Every finding on record at Bridgewater Home , Inc.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to develop comprehensive care plans (CCPs) that included the residents current code status for all residents in the survey sample. The findings included:The facility staff failed to develop CCPs that included the residents current code status. During the clinical record review, the surveyors were unable to locate information on the resident's CCPs that referenced their current code status. On 01/21/26 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Infection Preventionist the issue with the code status not being on the resident's CCP was reviewed. On 01/22/26 at 10:00 a.m., the facility staff provided the survey team with a copy of their policy titled, Comprehensive Person-Centered Care Planning. This policy read in part, .will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. On 01/22/26 at 10:30 a.m., during an interview with the Social Worker (SW) this staff stated they did not realize they needed to include the code status on the CCP and felt as if the resident's code status order was part of the CCP. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, and facility document review, the facility staff failed to recognize and respect the residents' right to exercise their rights as a resident/citizen of the United States to send/receive mail. The findings included:For the facility, the facility staff failed to recognize and respect the residents' right to exercise their rights as a resident/citizen of the United States to send/receive mail on Saturdays. On 1/21/2026 at 2:50 PM, this surveyor met with six members of the Resident Council, Resident #12, Resident #77, Resident #85, Resident #101, Resident #104, and Resident #117. The residents' concurred mail is not delivered to them on Saturdays at the facility. This concern was discussed at the end of day meeting on 1/21/26 at 5:08 PM with the administrator, director of nursing, and infection preventionist. On 1/22/26 at 8:41 AM, this surveyor interviewed other staff #4 (OS#4) and OS#4 informed surveyor the post office takes the mail to the main desk in the main lobby and the post office does not deliver mail on Saturdays because there is no one available to receive the mail. The receptionist brings the mail up to the units every day but Saturday. On 1/22/26 at 12:31 PM, this surveyor interviewed other staff #6 (OS#6) via phone conversation and OS#6 informed surveyor the postal service does not deliver to the facility on Saturdays because there is no one in the reception area of the facility and the lights are out. OS#6 informed surveyor that someone from the facility could pick-up the mail from the post office on Saturdays if they wanted to as the mail carriers are there until 11:30 AM. OS#6 also informed surveyor the post office could deliver the mail to the facility on Saturdays if they had a big mailbox to leave it in or a staff member there to receive it. On 1/22/26 at 12:39 PM, this surveyor interviewed other staff #7 (OS#7) and OS#7 informed this surveyor the receptionist works from 9:00 AM-5:00 PM Monday through Friday. OS#7 informed surveyor they had spoken with the post office and the postal carrier would deliver the mail on Saturdays, but there is no one available to take the mail. OS#7 agreed the facility residents could receive mail on Saturdays if someone was at the reception area and informed surveyor Saturdays are not the receptionist's hours. Surveyor requested and received a facility policy titled, Resident's Rights with a created date of 1/2019 which read in part, .[name of facility omitted] recognizes and respects that each resident has the right to exercise his or her rights as a resident of this community and as a citizen or resident of the United States.The resident has the right to send and receive mail. No further information was provided to the survey team prior to exit on 1/22/26.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a safe room environment for one of twenty-eight residents in the survey sample (Resident #99).The findings include:A portable heater was in use in Resident #99's room. The heater, placed during a heat outage, was not removed from the room when emergency use was no longer required.Resident #99 (R99) was admitted to the facility with diagnoses that included cerebral infarction, major depressive disorder, anxiety, benign prostatic hypertrophy, atrial fibrillation, chronic kidney disease, congestive heart failure, cervical disc disorder, neuromuscular dysfunction of bladder and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed R99 as cognitively intact and as requiring the assistance of one person for safe transfers.On 1/20/26 at 2:39 p.m., R99 was observed in a chair in the resident's room. Positioned near the center of the room was an electric heater plugged into a wall outlet. The heater was on (light on display) but not actively blowing heated air. There were no items observed near or on the heater. R99 was interviewed at this time about the portable heater. R99 stated that he had complained about cool air coming from the ceiling vent positioned above his recliner. R99 stated the maintenance department provided the portable heater yesterday (1/19/26) because he complained about the cold air blowing. R99 stated he positioned the heater in the center of the floor to not interfere with his moving about in his room and set the thermostat to his preference.On 1/20/26 at 3:36 p.m., the maintenance director (other staff #3) was interviewed about the space heater observed in R99's room. The maintenance director stated there was an underground water line break on Friday night (1/16/26) and that several of the nursing units/halls had no heat on Saturday night (1/17/26) due to lack of hot water during the water line repair. The maintenance director stated the portable heaters were distributed to the nursing units and were in use on Saturday night (1/17/26) to provide heat while the hot water system was in repair. The maintenance director stated the heaters had an anti-tip safety feature and six heaters were provided to each nursing unit. The maintenance director stated the space heaters were in use for approximately 12 hours until the heat was restored around 10:00 a.m. on Sunday (1/18/26). The maintenance director stated he had his employees retrieved the portable heaters from the units/nursing offices on Monday morning (1/19/26). The maintenance director stated he was not sure if R99's heater was missed when the heaters were taken up or if nursing had put the heater back in R99's room. On 1/20/26 at 3:49 p.m., the maintenance director stated he verified that R99's heater had not been provided by nursing and that the maintenance staff missed R99's space heater when the units were collected on Monday (1/19/26).On 1/20/26 at 5:05 p.m., R99's room was observed with the electric heater no longer in the room. On 1/20/26 at 5:26 p.m., accompanied by the administrator, the collected electric heaters were observed in a storage room. The administrator was interviewed at this time about the heaters. The administrator stated the heaters were provided on Saturday night (1/17/26) due to the lack of heat during the water line repair. On 1/20/26 at 5:55 p.m., the administrator stated he accounted for all the portable heaters that were issued and that all resident rooms had been inspected with no other portable heaters found in use.On 1/21/26 at 3:05 p.m., the licensed practical nurse unit manager (LPN #6) caring for R99 was interviewed about the portable heater. LPN #6 stated, The heater got missed. LPN #6 stated R99's hall did not have heat on Saturday night (1/17/26). LPN #6 stated maintenance provided the heater in R99's room due to the heat outage. LPN #6 stated the portable heater should have been removed from the resident's room after the heat was repaired on Sunday (1/18/26).This finding was reviewed with administrator and director of nursing during a meeting on 1/21/26 at 5:00 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during tracheostomy care for one of twenty-eight residents in the survey sample (Resident #13).The findings include:Infection control practices regarding hand hygiene and glove changes were not followed during Resident #13's tracheostomy care.Resident #13 (R13) was admitted to the facility with diagnoses that included dysphagia, neuromuscular dysfunction of bladder, chronic respiratory failure, dementia, psychotic disturbance, mood disturbance, anxiety, dysarthria, hypertension and depression. The MDS dated [DATE] assessed R13 as cognitively intact.R13's clinical record documented a physician order dated 7/1/25 for tracheostomy care each day that included cleaning around stoma with cotton swab wet with saline/hydrogen peroxide mix and an order dated 7/4/25 to insert new sterile inner cannula to tracheostomy (trach) daily.On 1/22/26 at 8:58 a.m., with R13's permission and accompanied by licensed practical nurse (LPN #6), tracheostomy care was observed. LPN #6 applied gloves, sanitized the bed tabletop and let dry. LPN #6 removed gloves, washed hands, put on gown, mask, and eye goggles. LPN #6 placed a clean field on the bed table and then placed trach care kit items on the field. LPN #6 put on sterile gloves and opened the care kit supplies/packets. LPN #6 then removed sterile gloves and without hand hygiene, put on a new pair of sterile gloves before opening the package with the new cannula. LPN #6 removed gloves and without hand hygiene, put on a new pair of sterile gloves. LPN #6 removed the speak valve then removed/discarded the used split gauze around the trach opening. Without glove change and hand hygiene, LPN #6 then removed the inner cannula from the trach and inserted/secured the new inner cannula into the tracheostomy. LPN #6 cleansed around the stoma with use of a cotton swab wet with sterile saline mix, repositioned the speak valve, and put a new split gauze around the trach device. LPN #6 then removed her gloves, gown, goggles and mask. LPN #6 did not change gloves after removing the soiled split gauze and prior to removal/insertion of the new inner cannula. LPN #6 sanitized the eye goggles with a wipe and then secured used/soiled items in a trash bag before disposal. LPN #6 did not wash her hands prior to leaving the room. LPN #6 discarded bagged used items and then sanitized hands after leaving the resident's room. R13's tracheostomy site was clean with no signs of infection or inflammation. R13's oxygen saturation percentage was monitored during the trach care with the resident reporting no difficulties during the care procedure.On 1/22/26 at 9:15 a.m., LPN #6 was interviewed about the observed trach care with lack of hand hygiene between glove changes and no glove change after removal of the soiled split gauze. Regarding placement of the new inner cannula, LPN #6 stated she held the cuff with her right hand, pulled the used cannula out with the left hand and then inserted the new cannula with the left hand, touching only the tip. LPN #6 stated, I didn't do hand sanitizer between glove changes. LPN #6 stated she should have washed hands or used hand sanitizer between glove changes and after removing the soiled dressing.On 1/22/26 at 9:25 a.m., the infection preventionist (RN #3) was interviewed about R13's observed trach care. RN #3 stated that hand hygiene was required between glove changes. RN #3 stated a glove change and hand hygiene should have been done after removal of the soiled dressing and prior to touching the inner cannulas. The facility's policy titled Tracheostomy Care (effective 6/28/25) documented regarding trach care when changing a disposable inner cannula, .Aseptic technique should be used .During tracheostomy tube changes, either reusable or disposable .Gloves must be used on both hands during any and all manipulation of the tracheostomy. Sterile gloves will be used during aseptic procedures .Wash hands .Put exam gloves on both hands .Inspect skin and stoma site for signs or symptoms of infection, leakage, subcutaneous crepitus, or dislodged tube .Remove old dressing. Pull soiled glove over dressing and discard into appropriate receptacle .Wash hands . This procedure documented regarding changing of disposable inner cannula, .Stabilize the neck of the tracheostomy tube and gently remove inner cannula. Discard inner cannula .Stabilize the neck plate of the tracheostomy tube, then insert the sterile disposable inner cannula over the ridge on the outer cannula .Apply clean gloves .Clean the stoma .Remove gloves and discard into appropriate receptacle. Wash hands .Document the procedure, condition of the site, and the resident's response .This finding was reviewed with the administrator and director of nursing on 1/22/26 at 1:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interviews and clinical record review, the facility staff failed to review and revise a care plan for one of twenty-eight residents in a survey sample.The Findings Include:Resident #56 (R56) care plan was not updated to include hearing aids.R56 diagnoses included communication deficit related to hard of hearing, depression, and pulmonary embolism. The most current MDS (Minimal Data Set) was a quarterly with an ARD (Assessment Reference Date) of 11/10/25. R56 was assessed with a cognitive score of 13 indicating cognitively intact. Review of R56's admission assessment dated [DATE] and section B (hearing and vision) of the MDS documented R56 used hearing aids.Review of R56's care plan for communication related to hearing deficit indicated how to speak with R56 (face to face without limited background noise) but did not indicate R56 wore hearing aids or any interventions regarding hearing aid usage and monitoring.On 1/22/2026 at 10:37a.m. registered nurse (RN # 1, MDS coordinator) was interviewed. RN #1 reviewed R56's care plan and verbalized that the hearing aids should be part of the care plan and would update the care plan to include the hearing aids.On 1/22/26 at 1:15 p.m. the above finding was presented to the administrator and director of nursing.No other information was presented prior to exit conference on 1/22/26.

Based on staff interview, clinical record review and facility policy review, the facility staff failed to follow physician's orders for 1 of 28 residents, Resident #11.The findings included:For Resident #11 the facility staff held the medication polyethylene glycol without a physician's order.Resident #11's clinical record listed diagnoses which included but not limited to major depressive disorder, recurrent, unspecified and other chronic pain.Resident #11's most recent minimum data set with an assessment reference date of 10/23/25 assigned the resident a brief interview for mental status score of 4 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired.Resident #11's comprehensive care plan was reviewed and contained a plan for The resident uses antidepressant medication r/t (related to) Depression and insomnia. Interventions for this plan include Monitor/document/report PRN (as needed) adverse reaction to ANTIDEPRESSANT therapy: . constipation, fecal impaction, diarrhea.Resident #11's clinical record contained a physician's order summary which read in part, Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION (R.15.0).Resident #11's electronic medication administration record for the month of December 2025 was reviewed and contained and entry which read in part, Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION (R.15.0). This entry was coded 5 on 12/21/25, 12/26/25, and 12/27/25 for evening shift, and 12/26/25 and 12/27/25 for day shift. This entry was coded 9 on 12/22/25 for day shift and 12/30/25 for evening shift. Chart code 5 is the equivalent of Hold/See Progress Notes and chart code 9 is the equivalent of Other/See Progress Notes.Resident #11's nurses notes were reviewed and contained notes which read in part, 12/21/2025 18:11 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. loose stools, 12/22/2025 09:22 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. loose stool, 12/26/2025 10:55 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. held r/t (related to) loose stools, 12/26/2025 16:10 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. resident is having loose stools, 12/27/2025 08:18 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. Loose stools, 12/27/2025 16:57 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. resident is having loose stools. Holding at this time, and 12/30/2025 18:33 Note Text: Polyethylene Glycol 3350 Powder. Give 17 gram by mouth two times a day for Constipation related to INCOMPLETE DEFECATION. held due to diarrhea. There is no note indicating that the physician had been notified to obtain a hold order.Surveyor spoke with the director of nursing (DON) on 01/21/26 at 2:30 pm regarding Resident #11. Surveyor asked DON if staff should be holding medications without an order, and DON stated they would have to look at the order. Surveyor asked DON specifically about Resident #11's polyethylene glycol order and DON stated staff should notify the physician to get an order to hold the medication.On 01/22/25 at 10:45 am, DON confirmed that staff had not called the physician to obtain a hold order for Resident #11's polyethylene glycol.Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, POLICY: This policy is designated to ensure that . (name omitted) provides pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering medications to meet each individual resident need.16. Resident's physician should be notified of any medication that was not administered.The concern of holding Resident#11's medication without a physician's order was discussed with the administrator and DON on 01/22/26 at 1:30 pm.No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for two of twenty-eight residents in the survey sample (Residents #3 and #13).The findings include:1. Resident #3's quarterly MDS dated [DATE] inaccurately documented the resident took anticoagulant medication and failed to indicate the resident took an antiplatelet medication.Resident #3 (R3) was admitted to the facility with diagnoses that included hypertension, hypothyroidism, anxiety, osteoarthritis, osteoporosis, vascular dementia, cerebral infarction, psychotic disturbance, mood disorder, chronic kidney disease, atrioventricular block, heart failure and hypoxia. The MDS dated [DATE] assessed R3 with severely impaired cognitive skills.R3's clinical record documented a physician's order dated 6/22/22 for aspirin 81 milligrams each day for treatment of cerebral infarction. R3's clinical record documented no physician's order for any anticoagulant medication. R3's medication administration record for November 2025 listed the daily administration of aspirin and no administration of anticoagulant medicines.Review of R3's clinical record revealed a quarterly MDS assessment with reference date of 11/13/25. Section N0415 of this MDS listed the resident had taken anticoagulant medication during the last seven days and that the indication for the medication was noted in the record. This MDS did not indicate the resident's use of an antiplatelet medication (aspirin).On 1/22/26 at 8:10 a.m., the registered nurse responsible for MDS assessments (RN #1) was interviewed about R3's MDS indicating anticoagulant use and no antiplatelet use. RN #1 stated she reviewed R3's clinical record and the resident had no order for an anticoagulant. RN #1 stated the resident was prescribed daily aspirin, which was an antiplatelet medication, not an anticoagulant. RN #1 stated the aspirin was inaccurately categorized on the 12/11/25 MDS as an anticoagulant.The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages N-6 through N-8 documents regarding high-risk drug use and indications, .Code all high-risk drug class medications according to their pharmacological classification, not how they are being used .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period .Check if there is an indication noted for all anticoagulant medications taken Antiplatelet: Check if there is an indication noted for all antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period .Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period . (1) 2. Resident #13's quarterly MDS dated [DATE] inaccurately listed the resident's urinary continence as always continent when the resident had an indwelling catheter.Resident #13 (R13) was admitted to the facility with diagnoses that included dysphagia, neuromuscular dysfunction of bladder, chronic respiratory failure, dementia, psychotic disturbance, mood disturbance, anxiety, dysarthria, hypertension and depression. The MDS dated [DATE] assessed R13 as cognitively intact.R13's clinical record documented a physician's order dated 7/1/25 for a Foley urinary catheter due to neuromuscular bladder dysfunction. R13's treatment administration records reviewed from October 2025 through 1/20/26 revealed care/monitoring related to use of the Foley catheter.Section H0100 of R13's quarterly MDS dated [DATE] documented the resident had an indwelling urinary catheter. Section H0300 of this MDS inaccurately listed the resident as always continent (code 0) instead of indicating use of the indwelling catheter (code 9).On 1/22/26 at 8:10 a.m., the registered nurse responsible for MDS assessments (RN #1) was interviewed about the conflicting continence assessment on R13's MDS dated [DATE]. RN #1 stated R13 had an indwelling catheter and that coding under section H0300 should not have indicated the resident as always continent. RN #1 stated coding for section H0300 should have been code 9, indicating use of the indwelling catheter.The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on page H-10 documents regarding coding of urinary continence, .Code 0, always continent: if throughout the 7-day look back period the resident has been continent of urine, without any episodes of incontinence .Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter .for the entire 7 days . (1) These findings were reviewed with the administrator and director of nursing on 1/22/26 at 1:00 p.m. with no further information presented prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, Centers for Medicare & Medicaid Services, Revised October 2025.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of the reason(s) for transfer/discharge to the resident's representative and/or failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer/discharge for (2) two of (28) twenty-eight sampled residents, Resident #121 and Resident #2. The findings included:1.For Resident #121 the facility staff failed to provide written notification of the reason(s) for transfer/discharge to the resident's representative and failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer/discharge for a transfer/discharge that occurred on 12/8/25. Resident #121's diagnosis list indicated diagnoses that included, but were not limited to, neoplasm of the brain, hydrocephalus, hypertension, urinary retention, and hyponatremia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 11/20/25, Section C (Cognitive Patterns) was coded to reflect the resident was never/rarely understood, exhibited short and long-term memory problems, and was severely impaired in decision making, indicating the resident was severely impaired in cognition. A review of the clinical record disclosed Resident #121 was transferred to the hospital on [DATE]. No evidence of a written notice of the reason(s) for the transfer/discharge being provided to the resident representative could be located and no evidence the bed hold policy was provided to the resident and/or resident representative could be located. Surveyor requested evidence of written notice for the reason(s) transfer/discharge was provided to the resident representative and requested evidence the bed hold policy was provided to the resident and/or resident representative for the transfer/discharge on [DATE]. On 1/22/26 at 10:06 AM, other staff #1 (OS#1) informed this surveyor that nothing in writing could be located for the bed hold, as this was verbal and the facility practice is to always hold the bed for residents. On 1/22/26 at 12:46 PM, the director of nursing (DON) informed this surveyor the bed hold would not have been sent with the resident and there was no evidence of written notice being sent to the resident's representative as she lives three hours away. This concern was discussed at the pre-exit meeting on 1/22/26 at 12:59 PM with the administrator and director of nursing. Surveyor requested and received a facility policy titled, .Initiated Transfer and Discharge with an origination date of 1/2019 which read in part, .will notify.the resident's representative(s) of the transfer or discharge and the reasons for the move in writing.b. Notice must be made as soon as practicable.iv) An immediate transfer or discharge is required by the resident's urgent medical needs.9. The written notice will include.a)The reason for transfer or discharge. Surveyor requested and received a facility policy titled, Acknowledgement of Bed-Hold Policy which read in part, .Our bed hold policy ensures that the resident has a bed to return to following a hospital stay.Reason for this notice.You are being transferred to the hospital for further evaluation and treatment. No further information regarding this concern was presented to the survey team prior to the exit on 1/22/26. 2. Resident #2 (R2) did not receive required bed hold policy upon discharge to the hospital with return to facility anticipated. R2 diagnoses include heart failure, venous embolism, edema, chronic kidney disease, and diabetes. The most recent MDS (minimum data set) was a quarterly dated 12/3/25 which indicated R2 was cognitively intact. Review of the clinical record indicated R2 was discharged to the hospital on [DATE] due to acute heart failure. Further review of the clinical record did not include evidence R2 received a written bed hold policy prior to leaving the facility. On 1/21/2026 at 3:41 p.m. license practical nurse (LPN #4, clinical coordinator) was interviewed. LPN #4 verbalized that the nursing staff doesn't typically present a bed hold policy, verbalizing the admission director would be the person to handle discharge information. On 1/21/2026 at 3:45 p.m. the admission director (other staff, OS #9) was interviewed. OS #9 verbalized that all private pay residents must keep paying for their room. If residents are under Medicaid, then residents will still have a room even if it's not the one they had when they left. OS #9 said that they always keep in touch with the hospital and if they have an extended stay, they will let the family know their options, but a bed hold policy is not given out upon discharge. On 1/22/26 at 1:45 p.m. the above information was presented to the administrator and director of nursing. No other information was provided prior to exit conference on 1/22/26.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain a comfortable homelike environment for 1 of 28 residents in the survey sample, Resident #105.The findings included:A large area of drywall/sheetrock next to the resident's bed was visibly scuffed and damaged.Resident #105's diagnoses included Alzheimer's disease and dementia.Section C (cognitive patterns) of Resident #105's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/24/25 had been coded to indicate this resident was moderately impaired in cognitive skills for daily decision making.On 01/20/26 during initial tour of the facility the surveyor observed a large area of drywall beside the resident's bed to be scuffed and damaged.A second observation was made of this area on 01/21/2026 at 4:39 p.m. On 01/21/2026 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Infection Preventionist the issue with Resident #105's drywall being damaged and in need of repair was reviewed. On 01/22/2026 at 8:30 a.m., the Home Maintenance Supervisor was interviewed regarding the damaged area on Resident #105's wall. This staff stated they were not aware of the area, and they do patch and paint upon request. The Home Maintenance Supervisor stated he did not have a work order for this area. On 01/22/2026 at 9:15 a.m., Maintenance Personnel #1 was observed by the surveyor patching this area. This staff stated he did not have a work order prior to today. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 28 residents in the survey sample, Residents #10 and #84.The findings included:1. For Resident #10, the clinical record included provider orders for Acetaminophen and Milk of Magnesium by mouth. Resident #10 had a feeding tube and was NPO (nothing by mouth). Resident #10's diagnoses included, spastic quadriplegic cerebral palsy, epilepsy, and dysphagia. Section C (cognitive patterns) of Resident #10's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 10/28/25 was coded to indicate the resident was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate this resident had a feeding tube. Resident #10's comprehensive care plan (CCP) included the focus area all nutrition and fluids via feeding tube. Resident #10's clinical record included the following provider orders. NPO/Tube Feeding diet NPO texture, no liquids by mouth consistency for dysphagia. Acetaminophen extra strength oral liquid give 20 ml (milliliters) by mouth every 24 hours as needed for pain mix with 15 mls of water. Milk of Magnesia oral suspension give 30 mls by mouth every 24 hours as needed. A review of the medication administration records for January 2026 and December 2025 revealed neither of these medications had been administered. On 01/21/2026 at 3:53 p.m., during an interview with Licensed Practical Nurse (LPN) # 2 this staff verified that Resident #10 was administered all their medications via a feeding tube. On 01/21/26 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Infection Preventionist the issue with Resident #10 having orders for medications by mouth when they were NPO was reviewed. On 01/22/2026 at 12:35 p.m., during an interview with the DON this staff stated they did not have a policy on documentation, and the expectation would be for the documentation to be entered correctly and per the provider's orders. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. A physician's order for Calcium 600 milligrams (MG) was incorrectly transcribed for resident number 84 (R84). R84 diagnoses include vitamin deficiency, osteoporosis, and muscle weakness. The most recent MDS (minimum data set) was a quarterly dated 12/24/25 and indicated R84 was cognitively intact. During medication pass observation conducted on 1/21/26 at 9:10 a.m. registered nurse (RN #2) gave R84 physician ordered Calcium 600 mg. The medication was reviewed for correct medication and dosage. After completing the medication pass observation, medications that were given to R84 were reviewed for accuracy via the physician's orders. Review of R84's Calcium order instructions documented Give 600 mg by mouth one time a day for Supplement Take 900mg by mouth once per day. On 1/21/2026 at 10:06 a.m. RN #2 was interviewed regarding the Calcium given. RN #2 reviewed the order and verbalized that R84 had always been given 600 mg of Calcium and the order needed to be rectified because the actual dose on the physician's order is for 600 mg. At this time RN #2 informed the clinical coordinator license practical nurse (LPN #4). On 1/21/2026 at 2:16 p.m. LPN #4 was interviewed. LPN #4 verbalized that she had spoken to the physician and verified that Calcium 600 mg was to be given but the instructions had a typographical error and would be corrected. On 1/21/26 at 5:00 p.m. the above finding was presented to the administrator and director of nursing. No other information was presented prior to exiting the facility on 1/22/26.

Based on staff interview, clinical record review and complaint investigation, the facility staff failed to employ a qualified activity professional for the facility. For two years, the facility had no qualified therapeutic recreation specialist or activities professional providing direction/supervision of the activity programs for residents. The findings include: During a complaint investigation regarding Resident #37's activities, the household coordinator (CNA #1) was identified as the staff person responsible for providing recreational activities on the resident's living unit. On 1/12/22 at 2:37 p.m., certified nurses' aide (CNA) #1 was interviewed about Resident#37's activities program. During this interview, CNA #1 stated she was responsible for completing activity assessments and implementing the activity programs for residents on her assigned unit. When asked what training and/or qualifications she had regarding recreational activities, CNA #1 stated the previous CNA household coordinator provided her training. CNA #1 stated she had received training about dementia care but had no formal education or training regarding recreational activity programming. CNA #1 stated she worked together with the other household coordinators. When asked who provided supervision and direction of the facility's recreation activities, CNA #1 stated she reported to the administrator. CNA #1 was not aware of a qualified recreation specialist or activity professional in the facility. On 1/12/22 at 4:08 p.m., the administrator was interviewed about a qualified recreation specialist for the facility. The administrator stated there was a certified therapeutic recreation specialist working in the retirement community but that person was not involved with assessment, planning or implementing of the long-term care activity programs. The administrator stated they did not currently have a qualified activity professional and had not had one employed at the facility for approximately two years. This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m.

Based on clinical record review and staff interview, the facility staff failed to ensure 2 of 26 residents in the survey sample were free from unnecessary [CONDITION(S)] medications, Resident #45 and Resident #37. Resident #45 had physician orders for as needed (PRN) antianxiety medication [MEDICATION(S)] that extended more than 14 days without a stop date. Resident #37 had physician orders for as needed (PRN) antipsychotic medication [MEDICATION(S)] and the antianxiety medication Lorazepam that extended for more than 14 days without a stop date; and an as needed (PRN) dose of [MEDICATION(S)] was administered to Resident #37 without an indication for use or documented prior attempts of non-drug interventions. The findings include: 1. Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with behavioral disturbance, depression, dementia with lewy bodies, [CONDITION(S)], generalized anxiety disorder, type 2 diabetes, and delusional disorders. The most recent minimum data set (MDS) dated [DATE] was a 5-day assessment and assessed Resident #45 as severely cognitively impaired for decision making with a score of 3 out of 15. The MDS assessed Resident #45 with periods of fluctuating inattention, consistent disorganized thinking and displaying physical, verbal and wandering behaviors. On 01/12/2021, Resident #45's clincial record was reviewed. Observed on the physician's order sheet was the following order: [MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) *Controlled Drug* Give 0.5 mg (milligrams) by mouth every 8 hours as needed for anxiety related to GENERALIZED ANXIETY DISORDER. Give 1 tablet by mouth every 8 hours as needed for Anxiety Medication must continue > (greater than) 14 days for PRN (as needed) use and > (greater than) 60 days due to resident requiring intermittent administration for dx (diagnosis) of dementia with behaviors. AND Give 0.5 mg (milligrams) by mouth one time a day for Anxiety. Order Start Date: 01/18/2021. There was no documented stop date for the PRN (as needed) [MEDICATION(S)] order. A review of the medication administration records (MAR) for the months of October 2021 through January 2022 documented Resident #45 received her scheduled dose of [MEDICATION(S)] and received the PRN (as needed) dose of [MEDICATION(S)]. The MAR documented Resident #45 received the PRN (as needed) dose of [MEDICATION(S)] as followed: October 1, 3, 5, 6, 7, 9, 12, 15, 16, 17, 19, and 21; November 4, 6, and 13; December 2, 4, 5, 7, 10, 13, 14, 15, 16, 18, 19, and 22; and January 1, 7 8, 9, 10, and 12. The clinical record included documentation for indication of use including moods and behaviors and attempts of non-pharmacological interventions including 1:1 activities, incontinent care, snacks, turn/reposition, and/or attention diversion. A review of the Consultant Pharmacist's Medication reviews did not document any recommendations regarding the PRN [MEDICATION(S)]. On 01/13/2022 at 10:03 a.m., the Household Clinical Coordinator (LPN #6) was interviewed regarding the PRN (as needed) [MEDICATION(S)] order not having an end date. LPN #6 stated she completed a quarterly review of medications on her unit and recently had a conversation with the nurse practitioner regarding the order since it was written for greater than 60 days. LPN #6 stated Resident #45 displayed moods/behavior mostly in the evening hours and was recently started on a new [CONDITION(S)] medication which seemed to reduce some of Resident #45's moods and behaviors. LPN #6 was asked if the pharmacy consultant had made any recommendations regarding the PRN [MEDICATION(S)] (as needed) order. LPN #6 stated, The pharmacy does things a little different here compared to my experience in another facility. I know [Nurse Practitioner] is good about monitoring [Resident #45] medications and that is why the order was written for greater than 60 days. I will discuss with her the importance of the mediation review and placing a stop date on the PRN medication. Also, [Resident #45] is seen by psych services and [Psych Provider] has been instrumental in helping with medication changes as well. The above findings were reviewed with the Administrator and the Director of Nursing during a meeting on 01/13/2021 at 1:48 p.m. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, dementia with behaviors, [CONDITION(S)], urinary tract infection, [CONDITION(S)] with pacemaker, hypertension, gastroesophageal reflux disease, [CONDITION(S)], history of [CONDITION(S)], history of colon cancer and major depressive disorder. The minimum data set (MDS) dated [DATE] assessed Resident #37 with short and long-term memory problems and severely impaired cognitive skills. Resident #37's clinical record documented a physician's order dated 12/8/21 for the medication lorazepam 2 mg/ml (milligrams per milliliter) intramuscularly every 4 hours as need (prn) for agitation. The record documented a physician's order dated 12/9/21 for [MEDICATION(S)] ([MEDICATION(S)]) disintegrating tablet 5 mg by mouth every 6 hours as needed for restlessness and agitation. These prn orders for [CONDITION(S)] medications had been in place for over 30 days with no stop or end dates. Resident #37's medication administration records (MARs) from 12/1/21 through 1/11/21 documented the resident was administered five doses of the as needed lorazepam. As needed lorazepam was administered on 12/8/21, 12/9/21, 12/10/21, 12/13/21 and 1/2/22. As needed doses of [MEDICATION(S)] were administered on 12/10/21, 12/21/21, 12/26/21 and on 1/11/22. Resident #37's clinical record included no documentation or assessment indicating the need for the 1/11/22 dose of [MEDICATION(S)]. A nursing note dated 1/11/22 at 11:52 p.m. documented [MEDICATION(S)] 5 mg was given for increased agitation. There was no documentation of any non-drug interventions implemented prior to the 1/11/22 dose of [MEDICATION(S)]. There was no other assessment and/or description of the resident on 1/11/22 describing any behaviors demonstrated by the resident or events requiring the need to the antipsychotic medication. Resident #37's plan of care (revised 1/11/22) listed the resident had behavior problem of touching/talking to team members, and a resident in a sexually inappropriate manner . No other behaviors were included in the care plan. Interventions regarding sexual comments included Assist the resident to develop more appropriate methods of coping .(distraction and redirection). Encourage resident to express feelings .Explain all procedures .30 minute checks due to history of wandering . The plan listed the resident used [CONDITION(S)] medication due to depression with interventions documented to administer medications as ordered and to monitor for adverse effects. The plan documented the resident had potential for psychosocial problems and anxiety due to health problems. Interventions to maintain psychosocial adjustment included pastoral care, communication with family, resident participation in care and monitoring by psychiatric services. The only intervention listed to minimize anxiety was, Resident takes comfort in holding a baby doll. A pharmacist's recommendation dated 12/21/21 documented, This resident has a current PRN order for [MEDICATION(S)] as needed for aggression/restlessness (start date 12/01/2021) with no stop date indicated in the MAR. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident .please be sure the proper documentation is made in the resident's medical record . On 1/13/22 at 8:08 a.m., the licensed practical nurse (LPN #1) unit manager was interviewed about Resident #37's prn [CONDITION(S)] medications. Concerning the medication orders with no end date, LPN #1 stated the nurse practitioner reviewed the medications at least every two week. LPN #1 stated she thought the orders had been updated to include a stop date. LPN #1 reviewed the note on 1/11/22 and stated she did not see an assessment or description of why the medication was administered or any non-drug interventions attempted. LPN #1 stated the nurse should have documented a complete assessment and rationale for the [MEDICATION(S)] dose administered on 1/11/22. LPN #1 stated the resident had a history of aggressive physical and verbal behaviors. LPN #1 stated she had added the baby doll to the care plan as a non-drug intervention but the care plan did not include the all of the physically aggressive behaviors. The Nursing 2022 Drug Handbook on page 909 describes lorazepam as an anxiolytic used for the treatment of anxiety and [CONDITION(S)] with adverse reactions that include drowsiness, sedation, agitation and respiratory depression. This reference on page 910 documents, .Use cautiously in elderly, acutely ill, or debilitated patients . (1) The Nursing 2022 Drug Handbook on 1084 describes [MEDICATION(S)] ([MEDICATION(S)]) as an antipsychotic medication used for the treatment of [CONDITION(S)], manic episode associated with [CONDITION(S)] disorder, agitation caused by [CONDITION(S)] and treatment-resistant depression and lists adverse reactions that include somnolence, [CONDITION(S)] and dizziness. This reference documents on page 1086, .Black Box Warning Drug may increase risk of CV [cardiovascular] or infection -related death in elderly patients with dementia. [MEDICATION(S)] isn't approved to treat patients with dementia-related [CONDITION(S)] . (1) This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m. (1) Woods, Anne Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to develop a comprehensive plan of care for two of 26 residents in the survey sample. Resident #37 had no care plan developed regarding hydration and behaviors. Resident #60 had no care plan about behaviors. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #37 with short and long-term memory problems and severely impaired cognitive skills. This MDS documented the resident demonstrated physical behaviors directed toward others (hitting, kicking, grabbing), verbal behaviors (screaming, yelling) and other behaviors such as hitting, rummaging and throwing food/items. a) Resident #37's clinical record from October 2021 through 1/10/22 documented the following behaviors. 10/8/21 - .attempting to climb out of chair .got verbally aggressive with the aide and nurses. when the nurse attempted to give him medication he kicked her and attempt to grab her wrists and pull her close to him. he remained verbally aggressive . 10/12/21 - .today tearing up papers, books, boxes . 10/21/21 - .continuing to spit all over med cart and on floor. took his drink cup and dumped it all over the table and floor in dining room . 10/27/21 - .spit his meds out, and spit on the floor. Pouring water on the floor . 10/31/21 - .was opening and slamming his cabinet doors shut, hitting on dresser .threw his mug on the floor, which then broke .spitting on the floor and in his plate . 11/9/21 - .began to spit on the floor and after eating his ice cream he threw the empty container across the dining room floor . 11/19/21 - .has been yelling at other residents and arguing with the aids [aides]. He attempted to punch one of the aids .threw his water at the nurse and his beer at another aid . (sic) 12/1/21 - .Resident became physically aggressive when aides attempted to wash and dress him. Resident grabbed aide .by throat and would not let go .released aide, but was yelling . 12/1/21 - .noted resident grabbing wife's arm .small bruise to wife's wrist . 12/1/21 - .in dining room .knocked the plant off the window sill .arch his back in attempt to break the window .climbed up onto the table .scooting across the table .continues to spit . (sic) 12/8/21 - .spitting on the recliner and the floor . 12/17/21 - .was noted to be tearing up newspaper and moving things around in his room . 12/17/21 - .resident started to hit another resident with a brush and then began spitting on the floor . The clinical record documented redirection, diversion activities, family visits, psychiatric evaluations and multiple medication changes to address the ongoing behaviors. Resident #37's plan of care (revised 1/11/22) included no problems, goals and/or interventions regarding the aggressive physical and verbal behaviors. The plan of care documented the resident had .a behavior problem of touching/talking to team members, and a resident in a sexually inappropriate manner . The problem was initiated on the plan on 9/10/21. The care plan made no mention of the resident's hitting, kicking, grabbing, rummaging, tearing books, spitting or throwing items. On 1/13/22 at 8:08 a.m., the licensed practical nurse (LPN #1) unit manager responsible for care plans was interviewed about Resident #37. LPN #1 stated not all of the resident's behaviors were listed on the care plan and the plan did not include interventions implemented to address the resident's aggressive behaviors. This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m. b) Resident #37's clinical record documented the resident had ongoing physical and verbal behaviors that included hitting, grabbing, kicking, sexual comments, yelling and screaming and an ongoing issue with falls. Intake records documented the resident had decreased fluid and meal intake on 10/3/21, 10/4/21 and 10/5/21 with the resident refusing food and drink. The nurse practitioner (NP) progress note dated 10/5/21 documented the resident had experienced a fall on 10/4/21, hit his head and the responsible party refused for the resident to go to the emergency room . This progress note dated 10/5/21 documented, Nursing call this afternoon around 1245 stating that resident has become increasingly lethargic throughout the day, now lying in bed most of the late morning .he is not eating and drinking .POA [power of attorney] is now agreeable to have him sent in [to emergency room ]. The emergency room report dated 10/5/21 documented, .Incidentally found to have evidence of acute kidney injury and admitted .Concerning patient's mild acute kidney injury this was likely secondary to his recent worsening nutritional status and diminished p.o. [oral] intake in his nursing facility .Metabolic [CONDITION(S)] likely due to dehydration due to poor oral intake likely due to worsening advanced dementia . The resident received intravenous fluids and discharged back to the nursing facility on 10/7/21 with instructions to maintain adequate nutritional status and intake after discharge to the nursing facility. The clinical record documented the resident at times refused meals/drinks. Fluid intake records documented the resident routinely accepted daily fluid amounts less than those recommended by the registered dietitian. Resident #37's plan of care (revised 1/11/22) included no problems, goals and/or interventions regarding fluid intake or dehydration prevention following the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/13/22 at 8:08 a.m., the licensed practical nurse (LPN #1) unit manager responsible for care plans was interviewed. LPN #1 stated the staff members encouraged fluids with Resident #37. LPN #1 stated the resident at times accepted all fluids and other days refused due to advanced dementia and behaviors. LPN #1 stated alternate supplements had been attempted with the resident preferring med-pass. LPN #1 stated hydration was typically included in the care plan for residents with impaired intake. LPN #1 stated the last care plan meeting for Resident #37 was held in November 2021 and the plan was focused on family concerns and nothing had been added to the care plan specifically about fluid intake and dehydration prevention. This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m. 2. Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] documented Resident #60 had short and long-term memory problems and moderately impaired cognitive skills. Resident #60's clinical record documented the following nursing notes regarding ongoing behaviors. 12/29/21 - .Resident had some sexual behaviors directed to this nurse .Resident grabbed penis and stated, 'I have some medication here for you some of my penis, do you want it.' .Resident kept grabbing himself and stating to this nurse vulgar things . 12/30/21 - .Resident displaying inappropriate sexual advances toward staff . 1/1/22 - .Resident sexually inappropriate x 1 with team . 1/4/22 - .resident displayed short outburst of inappropriate behavior earlier in the shift . 1/9/22 - .Res [resident] observed pulling down pants and pullup while reclined in chair . A nurse practitioner (NP) progress note dated 1/4/22 documented, .seen for abnormal urine and urine culture along with continued inappropriate sexual behavior. He is exhibiting confusion and behaviors .He has been sexually inappropriate with staff and around the other residents .Pleasant but does make some sexual comments today . Resident #60's plan of care (revised 12/27/21) included no problems, goals and/or interventions regarding sexually behaviors. The plan listed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/13/22 at 9:04 a.m., the licensed practical nurse (LPN #1) unit manager responsible for care plans was interviewed about Resident #60. LPN #1 stated the resident started with sexual behaviors about 3 to 4 weeks ago. LPN #1 stated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated the behaviors were ongoing after treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m.

Based on family interview, staff interview and clinical record review, the facility staff failed to perform routine skin assessments prior to development of a pressure ulcer for one of 26 residents in the survey sample, Resident #79. Resident #79 developed a stage 2 pressure ulcer on her sacrum after going over four months without a documented skin assessment for pressure ulcer prevention. The findings include: Resident #79 was admitted to the facility on [DATE] with a re-admission on 4/23/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] documented Resident #79 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of one person for transfers and bed mobility. On 1/11/22 at 11:45 a.m., Resident #79's family member was interviewed about quality of care in the facility. The family member stated the resident had recently developed an open area on her bottom and nurses were providing daily treatment to the wound. The family member stated the resident had declined and was now entering hospice. Resident #79's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #79's treatment administration record documented daily treatments as ordered to the stage 2 pressure injury starting on 1/5/22. Nursing notes failed to evidence an assessment of a pressure ulcer on 1/4/22 by nursing. A nurse practitioner (NP) progress note dated 1/4/22 documented, XXX[AGE] year-old resident being seen for open skin area on her sacral region. There is intermittent pain noted to the area .Stage 2 sacral wound .Noted to her buttocks over the sacral region is a open skin area, discolored. The area is approximately nickel size with a central darkening of the skin noted. There is some surrounding [CONDITION(S)] that is blanchable. The area is mildly tender to palpation. There is no active drainage noted but the dressing does have some serosanguineous drainage present .there is no slough notable, only epithelial tissue which is no longer intact . (Sic) The clinical record documented no measurements of the pressure injury until 1/6/22. A nursing note dated 1/6/22 documented the resident had an open area on the sacrum measuring 0.5 centimeters (cm) in width, 1.5 cm in length with no depth measurement listed. The most recent assessment of the pressure injury dated 1/10/22 listed the pressure ulcer as a Kennedy Terminal Ulcer with measurements of 2.7 cm length, 2.0 cm width and area of 3.5 cm. The assessment documented slough present on the wound bed with serosanguineous exudate and dark-reddish brown skin color surrounding the wound. Resident #79 had no documented skin assessments and/or body audits in the weeks and months prior to the pressure injury noted on 1/4/22. The clinical record documented the most recent skin assessment prior to the pressure injury was on 8/14/21. Resident #79's most recent pressure ulcer risk assessment was completed on 11/26/21. The Braden Scale for Predicting Pressure Sore Risk listed the resident with moderate risk for pressure ulcer development with a score of 14. Risk factors listed on this assessment included bedfast status, very limited mobility, probable inadequate nutrition and potential for friction/shear. Resident #79's plan of care (revised 3/1/21) listed the resident required the extensive assistance of one staff person for turning and repositioning in bed and had potential for pressure ulcer development due to immobility. Interventions to maintain intact skin included, Inform the resident/family/caregivers of any new area of skin breakdown .Monitor nutritional status. Serve diet as ordered .Monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing .infection wound size (length x width x depth), stage. On 1/12/22 at 7:30 a.m., the registered nurse (RN #1) caring for Resident #79 was interviewed about skin assessments. RN #1 stated she thought skin assessments were required every week or every other week. RN #1 stated required skin assessments popped up on the computer screen from the electronic health record when they were due so nurses knew when to complete the assessments. Resident #79's sacral pressure injury was not observed during the survey as the family representative declined permission for the surveyor to see the wound or observe wound care. On 1/13/22 at 8:30 a.m., the unit manager (LPN #1) was interviewed about the lack of skin assessments prior to the 1/4/22 pressure ulcer. LPN #1 stated skin assessments were supposed to be completed weekly on all residents by the floor nurses. LPN #1 reviewed Resident #79's clinical record and stated she did not see a routine skin assessment prior to the pressure injury since August 2021. LPN #1 stated the electronic health record was supposed to prompt nurses each week for completion and documentation of the assessments. LPN #1 stated Resident #79's skin assessment schedule had been altered and/or rescheduled and no prompts were being initiated by the computer system. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as, .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . The NPIAP defines a stage 2 pressure injury as, Partial-thickness loss of skin with exposed dermis. The wound bed in viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister . (1) The NPIAP Pressure Injury Prevention Points documents concerning skin care to prevent pressure ulcers, .Inspect all of the skin upon admission as soon as possible (but within 8 hours) .Inspect the skin at least daily for signs of pressure injury, especially nonblanchable [CONDITION(S)] .Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices . (2) This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m. (1) NPIAP Pressure Ulcer Stages/Categories. National Pressure Ulcer Advisory Panel. 1/15/22. www.npiap.com (2) Pressure Injury Prevention Points. 2020 National Pressure Injury Advisory Panel. 1/15/22. www.nipiap.com

Based on clinical record review and staff interview, the facility staff failed to maintain a complete and accurate clinical record for two of 26 residents, Resident #76 and #103. Resident #76's pharmacy review for December was altered. Resident #103's code status was not correctly identified in the clinical record. Findings were: 1. Resident #76 was added to the survey sample for review of unnecessary medications. The clinical record was reviewed on 01/12/2022. A pharmacy review for the month of December 2021 was not observed. On 01/13/2021 a pharmacy review was presented by the Director of Nursing (DON). The form provided was a Medication Review Regimen Review-Note to Attending Physician. The MRR (Medication Review Date) was 12/21/2021. The form was recognized as the form that was observed the previous day that had been signed by the nurse practitioner and scanned into the computer system on 01/04/2022. The form presented had been altered and signed by the clinical coordinator, LPN (licensed practical nurse) #5. The original form had been in the system but the date of the review was mistaken for January, when it had occurred in December. The pharmacy recommendations on the form were: Recommend review Resident's Current condition and consider tapering [MEDICATION(S)] 50 mg QHS [at hour of sleep] to evaluate if Resident is on the lowest possible does, or continues to need the medication The nurse practitioner responded to the request with: Resident has good response to current treatment which maintains baseline function. Dose reduction is not indicated due to benefits outweigh risks . The form was signed by the nurse practitioner and dated 01/04/2022. The form presented on 01/13/2022 marked through the nurse practitioner's response and error was written. A new response of Other was marked and the handwritten on the form was 12/22-Res [resident] verbalized request for increase in [MEDICATION(S)] for [CONDITION(S)]. See order & encounter. Family Aware. The form was signed by LPN #5 and dated 12/28/2021. LPN #5 was interviewed on 01/13/2022 at approximately 8:30 a.m. She was asked about the changes to the form and when they occurred. She stated, Yesterday, I thought that's what they wanted me to do. During a meeting with the DON and the administrator on 01/13/2022 at approximately 1:30 p.m., the above information was discussed. Concerns were voiced that LPN #5 had altered the form, signed her name, and back dated her signature. The DON stated, I looked at the record yesterday, I didn't see the December review either, I asked her to see if she could find it. I didn't ask her to do that. No further information was obtained prior to the exit conference on 01/13/2022. 2. Resident # 103 was admitted to the facility 12/9/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was an admission assessment dated [DATE]. Resident # 103 was assessed as having severe impairment in cognition with a score of 7 out of 15. The clinical record was reviewed 1/12/22 beginning at 8:00 a.m. The resident did not have a code status documented in the record to indicate whether she wanted any life-saving measures performed. On 1/12/22 the clinical coordinator, LPN (licensed practical nurse) # 3 for Resident #103's unit was asked for assistance in locating the code status. She reviewed the record and stated Well, I admitted her, so I know she is a 'DNR' [Do Not Resuscitate]. The code status should be here on the face sheet where her picture is right under 'allergies'. I don't know how that was missed; I should have put it in there. I will fix that right now. The administrator and the DON (director of nursing) were informed of the above findings during a meeting with facility staff 1/12/22 beginning at 3:50 p.m. No further information was provided prior to the exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to ensure an open bottle of liquid [MEDICATION(S)] (an anti-anxiety medication) was dated when opened, on one of 6 units, Joy unit. Findings include: On 1/12/22 at 9:30 a.m. an inspection of the Joy unit's medication room was conducted with LPN (licensed practical nurse) #4. Two bottles of liquid [MEDICATION(S)] were located in the narcotic drawer of the refrigerator. One bottle was open, but did not have a date when opened on any of the packaging. LPN #4 stated I'm not sure about what to do with that, let me get the clinical coordinator. LPN # 4 left the medication room and returned with LPN #3, who was the clinical coordinator. LPN #3 was shown the box and vial of [MEDICATION(S)], and was asked if there should be an opened date. LPN #3 stated Yes, and I don't see one either. She then turned the box upside down and stated Well, there is smudged writing on here, I can't tell what it says, but I think that's maybe the date .looks like some condensation occurred and has smudged the writing. On 1/12/22 at 10:15 a.m. the DON (director of nursing) was asked for a policy on labeling and storage of medications. The DON stated there was no policy; and that perhaps she could contact the pharmacy. The DON left and returned with an email from the pharmacy about shortened expiration dates. The email, meds with shortened expiration dates documented Lorazepam ([MEDICATION(S)]) Intensol: Pharmacy opens it and transfers it to another bottle with markings on side to measure, then send it to us. This means it expires 90 days from the fill date, as it has a short shelf-life. The administrator and the DON (director of nursing) were informed of the above findings during a meeting with facility staff 1/12/22 beginning at 3:50 p.m. No further information was provided prior to the exit conference.

Based on clinical record review, staff interview, and review of facility documents, the facility failed to maintain acceptable parameters of nutrition for one of 26 residents in the survey sample, Resident # 81. Upon the identification of a significant weight loss of 19.2 pounds (13.8% loss) in 30 days, the facility failed to initiate measures to prevent further unplanned weight loss. No interventions were implemented until a month after the initial significant weight loss occurred and the resident continued to lose weight. The findings were: Resident # 81 in the survey sample was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/2021, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 5 out of 15. Under Section G (Functional Status), the resident was assessed as being independent with set-up help only for eating. Review of the weight records in the resident's Electronic Health Record (EHR) noted the following weights: 7/2/2021 - 139.2 pounds 8/13/2021 - 120.0 pounds 9/13/2021 - 116.0 pounds 10/2/2021 - 115.6 pounds Resident # 81's weight loss between 7/2/201 (139.2 pounds) and 8/13/2021 (120.0 pounds) was 19.2 pounds, or a 13.8% weight loss in 30 days. The resident's weight loss between 7/2/2021 (139.2 pounds) and 9/13/2021 (116.0 pounds) was 23.2 pounds, or a 16.6% weight loss in two months. Review of the Nutrition Progress Assessment, dated 7/1/2021, noted the following: Tolerating regular diet regular texture thin liquids without problems. PO (Oral) intake varies 12-100% at meals. Fair to good fluid intake. Occasional snacks. Weights discontinued for comfort. No diet changes indicated at this time. Continue to encourage increased food/fluid intake. (NOTE: There was no documentation that the resident's weights were .discontinued for comfort.) A Nutrition Dietary Note contained in the Progress Notes, dated 9/3/2021, noted the following: Weight change note: RT (Resident) with a weight change -5% in 30 (days), BMI 24.2 WNL (within normal limits). On regular diet with thin liquids; PO intake fluctuates 25% to 50%. No dietary changes needed at this time; will continue to monitor. Review of the Nutrition Progress Assessment, dated 9/15/2021, noted the following: RT on regular diet with thin liquids. Her PO intake varies from < (less than) 50% to 75%; Her fluid intake also fluctuates. BMI (Body Mass Index) 23.4 WNL (Within Normal Limits); however her wt (weight) is trending downwards with a noted change of -10% X 108 days. At times she is depressed and states she does not like the food here per Dr. (name) notes. May recommend Med Pass bid (two times a day). Will continue to monitor. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The addition of Med Pass came approximately one month after the resident's weight loss of 19.2 pounds, or a 13.8%, was identified. A Progress Note, dated 9/23/2021, noted the following, .Dietician recommended Medpass protein shake but resident doesn't care for it. Staff attempted Thrive (frozen ice cream-caloric equivalent of Medpass) and resident enjoyed it . Review of Resident # 81's Quarterly Review MDS, with an ARD of 9/9/2021, found that under Section K (Swallowing/Nutritional Status), the resident was assessed as having a weight loss of 5% or more in the last month or loss of 10% or more in last six months that was not part of a physician prescribed weight loss regimen. At approximately 1:00 p.m. on 1/13/2022, the facility's Registered Dietitian (RD), identified as Other Staff # 2, was interviewed regarding Resident # 81's weight loss and mitigation measures. The RD said she was not the RD at the time the resident's weight loss occurred. Asked about the lack of mitigating interventions, the RD said she would have been more aggressive and would have taken action when the weight loss was identified. Resident # 81's care plan, dated 3/16/2021, and updated on 3/18/2021, included the following problem: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia, Limited Mobility, weakness and HX (history of) dizziness. The goal for the problem was: .The resident will improve current level of function in ADLs and ambulation through the review date. The interventions for the stated problem include: The resident is able to eat independently after set up; The resident prefers the following fluids: OJ and black coffee with breakfast. Likes cranberry juice with pineapple, water, root beef floats. Resident # 81's care plan also had the following problem, dated 7/1/2021 and updated on 10/5/2021: The resident has nutritional problem or potential nutritional problem r/t CKD3 (stage 3 [CONDITION(S)]), Alzheimer's dementia, constipation. The goal for the problem was: The resident will have gradual weight gain to within 10% of IBW (Ideal Body Weight) for sex and height range by review date. The interventions for the stated problem, added on 10/5/2021, included: Provide and serve diet as ordered. Offer finger foods, particular likes, encourage to try food before declining meals. Family may assist with meals/snacks during routine weekly visits, to promote health; Provide and serve supplements as ordered: Thrive BID, after meals. The findings were discussed during a meeting at 2:00 p.m. on 1/13/2022 that included the Administrator, Director of Nursing, and the survey team.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide appropriate catheter care for one of 26 residents in the survey sample, Resident #60. Resident #60 had a urinary catheter in use without the tubing secured to prevent pulling/tugging at the insertion site. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] documented Resident #60 had short and long-term memory problems and moderately impaired cognitive skills. Resident #60's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/12/22 at 2:13 p.m., certified nurses' aide (CNA) #2 was interviewed about Resident #60's catheter. CNA #2 stated she did not think the resident's catheter tubing was attached with an anchor or stabilizing device. On 1/12/22 at 2:15 p.m., accompanied by CNA #2 and with the resident's permission, the resident's catheter and tubing were observed. There was no anchor or stabilizing device attached to the catheter tubing. CNA #2 was interviewed at this time about an anchor device. CNA #2 stated the resident was supposed to have an anchor. CNA #2 stated she bathed the resident earlier in the morning and no device was in place. On 1/12/22 at 2:16 p.m., the registered nurse (RN #1) caring for Resident #60 was interviewed. RN #1 stated, He [Resident #60] usually has one [anchor] attached to the upper leg. RN #1 stated she did not know why the tubing was not secured. On 1/13/22 at 9:06 a.m., the licensed practical nurse (LPN #1) unit manager was interviewed about Resident #60's unsecured catheter tubing. LPN #1 stated the tubing should be secured. LPN #1 stated anchor devices were available in the supply room. Resident #60's plan of care (revised 12/27/21) documented the resident had a Foley catheter. Interventions to prevent catheter related trauma included checking tubing for kinks every shift and monitoring for signs of urinary tract infection. The Lippincott Manual of Nursing Practice 11th edition documents on page 602 concerning tubing placement with male catheterization, Make sure catheter is secured to patient's thigh and tubing is not creating traction on catheter, which will cause pain . (1) This finding was reviewed with the administrator and director of nursing on 1/13/22 at 1:50 p.m. (1) Nettina, [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2019.

Based on observation, staff interview, and facility document review, the facility staff failed to perform quality control checks for a glucometer (a device to measure blood sugar) on one of 6 units, Joy unit. A glucometer located in the medication cart had not had a quality control check since October 2021. Findings include: On 1/12/22 at 9:45 an inspection of the medication cart was conducted with LPN (licensed practical nurse) #4. A glucometer was located in the first drawer, and LPN #4 was asked when the most recent quality control had been performed. LPN #4 stated she did not know, as that was done on second or third shift. LPN #4 was then asked if there was a log for the quality control checks. She stated there was, and retrieved the book. The review revealed that the checks had been performed monthly, and the last documented quality control check was 10/21. LPN #4 stated Ill get the clinical coordinator; I'm not sure why that's the last time it was performed, but I don't know why LPN #4 then went and got LPN #3, who was the clinical coordinator. LPN #3 stated there were no residents on the unit getting blood sugar monitoring, and therefore the quality control check had not been done. LPN #3 stated the only resident with diabetes currently on the unit had a system that was checked with an application on their cell phone, but did not have routine blood sugar monitoring ordered. On 1/12/22 at 10:15 a.m. the DON (director of nursing) was informed of the above findings. The DON stated There should not even be a glucometer in the medication cart. If a resident is ordered blood sugar monitoring, they are assigned their own glucometer and quality control checks are performed and documented on their MAR (medication administration record). I have no idea why that is in the cart. Let me see what I can find out. The administrator and the DON (director of nursing) were informed of the above findings during a meeting with facility staff 1/12/22 beginning at 3:50 p.m. The DON stated After talking to staff, it seems the glucometer was in the cart in case the resident with the self-check system would need to have a blood sugar check The DON was asked if, in that case, the quality control check should be performed and up-to-date in case of an emergency, she stated Yes. No further information was provided prior to the exit conference

Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to attempt appropriate alternatives and assess for entrapment risks prior to use of bed rails for four of 28 residents in the survey sample (Residents #10, #23, #37 and #105). Residents #10 and #23 used special mattresses with bed rails without a prior assessment for bed safety. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with a re-admission on 8/9/16. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #10 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of two people for bed mobility. On 10/15/19 at 12:55 p.m., Resident #10 was seated in a Broda chair in the day area. The resident was raising up, attempting to get out of the chair unassisted. On 10/16/19 at 10:00 a.m., Resident #10's bed environment was inspected. The resident's bed had two quarter length side rails in the raised position near the head of the bed. There was a concave shaped mattress on the bed with an approximately 6-inch gap from the end of the mattress to the headboard. There was approximately a 2-inch gap from the bottom of the mattress to the bed's footboard. There was no assessment of bed safety or potential entrapment risks related to use of the concave mattress with the side rails in Resident #10's clinical record. The record documented a physician's order dated 9/5/17 for 2 half side rails @ (at) head of bed to enable self turning and positioning. The most recent side rail assessment dated [DATE] listed the resident had no altered safety awareness, no cognitive decline and required the rails to promote independence and mobility. There were no prior attempted alternatives to the rails listed on the assessment or in the clinical record. Resident #10's signed a consent form on 11/21/13 documenting the potential risks for rails had been explained but no risks were identified on the form. The record documented no bed assessment regarding the concave mattress and no other bed rail assessment since 11/21/13. Resident #10's clinical record documented the resident had a history of [REDACTED]. On 7/29/19,Resident #10's rolled out of bed onto protective floor mats resulting in a skin tear to her right arm and a knee abrasion. The concave mattress was documented in use at the time of this fall. Resident #10's had additional falls from a Broda type chair on 5/28/19, 8/26/19, 10/2/19 and 10/4/19. Resident #10's plan of care (revised 10/11/19) listed the resident was at high risk of falls due to impulsive behaviors, severe cognitive impairment, poor safety awareness, history of falls, visual impairment, auditory hallucinations/delusions and attempts to self-transfer without staff assistance. The plan documented, I (Resident #10) often make poor/un-safe decisions regarding safe mobility and transfers and do not like staff to try to educate/correct. I have impulsive Behaviors that can be difficult for staff to anticipate or re-direct to safer alternatives . Interventions listed to prevent falls included, .assure concave mattress is on bed which is a wider bed, bed in lowest position, with body pillows for positioning and now has (2) mattresses next to bed on floor to prevent injury if Res. (resident) self-transfers OOB (out of bed) . Two side rails were listed under the resident care summary as an enabler. On 10/16/19 at 1:48 p.m., the certified nurses' aide (CNA #1) routinely caring for Resident #10 was interviewed. CNA #1 stated the rails and concave mattress had been in place with the resident for an extended time. CNA #1 stated when Resident #10 was awake and alert, she was able to pull or hold the rails when care was performed. CNA #1 stated Resident #10 did not independently use the rails to sit in bed and required help from staff for turning. On 10/16/19 at 1:52 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed about bed rail assessments and bed safety. LPN #3 stated bed rail assessments were completed upon admission to see if the resident and/or responsible party wanted the rails. When asked if any re-assessment of the bed rails was completed, LPN #3 stated rails were re-assessed if the interdisciplinary team felt there was a need or if therapy made a recommendation about the rails. When asked about any assessment of Resident #10's bed rail use since 11/21/13, LPN #3 stated she did not see a recent assessment. LPN #3 stated she had no knowledge of any attempted alternatives to the bed rails. LPN #3 stated maintenance installed the concave mattress and was responsible for bed safety checks when mattresses were changed. On /10/16/19 at 2:47 p.m., the director of nursing (DON) was interviewed about assessments for bed rail safety. The DON stated all the beds in the facility were purchased after 2006 and according to the bed manufacturer, had no entrapment zones. The DON stated a gap measurement device was ordered in case specialty mattresses were used. The DON stated maintenance performed bed safety checks and again stated the beds in use in the facility did not have entrapment risks. The DON presented a letter from the bed manufacturer stating the beds with rails and mattresses were purchased by the facility in 2009. On 10/16/19 at 4:20 p.m., the maintenance supervisor (other staff #2) was interviewed about bed safety inspections. The maintenance supervisor stated he checked beds/mattresses/rails once per year. The maintenance director stated they checked to be sure the mattress and bed were in good condition and that the side rails functioned properly. The maintenance director stated he did not perform gap measurements because their bed manufacturer informed them they complied with FDA (Food and Drug Administration) bed safety guidelines when the beds were purchased. The maintenance director stated if a specialty mattress was installed, a bed safety check was supposed to be performed. On 10/16/19 at 4:32 p.m., accompanied by the maintenance supervisor, Resident #10's bed, rails and mattress were inspected. The maintenance supervisor was shown and interviewed about the approximately 6-inch gap between the mattress and the head of the bed. The maintenance supervisor identified Resident #10's bed as bed #60. The maintenance supervisor stated concerning the gap, Yes. That's a concern. The maintenance supervisor stated a safety check had not been performed on this bed with the concave mattress in place. The maintenance supervisor stated he was not aware the concave mattress had been installed and that Resident #10's bed was a wide bed and not the standard resident bed. The maintenance supervisor presented documented bed inspection records. Bed number 60 was most recently inspected in (MONTH) (YEAR) and there was no evidence the concave mattress was in place at the time of the inspection. On 10/16/19 at 4:54 p.m., the DON was interviewed again about any resident assessment regarding bed rails, the concave mattress or any attempted alternatives to the rails. The DON stated Resident #10 started using the concave mattress in (MONTH) 2019. The DON stated the concave mattress was put in place because the resident was having frequent falls. These findings were reviewed with the administrator and DON during meetings on 10/16/19 at 4:45 p.m. and 10/17/19 at 10:20 a.m. 2. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #23 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility. On 10/15/19 at 3:30 p.m., Resident #23 was in bed. Two quarter length bed rails were in the raised position near the head of the bed. An alternating air mattress was in place on the bed. Resident #23 was observed again on 10/16/19 at 10:00 a.m. and 11:00 a.m. in bed with the air mattress in place with raised bed rails. Resident #23's clinical record documented no assessment of entrapment risks related to the bed rails with the alternating air mattress or of any prior attempted alternatives to the rails. Resident #23's clinical record documented a physician's order dated 9/5/17 for 2 side rails @ (at) head of bed to enable self turning and repositioning. The was no physician's order for the air mattress but it was listed as an intervention under point of care devices for skin protection. The most recent side rail assessment was dated 12/23/13 and listed the resident had no altered safety awareness, no cognitive decline, had a history of [REDACTED]. This form made no mention of any risks associated with the resident's use of bed rails and stated the resident required the rails to promote independence and to provide safety. There were no attempt alternatives to side rails listed on the assessment or in the clinical record. A consent form signed by the resident on 12/23/13 documented the potential risks for rails had been explained but no risks of the rails were identified or listed on the form. The record documented no bed assessment regarding the air mattress and no other bed rail assessment since 12/23/13. Resident #23's plan of care listed the resident had impaired decision-making, impaired vision and was at risk of falls due to limited mobility, weakness and incontinence. Interventions to prevent falls included, .side rail use as needed/appropriate. Resident and POA (power of attorney) request use of 2 1/2 upper siderails for safety and to promote turning and positioning . The plan listed the air mattress as a device intervention to prevent skin breakdown. On 10/16/19 at 1:46 p.m., the certified nurses' aide (CNA #1) routinely caring for Resident #23 was interviewed. CNA #1 stated when Resident #23 was awake and alert, she was able to pull or hold the rails when care was performed. CNA #1 stated Resident #23 did not independently use the rails to sit up and required help from staff for turning in bed. On 10/16/19 at 1:52 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed about bed rail assessments and bed safety. LPN #3 stated bed rail assessments were completed upon admission to see if the resident and/or responsible party wanted the rails. LPN #3 stated rails were re-assessed if the interdisciplinary team felt there was a need or if therapy made a recommendation about the rails. When asked about any assessment regarding Resident #23's bed rails use since 12/23/13, LPN #3 stated she did not see a recent assessment. LPN #3 stated she had no knowledge of any attempted alternatives to the bed rails. LPN #3 stated maintenance installed the air mattress and was responsible for bed safety checks when mattresses were changed. On /10/16/19 at 2:47 p.m., the director of nursing (DON) was interviewed about assessments for bed rail safety. The DON stated all the beds in the facility were purchased after 2006 and according to the bed manufacturer, had no entrapment zones. The DON stated a gap measurement device was ordered in case specialty mattresses were used. The DON stated maintenance performed safety checks on beds/mattresses and again stated the beds in the facility did not have entrapment risks. The DON presented a letter from the bed manufacturer stating the beds with rails and mattresses were purchased by the facility in 2009. On 10/16/19 at 4:20 p.m., the maintenance supervisor (other staff #2) was interviewed about bed safety inspections. The maintenance supervisor stated he checked beds/mattresses/rails once per year. The maintenance director stated they checked to be sure the mattress and bed were in good condition and that the side rails functioned properly. The maintenance director stated he did not perform gap measurements because their bed manufacturer informed them they complied with FDA bed safety guidelines when the beds were purchased. The maintenance director stated if a specialty mattress was installed, a bed safety check was supposed to be performed. On 10/16/19 at 4:32 p.m., accompanied by the maintenance supervisor, Resident #23's bed, rails and mattress were inspected. The maintenance supervisor was interviewed about the air mattress in use on the bed. The maintenance supervisor stated he had not performed a bed inspection with the air mattress in place. The maintenance director stated he was not aware the air mattress was installed on the bed. The maintenance director identified Resident #23's bed and #102. The maintenance supervisor presented documented bed inspection records. Bed number 102 was most recently inspected in (MONTH) (YEAR) and there was no documentation the air mattress was in place at the time of the inspection. On 10/16/19 at 4:54 p.m., the DON stated Resident #23's air mattress had been in use since (MONTH) 2019. These findings were reviewed with the administrator and DON during meetings on 10/16/19 at 4:45 p.m. and 10/17/19 at 10:20 a.m. 3. Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #105 with moderately impaired cognitive skills and to require the extensive assistance of one person for bed mobility. On 10/15/19 at 3:30 p.m., Resident #105 was observed in bed with two quarter length bed rails in the raised position near the head of the bed. The resident was observed in bed again with raised side rails on 10/16/19 at 7:53 a.m. Resident #105's clinical record documented no assessment for entrapment risks related to use of the bed rails and no prior attempted alternatives to the bed rails. Resident #105's clinical record documented a physician's order dated 4/24/18 for, 2 half side rail @ (at) head of bed to enable self turning and repositioning. The most recent side rail assessment was dated 4/1/09 and listed the resident had no altered safety awareness, no cognitive decline and no history of falls. This form made no mention of any risks associated with the resident's use of bed rails and stated the resident required the rails to promote independence and to provide safety. There were no attempt alternatives to side rails listed on the assessment or in the clinical record. The resident/family signed a consent form on 1/21/09 documenting the potential risks for the rails had been explained but no risks were identified on the form. The record documented no bed rail assessment since 4/1/09. Resident #105's plan of care (revised 9/26/19) listed in the resident care summary that the resident used two-half length side rails at the head of the bed as an enabler. On 10/16/19 at 1:45 p.m., the certified nurses' aide (CNA #1) routinely caring for Resident #105 was interviewed. CNA #1 stated the resident was able to use the rails to turn partially in bed. On 10/16/19 at 1:52 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed about bed rail assessments and bed safety. LPN #3 stated bed rail assessments were completed upon admission to see if the resident and/or responsible party wanted the rails. LPN #3 stated rails were re-assessed if the interdisciplinary team felt there was a need or if therapy made a recommendation about the rails. When asked about any assessment regarding Resident #105's bed rails use since 4/1/09, LPN #3 stated she did not see a recent assessment. LPN #3 stated she had no knowledge of any attempted alternatives to the bed rails. LPN #3 stated Resident #105 was able to use the rails to turn in bed. On /10/16/19 at 2:47 p.m., the director of nursing (DON) was interviewed about assessments for bed rail safety. The DON stated all the beds in the facility were purchased after 2006 and according to the bed manufacturer, had no entrapment zones. The DON stated a gap measurement device was ordered in case specialty mattresses were used. The DON stated maintenance performed safety checks on beds/mattresses and again stated the beds in the facility did not have entrapment risks. The DON presented a letter from the bed manufacturer stating the beds with rails and mattresses were purchased by the facility in 2009. This finding was reviewed with the administrator and DON during meetings on 10/16/19 at 4:45 p.m. and 10/17/19 at 10:20 a.m. 4. Resident #37 was admitted to the facility on [DATE] with a re-admission on 10/3/19. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #37 with moderately impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 10/15/19 at 11:30 a.m., Resident #37's bed environment was inspected. The resident's bed had two quarter length side rails in the raised position near the head of the bed. Resident #37's clinical record documented no assessment for entrapment risks related to use of the bed rails and no prior attempted alternatives to bed rail use. Resident #37's clinical record documented a physician's order dated 10/3/19 for, 2 half side rails @ (at) head of bed to enable self turning and repositioning. The most recent side rail assessment was dated 5/9/16 and listed the resident had altered safety awareness due to cognitive decline, a history of falls, poor bed mobility, history of postural [MEDICAL CONDITION], poor balance/trunk control and took medications that would require increased safety precautions. This form made no mention of any risks associated with the resident's use of bed rails and did not indicate any evaluation and/or recommendation regarding the resident's use of bed rails (recommendation section was blank). There were no prior attempted alternatives to side rails listed on the assessment or in the clinical record. The resident's family member signed a consent form on 5/19/16 documenting the potential risks for rails had been explained but no risks were identified on the form. The record documented no bed rail assessment regarding entrapment risks since 5/9/16. The clinical record documented attempts by the resident to get out of bed unassisted. A nursing note dated 8/16/19 documented the resident was found with his legs over the bedside table, attempting to get out of bed. An additional note on 10/4/19 documented the resident was disoriented and attempting to climb out of his chair unassisted and was not responsive to re-direction. Resident #37's plan of care (revised 10/3/19) listed the resident was at risk of falls due to impaired decision-making skills and a history of falls. Interventions for fall/injury prevention included, .siderail use as needed/appropriate. Resident and POA request use of 2 1/2 upper siderails for safety and to promote turning and positioning while in bed and to be able to position self by using the controls . On 10/16/19 at 1:49 p.m., the certified nurses' aide (CNA #1) routinely caring for Resident #37 was interviewed. CNA #1 stated the resident used the bed rails when turning or repositioning in bed but required assistance from staff with bed mobility. On 10/16/19 at 1:52 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed about bed rail assessments and bed safety. LPN #3 stated bed rail assessments were completed upon admission to see if the resident and/or responsible party wanted the rails. LPN #3 stated rails were re-assessed if the interdisciplinary team felt there was a need or if therapy made a recommendation about the rails. When asked about any assessment regarding Resident #37's bed rails use since 5/9/16, LPN #3 stated she did not see a recent assessment. LPN #3 stated she had no knowledge of any attempted alternatives to the bed rails. LPN #3 stated Resident #37 was able to hold the rails when staff assisted him with bed mobility. On /10/16/19 at 2:47 p.m., the director of nursing (DON) was interviewed about assessments for bed rail safety. The DON stated all the beds in the facility were purchased after 2006 and according to the bed manufacturer, had no entrapment zones. The DON stated a gap measurement device was ordered in case specialty mattresses were used. The DON stated maintenance performed safety checks on beds/mattresses and again stated the beds in the facility did not have entrapment risks. The DON presented a letter from the bed manufacturer stating the beds with rails and mattresses were purchased by the facility in 2009. This finding was reviewed with the administrator and DON during meetings on 10/16/19 at 4:45 p.m. and 10/17/19 at 10:20 a.m.

Based on a medication pass and pour observation, staff interview, a Facility Reported Incident review and clinical record review, the facility staff failed to ensure one of 25 residents in the survey sample was free from a significant medication error Resident #22. Resident #22 was administered 100 units of [MEDICATION NAME] instead of the physician's orders [REDACTED]. On 5/7/14, the facility staff also failed to verify the order on the eMAR (electronic medication administration record) prior to administering insulin to Resident #16. Resident #16 received 10 units of insulin instead of 12 units as ordered by the physician. The findings include: Resident #22 was admitted to the facility on [DATE] and discharged home on[DATE]. The admitting [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/14 was an admission assessment. The resident was assessed as a 13 for cognitive skills, no memory impairments and able to make decisions. On 5/8/14 Resident #22's electronic closed clinical record was reviewed to include the following: Nursing Note: "3/29/14 21:51 (9:51 p.m.) Resident received 100 units of [MEDICATION NAME] at HS (hour of sleep). Alert, responsive, eating, and drinking....MD (doctor) alerted and requests that resident be sent to ER..." Physician Order: "[MEDICATION NAME] 100 units: Give 10 units SQ QPM for Diabetes" (1)[MEDICATION NAME]-"Insulin [MEDICATION NAME]-treatment of [REDACTED]. Statement from the nurse administering the 100 units of insulin: "On 3/29/14 at approximately 20:45, ...seeing [MEDICATION NAME] (Insulin [MEDICATION NAME]) 100 units and drawing 100 units of [MEDICATION NAME] in the insulin syringe. I requested that co working nurse (named), look at the syringe and I told her verbally that the order stated [MEDICATION NAME] 100 units. She checked the syringe visually for that amount. I returned to the resident's room and administered the medication as listed above. After giving medications, I asked co working nurse as stated above to sign this [MEDICATION NAME] medication administration order since she visualized the syringe amount. She asked me to reread the order and we noted the medication error...Resident physician was paged...he was told of the medication error with usual medication dose and current medication dose of [MEDICATION NAME] provided...MD verbalized that this was not a resident he was closely familiar with and that because he did not know her he preferred to send her to the emergency room for assessment and monitoring. He verbalized that this medication would be active for the next 24 hrs..." Incident Report: "3/29/14 Describe Incident: Resident HS insulin dose incorrectly read and resident was administered 100 units of Insulin instead of 10 units...Co working nurse had checked insulin amount with nurse be nurses together had not checked complete order together until order co sign was completed...MD was made aware of insulin given and insulin ordered. MD did not want to monitor blood sugar closely for nest 24 hrs, he ordered transfer to ER for observation. He verbalized that due to type of insulin resident blood sugar levels would change slowly, but felt observation would be easier at hospital since she did not know this resident and her entire (sic)." History and Physical from admitting hospital: "3/29/14...Chief Complaint: Accidental overdose of [MEDICATION NAME] at skilled nursing facility...Patient apparently received accidental overdose of 100 units of [MEDICATION NAME] instead of her 10 units at bedtime. Patient was sent here for evaluation and monitoring...Hospitalist service was asked for admission to monitor this pleasant lady. In the ER, she was placed on D5 [MEDICATION NAME] Ringers." Progress Report from admitting hospital: "3/30/14 Current Complaints: Insulin Overdose in the form of [MEDICATION NAME]. Patient was given 100 units instead of 10 units...Plan: We will continue to observe her blood sugars as planned. We will keep [MEDICATION NAME] and [MEDICATION NAME] on hold. Most probable discharge will be tomorrow morning." On 5/8/14 at approximately 11:30 a.m., the nurse who administered the 100 units of [MEDICATION NAME] to the resident, a registered nurse (RN) #6 was interviewed regarding the incorrect insulin dosage. RN #6 stated, "I was working as a fill in nurse. I went to the eMAR (electronic medical records) and pulled up the resident. I read the order and thought the order said I was to give 100 units. Another nurse (named), was standing there getting ready to enter another resident's room; she was standing at the doorway. I verbalized the order to her and showed her the syringe. I pulled up the order and I wasn't paying attention, I didn't have the red part sitting on the order. I clicked above the order (nurse showed this Surveyor on the computer) see, and it did not bring up the entire order, it only showed this part, (pointing to the computer screen) which read '[MEDICATION NAME] 100 units.' When I went back in and opened the order and clicked on the order, I realized what happened when I went to sign the medication as given, I immediately called the doctor (sic)." RN #6 was asked if the co-signing nurse held the syringe in her hand or if she held the syringe for the co-signing nurse, RN #6 stated that the nurse was already gloved and gowned to enter another resident's room, "so I am pretty sure I held it and she, co-signing nurse, visualized it that way. She did not do anything wrong; she trusted what I told her and that's what I told, director of nursing (named), when I called her." On 5/8/14 at approximately 11:40 a.m., the Quality Assurance Nurse, who was a registered nurse, RN #7, was interviewed regarding the above incident. RN #7 stated that after the incident memos were sent out on insulin orders and an incident form was filled out. RN #7 also presented to this Surveyor a "Quality Assurance Performance Improvement Report," to include the following: "3/29/14 Concern: Insulin Orders and Administration Error... Cause/Effect: Based on the medication error the staff failed to administer the correct dosage of insulin. The strength of the insulin was given as the dosage amount due to staff not reading the complete order. Nurse co-signing the administration of the insulin failed to verify the complete order and verified only the amount that the administrating nurse stated was to be given. Actions: Charge Nurses were re-educated on the 5 rights to safe medication administration. Drug medication pass observed by staff education coordinator. DON and QAPI completed the investigation of the incident with appropriate documentation and incident was reported to state authorities. Staff education including all nurses and Nursing Supervisors, via memo from the DON regarding Insulin orders and Administration. All insulin orders where rechecked for compliance with the new insulin order and administration memo. Status: Nursing facility named Insulin orders are written in our computer system in a new format; Insulin strength is not to be written in the orders since all insulin is labeled as 100 units/ml. This is done so as not to confuse strength with dosage to be given. New order format to be posted on each floor as part of staff education. Staff will read the complete order on the e-MAR when administering insulin and for sliding scale insulin. Improved /Resolved: 5/1/14 No insulin errors since new procedure implemented. No insulin order discrepancies found when orders written in our computer system. No insulin administration errors have been found since staff reeducated. On 5/8/14 at approximately 11:45 a.m., RN #7 was made aware of the medication pass and pour observation on 5/7/14 at approximately 8:15 a.m., related to insulin administration. The medication nurse and the co-signing nurse did not verify the order on the eMAR to ensure Resident #16 received insulin as ordered by the physician. Staff were observed giving 10 units of insulin instead of 12 units as ordered. The box that the [MEDICATION NAME] was housed read "[MEDICATION NAME] 10 units subcutaneously in the morning for DM (diabetes mellitus)." On 5/7/14 at approximately 9:30 a.m., a physician order [REDACTED]." On 5/8/14 at approximately 2:00 p.m., the administrator, director of nursing and the nursing supervisors from Units 1, 2 and 3 were made aware of the above findings. Cross reference to F 332 Reference Beatrice B. Turkoski; Brenda R. Lance and Mark F. Bonfiglio; Drug Information Handbook for Nursing; 8th edition; Lexi-Comp 2007 page 655.

Based on staff interview, resident interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure that one resident (Residents # 1) was free of a significant medication error, which resulted in Resident # 1 being hospitalized . Resident # 1 shared a room at the facility with Resident # 2. On 12/16/2010, Resident # 1 was administered medication that belonged to her roommate (Resident # 2). As a result, Resident # 1 suffered an extremely low blood pressure and a weak pulse rate. Resident # 1 was subsequently sent to the emergency department where she was admitted . Resident # 1 remained in the hospital until 12/19/2010, at which time she was discharged from the hospital and readmitted to the facility. Findings include: Resident # 1 was admitted to the facility originally on 11/03/04, with the most current readmission on 12/19/10. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) dated 03/04/11, was a quarterly assessment. Resident # 1 was assessed as having a cognitive score of 12, which indicates the resident is cognitively intact. Resident # 1 was also coded as requiring limited assistance for most ADL's (activities of daily living) with the physical assistance of one staff member. This was a complaint investigation and this is a complaint deficiency. The complainant alleged that Resident # 1 received the wrong medications, suffered a very low blood pressure and pulse, which resulted the resident being sent to the hospital for evaluation and subsequently hospitalized for [REDACTED]. The FRI's (facility reported incidents) were reviewed. A "FRI" dated 12/16/10 documented, "...Residents involved: (Name of Resident # 1) and (Name of Resident # 2) Injuries: YES Medications...switched in error. Blood pressure dangerously low of (Name of Resident # 1) as a result. Transferred to hospital...Nurse (Name of LPN {Licensed Practical Nurse} # 1) not focused... medications...wrongfully administered Resident # 1's BP (blood pressure) went dangerously low to 60/30 & pulse was weak, cool, clammy, & lethargic...order to send to E.R. (emergency room )...Name and Title of Reporting Person: Name of DON (Director of Nursing)." Resident # 1's clinical record was reviewed and revealed a nursing note dated 12/16/10, which documented: "11am Res. (resident) c/o (complained of) nausea, abd (abdominal) pain. Res. diaphortic (sic), pale at present. BP 60/30, T (temperature) 96.7 at present. May have received: [MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] 80 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 0.5 mg. Spoke to Dr. (Name of physician) to send (sic) to ER for eval. (evaluation). Spoke with...daughter regarding...signature of LPN # 1" On 05/25/11 at approximately 9:00 a.m., the facility's investigation regarding the significant medication error for Resident # 1 was requested. The facility's investigation was presented and reviewed. At approximately 10:10 a.m., LPN # 2 (3rd floor Unit Manager) was interviewed in the presence of the survey team regarding the significant medication error that occurred with Resident # 1 on 12/16/2010. LPN # 2 verbalized that it happened in the morning and wasn't sure on the exact time and then requested to look at the report (the facility investigation) to refresh her memory. LPN # 2 then stated that it was about 9:45 a.m. when LPN # 1 came in (to the nursing station) and said, "I think I may have switched meds..." LPN # 2 was asked what her thoughts were, on how this type and degree of error could have occurred. LPN # 2 stated that she could not determine how the error occurred, but did verbalized that Resident # 1 had expressed concern to LPN # 1 regarding the color of the medication mixture (medications were crushed) and voiced that it was a different color (red) than it usually was. LPN # 2 then stated that at approximately 11:00 a.m. the resident's BP and pulse were down and weak and that the resident complained of feeling bad; the resident was alert, but lethargic. LPN # 2 then voiced that the resident was sent out to the ER at that time. On 05/25/11 at approximately 2:45 p.m. LPN # 1 was interviewed regarding this incident. LPN # 1 stated that she came in about 6:30 a.m. and was scheduled to work a 16 hour shift. LPN # 1 voiced that Resident # 1 and Resident # 2 were her last two residents to administer medications. She (LPN # 1) verbalized that she opened up the MAR (medication administration) book and was on the wrong MAR and then pulled the wrong pills. LPN # 1 stated, "...I'm thinking it's (first name of Resident # 1's) (medications), when in fact it was (first name of Resident # 2's)...signed off, crushed, walked in, still in my mind giving (first name of Resident # 1) her meds...ran out of applesauce (first name of Resident # 1) asked what was the red in her meds...I told her it was strawberry yogurt and explained running out of applesauce...then she (Resident # 1) said "ok" and took the meds...Her questioning me made me think...locked the med cart and went straight to (first name of) LPN # 2...told her I may have gave wrong meds..." LPN # 1 then voiced that LPN # 2 told her to watch the resident; approximatley 15 minutes later the resident was observed in the hallway and looked very sleepy, the resident was then laid down and the Nurse Supervisor (was notified and was requested to come see the resident) came to look at Resident # 1. LPN # 1 verbalized that we (staff) couldn't get a BP on her with the electronic blood pressure machine, so we did it manually and it was "really low", at that time the physician and daughter were informed and we got an order to send her to the ER. LPN # 1 then stated that, I gave Resident # 2 medications first, which belonged to Resident # 1, and then gave Resident # 1 medications that belonged to Resident # 2. LPN # 1 voiced that she could not explain what happened or how the error occurred. LPN # 1 expressed that she did not feel distracted and just could not explain it, but when she went to give those medications it was in her mind (LPN # 1's mind) that she was giving Resident # 1 her medicine (the right medicine). LPN # 1 was asked if she had used the 5 rights of medication administration; LPN # 1 voiced yes and stated that she always double checks everything and could not explain the error, and expressed remorse for Resident # 1 having to experience this. On 05/25/11 at approximatley 4:37 p.m., the administrator and DON were made aware in a meeting with the survey team of the concerns regarding the seriousness of this medication error, which resulted in Resident # 1 being hospitalized . The facility's policy on medication administration was requested at this time. On 05/26/11 at approximately 8:55 a.m., Resident # 1 was interviewed. Resident # 1 voiced not remembering a whole lot about that particular day, but did remember it. Resident # 1 stated that she didn't know who she was and that staff told her she was going to the hospital and that she thought she was going to die. Resident # 1 remembered who administered the medications to her and called LPN # 1 by name. Resident # 1 voiced that she knew that LPN #1 didn't do it intentionally. Resident # 1 was asked if she felt anything contributed to the error. Resident # 1 could not determine what happened that day, but did voice that "sometimes" the nurses are "loose." When asked what that meant, Resident # 1 voiced that the nurses will be discussing things that happened the day before (not particularly that day or that nurse-LPN # 1) or will be discussing their children or other things are going on and that those things can be a distraction. Resident # 1 shared that she was a retired RN (Registered Nurse) and had been a nurse for many years and realized that things happen. Resident # 1 also expressed that she was grateful that she recovered. On 05/26/11 at approximatley 10:30 a.m., the administrator and DON were again made aware of concerns regarding the medication error that occurred with Resident # 1. The DON voiced that "we" (the facility) can't do anything else...LPN # 1 could have easily denied, but didn't and "we" applaud her honesty. The DON further voiced that she felt "they" (the facility) had taken proper action with LPN # 1." The facility's policy was reviewed and documented: "PURPOSE 1. To administer medications to the residents as ordered by the physician. 2. To administer medications accurately, e.g. give the RIGHT medication in the RIGHT dose, to the RIGHT resident, at the RIGHT time by the RIGHT route, using the RIGHT technique...MINIMIZE INTERRUPTIONS 6. Discourage interruptions while administering medications...7. Identify the resident a. Check identification band on wrist with name on the Medex sheet b. Call resident by name and listen for response c. Match photograph on Medex sheet with face of resident...QUESTIONS 45. ...A prudent nurse questions and confirms accuracy of drug orders whenever there is an element of doubt...46. Accountability for administration of drugs centers on the licensed nurse..." No further information or documentation was provided prior to the exit conference on 05/26/11. This is a complaint deficiency.