Every finding on record at Briarwood Rehabilitation & Healthcare Center

Based on record review and interview, the facility failed to document whether the facility educated its staff about severe acute respiratory syndrome (SARS) or the COVID-19 vaccine, or whether its staff received the COVID-19 vaccine. Findings include:Review of the facility policies for COVID-19 Vaccine and Employee Infection and Vaccination Status, last reviewed in 2026, indicated:Prior to or upon an employee's duty assignment, the facility will assess the status of an employee's vaccination against infectious conditions, screening and recent history of communicable diseases. Employees will be current with mandated vaccinations prior to performing resident care. Documentation of vaccinations include the signature of a licensed healthcare provider and employee when being administered. Vaccinations that are declined by the employee are documented on the applicable (sic). During an interview with the Infection Preventionist on 6/17/26 at 7:47 A.M., the surveyor requested documentation that one sampled employee had been provided education about severe acute respiratory syndrome (SARS) or the COVID-19 vaccine, and whether the employee either accepted or declined the vaccine. The Infection Preventionist said she did not think the facility documented employees' education or vaccination status. The surveyor then asked the Infection Preventionist to provide documented education and vaccination status for an additional four sampled staff members. The Infection Preventionist said the facility did not keep employee records of SARS or COVID-19 vaccine education, or a record of any of their employees' SARS and COVID-19 education or whether they had received the COVID-19 vaccine. During an interview with Nurse Consultant #1 on 6/17/26 at 11:01 A.M., she said the facility had not documented whether the five sampled staff had declined or been administered the COVID-19 vaccine.

Based on observations, record review and interviews, the facility failed to ensure for one resident (#129) out of a total sample of 25 residents, that standards in quality nursing care were provided in accordance with the physician's orders. Specifically, for Resident #129:A. facility staff failed to implement the order to check the external length of the IV (intravenous) catheter with the dressing change and as needed. and B. facility staff failed to obtain an order and document an intravenous dressing change dated 6/14/26, which was outside of the established physician's orders to change the intravenous catheter every seven days.Findings include:Review of the [NAME] & [NAME] article, when to use a midline catheter, dated April 2025 indicated: Monitor catheter migration by measuring and documenting the external catheter length at each dressing change. Use a site stabilizing device to help prevent catheter migration.Review of the facility's policy, titled 'Peripheral and Midline IV (intravenous) Dressing Changes, revision date October 2024, indicated the following:This (sic) purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter- related infections associated with contaminated, loosened or soiled catheter- site dressings. General guidelines include but are not limited to the following: 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). Documentation: The following should be documented in the resident's medical record: a. date, time type of dressing, and reason for dressing change. b. Any complications/interventions related to insertion side or surrounding area, and c. Resident's response to procedureResident #129 was readmitted to the facility in June 2026 with diagnoses that included osteomyelitis in vertebra, pressure ulcer of the sacral ulcer, sepsis, chronic kidney disease, and adult failure to thrive.Review of Resident #129's Minimum Data Set (MDS) assessment, dated 5/28/26, indicated he/she was assessed by nursing staff to have severe cognitive impairment.During an observation on 6/15/26 at 10:30 A.M., Resident #129 was in bed, with his/her eyes closed and could not be interviewed. An IV pole was located next to his/her bed.Review of Resident #129's hospital discharge summary indicated Resident #129 had a Midline Double Lumen (a midline is peripheral intravenous catheter inserted into a vein in the upper arm, used for intermediate duration IV therapy), placement on 6/2/26. A. Review of Resident #129's physician order, dated 6/3/26, indicated IV: (Midlines and PICCs (peripherally inserted central catheter) Document baseline external length of IV catheter, check external length with each dressing change and as needed.Review of the Medication Administration Record dated June 2026 indicated the order to check the external length of the IV catheter was documented as blank and not signed by nursing staff on 6/4/26 and documented NA and initialed by Nurse #1 on 6/11/26. Review of the chart codes indicated NA = No interventions required.Review of Resident #129's care plans failed to indicate a person-centered care plan with a measurable goal and specific interventions was developed for the administration of intravenous therapy.Review of Resident #129's clinical record including the Medication Administration Record (MAR), Treatment Administration Record (TAR) and, progress notes dated 6/3/26 through 6/16/26 failed to indicate documentation that the external length of the IV catheter was obtained on 6/4/26 and 6/11/26 in accordance with the physician's order.During an interview on 6/17/26 at 9:08 A.M., Nurse #1 said Resident #129 has an IV for antibiotics to treat a wound infection. Nurse #1 said nursing staff follow the physician's order for the intravenous care and that the IV dressing is changed weekly on the evening shift. Nurse #1 said she did not measure the external length of the IV catheter on 6/11/26 and that is why she documented NA.During an interview on 6/17/26 at 9:43 A.M., Unit Manager #1 said it is not the facility policy to measure a midline IV catheter. Unit Manager #1 said unless the order is changed the nursing staff should follow the physician's order. During an interview on 6/17/26 at 10:38 A.M., the Director of Nursing said the nursing staff should review the orders and unless they ask the nurse practitioner or physician for clarification of an order the physician's order should be completed as ordered.B. During an observation and interview on 6/17/26 at 9:08 A.M., Nurse #1 and the surveyor observed Resident #129's dressing to the IV site on his/her right upper arm. Nurse #1 said the dressing date handwritten on the dressing read 6/14/26. Nurse #1 said the dressing is changed every seven days on the evening shift.Review of the MAR indicated an order: IV (midline, PICC (peripheral inserted central catheter), CVAD (central venous access device)) change transparent dressing on admission and then every 7 days, caps to be changed during dressing changes one time only until 6/4/26 one time, was documented by nursing staff as administered on 6/5/26 (one day after the one time only date of 6/4/26). Further review of the MAR indicated the order: IV (Midline and PICC, CVAD) change transparent dressing on admission and then every 7 days; caps to be changed during dressing changes. One time a day every 7 days. Start date 6/4/26 and was documented by nursing staff as administered on 6/11/26. Review of Resident #129's clinical record including the MAR, Treatment Administration Record (TAR) and, progress notes dated 6/3/26 through 6/16/26 failed to indicate that there was documentation that a physician's order to change the IV dressing on 6/14/26 was ordered. In addition, neither the MAR nor progress notes indicated the reason the IV dressing was changed, or documentation of Resident #129's response to the procedure of the dressing change.During an interview on 6/17/26 at 10:38 A.M., the Director of Nursing said there was no order for the dressing change dated 6/14/26 and that there should have been. The DON said there was no documentation in Resident #129's progress notes as to why the dressing was changed outside of the physician's order and that there should have been documentation entered by the nurse.

Based on observations, records reviews and interviews, the facility failed for two Residents (#6 and #12), to maintain medical records accurately and reflect the resident's status. Specifically,1. Nursing staff failed to maintain an accurate medical record, when they documented Resident #6 had a central venous catheter when he/she had it removed, and2. Nursing staff failed to maintain an accurate medical record, when they documented Resident #12 had a blood sugar monitoring device that he/she did not have.Findings include: 1. Resident #6 was admitted to the facility in [DATE] and has diagnoses that include end stage renal disease, and dependence on renal dialysis. Review of the most recent Minimum Data Set assessment, dated [DATE], indicated Resident #6 scored 14 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as cognitively intact. Further, the MDS indicated Resident #6 is on dialysis. During an observation and interview on [DATE] at 8:32 A.M., Resident #6 said he/she goes out for dialysis on Tuesdays, Thursdays, and Saturdays. Resident #6 said the access site for dialysis is his/her right arm. Resident #6 moved his/her right arm out revealing a large linear bulge on his/her arm. During an observation and interview on [DATE] at 4:14 P.M. Resident #6 said he/she did have a port in his/her left chest and that it was removed about one month ago. Resident moved his/her johnny revealing a small red area, there was no central port catheter present. Review of Resident #6's clinical record indicated an 'After Visit Summary: dated [DATE] indicated left TDC (tunneled dialysis catheter) removal completed. Review of Resident #6's Treatment Administration Record (TAR) dated [DATE] indicated the following order: Access site: Left chest wall, access type: central catheter Monitor dialysis access site for sign/symptoms of infection, drainage, bruising, and bleeding every shift, and as clinically indicated. Every shift Document abnormal findings in the progress notes and report to the physician. Start date [DATE]. Further, the [DATE], TAR indicated nursing staff signed off day, evening and night shifts on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. This documentation entered by nursing staff was completed after the left chest wall access central line catheter was removed, thus rendering the documentation as inaccurate and not reflecting Resident #6 clinical status. During an interview on [DATE] at 3:54 P.M., Nurse #2 said Resident #6 returns from dialysis on the day shift around 2:00 P.M., When asked where Resident #6's access site for dialysis is, Nurse #2 said she believes the Resident has a port in his/her chest. Nurse #2 said she goes by the physician's orders to assess Resident #6 and does a head-to-toe visual check of the Resident at the start of her shift. During an interview on [DATE] at 4:30 P.M., Unit Manager #1 said Resident #6 has an arm fistula which is not in use yet. Unit Manager #1 said her understanding is that Resident #6 has a left chest wall port for dialysis access. During an interview on [DATE] at 1:28 P.M. Unit Manager #1 said she did not know that Resident #6 was now receiving his/her dialysis treatment through his/her right arm fistula. Unit Manager #1 said Resident #6's left chest wall catheter was removed and that nursing staff should not sign off the order that is not provided. During an interview [DATE] at 1:31 P.M., Nurse #1 reviewed the TAR and said she signed the order for the left chest wall catheter and said she was confused about the order. During an interview on [DATE] at 8:22 A.M., the Director of Nurses (DON) said she expects nurses to sign off orders only if they are completed. The DON said the Resident no longer had the chest wall catheter, and the nursing staff should have been aware and should have reviewed the order, got clarification and not signed off on the order. 2. Resident #12 was admitted to the facility in [DATE] with diagnoses that included Type 2 Diabetes, chronic kidney disease, dementia and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During an interview on [DATE] at 8:48 A.M., Resident #12 said the sensor was not working over the weekend, and the staff is waiting for a new one from the pharmacy. Review of Resident #12's physician order, dated [DATE], indicated Dexcom G7 15 Day Sensor Miscellaneous (Continuous Glucose System Sensor). Inject 1 application subcutaneously one time a day every 15 day(s). Review of Resident #12's physician order, dated [DATE], indicated FreeStyle Libre 2 Plus Sensor Miscellaneous (Continuous Glucose System Sensor). Inject 1 application subcutaneously one time a day every 14 day(s). Review of Resident #12's physician order, dated [DATE], indicated Dexcom G7 15 Day Sensor. Collect and keep it charge at nurse med room, keep it on charge during the shift at bedtime for Dexcom. Review of Resident #12's [DATE] Medication Administration Record (MAR) indicated nursing staff applied the Libre 2 Plus sensor on [DATE]. Review of Resident #12's [DATE] Medication Administration Record (MAR) indicated nursing staff applied the Dexcom sensor on [DATE]. Review of Resident #12's [DATE] Medication Administration Record (MAR) indicated nursing staff from [DATE] through [DATE] and on [DATE] signed off the Dexcom G7 day sensor order as administered. During an interview and observation on [DATE] at 12:45 P.M., Resident #12 said he/she has been using a Libre 2 Plus sensor and not a Dexcom sensor. Resident #12 then showed the surveyor his/her upper arm confirming it was a Libre 2 plus sensor. During an interview on [DATE] at 1:38 P.M., Nurse #1 said the nurse on evening shift yesterday ([DATE]) applied the new Libre 2 Plus sensor when it arrived last night. Nurse #1 said she removed the old Libre 2 Plus sensor on Saturday during the day shift as it was no longer working. Nurse #1 said there was not another sensor to put on Saturday. During an interview on [DATE] at 1:39 P.M., Unit Manager #1 said they have had trouble getting the Libre 2 Plus so the Resident did not get a replacement Libre [NAME] until the evening shift on [DATE]. Unit Manager #1 said to her knowledge the Resident has never had a Dexcom sensor here at the facility. The Unit Manager said nurses should not be signing off orders as administered unless they actually are administered. During an interview on [DATE] 3:52 P.M., Nurse #2 said she did apply the new Libre 2 Plus sensor when it arrived around 10:00 P.M. on [DATE]. Nurse #2 said the old sensor expired and staff had to wait for a new one to arrive. Nurse #2 said she never knew of a Dexcom sensor for this Resident. During an interview on [DATE] at 8:22 A.M., the Director of Nurses (DON) said she expects nurses to sign off orders only if they are actually completed. The DON said nurses should not have been signing off two different sensors when the Resident has only had a Libre 2 Plus sensor applied.

Based on record review and interview, the facility failed to ensure it offered one Resident (#97) of 5 sampled residents the pneumococcal and COVID-19 vaccines.Findings include:Review of the facility policy for administration of the pneumococcal vaccine to residents, last reviewed in 2026, indicated: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. - Prior to or upon admission, resident will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident has already been vaccinated.- Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. - Resident/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Review of the facility policy for the administration of the COVID-19 vaccine to residents, last reviewed in 2026, indicated: All residents will be offered the COVID-19 vaccine to aid in preventing severe acute respiratory syndrome (SARS) virus. - Before receiving a COVID-19 vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the vaccine. Provision of such education shall be documented in the resident's medical record. - Resident/representative has the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the COVID-19 vaccination. Resident # 97 was admitted to the facility in April 2026. Review of Resident #97's medical record on 6/15/26 indicated there was no reference to staff offering either the pneumococcal or COVID-19 vaccines, or of the Resident accepting or refusing to accept the vaccines.During an interview with Resident #97 on 6/17/26 at 8:05 A.M., he/she said staff had not offered any vaccines to him/her on admission, which occurred approximately ten weeks ago. Resident #97 said the first time staff offered any vaccines to him/her was yesterday, on 6/16/26. Resident #97 said he/she signed consents to have the pneumococcal and RSV (respiratory syncytial virus) vaccines but declined the COVID-19 vaccine. During interviews with the Infection Preventionist and Nurse Consultant #1 on 6/17/26 at 11:00 A.M., they said they thought staff had offered the pneumococcal and COVID-19 vaccines to Resident #97 on admission to the facility, but there was no record of this, or of the Resident refusing vaccines. Review of Resident #97's medical record on 6/17/26 indicated he/she signed informed consent forms to receive the RSV and pneumococcal vaccines and to decline the COVID-19 vaccine.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a history of pulmonary embolism (PE, blood clot in the lung), deep vein thrombosis (DVT, blood clot) in his/her leg, and was being treated with Eliquis (anticoagulant) which per physician's order had a stop date of 01/04/25, the Facility failed to ensure nursing provided care and services that met professional standards of practice related to medication review and physician follow-up, when Resident #1's Health Care Agent (HCA) requested that nursing contact the physician to request that Resident #1 remain on Eliquis, and although his/her physicians' progress note indicated to continue the Eliquis, no new order for the Eliquis was obtained by nursing and Resident #1's Eliquis was discontinued. On 02/13/25, Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation of new onset acute shortness of breath, he/she was diagnosed with a new blood clot in both of his/her lungs and was admitted for treatment. Findings include: Review of the Facility Policy titled Anticoagulation-Clinical Protocol, dated as last revised November 2018, indicated the physician and staff will identify individuals who are currently being anticoagulated, identify situations where an individual is not anticoagulated but where anticoagulation should be indicated, and will seek the underlying cause of conditions requiring anticoagulation. The Policy further indicated the following; -The Physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines; -The Physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions; -The Physician will review the progress of individuals who are being anticoagulated; and -The Physician will periodically identify individuals whose anticoagulation can be discontinued or reduced and will document a rationale for continuing anticoagulation over time, including the medication and dosage. Resident #1 was admitted to the facility in June 2024, diagnoses included a pulmonary embolism, a lower left extremity Deep Vein Thrombosis (DVT) and a history of a cerebral vascular accident (CVA, stroke). Review of Resident #1's Hospital Discharge (DC) Summary, dated 06/24/24, indicated he/she had been started on anticoagulation therapy related to a newly identified pulmonary embolism and left lower extremity DVT. The DC Summary indicated that he/she should be administered Eliquis 10 milligrams (mg) twice a day for seven (7) days, then decrease to Eliquis five (5) mg twice a day for at least the following six (6) months, and to follow-up with his/her physician in the next 1-2 months. Review of Resident #1's Physician's Orders, dated 06/26/24, indicated to administer Eliquis 5 mg, give two (2) tablets (10 mg) by mouth 2 times a day for 7 days and then administer Eliquis 5 mg, give one (1) tablet by mouth 2 times a day for 6 months, with an end date of 01/04/25. Review of Resident #1's Care Plan Meeting Review Note, dated 01/02/25, indicated that his/her HCA requested that nursing contact his/her physician to address the need for Resident #1 to remain on Eliquis. Review of Resident #1's Nurse Progress Note, dated 01/07/25, indicated that his/her HCA wanted nursing to contact the Nurse Practitioner (NP) to ensure that he/she was placed back on Eliquis. The Note indicated that the NP was contacted and that the NP would review Resident #1's orders. Review of Resident #1's Nurse Progress Note (written by the DON), dated 01/07/25, indicated that his/her physician would be in on 01/08/25 to review reinstating Resident #1's Eliquis. Review of Resident #1's Physician Progress Note, dated 01/08/25, indicated he/she was being treated for a pulmonary embolism, a DVT of his/her left lower extremity, was on Eliquis currently for 6 months and indicated to continue Eliquis. Review of Resident #1's Medication Administration Record (MAR), dated January 2025, indicated his/her last dose of Eliquis was administered on 01/04/25. Review of Resident #1's medical record, including but not limited to nurse progress notes, physician/NP progress notes, and physician orders, indicated that there was no documentation to support that a new order was obtained by nursing to continue Resident #1's anticoagulation (Eliquis). Resident #1 did not receive Eliquis 5 mg by mouth twice a day in the facility starting 01/05/25 up to and including 02/13/25, when he/she was transferred to the Hospital ED. Review of Resident #1's Nurse Progress Note, dated 02/13/25, indicated Resident #1 was found to be short of breath, using accessory muscles for breathing, oxygen saturation was 70% on room air, and he/she required a non-re-breather without effect. The Note indicated Resident #1 was transported to the Hospital ED for evaluation. Review of Resident #1's emergency room Department Report, dated 02/13/25, indicated he/she was found to have bilateral pulmonary emboli and required a heparin (anticoagulant) drip. The Report further indicated that he/she had a recent history of a PE, however no Eliquis was noted on his/her medication list from the Facility, that secondary to his/her recurrent PE's, immobility, and now Flu positive, Resident #1 should be on lifelong anticoagulation. During an interview on 02/14/25 at 10:57 A.M., Resident #1's HCA said that she made it very clear to the Social Worker (SW), Assistant Director of Nurses (ADON), Director of Nurses (DON), and Resident #1's Physician, that she wanted to keep him/her on Eliquis related to his/her history of blood clots or she wanted to be provided with an explanation as to why the physician would discontinue the anticoagulation medication. During an interview on 02/18/25 at 11:30 A.M., the Social Worker said that there had been a care plan meeting on 01/02/25, and Resident #1's HCA requested that his/her physician keep him/her on Eliquis. The SW said the Assistant Director of Nurses (ADON) was present in that care plan meeting and said that she (the ADON) would follow up with the physician regarding his/her HCA request to keep Resident #1 on Eliquis. During an interview on 02/18/25 at 4:10 P.M., the Director of Nurses (DON) said that on 01/07/25 Resident #1's HCA requested to have him/her remain on Eliquis. The DON said that she spoke to the NP and the NP told her that Resident #1's MD was going to address the issue upon his next review. The DON said she spoke to the MD, and he said that Resident #1 was going to continue Eliquis. During a telephone interview on 02/28/25 at 11:50 A.M., the Physician said that he had been made aware that Resident #1's HCA was concerned about keeping him/her on Eliquis, said when he spoke to the HCA in early January (01/08/25), he thought that Resident #1 was still on the Eliquis as ordered and was unaware that it had been discontinued at the facility. The DON said that she was not aware that the stop date had already passed, that Resident #1's Eliquis had been discontinued, and a new physician's order had not been obtained to restart the Eliquis. The DON said the Facility's expectation is that all anticoagulation orders must be reviewed with the Physician or NP if a stop date is initiated upon admission. The DON said that if any resident or HCP/Responsible Party requests medications be reinstated, nursing must notify the DON, Physician/NP, Administrator and a progress note must be written by the nurse to ensure the continuity of care. On 02/18/25, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of 02/17/25) that addressed the area(s) of concern as evidenced by: A) On 02/13/25 Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, treatment and was admitted for recurrent bilateral PE's and Influenza A. B) On 2/17/25 an Ad-[NAME] Quality Assurance Performance Improvement (QAPI) meeting was conducted to review the incident. C) On 02/17/25, the DON completed a Facility wide audit of all residents on anticoagulation therapy to ensure all orders are current and valid. D) On 02/17/25, the DON educated all licensed nursing staff on reviewing medications with stop dates for follow-up, the policy for medication errors, physician orders, documentation and placing medications on hold. E) On 2/17/25, the DON educated the Providers on follow up for anticoagulation medications that have a stop date for new orders to be provided, either continuing or discontinuing the medication and the policy for documentation. F) On 2/17/25, the DON/designee will continue to audit residents with anticoagulation medications that have a stop date to ensure compliance with Physician's Orders, and/or need for new orders. G) Audit results will be reported to the DON or designee weekly and brought to the Quality Assurance and Performance Improvement (QAPI) meeting monthly until 100 percent compliance is achieved for three consecutive months. H) The Director of Nurses and/or designee are responsible for overall compliance.

Based on record review, interview, and policy review, the facility failed to follow professional standards of practice for two Residents (#261 and #211), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #261, to monitor the Resident's right upper extremity Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava (SVC) insertion site for signs/symptoms of infection in accordance with the physician's order; and 2. For Resident #211, to ensure the Resident's medications that should not be crushed were administered as whole pills in accordance with the physician's order, pharmacy label, and medication administration guidelines. Findings include: 1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers 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's policy titled Central Venous Catheter Care and Dressing Changes, revised March 2022, indicated but was not limited to the following: -Apply sterile dressing a. Center the dressing over the insertion site. b. Starting at the catheter, smooth dressing outward toward the edges to remove air. c. Press down on the edges of the dressing while removing the paper around edges of the dressing. d. Sterile tape from the kit may be used to secure the edges if needed. The tape should not cover the insertion site. Resident #261 was admitted to the facility in July 2024 with diagnoses which included osteomyelitis (infection of the bone) of the lumbar vertebra and pneumonia. Review of the Physician's Orders indicated but were not limited to the following: -Intravenous (IV): Right arm double lumen PICC. Change transparent dressing on admission and then every seven days; caps to be changed during dressing change. Effective date 7/17/2024. -IV: Assess IV site for unusual redness, drainage, skin, irritation, pain at the site, patient confusion, and patient diaphoresis (excessive sweating), observe for tenderness or induration when gently palpating the vein pathway above the IV site, every shift document in progress note. Effective 7/17/2024. -IV: Assess that the IV catheter is secured well and does not slide around in the vein or become dislodged, the dressing is adhered with no moisture accumulation underneath it every shift. Document in progress notes. Effective 7/17/2024. Review of the Medication Administration Record (MAR) indicated the above listed orders were completed every shift, 19 out of 19 opportunities as ordered by the physician 7/18/2024 through 7/24/2024. On 7/23/24 at 11:34 A.M., the surveyor observed Resident #261's right arm PICC dressing, dated 7/18, which had a large white gauze under the clear dressing completely obscuring the PICC line insertion site and skin. The insertion site was further obscured by the dated tape over the bottom of the dressing. On 7/24/24 at 5:00 P.M., the surveyor observed Resident #261's right arm PICC line dressing, dated 7/18, with the white gauze under the clear dressing completely obscuring the PICC line insertion site or skin. The insertion site was further obscured by the dated tape over the bottom of the dressing. During an interview on 7/24/24 at 5:15 P.M., Unit Manager (UM) #1 said there should be a clear dressing over the PICC line so they can monitor the site every shift for redness and swelling. On 7/24/24 at 5:17 P.M., the Surveyor, Nurse #1, and UM #1 observed Resident #261's PICC line dressing and observed the gauze under the clear dressing and the tape dated 7/18 at the base of the PICC line dressing. During an interview on 7/24/24 at 5:19 P.M., UM #1 said the gauze is covering the insertion site and you need to be able to see the site to monitor for signs of infection. UM #1 said she was not aware the nurses had been signing off on the MAR that they were monitoring the site since Resident #231's admission. During an interview on 7/24/24 at 5:20 P.M., Nurse #1 said she observed the insertion site today for signs and symptoms when she flushed the PICC line. During an interview on 7/24/24 at 5:31 P.M., the Assistant Director of Nursing (ADON) said she would expect the dressing to be transparent to view the PICC insertion site. The surveyor informed the ADON that Resident #231's PICC dressing had a white gauze under the transparent dressing and the insertion site could not be visualized to perform the assessments as ordered by the physician. The ADON said she was made aware the PICC dressing had a gauze under the clear dressing, and it will need to be changed. 48084 2. Review of the facility's policy titled Administering Medications, dated as last revised April 2019, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders. -The individual administering the medication check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -Each nurses' station has a current Physician Desk Reference (PDR) and/or access to another medication reference. Review of the facility's policy titled Preparation and General Guidelines, dated November 2021, indicated but was not limited to the following: -An individualized approach should be used when altering dosage forms by crushing or opening capsules. -An order to crush medications may be required or preferred in accordance with State regulation of facility preference. -Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example: long acting or Enteric Coated forms should not be crushed; an alternative should be sought. -The instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR/eMAR) so all personnel administering medications are aware of this need. On 7/24/24 at 9:20 A.M., the surveyor observed Nurse #1 prepare nine morning medications for Resident #211, eight of which were to be administered by mouth and one was a topical patch: a. Ferrous Sulfate 325 milligrams (mg) (iron supplement) b. Acidophilus with Pectin capsule (probiotic with soluble fiber additive) c. Loratadine 10 mg (allergies) d. Acetaminophen 500 mg (2 tablets) (pain relief) e. Alfuzosin HCL ER (extended release) 10 mg (long acting for enlarged prostate) f. Eliquis 2.5 mg (2 tablets) (anticoagulant) g. Metoprolol Succinate ER 25 mg (long acting for blood pressure) h. Rosuvastatin 10 mg (treat high cholesterol) i. Lidoderm 4% Pain Patch (pain) -Seven pills/tablets were put into a medication cup and one capsule was put into a separate cup. -The seven pills/tablets were all crushed together, and the powder mixed with applesauce. -The one capsule was opened, and the contents mixed with the applesauce. Review of the [NAME] Drug Book, 19th edition, indicated the following: -Ferrous Sulfate tablet should be taken with a full glass of water or juice and tablets should not be crushed or chewed. -Alfuzosin was an extended-release tablet and should not be crushed. -Metoprolol Succinate was an extended-release tablet and should not be crushed. Review of the Physician's Orders to reconcile the medications ordered versus the medications administered indicated the following: -Ferrous Sulfate 325 mg tablet was ordered but was administered crushed. -Alfuzosin HCL ER 10 mg was ordered but was administered crushed. -Metoprolol Succinate ER 25 mg was ordered but was administered crushed. Review of the medication cards used by the nurse to pour the Alfuzosin HCL ER and Metoprolol Succinate ER indicated a green sticker from the pharmacy was on the card and it read SWALLOW WHOLE DO NOT CRUSH OR CHEW. During an interview on 7/24/24 at 9:25 A.M., Nurse #1 said she crushed all the medications except the Acidophilus, she said she opened that capsule and mixed all the medications with applesauce. During an interview on 7/24/24 at 1:35 P.M., Nurse #1 said she thought Ferrous Sulfate could be crushed and it was only the Slow FE (ferrous sulfate) that could not be crushed. Additionally, she said the Alfuzosin and Metoprolol Succinate are both extended release and say not to crush them, so she should not have crushed those medications, but Resident #211 had been having trouble swallowing so she had to crush the medications. During an interview on 7/25/24 at 10:20 A.M., UM #1 said she thought Ferrous Sulfate could be crushed. UM #1 said the Alfuzosin and Metoprolol Succinate should not have been crushed. During an interview on 7/25/24 at 3:00 P.M., the ADON said the Ferrous Sulfate, Alfuzosin, and Metoprolol Succinate should not be crushed. She said those medications should be administered whole in applesauce or pudding or they would need to obtain an order for a different medication. Refer to F759

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#102), out of 24 sampled residents. Specifically, the facility failed for Resident #102, to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Dialysis Communication, undated, indicated but was not limited to the following: -The facility and dialysis center will establish a communication and reporting mechanism to promote situational awareness between both facilities. -Routine communication of relevant information will be provided by the facility to the dialysis center. -The facility and dialysis center will determine a method to exchange written information between the centers on dialysis days. Examples of communication methods may include but are not limited to forms, binders, books, and copies of medical records. -Examples of information that may be communicated between the facilities include: a face-sheet, hemodialysis communication form (or equivalent), Physician orders, laboratory results, weight records, and other records deemed appropriate. -The dialysis center will communicate relevant information to the facility upon the resident's return to the facility. -Clarification, questions, or need for additional information to or from the dialysis center may be communicated via telephone. Review of the Long-Term Care Facility Coordination Agreement, dated 5/12/2015, indicated but was not limited to the following: -Coordination and Communication: Both parties shall ensure there is coordination of care and communication between Long-Term Care (LTC) Facility and the End-Stage Renal Disease (ESRD) Facility. -Documentation of Coordination: Both parties shall maintain documented evidence of care coordination and communication between the LTC facility and ESRD facility. Resident #102 was admitted to the facility in May 2024 with diagnoses which included ESRD and dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 5/23/24, indicated Resident #102 was cognitively intact as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS) and he/she received dialysis services. Review of the Comprehensive Care Plan indicated Resident #102 required interpreter services because their primary language was not English. Review of the Dialysis Communication Book indicated but was not limited to the following: -Resident #102 had dialysis three times a week. -Face sheet, Advanced Directives and Physician Orders from May 2024. -Blank Copies of the Dialysis/Observation Communication Form (only page 1 of 3). May 2024: of six treatment dates, the following information was in the binder: -5/22/24 the three-page communication form was incomplete; a recommendation was made and implemented. -5/27/24 the three-page communication form was blank except for a weight in the top right corner. June 2024: of 12 treatment dates, the following information was in the binder: -6/3/24 the three-page communication form was filled out by the LTC facility with no return documentation from the dialysis facility. -6/19/24 the three-page communication form was filled out by the LTC facility with no return documentation from the dialysis facility. -6/26/24 the three-page communication form was not in the binder; only page 1 of 3 was in the binder and it form was filled out by the LTC facility with no return documentation from the dialysis facility. July 2024: of 11 treatment dates, the following information was in the binder: -7/8/24 lab results print out from the ESRD facility; a recommendation was made and implemented. -7/24/24 the three-page communication form was not in the binder; only page 1 of 3 was in the binder and it form was filled out by the LTC facility with no return documentation from the dialysis facility. Further review of the binder failed to indicate ongoing written communication between the LTC and dialysis facility to coordinate care. Review of the weight record indicated post-dialysis weights were documented 17 of 29 times, or 59% of the time. Review of the Nursing Progress Notes failed to indicate ongoing communication between the LTC facility and the dialysis facility regarding the treatments. Further review of the progress notes indicated two progress notes noting communication between the LTC facility and the ESRD facility had occurred. During an interview on 7/25/24 at 10:21 A.M., Unit Manager (UM) #1 said the Dialysis Communication Book is supposed to go with Resident #102 for every treatment. She said the nurses should be completing the first page and the dialysis center should be documenting on page 2, the post treatment report. UM #1 said the sheet doesn't always come back or weights are just on a post it/sticky note. She said if he/she does not come back with the sheet filled out staff should be calling to get report and the weight and documenting. She said all communication forms should be in the binder and did not know why it was missing so many sheets. During an interview on 7/25/24 at 2:04 P.M., Nurse #2 said the nurses are supposed to fill out the communication sheet everyday Resident #102 has a treatment, and the center is supposed to send the report back. He said the dialysis center is terrible with return communication and it is very inconsistent. He said if they even send a weight back, it's often on a post-it note and there is no report. He said he does not usually work the evening shift when Resident #102 returns, but said if the report didn't come back, then the nurse should be calling for the report and writing a progress note. He said he has never spoken to the dialysis center. During an interview on 7/25/24 at 3:00 P.M., the Assistant Director of Nurses (ADON) said they send the communication book to the dialysis center, and they do not always return it. She said they call us if there is a problem, but the daily communication is not good. She said she was unsure if the nurses were sending the communication sheets filled out and the dialysis center was taking them out or where the breakdown was. She said the weights are often just on a sticky note. She said the three-page communication sheet is a corporate form and it should probably be revised as it is too confusing and too long. The ADON said the first page should be filled out by us and the second page by the dialysis center and if it was not done a call should be made and a progress note written, but this does not always happen. She said there were many days of communication missing and the communication should be better. During a follow up interview on 7/25/24 at 3:40 P.M., UM #1 said she documents the post-weights in the computer from the post-it/sticky note if they send one or she will call to get the weight, but the daily communication is not good. She said the dialysis center will call if there is a significant problem and do not communicate how Resident #102 tolerated the procedure routinely or answer any of the questions on the communication form.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of five nurses made four errors in 27 opportunities, totaling a medication error rate of 14.81%. These errors impacted one Resident (#211), out of seven residents observed. Findings include: Review of the facility's policy titled Administering Medications, dated as last revised April 2019, indicated but was not limited to the following: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders. -The individual administering the medication check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -Each nurses' station has a current Physician Desk Reference (PDR) and/or access to another medication reference. Review of the facility's policy titled Preparation and General Guidelines, dated November 2021, indicated but was not limited to the following: -An individualized approach should be used when altering dosage forms by crushing or opening capsules. -An order to crush medications may be required or preferred in accordance with State regulation of facility preference. -Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example: long acting or Enteric Coated forms should not be crushed; an alternative should be sought. -The instructions or crushing medications should be included on the resident's orders and the medication administration record (MAR/eMAR) so all personnel administering medications are aware of this need. On 7/24/24 at 9:20 A.M., the surveyor observed Nurse #1 prepare nine morning medications for Resident #211, eight of which were to be administered by mouth and one was a topical patch: a. Ferrous Sulfate 325 milligrams (mg) (iron supplement) b. Acidophilus with Pectin capsule (probiotic with soluble fiber additive) c. Loratadine 10 mg (allergies) d. Acetaminophen 500 mg (2 tablets) (pain relief) e. Alfuzosin HCL ER (extended release) 10 mg (long acting for enlarged prostate) f. Eliquis 2.5 mg (2 tablets) (anticoagulant) g. Metoprolol Succinate ER 25 mg (long acting for blood pressure) h. Rosuvastatin 10 mg (treat high cholesterol) i. Lidoderm 4% Pain Patch (pain) -Seven pills/tablets were put into a medication cup and one capsule was put into a separate cup. -The seven pills/tablets were all crushed together, and the powder mixed with applesauce. -The one capsule was opened, and the contents mixed with the applesauce. Review of the [NAME] Drug Book, 19th edition, indicated the following: -Acidophilus did not contain Pectin. -Ferrous Sulfate tablet should be taken with a full glass of water or juice and tablets should not be crushed or chewed. -Alfuzosin was an extended-release tablet and should not be crushed. -Metoprolol Succinate was an extended-release tablet and should not be crushed. Review of the Physician's Orders to reconcile the medications ordered versus the medications administered indicated the following four errors: -Acidophilus Capsule 10 mg once daily was ordered but Acidophilus with Pectin was administered. -Ferrous Sulfate 325 mg tablet was ordered but was administered crushed. -Alfuzosin HCL ER 10 mg was ordered but was administered crushed. -Metoprolol Succinate ER 25 mg was ordered but was administered crushed. Review of the medication cards used by the nurse to prepare the Alfuzosin HCL ER and Metoprolol Succinate ER indicated that a green sticker from the pharmacy was on the card and it read SWALLOW WHOLE DO NOT CRUSH OR CHEW. During an interview on 7/24/24 at 9:25 A.M., Nurse #1 said she crushed all the medications except the Acidophilus, she said she opened that capsule and mixed all the medications with applesauce. During an interview on 7/24/24 at 1:35 P.M., Nurse #1 said the Acidophilus with Pectin was the only one they had in the facility, and she thought it was the same as regular Acidophilus. She said she thought Ferrous Sulfate could be crushed and it was only the Slow FE (ferrous sulfate) that could not be crushed. Additionally, she said the Alfuzosin and Metoprolol Succinate are both extended release and say not to crush them, so she should not have crushed those medications, but Resident #211 had been having trouble swallowing so she had to crush the medications. During an interview on 7/25/24 at 10:20 A.M., Unit Manager (UM) #1 said she thought Ferrous Sulfate could be crushed. Additionally, she said the Acidophilus with Pectin is the only one they have in the facility, and it is basically the same thing. She said the Pectin just helps hold the capsule together. UM #1 said the Alfuzosin and Metoprolol Succinate should not have been crushed. During an interview on 7/25/24 at 3:00 P.M., the Assistant Director of Nurse (ADON) said the Ferrous Sulfate, Alfuzosin, and Metoprolol Succinate should not be crushed. She said those medications should be administered whole in applesauce or pudding or they would need to obtain an order for a different medication. She said Acidophilus with Pectin is not the same as Acidophilus and they would have to change the order or order the correct house stock.

Based on record review and interview, the facility failed to ensure that the COVID-19 testing policy was followed during a COVID-19 outbreak. Specifically, the facility failed to conduct 48-hour testing intervals for residents and staff in accordance with its COVID-19 testing requirements policy. Findings include: Review of the facility's Infection Control program policy for COVID-19 Testing Requirements-MA, last revised 5/11/23, indicated but was not limited to the following: Outbreak Testing: -If a new case of COVID-19 is identified, the facility will test exposed residents and staff at least every 48 hours on the affected unit until the facility goes 7 days without a new case unless a DPH epidemiologist directs otherwise. During an interview on 7/26/24 at 9:33 A.M., the Infection Preventionist (IP) said that the facility experienced a COVID-19 outbreak on the [NAME] Unit on 6/26/24, where two residents tested positive. She said that 6/26/24 was Day 0. The IP said that she had not received additional guidance or recommendations from a DPH epidemiologist in regard to testing for COVID, so the facility followed their policy for outbreak testing. Review of the IP's testing schedule of residents on the [NAME] Unit during the COVID-19 outbreak indicated testing was not conducted every 48 hours on the affected unit until the facility goes 7 days without a new case as follows: 6/24/24- Two residents test COVID-19 positive; all residents tested 6/26/24- One resident tested who was showing signs/symptoms of COVID-19. The remaining residents were not tested . 6/27/24- All residents tested on the [NAME] Unit, 4 residents tested positive for COVID-19 6/29/24- All residents tested on the [NAME] Unit, a total of 13 residents tested positive for COVID-19 7/1/24- All residents tested on the [NAME] Unit, 13 residents tested positive for COVID-19 7/3/24- Log does not reflect that residents were tested 7/5/24- All residents tested on the [NAME] Unit, 7 residents tested positive for COVID-19 7/7/24- No evidence that residents were tested 7/8/24- All residents tested on the [NAME] Unit, 4 Residents tested positive for COVID-19 7/10/24- All residents tested on the [NAME], all tested negative for COVID-19 During an interview on 7/26/24 at 12:42 P.M., the [NAME] Unit Nurse Manager said that all of the [NAME] Unit residents were tested for COVID-19 on 7/3/24, however 10 residents remained positive. Review of Staff testing logs for COVID-19 indicated testing began on 6/24/24. The facility testing schedule indicated that staff testing was conducted as follows: 6/24/24- All staff on the [NAME] Unit were tested for COVID-19, no positives were detected. 6/26/24- No testing conducted as required. 6/27/24- All staff on the [NAME] Unit were tested for COVID-19, no positives were detected 6/29/24- All staff on the [NAME] Unit were tested for COVID-19, no positives were detected 7/1/24- All staff on the [NAME] Unit were tested for COVID-19, no positives were detected During an interview on 7/26/24 at 12:48 P.M., the IP said that she could not provide documentation to demonstrate that COVID-19 testing had been conducted on 7/7/24 on the [NAME] unit in accordance with the facility policy or that all staff who worked on the [NAME] Unit had been tested for COVID-19 on 6/26/24, 48 hours after the initial outbreak testing began. During an interview on 7/26/24 at 1:19 P.M., the Assistant Director of Nursing (ADON) said that the COVID-19 testing procedure was not conducted in accordance with the facility's COVID-19 testing requirements policy.

Based on interview and record review, the facility failed to ensure advanced directives were reviewed and followed-up on for one Resident (#44), out of 24 sampled residents. Specifically, the facility failed to ensure the wishes for Do Not Resuscitate (DNR) were pursued as legally allowed for Resident #44. Findings include: Review of the facility's policy titled Advanced Directives, dates as revised in [DATE], indicated the following: -Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. -If the resident or representative indicates that he/she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. Resident #44 was admitted to the facility in February 2024 with diagnoses including a history of a stroke and dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #44 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of the medical record for Resident #44 included the following: -Decree and Order of Appointment of Guardianship for an incapacitated person indicating three family members were co-guardians. A post-it note on the guardianship paperwork indicated Guardianship in place, guardian does NOT have authorization for Advanced Directives, no MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment), Resident is a Full Code -a MOLST form signed by two physicians in [DATE] indicating Resident #44 was a DNR. The title of the MOLST in the electronic medical record indicated *Void* not valid-no auth (authorization) on guardianship and signed by unknown -the electronic medical record Documents section included Pre-Admission Hospital Documentation with an additional note indicating enclosed MOLST is VOID During an interview on [DATE] at 10:30 A.M., the brother of Resident #44 said he was the guardian along with his spouse and child. He said Resident #44 had a history of being on hospice service and had graduated from hospice services but had continued to have advanced directives of Do Not Resuscitate. He said he believed he had discussed this with the facility and the previous living residence had sent over the DNR form. During an interview on [DATE] at 4:30 P.M., Social Worker #1 said she was not the regular Social Worker for Resident #44. She said Social Worker #2 was the assigned Social Worker but was not available. She said in Massachusetts, when a family member has been appointed the legal guardian, they have the authority to make decisions regarding code status (full code versus DNR). She said she believed the three co-guardians of Resident #44 had a conflict regarding the code status and that was why Resident #44 was a full code. She said she thought Social Worker #2 had reviewed this and the court had been petitioned to expand the guardianship to include advanced directives. She said she would review the medical record and any information from Social Worker #2 for documentation to support that the wishes for changes to the code status had been pursued. Review of the Social Service Progress Notes indicated the following: [DATE]: Resident #44 is a full code status as the guardianship does not include authorization for advanced directives. [DATE]: Social Worker inquired about treatment plan for use of antipsychotics. [DATE]: Social Worker spoke with guardian about extending the authority to admit to a nursing home and the court approval for the antipsychotic treatment plan. [DATE]: court appointed antipsychotic monitor missed court hearing on [DATE]. Social Worker referred case to the facility attorney to assist with treatment plan approval. [DATE]: new medical certificate sent for treatment plan court date of [DATE]. The medical record did not indicate the Social Worker had reviewed what, if any, legal pursuits would be needed to change the Resident's code status. During an interview on [DATE] at 10:30 A.M., Social Worker #1 said she was unable to locate any documentation to indicate there was a conflict regarding code status between the guardians. She said she thought the family was actively pursuing expanding the guardianship to include advanced directives. During an interview on [DATE] at 10:15 A.M., Social Worker #1 said she contacted the family's attorney who had been working on the expansion of guardianship for intent to admit to a nursing home and the antipsychotic treatment plan and the attorney said they were not working on the expansion of guardianship to include advanced directives. She said she did not know why the family thought Resident was a DNR as Social Worker #2 had checked a box indicating advanced directives had been reviewed with the family on [DATE]. During an interview on [DATE] at 10:55 A.M., Social Worker #1 said she had reviewed all hospital admission paperwork, guardianship paperwork, and progress notes and could not see any information to indicate the facility had pursued changing the code status of Resident #44, as indicated by the wishes of the family.

Based on record review, policy review, and interview, the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) program. Specifically, the facility failed to invite or involve the pharmacy in the QAPI program for over two years. Findings include: The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Design and Scope, undated, indicated the following * The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of life, resident choice and safety. During an interview with one of the facility's Consultant Pharmacists (#1) on 5/11/23 at 1:26 P.M., he said that he had come to the facility monthly between October 2021-August 2022 to conduct monthly medication regimen reviews however during that time the pharmacy was never invited to attend the facility's QAPI meetings. He explained that the pharmacy attempted to get invited but never got a response. He cannot remember who in the building this was addressed with. During an interview with the Nursing Home Administrator (NHA) on 5/12/23 at 11:07 A.M., she said QAPI meetings are held monthly at the facility and that the Pharmacy should absolutely be attending QAPI on a quarterly basis. The NHA confirmed that the pharmacist had not attended or participated in QAPI in all of 2022 or 2023.

Based on observation and interview, the facility failed to maintain the inside of 2 of 2 laundry dryers in a manner to prevent the potential spread of infection. Findings include: During an observation of the laundry room on 5/11/23 at 8:30 A.M., the surveyor observed the inside of two dryers in the laundry room. Both dryers had caked-on substances on the interior of the drums covering approximately 50% of the drum walls. The facility failed to produce a policy regarding the cleaning of the inside of the dryers. Review of the manufacturer's directions indicated the following: 1. Check the cylinder daily for foreign objects and clean. 2. Thoroughly clean the tumbler every year and have an authorized service representative complete the cleaning. During an interview on 5/11/23 at 8:35 A.M., the facility's Regional Director of Maintenance said that the dryer drums needed to be scraped because things had melted on them. During an interview on 5/11/23 at 8:34 A.M., the Director of Housekeeping could not answer how often the inside of the dryers were cleaned and said there was no log of when they were cleaned.

Based on record review, policy review, and interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for four sampled Residents (#29, #14, #30, and #44), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Medication Regimen Reviews, undated, included but was not limited to: - The consultant pharmacist reviews the medication regimen of each resident at least monthly. - Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: a. the resident's name; b. the name of the medication; c. the identified irregularity; and d. the pharmacist's recommendation. - An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. - If the identified irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally, and documents the notification. - If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. - The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. - An acute change of condition may prompt a request for a MRR. The staff member who identifies the change of condition follows reporting procedures to notify the physician. The physician may request a MRR be conducted within a specific timeframe (e.g., within 24 hours). - The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. - Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1. Resident #29 was admitted to the facility in March 2023 with diagnoses including diabetes, esophagitis, osteoporosis, and sepsis. Review of the Minimum Data Set (MDS) assessment, dated 4/27/23, indicated Resident #29 can make self understood and that he/she has the ability to understand others. -The MDS indicated: Did a complete drug regimen review identify potential clinically significant medication issues? Facility Response Coded: Yes -Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? Facility Response Coded: Yes Review of the Pharmacy Consultant Note, dated 4/29/23, indicated: -Orders reviewed recommendations submitted via IMRR. During an interview on 5/10/23 at 12:43 P.M., Unit Manager #1 said that she was unable to provide the surveyor with Resident #29's IMRR. Unit Manager #1 said that the Director of Nursing (DON) receives IMRR and then the DON reviews them and makes the changes. Unit Manager #1 said she did not have a copy of the recommendations. On 5/11/23, the DON provided the surveyor with the IMRR. Review of the Pharmacy Consultant Note, dated 4/29/23, indicated: -Orders reviewed-recommendations submitted via IMRR Review of the Interim Medication Regime Review note, dated 4/29/23, indicated: Clinically Significant Issue Identified. Must Act on Physician Response by Midnight Next Calendar Day--- due date: 4/30/23 For Clinically Significant Medication Issues. Facility was notified immediately. Spoke with: TRIED CALLING AND NO ANSWER ON UNIT Date: 4/29/23 Time: 8:30 P.M. Recommendation: Mycophenolate Mofenolate oral capsule, order on hospital sheet- cannot find in system; please clarify During an interview on 5/11/23 at 9:17 A.M., the DON said that she did not have any of the pharmacy recommendations for Resident #29. The DON explained that upon the surveyor's request for copies of the IMRR the day prior she realized that she had not been receiving any of the recommendations, for any resident, for an undetermined length of time, but well over a year. The DON said that she contacted the pharmacy yesterday and learned that the pharmacy recommendations have been going to a mailbox that she never checked. The DON said that she has never addressed this with the pharmacy as she was unaware that there was a problem until a week prior. Although the problem was identified a week prior, she had not yet attempted to obtain the recommendations. 2. Resident #14 was admitted to the facility in April 2023 with diagnoses including congestive heart failure, major depression, and anxiety. Review of the MDS assessment, dated 4/11/23, indicated that during the Drug Regimen Review issues were found for Resident #14. The MDS indicated: Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? The facility response was coded: Yes Review of the Pharmacy Consultant Note, dated 4/12/23, indicated: -orders reviewed recommendations submitted via IMRR. During an interview on 5/10/23 at 12:43 P.M., Unit Manager #1 said that she was unable to provide the surveyor with Resident #14's IMRR. Unit Manager #1 said that the DON receives IMRR and then the DON reviews them and makes the changes. Unit Manager #1 said she did not have a copy of the recommendations. On 5/11/23, the DON provided the surveyor with the IMRR. Review of the IMRR, dated 4/12/23, indicated: - PRN [as needed] Psychotropic orders need a 14-day stop date. Then ask MD to re-evaluate continued need for the following medication(s): hydroxyzine 25 milligrams Q24H [once daily] PRN anxiety During an interview on 5/11/23 at 9:17 A.M., the DON said that she did not have any of the pharmacy recommendations for Resident #14. The DON explained that upon the surveyor's request for copies of the IMRR the day prior she realized that she had not been receiving any of the recommendations, for any resident, for an undetermined length of time, but well over a year. The DON said that she contacted the pharmacy yesterday and learned that the pharmacy recommendations have been going to a mailbox that she never checked. The DON said that she has never addressed this with the pharmacy as she was unaware that there was a problem until a week prior. Although the problem was identified a week prior, she had not yet attempted to obtain the recommendations. 41105 3. Resident #30 was admitted to the facility in August 2021 and had diagnoses that included panic disorder and dementia. During a record review on 5/10/23 at 10:44 A.M., the record indicated the pharmacist had reviewed Resident #30's medication regimen on the following dates: * 4/7/23, with no recommendations; * 3/2/23, with documentation to see report for recommendations; * 2/4/23, with no recommendations; * 1/5/23, with documentation to see report for new recommendation. During an interview on 5/10/23 at 11:36 A.M., with Unit Manager #2 the surveyor requested to see copies of the pharmacy Medication Regimen Review (MRR) recommendations from 3/2/23 and 1/5/23. Unit Manager #2 said that she was unable to provide the surveyor with Resident #30's MRR. Unit Manager #2 said that the DON receives MRR and then the DON reviews them and makes the changes. Unit Manager #2 said she did not have a copy of the recommendations but that she would speak with the DON and obtain copies for the surveyor. During an interview on 5/11/23 at 9:17 A.M., the DON said that she did not have any of the pharmacy recommendations for Resident #30. The DON explained that upon the surveyor's request for copies of the MRRs the day prior she realized that she had not been receiving any of the recommendations, for any resident, for an undetermined length of time, but well over a year. The DON said that she contacted the pharmacy and learned that the pharmacy recommendations have been going to a mailbox that she never checked. The DON said that she has never addressed this with the pharmacy as she was unaware that there was a problem until a week prior. Although the problem was identified a week prior, she had not yet attempted to obtain the recommendations. 46339 4. Resident #44 was admitted to the facility in January 2020 with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage and contracture of left hand. Review of Resident #44's most recent Minimum Data Set (MDS) Assessment, dated 2/16/23, indicated a Brief Interview for Mental Status (BIMS) score of 0 out of possible 15 indicating Resident #44 has severe cognitive impairment. Review of Resident #44's medical record indicated a medication regimen review had been completed on the following dates: -9/7/22 -10/15/22 -11/7/22 -12/8/22 Further review of medical record failed to indicate the medication regimen review documents were available. During an interview on 5/11/23 at 9:17 A.M., the DON said that she did not have any of the pharmacy recommendations for Resident #44. The DON explained that upon the surveyor's request for copies of the MRR the day prior she realized that she had not been receiving any of the recommendations, for any resident, for an undetermined length of time, but well over a year. The DON said that she contacted the pharmacy yesterday and learned that the pharmacy recommendations have been going to a mailbox that she never checked. The DON said that she has never addressed this with the pharmacy as she was unaware that there was a problem until a week prior. Although the problem was identified a week prior, she had not yet attempted to obtain the recommendations.

Based on record review and interviews, the facility failed to ensure two Residents (#29 and #57) were free of significant medication errors, out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #29, to ensure that medications were accurately reconciled by nursing, resulting in a medication transcription error, resulting in Resident #29 going 17 days without being administered his/her anti-rejection medication; and 2. For Resident #57, to ensure that medications were accurately transcribed by nursing, resulting in Resident #57 going 106 days without being administered his/her Gabapentin (medication used for managing polyosteoarthritis pain). Findings include: 1. Review of the facility's policy titled Reconciliation of Medications on Admission, undated, indicated the purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. *Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form; b. Discharge summary from referring facility; c. Admission order sheet; d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. -Find a quiet place that is free from distractions. *General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. *Steps in the Procedure 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; b. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician from the referring facility; c. Discuss with the resident or family; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. 7. Document findings and actions 8. When a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented. *Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. 3. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse physician, pharmacy, and/or next shift. 4. If the discrepancy was resolved, document how the discrepancy was resolved. Resident #29 was admitted to the facility in March 2023 with diagnoses including diabetes, esophagitis, osteoporosis, and sepsis. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/27/23, indicated Resident #29 can make self understood and that he/she has the ability to understand others. The MDS indicated that Resident #29 does not have behaviors and he/she does not reject care (blood work, medications, activities of daily living assistance). The MDS indicated: Did a complete drug regimen review identify potential clinically significant medication issues? Facility Response Coded: Yes The MDS indicated: Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? Facility Response Coded: Yes Review of the Hospital Discharge Summary, dated 4/24/23, indicated for nursing to administer: -mycophenolate mofetil (immunosuppression medication, is a prescription medicine to prevent rejection (anti-rejection medicine) in people who have received a kidney transplant. Rejection is when the body's immune system perceives the new organ as a foreign threat and attacks it.) 250 milligrams, administer 2 capsules by mouth twice daily for kidney transplant to prevent organ rejection. Review of the Physician's Orders and Medication Administration Record, dated April and May 2023, indicated there was no documentation to support that nursing reconciled (transcribed) the orders for: -mycophenolate mofetil 250 milligrams, administer 2 capsules by mouth twice daily for kidney transplant to prevent organ rejection. Review of the Medication Administration Record, dated April 2023 and May 2023, indicated nursing did not transcribe, and Resident #29 did not begin his/her mycophenolate mofetil for his/her kidney transplant. According to the Mayo Clinic, review on 5/12/23, indicated that the health risks associated with a kidney transplant include those associated directly with the surgery and rejection of the donor organ. Risks also include the side effects of taking anti-rejection medications (immunosuppressants) needed to prevent the body from rejecting the donated kidney. Further review indicates that rejection is your body's way of not accepting the kidney transplant. Although rejection is most common in the first six months after surgery, it can occur at any time. Fortunately, the transplant team can usually recognize and treat a rejection episode before it causes any major or irreversible damage. It is very important for you to continuously take your medications as prescribed and have your blood work drawn as scheduled. Review of the Pharmacy Consultant Note, dated 4/29/23, indicated: -Orders reviewed-recommendations submitted via IMRR [Interim Medication Regime Review] Review of the Interim Medication Regime Review note, dated 4/29/23, indicated: Clinically Significant Issue Identified. Must Act on Physician Response by Midnight Next Calendar Day--- due date: 4/30/2023 For Clinically Significant Medication Issues. Facility was notified immediately. Spoke with: TRIED CALLING AND NO ANSWER ON UNIT Date: 4/29/23 Time: 8:30 P.M. Recommendation: Mycophenolate Mofenolate oral capsule, order on hospital sheet- cannot find in system; please clarify During an interview on 5/10/23 at 12:43 P.M., the surveyor met with Unit Manager #1 and reviewed Resident #29's medical record. The surveyor requested printed copies of the hospital discharge summary, April 2023 and May 2023 Medication Administration Records, and the Intermediate Drug Regime Review form. On 5/11/23 at 6:40 A.M., Resident #29 called out to the surveyor who was rounding on the [NAME] Rd Unit. Resident #29 was visibly upset and said he/she was told that the nurses made a mistake on his/her medications since April 2023. Resident #29 said, They [nursing staff] just told me last night I was not getting me my Cellcept (mycophenolate mofetil), and he/she said this medication is important for me; I am a kidney transplant recipient and I need this medication. The medication is so my body does not reject my kidney, I could die. During an interview on 5/11/23 at 6:57 A.M., the Director of Nursing said the facility just became aware of a significant medication error that Resident #29 was not receiving his/her prescription Cellcept. During an interview on 5/11/23 at 2:25 P.M., Nurse #4 said he was responsible to reconcile Resident #29's medications when he/she admitted to the facility but was not aware he made errors until 5/11/23. Review of the 24-Hour Chart Check Form, dated April 2023, indicated Nurse #6 completed a 24-hour chart check on 4/24/23. During an interview on 5/12/23 at 7:15 A.M., Nurse #6 said she completed the 24- hour chart check. Nurse #6 said she identified omissions that Nurse #4 did not reconcile from the discharge summary, but she did not address these omissions as required by policy. During an interview on 5/11/23 at 1:33 P.M., the Nurse Practitioner said that nursing missed some of the medications on Resident #29's hospital discharge summary including his/her Cellcept. The NP said she should have caught the omission, but she did not. The NP said that the transplant team at the hospital will need to manage Resident #29's treatment plan for the missed doses of Cellcept. During an interview on 5/11/23 at 2:11 P.M., the Risk Manager said nursing did not reconcile the discharge medication orders correctly and did not complete a 24-hour chart check correctly, but should have, resulting in the significant medication error. During an interview on 5/12/23 at 9:23 A.M., the Director of Nursing (DON) said Resident #29 had a significant medication error event. The DON said she was not aware of the impact Resident #29 would have regarding his/her kidney transplant and the DON said that Unit Manager #1 is in communication with the transplant clinic for further instructions. During an interview on 5/12/23 at 12:06 P.M., Unit Manager #1 said she called the transplant clinic to make the transplant clinic aware of the medication omission. Unit Manager #1 said that the clinic is working on an action plan for Resident #29, and she said this medication error could delay Resident #29's discharge plan. She indicated the facility was uncertain of the implications on the resident's health and well-being and that the transplant team had been notified of the significant medication error. She said the transplant team would be sending a kit to the facility to draw blood and return to them so that they could determine if Resident #29's body had begun to reject the transplant, due to not receiving the medication. 46339 2. Resident #57 was admitted to the facility in June 2021 with diagnoses including dementia with other behavioral disturbances and polyosteoarthritis. Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 2/16/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) exam score of 3 out of a possible 15, indicating he/she had severe cognitive impairment. The MDS further indicated Resident #57 did not have behaviors and required total assistance from staff for activities of daily living. Review of Resident #57's Physician's Order, dated 1/24/23, indicated the following: -Gabapentin capsule 100 mg (milligrams) give 100 mg by mouth three times a day related to polyosteoarthritis. The start date was scheduled for 1/24/2024. Review of Resident #57's Medication Administration Record (MAR) from 1/24/23-5/9/23 indicated Resident #57 did not receive his/her Gabapentin medication as ordered. During an interview on 5/10/23 at 1:18 P.M., Unit Manager #2 said Resident #57 was supposed to be taking Gabapentin, she reviewed the physician's orders with the surveyor and acknowledged the transcription error. During an interview on 5/12/23 at 11:52 A.M., the Director of Nursing said two nurses should verify orders at all times to prevent transcription errors. She acknowledged that in this case two nurses did not transcribe the order.

Based on observations and interview, the facility failed to ensure residents on the facility's Dementia Specialty Care Unit were provided with a dignified dining experience. Findings include: During an observation of the lunch meal in the third unit dining room on 5/10/23, the surveyor made the following observations: * At 12:32 P.M., a nurse stood over a resident, briefly fed him/her some spoonfuls of food and then walked away. * At 12:35 P.M., a Resident (#28) at another table yelled where's my food. The resident's tablemate had been eating for 10 minutes. * At 12:38 P.M., a Certified Nursing Assistant (CNA) stood over a resident, placed a bowl of applesauce below the resident's [NAME], and placed a spoonful of apple sauce in his/her mouth. * At 12:40 P.M., Resident #28 yelled again where's my food. * By 12:41 P.M., 11 residents in the dining room had been served lunch and 9 were waiting for their meals to be delivered to the unit on the second meal truck. * At 12:42 P.M., another unserved and unfed resident at a table yelled out where's my food at? * At 12:44 P.M., food was delivered to Resident #28, 20 minutes after his/her tablemate had been served. During an observation of the breakfast meal in the third unit dining room on 5/11/23, the surveyor made the following observations: * At 8:14 A.M., 13 residents were present in the dining room: seven had been served breakfast from the first food truck; six residents were waiting for their food to be delivered to the unit on the second food truck. * At 8:16 A.M., a resident began eating pancakes and syrup with his/her hands. There were several staff in the room, however none noticed the resident. The resident's table mate appeared to be upset and repeatedly instructed the resident to not eat with his/her hands. * At 8:26 A.M., the resident continued to eat pancakes and syrup with his/her hands. Four staff were in the dining room, however none of them were facing in the direction of the residents or aware. During an observation of the breakfast meal in the third unit dining room on 5/12/23, the surveyor made the following observations: * At 7:56 A.M., a resident sat at a table watching peers in the room eat, and stated loudly can you get me something to eat, I am hungry. * At 8:02 A.M., staff realized the resident's food was not on the first truck and wheeled him/her out of the dining room and placed the resident in front of his/her room, then went back into the dining room to continue passing trays. * At 8:04 A.M., the resident sat in the hall and said, I am hungry can you get me something to eat to the surveyor. The Nursing Home Administrator overheard the exchange and instructed staff to get him/her a snack while he/she was waiting. * At 8:14 A.M., the resident was served breakfast. During an interview with the Director of Nursing (DON) on 5/12/23 at 9:33 A.M., she said it is the expectation that staff sit at eye level while feeding residents and that if a resident needs assistance, the assistance is provided. As well, the DON said that meals in the main dining room should be delivered on the same truck so that residents don't have to sit around waiting while others eat.

Based on record review, policy review, and interviews, the facility failed to ensure that one Resident (#320), out of a total sample of 27 residents, whose right to be informed of, and participate in his/her treatment plan, was honored, when his/her Health Care Agent, which was not invoked, signed Resident #320's admission consents. Findings include: Review of the facility's policy titled Advanced Directives, undated, indicated that the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. *Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. *Health care decision-making - consent, refusal to consent, or withdrawal of consent to health care, treatment, service, or a procedure to maintain, diagnose, or treat a resident's physical or mental condition. * Health care decision-making capacity - refers to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. -Determining Existence of Advance Directive *Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. *The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. *Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. *If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. -Decision-Making Capacity *Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. *The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record. Review of the facility's policy titled Resident Rights, undated, indicated: *Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -self-determination; -be informed about his or her rights and responsibilities; -be notified of his or her medical condition and of any changes in his or her condition; -be informed of, and participate in, his or her care planning and treatment; Resident #320 was admitted to the facility in [DATE] with diagnoses including diabetes, osteoporosis, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #320 could make self understood and that he/she could understand others. The MDS indicated that Resident #320 has a health care agent and the agent had not been invoked. Review of the form titled Documentation of Resident Incapacity Pursuant to Massachusetts Health Care Proxy Act, undated, was blank in Resident #320's medical record. Review of the Physician's Orders on [DATE] indicated there was not an order for Resident #320's Health Care Proxy to be invoked. Therefore, Resident #320 was deemed competent and able to consent to his/her own treatment. Review of the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], indicated Do Not Resuscitate and the form indicated that Resident #320's Health Care Agent which was not invoked gave consent via the telephone. Further review indicated the form was not signed by Resident #320. Review of the form titled Agreement and its Attachments, dated [DATE], indicated Resident #320's Health Care Agent which was not invoked signed the following consents for Resident #320. Attachment A, Bed Hold Policy; Attachment B, Consent to Admission and Treatment; Attachment C1, Notice of Privacy Practices; Attachment C2, Acknowledgement of Receipt of Resident's Rights; Attachment D1 or D2, Smoking Policy; Attachment D3, Firearms and Other Weapons Policy, Policy Statement; Attachment E1, Management of Resident's Personal Funds; Attachment E2, Resident Fund Management Service; Attachment F1, Assignment of Benefits; Attachment F2, Social Security and/or SSI Payments; Attachment G, Medicare Secondary Payor (MSP) Screening; Attachment H, Readmission Agreement; Attachment I, Consent to Photograph / Publish; Attachment I2, Consent to Student Care and Treatment; Attachment J, Alternative Dispute Resolution Agreement; Attachment K, Private Therapy Rates; Attachment L, Medicare Part D; Attachment M, Notice of Medicare Non-Coverage; Attachment N, Skilled Nursing Facility Advance Beneficiary Notification (SNFABN); COVID-19 Rider During an interview on [DATE] at 1:32 P.M., Unit Manager #1 reviewed the record with the surveyor. The Unit Manager said that Resident #320 was his/her own responsible person and that he/she should sign his/her own consents. During an interview on [DATE] at 1:33 P.M., the Admission Director said that she completed the new admission consents with Resident #320's Health Care Agent. The Admission Director said that nursing told her that Resident #320 could not sign his/her own paperwork. During an interview on [DATE] at 1:43 P.M., the Director of Nursing said Resident #320 was his/her own person and Resident #320 should have signed his/her own consents. During an interview on [DATE] at 1:48 P.M., the Nurse Practitioner said that she did not invoke Resident #320's Health Care Agent. The Nurse Practitioner said that Resident #320 is his/her responsible person until the Health Care Agent is invoked.

Based on record review, policy review, and interview, the facility failed to report an allegation of abuse in the required timeframe for one Resident (#57), out of a total of 27 sampled residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, undated, indicated the following: Policy Statement: All reports of resident abuse, neglect, exploitation, injuries of unknown origin, theft/misappropriation of resident properly, and reasonable suspicions of crimes against residents are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation *3. immediately is defined as: a. Within two hours if the events that cause the allegation involve abuse or result in serious bodily injury; or b. Within 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #57 was admitted to the facility in June 2021 with diagnoses including dementia with other behavioral disturbances, polyosteoarthritis, and anxiety disorder. Review of Resident #57's Minimum Data Set (MDS) assessment, dated 2/16/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating he/she was severely cognitively impaired. The MDS further indicated Resident #57 did not have behaviors and required total assistance from staff for activities of daily living. Review of a note titled SBAR (Situation, background, assessment, recommendation), dated 9/20/22, indicated Resident #57 threatened his/her roommate with a back massager at approximately 1:20 P.M.; no physical contact was made. Review of the incident report write-up, dated 9/20/22, indicated the following: -Investigative statement: Resident roommate made allegation that he/she was threatened with a back massager by his/her roommate, roommate denied any physical contact at that time. Review of Resident #57's medical record indicated that the Resident was supposed to be on a 1:1 (one to one) staff supervision during the incident. During an interview on 5/11/23 at 2:13 P.M., Unit Manager #2 said allegations of abuse are reported immediately to the Director of Nursing. During an interview on 5/12/23 at 9:10 A.M., the Director of Nursing said she did not think the facility needed to report the incident as there was no physical contact during the threat/altercation.

Based on observations, record review, and interviews, the facility failed to identify and investigate the origin of a bruise for one Resident (#11), out of a total sample of 27 residents. Findings include: Review of the facility's policy titled Assessment of skin condition and integrity, undated, indicated the following: *Documentation: any new change in the resident's skin *Reporting: notify the supervisor of new skin alterations noted, notify family, guardian of resident of new skin alterations noted. Resident #11 was admitted to the facility in April 2022 with diagnoses including dementia and anemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/2/23, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderately impaired cognition. During an observation and interview on 5/9/23 at 9:08 A.M., the surveyor observed Resident #11 with a fading, purple bruise with a yellow center on his/her upper right hand. Resident #11 told the surveyor he/she got it after accidentally knocking it on the bed. Review of the May 2023 Physician's Orders indicated an order for Skin checks on Friday 3-11 every evening shifts every Friday. Review of the most recent skin assessment, dated 4/28/23, did not indicate a bruise on the right upper hand. The record failed to indicate the skin assessment scheduled for 5/5/23 was completed as ordered by the Physician. During an interview with Resident #11's Certified Nurse's Assistant (CNA) #4 on 5/11/23 at 8:46 A.M., she said any new bruises identified on the residents during care should be reported to the nurse. CNA #4 said that she had seen the bruise on Resident #11's hand but did not report to the nurse as required. During an observation and interview on 5/11/23 at 8:48 A.M., Nurse #7 and the surveyor observed Resident #11's fading bruise on the right upper hand. Nurse #7 said she was not aware of the bruise and that the CNAs were expected to observe the resident's skin during care and report any new bruises to her so she can start an incident report. During an observation and interview with the Assistant Director of Nurses (ADON) on 5/11/23 at 8:54 A.M., she observed the fading bruise on Resident #11's right upper hand with the surveyor. The ADON said CNAs are expected to notify the nurse when they identify new bruises and that the nurse then starts an incident report, notifies the responsible party and physician, notifies the Director of Nurses, and if a report needs to be made to the Department of Public Health, a report is made within two hours.

Based on observations, record reviews, and interviews, the facility failed to implement and/or develop the care plan for three Residents (#25, #57 and #55), out of a total of 27 sampled residents. Specifically, the facility failed: 1. For Resident #25, to ensure supervision and assistance were implemented with bed mobility and eating; 2. For Resident #57, to develop and implement one to one (1:1) monitoring per the physician's order; and 3. For Resident #55, to implement the care plan for left hand contracture care. Findings include: 1. Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, indicated the following: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident #25 was admitted to the facility in July 2020 and had diagnoses that included dementia without behavioral disturbance and Barrett's Esophagus (a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/30/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #25 scored a 6 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #25 had no behaviors and required extensive physical assistance for bed mobility and required set up and supervision for eating. On 5/9/23 at 8:13 A.M., the surveyor observed a Certified Nursing Assistant (CNA) deliver a breakfast tray to Resident #25. The CNA said, I have your breakfast, placed it on a tray table beside the bed and without assisting the Resident to a seated position or taking the covers off the drinks and food, exited the room. Resident #25 was lying flat on his/her back in bed and after a few minutes Resident #25 rocked his/her body back and forth until he/she was able to get to a seated position and reach the tray of food. During a record review on 5/10/23 the following was indicated: * The most recent Nutritional Assessment, dated 4/3/23, indicated Resident #25 feeds self with some assist for meal tray set up. * The current Kardex (resident specific care instructions) indicated I am continual supervision with eating and I require 1 staff to assist me to reposition and turn in bed. * The current ADL care plan in place indicates -I require 1 staff to assist me to reposition and turn in bed. -I am continual supervision with eating. On 5/10/23 at 12:24 P.M., the surveyor observed Resident #25 alone in his/her room, seated on the bed with his/her back to the door with lunch on the tray table in front of him/her. * At 12:28 P.M., Resident #25 remained unsupervised. There was an uncut piece of meat on his/her tray and Resident #25 used a fork and knife (running the knife back and forth several times) attempting to cut the meat, unsuccessfully. On 5/11/23 at 8:05 A.M., the surveyor observed Resident #25 awake and lying flat in bed. A CNA briefly entered the room, left breakfast on a tray table beside the bed, and exited the room to continue passing trays. The surveyor continued to make the following observation: * At 8:13 A.M., Resident #25 remained unsupervised, and the Resident was eating uncut pancakes and syrup with his/her hands. On 5/11/23 at 12:35 P.M., the surveyor observed a Nurse #11 deliver lunch to Resident #25. Nurse #11, placed the lunch on a tray table beside Resident #25's bed and exited the room, leaving Resident #25 alone and unsupervised. * By 12:45 P.M., Resident #25 remained without supervision. During an interview on 5/12/23 at 10:35 A.M., Resident #25's CNA #4 said that Resident #25 is independent with supervision with all care. CNA #4 said that she has access to the Kardex and was unaware that Resident #25 required supervision with eating. During an interview on 05/12/23 at 10:42 A.M., Nurse Unit Manager #2 said that continual supervision means someone should be with Resident #25 throughout the meal. Nurse Unit Manager #2 said that she does not think that Resident #25 needs assistance with bed mobility. 46339 2. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 10/2022, indicated 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. * When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. * Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Resident #57 was admitted to the facility in June 2021 with diagnoses including dementia with other behavioral disturbances, polyosteoarthritis, and anxiety disorder. Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 2/16/23, indicated the Resident had a Brief Interview for Mental Status (BIMS) exam score of 3 out of a possible 15, indicating he/she was severely cognitively impaired. The MDS further indicated Resident #57 did not have behaviors and required total assistance from staff for activities of daily living. Review of Resident #57's Physician's Orders, dated 9/8/22, indicated 1:1 monitoring until further notice. Review of Resident #57's resolved care plan with focus- I (Resident) have a behavior problem. Intervention date initiated 9/8/22 1:1 staff monitoring. Review of a note titled SBAR (Situation, background, assessment, recommendation), dated 9/20/22, indicated the Resident threatened his/her roommate with a back massager at approximately 1:20 PM. There was no physical contact made. During an interview on 5/11/23 at 2:13 P.M., Unit Manager #2 said at the time of the incident Resident #57 was on 15-minute checks and was never on 1:1 monitoring. The surveyor reviewed the physician's orders with Unit Manager #2 and she acknowledged that the Resident should have been on 1:1 monitoring per the orders. During an interview on 5/12/23 at 9:10 A.M., the Director of Nursing said that staff were using 1:1 and 15-minute checks interchangeably throughout the nurses' progress notes. The Director of Nursing was unaware that there was a physician's order for Resident #57 to be on 1:1 monitoring. 3.Resident #55 was admitted to the facility in March 2021 with diagnoses including dementia and dorsalgia (back pain). Review of Resident #55's Minimum Data Set (MDS) assessment, dated 3/9/2023, indicated a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #44 required total dependence of one-person for activities of daily living. On 5/9/23 at 9:40 A.M., the surveyor observed Resident #55 lying in bed with his/her left hand without a kerlix roll in it. There was dark brown matter observed between the index and middle finger. Review of Resident #55's medical record indicated: * A physician's order, dated 11/23/2022, to Cleanse left hand with soap and water. Dry and place kerlix roll in grasp daily to the left hand with contractures. * A care plan, dated as initiated 11/23/2022, indicated I have impaired skin integrity related to left hand contractures. An intervention on the care was Cleanse left hand with soap and water dry and place kerlix roll in grasp daily. On 5/9/23 at 1:44 P.M., the surveyor observed Resident #55 lying in bed holding a kerlix roll in his/her left hand. There was dark brown matter noted between the index finger and middle finger. On 5/10/23 at 8:10 A.M., the surveyor observed Resident #55 lying in bed holding a kerlix roll in his/her left hand. There was dark brown matter observed between the index finger and middle finger. During an observation and interview on 5/10/23 at 9:43 A.M., the surveyor and Unit Manager #2 observed Resident #55's left hand together and observed dark brown crusty matter between the fingers. Unit Manager #2 said the order for cleaning Resident #55's hand should be followed and if Resident #55 refused the care it would be documented by the nurses. Review of the current Treatment Administration Record (TAR) failed to indicate that Resident #55 had refused left hand care treatment as ordered.

Based on record review, policy review, observation, and interview, the facility failed to consistently follow professional standards of practice for three Residents (#29 ,#105, and #44), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #29, to reconcile medications correctly and complete a 24-hour chart check (process used to review reconciled orders placed into the physician's order); 2. For Resident #105, a. to write an accurate physician's order for medication administration for a Resident with a feeding tube, and b. to set an air mattress at the correct settings, per the physician's orders; and 3. For Resident #44, to follow the physician's orders for palm guard application for contracture management. Findings include: 1. Review of the facility's policy titled Reconciliation of Medications on Admission, undated, indicated the purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. *Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form; b. Discharge summary from referring facility; c. Admission order sheet; d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. -Find a quiet place that is free from distractions. *General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. *Steps in the Procedure 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; b. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician from the referring facility; c. Discuss with the resident or family; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. 7. Document findings and actions 8. When a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented. *Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. 3. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse physician, pharmacy, and/or next shift. 4. If the discrepancy was resolved, document how the discrepancy was resolved. Resident #29 was admitted to the facility in March 2023 with diagnoses including diabetes, esophagitis, osteoporosis, and sepsis. Review of the Minimum Data Set (MDS) assessment, dated 4/27/23, indicated Resident #29 can make self understood and that he/she has the ability to understand others. During a record review on 5/10/23 at 12:43 P.M., the surveyor and Unit Manager #1 reviewed Resident #29's medical record and the surveyor requested printed copies of the hospital discharge summary, April and May 2023 Medication Administration Records and the Intermediate Drug Regime Review form. Review of the Hospital Discharge Summary, dated 4/24/23, indicated for nursing to administer: -mycophenolate mofetil 250 milligrams, administer 2 capsules by mouth twice daily for kidney transplant to prevent organ rejection. -acetaminophen (pain medication) 325 mg, administer two tablets four times daily for 28 days. -Senna (constipation medication) 8.6 mg, 1 tablet at bedtime. -sodium bicarbonate (mediation used for sodium levels) 650 mg, two tablets two times a day. -insulin lispro (fast acting insulin for diabetes management typically administered with meals), inject 4 units three times a day with meals. Review of the Physician's Orders and Medication Administration Record, dated April and May 2023, indicated there was no documentation to support that nursing reconciled (transcribed) the orders for: -mycophenolate mofetil 250 milligrams, administer 2 capsules by mouth twice daily for kidney transplant to prevent organ rejection. -acetaminophen 325 mg, administer two tablets four times daily for 28 days. -Senna 8.6 mg, 1 tablet night at bedtime -sodium bicarbonate 650 mg, two tables two times a day. Further review indicated that nursing reconciled the orders incorrectly for: -insulin lispro, inject 4 units three times a day with meals, reconciled as after meals and not with meals as recommended. During a unit tour on 5/11/23 at 6:40 A.M., Resident #29 yelled out to the surveyor who was rounding on the [NAME] Rd Unit. Resident #19 was visibly upset and said he/she was told that 'the nurses made a mistake on his/her medications since April. They [nursing staff] just told me last night I was not getting me my Cellcept (Mycophenolate Mofetil 250 milligrams for kidney transplant to prevent organ rejection) this medication is important for me; I am a kidney transplant recipient and I need this medication. The medication is so my body does not reject my kidney, I could die. During an interview on 5/11/23 at 6:57 A.M., the Director of Nursing said the Cellcept was not reconciled but should have been. During an interview on 5/11/23 at 2:25 P.M., Nurse #4 said it was a busy night when Resident #29 returned to the facility. Nurse #4 said he was responsible to reconcile Resident #29's medications and said he was not aware he made errors until 5/11/23. Review of the 24-Hour Chart Check Form, dated April 2023, indicated Nurse #6 completed a 24-hour chart check on 4/24/23. During an interview on 5/12/23 at 7:15 A.M., Nurse #6 said she completed the 24-hour chart check. Nurse #6 said she identified omissions that Nurse #4 did not reconcile from the discharge summary. Nurse #6 said she did not address these omissions as required by policy. During an interview on 5/11/23 at 1:33 P.M., the Nurse Practitioner (NP) said that nursing missed some of the medications on Resident #29's hospital discharge summary including his/her Cellcept. The NP said she should have caught the omission but she did not. The NP said that the transplant team at the hospital will need to manage Resident #29's treatment plan. During an interview on 5/11/23 at 2:11 P.M., the Risk Manager said nursing did not reconcile the discharge summary orders correctly and nursing did not complete a 24-hour chart check correctly. 43807 2a. Resident #105 was admitted to the facility in April 2023 with diagnoses including traumatic brain injury and gastrostomy (external opening into the stomach for nutritional support) and tracheostomy status. Review of the Minimum Data Set (MDS) assessment, dated 4/17/23, indicated an incomplete Brief Interview for Mental Status (BIMS) score, indicating the Resident is non-interviewable. Review of Resident #105's May 2023 Physician's Orders indicated the following: -Glycolax powder, give 17 grams by mouth one time a day for constipation, mix the powder in 8 ounces of fluid of choice. During an interview with Nurse #7 on 5/10/23 at 8:16 A.M., she said Resident #105 receives the medication via the feeding tube and not via the mouth. During an interview on 5/10/23 at 11:11 A.M., the Director of Nurses said Resident #105 receives Glycolax powder via the feeding tube and the active physician's orders should reflect that. b. Review of Resident #105's wound note, dated 5/2/23, indicated Resident #105 has a right ischium wound, stage 3. Review of the May 2023 Physician's Orders indicated the following: *Air mattress on bed, check inflation set by weight every shift for prevention. Review of the most recent weights indicated the following: *5/8/23 13:48 160.5 pounds (lbs.) (Mechanical Lift) *5/8/23 22:42 160.5 lbs. (Bed Scale) *5/9/23 00:08 160.5 lbs. (Mechanical Lift) *5/10/23 10:45 160.5 lbs. (Mechanical Lift) *5/10/23 18:45 160.5 lbs. (Hoyer) *5/11/23 10:51 160.5 lbs. (Mechanical Lift) *5/11/23 22:21 160.5 lbs. (Bed scale) On 5/9/23 at 9:09 A.M.,12:36 P.M., 1:49 P.M., the surveyor observed Resident #105's air mattress was set at 130 lbs. On 5/10/23 at 7:47 A.M., the surveyor observed Resident #105's air mattress was set at 130 lbs. During an interview on 5/10/23 at 8:40 A.M., Certified Nurse's Assistant (CNA) #3 said air mattresses should always be set as ordered. She accompanied the surveyor to Resident #10's bed and stated that the air mattress should be set at 160 lbs. and not 130 lbs. During an interview on 5/10/23 at 8:39 A.M., Nurse #7 said the Resident's air mattress should be set at 160 lbs. and not 130 lbs. During an interview on 5/10/23 at 10:33 A.M., the Director of Nurses said air mattresses should be set by weight as indicated in the physician's orders. 46339 3. Review of the facility's policy titled Resident Mobility and Range of Motion, undated, indicated the following: * Residents with limited range of motion (ROM) will receive treatment and services to increase and or prevent further decrease of ROM. Resident #44 was admitted to the facility in January 2020 with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage and contracture of left hand. Review of Resident #44's most recent Minimum Data Set (MDS) assessment, dated 2/16/23, indicated a Brief Interview for Mental Status (BIMS) exam score of 0 out of possible 15, indicating severely impaired cognition. The MDS further indicated Resident #44 is totally dependent on staff for all activities of daily living. On 5/9/23 at 10:00 A.M., the surveyor observed Resident #44 lying in bed with his/her left hand in a closed fisted position. Resident #44 was observed with a bright green sponge between his/her fingers. Review of Resident #44's medical record indicated: * A physician's order, dated 5/9/2023, for a Left palm guard during day (sic) to reduce skin integrity risk with skin checks and hand hygiene completed before and after don/doffing every shift. * A care plan, dated as initiated 12/8/2022, for alteration in musculoskeletal status related to contractures to left and right hands. On 5/10/23 at 11:35 A.M., the surveyor observed Resident #44 lying in bed and he/she was not wearing a left-hand palm guard. On 5/10/23 at 1:42 P.M., the surveyor observed Resident #44 lying in bed and he/she was not wearing a left-hand palm guard. During an interview on 5/10/23 at 1:48 P.M., Nurse #8 said Resident #44 has an order to be wearing a left palm guard and that the order was not being followed. Nurse #8 was unable to locate the palm guard. During an interview on 5/11/23 at 8:20 A.M., the Assistant Director of Nursing (ADON) said Resident #44 should be wearing a palm guard to his/her left hand. The ADON said that if Resident #44 refused to wear the palm guard it would be documented in the medical record. Review of the medical record failed to indicate Resident #44 refused to wear the left-hand palm guard.

Based on interview, observation and clinical record review, the facility failed to ensure that staff provide care and services according to accepted standards of clinical practice for 1 Resident (#89) in a total sample of 24. Findings include: a. For Resident #89 the Facility staff failed to reconcile the Residents medications/treatments as per facility policy/protocols upon return to the facility after a medical leave of absence. Resident # 89 was admitted to the Facility in 2/2019 with [DIAGNOSES REDACTED]. Clinical record review indicated that the Resident was sent out to the hospital after a fall at the Facility on 2/16/19 and returned to the facility on [DATE]. The facility policy indicates the following: The purpose of the procedure(medication Reconciliation) is to ensure medication safety by accurately accounting for the Resident's medications, routes and dosages upon admission or readmission to the facility. Documentation: 1. Document the medication discrepancy on the Medication Reconciliation Worksheet for Post-Hospital Care form 2. Document what actions were taken by the nurse to resolve the discrepancy. 3. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or nest shift, 4. If the discrepancy was resolved, document how the discrepancy was resolved. Clinical record review indicated that upon readmission to the Facility there was no reconciliation of the Residents medications as per Facility policy/protocols. Although there was a readmission nurses note dated 2/17/19 indicating that the Resident returned to the Facility, there was no Reconciliation Worksheet completed as per facility policy/protocols. The nurses note also did not indicate that the physician was called upon the Residents readmission to the facility to confirm the changes/continuance of the Residents medications. The physician did come into the Facility and sign the Residents orders on 2/18/19 indicating that he/she approved the changes, however it was a day after the Resident had returned to the Facility. On 4/1/19 at approximately 11:45 A.M. The Assistant Director of Nursing was made aware of the above concern and said that the Facility failed perform the medication reconciliation according to the Facility policy/protocols. The Director of Nursing was also made aware of the above concerns at 2:51 P.M. b. For Resident #89 the facility staff failed to follow through on a recommendation that had been made by the hospital upon readmission of the Resident to the Facility resulting in a delay in treatment. Resident # 89 was admitted to the Facility in 2/2019 with [DIAGNOSES REDACTED]. Clinical record review indicated that the Resident was sent out to the hospital after a fall at the Facility on 2/16/19 and returned to the facility on [DATE]. Review of the discharge summary from the hospitalization [DATE] through 2/17/19 indicated the following additional instructions: -Follow up with neurology as already scheduled when you are discharged . Further clinical record review indicated that a neurology appointment was never addressed or scheduled as of 4/2/19. An appointment was made after Surveyor intervention, approximately 44 days after the recommendation was made. On 4/1/19 at approximately at 11:45 A.M. the Assistant Director of Nursing said that the Facility failed to follow-up on recommendations as indicated on the hospital discharge summary resulting in a 44 day delay in treatment.

Based on observation, record review and interview the Facility staff failed to ensure that for 1 Resident (#307), who was diagnosed with [REDACTED]. Findings include: 1. For Resident #307, the Facility failed to ensure that care and treatment was provided for the management of unabated physically aggressive behaviors toward fell ow Residents, staff, and the Facility's pet bird during a behavioral outburst in which the Resident threw a bird cage across the floor of the unit's lounge, sustained a 4 inch skin tear to his/her right shin and attempted to kill the Facility's pet bird. Resident #307 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. Review of the admission MD'S with a reference date of 3/14/19, indicated that Resident #307 had severe cognitive impairment as evidenced by a BIMS score of 1 out of 15, had physical and verbal behaviors directed toward others, and the behavioral symptoms put the Resident and others at significant risk. Review of the medical record indicated Resident #307 displayed a pattern of increasingly aggressive behavioral symptoms on multiple occasions toward staff and other Residents documented in nursing progress notes as follows: -3/8/19 Resident was noted to be restless, combative with care, verbally abusive, 1:1 with no effect. -3/10/19 Resident throwing objects, slamming doors. -3/11/19 At approximately 3:00 A.M., Resident came out of room racing around the unit with wheelchair in hallway; Resident difficult to redirect, held onto another Resident's wheelchair, pushing the wheelchair around the unit. Nurse tried to take the other Resident's wheelchair, Resident became combative hitting staff and yelling out. -3/13/19 Resident noted with periods of restlessness, refused to stay in bed, napped in wheelchair; increased agitation, attempted to hit staff, verbal redirection with poor effect. -3/14/19 Resident combative with care, hitting and kicking staff, redirection with poor effect. -3/17/19 At approximately 5:30 A.M., Resident was very agitated, combative, hitting, yelling out, spitting on staff, redirected with no effect, 1:1 interaction with no effect. Resident threw out all things on top of medication cart, threw out the bird food. -3/19/19 At approximately 4:30 A.M., Resident came to nursing station very agitated, redirected to room, refused to stay in room, came into hallway screaming, yelling, racing with his/her wheelchair, knocking things out, went to other Resident's rooms and attempted to knock out their belongings. Resident was difficult to redirect. Resident called the Police to say he/she was not safe. -3/24/19 Around 6:00 A.M., Resident became agitated, aggressive/combative, yelling, cursing and mimicking another Resident that was yelling for help. Became noncompliant with simple instructions and redirection. The Resident knocked down supplies on top of the medication cart, pulled at the bird's cage which fell to the floor. Resident intrusive and aggressive toward other Residents. -3/25/19 Resident was aggressive and intrusive toward other Residents and staff. No one was hurt or injured. Review of the interdisciplinary care plan for behaviors included the following: Focus: - I am/have potential to demonstrate physical behaviors related to anger, dementia, depression, poor impulse control (initiated 3/11/19) - Resident is able to call 911 when highly agitated and unable to redirect (3/19/19) telling police he/she is not safe and wants to go home. Goal: - I will demonstrate effective coping skills through the next review date (initiated 3/11/19) - I will not harm self or others through the next review date (initiated 3/11/19) - I will verbalize understanding of need to control physically aggressive behavior through the next review date (initiated 3/11/19) Interventions: - Intervene before agitation escalates (3/11/19) - guide away from sources of distress, engage calmly in conversation (3/11/19) - if response is aggressive, staff to walk calmly away, and approach later (3/11/19) - Monitor/document/report to MD danger to self and others (3/11/19) - Psychiatric/psychogeriatric consult as indicated (3/11/19) The interdisciplinary care plan for behaviors was not reviewed and revised by facility staff as required to ensure that effective interventions were in place to address the Resident's physical aggression toward other Residents, staff, and the Facility's pet bird. During interview on 3/26/19 at 10:40 A.M., Unit Manager #4 said that Resident #307 was a new admission and had a difficult psychiatric situation. She said that over this past weekend, the Resident pushed the unit's birdcage (containing live birds) off of a table, which crashed onto the floor. She said that when the bird cage hit the floor, the door to the cage opened, and the bird got out. She said that Resident #54 then stomped on the bird and tried to kill it. She said that the bird is still alive, but in rough shape, and is now secured in her office. Unit Manager #4 said that the Resident was not sent out to the hospital for evaluation after the incident, and that if she were working on the unit that day, she would have sent the Resident out to the hospital for evaluation out of concern for the safety of other Residents on the unit. She said that a few days prior to the incident, the Nurse Practitioner (NP) was on the unit, and noted that Resident #307 was napping in his/her wheelchair in the lounge area. The Unit Manager said that the NP decreased the dose of antipsychotic medication by half because she felt that the Resident was lethargic. The Unit Manager said that the Resident was not lethargic, but had just closed his/her eyes just before the NP arrived on the unit, and said that the NP did not speak with staff about the Resident's status. During interview on 3/26/19 at 1:25 P.M. the Facility's consultant psychiatrist said that he initiated the antipsychotic medication [MEDICATION NAME] on 3/12/19 to treat Resident #307's aggressive behaviors. He said that he had just reviewed the Resident's status with Facility staff and learned that the NP decreased the dose of [MEDICATION NAME] half on 3/18/19 because she thought the Resident was lethargic. He said that he learned from Facility staff today that on 3/24/19, Resident #307 had thrown a bird cage across the room and proceeded to stomp on the bird injuring it. He noted that the Resident's behavior had increased over the past few days and may have been a result of the NP reducing the Resident's dose of antipsychotic medication. Review of the medical record indicated an order by the NP dated 5/18/19 (incorrectly written instead of 3/18/19 according to Unit Manager #3) to decrease [MEDICATION NAME] to 25 mg twice a day. Further review of the medical record failed to indicate a NP progress note for that date. Review of the consultant psychiatrist's progress note dated 3/26/19, indicated that he discussed Resident #307's increased aggressive behavior and event in which the Resident threw a bird cage across the room, a bird escaped and the Resident proceeded to stomp on the bird injuring it significantly. Resident has been verbally and physically aggressive with staff. This behavior has increased over the past few days and may have been exacerbated by the NP reducing the antipsychotic medication dose by half. Patient is a clear danger to other staff and Residents. Will increase [MEDICATION NAME] to 100 mg twice a day and reassess in 2-3 days. During interview with the Dementia Special Care Unit's Therapeutic Activity Director (TAD) on 3/26/19 at 1:30 P.M., she said that the unit had 2 birds that the Residents can participate in caring for. The Surveyor referred to the incident told by Unit Manager #4 in which Resident #307 knocked over the bird cage and tried to kill the bird by stomping on it. The TAD said, They told you about that?. The Nurse Practitioner was interviewed by telephone on 4/01/19 at 11:43 A.M. She said that when she came into the facility a few weeks ago, she saw Resident #307 seated in a wheelchair in the lounge area with his/her eyes closed, sleeping, appeared lethargic, and falling out of his/her chair. She said the first thing she does when she thinks a patient is lethargic, is look at medications and decrease them. The NP said that she did not confer with the prescribing psychiatrist regarding the medication change because he was not in the building, could not recall speaking with staff about the Resident's status, could not recall reviewing the medical record prior to making the medication reduction, and could not recall if she documented her assessment in the medical record.

Based on records reviewed and interviews, the Facility failed to prevent an incident of neglect for one of three sampled residents (Resident #1). On 11/05/18, Nurse #1 and CNA #1 did not follow Resident #1's Plan of Care, and during care Resident #1 to rolled out of bed and fell on to the floor, sustaining both acute and chronic, femur fractures and tibial fractures in both legs. Findings include: The Facility's Abuse and Neglect Clinical Protocol, dated 03/2018, indicated that neglect is defined as 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 Complaint Form was submitted to the Department of Public Health (DPH) on 11/20/18, on the behalf of Resident #1. The Form indicated that Resident #1 said that a CNA, later identified as CNA #1, was turning him/her and trying to pull a blue pad from under him/her in bed. The Form indicated that Resident #1 asked CNA #1 several times to stop pushing him/her, but CNA #1 shoved him/her, causing Resident #1 to fall to the floor, wedged in between two beds. The Form indicated that CNA #1 walked out of the room and shut the door. The Form indicated that Resident #1 was on the floor alone and screaming, Help me for about 15 minutes before staff came in Resident #1's room. The Form indicated that Resident #1 said that he/she thought this was how he/she was going to die. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) assessment, dated 9/21/18, indicated that he/she was cognitively intact, required extensive assistance from one staff member for dressing and bathing, and required extensive assistance from two staff members for bed mobility, transferring, and incontinent care. Resident #1's Care Plan, dated 09/04/18, related to activities of daily living indicated two staff members were required when providing assistance for bed mobility, dressing, and toilet use. The Facility provided the Surveyor with an Investigation File which included an Occurrence Report, completed by Nurse #1, dated 11/05/18. The Occurrence Report indicated that Resident #1 fell during care, resulting in several fractures. The Report indicated that Resident #1 said, to Nurse #1, I told the CNA, do not push because my legs are hanging down, I am going to fall and she pushed and I fell . The Facility's Follow-Up Occurrence Report, completed by the DON, dated 11/06/18, indicated that CNA #1 was providing incontinent care/bed mobility to Resident #1 and did not follow Resident #1's plan of care, which indicated Resident #1 required two assist with care, resulting in Resident #1 falling out of bed. The Report did not include Nurse #1's name or involvement with the incident. A Witness Statement, dated 11/05/18, written by CNA #1, indicated that prior to providing care to Resident #1, CNA #1 asked Nurse #1 for assistance, but Nurse #1 said no. The Statement indicated that CNA #1 said that Nurse #1 told her that she could not provide assistance with cleaning Resident #1 because she was not a CNA and told CNA #1 to let her know when Resident #1 was ready for a dressing change. The Statement indicated that Nurse #1 placed Resident #1 very close to the edge of the bed with his/her legs crossed. The Statement indicated that Resident #1 fell while Nurse #1 was at door, about to leave Resident #1's room. Surveyor interviewed CNA #1 at 12:00 P.M on 01/07/19. CNA #1 said she cared for Resident #1 at the time Resident #1 fell from the bed to the floor. CNA #1 said that Nurse #1 raised the head of Resident #1's bed and then began to complete a dressing change on Resident #1's buttocks; however, after removing the dirty dressing, Nurse #1 told CNA #1 that Resident #1 needed to be cleaned before the new dressing could be applied to the wound. CNA #1 said she asked Nurse #1 to help with cleaning Resident #1 because Resident #1 required two staff members to provide personal care. CNA #1 said Nurse #1 was on her phone and said cleaning a resident was not her job, so she needed to ask another CNA for help. CNA #1 said, as Nurse #1 was walking out of Resident #1's bedroom, Resident #1's legs started to fall off the bed. CNA #1 said she called out in Creole for Nurse #1 to help because Resident #1 was falling. CNA #1 said that Resident #1 fell off his/her bed and onto the floor because she could not get around to the other side of the bed quick enough to prevent Resident #1 from falling onto the floor. CNA #1 said she believed Nurse #1 heard her call for help, but continued to walk out of the room to avoid being involved with Resident #1 falling. CNA #1 said Nurse #1 was leaving Resident #1's bedroom through a door located in Resident #1's bathroom, which is why the security camera did not show Nurse #1 walking out of Resident #1's bedroom. After Resident #1 fell out of bed, CNA #1 said she pushed Resident #1's call bell and yelled out for help, from Resident #1's bedroom. CNA #1 said that Nurse #1 told her that she would write up an incident report and asked CNA #1 to say she (Nurse #1) was not in Resident #1's room at the time of the fall since a nursing license is bigger than a CNA license. CNA #1 said she went to speak with Nursing Supervisor #2 shortly after the incident and reported everything that happened, leading up to Resident #1's fall. CNA #1 said Nursing Supervisor #2 and Nurse #1 were trying to force her to say that she was in the room alone with Resident #1 at the time of the fall. CNA #1 said that Nurse #1 wrote up the incident report and she went into the Facility the following day to provide a report to the DON about what happened to Resident #1. Surveyor interviewed Nurse Supervisor #2 at 9:00 A.M. on 01/08/19. Nurse Supervisor #2 said that he learned of Resident #1's fall after seeing the X-ray machine in the building around 9:00 P.M., prompting him to go speak with Nurse #1, who reported that Resident #1 had a fall while CNA #1 was in Resident #1's room. Nursing Supervisor #2 said that CNA #1 told him that Nurse #1 was in the room, but had her back to Resident #1 when Resident #1 fell . A Witness Statement, completed by Nurse #1, indicated that on or about 8:00 P.M. on 11/05/18, CNA #1 called her into Resident #1's room to complete a dressing change. The Statement indicated that Resident #1 was naked and lying on his/her left side while receiving personal care from CNA #1. The Statement indicated that Nurse #1 told CNA #1 that she preferred Resident #1 to be on his/her right side, so as Nurse #1 gathered her supplies, CNA #1 turned Resident #1, which is when CNA #1 noticed Resident #1's bed was wet and the linens needed to be changed. The Statement indicated that CNA #1 asked Nurse #1 to give her some time and she would call the Nurse #1 when she was done. The Statement indicated that prior to leaving Resident #1's room, Nurse #1 told CNA #1 to make sure to get another CNA to help with care. The Statement indicated that CNA #1 called out to her for help and when she entered Resident #1's bedroom, she saw Resident #1 sitting on the floor. The Statement indicated that while Nurse #1 assessed Resident #1, he/she had said, I told her not to push because I was on the edge of the bed, she pushed and my legs were hanging down. I asked her to stop because I'm going to fall, she pushed and I fell . Surveyor interviewed Nurse #1 at 11:58 A.M. on 12/21/18. Nurse #1 said that she worked on Resident #1's unit the evening and night shift on 11/05/18. Nurse #1 said she specifically remembers telling CNA #1 during a shift report that Resident #1 required assistance from two staff members and had a dressing change twice a day. Nurse #1 said she requested CNA #1 let her know when it was a good time for her to change Resident #1's dressing. Nurse #1 said CNA #1 called her into Resident #1's bedroom around 7:45 P.M. to complete the dressing change. Nurse #1 said she walked into Resident #1's room and saw CNA #1 providing care to Resident #1 alone and Resident #1 was naked, lying on her left side in bed. Nurse #1 said she reprimanded CNA #1 for providing care to Resident #1 by herself, as Resident #1 required two staff to assist with care, per his/her care plan. Nurse #1 said she asked CNA #1 to move to the other side of Resident #1's bed so she could access Resident #1's wound to complete the dressing change. Nurse #1 said that prior to beginning the dressing change, she and CNA #1 noticed Resident #1's linens were wet, but they did not have clean linens in the room since they did not expect to complete a linen change. Nurse #1 said another resident, who can be impatient having to wait for care, called for toileting assistance; therefore, Nurse #1 went to assist the other resident as CNA #1 told her give her some time to gather clean linenes and to come back to Resident #1's room once she was finished with the other resident. Nurse #1 said she told CNA #1 not to provide care to Resident #1 alone. Although Nurse #1 said she told CNA #1 this, it was Nurse #1 who left CNA #1 alone while providing care to Resident #1. Nurse #1 said she returned to Resident #1's bedroom around 8:00 P.M. Nurse #1 said she saw Resident #1 sitting on the floor with his/her legs straight out and saw CNA #1 standing behind Resident #1. Nurse #1 said she asked Resident #1 what happened and Resident #1 said that CNA #1 had pushed him/her to put something under him/her in bed. Nurse #1 said that Resident #1 said he/she asked CNA #1 to stop pushing him/her, but CNA #1 did not stop, so he/she fell from the bed and onto the floor. Nurse #1 said she assessed Resident #1 once he/she was back in bed. Nurse #1 said she took Resident #1's vitals, assessed for pain, movement in extremities, and checked if Resident #1 hit his/her head. Nurse #1 said that Resident #1 told her that she was fine and did not want to go to the hospital. Nurse #1 said she called Family Member #1 to report the fall and asked FM #1 if she wanted Resident #1 sent to the hospital. Nurse #1 said FM #1 asked if Resident #1 wanted to go to the hospital, so she told FM #1 that Resident #1 did not request to go to the hospital, but had reported a little knee discomfort, so she contacted Resident #1's physician and obtained an order to complete an X-Ray at the Facility. The Surveyor interviewed Resident #1's Physician at 4:10 P.M. on 12/28/18. The Physician said he was aware that Resident #1 fell on [DATE], which resulted in several fractures. The Physician said that Resident #1 was slightly confused but based on his last interaction with Resident #1, he/she was perfectly able to make his/her needs known and would consider him/her a reliable and credible historian. Review of Resident #1's medical records, indicated that following his/her fall at the Facility, Resident #1 was transferred to the hospital and admitted with findings of both acute and chronic, bilateral subcapital femur fractures and bilateral tibial plateau fractures. The Surveyor interviewed the Director of Nurses at 2:58 P.M. on 12/20/18. The Director of Nurses said that Nurse #1 and CNA #1 did not follow Resident #1's care plan at the time of the incident; therefore, Nurse #1 and CNA #1 were terminated. The DON said the details of Nurse #1 and CNA #1's involvement; in addition to, the facility's corrective actions were not documented on the facility's Follow-Up Occurrence Report and were not provided to the Department of Public Health (DPH), but these details should have been included on both Reports and reported to DPH, per facility policy.

Based on record review, observation and staff interview, the facility failed to ensure that a therapeutic dietary recommendation was implemented timely to prevent further weight loss for 1 Resident (#14) of 24 sampled Residents. Findings include: For Resident #14, the facility failed to implement a dietary recommendations timely to assist in stopping weight loss. Resident #14 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) signed as completed on 10/20/17, indicated that the Resident had a BIMS (Brief Interview for Mental Status) score of 14 of 15 indicating that the Resident was alert and oriented, required extensive assist for activity of daily living except for eating which required supervision with dining. The MDS also indicated that the Resident was 56 inches tall, weighed 110 pounds, received a therapeutic diet and had an unhealed/unstagable pressure ulcer. On 10/14/17 a covering dietitian completed a initial Nutritional Risk Assessment on Resident #14. The Dietitian documented that the Resident was 56 inches tall, weighed 110.4 pounds upon admission, but weight 116 pounds 6 months ago, representing a 5% weight change in 6 months. The dietitian also documented that the Resident was at nutrition risk due to an abdominal surgical wound and a left foot fracture. After the Dietitian visited the Resident for preferences, the Dietitian determined that the Resident's intake at the facility was suboptimal and the Resident agreed to received a nutritional supplement and Prostat (protein supplement). The Dietitian also documented that the Resident's family was bringing in the Resident's favorite foods. Review of the Weight Summary for Resident #14 indicated that on 10/21/17 the Resident weighed 100.6 pounds representing a 10 pound weight loss (5% significant weight change) in 30 days. Further Review of the weight Summary indicated that on 10/23/17 the Resident weighed 99 pounds. Review of the Resident's physician's orders [REDACTED]. The Resident was interviewed on 10/26/17 at 9:44 A.M. and said that he/she was being discharged home that day. The Resident had just finished breakfast and said that the food was ok but often served cold and it was not like his/her cooking at home. The facility dietitian was interviewed on 10/26/17 at 8:45 A.M. and asked about the system to ensure that dietary recommendations are implemented timely. The Surveyor asked the dietitian why there was a delay in implementing Resident #14's nutrition recommendations. The dietitian returned and identified that the covering dietitian put the recommendation sheet for Resident #14 in the Dietitian's Book and not flagged in the Resident's chart as per facility policy. The facility dietitian acknowledged that there was a delay in the implementation of the Resident's nutrition intervention due the covering Dietitian's error.

Based on record review and interview, the Facility failed to provide the necessary care and services to control the pain of one resident (Resident #1) in a total sample of 3 residents. On 2/19/11, the Facility called the Physician regarding the Hospice verbal recommendation for Resident #1 to receive the narcotic pain medication [MEDICATION NAME] around the clock; the Physician requested that written recommendations be faxed to the Facility; on 2/19/11, the Facility did not contact the Hospice Agency regarding the need for written orders; on 2/19/11, [MEDICATION NAME] was not ordered for Resident #1; on 2/20/11, Resident #1 had pain; there was no written order for [MEDICATION NAME]; the physician orders for the pain medications, [MEDICATION NAME] and [MEDICATION NAME] were not given to Resident #1, and there was a delay in Resident #1 receiving pain medication. The Facility also failed to assess Resident #1's pain per the Facility Pain Policy and the physician order. The Resident Admission Record indicated that Resident #1 was admitted to the Facility in February, 2007. The Accumulative [DIAGNOSES REDACTED]. The five day Medicare Minimum Data Set assessment, completed on 12/7/10, indicated that Resident #1: was able to make Resident #1's self understood and usually understood others; had cognitive issues; received scheduled pain medication, as needed (prn) pain medication, and non-medication interventions for pain during the past 5 days, and had shortness of breath when lying flat, sitting at rest, and with exertion. The February, 2011 physician orders, included: [MEDICATION NAME] 15 milligrams once a week and [MEDICATION NAME] 10 mg daily for vasculitis; the anti-anxiety medication, [MEDICATION NAME] 0.125 mg daily; [MEDICATION NAME] apply topically to lower back every morning and remove at bedtime; [MEDICATION NAME] 1 tablet every 6 hours as needed (prn) for moderate pain; [MEDICATION NAME] 2 tablets by mouth every 6 hours prn for severe pain; [MEDICATION NAME] with Tylenol 5/325 mg, give 1 tablet every 6 hours prn for severe pain; [MEDICATION NAME] 0.4 mg sublingually every 5 minutes, three times prn for chest pain, and document pain level within 1 hour after giving pain medication. The Pain Assessment, dated 2/17/11, indicated that Resident #1 had intermittent back pain Resident #1 had no pain during the past 24 hours. The Informed Consent for Hospice Services indicated that Hospice Services was initiated on 2/18/11. The plan of care related to Resident #1's end of life condition, dated 2/18/11, included: assess pain and symptoms; administer medications as prescribed; notify Hospice if current pain and symptoms management was not effective, and evaluate and alter plan to address and treat symptoms identified in assessment. The night shift nurse's note, dated 2/19/11, indicated that Resident #1 had pain and was medicated with [MEDICATION NAME] 2 tablets at 12:A.M. The Facility Narcotic book indicated that Resident #1 received [MEDICATION NAME] 2 tabs on 2/1/11, 2/3/11, 2/9/11, 2/12/11, 2/13/11, 2/14/11, and 2/19/11. The Narcotic book indicated that Resident #1 received one [MEDICATION NAME] on 2/2/11, 2/5/11, 2/12/11, and 2/14/11. The February, 2011, Medication Administration Record (MAR), did not always reflect the prn pain medications given to Resident #1 as evidenced in the Facility Narcotic book. The Facility Pain Policy indicated that a resident's pain level was to be assessed every shift prior to administration of medication and one hour post administration. The Pain Policy indicated that a resident's described or assessed level of pain was to be documented on the MAR based on the Pain Rating Scale of 0-10 (0 being no pain and 10 being the worst possible pain). The Director of Nurses (DON) was interviewed on 5/9/11, at 10:45 A.M. The DON said the nurses did not document all of the prn pain medication in the MAR per the Facility practice. The DON said the nurses did not consistently rate Resident #1's highest level of pain every shift and did not rate Resident #1's pain prior to and after pain medication was given per the Facility Policy. Hospice Nurse #1 was interviewed on 4/19/11, at 12:00 P.M. Hospice Nurse #1 said in the morning, on 2/19/11, Hospice Nurse #1 visited Resident #1 at the Facility. Hospice Nurse #1 said Resident #1 had shallow, labored breathing. Hospice Nurse #1 said Family Member #1 believed that Resident #1 had pain and Family Member #1 was agreeable to initiating the narcotic pain medication, [MEDICATION NAME] around the clock for Resident #1 that was to be initiated on 4/19/11. Hospice Nurse #1 said Hospice Nurse #1 discussed the [MEDICATION NAME] recommendations with a nurse at the Facility and the Nurse was to call the Physician for an order for [REDACTED].#1 may not have left the written recommendations at the Facility. The nurse's note, dated 2/19/11, at 6:30 P.M., indicated that the Hospice Nurse called Resident #1's unit and requested that this nurse follow up with the Physician regarding a recommendation for Resident #1 to receive [MEDICATION NAME] 20 mg/milliliter (ml), give 5 mg sublingual or orally every 6 hours. The nurse's note indicated that the Physician was paged. The nurse's note, dated 2/1911, at 7:30 P.M., indicated that the Physician was not satisfied with the Hospice verbal recommendations and wanted written recommendations to be faxed. The nurse's note indicated that there were no new physician orders. Nurse #3 was interviewed on 5/9/11, at 4:45 P.M. Nurse #3 said the Physician wanted written recommendations for [MEDICATION NAME] from the Hospice Agency, prior to ordering [MEDICATION NAME] for Resident #1. Nurse #3 said Nurse #3 told Nurse #1 to call the Hospice Agency, have the Hospice Nurse fax the written recommendations to the Facility, and call the Physician to obtain the [MEDICATION NAME] order for Resident #1, There was no documentation in the clinical record regarding a call to the Hospice Agency on 2/19/11, regarding the Physician's request for written recommendations for [MEDICATION NAME]. Nurse #1 was interviewed on 5/9/11, at 3:30 P.M. Nurse #1 said Nurse #3 told Nurse #1 that the Hospice Nurse would evaluate Resident #1 on 2/20/11. Nurse #1 said Nurse #3 did not tell Nurse #1 that the Hospice Nurse needed to fax written recommendations for [MEDICATION NAME] to the Facility for Resident #1 and the Physician needed to be called regarding the Hospice written recommendations. Nurse #1 said Nurse #1 did not call the Hospice Agency regarding the need for written recommendations for [MEDICATION NAME] for Resident #1. The DON said Nurse #1 did not call the Hospice Nurse to ensure the Physician had written recommendations for [MEDICATION NAME], and therefore, a [MEDICATION NAME] order was not obtained for Resident #1 on 2/19/11. Nurse #3 said Nurse #3 did not know when the Hospice Nurse would next evaluate Resident #1 and did not tell Nurse #1 that the Hospice Nurse would evaluate Resident #1 on 2/20/11. Nurse #1 said on 2/20/11, during the night shift, Resident #1 had no pain. Nurse #3 said on 2/20/11, during shift report, Nurse #1 did not report concerns with obtaining the [MEDICATION NAME] order for Resident #1. The nurse's note, dated 2/20/11, indicated that Resident #1 fainted in the dining room in the morning. The nurse's note indicated that Resident #1 had an oxygen saturation level of 88 percent on 2 liters of oxygen; Resident #1 was transferred back to bed, and had a large loose stool. The nurse's note indicated that Resident #1's oxygen saturation level increased to 99 percent on oxygen. Nurse #3 said on 2/20/11, Resident #1 had no complaints of pain between 7:00 A.M. and 2:10 P.M. Family Member #1 was interviewed on 4/4/11, at 4:30 P.M. Family Member #1 said on 2/20/11, at 2:00 P.M., Resident #1 had labored breathing and dull chest pain with intermittent crushing pain. Family Member #1 said the nurse gave Resident #1 three doses of [MEDICATION NAME] with no effect. Family Member #1 said Resident #1 continued to have severe pain and Family Member #1 requested that the Hospice Agency be called. The nurse's note, dated 2/20/11, indicated that at 2:10 P.M., Resident #1 complained of discomfort to the Family Member. The nurse's note indicated that Resident #1 had an oxygen saturation level of 80 percent on 2 liters of oxygen, was given a nebulizer treatment, and Resident #1's oxygen level increased to 86 percent. The nurse's note indicated Resident #1 complained of chest pain that came and went and Resident #1 was given 3 doses of [MEDICATION NAME]. The nurse's note indicated that the Physician was notified. Nurse #3 said Resident #1's pain ranged between 8 and 10. Nurse #3 said the [MEDICATION NAME] was not effective in treating Resident #1's chest pain and the physician orders did not include an order for [REDACTED].#3 did not give Resident #1 prn [MEDICATION NAME] or [MEDICATION NAME] for pain. The Assistant Director of Nurses (ADON) was interviewed on 5/10/11, at 11:00 A.M. The ADON said Nurse #3 notified the ADON that Resident #1 had chest pain and the ADON assessed Resident #1. The ADON said Resident #1 had chest pain and generalized pain. The physician order, dated 2/20/11, at 2:45 P.M., included [MEDICATION NAME] 20 mg/ml, give 2.5 mg every 4 hours prn for respiratory distress/pain. The Facility Controlled Substances book, indicated that on 2/20/11, at 3:00 P.M., Resident #1 received [MEDICATION NAME] 0.125 mg SL. The DON said on 2/19/11, the [MEDICATION NAME] order was not obtained from the Physician and therefore, on 2/20/11, an order for [REDACTED]. The nurse's note, dated 2/20/11, indicated that Resident #1 received [MEDICATION NAME] with minimal effect. The nurse's note, dated 2/20/11, indicated that the Hospice Agency faxed the written recommendations to the Facility; the Physician was notified, and the Physician said the [MEDICATION NAME] dose was not appropriate based on Resident #1's weight. The nurse's note indicated that Resident #1 described Resident #1's pain as a dull constant discomfort. The nurse's note, dated 2/20/11, indicated that the Physician said Resident #1's pain was not related to [MEDICAL CONDITION] and was likely related to vasculitis. Nurse #3 said after Resident #1 received [MEDICATION NAME], Resident #1's pain rating was 6. The physician orders, dated 2/20/11,at 4:00 P.M., included: [MEDICATION NAME] 20 mg/ml, give 5 mg SL every 15 minutes for chest pain for 4 doses; [MEDICATION NAME] 1 mg SL every 6 hours prn for anxiety and chest pain, and [MEDICATION NAME] 1 mg every 4 hours prn for agitation. The MAR, dated 2/20/11, indicated that Resident #1 received [MEDICATION NAME] 5 mg SL at 4:10 P.M., 4:25 P.M., 4:40 P.M., and 4:55 P.M., [MEDICATION NAME] 1 mg SL at 4:25 P.M., and [MEDICATION NAME] 1 mg at 6:00 P.M. Nurse #3 said shortly after 5:00 P.M., Resident #1's pain rating decreased to 3. The nurse's note, dated 2/20/11, at 6:30 P.M., indicated that Resident #1 continued to have some discomfort and settled. Nurse #3 said at 6:30 P.M., Resident #1's pain was tolerable for Resident #1. The nurse's note, dated 2/20/11, at 7:50 P.M., indicated that Resident #1 had no chest pain or discomfort and Family Member #1 wanted Resident #1 to have additional [MEDICATION NAME]. Nurse #3 said at 7:50 P.M., Resident #1's pain rating was 0. See F 282