Every finding on record at Bridgewater Park Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure staff hired in the position of Dietary Manager had obtained the required qualifications to serve as Dietary Manager of the facility.Findings include: During an interview on 3/2/2026 beginning at 9:22 AM, Staff A, Dietary Manager, stated he was employed by the facility as the Dietary Manager. Review of personnel records for Staff A, Dietary Manager, revealed the Dietary Manager had high school education and had worked as the facility Dietary Manager since September 2025. Staff A's records did not show documentation indicating Staff A had completed a course of study in food safety and management by no later than October 1, 2023.During interview on 3/3/2026 beginning at 12:13 PM, Staff A, Dietary Manager, stated that he was not qualified as a Certified Dietary Manager. He stated that he had no other certifications or credentials related to kitchen management. He confirmed that he had obtained a high school diploma and had worked as a Dietary Manager in another state.During an interview on 3/3/2026 at 1:50 PM, the Administrator confirmed Staff A had not yet completed a course of study in food safety and management.Review of the job description titled Director of Dining and Nutrition Services with review/revision date of 8/10/2020, and signed by Staff A, Dietary Manager, on 9/15/2025 read, Minimum Qualifications/Requirements: Must meet one of the following criteria, as defined by federal regulation, or be willing to complete these requirements within a defined timeframe: A certified dietary manager; or A certified food service manager; or Has similar national certification for food service management and safety from a national certifying body; or Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. Food and Nutrition Directors hired prior to November 28, 2016 will meet the above requirements no later than 5 years after November 28, 2016. Food and Nutrition Directors hired after November 28, 2016 will meet the above requirements no later than 1 year after November 28, 2016.

Based on observation, interview, and record review, the facility failed to ensure staff dated the wound dressing for 1 of 2 residents reviewed for skin integrity (Resident #15), failed to ensure physician-ordered weights were obtained for 1 of 6 residents reviewed for medication management (Resident #15), and failed to ensure staff followed physician-ordered parameters for administering blood glucose medications for 1 of 6 residents reviewed for medication management (Resident #66).Findings include:1) During an observation on 3/2/2026 at 9:14 AM, Resident #15's left shin wound was covered with a bandage. There was no date on the dressing.Review of Resident #15's physician order dated 2/3/2026 read, Cleanse left lower shin skin tear with NS [normal saline], place one single layer xeroform, cover with dry dressing one time a day for skin tear.During an observation on 3/4/2026 at 11:12 AM, Resident #15's left shin wound was covered with a bandage. There was no date on the dressing.During an interview on 3/4/2026 at 12:15 PM, the Assistant Director of Nursing (ADON) confirmed that the dressing had no date. The ADON followed up with Staff O, Licensed Practical Nurse (LPN), who reported that the dressing had been changed that day, but was not dated. The ADON stated that wound dressings should always be dated.During an interview on 3/4/2026 at 2:14 PM, Staff O, LPN, stated that she had changed the dressing as ordered, but must have overlooked placing the date on the dressing and acknowledged that the dressing should have been dated.During an interview on 3/4/2026 at 3:29 PM, Staff P, LPN, stated that Staff E, Registered Nurse (RN), had completed the dressing change on that date [3/2/2026], and had not documented a date on the dressing.Review of the facility policy and procedure titled Clean Dressing Change Policy with the last review date of 12/23/2025 read, Policy Explanation and Compliance Guidelines: 16. Secure dressing. [NAME] with initials and date. (Add time of dressing is more than once daily.)2) Review of Resident #15's physician order dated 2/3/2026 read, Obtain weight daily for CHF [Congestive Heart Failure] in the morning. Notify physician of gain of more than 5 lbs [pounds] or loss of 3 lbs.Review of Resident #15's Weights and Vitals Summary showed no weights were documented on 2/5/2026, 2/6/2026, 2/8/2026, 2/11/2026, 2/16/2026, 2/18/2026, 2/20/2026, 2/21/2026, 2/27/2026, and 2/28/2026.During an interview on 3/4/2026 at 12:45 PM, the Director of Nursing (DON) stated, There are multiple dates when weights are not obtained or documented. My expectation is that staff follow physician orders and obtain daily weights as ordered.3) Review of Resident #66's physician orders dated 2/1/2026, 2/11/2026, and 2/24/2026 read, Humalog Solution 100 unit/ml [milliliter] (Insulin Lispro (human)), Inject as per sliding scale: if 0-69, Give Carb Replacement and call the on call MD/NP [Medical Doctor/Nurse Practitioner]. Recheck in 30 minutes; 70-149, No insulin coverage required; 150-200= 2 units, inject 2 units subcutaneous; 201-250= 4 units, inject 4 units subcutaneous; 251-300= 6 units, inject 6 units subcutaneous; 301-350= 8 units, inject 8 units subcutaneous; Recheck in 30 minutes; 351-399= 10 units, inject 10 units subcutaneous; Recheck in 30 minutes; 400+ Call the MD/NP, subcutaneously before meals for diabetes.Review of Resident #66's MAR for February 2016 for administration of Humalog Solution 100 unit/ml with the Start Date of 2/2/2026 at 6:30 AM and discontinuation date of 2/5/2026 at 3:41 PM showed the blood sugar level documented as 323 mg/dL [milligram/deciliter] on 2/3/2026 at 11:28 AM, and 353 mg/dL on 2/5/2026 at 1:56 PM.Review of Resident #66's MAR for February 2016 for administration of Humalog Solution 100 unit/ml with the Start Date of 2/5/2026 at 5:00 PM and discontinuation date of 2/20/2026 at 12:23 AM showed the blood sugar level documented as 373 mg/dL on 2/7/2026 at 4:14 PM; 479 mg/dL on 2/7/2026 at 8:11 PM; 368 mg/dL on 2/9/2026 at 6:08 PM; 308 mg/dL on 2/9/2026 at 11:54 PM; 363 mg/dL on 2/10/2026 at 5:40 PM; 313 mg/dL on 2/11/2026 at 5:44 PM; 367 mg/dL on 2/12/2026 at 4:01 PM; 322 mg/dL on 2/12/2026 at 9:16 PM; and 308 mg/dL on 2/16/2026 at 9:08 PM.Review of Resident #66's MAR for February 2016 for administration of Humalog Solution 100 unit/ml with the Start Date of 2/20/2026 at 7:30 AM and discontinuation date of 3/4/2026 at 4:04 PM showed the blood sugar level documented as 351 mg/dL on 2/20/2026 at 10:44 PM; 350 mg/dL on 2/21/2026 at 11:18 AM; 66 mg/dL on 2/21/2026 at 4:04 PM; 332 mg/dL on 2/22/2026 at 11:22 AM; 320 mg/dL on 2/23/2026 at 12:10 PM; 365 mg/dL on 2/25/2026 at 12:27 PM; 343 mg/dL on 2/26/2026 at 12:15 PM; 370 mg/dL on 2/26/2026 at 4:11 PM; 321 mg/dL on 2/27/2026 at 10:58 AM; and 378 mg/dL on 2/27/2026 at 6:02 PM.Review of Resident #66's medical record showed no documentation for rechecking the blood glucose levels within 30 minutes as ordered by the physician or no documentation indicating notification of the physician on 2/3/2026, 2/5/2026, 2/7/2026, 2/9/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/16/2026, 2/20/2026, 2/21/2026, 2/22/2026, 2/23/2026, 2/25/2026, 2/26/2026, and 2/27/2026.Review of Resident #66's MAR for February 2016 for administration of Humalog Solution 100 unit/ml with the Start Date of 2/20/2026 at 7:30 AM and discontinuation date of 3/4/2026 at 4:04 PM showed the blood sugar level documented as 316 mg/dL on 3/1/2026 at 12:19 PM.During an interview on 3/5/2026 at 8:28 AM, Staff T, LPN, stated, The parameters in the physician order are not the typical parameters utilized by the facility. I was not aware that the order directed staff to recheck the resident's blood glucose and therefore did not perform the rechecks.During an interview on 3/5/2026 at 9:03 AM, Staff U, LPN, stated, I do not recall the resident. I work at the facility approximately once per month. If I did not document blood glucose recheck, it is likely that I was not aware that the physician order required the blood glucose to be rechecked.During an interview on 3/4/2026 at 1:33 PM, the DON stated, I am unable to locate documentation indicating that blood glucose levels were rechecked following the out-of-range results. I was unable to find documentation showing that the physician or provider had been notified as directed by the physician order. My expectation is that staff follow physician orders, including rechecking the resident's blood glucose and notifying the physician when blood glucose results fall outside of the ordered parameters.Review of the facility policy and procedure titled Following Physician Orders/Parameters with the last review date of 12/23/2025 read, Policy. 2) Licensed healthcare personnel will consult and follow the physician/clinician order when performing any resident procedures.

Based on record review and interview, the facility failed to monitor weights for residents who were at nutritional risk for 2 of 4 residents reviewed for weight loss (Residents #63 and #88).Findings include:1) Review of Resident #63's physician order dated 2/16/2026 read, Obtain Weight Daily x [times] 3 Days every day shift for 3 Days.Review of Resident #63's physician order dated 2/19/2026 read, Obtain weight daily x 3 days every day shift for 3 Days.Review of Resident #63's physician order dated 2/25/2026 read, Daily weights x 7 days in the morning for weight monitoring for 7 days.Review of Resident #63's Treatment Administration Record for February 2026 for obtaining weights showed no entry on 2/15/2026, code 12 (not applicable) on 2/16/2026, NA (not applicable) on 2/17/2026, and code 12 on 2/19/2026, and 2/20/2026. Review of Resident #63's Weight Summary showed weights documented as 111.4 pounds on 2/14/2026, 104.4 pounds on 2/24/2026, and 105.4 pounds on 3/3/2025. There were no other weights documented for February and March 2026. Review of Resident #63's nutrition assessment dated [DATE] read, 10. Comments: discussed at NAR [Nutritionally at Risk] meeting 2/25 [Sic.], added to daily weights. 2) Review of Resident #88's physician order dated 2/18/2026 read, Obtain Weight Daily x 3 days every day shift for 3 Days.Review of Resident #88's TAR for February 2026 for obtaining weights with the start date of 2/18/2026 showed N/A on 2/19/2026 and code 12 on 2/20/2026.Review of Resident #88's physician order dated 2/25/2026 read, Obtain weight daily x 3 days one time a day, Notify physician of gain of more than 3 lbs [pounds] in one day.Review of Resident #88's TAR for February 2026 for obtaining weights with the start date of 2/26/2026 and discontinuation date of 3/4/2026 showed no entries documented on 2/26/2026, 2/27/2026, and 2/28/2026. Review of Resident #88s Weight Summary showed weights documented as 119.8 pounds on 2/17/2026, 113.8 pounds on 2/24/2026, 114.2 pounds on 3/3/2026, and 113.4 pounds on 3/4/2026. There were no other weights documented for February and March 2026. Review of Resident #88's nutrition assessment dated [DATE] read, M. Recommendations. will monitor for wt [weight] loss and s/s [signs and symptoms] malnutrition.During an interview on 3/3/2026 at 3:15 PM, Staff D, Licensed Practical Nurse (LPN), stated, Sometimes the person who has to do the weights is not available to do them; that is why I put not applicable.During an interview on 3/4/2026 at 11:39 AM, the Director of Nursing stated, One hundred percent the weights for [names of Resident #63 and Resident #88] were not done. The floor staff did not pick up on doing the weights.Review of the facility policy and procedure titled Weight Monitoring with the last review date of 12/23/2025 read, Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.

Based on observation, record review, and interview, the facility failed to ensure residents received oxygen as ordered by physician for 1 of 4 residents reviewed for oxygen therapy (Resident #106).Findings include:During an observation on 3/2/2026 at 9:34 AM, Resident #106 was sitting in her wheelchair in her room. No oxygen was being administered. There was a portable oxygen concentrator in the room against the wall near the door.During an interview on 3/2/2026 at 9:34 AM, Resident #106 stated, The concentrator is not mine. It was in the room when I first arrived.During an observation on 3/2/2026 at 2:37 PM, Resident #106 was participating in therapy, with no oxygen being administered at the time of observation.During an observation on 3/3/2026 at 8:24 AM, Resident #106 was sitting up in bed. No oxygen was being administered and there was no portable oxygen concentrator in the resident's room.During an observation on 3/3/2026 at 2:13 PM, Resident #106 was in bed. There was no oxygen being administered and no oxygen concentrator in the resident's room.During an interview on 3/3/2026 at 2:13 PM, Resident #106 stated, They took the oxygen machine this morning. They cannot make up their mind if I need oxygen or not. I have COPD [Chronic Obstructive Pulmonary Disease], asthma and shortness of breath. The staff will come measure my oxygen on my finger and if I need the oxygen, they will go ahead and put it on.Review of Resident #106's physician order dated 2/24/2026 read, Oxygen order 2L [liter].During an interview on 3/3/2026 at 2:15 PM, Staff F, Licensed Practical Nurse (LPN), stated, [Resident #106's name] has an order for oxygen at 2 liters. When asked if this is for continuous or as needed administration, Staff F stated, I do not know. I would have to find out.During an observation on 3/3/2026 at 2:15 PM, Staff F, LPN, confirmed Resident #106 was not being administered oxygen at this time and did not have a portable oxygen concentrator in her room.During an interview on 3/4/2026 at approximately 9:10 AM, Staff E, Registered Nurse (RN), (staff member who wrote the order in the system] stated, To me, the order means oxygen to be continuously administered. If it was prn [as needed] it would be included in the order.During an interview on 3/4/2026 at 9:19 AM, the Director of Nursing (DON) stated, The order would need to specify if the oxygen is continuous or prn. If this is not part of the order, the nurse should clarify the order. The nurses are expected to follow MD [Medical Doctor] orders.Review of the facility policy and procedure titled Oxygen Administration with the last review date of 12/23/2025 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication order had limit in duration and was clinically appropriate for 1 of 5 residents reviewed for unnecessary medications (Resident #10).Findings include:Review of Resident #10's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include generalized anxiety disorder, and mild single episode major depressive disorder.Review of Resident #10's physician order dated 2/23/2026 read, Alprazolam Oral Tablet 0.25 mg [milligram] (Alprazolam), Give 1 tablet by mouth every 24 hours as needed for anxiety. The order reflected a start date of 2/23/2026 with an indefinite end date.Review of Resident #10's Medication Administration Record for February 2026 and March 2026 for administration of Alprazolam showed the resident was administered the medication on 2/23/2026 at 1:41 PM, 2/28/2026 at 12:53 PM, and 3/3/2026 at 2:11 AM.During an interview on 3/3/2026 at 1:07 PM, the Director of Nursing (DON) stated that the medication order for Alprazolam should have included an end date of 14 days from the start date and that an indefinite end date was not acceptable.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles in 2 of 4 units.Findings include: 1) During an observation on 3/2/2026 at 10:14 AM, Resident #134 was not in his room. There was an intravenous infusion pole in the room with an infusion bag of Daptomycin connected to the intravenous tubing that was not labeled with time and date (Photographic evidence obtained). During an observation on 3/2/2026 at 10:45 AM, Staff D, Licensed Practical Nurse (LPN), confirmed the intravenous infusion bag nor the intravenous tubing were labeled with time and date. Review of Resident #134's physician order dated 2/26/2026 read, Daptomycin Intravenous Solution Reconstituted 500 MG [milligram] (Daptomycin), Use 1000 mg intravenously one time a day for MRSA [Methicillin-resistant Staphylococcus aureus] (wound in back) until 3/16/2026 23:59 [11:59 PM]. During an interview on 3/2/2026 at 10:45 AM, Staff D, LPN, stated, The tubing needs to be dated. I do not see a date on this tubing. It had to be hung yesterday. During an interview on 3/4/2026 at 11:25 AM, the Director of Nursing stated, Intravenous tubing should be dated and changed every 24 hours. Review of the facility policy and procedure titled Intravenous Therapy with the last review date of 12/23/2025 read, Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines: 5. All IV tubing is to be labeled with date, time and initials. 2) During an observation on 3/2/2026 at 10:48 AM, there was one plastic bottle of Nystatin 100,000 units powder on the dresser in Resident #78's room. The bottle was labeled with the name of Resident #112 (Photographic evidence obtained). During an interview on 3/2/2026 at 11:06 AM, Resident #78 stated, I sweat under my breasts and I put the powder there. When asked if she puts the powder under her breasts, Resident #78 stated, No aides put the powder in places where I sweat During an interview on 3/4/2025 at 1:20 PM, the Director of Nursing (DON) confirmed Nystatin powder in Resident 78's room with Resident 112's name on it. The DON confirmed Nystatin should not have been in Resident #78's room and used on Resident #78 and stated, I will be looking into this. During an interview on 3/5/2026 at 11:13 AM, Staff J, LPN stated, [Resident #78's name] does not have any current order for Nystatin. During an interview on 3/5/2025 at 11:15 AM, Staff S, Certified Nurse Assistant (CNA), stated If the resident has a complaint about sweating and wants to use something for a rash or sweating, I notify the nurse and follow her instructions. During an interview on 3/5/2026 at 11:20 AM, Staff R, CNA, stated, I only use baby powder for [Resident #78's name) when she complains of sweating under breasts and abdominal area. Review of the facility policy and procedure titled Medication Storage with the last review date of 12/23/2025 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts. cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments.

Based on record review and interview, the facility failed to ensure residents Minimum Data Set (MDS) assessments were accurate for 1 of 3 residents reviewed for behavioral health (Resident #131).Findings include:Review of Resident #131's admission record showed the resident was admitted on [DATE] with diagnoses to include major depressive disorder (onset date of 2/20/2026).Review of Resident #131's admission MDS dated [DATE] did not show depression documented as a diagnosis under Section I. Active Diagnoses.Review of Resident #131's physician order dated 2/20/2026 read, Bupropion HCl [Hydrochloride] ER [Extended Release] Tablet Extended Release 24-hour 300 mg [milligram], Give 1 tablet by mouth one time a day for depression.Review of Resident #131's physician order dated 2/21/2026 read, Sertraline HCl 100 mg Tablet, Give 2 tablet by mouth one time a day for depression.Review of Resident #131's Medication Administration Record (MAR) for February 2026 for administration of Bupropion showed the medication was administered from 2/21/2026 through 2/28/2026.Review of Resident #131's MAR for February 2026 for administration of Sertraline showed the medication was administered from 2/21/2026 through 2/28/2026.Review of Resident #131's Psychiatry admission Note dated 2/23/2026 read, Chief Complaint: Depression. History of Present Illness: The patient is a [age of Resident #131] female with a past neuropsychiatric hx [history] of dementia and depression.During an interview on 3/4/2026 at 9:20 AM, Staff W, MDS Coordinator Licensed Practical Nurse, stated, [Resident #131's name] had a diagnosis of depression in the system as of 2/20 [2/20/2026] and the MDS will need to be corrected.During an interview on 3/5/2026 at 10:05 AM, the Director of Nursing stated, The facility does not have a policy for MDS. The facility follows the RAI [Resident Assessment Instrument].

Based on record review and interview, the facility failed to coordinate Preadmission Screening and Resident Review (PASRR) for the residents with newly evident or possible serious mental disorder for 3 of 7 residents reviewed for PASRR (Residents #7, #10, and #131).Findings include: 1) Review of Resident #7's admission record showed the resident was admitted on [DATE] with diagnoses to include delusional disorders (onset date of 7/24/2025); unspecified dementia, unspecified severity, with other behavioral disturbance (onset date of 5/16/2025); and mild cognitive impairment of uncertain or unknown etiology (onset date of 5/16/2025). Review of Resident #7's Level I PASRR dated 5/16/2025 showed no diagnosis of mental illness or suspected mental illness documented under section I. PASRR Screen Decision-Making. Further review of the PASRR read, Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following: [checked box] No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASR evaluation not required. Review of Resident #7's progress notes dated 7/24/2025 read, Chief Complaint/ Nature of Presenting Problem: Increased agitation/delusions. Review of Resident #7's progress notes dated 2/16/2026 read, Medications: Quetiapine Fumarate Oral Tablet 24 mg [milligram], 2 tablets by mouth two times a day, Give 2 tablets by mouth two times a day for delusional disorder. Active. Start Date: 02/05/2026. During an interview on 3/4/2026 at 3:00 PM, the Social Services Director stated, The initial PASRR was completed by the hospital nurse and after the resident had a change in behavior as delusional that warranted a psychotropic medication, the PASRR should have been updated. During an interview on 3/5/2026 at 8:58 AM, the Advanced Practice Registered Nurse (APRN) #3 stated, The caregiver did cite that [Resident #7's name] was seeing things that were not there while outside in the courtyard and the [Resident #7's name] was prescribed with Quetiapine, which she had taken at home. I did receive a call from the Director of Nursing asking what the supporting diagnosis for the medication is and I told her delusional. 2) Review of Resident #10's admission record showed the resident was admitted originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include generalized anxiety disorder (onset date of 1/16/2026) and major depressive disorder (onset date of 11/23/2023). Review of Resident #10's Level I PASRR dated 1/7/2026 showed no diagnosis of mental illness or suspected mental illness documented under section I. PASRR Screen Decision-Making. Further review of the PASRR read, Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following: [checked box] No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASR evaluation not required. During an interview on 3/3/2026 at 1:07 PM, the Director of Nursing (DON) stated that the PASRR should have been updated to reflect the resident's diagnoses of generalized anxiety disorder and major depressive disorder. 3) Review of Resident #131's admission record showed the resident was admitted on [DATE] with diagnoses to include cognitive communication deficit (onset date of 2/20/2026), dementia (onset date of 2/20/2026), and major depressive disorder (onset date of 2/20/2026), and Alzheimer's Disease (onset date of 2/20/2026). Review of Resident #131's PASRR dated 2/16/2026 showed no diagnosis of mental illness or suspected mental illness documented under section I. PASRR Screen Decision-Making. Further review of the PASRR read, Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following: [checked box] No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASR evaluation not required. During an interview on 3/4/2026 at 11:59 AM, the Social Services Director stated, [Resident #131's name] PASSR needs to be corrected. I am a bit confused. I was correcting them, but I was not sure if I would get in trouble if I did since it is a preadmission assessment. I typically will review the PASSR and if it needs to be corrected, I will go to our case manager, and she will correct them and I will follow up with any paper worker that is needed.

Based on record review and interview, the facility failed to ensure residents received medications as ordered by physician for 1 of 3 residents reviewed, Resident #2. Findings include: Review of Resident #2's admission record showed the resident was admitted on [DATE] with the diagnoses including muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #2's physician order dated 7/11/2024 read, Milk of Magnesia [MOM] Suspension 400 MG [milligram]/5 ML [milliliter], Give 30 ml by mouth every 12 hours as needed for constipation daily if no BM [Bowel Movement] for 2 days. Review of Resident #2's Medication Administration Record (MAR) for July 2024 showed no entries documented on 7/11/2024 through 7/18/2024 for administration of Milk of Magnesia with the start date of 7/11/2024 and discontinuation date of 7/18/2024. Review of Resident #2's physician order dated 7/11/2024 read, Bisacodyl Suppository 10 mg (Bisacodyl), Insert 1 suppository rectally every 24 hours as needed for constipation daily if MOM is not effective. Review of Resident #2's MAR for July 2024 showed no entries documented on 7/11/2024 through 7/15/2024 and on 7/17/2024 and 7/18/2024 for administration of Bisacodyl Suppository with the start date of 7/11/2024 and discontinuation date of 7/18/2024. Review of Resident #2's physician order dated 7/11/2024 read, Disposable Enema Enema 19-7 GM [gram]/118 ml (Sodium Phosphates), Insert 1 application rectally every 24 hours as needed for constipation daily if MOM is not effective. Review of Resident #2's MAR for July 2024 showed no entries documented on 7/11/2024 through 7/18/2024 for administration od Disposable Enema with the start date of 7/11/2024 and discontinuation date of 7/18/2024. Review of Resident #2's nursing progress note dated 7/16/2024 at 4:39 AM authored by Staff A, Licensed Practical Nurse (LPN), showed the resident called 911 around 2 AM and stated she needed enema and she had yet to receive it. During a telephone interview on 12/2/2024 at 10:38 AM, Resident #2 stated that the last time she had a BM was 7/7/2024 and was admitted to the facility on [DATE]. During a telephone interview on 12/2/2024 at 12:52 PM, Staff A, LPN, stated, This was the first night that I was assigned to [Resident #2's name]. She complained to me that she did not receive her enema. I told her that I would give it to her. I gave her a suppository. I just assumed that day shift had given her the Milk of Magnesia. She should have received MOM first, then the suppository or the enema. During an interview on 12/2/2024 at 12:58 PM, Staff B, LPN Supervisor, stated. [Resident #2's name] was not administered MOM on day 2 [7/13/2024] of admission when she had not had a BM and should have been with additional suppository or laxative if no BM occurred. During a telephone interview on 12/2/2024 at 1:16 P, Staff D, LPN, stated, I gave her [Resident #2] a suppository when she called 911 for constipation. I am not sure what our bowel protocol is, but we have to have physician orders and follow the orders. During an interview on 12/2/2024 at 1:30 PM, Staff E, Physician Assistant-Certified (PA-C), stated, Physician orders must be followed. No harm occurred to the resident [Resident #2]. If a resident complains of constipation or there is no documentation of a BM within 2 days of admission, physician orders should have been followed. MOM should have been administered, if no bowel movement with 24 hours after the MOM, then suppository or enema should have been given. I have been informed that morning of 7/16/2024 prior to the resident going to the hospital that an enema had been given. The resident called 911 herself. During an interview on 12/2/2024 at 2:00 PM, the Assistant Director of Nursing (ADON) stated, The MOM was not administered as ordered on 7/12/2024 and should have been with a suppository 24 hours later by 7/14/2024, then enemas. The physician would be notified if no BM after orders were followed, and the resident still did not have a BM. During an interview on 12/2/2024 at 2:20 PM, the Director of Nursing (DON) stated, MOM was not administered as ordered when constipation was identified. If the resident [Resident #2] requested an enema because she was constipated and there were orders the enema should have been given. There is no written protocol or policy related to bowel regiment but there is batch orders that is placed. The MOM nor the enema was administered as ordered. Review of the facility's policy and procedure titled Bowel Elimination Policy read, Policy: It is the policy of this facility to ensure residents receive proper treatment for constipation . Definition: Constipation - A buildup of hardened feces in the bowel that the resident cannot move naturally. Diarrhea may be a sign of a fecal impaction because only liquid material is able to pass the blockage. Fecal impaction can cause urinary difficulty from the pressure in puts on the bladder . 1. Follow specific physician orders for the resident . 4. The nurse that is notified of no bowel movement in 48 hours will give the first line of intervention for those residents who have not had a bowel movement for two day (six shifts), as ordered by physician. 5. If no results from the first intervention, an enema will be given on the next shift. If no order for enema, call physician and obtain order. Review of the facility's policy and procedure titled Following Physician Orders/Parameters read, Purpose: To administer resident care in a safe and effective manner and following physician orders and ordered parameters.

Based on observation, interview, and record review, the facility failed to ensure accuracy of the minimum data set for 1 of 4 residents reviewed for skin conditions, Resident #106. Findings include: During an observation on 9/3/2024 at 9:05 AM, Resident #106 was lying in bed, with tubular stretch net bandage with dressing on her right lower leg. During an interview on 9/3/2024 at 9:05 AM, Resident #106 stated, I came to the facility with wounds. I have one on my bottom and on my right leg. Review of Resident #106's physician order dated 8/12/2024 read, Cleanse wound to Right lower ext [extremity] with NS [Normal Saline], apply calcium alginate, medi honey and foam dressing daily, every day shift for wound. Review of Resident #106's physician order dated 8/12/2024 read, Cleanse buttock with NSS [Normal Saline Solution] apply medi honey and cover with foam dressing every day shift for buttock wound. Review of Resident #106's Minimum Data Set (MDS) titled Admission Medicare 5 day dated 8/15/2024 showed no skin condition documented under Section M- Skin Conditions. During an interview on 9/5/2024 at 11:54 AM, Staff C, MDS Coordinator, stated, I marked on my paperwork [Resident #106's name] came in with a non-healing diabetic ulcer. We had a remote MDS who coded the section incorrectly. During an interview on 9/5/2024 at 2:45 PM, the Director of Nursing stated, Facility follows the Resident Assessment Instrument (RAI) manual for the MDS process.

Based on record review and interview, the facility failed to ensure residents who were diagnosed with possible serious mental disorder were referred for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was initially admitted on [DATE] with diagnoses that included other bipolar disorder (onset date 1/2/2024). Review of Resident #38's Level I PASARR dated 12/28/2023 showed no entries in Section I- PASRR Screen Decision-Making under mental illness or suspected mental illness. Review of Resident #38's clinical records failed to show documentation Resident #38 had been referred for a Level II PASARR evaluation following the diagnosis of other bipolar disorder on 1/2/2024. During an interview on 9/6/2024 at 8:09 AM, the Director of Nursing confirmed that Resident #38 had not been referred for a Level II PASARR after she was identified with a newly evident or possible serious mental disorder. Review of the facility policy and procedure titled Behavioral Health Services implemented on 3/5/2024 read, Policy: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . Policy Explanation and Compliance Guidelines . 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will: a. Complete PASARR screening.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for PICC (Peripherally Inserted Central Catheter) access devices for 2 of 6 residents reviewed with a central venous access device (CVAD), Resident #212 and Resident #215, and for 1 of 3 residents reviewed for pain management, Resident #92. Findings include: 1) During an observation on 9/3/2024 at 9:18 AM, Resident #212's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible (Photograph evidence obtained). During an observation on 9/3/2024 at 12:02 PM, Resident #215's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible During an observation on 9/4/2024 at 12:40 PM, Resident #215's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible During an observation on 9/4/2024 at 3:45 PM, Resident #212's PICC line was visible in left upper arm. There was a transparent dressing dated 9/1/2024 over top of gauze securing PICC, and the insertion site was not visible. Review of Resident# 212's physician order with the start date of 8/26/2024 read, Change Catheter Site Dressing every week and PRN [as needed] with transparent dressing every day shift every 7 day(s) for IV [Intravenous] therapy. Review of Resident# 215's physician order with the start date of 8/23/2024 read, Change Catheter Site Dressing every week and PRN with transparent dressing every day shift every 7 day(s) for IV therapy. During an interview on 9/4/2024 at 3:45 PM, Staff A, Licensed Practical Nurse (LPN), stated, The PICC dressing kit comes with the gauze. I didn't know the dressing should be changed within 24 hours since gauze was used under the transparent dressing. During an interview on 9/4/2024 at 4:00 PM, the Infection Prevention Officer confirmed PICC line transparent dressing noted over gauze and dated 9/1/2024 and stated, The PICC line dressing should have been changed within 24 hours. Gauze cannot be left under the transparent dressing we use bio patches [antibiotic patch] so we can see the site and monitor for signs and symptoms of infection. During an interview on 9/4/2024 at 4:30 PM, the Director of Nursing stated, Our policy does not say that gauze cannot be placed on the IV site under the transparent dressing. I am not aware that the transparent dressing has to be changed again within 24 hours. Review of the facility policy and procedure titled PICC/Midline/CVAD Dressing Change dated 11/28/2023 read, Policy: It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes . Policy Explanation and Compliance Guidelines . 6. Inspect the catheter-skin junction and surrounding area, palpating through the intact dressing for redness, tenderness, swelling and drainage. Be attentive to any reports of pain, paresthesias, numbness, or tingling . 18. Apply a transparent semipermeable dressing to the insertion site. Review of Omnicare guidelines titled Central Vascular Access Device (CVAD) Dressing Change revised on January 15, 2004 read, Guidance . 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed . 2.2 Every two days . 3. Sterile gauze dressings must be occlusive and are changed . 3.2 Every two days. 46523 2) Review of Resident #92's physician order dated 7/2/2024 read, Acetaminophen Tablet 325 MG [milligram] Give 2 tablets by mouth every 4 hours as needed for pain 1-3 do not exceeded 4 gm [grams] (4000 mg) in 24 hours and give 2 tablets by mouth every 4 hours as needed for elevated temp > 100.2 [temperature higher than 100.2]. Review of Resident #92's Medication Administration Record (MAR) for August 2024 showed the resident received Acetaminophen 325 mg on 8/1/2024 at 3:24 AM for pain level of 6, 8/2/2024 at 9:49 PM for pain level 4, 8/10/2024 at 2:39 AM for pain level of 4, 8/12/2024 at 1:23 AM for pain level of 6 and at 5:36 AM for pain level of 5, 8/13/2024 at 1:32 AM for pain level of 4 and at 4:50 PM for pain level of 4, 8/15/2024 at 5:36 AM for pain level of 7 and at 11:20 PM for pain level of 4, 8/17/2024 at 12:38 AM for pain level of 4 and at 1:35 PM for pain level of 4, 8/18/2024 at 5:25 AM for pain level of 6, 8/20/2024 at 11:47 PM for pain level of 4, 8/21/2024 at 6:11 AM for pain level of 5, 8/22/2024 at 1:00 AM for pain level of 6, 8/23/2024 at 5:43 AM for pain level of 5, 8/25/2024 at 1:31 AM for pain level of 6, 8/26/2024 at 11:50 PM for pain level of 4, 8/29/2024 at 12:51 AM for pain level of 6, and 8/30/2024 at 4:57 AM for pain level of 5. Review of Resident #92's MAR for September 2024 showed the resident received Acetaminophen 325 mg on 9/4/2024 at 1:36 AM for pain level of 4. During an interview on 9/5/2024 at 3:00 PM, the Director of Nursing stated, [Resident #92's name] medication was given out of parameters. Staff are expected to follow the parameters and if pain is higher, they should contact the physician for orders. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/11/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: 1) During an observation on 9/3/2024 at 9:28 AM, Resident #264 was lying in bed. There was one bottle of lubricant eye drops on the resident's night stand. During an interview on 9/3/2024 at 9:28 AM, Resident #264 stated, I use these eye drops every day for my eyes because they will get dry. During an interview on 9/3/2024 at 10:40 AM, Staff B, Licensed Practical Nurse (LPN), stated, [Resident #264's name] does not have orders in the system for eye drops. I will take them from her and let the physician know in order for us to provide her with the eye drops she needs. The eye drops should not be in her room. 2) During an observation on 9/3/2024 at 9:33 AM, Resident #92 was eating breakfast. There was one large light yellow circular tablet near her plate. During an interview on 9/3/2024 at 9:33 AM, Resident #92 stated, The nurse brought the [antacid brand name] so that I can drink it after breakfast. I had almost forgotten I had it there. During an interview on 9/3/2024 at 10:42 AM, Staff B, LPN, stated, Yes, I gave [Resident #92's name] two [antacid brand name] one before breakfast and left one, so she would take the [antacid brand name] after breakfast. [Resident #92's name] does not have orders to self-administer medications. 3) During an observation on 9/3/2024 at 9:55 AM, Resident #266 was sitting in his wheelchair in his room. On top of his drawer, there was a vial of Albuterol next to his nebulizer machine. During an interview on 9/3/2024 at 9:55 AM, Resident #266 stated, I do breathing treatments since before coming here. The nurse will set up the machine and I will give myself the treatment. During an interview on 9/3/2024 at 10:33 AM, Staff B, LPN, stated, Yes, this is a vial of Albuterol. I came into the room and [Resident #266's name] was on the phone. I left the breathing treatment here in the room with the intention to come back and give it to him. 45576 4) During an observation on 9/3/2024 at 9:05 AM, there was one Albuterol inhaler on bedside table in Resident #212's room. During an interview on 9/3/2024 at 9:05 AM, Resident #212 stated, I use the inhaler whenever I need it maybe once or twice a day. During and observation on 9/4/2024 at 12:55 PM, there was one Albuterol inhaler on bedside table in Resident #212's room. During an observation on 9/4/2024 at 4:10 PM with the Infection Control Officer, there was one Albuterol inhaler on bedside table in Resident #212's room. During an interview on 9/4/2024 at 4:10 PM, the Infection Control Officer confirmed Resident #212's albuterol Inhaler was unsecured at the bedside. 5) During an observation on 9/3/2024 at 10:00 AM, there was one nasal spray (Phenylephrine hydrochloride 1% nasal decongestant) lying on bedside table in Resident #213's room. During an interview on 9/3/2024 at 10:00 AM, Resident #213 stated, I've been addicted to nasal spray for years. I use the spray 2 to 4 times a day. During an observation on 9/4/2024 at 4:15 PM with the Infection Control Officer, there was one nasal spray (Phenylephrine hydrochloride 1% nasal decongestant) lying on bedside table in Resident #213's room. During an interview on 9/4/2024 at 4:15 PM, the Infection Control Officer stated, No medications should be at the bedside unless the resident has been assessed for self-administration and the doctor has ordered that the medication can be self-administered. Then, the resident's medication is secured in their bedside table. During an interview on 9/5/2024 at 4:30 PM, the Director of Nursing stated, Medications cannot be at the bedside unless the resident has been assessed for self-administration of medication. The doctor has to approve and write the order for self-administration of the medication. The medications are then locked in the resident's bedside table. 49777 6) During an observation on 9/3/2024 at 9:35 AM, there were three pills in a medication cup on the bedside table in Resident #75's room. During an interview on 9/3/2024 at 9:35 AM, Resident #75 stated, It is aspirin, my probiotic and iron pill. I cannot take it on an empty stomach, so I take it after breakfast. During an interview on 9/5/2024 at 8:43 AM, with the Director of Nursing stated, Medication should not be at resident's bedside. Residents need an order for self administration of medication and an assessment of their capability. Medication would need to be stored in the first drawer which has a lock to secure medication kept in the resident's room. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/11/2024 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Policy Explanation and Compliance Guidelines. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the walk-in and reach-in coolers in the areas of the main and satellite kitchens. Findings include: During an observation while conducting the initial walk-through tour of the kitchen on 9/3/2024 at 9:06 AM with the Kitchen Manager, there were bulk raw tomatoes with the tomatoes having a black and white areas, and one opened large partially covered container of boiled eggs in the walk-in cooler. There were one container of puree food without an identifying label or date, one container of ground beef patties with no identifying label or date, two open containers of whole milk without an open date, and one container of sour cream with a use by date of 9/1/24 in the reach-in cooler in the main kitchen. There were two flats of raw shell eggs stored directly over the whole milk individual containers without a protective barrier between the shelves in the satellite kitchen reach-in cooler. During an interview on 9/3/2024 at 9:20 AM, the Kitchen Manager stated that any bad tomatoes in the walk-in cooler should have been observed and removed and the boiled egg container should have been sealed properly when stored; the unidentified pureed product was pureed bread and that the pureed bread and ground beef patties were all in the reach-in cooler without an identifying label or date; and the opened whole milk containers should have had an opened date. The Kitchen Manager confirmed that raw shell eggs were located on a shelf directly over the individual milk cartons and stated the raw shell eggs should have been stored on the bottom shelves and not directly over ready to eat/drink products. Review of the facility policy and procedure titled Food Safety Requirements implemented on 4/9/2024 read, Definitions . Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness . Policy Explanation and Compliance Guidelines . 1 . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . 3 . c . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded, and v. keeping foods covered or in tight containers. Review of the facility policy and procedure titled Leftovers last revised in February 2020 read, Procedure . 2. All foods stored for later shall be covered, labeled with the food name, and dated with the current date, as well as a use-by date, then stored appropriately.

Based on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE) while providing services to 1 of 3 residents reviewed for isolation precautions, Resident #96, to prevent the possible spread of infection and communicable disease. Findings include: During an observation on 9/5/2024 at 1:40 PM, Staff D, Dietary Aide, entered Resident #96's room with lunch tray in her hands without donning PPE. There were personal protective equipment and signage for transmission-based precaution-contact isolation posted on the door to Resident #96's room. During an interview on 9/5/2024 at 1:40 PM, Staff D, Dietary Aide, stated, I delivered tray to [Resident #96's name] room and I did not use PPE when entering the room. I should have followed the contact precaution signage. Review of Resident #96's physician order dated 8/5/2024, read, Contact precautions for c diff [Clostridioides difficile] every shift for C-Diff until 8/10/2024 23:59 [11:59 PM]. Review of Resident #96's physician order dated 8/30/2024 read, Obtain stool sample for C-Diff one time only for 2 days. Review of Resident #96's daily skilled note dated 8/31/2024, read, P. Other Information, 1. Comments . Patient to start precautions for c-diff and orders to start vancomycin 250 for 10 days. During an interview on 9/5/2024 at 3:15 PM, the Director of Nursing, stated, Staff should use the appropriate personal protection equipment required for transmission-based precautions. For Clostridium Difficile, staff should use gown, gloves, and mask. If wound care or risk for fluid contact, a face shield should be used. During an interview on 9/6/2024 at 10:10 AM, the Director of Nursing stated, If a resident is suspect for C Diff, we place resident in transmission-based precautions- Contact Precaution while awaiting stool culture results. [Resident #96's name] should have had contact precautions in the system. Review of the facility policy and procedure titled Management of C. Difficile Infection with the last review date of 1/11/2024 read, Policy: This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C. Difficile) infections . Policy Explanation and Compliance Guidelines . 5. General principles related to contact precautions for C. difficile: a. All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for resident with C. difficile infection.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 3 of 4 Halls in the rooms of Resident #41, Resident #55, Resident #324, and Resident #164 (Photographic evidence obtained). Findings include: 1. During an observation of Resident #55's room on 5/1/2023 at 9:53AM, there was an Aluterol Inhaler on top of the resident's bedside table. No nursing staff was present in the room. Review of Resident #55's physician orders revealed no orders for self-administration of medications. During an interview on 5/1/2023 at 9:53 AM, Resident #55 stated, The nurse left the inhaler here but will be right back to pick it up. 2. During an observation of Resident #324's room on 5/1/2023 at 10:07 AM, there were one opened bottle of Nystatin topical powder and Timolol Maleate Ophthalmic Solution 0.5% (eye drops) on the resident's bedside table. During an interview on 5/1/2023 at 10:07 AM, Resident #324 stated, Those medications are mine. I administer them myself. I have administered them for over 3 years now. Review of Resident #324's physician orders revealed no orders for self-administration of medications. During an interview on 5/2/2023 at 1:25 PM, the Director of Nursing stated, I was aware [Resident #55's name] inhaler was left in the room. The nurse told me. [Resident #55's name] does not have a self-administration order. [Resident #324's name] does not have a self-administration order. When residents are admitted , if they bring medication, nurse calls the doctor and gets approval for those medications. If the resident can self-administer, the medication will be kept in top drawer and key will be provided. Prior to the resident being allowed to self-administer, the nurse will do a self-administration assessment and demonstration will be required. This will all be documented in the system. 46288 2. During an observation of Resident #41's room on 5/1/2023 at 9:18 AM, there was Clotrimazole Betamethasone Dipropionate Cream 1%/ 0.05% on the resident's TV stand. Review of Resident #41's care plan revealed no documentation that the resident could self-administer medications. During an interview on 5/3/2023 at 8:42 AM, Staff C, Licensed Practical Nurse (LPN), stated, [Resident #41] is not supposed to have medications at her bedside. There is no care plan for medication at her bedside. During an interview on 5/3/2023 at 9:48 AM, the Director of Nursing stated, My expectation is that no medications are to be left at the bedside unless there is a physician order and a care plan stating that it is the resident's preference to administer their own medication. All meds should be kept in a lock box when the resident is done with it. 15234 3. During an observation of Resident #164's room on 5/1/2023 at 10:21 AM, there was an opened Menthol and [NAME] Oxide Ointment with the prescription label stored on Resident #164's dresser. There were no facility staff in the room. Review of Resident #164's care plan, initiated on 3/20/2023, did not reveal any documentation that Resident #164 had been assessed as able to safely self-administer medications. During an interview on 5/3/2023 at 9:25 AM, Staff A, Registered Nurse (RN), confirmed that medications should be returned to and stored in the medication room after use. During an interview on 5/3/2023 at 10:40 AM, the Director of Nursing stated that she was aware the topical medication stored on Resident #164's dresser in his room was prescribed at another facility. She stated she believed Resident #164's spouse brought the topical ointment into the facility. Review of the facility policy and procedure titled Guidelines For Medication Storage and Labeling last reviewed on 2/9/2023 read, Purpose: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. General Guidelines: 1. Medications and biological in medication rooms, carts, and refrigerators are maintained within: a. Secured (locked) locations, accessible only to designated staff.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 7 residents reviewed for oxygen administration, Residents #62, #68, and #265 (Photographic evidence obtained). Findings include: 1. During an observation on 5/1/2023 at 1:00 PM, Resident #68 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 3.5 liters per minute. During an observation on 5/2/2023 at 8:14 AM, Resident #68 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 3 liters per minute. Review of Resident #68's admission record revealed the resident was admitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, other asthma, peripheral vascular disease, and hypertensive heart disease with heart failure. Review of Resident #68's physician order dated 11/29/2022 read, Oxygen at 2 L/min [Liters/ Minute] via NC [nasal cannula] as needed. every shift for COPD. During an interview on 5/3/2023 at 8:58 AM, Staff B, LPN, stated, [Resident #68's name] has an order for 2 liters. His concentrator is set to 3.5 liters and that is not correct. 2. During an observation on 5/1/2023 at 11:43 AM, Resident #265 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 2 liters per minute. During an observation on 5/2/2023 at 8:18 AM, Resident #265 was in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 2 liters per minute. During an interview on 5/3/2023 at 8:42 AM, Staff B, LPN, stated, The order says that she [Resident #265] is supposed to get 4 liters of oxygen. Her concentrator is set to 2 liters per minute. Review of Resident #265's admission record revealed the resident was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, and occlusion and stenosis of right carotid artery. Review of Resident #265's physician order dated 4/29/2023 read, Oxygen 4 LPM continuous via nasal cannula every shift for oxygen therapy maintain O2 SAT's [Oxygen saturation] above 92%. 3. During an observation on 5/1/2023 at 1:37 PM, Resident #62 was observed in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 1.5 liters per minute. During an observation on 5/2/2023 at 8:23 AM, Resident #62 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set to 2 liters per minute. Review of Resident #62's admission record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, solitary pulmonary nodule, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), and shortness of breath. Review of Resident #62's physician order dated 10/10/2022 read, Oxygen: 3 L/min via nasal cannula. as needed for SOB [Shortness of Breath] Note: for O2 sat below 92%. During an interview on 5/3/2023 at 8:39 AM, Staff C, Licensed Practical Nurse (LPN), stated, [Resident #62's name] is supposed to be on 3 liters per minute, and her concentrator is set to 1.5 liters per minute. That is not correct. During an interview on 5/3/2023 at 9:48 AM, the Director of Nursing stated, The nurses need to follow physician orders to ensure the correct settings for oxygen is being used. Review of the facility policy and procedure tilted Oxygen Therapy last revised in June 2022 read, Oxygen Administration- Concentrator. 1. Verify physician order (except in an emergency) . 5. Attach tubing and delivery device (nasal canula/ mask) and adjust the flow rate to the ordered liter flow.

Based on record review and interview, the facility failed to ensure the arbitration agreements provided for the selection of a venue convenient to both parties for 3 of 3 reviewed residents, Residents #114, #115 and #166. Findings include: Review of the facility's Voluntary Binding Arbitration Agreements presented to Resident #114 on 5/1/2023, presented to Resident #115 on 5/1/2023 and presented to Resident #166 on 5/2/2023 failed to show the arbitration agreement provided for the selection of a venue convenient to both parties. During an interview on 5/2/2023 at 9:00 AM, the Administrator confirmed the facility arbitration agreements presented to Residents #114, #115 and #166 did not contain information related to selection of a venue convenient to both parties.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there was a critical laboratory result that required a change in medication for 1 of 2 residents reviewed for change in condition in a total sample of 38 residents, Resident #69. The resident was transferred to a higher level of care and did not survive. This facility failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 5:03 PM. The Immediate Jeopardy was ongoing at the time of the exit on [DATE]. Findings: Cross reference to F600. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Minimum Data Set (MDS), Comprehensive Admission assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 2 (Severe Cognitive Impact). Review of the physician orders for Resident #69 dated [DATE] read, BMP [Basic Metabolic Profile] CBC [Complete Blood Count], u/a [urinalysis], C&S [Culture and Sensitivity] one time only for weakness for 3 days. Review of the physician orders for Resident #69 dated [DATE] read, [MEDICATION(S)] [[MEDICATION(S)], an antibiotic] Tablet 500 mg [milligrams] give 1 tablet by mouth in the morning for [CONDITION(S)] [Urinary Tract Infection] Tx [treatment] for 10 days. Review of the physician encounter note for Resident #69 dated [DATE] at 1:00 AM authored by APRN (Advanced Practice Registered Nurse) read, Chief complaint/Nature of Presenting Illness: [CONDITION(S)]. History of presenting illness: Urinalysis and culture showing E. Coli [Escherichia coli], sensitivity to follow, patient started on [MEDICATION(S)] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is more alert today and his white count is trending down. Review of the urine culture and sensitivity report for Resident #69 read, Collection Date: [DATE], 04:00 [4 AM], received Date: [DATE], 17:17 [5:17 PM], Reported Date: [DATE], 12:02 [12:02 PM]. Site: clean catch. Result > 100,000 CFU [Colony Forming Unit) ml (per milliliter) gram negative rods, Escherichia Coli. This isolate is Extended Spectrum Beta-Lactamase (ESBL) producing microorganism [this is an enzyme produced by the bacteria that makes it harder to treat with antibiotics]. Critical result called to [Staff A's name] on [DATE], 12:02 PM by [Lab Employee's name]. Results were read back to caller. Result: Escherichia Coli (Isolate 1). Sensitivity Analysis: Isolate 1. [MEDICATION(S)] >=8. R=Resistant. [Resistance happens when germs like bacteria develop the ability to defeat the drugs designed to kill them]. Review of the nursing progress note for Resident #69 dated [DATE] at 3:16 PM authored by Staff A, Licensed Practical Nurse (LPN), read, Narrative: Res [resident] lethargic this shift. Poor appetite noted, couldn't complete therapy today. Res [respirations] even and unlabored. No sob [shortness of breath] or cough noted. Resting comfortably at this time. Review of Resident #69's clinical records revealed no documentation indicating the physician or resident representative was notified of the [CONDITION(S)] or critical lab results. Review of the physician encounter note for Resident #69 dated [DATE] read, Chief complaint/Nature of Presenting Problem: [CONDITION(S)]/ESBL. History of Present Illness: Patient was started on [MEDICATION(S)] for E. coli urinary tract infection. However, complete culture and sensitivity showing E. coli ESBL. I do not see where this was called to the on call provider, organism is resistant to [MEDICATION(S)]. Patient has no complaints of dysuria [pain or difficult urination], no reports of fever or chills. Plan: Discontinue [MEDICATION(S)], may insert midline [a long intravenous catheter placed in the arm for intravenous antibiotic administration], [MEDICATION(S)] [an antibiotic] 1 g [gram] daily x 10 days, [MEDICATION(S)] [a nutritional supplement made up of live bacteria] twice daily x 14 days, continue [MEDICATION(S)] [a medication for pain], PT/OT [Physical Therapy/Occupational Therapy] skilled nursing, follow up with psych. Review of the nursing progress note for Resident #69 dated [DATE] at 4:15 PM authored by Staff B, RN, read, Earlier today resident seen by [APRN's name]. New orders for midline and IV [intravenous] [MEDICATION(S)] daily x 10 days for [CONDITION(S)]. Called for midline placement, labs drawn today and later critical BUN [Blood Urea [MEDICATION(S)]] of 110 noted. All labs called to [APRN's name]. New order to send to ER [emergency room ] for evaluation due to ARF [Acute Renal Failure]. Family updated. Resident transported to [Name of Hospital]. Review of the physician orders for Resident #69 dated [DATE] read, Transfer to the ER, dx [diagnosis] ARF. Review of the hospital emergency department notes for Resident #69 dated [DATE] authored by [Medical Doctor's name] read, Clinical impression: Primary impression: [CONDITION(S)] [a life-threatening medical emergency when the body has an extreme response to infection], Secondary Impression: [CONDITION(S)] [high level of sodium in the blood], AKI [acute kidney Injury], [CONDITION(S)], dehydration. discharge date [DATE], DC [discharge] back to ALF [Assisted Living Facility] with hospice. Resident #69 died on [DATE]. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated, I was not aware of any problems with [Resident #69's name]. I was not aware that he had a urine culture reported and not called to the physician. I was not aware that the resident had an ESBL [CONDITION(S)] that was not being treated with the correct antibiotic. I need to investigate this to determine what actually happened. If this happened, it is not representative of what we do and is not acceptable. I see this is a very serious problem if we didn't notify the on-call physician, but maybe the staff just forgot to document that they called them. I will look into this and get back to you. During an interview on [DATE] at 8:05 AM, the DON stated, We did not notify anyone about this urine culture result. I spoke to the nurse, and she cannot remember whether she did a text to a provider, and I am trying to see if there is a way that we can find out. We should have called the physician or nurse practitioner. It is a nursing standard of care to call a physician with critical laboratory results. We did not do this. There is no documentation in the chart that anyone was called. He [Resident #69] has dementia and we should have notified his family also when the lab result came back. During an interview on [DATE] at 11:32 AM, the APRN stated, I did see this resident [Resident #69] on [DATE] and did know that the urine culture was E. coli, but the sensitivities were not back at the time that I saw him, so there was no need to change antibiotics at that time. I would absolutely expect that I should be notified that the resident had an ESBL [CONDITION(S)] and that the antibiotic was not appropriate for the organism. If I had been notified, I would have ordered the midline and the IV antibiotics on [DATE] the day the sensitivities were back. This resident had a very complex course prior to his being treated at the rehab center. I expect staff to call me with any critical lab results and let me know them. I'm not sure why they did not call and let someone know. It does take some time to get a midline in and get the antibiotics ordered. This can take time, but I would have placed the orders. During a telephone interview on [DATE] at 7:40 AM, Staff A, LPN, stated, I really can't remember whether I called the doctor or [APRN's name] not really. I remember that [APRN's name] the nurse practitioner came in that day. He knew the resident had E. coli in his urine. I don't think the results were back for what the sensitivity was. I was called by the lab, and they did give me the results. I really don't remember if I called [APRN's name], but if I didn't chart that I made the call then, I guess I didn't. When the lab calls with critical results, we are supposed to call the doctor and the family, but I don't know if I did or not. The resident was lethargic. I think I documented that. I should have called. That is the policy to call the doctor with critical lab results. I don't know why I didn't. I should have called the family and done a change of condition notification. During a telephone interview on [DATE] at 7:55 AM, Staff B, RN, stated, I did take care of [Resident #69's name] the day he went to the hospital [[DATE]]. I know he was out to the hospital related to his BUN being through the roof. It was very high. I called [APRN's name], the provider and told him he needs to go to the ER, and I called the family and let them know that he was going. He was very thin and not responding much, he would look at me, but he was not talking or responding to questions, but he was opening his eyes. I thought, Oh boy, this poor guy, he is in bad shape. During an interview on [DATE] at 1:26 PM, the Medical Director stated I am now aware of the situation with [Resident #69's name]. The administrator and the DON informed me of the concerns yesterday or the day before related to his BUN and needing to be sent out to the Emergency Department and his not having appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I will be reviewing the documentation to see where the break down occurred, whether it was the provider or the nursing staff that didn't respond as they should have. This is harm when a resident needs hospitalization . There is a process that definitely needs to be fixed, a process that broke down. This is an environment unlike the hospital. We are not here even daily. We are dependent much more on the nursing staff to recognize complex problems or situations and alert us when we need to know something. I expect the nursing staff to respond and to understand that calling culture results and critical labs, that these notifications are time sensitive and must be done immediately for the welfare of the patients. We need to be aware of and fix any situation that will cause a patient to have to go out to the hospital because of our actions or inaction. Review of the facility policy and procedure titled Laboratory-Testing and Reporting with the last revision date of ,d+[DATE] read, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are promptly reported to the physician/clinician. Standards: 4. A nurse is responsible for monitoring all test results received. 5. Test results are promptly reported to the physician/clinician who ordered them (or another clinician on call) and their response documented in the medical record. 7. The licensed nurse is responsible for documenting physician/clinician notification in the residents medical record. Review of the facility policy and procedure titled Physician/Clinician/Family Responsible Party Notification for Change in Condition with a revision date of ,d+[DATE], and last approval date of [DATE] read, Purpose: To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely, efficient and effective manner. Policy: 1. The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident's representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 2. When making notification as listed above, the facility must ensure that all pertinent information is documented in the resident's medical record. and appropriate information is communicated to the receiving health care institution or provider. 6. If the resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make required decisions, but the resident must still be told what is happening to him or her.

Based on observation, interview, and record review, the facility failed to ensure the residents were free from neglect by not notifying the resident's physician of a change in condition related to critical laboratory results, Resident #69, and for not ensuring proper medical equipment supplies for a suprapubic catheter, Resident #36, for 2 of 8 residents, in a total sample of 38 residents. Resident #69 had a serious urinary tract infection, was transferred to a higher level of care for further treatment because the critical laboratory results were not reported to the physician. Resident #69 did not survive. This facility failure to ensure Resident #69 was free from neglect resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 5:03 PM. The Immediate Jeopardy was ongoing at the time of the exit on [DATE]. Findings: Cross reference to F580. 1. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Minimum Data Set (MDS), Comprehensive Admission assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 2 (indicating severe cognitive impairment). Review of the physician orders for Resident #69 dated [DATE] read, BMP [Basic Metabolic Profile] CBC [Complete Blood Count], u/a [urinalysis], C&S [Culture and Sensitivity] one time only for weakness for 3 days. Review of the physician orders for Resident #69 dated [DATE] read, [MEDICATION(S)] [[MEDICATION(S)], an antibiotic] Tablet 500 mg [milligrams] give 1 tablet by mouth in the morning for [CONDITION(S)] [Urinary Tract Infection] Tx [treatment] for 10 days. Review of the physician encounter note for Resident #69 dated [DATE] at 1:00 AM authored by APRN (Advanced Practice Registered Nurse) read, Chief complaint/Nature of Presenting Illness: [CONDITION(S)]. History of presenting illness: Urinalysis and culture showing E Coli [Escherichia coli], sensitivity to follow, patient started on [MEDICATION(S)] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is more alert today and his white count is trending down. Review of the urine culture and sensitivity report for Resident #69 read, Collection Date: [DATE], 04:00 [4 AM], received Date: [DATE], 17:17 [5:17 PM], Reported Date: [DATE], 12:02 [12:02 PM]. Site: clean catch. Result > 100,000 CFU [Colony Forming Unit) ml (per milliliter) gram negative rods, Escherichia Coli. This isolate is Extended Spectrum Beta-Lactamase (ESBL) producing microorganism [this is an enzyme produced by the bacteria that makes it harder to treat with antibiotics]. Critical result called to [Staff A's name] on [DATE], 12:02 PM by [Lab Employee's name]. Results were read back to caller. Result: Escherichia Coli (Isolate 1). Sensitivity Analysis: Isolate 1. [MEDICATION(S)] >=8. R=Resistant. [Resistance happens when germs like bacteria develop the ability to defeat the drugs designed to kill them]. Review of the nursing progress note for Resident #69 dated [DATE] at 3:16 PM authored by Staff A, Licensed Practical Nurse (LPN), read, Narrative: Res [resident] lethargic this shift. Poor appetite noted, couldn't complete therapy today. Res [respirations] even and unlabored. No sob [shortness of breath] or cough noted. Resting comfortably at this time. Review of Resident #69's clinical records revealed no documentation indicating the physician or resident representative was notified of the [CONDITION(S)] or critical lab results. Review of the physician encounter note for Resident #69 dated [DATE] read, Chief complaint/Nature of Presenting Problem: [CONDITION(S)]/ESBL. History of Present Illness: Patient was started on [MEDICATION(S)] for E. coli urinary tract infection. However, complete culture and sensitivity showing E. coli ESBL. I do not see where this was called to the on call provider, organism is resistant to [MEDICATION(S)]. Patient has no complaints of dysuria [pain or difficult urination], no reports of fever or chills. Plan: Discontinue [MEDICATION(S)], may insert midline [a long intravenous catheter placed in the arm for intravenous antibiotic administration], [MEDICATION(S)] [an antibiotic] 1 g [gram] daily x 10 days, [MEDICATION(S)] [a nutritional supplement made up of live bacteria] twice daily x 14 days, continue [MEDICATION(S)] [a medication for pain], PT/OT [Physical Therapy/Occupational Therapy] skilled nursing, follow up with psych. Review of the nursing progress note for Resident #69 dated [DATE] at 4:15 PM authored by Staff B, RN, read, Earlier today resident seen by [APRN's name]. New orders for midline and IV [intravenous] [MEDICATION(S)] daily x 10 days for [CONDITION(S)]. Called for midline placement, labs drawn today and later critical BUN [Blood Urea [MEDICATION(S)]] of 110 noted. All labs called to [APRN's name]. New order to send to ER [emergency room ] for evaluation due to ARF [Acute Renal Failure]. Family updated. Resident transported to [Name of Hospital]. Review of the physician orders for Resident #69 dated [DATE] read, Transfer to the ER, dx [diagnosis] ARF. Review of the hospital emergency department notes for Resident #69 dated [DATE] authored by [Medical Doctor's name] read, Clinical impression: Primary impression: [CONDITION(S)] [a life-threatening medical emergency when the body has an extreme response to infection], Secondary Impression: [CONDITION(S)] [high level of sodium in the blood], AKI [acute kidney Injury], [CONDITION(S)], dehydration. discharge date [DATE], DC [discharge] back to ALF [Assisted Living Facility] with hospice. Resident #69 died on [DATE]. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated, I was not aware of any problems with [Resident #69's name]. I was not aware that he had a urine culture reported and not called to the physician. I was not aware that the resident had an ESBL [CONDITION(S)] that was not being treated with the correct antibiotic. I need to investigate this to determine what actually happened. If this happened, it is not representative of what we do and is not acceptable. I see this is a very serious problem if we didn't notify the on-call physician, but maybe the staff just forgot to document that they called them. I will look into this and get back to you. During an interview on [DATE] at 8:05 AM, the DON stated, We did not notify anyone about this urine culture result. I spoke to the nurse, and she cannot remember whether she did a text to a provider, and I am trying to see if there is a way that we can find out. We should have called the physician or nurse practitioner. It is a nursing standard of care to call a physician with critical laboratory results. We did not do this. There is no documentation in the chart that anyone was called. He [Resident #69] has dementia and we should have notified his family also when the lab result came back. During an interview on [DATE] at 11:32 AM, the APRN stated, I did see this resident [Resident #69] on [DATE] and did know that the urine culture was E. coli, but the sensitivities were not back at the time that I saw him, so there was no need to change antibiotics at that time. I would absolutely expect that I should be notified that the resident had an ESBL [CONDITION(S)] and that the antibiotic was not appropriate for the organism. If I had been notified, I would have ordered the midline and the IV antibiotics on [DATE] the day the sensitivities were back. This resident had a very complex course prior to his being treated at the rehab center. I expect staff to call me with any critical lab results and let me know them. I'm not sure why they did not call and let someone know. It does take some time to get a midline in and get the antibiotics ordered. This can take time, but I would have placed the orders. During a telephone interview on [DATE] at 7:40 AM, Staff A, LPN, stated, I really can't remember whether I called the doctor or [APRN's name] not really. I remember that [APRN's name] the nurse practitioner came in that day. He knew the resident had E. coli in his urine. I don't think the results were back for what the sensitivity was. I was called by the lab, and they did give me the results. I really don't remember if I called [APRN's name], but if I didn't chart that I made the call then, I guess I didn't. When the lab calls with critical results, we are supposed to call the doctor and the family, but I don't know if I did or not. The resident was lethargic. I think I documented that. I should have called. That is the policy to call the doctor with critical lab results. I don't know why I didn't. I should have called the family and done a change of condition notification. During a telephone interview on [DATE] at 7:55 AM, Staff B, RN, stated, I did take care of [Resident #69's name] the day he went to the hospital [[DATE]]. I know he was out to the hospital related to his BUN being through the roof. It was very high. I called [APRN's name], the provider and told him he needs to go to the ER, and I called the family and let them know that he was going. He was very thin and not responding much, he would look at me, but he was not talking or responding to questions, but he was opening his eyes. I thought, Oh boy, this poor guy, he is in bad shape. During an interview on [DATE] at 1:26 PM, the Medical Director stated I am now aware of the situation with [Resident #69's name]. The administrator and the DON informed me of the concerns yesterday or the day before related to his BUN and needing to be sent out to the Emergency Department and his not having appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I will be reviewing the documentation to see where the break down occurred, whether it was the provider or the nursing staff that didn't respond as they should have. This is harm when a resident needs hospitalization . There is a process that definitely needs to be fixed, a process that broke down. This is an environment unlike the hospital. We are not here even daily. We are dependent much more on the nursing staff to recognize complex problems or situations and alert us when we need to know something. I expect the nursing staff to respond and to understand that calling culture results and critical labs, that these notifications are time sensitive and must be done immediately for the welfare of the patients. We need to be aware of and fix any situation that will cause a patient to have to go out to the hospital because of our actions or inaction. Review of the facility policy and procedure titled Laboratory-Testing and Reporting with the last revision date of ,d+[DATE] read, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are promptly reported to the physician/clinician. Standards: 4. A nurse is responsible for monitoring all test results received. 5. Test results are promptly reported to the physician/clinician who ordered them (or another clinician on call) and their response documented in the medical record. 7. The licensed nurse is responsible for documenting physician/clinician notification in the residents medical record. Review of the facility policy and procedure titled Physician/Clinician/Family Responsible Party Notification for Change in Condition with a revision date of ,d+[DATE], and last approval date of [DATE] read, Purpose: To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely, efficient and effective manner. Policy: 1. The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident's representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 2. When making notification as listed above, the facility must ensure that all pertinent information is documented in the resident's medical record. and appropriate information is communicated to the receiving health care institution or provider. 6. If the resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make required decisions, but the resident must still be told what is happening to him or her. 2. During a 200 Hall tour on [DATE] at 9:40 AM, the surveyor observed a family member loudly discussing with a staff member, later identified as Staff C, LPN, the lack of assistance with getting a urinary catheter drainage bag replacement. The family member stated, I can get them on Amazon. Why can't you get them? Review of Resident #36's admission record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's MDS (Minimum Data Set), Comprehensive Quarterly assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 15 (Intact Cognition). Review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 9:48 AM, Resident #36 was frowning and speaking rapidly and loudly as she stated, My catheter bag has been leaking for several days. I have a suprapubic catheter that was put in on [DATE] and the bag has been leaking quite a while and when I reported it to a nurse, they put it in a zip lock bag, and it is still leaking and getting on my leg. During an observation on [DATE] at 9:56 AM, Resident #36's room had a strong odor of urine, which became more pronounced when the resident lifted her sheets and blankets to reveal an adult brief placed between the catheter bag and the resident's leg. The odor intensified when she opened the brief. There was a plastic zip lock bag with a urinary catheter bag floating in clear yellow liquid. The urinary catheter bag was labeled that it could hold 600 ml (milliliters) and contained approximately 200 milliliters of yellow fluid. The plastic zip lock bag contained approximately the same amount of yellow fluid. The catheter bag was covered entirely with the clear yellow fluid and floating in the plastic bag. There was approximately one inch separation at the seam of the catheter bag observed at the 400 ml marking on the left side of the catheter bag. During an interview on [DATE] at 9:56 AM, Resident #36 stated, I am very upset. My catheter has been leaking for many days and the staff will not help me. I have been telling them for a long time that my catheter was leaking, and they told me I was imagining it. I knew I wasn't as I was getting wet and sometimes the staff would ask me if I did something to make the catheter leak. I tried to tell them that the bag was leaking. They say it started Friday, but it didn't. It was going on before then. On Friday, they finally saw it was leaking and they put it in this plastic bag. This smells so awful and if I lift my covers, it smells so bad. They finally put it in a diaper when I kept getting wet to try to stop that. This is so embarrassing. My daughter in law has been trying to get them to fix this. They say they don't have the right kind of bag to put on it. I want them to fix this because I keep getting wet and it really seems bad. I have told all the nurses that this is happening. I just can't understand what the problem is. Why it can't be changed. I had surgery. There is this urinal that's hanging beside my head. I have to lay on my back and so I turn the urinal around so it's not right in my face. During an interview on [DATE] at 10:06 AM, Staff C, LPN, assigned to the 200 Hall, entered Resident #36's room and saw the catheter bag and zip lock baggie. She confirmed the catheter bag with 200 ml was floating in a zip lock bag with 250 ml of urine. Staff C stated she was flabbergasted, and it shouldn't be like this. Review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes for Resident #36 dated [DATE] at 2:24 PM authored by Staff C, LPN, read, Catheter bag was empty. Line was cleaned and opening around abdomen was cleaned and covered with drain sponges. Daughter-in-law handed cell phone to nurse. Was instructed by [name] and [MD's name] to send resident to [Name of Hospital] non-emergency for catheter to be changed out. Called 911 and sent resident out to [Name of Hospital]. Daughter-in-law at her side. Supervisor [Staff D's name] was advised. Review of the nursing progress note for Resident #36 dated [DATE] at 4:15 PM authored by Staff D, LPN, read, Additional information for Friday [DATE]. Pinpoint leak noted to urine drainage bag, because of the type of catheter inserted needs a special bag, spoke to MD [Medical Doctor] regarding getting urology appt [appointment] ASAP and will try to get bag as soon as possible. Orders given for urology appt and to secure and maintain drainage system. Review of the nursing progress note for Resident #36 dated [DATE] at 7:09 PM read, Daughter phoned to inform that resident will be held overnight and procedure will happen tomm [tomorrow]. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed Resident #36 was transferred from [Name of Hospital] back to the facility with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #36's receiving hospital's laboratory results dated [DATE] read, Laboratory Test Results: Collection Time: [DATE] at 17:20 [5:20 PM]. Ur [Urine] Leukocyte Esterase: Result: Large. Urine RBC [Red Blood Cells]: Result: ,d+[DATE]. Urine WBC [White Blood Cells]: Result: > [greater than] 100 A, normal reference 0 [zero, it could be a sign of infection. WBCs help your body fight germs]. Urine Bacteria: Result: Many. Review of the receiving hospital's discharge medication list dated [DATE] at 1:33 PM read, [MEDICATION(S)] (Trade Name: [MEDICATION(S)]) [used to treat infections caused by bacteria. It's often given to treat the urinary tract] 500 MG Oral every 8 hours. During an interview on [DATE] at 2:10 PM, the Director of Nursing (DON) stated, I expect the staff to notify me of any issues outside of the norm. I was aware that we were not able to get the supply of the proper catheter bags for [Resident #36's name]. I think we ordered them, but I am not sure when. I found out the order was not placed until today. I know we had an order from the doctor to contain it as best we could until we received the right supplies. I was not aware that the leak in the bag was so bad that it would have the catheter bag floating in urine. That is a very big infection control problem. I was not aware that the leak worsened over the weekend. The staff should have called the doctor if they could not contain the leak with what we have here. I would expect the staff to have let the doctor know. During an interview on [DATE] at 8:45 AM, Staff D, LPN, stated, I became aware of the catheter for [Resident #36's name] having a pinpoint leak on Friday morning. I was instructed to order a new bag, but some type of emergency came up and I forgot to place the order. I realized that I didn't do it Sunday night, but thought to myself, it's okay. It was just a pinpoint leak. During an interview on [DATE] at 10:45 AM, Staff I, Certified Nursing Assistant (CNA), confirmed she usually takes care of Resident #36 daily. Staff I stated she noticed that on Friday morning, [DATE], the catheter had a drip-drip-drip leak. Staff I stated she told the nurse, Staff C, who told her to empty the bag and she would take care of it. During an interview on [DATE] at 2:15 PM, Staff C, LPN, stated, I was not told the amount of urine that was draining and that there was a large hole in the catheter bag. I was not aware that it was draining so much that it would leak out of the zip lock bag that we placed the catheter in on Friday when we saw that it was leaking. It was a small leak on Friday, not the large tear in the catheter bag that I saw yesterday. I am horrified that no one told me how bad it was. The catheter bag should not have been floating in urine. That is a very big risk for infection for the resident. I just was not told by the nurse I got report from. I would have assessed it sooner and I would have let the doctor know that we could not contain the urine and something else needed to be done. I told the Unit Manager on Friday, and she is the one who put it in the plastic bag or told me to. I didn't put it inside the brief. During a telephone interview on [DATE] at 1:00 PM, Staff J, LPN, stated, I worked the second shift over the weekend and remembered caring for [Resident #36's name]. [Staff C's name] told me she was concerned about [Resident #36's name] as the resident's catheter bag had a tear in the seam about ½ cm [centimeter] and the resident was agitated and upset. The catheter bag did have a pretty large hole in it, and I tried to tape it closed but found urine and tape don't mix. I didn't really think about calling the doctor. They already knew that it had a hole in it. It was leaking and was in a plastic bag. I can't remember if it was in any brief. During an interview on [DATE] at 1:15 PM, the Medical Director stated, I did give the order to attempt to contain the urine as best they could, but I was not aware that it was not the usual catheter bag and that it wasn't positioned for gravity flow. I had no idea that it was lateral to the patient's bladder allowing it to freely flow back into the bladder. That would certainly create a higher risk for infection. I would expect someone with some level of competency to make an informed decision to take care of the problem, to recognize that it was a problem and take care of it for the safety of the patient. Even if that meant additional call to the provider and sending the patient out to the hospital for this to be resolved. The staff should have called the provider or me back when they could not contain the urine safely. I would have expected to be called. This setting is different than acute care. They don't have supplies at their fingertips like the hospitals do, but we must do the right thing for the patient. The staff might have started off with the right intentions however, it didn't turn out that way. Definitely not! It is a big concern when our failure to act results in a patient needing to be hospitalized or has any adverse outcome. Review of the facility policy and procedure titled Abuse, Neglect and Misappropriation of Resident Property with the last revision date of ,d+[DATE] read, Purpose: The policy's purpose is to ensure that resident rights are protected by providing a method for investigation and reporting of allegations of mistreatment, neglect, abuse, including injuries of unknown source, unusual occurrences, and misappropriation of resident property. Definitions: Neglect: This occurs on an individual basis when a resident is not cared for in one or more areas. Neglect is also lack of attentiveness, carelessness or the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in neglect. And, neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Examples: an action or lack of action that actually harms a resident such as: - Failing to provide personal hygiene resulting in embarrassment, depression, poor self-esteem, self-isolation, or physical harm that requires medical treatment beyond an ER/physician evaluation. - Staff failing to identify, assess, monitor, and respond to a resident suffering an acute condition.