Every finding on record at Brighton Post Acute Care

Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and readily accessible for facility staff for four Residents (#8, #44, #32 and #42) out of a total sample of 22 residents. Specifically:1. For Resident #44 and #8, the facility failed to ensure the Physician and other licensed professionals' progress notes were documented in the Electronic Health Record (EHR).2. For Resident #42, the facility failed to ensure nursing staff accurately documented the administration of lidocaine pain patches.3. For Resident #32, the facility failed to accurately document the cleaning of an oxygen concentrator filter. Findings include: 1. Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease, acute kidney failure, dependence on renal dialysis, shortness of breath atherosclerotic heart disease, essential primary hypertension, chronic atrial fibrillation, polyneuropathy, cardiomegaly, and tachycardia and dependence on supplemental oxygen. Review of Resident #44's Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the Resident scored 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she had severe cognitive impairment. Review of Resident #44's Electronic Health Record (EHR) indicated that a Nurse Practitioner (NP) examined the Resident on 2/20/25 at 11:59 P.M. Further review of the EHR indicated a Physician (MD) examined the Resident on 12/27/24. Review of the EHR failed to indicate the Nurse Practitioner or Physician visited Resident #44 after 2/20/25, there were no documented notes in the medical record after 2/20/25. On 9/26/25 at 9:00 A.M., the surveyor requested the facility to provide any NP/MD progress notes dated after 2/20/25. Staff said there were no NP/MD documented visits after 2/20/25 in the EHR or hard copy medical record. During an interview on 9/26/25 at 11:03 A.M., the Medical Director said that he rounds on residents every four months and the NP rounds on residents every couple of months, unless there is a need for a resident to be seen sooner. The Medical Director said the progress notes are supposed to be uploaded to the electronic health record faster than they have been though they are usually uploaded within the month. Furthermore, the Medical Director said he was aware of the issue and will be working on fixing it. The Medical Director said progress notes are written in a different system and said staff do not have access to visit notes until they are uploaded into the residents' electronic medical records. Further review of the EHR indicated that a late entry physician progress note, dated 4/8/25 at 8:30 A.M., was entered into the EHR on 9/26/25 at 8:31 A.M. In addition, a physician progress note dated 8/12/25 at 9:19 A.M., was entered into the EHR on 9/26/25 at 9:19 A.M. These progress notes were added after the surveyor requested progress notes. During an interview on 9/26/25 at 12:18 P.M., the Director of Nursing said acute residents should be seen every 30 days and long-term residents every 60 days. She furthermore said she was aware of the issues with the providers uploading the progress notes and said staff do not have access to provider notes if they are not entered into the electronic health record. 2. Resident #8 was admitted to the facility in June 2022 with diagnoses including chronic obstructive pulmonary disease (COPD) and schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/27/25, indicated Resident #8 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. Review of Resident #8's Electronic Health Record (EHR) indicated that the last nurse practitioner progress note was documented on 7/24/25 at 2:10 P.M. Further review of the EHR indicated that the last (late entry) physician progress note was documented on 4/29/25 at 10:46 A.M. On 9/26/25 at 9:00 A.M., the surveyor requested the facility staff to provide any nurse practitioner progress notes for Resident #8 completed after 7/24/25, and any physician progress notes completed after 4/29/25. Further review of the EHR indicated that one of the requested physician progress notes, dated 8/12/25 at 9:39 A.M., was documented as a late entry on 9/26/25 at 9:40 A.M., by the physician. During an interview on 9/26/25 at 11:03 A.M., the Medical Director said that he rounds on residents every four months and the NP rounds on residents every couple of months, unless there is a need for a resident to be seen sooner. The Medical Director said the progress notes are supposed to be uploaded to the EHR faster than they have been and are usually put in within the month. The Medical Director said he was aware of the issue. During an interview on 9/26/25 at 12:18 P.M., the Director of Nursing said acute residents should be seen every 30 days and long-term residents every 60 days. She furthermore said she was aware of the issues with the providers uploading the progress notes. 3. Resident #42 was admitted to the facility in September 2025 and has diagnoses that include status-post left knee surgery and arthritis. Review of Resident #42's most recent Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15, indicating intact cognition. On 9/24/25 at 10:07 A.M., the surveyor observed Resident #42 awake in bed. The Resident had two surgical dressings covering the left knee and two lidocaine patches, one located on the medial side of the left knee, and the other on the left shin. The patch on the medial side of the knee was dated 9/21 and the patch on the shin was undated. During an interview with Resident #42, he/she said a nurse applied both patches to his/her left leg on 9/21/25 and had not changed them since that date. Review of Resident #42's physician order dated 9/17/25 indicated: Lidocaine External Patch 4% (Lidocaine). Apply skin topically one time a day for pain and removed per schedule. (Lidocaine is an externally applied topical anesthetic used for the temporary relief of minor pain.) Review of Resident #42's September MAR indicated nursing staff applied a patch on 9/21/25 at 8:00 A.M., and then removed it on 9/22/25 at 7:59 A.M. The MAR indicated patches were removed and applied on 9/22/25 and 9/23/25, contrary to the surveyor's observation made on 9/24/25 of the patch dated 9/21/25. During an interview on 9/24/25 at 2:16 P.M., Unit Manager #1 said she thought she had removed and applied a new patch for Resident #42 on the medial side of the left knee on 9/22/25 but may have accidentally dated the patch 9/21/25. Unit Manager #1 said she did not understand why the patch was still dated 9/21 as of 9/24/25. During an interview with the Director of Nurses (DON) and Regional Nurse #2 on 9/25/25 at 8:03 A.M., they said Unit Manager #1 applied two lidocaine patches to Resident #42 on 9/22/25 but accidentally wrote a date of 9/21 on the patch located on left knee and forgot to date the patch located on the shin. They said the nurse who was responsible for removing and applying Resident #42's lidocaine patch on 9/23/25 did not do the treatment and in error documented in the MAR the patch was changed on this date. 4. Resident #32 was admitted to the facility in May 2025 and had diagnoses which included respiratory failure and heart failure. Review of Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status score of 13 out of a possible 15, indicating intact cognition. Resident #32 received oxygen therapy. On 9/24/25 at 8:52 A.M. the surveyor observed Resident #32 sitting in a wheelchair. The Resident wore a nasal cannula, and an oxygen concentrator was located next to his/her bed and running at 2 liters per minute. The surveyor observed that the surface of the oxygen concentrator filter was covered in a thick, white layer of dust. Review of Resident #32's physician orders indicated: Change Oxygen tubing, change O2 humidification bottle as applicable and clean filter (wash, rinse and pat dry filter) and change storage bag every week. Every nightshift every Sunday, dated 5/25/25. Review of Resident #32's September 2025 Treatment Administration Record (TAR) indicated staff last changed the oxygen concentrator air filter on 9/21/25. During an interview with Clinical Nurse Consultant #2 on 9/25/25 at 9:24 A.M., she said it did not appear that the filter was changed or cleaned on 9/21/25, as indicated on Resident #32's September TAR. Clinical Nurse Consultant said it was the facility's policy to change, or clean, oxygen concentrator filters one time per week to remove dust build up. Review of the facility policy Use of Oxygen dated September 2024 did not reference the oxygen concentrator filter or cleaning.

Based on record review and interview, the facility failed to ensure physician visits were completed as required for three Residents (#32, #4 and #15) out of a total of 22 sampled residents. Findings include: 1. Resident #32 was admitted to the facility in December 2024 with diagnoses including heart failure, asthma and respiratory failure. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #32 was cognitively intact evidenced by a score of 13 out of a possible 15 on the Brief interview for Mental Status Exam (BIMS). Review of Resident #32's clinical record indicated he/she had been seen by the Physician on 12/28/24 and 9/2/25 and by the Nurse Practitioner (NP) on 1/3/25, 1/4/25, 1/7/25, 3/28/25, 4/15/25, 5/20/25, 6/8/25, 7/9/25, 7/27/25, 8/1/25 and 8/8/25. Resident #32 was not seen in February 2025 as required and the Physician did not alternate visits with the NP, as required. During an interview on 9/26/25 at 11:03 A.M., the Medical Director (Resident #32's attending physician) said that he usually sees new admissions within the first 48 hours and they are seen every month for the first three months. The Medical Director said he usually sees residents every four months and the NP also visits every couple months. During an interview on 9/26/2025 at 12:18 P.M., the Director of Nursing said that the expectation is for the physician and nurse practitioner to alternate visits and complete visits every 30 days for acute patients and every 60 days for long term residents. 2. Resident #4 was admitted to the facility in July 2024 with diagnosis of aphasia and coronary artery disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was severely cognitively impaired and dependent on staff for all activities of daily living. Review of Resident #4's clinical record indicated that he/she had been seen by the Physician on 9/11/24, 9/21/24, 9/23/25 and had been seen by the Nurse Practitioner (NP) on 9/10/24, 9/15/24, 9/19/24, 6/4/25, and 7/27/25. The Physician did not alternate visits with the NP as required. During an interview on 9/26/25 at 11:03 A.M., the Medical Director (Resident #4's attending physician) said that he usually sees residents every four months and the NP also visits every couple months. During an interview on 9/26/25 at 12:18 P.M., the Director of Nursing said that the expectation is for the physician and nurse practitioner to alternate visits and complete visits every 30 days for acute patients and every 60 days for long term residents. 3. Resident #15 was admitted to the facility in January 2023 with diagnoses including stroke and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam and is dependent on staff for all activities of daily living. Review of Resident #15's clinical record indicated he/she had been seen by the physician on 7/12/24, 9/16/25 and 9/19/25 and was seen by the Nurse Practitioner (NP) on 10/3/24, 10/7/24, 10/8/24, 10/29/24, 11/11/24, 11/19/24, 1/30/25 and 6/6/25. The Physician did not alternate visits with the NP as required. During an interview on 9/26/25 at 11:03 A.M., the Medical Director (Resident #15's attending physician) said that he usually sees residents every four months and the NP also visits every couple months. During an interview on 9/26/25 at 12:18 P.M., the Director of Nursing said that the expectation is for the physician and nurse practitioner to alternate visits and complete visits every 30 days for acute patients and every 60 days for long term residents.

Based on observations, record review, and interviews, the facility failed to provide supervision with meals for one Resident (#44) out of a total sample of 22 residents. Findings include:Review of the facility policy titled Activities of Daily Living (ADL) Supporting, dated as revised September 2024, indicated: - Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. ADLs are provided in according with resident preference and needs. - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Dining (meals and snacks). - Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Findings include: Resident #44 was admitted to the facility in March 2022 with diagnoses including aphasia (communication disorder), other lack of coordination, end stage renal disease, and shortness of breath. Review of Resident #44's Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the Resident scored 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she had severe cognitive impairment. On 9/24/2025 at 8:12 A.M., the surveyor observed Resident #44 in bed, with his/her breakfast attempting to eat the meal. The Resident had eggs on his/her clothing and bed linen. The Resident was not visible from the hallway; no staff were present in the room throughout the breakfast meal.On 9/25/25 at 8:41 A.M., the surveyor observed Resident #44 in bed, with his/her breakfast attempting to eat the meal. The Resident had eggs on his/her clothing and floor. The Resident was not visible from the hallway; no staff were present in the room throughout the breakfast meal.On 9/26/25 at 6:48 A.M., the surveyor observed Resident #44 in bed, with his/her breakfast attempting to eat the meal. The Resident had food on his/her clothing. The Resident was not visible from the hallway; no staff were present in the room throughout the breakfast meal.Review of Resident #44's Risk for Aspiration Care Plan, dated 2/28/23, indicated but was not limited to:- Resident to eat only with supervision.- Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris.- Encourage resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly.- Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards - Monitor for shortness of breath, choking, labored respirations, lung congestion.- All staff to be informed of resident's special dietary and safety needs.Review of Resident #44's nutritional assessment dated [DATE], failed to indicate dining ability and was left blank. Review of Resident #44's current September 2025 Kardex (form indicating level of care needs) indicated the following: Eating/Nutrition- Resident to eat only with supervision.- Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. - Encourage resident to eat in an upright position, to eat slowly, and to chew each bit thoroughly.- Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris.Resident Care: - All staff to be informed of resident's special dietary and safety needs.Review of the Speech Discharge summary dated [DATE], indicated:- Assistance to be provided: A.M., assistance/caregiver available, P.M., assistance/caregiver available.- To facilitate safety and efficiency, it is recommended that patient use the following strategies during oral intake: alteration of liquids/solids, bolus size modifications, cyclic ingestion technique, ratio modification, hard throat clear/swallow and general swallow techniques/precautions, along with the following maneuvers: upright posture during meals and upright posture for >30 minutes after meals. During an interview on 9/25/25 at 9:22 A.M., Certified Nursing Assistant (CNA) #2 said Resident #44 eats in his/her room and requires set up and said staff check on him/her during the meal but he/she does not need to be supervised.During an interview on 9/25/25 at 9:59 A.M., Nurse #4 said Resident #44 does not require supervision with meals and prefers to eat in his/her room. During an interview on 9/25/25 at 10:08 A.M., Unit Manager #2 said Resident #44 needs supervision during meals and said the care plan and Kardex must be followed. Unit Manager #2 said staff should stay with the Resident during meals because he/she eats in his/her room and must be monitored.During an interview on 9/26/25 at 11:38 A.M., the Director of Nursing (DON) said she expects the Kardex and care plan to be followed and said residents who need supervision during meals should not be left alone while eating. The DON said she was not aware that Resident #44 required supervision due to aspiration risks and said he/she should not be left unattended during meals.

Based on observation, interview and record review the facility failed for one Resident (#42) of 22 sampled residents, to provide adequate pain relief. Specifically, did not remove the used patch and replace it with a new patch for two days, which resulted in the Resident experiencing mild pain, and the potential for the body to absorb excessive amounts of lidocaine. In addition, facility staff applied two patches when there was an order for only one patch, which also contributed to the potential for the body to absorb excessive amounts of lidocaine. Findings include:Review of the facility policy Pain Management Guidelines dated September 2024 indicated it did not reference the use of Lidocaine patches, specifically.Lidocaine is an externally applied topical anesthetic used for the temporary relief of minor pain.Review of the Federal Drug Administration guidance for the use of lidocaine 4% patches indicated:- - Do not use more than one patch on your body at a time or with other topical analgesics at the same time.- - Patch may be used for up to 24 hours.- - Use of the same lidocaine patch for over 24 hours can lead to increased absorption, overdose risk, systemic toxicity and skin reactions.Resident #42 was admitted to the facility in September 2025 and has the following diagnoses: Status-post left knee surgery and arthritis.Review of Resident #42's most recent Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 15, signifying intact cognition.On 9/24/25 at 10:07 A.M., the surveyor observed Resident #42 awake in bed. The Resident had two surgical dressings covering the left knee and two lidocaine patches, one located on the medial side of the left knee, and the other on the left shin. The patch on the medial side of the knee was dated 9/21 and the patch on the shin was undated.During an interview with Resident #42, he/she said a nurse applied both patches to his/her left leg on 9/21/25 and had not changed them since that date. Resident #42 said he/she experienced mild pain but expected that a nurse would be giving him/her more pain medication this morning.Review of Resident #42's physician order dated 9/17/25 indicated: Lidocaine External Patch 4% (Lidocaine). Apply skin topically one time a day for pain and removed per schedule.Resident #42's physician order did not indicate the placement location for the patch and did not indicate more than one patch was to be applied.Review of Resident #42's September 2025 Medication Administration Record (MAR) indicated the lidocaine patch was scheduled to be applied at 8:00 A.M. and removed the next day at 7:59 A.M.Review of Resident #42's September MAR indicated nursing staff applied a patch on 9/21/25 at 8:00 A.M., and then removed it on 9/22/25 at 7:59 A.M. The MAR indicated patches were removed and applied on 9/22/25 and 9/23/25, contrary to the surveyor's observation made on 9/24/25 of the patch dated 9/21/25.Review of Resident #42's pain assessments dated 9/21/25, 9/22/25 and 9/23/25 indicated he/she did not complain of pain.During an interview on 9/24/25 at 2:16 P.M., Unit Manager #1 said she thought she had removed and applied a new patch for Resident #42 on the medial side of the left knee on 9/22/25 but may have accidentally dated the patch 9/21/25. Unit Manager #1 said she did not understand why the patch was still dated 9/21 as of 9/24/25. Unit Manager #1 said Resident #42's lidocaine pain patch should be changed every 12 hours. Unit Manager #1 said she did not know why there were two lidocaine patches on Resident #42's left leg when the physician's order only indicated one patch. Unit Manager #1 said she did not understand why the patch on the left shin was undated. Unit Manager #1 said the physician's order should have included the placement location and the admitting nurse should have called the provider to clarify the order. Unit Manager #1 said that keeping a lidocaine patch on the skin longer than 12 hours could result in the patch losing some of its pain control efficacy. During an interview with the Director of Nurses (DON) and Regional Nurse #2 on 9/25/25 at 8:03 A.M., they said Unit Manager #1 applied two lidocaine patches to Resident #42 on 9/22/25 but accidentally wrote a date of 9/21 on the patch located on left knee and forgot to date the patch located on the shin. They said the nurse who was responsible for removing and applying Resident #42's lidocaine patch on 9/23/25 did not do the treatment and in error documented in the MAR the patch was changed on this date. They said the physician's order should have included placement location. They said the physician's order only indicated one lidocaine patch and that staff should not have applied two patches.

Based on observation, interview, and records reviewed, the facility failed to meet professional standards of practice for two Residents (#44, and #35) out of a total of 22 sampled residents. Specifically:1. For Resident #44, the facility failed to implement physician orders for fluid restrictions.2. For Resident # 35, the facility failed to implement physician's orders for fluid restrictions.Findings include: Review of facility policy titled Encouraging and Restricting Fluids dated September 2024, indicated: - The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. - Verify there is a physician's order for this procedure. - Review the residents care plan and or your daily assignment sheet to assess for any special needs of the resident. - Follow specific instructions concerning fluid intake or restrictions. - Record the amount of fluids consumed on the intake side of the intake and output record fluid intake in mLs. (milliliters). Documentation - Following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. Any changes in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. Any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin, etc. 6. The amount (in mls.) of fluids or the amount of fluids if outside the parameter. 1. Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease, dependence on renal dialysis, shortness of breath, atherosclerotic heart disease, tachycardia and dependence on supplemental oxygen. Review of Resident #44's Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the Resident scored 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she had severe cognitive impairment. The MDS further indicated Resident #44 is frequently incontinent of urine and is dependent on staff for toileting. On 9/24/25 at 8:41 A.M., the surveyor observed Resident #44 resting in bed. There was one cup of coffee and one cup of juice on the Resident's overbed table. On 9/25/25 at 6:48 A.M., the surveyor observed Resident #44 resting in bed. There was one cup of water on the Resident's overbed table. On 9/25/25 at 8:48 A.M., the surveyor observed Resident #44 resting in bed. There was one cup of coffee and one cup of cranberry juice on the Resident's overbed table. On 9/26/25 at 9:50 A.M., the surveyor observed Resident #44 resting in bed. There was one cup of coffee and one cup of cranberry juice on the Resident's overbed table. On 9/29/25 at 8:25 A.M., the surveyor observed Resident #44 resting in bed. There was one cup of coffee and one cup of juice on the Resident's overbed table. Review of Resident #44's active physician orders indicated the following: - Fluid restriction to 1000 ml/24 hours Nursing (360 ML/24 hours) Dietary (640 ML/24 hours) 7-3pm allowance: Nursing 120 cc Dietary 390 cc Total= 510cc 3-11pm allowance: Nursing 120cc Dietary 250cc Total = 370cc 11-7am allowance: 120 Nursing (120cc) Dietary (0) Total=120cc every shift. Start Date 8/10/23. Review of Resident #44's Medication Administration Record (MAR) for September 2025 failed to include daily fluid intake and output (I&O's) for each nursing shift indicating no fluid intake or output was measured. Further review of the medical record failed to indicate intake and output was measured or documented in the medical record. Review of the CNA documentation survey report for the month of September 2025 did not include I&O values. During an interview on 9/25/25 at 8:47 A.M., Nurse #4 said Resident #44 is on a fluid restriction and needs I&O's monitored because he/she is a dialysis patient and needs monitoring for fluid overload. Nurse #4 said CNA's track the I&O levels and document it in the medical record or tell the nurses so we can put it in the medical record. During an interview on 9/25/25 at 9:01 A.M., Unit Manager #2 said Resident #44 is on a fluid restriction because he/she is on dialysis and has a history of fluid overload. Unit Manager #2 said urinary output is measured and fluid intake is tracked by the CNA's and reported to the nursing staff to document values in the electronic medical record. Unit Manager #2 said nurses must follow the physician orders and care plan to care for the Resident. The surveyor along with Unit Manager #2 reviewed Resident #44's electronic medical record. Unit Manager #2 said the order for fluid restrictions is in place, but I&O values are not being documented in the medical record and said she expects them to be documented to monitor his/her fluid status. During an interview on 9/26/25 at 11:56 A.M., Regional Clinical Consultant #1 said Resident #44 has an order in place for fluid restrictions that need to be followed, and I&O should be documented each shift to monitor the resident's status as he/she is a dialysis patient and requires close monitoring. During an interview on 9/29/25 at approximately 8:19 A.M., the surveyor observed Nurse #6 in Resident #44's room and said she does not know if Resident #44 is on a fluid restriction. Nurse #6 then left a cup of water with the Resident before exiting the room. During an interview on 9/29/25 at 1:05 P.M., the Director of Nursing said residents on fluid restrictions must have intake and output values measured and documented as ordered and said she expects staff to be aware of the resident's fluid restrictions. 2. Resident #35 was admitted to the facility in August 2025 with diagnoses including sepsis, heart failure and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #35 was moderately cognitively impaired evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #12 is frequently incontinent of urine. During an interview on 9/24/25 at 8:45 A.M., the surveyor observed boxes of nutritional supplement drinks on Resident #35's dresser. Resident #35 said his/her family brought them in for him/her. Resident #35 then pointed to an open container of a chocolate flavored nutritional supplement on his/her overbed table and said he/she drinks them daily. Review of Resident #35's physician orders indicated the following: MD Orders: Fluid restriction to 1500 ml/24 hours. Nursing 500 ML/24 hours Dietary 1000 ML/24 hours). 7-3pm allowance: 690. Nursing (210mL) Dietary (480mL) 3-11pm allowance:690 Nursing (210mL) Dietary (480mL) 11-7am allowance:120. Nursing (120mL) Dietary (0mL), 8/20/25. Review of Resident #35's Medication Administration Record for September 2025 indicated three sections for nursing staff to document Resident #35's daily fluid intake and output for each nursing shift. Review of the 7:00 A.M. - 3:00 P.M., documentation indicated output N/A (not applicable) on 9/3/25, 9/9/25, 9/11/25 -9/16/25, and 9/20/25. Additionally, 9/10/25 was left blank; indicating no fluid intake or output was measured. Review of the 3:00 P.M. - 7:00 A.M. documentation indicated output N/A on 9/9/25-9/14/25, 9/17/25, 9/20/25 and 9/26/25. Review of the 11:00 P.M. - 7:00 A.M. documentation indicated output N/A on 9/4/25, 9/9/25, 9/11/25, 9/13/25, 9/15/25, 9/22/25, 9/24/25 and 9/25/25. Additionally, 9/2/25-9/3/25, 9/5/25-9/6/25, 9/8/25, 9/12/25, 9/14/25, 9/17/25, 9/21/25 and 9/23/25 were left blank; indicating no fluid intake or output was measured. During an interview on 9/29/25 at 10:55 A.M., Nurse #4 said that Resident #35 is on a fluid restriction and he/she doesn't like to drink a lot. Nurse #4 said that nursing staff will check his/her urinal to measure Resident #35's output. Nurse #4 said that Certified Nursing Aids (CNA's) are aware and that he/she is on a fluid restriction and will report to the nursing staff his/her fluid intake as well. During an interview on 9/29/25 at approximately 11:00 A.M., the surveyor observed CNA #1 in Resident #35's room and said she was about to provide care. CNA #1 said that she did not think Resident #35 is on a fluid restriction and that staff give him/her water, juice and ginger ale. During an interview on 9/29/25 at approximately 11:05 A.M., Unit Manager #1 said that Resident #35 is on a fluid restriction but would have to check if there was an order to monitor his/her output. Unit Manager #1 said that she was not aware that CNA staff did not know Resident #35 was on a fluid restriction. During an interview on 9/29/25 at 1:05 P.M., the Director of Nursing said that for residents on fluid restrictions, intake and output should be measured and documented as ordered.

Based on record review and interview, the facility failed to ensure attending care plan meetings was offered to one Resident (#44) out of a total of 22 sampled Residents. Specifically, the facility failed to ensure the Resident was notified of the care plan meetings or was offered to attend. Findings include: Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease and major depressive disorder. A diagnosis of dependence on supplemental oxygen was added to his/her record on 9/12/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 is severely cognitively impaired as evidenced by a score of seven out of a possible 15 on the Brief Interview for Mental Status exam. During multiple interviews throughout the survey, Resident #44 was able to engage in discussions about his/her healthcare related to his/her use of oxygen, attendance at dialysis and pain levels. Review of Resident #44's clinical record indicated his/her health care proxy was not activated (indicating Resident #44 is his/her own decision maker) and his/her most recent care plan meeting was held on 6/28/25; but failed to indicate who was in attendance at the meeting. During an interview on 9/29/25 at 10:39 A.M., Social Worker #1 said that Resident #44 has an activated health care proxy, but she was not sure who it was. Social Worker #1 said she is not responsible for inviting residents or family members to care plan meetings and she is not sure who is responsible for inviting residents or families to care plan meetings. Social Worker #1 said Resident #44 and his/her family do not attend his/her care plan meetings and she is not sure if they had ever been offered to attend. Review of the electronic and paper clinical record failed to indicate any attendance records for any care plan meetings for Resident #44. During a follow up interview on 9/29/25 at 12:50 P.M., Social Worker #1 also looked through Resident #44's paper record and was not able to locate copies of attendance sheets. Social Worker #1 said she was not aware that Resident #44 did not have an activated healthcare proxy and said that residents who are their own person have the right to attend care plan meetings. During an interview on 9/29/25 at 1:04 P.M., the Director of Nursing (DON) said that the receptionist is responsible for sending out care plan invitations to residents and their families, but there has been changes in staffing in reception services. The DON said residents who are their own person have the right to be invited and attend their own care plan meetings.

Based on observation, record review and interview, the facility failed to ensure a call light was able to be utilized for one Resident (#15), out of a total of 22 sampled residents. Findings include: Review of the facility policy titled, Call Bell Procedure, dated as reviewed September 2024, indicated: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Resident #15 was admitted to the facility in January 2023 with diagnoses including stroke and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam and is dependent on staff for all activities of daily living. During an interview on 9/24/25 at 8:29 A.M., Resident #15 asked the surveyor to pick up his/her television remote control off the floor. When asked if he/she has a functioning call light Resident #15 said no. The surveyor observed a red call bell string tied to the upper corner on his/her left bedrail. Resident #15 demonstrated he/she could reach it, but due to the way it was tied to the bedrail, he/she could not pull the cord down fully to activate the call light system. Review of Resident #15's fall care plan indicated: The resident is at risk for fall r/t deconditioning, gait/balance problems, paralysis, poor communication/comprehension, CVA (stroke) R-(right) side weakness 2022 and 2008, 1/12/23. Interventions: be sure resident's call light is within reach and encourage the resident to use it for assistance as needed, 1/12/23. On 9/25/25 at 7:27 A.M., the surveyor observed Resident #15 in bed. The red call light cord was still tied to the left side bedrail and Resident #15 said he/she could not use his/her call light. During an interview on 9/25/25 at 8:50 A.M., CNA #1 said that Resident #15 does not use a call light and staff check on him/her regularly. On 9/25/25 at 8:55 A.M., the surveyor observed Nurse #3 deliver Resident #15's breakfast tray. Nurse #3 observed Resident #15's call light and the surveyor attempted to pull the cord but could not pull the cord down completely to activate the call light system. Resident #15 said he/she could not pull his/her call light. Nurse #3 said that the call light should not be tied in that manner and should be closer to the Resident. During an interview on 9/25/25 at 9:43 A.M., Unit Manager #1 said that Resident #15 used to have a tap call light when he/she was in his/her previous room. Review of Resident #15's clinical record indicated he/she had changed rooms on 3/18/25.

Based on observation, record review and interview, the facility failed to ensure medications were stored as required for one Resident (#22), out of a total sample of 22 residents. Specifically, the facility failed to ensure that medications were not left at the bedside for Resident #22 while unsupervised by staff.Findings include: Review of the facility policy titled Medication Management-Medication Storage, dated and revised September 2024, indicated the following:-The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.Review of the facility policy titled Self-Administration of Medications, dated and revised September 2024, indicated the following:-It is the responsibility of the interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer medications.-The decision that a resident has the ability to self-medicate is subject to periodic review based on changes in the resident's status. An assessment must be done at least annually. -Upon request, assess the resident's ability to meet criteria outlined above and document outcomes on the form Assessment for the Self-Administration of medication.-If determined that the resident is capable of self-administration medications, review with MD.-Document on the resident's care plan. Resident #22 was admitted to the facility in December 2022 with diagnoses including cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain cell damage or death), contracture of left hand and depression.Review of Resident #22's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #22 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. On 9/24/2025 at 8:19 A.M., the surveyor observed a medication cup on Resident #22's bedside table with 3 white pills inside. Resident #22 stated those were his/her morning pills and he/she just hadn't taken them yet.Review of Resident #22's physician orders and care plans failed to indicate that the Resident had met criteria to self-administer medications at his/her bedside.Review of the Self-Administration of Medication BC-V5 assessment dated [DATE] indicated that the Resident did not have medications he/she wants to keep at bedside or wishes to administer his/her own medication. Review of the Self-Administration of Medication BC-V5 assessment dated [DATE] at 9:34 A.M., indicated that the Self-Administration of Medication BC-V5 assessment was completed after the surveyor's observation.During an interview on 9/24/25 at 2:25 P.M., Nurse #2 said she was not aware of Resident #22's medications being left at the bedside. Nurse #2 said that when she investigated the medications it was noted these were Resident #22's scheduled 6:00 A.M. Tylenol that were left by the overnight nurse. Nurse #2 said that a Self-Administration assessment should have been completed prior to leaving the medications with the Resident. Review of Resident #22's physician order dated 10/31/24 indicated the following:-Tylenol Tablet 325 MG (Acetaminophen) Give 3 tablet by mouth three times a day for Pain TD (total dose) =975mg. Review of Resident #22's September Medication Administration Record indicated that Resident #22's scheduled 6:00 A.M. Tylenol was signed off as Resident receiving medication on 9/24/25. During an interview on 9/25/25 at 12:51 P.M., the Director of Nursing said when residents ask to self-administer medications, an assessment is performed at the bedside to observe the resident self-administer medications. After the assessment is completed and the resident was deemed to be appropriate to self-administer medications, the provider is contacted to receive an order before the resident is allowed to self-administer. The Director of Nursing said a Self-Administration assessment should have been completed prior to leaving the medications with Resident #22.

Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#44, #1, and #32) out of sample of 22 residents. Specifically:For Resident #44, the facility failed to obtain physician orders for oxygen use prior to administration.For Resident #1, the facility failed to obtain physician orders for oxygen use prior to administration.For Resident #32, the facility failed to clean the oxygen concentrator filter, resulting in a thick build-up of dust. Findings include:Review of facility policy titled Resident Care and Treatment- Use of Oxygen dated as reviewed September 2024, indicated the following but not limited to- Nursing personnel administer oxygen as prescribed by policy and ensure compliance with all Life Safety Codes.- Adjust the oxygen delivery device so that it is comfortable for the Resident and the proper flow of oxygen is being administered. Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease, dependence on renal dialysis, shortness of breath, atherosclerotic heart disease, tachycardia and dependence on supplemental oxygen. Review of Resident #44's Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the Resident scored 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she had severe cognitive impairment. The MDS further indicated that the Resident was on oxygen therapy. On 9/24/25 at 8:41 A.M., the surveyor observed Resident #44 resting in bed. The Resident was receiving oxygen at 2 liters via nasal cannula. On 9/25/25 at 6:48 A.M., the surveyor observed Resident #44 resting in bed. The Resident was receiving oxygen at 2 liters via nasal cannula. On 9/25/25 at 8:48 A.M., the surveyor observed Resident #44 resting in bed. The Resident was receiving oxygen at 2 liters via nasal cannula. On 9/26/25 at 9:50 A.M., the surveyor observed Resident #44 resting in bed. The Resident was receiving oxygen at 2 liters via nasal cannula. On 9/29/25 at 8:25 A.M., the surveyor observed Resident #44 resting in bed. The Resident was receiving oxygen at 2.5 liters via nasal cannula. Review of Resident #44's active physician orders indicated the following: Review of the medical record failed to indicate a physician order for oxygen therapy was active. Further review of the medical record indicated the following physician order: May administer oxygen at 2 liters/min via nasal cannula as needed for Shortness of Breath. Start Date 6/3/25 and discontinued on 8/7/25. Review of Resident #44's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from June 2025 through September 2025 was left blank and did not contain documented administration of oxygen therapy at 2L. During an interview on 9/25/25 at 8:47 A.M., Nurse #4 said Resident #44 needs oxygen because his/her oxygenation levels drop and said the Resident is always on oxygen. During an interview on 9/25/25 at 9:01 A.M., Unit Manager #2 said Resident #44 is oxygen because he/she has a hard time breathing without it. Unit Manager #2 said nurses must follow the physician orders and care plan to care for the Resident and said Resident #44 should have an order in place for continuous oxygen at 2L because his/her oxygen levels will drop without it. The surveyor along with Unit Manager #2 reviewed Resident #44's electronic medical record and Unit Manager #2 said she is not sure why the order for 2L oxygen was discontinued on 8/7/25. Unit Manager #2 said the Resident needs oxygen continuously and does not remove it. During an interview on 9/26/25 at 11:56 A.M., Regional Clinical Consultant #1 said Resident #44 should have orders in place when receiving oxygen. During an interview on 9/29/25 at approximately 8:19 A.M., the surveyor observed Nurse #6 in Resident #44's room. Nurse #6 said Resident #44 requires oxygen because he/she can't breathe without it. During an interview on 9/29/25 at 1:05 P.M., the Director of Nursing said she expects orders to be in place and documented in the medical record for oxygen therapy. 2. Resident #1 was admitted to the facility in June 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), asthma and obstructive sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/22/25, indicated Resident #1 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. Further view of the MDS indicated that Resident #1 was documented as receiving oxygen. Review of Resident #1's active physician orders failed to indicate orders for either continuous or as needed [PRN] oxygen. Review of Resident #1's care plan, included but not limited to: -Focus: Resident has altered respiratory status/difficulty breathing with O2 use at 2 l/min (liters/minute) continuously r/t (related to) COPD, asthma. NP (an advanced practice registered nurse)/MD (Doctor of Medicine) to evaluate for weaning of oxygen and plan of care will be updated as indicated, initiated 1/7/25. -Interventions: Administer oxygen per ordered, initiated 9/25/25. On 9/24/25 at 9:32 A.M., the Surveyor observed Resident #1 lying in bed with a nasal cannula (a device that gives additional oxygen through the nose) in nostril. The oxygen tubing was connected to an oxygen concentrator set at 1.5 liters per minute (LPM). On 9/25/25 at 9:00 A.M., the Surveyor observed Resident #1 lying in bed with a nasal cannula (a device that gives additional oxygen through the nose) in nostril. The oxygen tubing was connected to an oxygen concentrator set at 1.5 liters per minute (LPM). During an interview on 9/25/25 at 11:41 A.M., Nurse #1 said when a resident requires oxygen, an order is received from the physician. The physician provides orders for the nurse that includes how many liters of oxygen should be administered. Review of Resident #1's active physician orders with Nurse #1 indicated that a physician order was documented in the Electronic Health Record (EHR) on 9/25/25 at 9:32 A.M., indicating the following: -Administer oxygen at 2 L/min (LPM) via nasal canula. During a follow up interview on 9/25/25 at 11:50 A.M., Nurse #1 said that the oxygen should not have been administered without a physician order. During an interview on 9/25/25 at 12:41 P.M., the Director of Nursing (DON) said, residents should have a physician order to receive oxygen with the number of liters per minute to be administered transcribed within the order. 3. Resident #32 was admitted to the facility in May 2025 and had diagnoses which included respiratory failure and heart failure. Review of Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status score of 13 out of a possible 15, indicating intact cognition. Resident #32 received oxygen therapy. On 9/24/25 at 8:52 A.M. the surveyor observed Resident #32 sitting in a wheelchair. The Resident wore a nasal cannula, and an oxygen concentrator was located next to his/her bed and running at 2 liters per minute. The surveyor observed that the surface of the oxygen concentrator filter was covered in a thick, white layer of dust. Review of Resident #32's physician orders indicated: Change Oxygen tubing, change O2 humidification bottle as applicable and clean filter (wash, rinse and pat dry filter) and change storage bag every week. Every nightshift every Sunday, dated 5/25/25. Review of Resident #32's September 2025 Treatment Administration Record (TAR) indicated staff last changed the oxygen concentrator air filter on 9/21/25. During an interview with Clinical Nurse Consultant #2 on 9/25/25 at 9:24 A.M., she said it was the facility's policy to change, or clean, oxygen concentrator filters one time per week to remove dust build up. She said dust has the potential of increasing the risk of infection and decreasing the efficiency of the concentrator. The Clinical Nurse Consultant said it did not appear that the filter was changed or cleaned on 9/21/25, as indicated on the September TAR. Review of the facility policy Use of Oxygen dated September 2024 did not reference the oxygen concentrator filter or cleaning.

Based on observations, record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four Residents (#61, #41, #59, and #32) out of a total sample of 17 residents. Specifically, 1. For Resident #61 the facility inaccurately coded no significant weight gain when there was one. 2. For Resident #41 and Resident #59, the facility inaccurately coded their ability to be understood. 3. For Resident #32, the facility inaccurately coded that the Resident was in a comatose state. Findings Include: 1. Resident #61 was admitted to the facility in November 2023 with diagnoses including stroke, heart disease, asthma and diabetes. Review of the medical record indicated the following weights: 2/27/2024 15:14 146.2 Lbs. (pounds) 3/5/2024 13:51 151.4 Lbs. 3/12/2024 12:11 147.0 Lbs. 3/19/2024 14:24 147.0 Lbs. 3/26/2024 16:26 149.0 Lbs. 4/2/2024 08:34 148.0 Lbs. 4/10/2024 13:10 146.3 Lbs. 4/17/2024 12:06 148.0 Lbs. 4/23/2024 15:06 148.7 Lbs. 4/30/2024 07:50 147.0 Lbs. 5/7/2024 14:18 148.0 Lbs. 6/4/2024 13:55 154.2 Lbs. 6/21/2024 11:48 157.2 Lbs. 6/25/2024 14:55 157.4 Lbs. 7/2/2024 15:51 172.8 Lbs. 7/24/2024 15:17 172.6 Lbs. 7/29/2024 07:57 174.0 Lbs. 8/8/2024 12:56 176.2 Lbs. 8/16/2024 15:14 173.8 Lbs. 8/22/2024 08:22 175.4 Lbs. 8/28/2024 13:28 178.8 Lbs. Further review of the recorded weights indicated that Resident #61 had experienced a significant weight gain of 22.30% of his/her total body weight in 6 months. Review of the MDS dated [DATE], indicated that Resident #61 did not have a significant weight gain. During an interview on 10/30/24 at 09:33 A.M. the Regional MDS nurse said that the MDS was coded in error and should indicate a significant weight gain. 36876 2a. Resident #41 was admitted to the facility in December 2022 with diagnoses including Parkinson's disease and cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #41's primary language was Spanish and he/she wants/needs an interpreter. Additional review of the MDS indicated in section C that the Brief Interview for Mental Status Exam (BIMS) should not be completed as Resident #41 was rarely/never understood. Review of the MDS' dated 3/3/24 and 6/3/24 also indicated Resident #41 was rarely/never understood and staff did complete the BIMS. During interviews on 10/30/24 at 9:01 A.M., and 9:34 A.M., the MDS Coordinator said that indicating Residents are rarely/never understood on the MDS was not related to their ability to speak English, but related to their cognitive status. Review of Resident #41's Patient Health Questionnaire (PHQ) - 9 completed with psych services and dated 8/28/24 indicated Resident #41 was able to participate in the interview process. During an interview on 10/30/24 at 10:13 A.M., the Psychiatric Nurse said that when she meets with Resident #41 she utilizes a language line to facilitate communication. The Psychiatric Nurse said that Resident #41 was able to converse and communicate. 2b. Resident #59 was admitted to the facility in April 2024 with diagnoses including cognitive communication deficit and dysphagia. Review of Resident #59's Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #59's primary language was Cantonese and he/she required an interpreter. Additional review of the MDS indicated that Resident #59 was rarely/never understood and staff did not complete the Brief Interview for Mental Status exam (BIMS). Review of the Psychiatric Evaluation and Consultant note dated 8/28/24 indicated: Pt (patient) was alert and cooperative with assessment. No agitation or aggression noted. No acute MH (mental health) concerns noted today. Review of Resident #59's Occupational Therapy Evaluation dated 10/17/24 indicated: Interpreter: Present. PT (patient) present able to communicate with patient in Cantonese. During interviews on 10/30/24 at 9:01 A.M., and 9:34 A.M., the MDS Coordinator said that indicating Residents are rarely/never understood on the MDS is not related to their ability to speak English, but related to their cognitive status. During an interview on 10/30/24 at 11:06 A.M., the Psychiatric Nurse said that Resident #59 was confused, but he/she was able to communicate with him/her through the use of the interpreter line. 49880 3. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated: -Comatose is defined as a pathological state in which neither arousal (wakefulness, alertness) nor awareness exists. The person is unresponsive and cannot be aroused; they do not open their eyes, do not speak and do not move their extremities on command or in response to noxious stimuli (e.g., pain). -To code yes to comatose if the record indicates that a physician, nurse practitioner or clinical nurse specialist has documented a diagnosis of coma or persistent vegetative state that is applicable during the 7-day look-back period. Resident #32 was admitted to the facility in April 2021 with diagnoses that include pneumonia and acute respiratory failure with hypoxia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 7/22/24, indicated that Resident #32 was comatose and could not participate in cognitive testing. On 10/29/24 at 7:58 A.M., the surveyor observed Resident #32 in bed awake with his/her eyes open. On 10/30/29 at 9:26 A.M., the surveyor observed Resident #32 in bed awake with his/her eyes open. Resident #32 did not respond verbally to the surveyor but looked at the surveyor when spoken to. Review of Resident #32's medical record failed to indicate a diagnosis of coma or persistent vegetative state. During an interview on 10/30/24 at 8:51 A.M., Nurse #2 said that Resident #32 was not comatose. Nurse #2 said that the Resident was awake and alert at times and opens his/her eyes when their spouse was visiting. During an interview on 10/30/24 at 8:42 A.M., Unit Manager #1 said that Resident #32 was not comatose and responded by opening his/her eyes especially when family was visiting, talking to, or touching him/her. During an interview on 10/30/24 at 9:34 A.M., the Regional MDS coordinator said that if Resident #32 opened his/her eyes and was awake and alert, then the Resident would not be considered comatose. During an interview on 10/30/24 at 10:17 A.M., the Director of Nurses and Infection Preventionist said that Resident #32 was not comatose and this would be a coding error on the MDS.

Based on observation, policy review and interview the facility failed to store medications in a safe manner, store medications in accordance with currently accepted professional principles and failed to follow manufacturer's instructions for storage. Specifically the facility failed to: 1. Store medication in secured (locked) locations, accessible only to designated staff in two medication carts on one of two units. 2. Store and label medications in accordance with currently accepted professional principles in one medication cart on one of two units. 3. Maintain temperatures in accordance with manufacturer specifications on one of two units Findings include: Review of the facility policy titled Medication Management-Medication Storage and dated reviewed 9/24 indicated that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Further review indicated that medications requiring refrigeration must be stored and monitored in a refrigerator located in the drug room at the nurse's station or other secured location. 1. On 10/29/24 at 7: A.M., the surveyor observed two medication carts on the first floor unit, open and not within sight of the nurse sitting at the nurse's station. The surveyor also observed three residents and several staff members in the hall with potential access to the medication carts. 2. On 10/29/24 at 2:56 P.M., the surveyor observed a medication cup with applesauce and crushed medications in the top drawer of the medication cart on the first floor unit. The surveyor observed that the medication cup was not labeled with the medications it contained or the name of the resident they belonged to. During an interview on 10/29/24 at 2:56 P.M., Nurse #1 said that she had placed the unlabeled medication cup with a resident's medication in the top drawer of the medication cart and she should not have. 3. On 10/29/24 at 3:07 P.M., the surveyor observed a warm, unopened, Levemir Flex Pen (insulin), in the top drawer of the medication cart on the second floor unit. Review of the manufacturer's directions indicated that the Levemir Flex Pen is to be kept refrigerated until opened. During an interview on 10/29/24 at 3:07 P.M., Nurse #2 said that she didn't know when the unopened Levemir Flex Pen had been put in the medication cart but that it should remain in the refrigerator until opened.

Based on record review and interviews, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#16), out of a total sample of 17 residents, when the Resident was discharged from hospice services. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated: - A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (assessment reference date) must be within 14 days from the effective date of the hospice election revocation. Resident #16 was admitted to the facility in November 2021 with diagnoses that include dementia and history of Covid-19. Review of the most recent Minimum Data Set Assessment, (MDS) Assessment, dated 9/6/24 indicated that the Resident could not participate in a Brief Interview for Mental Status exam, but was assessed by staff to have severe cognitive impairment. The MDS further indicated that the resident was not receiving hospice services. Review of the quarterly MDS Assessment, dated 3/6/24, indicated that Resident #16 was receiving hospice services. Review of the quarterly MDS Assessment, dated 6/6/24, indicated that Resident #16 was not receiving hospice services. Review of Resident #16's medical record indicated a form for revocation of hospice services indicating the hospice disenrollment date of 4/19/24. Review of the medical record failed to indicate a Significant Change in Status Assessment was completed upon disenrollment of hospice services. During an interview on 10/30/24 at 8:55 A.M., Unit Manager #1 said that Resident #16 was receiving hospice services but was doing well and gaining weight so he/she was taken off hospice services. Unit Manager #1 said she was unaware of whether a Significant Change in Status Assessment should have been completed when hospice services ended. During an interview on 10/30/24 at 9:34 A.M., the Regional MDS coordinator said that for a change in status, such as stopping hospice services, a Significant Change in Status Assessment should have been completed, but it was not. During an interview on 10/30/24 at 10:15 A.M. with the Director of Nurses and the Infection Preventionist they said a Significant Change in Status Assessment should have been completed for Resident #16.

Based on observation, record review, and interview, the facility failed to 1.follow the care plan intervention to prevent a fall with a fracture and laceration for one Resident #1.2. implement and develop appropriate interventions to prevent a fall with a fracture for one Resident (#35), 3. complete a fall investigation report after a fall for one Resident (#7), and 4. keep one Resident (#67) free from accidents/hazards after ingestion of lotion with subsequent hospitalization, . 5(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition out of a total sample of 30 residents. Findings include: Review of the facility policy titled Falls Program Policy, dated 09/2023, indicated the following: - Fall assessment should be completed upon admission, re-admission, quarterly, significant change in resident status and as needed. Identify residents fall risk after completing and reviewing the fall assessment. - Develop individualized care plan. - Review and revise care plan regularly, as needed. - Documentation of falls: complete incident report, fall investigation report and obtain witness statements. Monitor resident vital signs. Monitor neurological checks for any unwitnessed fall. Care plan needs to be updated reflective of resident status. Residents who have had a fall need this information shared with the IDT (interdisciplinary team). Rehab screen to be completed as indicated. Completed incident report and fall investigation report are to be submitted to the DNS or designee for review. 1. Resident #1 was admitted to the facility in July 2023 with diagnoses including wedge compression fracture of the lumbar vertebra, need for assistance with personal care and anxiety. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 9 out of possible 15 on the Brief Interview for Mental Status. The MDS further indicated that he/she required extensive assistance of two people for bed mobility and transfers. Review of the care plan related to falls, dated 7/20/23, indicated: -The resident is at risk for falls related to history of falls, acute on chronic low back pain due to acute compression fractures, chronic lumbar/ low back pain, multiple vertebral fractures, muscle weakness, impaired mobility, and dizziness. Intervention date initiated 7/20/23, indicated the following: -Ensure that the resident is wearing appropriate footwear. Intervention date initiated 8/14/23, indicated the following: -Bed/ chair alarm at all times. Review of the current physician orders date initiated 8/16/23, indicated the following: -Bed sensor alarm on when resident is in bed. Check every shift for proper placement and is in good working order every shift. Review of the nursing note indicated: 10/21/2023 at 11:23 P.M.: Nurse's Note: Note text; Patient alert and responsive, was compliant his/her medication. At about 11:15 P.M. this nurse was called in by a nursing aide to see patient was on the floor. This nurse observed that patient was lying face down in a pull of her own blood. This nurse called emergency ambulance for patient to be taken to hospital for further evaluation. The primary physician and the patient's granddaughter were called and a voice mail left. Both calls were not returned by the time this nurse finally handed over to incoming nurse. We will continue to monitor (sic). Review of the fall incident report dated 10/21/23 indicated: -11:15 P.M patient found on the floor of his/her room next to his/her bed, patient found face down in a pull (sic) of blood, wet cloth used to apply pressure and 911 was called. -Nature of injury- Laceration to the face. Review of the fall investigation work sheet included as part of the fall investigation indicated at the time of the fall the following footwear/equipment (at the time of fall), failed to include use of appropriate footwear and use of bed alarm. Further review of the fall investigation worksheet indicated that following the fall the recommendations were implemented to prevent further falls/immediate interventions including: -Floor mats both sides of the bed, bed alarm. Review of written staff statement from staff members indicated the following: -Nurse #1 statement, dated 10/21/23: Last saw resident in bed at 11:25 P.M. Nurse was called in to see the patient who was on the floor in a pull [sic] of blood. -Certified Nursing Assistant (CNA) #5 statement, dated 10/22/23: Last saw resident when doing rounds and found the resident on the floor, did not see anything that would contribute to the fall, alerted the nurse. Further review of the incident report and the witness staff statements failed to include information indicating Resident #1's bed alarm was sounding. Review of fall incident report submitted to the state agency, 10/22/23, indicated that Resident #1 had nothing on his/her feet at the time of the fall. Review of the hospital Discharge summary, dated [DATE], indicated the following: -Resident #1 sustained a right periprosthetic humeral (large bone in the arm) shaft fracture, metacarpal (bone in hand) fractures and eight sutures to the left eyelid laceration On 11/3/23 at 11:24 A.M., the surveyor attempted to interview CNA #5, CNA #5 did not return the request for interview. During a phone interview on 11/8/23 at 8:42 A.M., Nurse #8 said Resident #1 had the alarm on at the time of the fall, but he was not sure if it was functioning. Nurse #8 said he did not hear the alarm sound. During an interview on 11/3/23 at 10:38 A.M., the Director of Nursing (DON) said the alarm for Resident #1 should have sounded when the Resident was found on the floor. The DON and the surveyor reviewed the fall incident report. The DON said that the footwear at the time of the event and the alarm were not checked off as being utilized at the time of the fall but should have been checked of if the alarm was being used. 3(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition. Resident #5 was admitted to the facility in February 2019 with diagnoses including a history of falls. The most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. A review of the Nurses progress notes dated 11/1/23 indicated that Resident #5 had fallen. Further review of the fall care plan indicated a fall intervention created on 11/1/23 indicating the following: *Fall out of bed with bruise to right upper side of forehead. Intervention: Scoop mattress During an observation on 11/3/23 at 8:42 A.M., the surveyor observed the Resident sleeping in bed on an air mattress. During an observation and interview with Certified Nurse's Assistant (CNA) #4 on 11/3/23 at 8:51 A.M., she said the Resident was sleeping on an air mattress and not a scoop mattress. During an interview with the Unit Manager #2 at 11/3/23 at 9:34 A.M., she said the Resident had a fall on 11/1/23, interventions were added to his/her fall care plan to get him/her a scoop mattress, she said when fall interventions are added, they should be implemented immediately. During an interview with the Director of Nurses on 11/3/23 at 9:46 A.M., he said he expects fall interventions added after a fall to be implemented immediately. (b). Resident #5 was admitted to the facility in February 2019 with diagnoses including a history of falls. The most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. A review of the November physician's orders indicated the following: * Bed sensor alarm on when resident is in bed. Check every shift for proper placement and is in good working order. Start date 11/1/23. During an observation on 11/3/23 at 8:42 A.M., the surveyor observed the Resident sleeping. The Resident was observed moving around the bed in his/her sleep, there was no sound from the bed alarm. During an observation and interview with Unit Manager #2 on 11/3/23 at 9:34 A.M., Resident # 5 was observed out of bed in a broda chair. Unit Manager #2 removed the bed alarm placed under the Resident's bed sheets, she repeatedly tried to press the alarm but there was no sound, she checked the battery port, there were only two batteries, she said the alarm should have three batteries so it can work properly. During an interview with the Director of Nurses on 11/3/23 at 9:46 A.M., he said bed alarms should be always functional, staff should be checking every shift for proper placement and making sure the alarm is in good working order. 2. Resident #35 was admitted in 03/2023 with diagnoses including depression and hypertension. Review of the Minimum Data Set (MDS), 9/27/23, indicated that Resident #35 is rarely/never understood. Resident #35 requires extensive assist with toilet use, personal hygiene, bed mobility, and transfers. Review of the care plan, dated 3/30/23, indicated the following: - The resident is at risk for falls related to confusion, deconditioning, gait/balance problems < s/p falls, R-humerus fracture, UTI, confusion Review of the activities of daily living flow sheets for April 2023 indicated that toileting every 2 hours was in place at the beginning of April. Review of the fall incident reports indicated that Resident #35 had the following falls and interventions: - On 4/8/23 at 11:35 P.M., Resident #35 was observed sitting on the floor in his/her room going to the bathroom. The intervention put in place after the fall was toileting every 2 hours. - On 4/28/23 at 5:45 A.M., Resident #35 was observed lying on the floor in his/her room after attempting to go to the bathroom. The intervention put in place after the fall was to toilet every 2 hours and offer to toilet on 11-7 shift. - On 9/4/23 at 9:45 A.M., Resident #35 was observed in his/her bathroom on the floor after hitting the top of his/her head on the toilet paper dispenser. The intervention put in place was to educate and ensure Resident #35 is not carrying liquids when ambulating. - On 10/7/23 at 10:45 P.M., Resident #35 was found on the floor on left side in the bathroom after falling head first while reaching for toilet paper. The Resident sustained a laceration with 5 sutures to his/her left eye. The intervention was to offer toileting to Resident #35 after breakfast. Review of the care plan indicated that the last intervention updated was on 3/30/23. During an interview on 10/20/23 at 10:12 A.M., the Director of Nursing said that he doesn't usually like the 2 hour toileting and is usually a quick intervention that you put in place. The DON said that the 2 hour toileting intervention should have been re-evaluated because if the Resident is still falling then it means the intervention is not working. The DON said that the interventions should be appropriate for the fall and address the reason for the fall. He said that the intervention to not carry liquids when ambulating should have been related to the fall. 3. Resident #7 was admitted in February, 2018 with diagnoses including dementia and heart failure. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 scored a 1 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated severe cognitive impairment. Resident #7 requires limited assistance with toilet use, bed mobility, and transfers. During an observation on 10/17/23 at 10:32 A.M., Resident #7 was found on the floor by the surveyor. The surveyor notified the nurse on duty and the nurse responded. Vitals were taken on the Resident and the Resident was put back into bed. On 10/18/23, review of the fall incident reports did not indicate that a fall investigation had been started on the incident that occurred on 10/17/23. During an interview on 10/19/23 at 12:37 P.M., the Director of Nursing said he was not made aware of the fall that occurred with Resident #7 and that he did not have an investigation for the fall. 4. Resident #67 was admitted in March, 2023 with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #67 scored a 1 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated severe cognitive impairment. Review of the MDS indicated that Resident #67 requires extensive assistance with all activities of daily living and is independent with eating. Review of the clinical record indicated that on 10/13/23, Resident #67 was observed in his/her room ingesting a bottle of lotion. Resident #67 was sent out to the hospital for further evaluation. Review of the care plan did not indicate that Resident #67 had any interventions put in place after the incident occurred. During an observation on 10/19/23 at 8:26 A.M., Resident #67 had a tube of polygrip (a denture adhesive cream) in his/her bedside table. During an observation on 10/20/23 at 7:45 A.M., Resident #67 had a tube of polygrip in his/her bedside table. During an interview on 10/20/23 at 7:40 A.M., the Director of Nursing said that Resident #67 should not have any non-food items within reach after an incident of ingestion. He also said that a care plan should be put in place with interventions to prevent ingestion of non-food items.

Based on observations, policy review, and interview, the facility failed to 1.) ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents and 2.) ensure nursing staff disinfected a blood glucose monitor after use. 3.) maintain measures they have in place to prevent the growth of Legionella, specifically, failed to monitor and document weekly testing protocols. Findings include: Review of the facility policy titled, Cleaning Equipment, dated as reviewed September 2023, indicated: 4. DME (durable medical equipment) must be cleaned and disinfected before reuse by another resident. 1.) The facility failed to ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents. On 10/19/23 at 8:30 A.M., the surveyor observed Nurse #3 obtain a Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. The surveyor continued to observe Nurse #3. On 10/19/23 at 8:34 A.M., the surveyor observed Nurse #3 obtain another Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. The surveyor continued to observe Nurse #3. On 10/19/23 at 8:40 A.M., the surveyor observed Nurse #3 obtain another Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. During an interview on 10/19/23 at 8:45 A.M., Nurse #3 said he should have cleaned the blood pressure between Residents but he did not. During and interview on 10/20/23 at 9:11 A.M., the Infection Control Nurse said the Nurse #3 should have cleaned the blood pressure cuff between Residents. During an interview on 10/20/23 at 10:55 A.M., the Director of Nursing said the Nurse #3 should have cleaned the blood pressure cuff between the Residents. 2.) The facility failed to ensure nursing staff disinfected a blood glucose monitor after use. Review of the facility policy titled, Glucose Testing with Glucometer, dated as reviewed September 2023, indicated: 14. Clean according to manufacture's guidelines, meter shut down after 2 minutes, first to clean and the 2nd to disinfect. On 10/19/23 at 8:42 A.M., the surveyor observed Nurse #3, obtain a storage bag from the medication cart containing a glucometer (machine used to obtain a blood sugar level), test strips, lancets, gauze and alcohol swabs, and bring the storage bag into a resident room. -Nurse #3 placed the storage bag directly on the Resident's bedside table, which had papers and crumbs. -Nurse #3 took out the glucometer, the bottle of test strips, a lancet, gauze and an alcohol swab and placed these items directly on the bedside table. -Nurse #3 obtained the Resident's blood sugar, removed the test strip from the glucometer without cleaning the glucometer, with the same hand that he had just removed the bloody test strip, Nurse #3 then placed the glucometer and the bottle of tests strips back into the storage bag. -Nurse #3 returned to the medication cart. During an interview on 10/19/23 at 8:44 A.M., Nurse #3 said that he should have cleaned to glucometer before placing it into the storage bag. During an interview on 10/20/23 at 9:10 A.M.,the Infection Control Nurse said that Nurse #3 should have only brought in the supplies for the blood sugar check. The Infection Control Nurse said that Nurse #3 should have disinfected the glucometer after use. During an interview on 10/20/23 at 10:56 A.M., the Director of Nursing (DON) said that Nurse #3 should have only brought in the supplies for the blood sugar check. The DON said that Nurse #3 should have disinfected the glucometer after use. 43807 3. The facility failed to maintain measures they have in place to prevent the growth of Legionella, specifically, failed to monitor and document weekly testing protocols. A review of the facility policy titled 'Water Management Program' with no revision date indicated the following: *The Maintenance Director is responsible for the documentation, coordination and communication of all water management program activities. *Weekly monitoring and documentation of water pressure in the building *Weekly testing and documentation of water temperatures A review of the record indicated that the weekly water management protocols to test water temperature and water pressure was last done in 2022. During an interview with the Maintenance Director on 10/20/23 at 8:54 A.M., he said he is expected to document all the weekly testing protocols in the facility, he said he has not documented any weekly monitoring of the water pressure and water temperatures from the beginning of 2023 to date. During an interview with the Administrator on 10/20/23 at 10: 56 A.M., she said the Maintenance Director is expected to document weekly testing protocols that include water temperature and water pressure. She said he has not documented any weekly testing water management protocols in 2023 to date.

Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve nutritional value, flavor, palatability and at appetizing temperatures on two of two units. Findings include: During the initial Resident screening process, numerous residents voiced concerns and displeasure about the overall food quality, temperature, and variety they are provided. During the resident council group meeting on 10/19/23 at 10:00 A.M., 15 out of 15 participating residents said they did not like the food quality, and everything is always covered in chicken gravy. On 10/19/23 at 12:20 P.M., the second-floor unit test tray arrived. After all residents received this lunch tray, the surveyor received the test tray at 12:26 P.M. The following was recorded: *Baked ham with brown gravy and pineapple: temperature 134 degrees Fahrenheit. Warm to taste, not hot. Tasted very bland, was rubbery and salty. *Spinach: 118 degrees Fahrenheit. Warm to taste, not hot. Mushy in texture and was very salty. *Cheesy Potatoes: 138 degrees Fahrenheit. Warm to taste, not hot. *Cake: Very dry upon opening it and fell apart. Dry to taste, no taste. On 10/19/23 at 12:45 P.M., the first-floor unit test tray arrived. The following was recorded: *Baked ham with brown gravy and pineapple: temperature 143 degrees Fahrenheit. Warm to taste, not hot. Tasted very bland, was rubbery and salty. *Spinach: 146 degrees Fahrenheit. *Cheesy Potatoes: 152 degrees Fahrenheit. Warm to taste, not hot. *Cake: Very dry upon opening it and fell apart. Dry to taste, no taste. *Juice: 57 degrees Fahrenheit. Not cold to taste. During an interview on 10/20/23 at 11:08 A.M., the Foodservice Director acknowledged that the Residents are not happy with the food and that changes need to be made to the food.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 4 nurses observed made 4 errors out of 31 opportunities, resulting in a medication error rate of 12.9%. Those errors impacted 2 Residents (#11 and #63), out of 4 residents observed. Findings include: Review of the facility policy titled, Administering Medications, dated as Revised December 2012, indicated medications shall be administered in a safe and timely manner and as prescribed. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the administration. 1.) For Resident # 11, Nurse #1 administered the incorrect dose of calcium with vitamin d, the incorrect dose and incorrect form of metoprolol (cardiac medication) and opened a zonisamide (seizure medication) capsule that indicated to swallow whole. On 10/19/23 at 8:09 A.M. the surveyor observed Nurse #1 prepare and administer medications to Resident #11 including: - calcium (600 milligrams/mg) with vitamin d (10 micrograms/mcg) , 1 tablet - metoprolol ER 25 mg, 2 tablets crushed. Further review of the medication card indicated **DO NOT CRUSH** - zonisasmide 100 mg, 2 capsules. Further review of the medication card indicated Swallow Whole. Do Not Chew Or Crush Review of the physician's orders indicated the following: - 9/20/23: Calcium 600-Vitamin D3 Oral Tablet 600 mg-20 mcg, give 1 tablet by mouth one time a day for SUPPLEMENT (incorrect dose). - 10/16/23: Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 50 MG (Metoprolol Succinate), give 1 mg by mouth two times a day for HTN (hypertension). (incorrect dose and incorrect form) - 10/16/23: Zonisamide Oral Capsule 100 MG (Zonisamide), give 2 capsule by mouth one time a day for seizure (opened capsule) During an interview on 10/19/23 at 1:00 P.M., Nurse #1 said she administered the incorrect dose of calcium with vitamin d. Nurse #1 said she did not read the instructions and crushed the metoprolol and she did not administer the correct dose or form of metoprolol. Nurse #1 said she did not read the instructions for the zonisamide and should not have opened the capsules. During an interview on 10/20/23 at 9:14 A.M., the Infection Control Nurse said that Nurse #1 should have verified the physician's orders and administered the correct dose of calcium and vitamin d and metoprolol. The Infection Control Nurse said Nurse #1 should have followed the manufacture's guidelines for the zonisamide. During an interview on 10/20/23 at 10:54 A.M., Director on Nursing said that Nurse #1 should have verified the physician's orders and administered the correct dose of calcium and vitamin d and metoprolol. The DON said said Nurse #1 should have followed the manufacture's guidelines for the zonisamide. 2.) For Resident #63 Nurse #2 administered the incorrect dose of calcium with vitamin d. On 10/19/23 at 8:05 A.M. the surveyor observed Nurse #2 prepare and administer medications to Resident #63 including: -calcium with d 500 mg/ 5 mcg, 1 tablet Review of the physician's order, dated 6/23/23, indicated for nursing to administer: Calcium+D3 Oral Tablet 500 mg-10 mcg, give 400 unit by mouth one time a day related to vitamin d deficiency. During an interview on 10/19/23 at 2:10 P.M., Nurse #2 said he administered the incorrect dose of calcium with vitamin d. During an interview on 10/20/23 at 9:20 A.M., the Infection Control Nurse said Nurse #2 should have administered the correct dose of calcium with vitamin d. During an interview on 10/20/23 at 10:54 A.M., the Director of Nursing said Nurse #2 should have administered the correct dose of calcium with vitamin d.

Based on observation, interview, and policy review, the facility failed to ensure controlled medications were locked appropriately, medications were stored in clean/sanitary conditions, medications were labeled/dated appropriately and medications that had a shortened expiration date were not available for use in two out of two observed medication carts and one medication storage room. Findings include: Findings include: Review of the facility policy titled Storage of Medications undated included the following: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use. On 10/20/23 at 9:14 A.M., the surveyor observed the following on the 2nd Floor B side Medication Cart: -Opened and undated bottle of Prostat. During an interview on 10/20/23 at 9:14 A.M., Nurse #7 said the prostat should have a date that it was opened. On 10/20/23 at 9:33 A.M., the surveyor observed the following on the 1st Floor A side Medication Cart: -Opened and undated bottle of Prostat. - An opened and undated Trelegy inhaler. During an interview on 10/20/23 at 9:35 A.M., Nurse #6 said the expectation for Trelegy inhaler is to be dated once opened. On 10/20/23 at 9:40 A.M., the surveyor observed the following in the 1st Floor Medication Storage Room: - A box of liquid Lorazepam (a benzodiazepine used for seizure disorder or anxiety) in the fridge, not in a lock box. - A plastic bag full of water that contained four bottles of Latanoprost eye drops. - An opened Humalog insulin vial dated, opened 8/5/23. - A box containing a new vial of Lantus that was wet. During an interview on 10/20/23 at 9:40 A.M., Nurse #6 said the Lorazepam should have been locked in the lock box located in the refrigerator. Nurse #6 said insulin is only good for 28 days once opened and the bottle should have been discarded. Nurse #6 was unsure why the plastic bag containing Latanoprost eye drops and Lantus insulin was full of water but should not be like that. During an interview on 10/20/23 at 11:16 A.M., the Director of Nursing (DON) said the expectation for controlled medications that are refrigerated is to be locked within the lock box inside the fridge. The DON said medication areas are expected to be clean. The DON said insulin should be discarded after 28 days, and Prostat and Trelegy should have been dated once opened.

Based on observation, record review and interview, the facility failed to notify the physician of a change in status for one Resident (#23) out of a total sample of 30 Residents. Specifically, the facility failed to notify the physician when the Resident was observed to have vomited significantly while in bed. Findings include: Resident #23 was admitted to the facility in December 2022 with diagnoses including cerebral infarction and hemiplegia/hemiparesis. Review of Resident #23's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living. On 10/17/23 at approximately 8:35 A.M., the surveyor walked into Resident #23's room and observed a large amount of vomit on the floor next to his/her bed. Upon entering, a nurse entered the room and asked for assistance to clean up Resident #23. Review of Resident #23's physician's orders indicated the following: *Monitor for adverse effects of opioid medication including: constipation, vomiting, dry mouth, fatigue, dizziness, confusion and new or worsened depression, itching, sweating. Notify MD (medical doctor) of any significant findings every shift. Order date: 3/28/23 *Tramadol HCl Tablet 50 MG (milligrams) (an opioid medication used to treat pain). Order date: 3/28/23. Review of Resident #23's medical record on 10/20/23 at 7:05 A.M., including all nursing and physician progress notes failed to mention that Resident #23 vomited and did not indicate that the physician was ever notified of the change in condition. During an interview on 10/20/23 at 7:39 A.M., Nurse #7 said whenever the doctor or nurse practitioner is notified it should be documented in the medical record. She continued to say they should have documented in the medical record that the nurse practitioner was notified so the entire interdisciplinary team is updated on Resident #23's condition. During an interview on 10/20/23 at 8:27 A.M., the Director of Nurses said the facility needs to be documenting when the physician is notified otherwise it did not happen. He said the physician should have been notified after Resident #23 vomited and it should have been documented in the medical record and he said it is a concern.

Based on record review and interview, the facility failed to 1. investigate a bruise of uknown origin for one Resident (#35) and 2. failed to investigate injury of unknown origin (laceration to head) for one Resident (#34) out of a total sample of 30 residents. Findings include: 1. Review of the facility policy titled Resident Rights and Ethics- Abuse/Neglect, dated 09/2023, indicated the following: - Injuries of uknown source: * the source of the injury was not observed by any person * the source of the injury could not be explained by the resident * the injury is suspicious because of the extent of the injury or the location of the injury Resident #35 was admitted in 03/2023 with diagnoses including depression and hypertension. Review of the Minimum Data Set (MDS), 9/27/23, indicated that Resident #35 is rarely/never understood. Resident #35 requires extensive assist with toilet use, personal hygiene, bed mobility, and transfers. Review of the progress note, dated 5/22/23, indicated that staff had discovered a bruise of uknown origin on Resident #35's back on his/her left ribs. During an interview on 10/19/23 at 12:54 P.M., the surveyor asked the Director of Nursing for the investigation regarding the bruise, but was never provided an investigation. 46339 2. Resident #34 was admitted to the facility in March 2023, with diagnoses including Alzheimer's disease, dementia and falls. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 00 out of a possible 15 indicating severe impaired cognition. The MDS further indicated the Resident requires extensive assist for activities of daily living. Review of progress note dated 10/19/23 indicated the Resident was noted with blood on his/her pillowcase and a laceration on the back of his/her head. Resident was sent to the hospital. During an interview on 10/20/23 at 7:42 A.M., the Director of Nursing (DON) said injuries of unknown origin have to be assessed and an incident report with investigation should be completed to find the root cause. The DON was unable to provide an incident report with investigation.

Based on observation and interview, the facility failed to provide a homelike environment, specifically, failed to address a chirping fire alarm. Findings include: During an observation on 10/17/23 at 8:15 A.M., the surveyor observed a fire alarm in room [ROOM NUMBER] chirping repeatedly. During an observation on 10/20/23 at 8:16 A.M., the surveyor observed the same fire alarm in room [ROOM NUMBER] chirping repeatedly. During an interview on 10/20/23 at 8:16 A.M., the Maintenance Director said that he is usually told about an issue in the building via the log book or is called if there is an emergency. The Maintenance Director said that he was not aware or told of the chirping fire alarm in room [ROOM NUMBER].

Based on record review, observation and interview the facility failed to ensure that one Resident's room (#6) was kept clean and free from offensive odors in a total sample of 15 residents. Findings include: Resident #6 was admitted to the facility in 2007. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) coded the resident as "3" or severely cognitively impaired. The MDS coded the resident as "4" (requiring total care) for all activities of daily living. The surveyor entered the first floor unit on 8/14/12 at around 8:00 A.M. The unit consists of rooms along two sides, and the central section of the unit is reserved for offices, the nurses station and the nutrition kitchen. The surveyor detected a very strong urine odor walking down the left side corridor begining at rooms 113-114 which were located towards the front entrance of the unit. The odor increased as the surveyor walked the length of the left corridor. The odor was more pronounced near the Resident's room which was located in the right hand corridor towards the back of the unit. When the surveyor entered the Resident's room the smell was almost overpowering. The Unit Manager, who accompanied the surveyor on the tour of the unit, told the surveyor that the Resident's roommate had "hygiene issues" and had a specific behavior care plan and behavior contract dated 2/12 for hygiene, as the roommate was incontinent and refused to allow staff to either clean the room, change the linens on the bed, or wash and change him/her. During the initial tour, the surveyor observed housekeeping cleaning rooms on the unit. There were no odors emanating from any of the other rooms. The surveyor briefly interviewed one of the housekeeping staff on 8/14/12 at around 8:45 A.M. During interview the housekeeping staff told the surveyor that although the staff entered Resident #6's room at least twice a day to clean and wash floors, the smell wouldn't go away. The surveyor interviewed the Resident's family member around 1:00 P.M on 8/14/12 in the rear section of the unit. The surveyor asked the family member if they noticed an odor in the room. The family member told the surveyor that they visited the resident every day and that the smell was pervasive and occurred on almost a daily basis. The family member told the surveyor that the roommate would throw food remains, spill liquids, urinate and defecate in briefs and throw the briefs onto the floor. The family member told the surveyor that the roommate would not allow housekeeping to clean up his/her side of the room. The family member told the surveyor that the roommate would open the windows in the room and keep them open no matter what the outside temperature was. On 8/14/12 the temperature was recorded at 86 degrees. During the family interview, the family member invited the surveyor to view some family photos on the wall of the room. When the surveyor and family member entered the room, both the family member and the surveyor inadvertently gagged because of the overwhelming smell of old urine in the very warm room. The windows were open in the room. After the 1:00 P.M. family interview the surveyor spoke with the Unit Manager and asked the Manager to accompany her to the room. The Unit Manager confirmed the presence of the very strong smell. The Unit Manager arranged for the room to be "terminally cleaned" starting that afternoon. The roommate's mattress was replaced, the curtains were replaced and the room was thoroughly cleaned. On 8/15/12 the surveyor entered the room at around 10:30 A.M. and there was no odor. The Resident's family consented to a temporary room change while the room was being cleaned. The roommate was moved to a private room during the room cleaning. The Unit Manager told the surveyor that the roommate was residing in the new room at the end of survey on 8/16/12.