnoses that include acute respiratory failure with hypoxia and aspiration. Review of Resident #19's most recent Minimum Data Set (MDS) Assessment, dated as 10/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicates that the Resident is at risk for pressure ulcer development and failed to indicate any behaviors for refusal of care. Review of Resident #19's physician's orders indicated the following: -Weekly skin checks every Monday day shift, dated 10/7/24. Review of Resident #19's active potential for skin breakdown care plan, dated 11/1/24, indicated to document skin checks weekly and PRN (as needed). Review of Resident #19's medical record failed to indicate that a weekly skin check had been completed since admission to the facility. Further review of the medical record failed to indicate that a Norton Assessment (an assessment to determine the risk for pressure ulcer development) had been completed since admission to the facility. During an interview on 11/5/24 at 12:26 P.M., Nurse #2 said that a physician's order for skin checks means that the nurse should do a head-to-toe assessment and document it in the evaluations portion of the electronic medical record under weekly skin checks. During an interview on 11/6/24 at 9:31 A.M., the Director of Nurses said that if there is an order for weekly skin checks then the nurses should be documenting their assessments in the evaluations tab in the electronic medical record to indicate it was completed. 10. Resident #106 was admitted to the facility in May 2024 with diagnoses that include protein calorie malnutrition, non-pressure chronic ulcer of the skin and lack of coordination. Review of Resident #106's most recent Minimum Data Set (MDS) Assessment, dated 8/30/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicates that the Resident is at risk for the development of pressure areas. Review of Resident #106's most recent Norton Assessment (an assessment to determine risk for pressure ulcer development) completed 8/13/24 indicated a score of 14, which indicates moderate risk for skin breakdown. Review of Resident #106's physician's orders indicated the following: -Weekly skin check on Tuesday 7-3, dated 10/21/24. Review of weekly skin checks indicated that since admission, skin checks have been completed only on the following dates: 5/23/24, 7/14/24, 8/4/24, 8/11/24 and 9/7/24. During an interview on 11/5/24 at 12:26 P.M., Nurse #2 said that a physician's order for skin checks means that the nurse should do a head-to-toe assessment and document it in the evaluations portion of the electronic medical record under weekly skin checks. During an interview on 11/6/24 at 9:31 A.M., the Director of Nurses said that if there is an order for weekly skin checks then the nurses should be documenting their assessments in the evaluations tab in the electronic medical record to indicate it was completed. 36431 11. Resident #2 was admitted to the facility in May 2024 and has diagnoses that include chronic obstructive pulmonary disease, weakness, ventricular fibrillation, peripheral vascular disease, and unspecified dementia. Review of the Minimum Data Set assessment, dated 8/21/24, indicated Resident #2 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment and required partial to moderate assistance from staff for toileting, and bathing. Review of Resident #2's care plans indicated the following: A Care plan focus: I have potential for impaired skin integrity r/t (related to) . (was blank), dated 5/22/24. Interventions included, -Administer treatments as ordered and monitor effectiveness, Monitor for new or worsening s/sx (signs and symptoms) of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness fever, chills, etc. Report to physician if noted and follow-up as indicated, date initiated 5/22/24. a. During an observation and interview on 11/3/24 at 8:00 A.M., Resident #2's right forearm had multiple scabbed areas the size of pencil erasers and smaller reddened areas. Resident #2 scratched the areas then said it was not itchy. Resident #2 said his/her feet looked worse and proceeded to take off his/her left sock revealing a scaly, red, discolored left lower extremity from the calf down. When asked what was being done about his/her skin, he/she pointed to a bottle of body wash. On 11/04/24 at 8:25 A.M., Resident #2 was observed in his/her room. Resident #2's right forearm was observed with multiple round dark red areas consistent with scabbing and smaller scattered redness on his/her skin. His/her left arm had a smaller amount of reddened areas on his/her forearm. At this time Resident #2's lower extremities were not observed. On 11/4/24 at 11:00 A.M., Resident #2 was observed sitting on the side of his/her bed in the dark with the television on. Resident #2 used his/her left hand to scratch his/her right forearm that had scattered pencil eraser size and smaller reddened areas on his/her forearm. On 11/5/24 at 7:26 A.M., Resident #2 was observed sitting on the side of his/her bed. Resident #2's right forearm had red scabbed areas and a few smaller areas on his/her left arm. Resident #2 pointed to a bottle of body wash and said they use that for his/her skin. Review of Resident #2's medical record indicated the following: -A health status progress note dated 10/29/24 entered by nursing, Note text: Resident noted with rash, bilateral arms, feet, groin, new order to wash areas with soap and water, dry and apply antifungal cream twice daily. -A weekly skin check dated 10/30/24, are there any skin impairments noted? yes, type of skin impairment rash site 1d. groin, 2d. other specify feet, and 3d. other both hands. The weekly skin check did not indicate any areas on Resident #2's forearms or lower extremities. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 10/29/24-10/31/24, failed to indicate that the treatment order to wash areas with soap and water, dry and apply antifungal cream twice daily for Resident #2 was implemented. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 11/1/24-11/5/24 failed to indicate that the treatment order to wash areas with soap and water, dry and apply antifungal cream twice daily for Resident #2 was implemented. During an interview on 11/6/24 at 7:08 A.M., Nurse #10 said if a Resident is identified with a skin area the DON is notified the NP/MD (nurse practitioner/Medical doctor) is notified and a treatment order is put in place. Nurse #10 said she got in report that Resident #2 has a rash on his/her hands and legs. Nurse #10 reviewed Resident #2's, physician's orders and said there was no order entered for the antifungal treatment and that the treatment order should be there. b. Review of Resident #2's active orders indicated an order dated 10/23/24 skin checks weekly on Wednesdays 3-11. Review of Resident #2's care plans indicated a care plan dated 5/22/24 that indicated I have potential for impaired skin integrity r/t (related to) . was left blank. The care plan failed to indicate the intervention to for weekly skin checks. Review of Resident #2's medical record indicated the following: -PCC skin and Wound-Norton Plus Assessments dated 5/27/24 with a score of 15, and 8/18/24 with a score of 14 indicating Resident #2 is at moderate risk for developing pressure injuries. Further review of Resident #2's medical record indicated the following: -A MAR dated 8/1/2024-8/31/24 failed to indicate an order for weekly skin checks. There was no order data found for a TAR dated 8/2024. -A MAR dated 9/1/2024-9/30/24 failed to indicate an order for weekly skin checks. There was no site administration data for the 9/2024 TAR. -A TAR dated 10/1/24 -1031/2024 indicated an order with a start date 10/23/24, skin checks weekly on Wednesday 3-11 one time a day. Review of the completed weekly skin check V.2019-V4-NE for Resident #2 indicated the following: -A weekly skin check was completed on 5/22/24. No further weekly skin checks were completed for over 6 weeks, until a weekly skin check was completed on 7/1/24. -A weekly skin check was completed 7/1/24. No further weekly skin checks were completed for over 8 weeks, until a weekly skin check was completed on 9/1/24. -A weekly skin check was completed 9/1/24. No further weekly skin checks were completed for over 6 weeks, until a skin check was completed on 10/23/24. During an interview on 11/6/24 at 8:08 A.M., the Director of Nursing said all residents are expected to have weekly skin checks completed with no exception, and documented on the weekly skin evaluation document in the medical record. 12. For Resident #75 the facility failed to implement the physician's order to hold insulin for a blood sugar below 100 and to notify the Medical Doctor/Nurse Practitioner that his/her blood sugar was less than 100, and b.) failed to complete weekly skin checks. Resident #75 was admitted to the facility in September 2020 and has diagnoses that include Diabetes Mellitus, and type 2 Diabetes Mellitus with diabetic chronic kidney disease. Review of the Minimum Data Set assessment, dated 9/6/24, indicated Resident #75 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately intact cognition and is dependent on staff for care. a.) Review of the facility's policy titled Diabetes-Clinical Protocol, not dated included but was not limited to the following: Treatment/Management 1. Based on preceding assessment, including causes and complications, the Physician will order appropriate interventions, which may include: d. Insulin. Monitoring and Follow-Up 4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. During an observation and interview on 11/3/24 at 8:47 A.M., Resident #75 was observed eating his/her breakfast. He/she said the nursing staff checks his/her blood sugars and that he/she is diabetic. Review of Resident #75's medical record indicated the following: -A care plan dated 9/16/202, I have Diabetes Mellitus, with the intervention Diabetes medication as ordered by the doctor. -A Physician's order NovoLog (a rapid acting insulin) mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector (70-30) 100 unit/ML (insulin Aspart Protamine and Aspart (Human) Inject 15 unit subcutaneously two times a day related to Diabetes Mellitus Due To Underlying Condition With Diabetic Mononeuropathy, Hold if Blood Sugar is less than 100 before meals, notify the MD (medical doctor) if Blood Sugar is less than 100 and monitor, dated 9/5/24. Review of Resident #75's October 2024 MAR indicated the following recorded blood sugars documented at 4:30 P.M. -October 2, 2024, Blood Sugar 94. -October 4, 2024, Blood Sugar 74. -October 6, 2024, Blood Sugar 93. -October 8, 2024, Blood Sugar 83. Further, review of the MAR indicated the Novolog Mix 70/30 FlexPen was signed off as administered on October 2, 2024, October 4, 2024, October 6, 2024, and October 8, 2024, when Resident #75's blood sugar was below 100, resulting in 4 doses of unnecessary Novolog. Review of the progress notes in Resident #75's medical record, dated October 2024 failed to indicate any nursing entries that Resident #75's physician or nurse practitioner were notified of the recorded blood sugars below 100, nor were there notes indicating the monitoring of Resident #75, when his/her blood sugar was below 100. During an interview on 11/4/24 at 11:19 A.M., Nurse #7 reviewed the MAR and said on the days when Resident #75's Blood Sugars were documented below 100 the Novolog insulin should not have been administered. During an interview on 11/6/24 at 1:32 P.M., the Director of Nursing said if the orders said to call the doctor when the blood sugar is below 100, then the call should have been made, documented in the medical record, and the Resident should be monitored. b.) Review of Resident #75's physician's orders indicated an order dated 4/8/2024, Skin Check Weekly Mondays, 3-11 one time a day every MON (Monday), Document Findings on PCC evaluations tab: Review of Resident #75's weekly skin checks and interim skin evaluations indicated the following: May 2024, the week of 5/20/24, failed to have a weekly skin check. June 2024, the week of 6/24/24, failed to have a weekly skin check. July 2024, the week of 7/8/24, failed to have a weekly skin check. August 2024, the week of 8/19, failed to have a weekly skin check. September 2024 a weekly skin check was completed on 9/2/24. There were no other weekly skin checks completed. October 2024, one interim skin evaluation dated 10/17/24. There were no other weekly skin checks completed. During an interview on 11/4/24 at 4:00 P.M., Nurse #11 said that all residents have weekly skin checks. Nurse #11 said Resident #75 is at risk for developing impaired skin due to having diabetes and not wanting to get out of bed. Nurse #11 reviewed the medical record and said the last recorded weekly skin check was dated 9/2/24.

Based on observation, record review and interview, the facility failed to ensure six Residents (#41, #43, #73, #87, #61 and #19) were provided a dignified existence and were able to exercise their rights as residents of the facility, out of a total of 39 sampled residents. Specifically; 1. For Resident #41, Resident #43, Resident #73, and Resident #87 the facility failed to ensure mail in ballots were obtained and submitted for the 11/5/24 Presidential election. 2. For Resident #61, the facility failed to respect the Residents right to self determination when he/she expressed interest in being intimate with his/her spouse. 3. For Resident #19, the facility failed to ensure a dignified dining experience when staff stood over the Resident while assisting with meals. Findings include: Review of the facility policy titled Voting Rights, undated, indicated: - Residents are encouraged to exercise their right to vote in local, state and national elections. The facility assists residents expressing a desire to vote. The Resident exercises his or her right to vote without interference, coercion, discrimination or reprisal from the facility or facility staff. 1a. Resident #41 was admitted to the facility in July 2020 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and schizophrenia. Review of the Minimum Data Set Assessment, dated 9/25/24, indicated Resident #41 was moderately cognitively impaired evidenced by a score of nine out of a possible 15 on the Brief Interview for Mental Status Exam. On 11/03/24 at approximately 7:45 A.M., and 12:00 P.M. the surveyor observed a sealed absentee ballot addressed to Resident #41 for the presidential election on top of desk at Hale Unit Nursing station. The undelivered sealed absentee ballot was postmarked 10/4/24. During an interview on 11/3/24 at 1:32 P.M., the Activities Director said that she had worked with the Resident and completed his/her ballot, and it was sent out. During an interview on 11/4/24 at 11:35 A.M., the Regional Activities Director said she was aware the Activities Director had been registering residents to vote, however, was unaware of how many residents still needed absentee ballots. The Regional Activities Director said the Activities Director seemed to not be aware that after registering a resident to vote, there still had to be a request for an absentee ballot and assistance with mailing the ballot back. Review of checkmyballot.org indicated Resident #41's ballot was mailed to the facility on [DATE] and not returned to the clerks office. During an interview on 11/6/24 at approximately 7:15 A.M., the Activities Director said she made a mistake by not following up and confirming resident's ballots were sent out or residents were registered locally to vote. 41456 1b. Resident #43 was admitted to the facility in January 2024 with diagnoses including muscular dystrophy. Review of Resident #43's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she was cognitively intact. During an interview on 11/3/24 at 8:28 A.M., Resident #43 said he/she would like to vote and he/she has not been assisted with this. During an interview on 11/3/24 at 1:15 P.M., the Activities Director said she has gotten every resident who wanted to vote registered and has sent all the registrations and absentee ballots back in to the voting center. The Activities Director provided the surveyor with the list of residents registered to vote and Resident #43 was not on the list. During an interview on 11/4/24 at 11:35 A.M., the Regional Activities Director said she was aware the Activities Director had been registering residents to vote, however, was unaware of how many residents still needed absentee ballots. The Regional Activities Director said the Activities Director seemed to not be aware that after registering a resident to vote, there still had to be a request for an absentee ballot and assistance with mailing the ballot back. During a follow-up interview on 11/4/24 at 1:32 P.M., the Activities Director again said she had registered residents to vote but was unable to provide a full list of all residents who had successfully sent in absentee ballots. Review of checkmyballot.org failed to indicate Resident #43 was sent an absentee ballot. During an interview on 11/5/24 at approximately 7:15 A.M., the Activities Director said she made a mistake by not following up and confirming residents ballots were sent out or residents were registered locally to vote and Resident #43 had not yet voted. 1c. Resident #73 was admitted to the facility in September 2020 with diagnoses including heart failure. Review of Resident #73's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she is cognitively intact. During an interview on 11/3/24 at 7:53 A.M., Resident #73 said he/she was never given a mail-in ballot and he/she really wanted to vote because it is an important right. During an interview on 11/3/24 at 1:15 P.M., the Activities Director said she has gotten every resident who wanted to vote registered and has sent all the registrations and absentee ballots back in to the voting center. The Activities Director provided the surveyor with the list of residents registered to vote and Resident #73 was on the list as already have voted. During an interview on 11/4/24 at 11:35 A.M., the Regional Activities Director said she was aware the Activities Director had been registering residents to vote, however, was unaware of how many residents still needed absentee ballots. The Regional Activities Director said the Activities Director seemed to not be aware that after registering a resident to vote, there still had to be a request for an absentee ballot and assistance with mailing the ballot back. During a follow-up interview on 11/4/24 at 1:32 P.M., the Activities Director again said she had registered residents to vote but was unable to provide a full list of all residents who had successfully sent in absentee ballots. Review of checkmyballot.org failed to indicate Resident #73 was sent an absentee ballot. During an interview on 11/5/24 at approximately 7:15 A.M., the Activities Director said she made a mistake by not following up and confirming residents ballots were sent out or residents were registered locally to vote and Resident #73 had not yet voted. 1d. Resident #87 was admitted to the facility in April 2023 with diagnoses including heart failure. Review of Resident #87's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she was cognitively intact. During an interview on 11/3/24 at 1:44 P.M., Resident #87 said he/she had not been given an absentee ballot and would like to vote and the right to vote is extremely important to him/her. During an interview on 11/3/24 at 1:15 P.M., the Activities Director said she has gotten every resident who wanted to vote registered and has sent all the registrations and absentee ballots back in to the voting center. The Activities Director provided the surveyor with the list of residents registered to vote and Resident #87 was on the list as already voted. During an interview on 11/4/24 at 11:35 A.M., the Regional Activities Director said she was aware the Activities Director had been registering residents to vote, however, was unaware of how many residents still needed absentee ballots. The Regional Activities Director said the Activities Director seemed to not be aware that after registering a resident to vote, there still had to be a request for an absentee ballot and assistance with mailing the ballot back. During a follow-up interview on 11/4/24 at 1:32 P.M., the Activities Director again said she had registered residents to vote but was unable to provide a full list of all residents who had successfully sent in absentee ballots. Review of checkmyballot.org failed to indicate Resident #87 was sent an absentee ballot. During an interview on 11/5/24 at approximately 7:15 A.M., the Activities Director said she made a mistake by not following up and confirming residents ballots were sent out or residents were registered locally to vote and Resident #87 had not yet voted. 43846 2. Review of the facility policy titled Resident Rights, not dated, indicated employees shall treat all residents with kindness, respect, and dignity. e. self-determination; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. Resident #61 was admitted to the facility in August 2023 with diagnoses that included cerebral infarction, type 2 diabetes, and anxiety. Review of Resident #61's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated the Resident had intact cognition. Further review of the MDS indicated the Residents' health care proxy had not been invoked. Review of Resident #61's nursing progress note, dated 10/24/24, indicated the following: - CNA (Certified Nurse Aide) came to this writer and asked for this writer to speak with resident. Resident had made a comment stating I want to have sex with my [spouse] I have not had sex in 3 years. Resident wanted to know if sex in the facility was a possibility. This writer stated that it was not a good idea as resident was not strong enough and it could reopen coccyx wound. During an interview on 11/6/24 at 8:43 A.M., Resident #61 said he/she would like to have private time with his/her spouse but staff told them it was not a good idea and did not want him/her to engage in that activity. During an interview on 11/6/24 at 8:46 A.M., Nurse #3 said she was the nurse that had the conversation with Resident #61 about intimacy with his/her spouse. Nurse #3 said she educated the Resident against having any intimacy with their spouse. Nurse #3 said she told the Resident to wait until he/she was discharged home because it would not be appropriate because the Resident has a roommate. Nurse #3 said she didn't know it if intimacy was allowed in long term care and said she was not sure if she told anyone of the Resident's wishes. During an interview on 11/6/24 at 8:51 A.M., the Social Worker said Resident #61 is cognitively intact and is able to make their own choices. The Social Worker said if the Resident wants to have intimate relations with his/her spouse the facility would have to make accommodations for that. The Social Worker said she was unaware that Resident #61 wanted to have intimate relations with their spouse at the facility. 49880 3. Resident #19 was admitted to the facility September 2024 with diagnoses that include acute respiratory failure with hypoxia and aspiration. Review of Resident #19's most recent Minimum Data Set (MDS) Assessment, dated 10/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. Review of Resident #19's active ADL (activities of daily living) care plan, dated as initiated 10/1/24, indicated the following intervention for eating: - I require supervision with eating and drinking, dated 10/21/24. The surveyor made the following observations of Resident #19 during meals: - On 11/3/24 at 11:57 A.M., a staff member was assisting Resident #19 with his/her meal and was standing over the Resident to assist. - On 11/4/24 at 8:02 A.M., a staff member was standing over Resident #19 to assist him/her with their breakfast meal. The staff member stood over the Resident for the duration of the meal. - On 11/5/24 at 8:11 A.M., a staff member was supervising and assisting Resident #19 with his/her breakfast meal while standing over the Resident who was sitting on the side of the bed. During an interview on 11/5/24 at 8:24 A.M., Certified Nursing Assistant (CNA) #2 said that staff should be sitting while assisting residents with their meals. During an interview on 11/5/24 at 8:25 A.M., Nurse #3 said that staff should not be standing over the Resident while assisting with meals and should be sitting at the Resident's level while assisting. During an interview on 11/6/24 at 9:29 A.M., the Director of Nursing said that she would expect staff to sit while assisting residents with meals as it is more dignified than standing over them.

Based on observations, interviews and record review, the facility failed to provide services for two Residents (#37 and #52) out of a total sample of 31 residents that resulted in mental anguish and psychological distress. Specifically: 1. For Resident #37, the facility failed to follow up on the Resident's voiced side effect concerns and schedule an eye specialist appointment as recommended by the optometrist which resulted in psychological harm and mental anguish. 2. For Resident #52, the facility failed to provide bladder incontinence care which resulted in the Resident experiencing psychological distress leading to suicidal ideations. Findings include: A review of the facility policy titled 'Abuse and Neglect-Clinical Protocol' revised July 2017 indicated the following: *Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including caretaker of goods and services that are necessary to attain or maintain physical, mental and psychological wellbeing. *Neglect as defined at 483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the facility policy titled 'Visually impaired Resident Care' with no revision date indicated the following: *While it is not required that our facility provide devices to assist with vision, it is our responsibility to assist the resident and representatives in locating available resources , scheduling appointments and arranging transportation to obtain needed services. 1. Resident #37 was admitted to the facility in October 2022 with diagnoses including glaucoma. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. On 10/22/23 at 9:18 A.M., Resident #37 told the surveyor he/she gets several eye drops throughout the day. Some of the staff do not always administer the correct amount of drops as ordered. The Resident stated he/she has taken these eye drops for a while but recently, his/her eyes, mostly the left eye stings, feels irritated and appears red. The Resident said he/she is very scared and worried about the whole situation. Resident #37 said he/she does not trust most of the nurses, he/she is afraid to go blind, he/she has requested to see an eye doctor, but no one has scheduled an appointment yet. During this conversation, Resident #37 appeared upset, evidenced by rocking his/her body back and forth. On 10/23/23 at 9:09 A.M., Resident #37 told the surveyor that one of the eye drops was administered wrong and that he/she got two drops instead of one. Resident #37 said his/her eyes stung, the left eye felt irritated, and a different nurse who he/she trusts was assigned to give him/her the rest of his/her eye drops throughout the rest of the day. The Resident was rocking back and forth, told the surveyor he/she is fearful of going blind. The surveyor observed Resident #37's left eye appeared red and irritated. The Resident said he/she needs to see an eye doctor, and that he/she has requested the Nurses to make an appointment for him/her, but no appointment has been scheduled yet. During an observation on 10/25/23 at 10:19 A.M., Nurse #10 had just finished administering Resident #37's eye drops. Resident #37 told the surveyor that the Nurse had administered them correctly, but his/her eyes, especially the left eye, was stinging and felt irritated. Resident #37 said that deep down he/she knows something is wrong and he/she does not want to go blind. Resident #37 went on to say that his/her son went blind in one eye, and he/she does not want to go through the same ordeal. The Resident requested Nurse #10 to schedule an eye appointment for him/her. Nurse #10 proceeded to tell the Resident that nothing was wrong and his/her eyes were stinging because the eye drops touched his/her eyelid during administration. The Resident started rocking back and forth as the Nurse moved on to take care of the next resident. Resident #37 told the surveyor he/she has seen an eye doctor in the facility before and he/she wants to see them again. During an interview with Resident #37 on 10/26/23 at 6:49 A.M., he/she told the surveyor he/she has been up most of the night concerned about his/her eyes because they are now blurry, especially the left eye. Resident #37 said the eyes are blurry off and on. The left eye is usually more blurry than the right eye. The surveyor asked if Resident #37 could see the surveyor clearly, he/she said he/she could only see a blurry figure. The Resident said this has happened before during bingo which is his/her favorite activity, and he/she was not able to participate in the activity and enjoy the game because he/she could not see clearly. The Resident said his/her love of bingo has been affected by the condition of his/her eyes. Resident #37 said he/she was very nervous about everything happening with his/her eyes and he/she did not want to go blind. A review of Resident #37's behavioral health notes dated 9/28/23 indicated the chief complaint as agitation and aggression with target symptoms of anxiety and confusion. The note indicated that Resident #37 sometimes stays up all night and has more behaviors when this happens, Resident #37 appeared flat during that meeting, and was rocking his/her body back and forth. A review of Resident #37's behavioral health notes dated 10/10/23 indicated the chief complaint as anxiety, with target symptoms of agitation and anxiety. A review of Resident #37's October 2023 physician's orders indicated the following: *Brimonidine Tartrate Solution 0.2% instill 1 drop in left eye three times a day related to glaucoma. *Dorzolamide HCI solution 2% instill 1 drop in both eyes three times a day related to glaucoma. *Latanoprost solution 0.005% Instill 1 drop in left eye at bedtime related to glaucoma. During an interview with Nurse #6 on 10/26/23 at 7:17 A.M., she said Nurses should follow the physician's orders while administering medications and it is the responsibility of the Nurse administering medications to listen to residents voicing concerns after medications are administered. Nurse #6 said the Nurse is expected to reach out to the physician for further instructions especially if the concerns the resident is voicing are causing them pain and distress. During an interview with the Director of Nurses on 10/26/23 at 7:53 A.M., she said she expects the Nurses to follow the physician's orders while administering medications, she also expects the Nurses to monitor any side effects from the medications they administer to the Residents, she also expects the Nurses to listen to residents who are expressing distress and pain after getting their medications. She expects the Nurses to notify the physician of the resident's concerns. She said an appointment had been made for the resident to be seen by an eye doctor. The Director of Nurses provided an email dated 10/24/23 to the eye care group requesting the resident to be seen. A review of the visual function related to glaucoma care plan initiated 11/8/22 indicated the following interventions: *Arrange consultation with eye care practitioner as needed *Monitor/document/report to MD s/sx of acute eye problems, sudden vision loss, pupils dilated, gray or milky, halos around lights, double vision, tunnel vision, blurred or hazy vision. *Ensure appropriate visual aids are available to support participation in activities. A review of the October 2023 Physician's orders indicated the following: *Monitor the left eye redness and notify the provider of any changes, alterations of vision every shift. Start date 10/23/23. A review of the eye care group notes dated 8/29/23 indicated the following plan: Please make ophthalmology appointment for further testing due to continued eye pressure in left eye despite medication, can try Microsurgical eye consultants [PHONE NUMBER], risk of permanent vision loss if patient is not seen. During a telephone interview with the Resident's son on 11/6/23 at 8:30 A.M., he told the surveyor he has been having concerns with the facility regarding his father/mother's doctor's appointments, he is the primary invoked health care proxy, no one has reached out to him regarding the recommendation given on 8/29/23 by the eye doctor for his parent to see an eye consultant specialist. He is worried because his parent has recently been concerned with his/her eyes. During a telephone interview 11/6/23 at 11:19 A.M., the Concierge said she is responsible for making follow up doctor's appointments for residents in the facility. She said Nurses are expected to review any clinical recommendations left by the physicians. The Nurses then direct her to schedule appointments. The Concierge said she was notified about making a follow up eye appointment for the Resident with the eye consultant a week ago, during the survey. The Concierge said she was not made aware that Resident #37 required a follow up appointment for his/her optometry visit on 8/29/23. During an interview with the Optometrist on 10/27/23 at 4:11 P.M., she said the eye drops the Resident takes do cause side effects such as stinging, irritability, red eyes, and blurriness and some of the side effects can last for a period of 15-20 minutes. She said that Resident #37's left eye has cataracts with continued pressure elevation and the right eye already had surgery. The Optometrist said she made a recommendation for the Resident to be seen by a specialist on 8/29/23. The Optometrist said she did tell Resident #37 the appointment needed to be made a soon as possible or he/she could face permanent vision loss. The Optometrist said she told Resident #37 the specialist would offer other options including eye surgery which if the Resident agreed to, could reduce the amount of eye drops he/she has to take, which in turn would reduce the side effects and his/her constant worry. The Optometrist said she was not aware that this appointment with the specialist had not been made by the facility, it can take months to get an appointment with this specialist. She said the requested appointment with the Optometrist made by the Director of Nurses for Resident #37 on 10/24/23 did not need to be made as there was already one scheduled for Resident #37 for 1/12/24. 2. Resident #52 was admitted to the facility in March 2020 with diagnoses including hemiplegia and hemiparesis, functional urinary incontinence and a history of a suicide attempt. Review of the facility policy titled 'Urinary Continence and Incontinence' revised August 2022 indicated the following: *The staff and practitioner will appropriately screen for and manage individuals with urinary incontinence *Nursing staff will seek and document details related to continence, relevant details include the following, voiding patterns(frequency, volume, night time or daytime, quality of stream). *An evaluation will include a review of medications that might affect continence such as diuretics (may cause urgency, frequency, or overflow incontinence). A review of the Resident's most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 12 out of a possible 15 indicating moderate impairment. Further review of the MDS indicated Resident #52 is always incontinent of urine. During an interview with Resident #52 on 10/22/23 at 9:03 A.M., he/she told the surveyor that at the beginning of last week, (10/15/23), he/she was left to sit in urine for a period of more than six hours and the Certified Nurses Assistants (CNAs) on the unit were being mean to him/her and refused to change him/her. Resident #52 said he/she had to call his/her daughter for help. Resident #52 said this happens often and in those moments, he/she feels hopeless, sad, angry, helpless and starts to have suicidal thoughts. Resident #52 said the CNAs refuse to come and change him/her when he/she presses the call bell for help. A review of Resident #52's behavioral health notes dated 10/21/23 indicated a psychiatric history of depression with suicide attempt, and the Resident reporting low mood and frustration with inpatient setting. A review of Resident #52's behavioral health notes dated 10/10/23 indicated a psychiatric history of depression with suicide attempt, and mood as congruent with current frustrated mood. A review of the Resident's Activities of Daily Living (ADL) care plan initiated 12/2/22 indicated the following: *Personal hygiene-I am dependent on staff for grooming and personal hygiene *Toileting-I am dependent on staff for toileting Further review of the Resident's October Medication Administration Record (MAR) indicated the following: *Lasix (a medication used to treat excess fluid in the body which can cause increased urination) oral tablet 20 milligrams, give 0.5 tablet by mouth in the morning for edema, give half tablet=10 milligrams with a start date of 9/29/23 administered as ordered. During an interview with the Resident's daughter on 10/24/23 at 1:48 P.M., she said Resident #52 calls a lot of times to tell her the CNAs are not changing him/her and he/she has to sit in urine for hours. She said Resident #52 is usually frustrated, angry, helpless and hopeless. She said that Resident #52 called her on 10/16/23 at 8:30 A.M. and 12:51 P.M., and told her that he/she had been sitting in urine for hours. Resident #52's daughter called the facility, left a message for someone to return her call but no one ever did. She said during that week, the Resident called her again on the following dates, 18th, 20th, 22nd and 23rd with the same concern. A review of the bladder incontinence documentation did not indicate any documentation was completed on 10/15/23, a 24-hour period, from 7:00 A.M. on 10/15/23 -7:00 A.M. 10/16/23. A review of the bladder incontinence documentation dated 10/16/23 indicated the Resident was incontinent at 14:49-2:49 P.M. and 21:47-9:47 P.M. only, indicating no documentation for an estimated 8 hours from 7:00 A.M. to 2:49 P.M. and an estimated 6 hours and 58 minutes in between 2:49 P.M. and 9:47 P.M. During an interview with CNA #2 on 10/26/23 at 7:04 A.M., he said for Residents who require assistance with toileting and are incontinent, CNAs are supposed to check on them at least every two hours, document in the tasks section when they toilet them and whether the resident was incontinent of bowel or bladder. CNA #2 said the CNAs are expected to document right after checking on and changing the resident and not at the end of the shift. CNA #2 said the time entered into the tasks section also indicates that the Resident was changed at that time. CNA #2 said if the Resident is checked on by staff and hasn't voided or refuses, the staff are supposed to check off the 'did not void' column ' or 'Resident refused' column. During an interview with the Director of Nurses at 1:42 P.M., she said CNAs should be checking on Residents who require assistance with toileting at least every 2-3 hours. The CNAs are supposed to document in the tasks section when the resident voids, specifying whether they voided bowel or bladder immediately after checking on them, if the Resident has not voided, or refuses, they are supposed to check off the 'did not void' column or 'Resident refused' column. The Director of Nurses said if there is missing bladder documentation in the record, then the task was not completed.

Based on interviews and records reviewed for one Resident (#81) of 31 sampled residents, the facility failed to implement falls care plans. Specifically: 1) for Resident # 81, the facility failed to provide supervision per the fall care plan resulting in a fall with a hand fracture. Findings include: Review of the facility policy (undated), titled Fall and Fall Risk Managing, indicated the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. Resident #81 was admitted to the facility in April 2022 with diagnoses including Alzheimer's disease, malnutrition, and traumatic brain injury. Review of the Minimum Data Set (MDS) assessment, dated 6/28/23, indicated that Resident #81 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Further review of the MDS indicated Resident #81 required supervision with walking. Review of Resident #81's Kardex on 10/26/23 indicated Resident #81 required supervision with ambulation. Review of Resident #81's Occupational Therapy treatment encounter note, dated 6/13/23, indicated Resident #81 required supervision for mobility due to cognition. Review of the incident report, dated 8/24/23, indicated Resident #81 experienced an unwitnessed fall at 3:00 P.M., near his/her roommate's bed. Review of Resident #81's falls care plan, initiated 5/8/21, indicated Resident #81 was at risk for falls due to confusion, lack of awareness of safety needs, wandering, psychotropic medication use, incontinence, and lack of coordination. Further review of the falls care plan indicated the following new intervention initiated on 8/24/23, after his/her unwitnessed fall: -I will be supervised while ambulating in the dining area and hallways in the unit to ensure my safety and to assist with navigation to my destination. (sic.) Review of the incident report, dated 8/26/23, indicated staff found Resident #81 on the floor in the hallway/corridor at 3:30 P.M. (two days after his/her previous fall on 8/24/23). Further review of the report indicated the fall was unwitnessed, the staff were unable to determine how the fall occurred and that prior to the fall the Resident was wandering on the floor per his/her baseline. Subsequently, Resident #81 was sent to the hospital. Review of the nursing progress note, dated 8/26/23, indicated Resident #81 was wandering on the floor per his/her baseline, and was later found lying in the prone position, bleeding, at which time he/she was sent to the emergency room . Review of the emergency room After Visit Summary, dated 8/26/23 indicated Resident #81 had sustained a hand fracture. Review of a nurse practitioner progress note, dated 8/27/23, indicated Resident #81 had sustained a left hand fracture as a result of his/her fall on 8/26/23. During an interview on 10/26/23 at 9:01 A.M., Nurse #9 said she was the nurse who completed the fall incident report. Nurse #9 said Certified Nursing Assistant (CNA) #3 made her aware of the fall. Nurse #9 said no staff members were supervising Resident #81 while he/she was wandering in the hall. Nurse #9 said CNAs found him/her on the floor in the hallway during rounds. Nurse #9 said she does not know what caused the fall and that Resident #81 always wanders around the unit. Nurse #9 said that staff is unable to supervise all of the residents all of the time. During an interview on 10/26/23 at 9:59 A.M., CNA #3 said he was working at the time of the fall and that Resident #81 was unsupervised at the time of the fall because no staff members witnessed him/her fall. CNA #3 said the Resident tends to wander around a lot, but must always be supervised. CNA #3 said if Resident #3 wanders out of eyesight of staff, the expectation would be for staff to follow the Resident to maintain supervision. During an interview on 10/26/23 at 9:14 A.M., CNA #4 said Resident #81 tends to wander and must be supervised at all times. During an interview on 10/26/23 at 9:17 A.M. Nurse #10 said Resident #81 wanders around the unit and would expect staff to supervise the Resident. During an interview on 10/26/23 at 12:15 P.M., Regional Nurse #2 said she expects staff to follow and implement care plans developed to keep the Resident safe from falling.

Based on observation, record review and staff interview the facility failed to promote healing and prevent worsening of a deep tissue injury for 6 days for 1 Resident (#6) from 32 sampled residents. Findings include: Resident #6 was admitted to the facility in 11/2012 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE] indicated the resident's cognition was severely impaired and he/she required an extensive assist of two persons for bed mobility, transfer, dressing and toileting. Resident #6 was observed lying supine in bed on 12/18/17 at 8:15 A.M. A specialty mattress was in place and foam boots were on both lower extremities. He/she was sleeping. Record review indicated that a skin observation was recorded 8/24/17 at 12:45 A.M. by Nurse #2 and indicates that the right heel is dark, nonblanchable and measured 4 centimeters (cm) by 5 centimeters. There was no corresponding nursing progress note regarding the observation, no treatment for [REDACTED]. On 8/30/17 at 10:23 A.M., a skin observation of dark blisters noted to both heels, was recorded (6 days after the initial observation of a deep tissue injury). During interview with Consultant Nurse #1 she said interventions should have occurred immediately upon identifying a change in skin integrity to the resident's right heel. Currently Resident #6 has had a Stage IV pressure wound of the left heel for a duration of more than 104 days, requiring daily dressing changes. He/she is medicated for pain three times daily.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to effectively manage pain. On 3/9/17, Resident #1, who had undergone back surgery and had physician's orders [REDACTED]. Resident #1 was not administered pain medication until 4 hours after his/her medication was due. Findings Include: The Policy, titled Pain Assessment and Management and dated 4/2016, indicated that pain management was the process of alleviating the resident's pain to a level that is acceptable to the resident and pain management included effectively recognizing the presence of pain and developing and implementing approaches to pain management. Resident #1's Admission Record indicated that he/she was admitted on [DATE] with medical [DIAGNOSES REDACTED]. A Hospital Discharge Summary dated 3/9/17 indicated that Resident #1 underwent back surgery on 3/7/17. The Discharge Summary indicated that Resident #1 had received [MEDICATION NAME] (an opioid pain medication) 2 mg by mouth at 4:10 P.M. at the Hospital. An Admission Nursing Evaluation, dated 3/9/17, indicated that Resident #1 was alert and oriented to person, place, and time. The Admission Nursing Evaluation did not include a pain assessment. A physician's orders [REDACTED]. A Nurse's note, dated 3/10/17 and timed at 12:44 A.M., indicated that Resident #1 was admitted at 5:00 P.M. and complained of a pain level rating 8 out of 10 and [MEDICATION NAME] was administered (the Medication Administration Record [REDACTED].M., which was approximately 7 hours after Resident #1 complained of severe pain). The note further indicated that the Nurse was unable to conduct an assessment because Resident #1 was in too much pain. A Narcotic Emergency Drug Kit Control Form signed by Nurse #1, on 3/9/17, indicated she removed 2 [MEDICATION NAME] 2 mg tablets for Resident #1 at 10:37 P.M. but documentation indicated that the medication was not administered by Nurse #1 until 12:05 A.M. on 3/10/17. Resident #1's Medication Administration Record [REDACTED]#1 at 12:05 A.M. for a pain level of 8 out of 10, approximately 4 hours later than the medication was due. The Surveyor interviewed Resident #1 on 6/5/17 at 2:05 P.M. Resident #1 said shortly after he/she arrived at the Facility he/she asked the Nurse for pain medication because his/her pain level was 8 out of 10. Resident #1 said he/she was unable to eat dinner because the pain was so bad, he/she was in severe pain for several hours, and by the time Nurse #1 brought his/her [MEDICATION NAME] his/her pain level had increased to 9 out of 10. The Surveyor interviewed Nurse #1 on 6/1/17 at 10:31 A.M. Nurse #1 said she worked the 3:00 P.M.-11:00 P.M. shift when Resident #1 was admitted to the Facility and when Resident #1 arrived he/she was in pain and requested pain medication. Nurse #1 said she could tell that Resident #1 was in a lot of pain by his/her facial expressions, and by the way he/she was moving. Nurse #1 said she called Resident #1's Physician to notify him/her about Resident #1's pain and that she needed to access the Emergency Drug Kit for Resident #1's medication. Nurse #1 said she remembered she was busy that evening and could not recall when she administered Resident #1's [MEDICATION NAME], however confirmed that she removed Resident #1's [MEDICATION NAME] at 10:37 P.M. after she reviewed her entry, dated 3/9/17, on the Narcotic Emergency Drug Kit Control Form. The Surveyor interviewed the Director of Nursing (DON) on 6/1/17 at 9:50 A.M. The DON said Nurse #1 did not complete a pain assessment for Resident #1 upon admission, documentation was not thorough, and Nurse #1 did not remove Resident #1's [MEDICATION NAME] from the Emergency Kit until 10:37 P.M.

Based on observations, staff interview, and record review, the facility failed to prevent the development of a pressure sore for 1 of 4 applicable residents (Resident #6) in a total sample of 24 residents. Findings include: For Resident #6, review of the clinical record on 6/12/13 and 6/13/13 indicated that the resident was originally admitted to the facility in 03/2012 and was readmitted to the facility in 06/2013. The resident's [DIAGNOSES REDACTED]. Review of the plan of care for potential skin breakdown, initiated on 12/27/12, indicated the following: *turn/reposition at least every two hours, more often as needed or requested. *monitor nutritional status. *monitor intake and output. *monitor/document/report to physician as needed changes in skin status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 5/13/13, indicated that the resident had no long and/or short term memory loss. The MDS further indicated that the resident was dependent for transfers and bed mobility and required extensive assistance with bathing and personal hygiene. The MDS indicated that the resident had an indwelling urinary catheter, was incontinent of feces, and no pressure sores were present. Review of the resident's readmission nursing evaluation, dated 6/1/13, indicated that his/her skin was warm, dry, and intact. Review of nursing progress note, dated 6/5/13 at 1:04 P.M. indicated that resident had trace to 1+ [MEDICAL CONDITION] in his/her bilateral lower extremities (BLE); blister areas to right upper thigh reabsorbed, dry and intact. Review of the nursing progress note, dated 6/7/13 at 12:54 P.M., indicated that the resident had 1-2+ BLE [MEDICAL CONDITION]. Review of the nursing progress note, dated 6/7/13 at 3:56 P.M., indicated that an air mattress was ordered. A progress note documented that at 8:30 P.M. an air mattress was delivered to the resident. Review of the Weekly Skin Check, dated 6/8/13, indicated that the resident had: *left heel - a fluid filled blister, intact with slight discoloration/purplish to distal edge of blister, measuring 3.3 centimeters (cm) by 2.0 cm. *right heel - reddened but blanchable. Review of the nursing progress note, dated 6/8/13 at 12:55 P.M., indicated that a new order was obtained to use skin prep to the left heel blister twice daily. Review of the nursing progress note, dated 6/11/13, indicated that treatment to the left heel (skin prep twice a day) was to be used on the resident's right heel for the prevention of skin breakdown. The note indicated that the resident was to wear padded booties on both heels at all time. Review of the Weekly Pressure Sore Report, dated 6/13/13, indicated that the resident's left heel measured 3.0 cm by 2.5 cm. On 6/13/13 at 11:05 A.M., the surveyor and Nurse #1 observed the resident's feet. The left heel pressure sore measured approximately 3.5 cm by 3.0 cm with purplish discoloration noted surrounding the absorbed blister. The right heel's skin was clear and intact. Nurse #1 agreed to the size of the resident's left heel pressure sore. During an interview with the Director of Nurses (DON) on 6/13/13 at 12:30 P.M., she said she did not know why the nursing staff did not institute off loading the resident's heels prior to the development of his/her blister on the left heel despite the presence of risk factors and the resident's BLE.

Based on record review and interviews, for one of three residents (Resident #2) who were at risk for falls, the Facility failed to ensure Resident #2 had a personal alarm in place per the fall prevention plan of care when on 1/18/11, Resident #2 fell from bed and sustained a fractured left femur and at the time of the fall, the bed alarm was found on the bedside and labeled broken. The findings included: Resident #2's Minimum Data Set assessment, dated 12/13/10, and indicated that Resident #2 required extensive assistance with bed mobility and transfers, and limited assistance with ambulation. The assessment indicated that Resident #2's [DIAGNOSES REDACTED]. The fall prevention plan of care, dated 11/30/10, indicated that Resident #2 was assessed as being at risk for falls due to decreased strength and mobility, chronic pain, and use of certain medications. The care plan indicated that as of 1/12/11, the care plan interventions included the use of a bed and chair alarm, a low bed, and mats next to the bed. The nurse's note, dated 1/18/11 8:45 AM, indicated that Resident #2 fell while in Resident #2's room, and that no alarm sounded prior to the fall. The note indicated that there was urine and feces on the floor around Resident #2 and when assessed, Resident #2 cried out in pain. The note indicated that the right leg presented with symptoms of possible fracture and was transferred to the Hospital. Contained within the investigation file, was a statement dated 1/18/11 from one of the nurses who responded at the time of the fall. The statement indicated that at approximate 8:15 AM on 1/18/11, Resident #1 was observed on the floor naked, and the right leg was observed to be externally rotated. The statement indicated that the alarm was on a bedside table and there was no sensor pad on Resident #2's bed. The statement indicated that Resident #2 reported attempting to obtain clothing from the closet when Resident #2 fell . Nurse #1 was interviewed at 4:59 PM on 2/17/11. Nurse #1 said that Nurse #1 was consistently assigned to care for Resident #2. Nurse #1 said that Resident #2 was assessed as being at risk for falls due to previous falls and care plan interventions included the use of alarms when Resident #2 was in bed and seated in a chair. Nurse #1 said that on 1/18/11, Nurse #1 was called to Resident #2's room by Nurse #2 and Nurse #3 who reported that Resident #2 was on the floor. Nurse #1 said that upon entering Resident #2's room, Resident #2 was observed on the floor with the right leg at an odd angle. Nurse #1 said that an ambulance was called and Resident #2 was transferred to the Hospital where it was determined Resident #2 had a fractured leg. Nurse #1 said that Nurse #3 informed Nurse #1 that no alarm sounded at the time of the fall and that Nurse #2 heard a loud noise, which prompted Nurse #3 to investigate to determine the source. Nurse #1 said that there was no alarm present on Resident #1's bed and the alarm itself was found on a bedside table and it was labeled with tape with the word "broken" written on the tape. Nurse #2 was interviewed at 3 PM on 2/18/11. Nurse #2 said that on 1/18/11, Nurse #2 was asked to respond to Resident #2's room because Resident #2 fell ; and no alarm sounded prior to being asked to go to Resident #'2's room. Nurse #2 said that upon entering the room, Resident #2 was observed on the floor and Resident #2's alarm was on a bedside table in the room and attached to the unit was tape with words which indicated that the alarm was not working. Nurse #2 said that no sensor pad was on Resident #2's bed. Nurse #2 said that it was Nurse #2's belief that another nurse, who was identified by name, admitted to having removed the alarm the day before the fall, because it was not functioning properly. Nurse #3 was interviewed 1:10 PM on 2/22/11. Nurse #3 said that Nurse #3 heard a loud noise and when Nurse #3 investigated to determined to source observed Resident #2 on the floor to the room. Nurse #3 said that no alarm sounded and one was not observed to have been in place. Nurse #3 said that the alarm itself was found on a bedside table. Nurse #8 was interviewed at 5:30 PM on 2/18/11. Nurse #8 said that Nurse #8 was consistently assigned to care for Resident #2. Nurse #8 said that Resident #2 was at risk for falls and used personal alarms when in bed and seated in a chair. Nurse #8 said that a day or so before Resident #2 fell , a therapist informed Nurse #8 that Resident #2's personal alarm was not working. Nurse #8 was not certain of the identity of the therapist. Nurse #8 said that Nurse #8 did not remove the alarm or label it broken and did not know who did. An inservice record, dated 1/18/11, indicated that the Interim Director of Nurses completed re-education that indicated the staff were to ensure that all assigned residents who are to use alarms, have the alarms on and that the alarms were functioning. Review of the investigation file, dated 1/20/11, indicated that the Interim Director of Nurses documented that an investigation was completed and reported the incident to the Department of Public Health. The documentation provided to the Department of Public Health was dated 1/20/11, two days after the 1/18/11 incident. The report indicated that there were no unusual circumstances involved at the time of the fall, however contained within the Facility investigation file were statements from the nurses who responded at the time of Resident #2's fall on 1/18/11. Despite the Interim DON being aware that the alarm was not in place at the time of Resident #2's fall on 1/18/11, there was no indication that this information was reported to the Department of Public Health when the required report was filed on 1/20/11.