Every finding on record at Cambridge Rehabilitation & Nursing Center

Based on observations, record review, and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure that two of two medication room refrigerators were maintained at an appropriate temperature for medication storage. Findings include:Review of the facility policy titled, Storage - Labeling - Maintenance of Medications, dated 7/8/25, indicated medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. 2. Medications requiring refrigeration shall be kept separate from food. a. The refrigerator must maintain a proper temperature 36 to 46 degrees Fahrenheit. b. Medications requiring refrigeration or temperatures between 36 to 46 are kept in a refrigerator with a thermometer. 1. On 5/6/26 at 7:25 A.M., the surveyor and Nurse #4 observed in the first-floor medication room a medication refrigerator with a temperature reading as 52 degrees Fahrenheit (F). There was condensation observed within the refrigerator with drops of water dripping from the ice section on to the lower shelf. Inside the refrigerator were the following medications that were warm to touch: -two Insulin Lispro Injection pens, Manufacture's guidelines indicate to store in refrigerator at temperature between 36 degrees F and 46 degrees F. -three Prolia (denosumab) Injections, Manufacture's guidelines indicate to store in refrigerator at temperature between 36 degrees F and 46 degrees F. -ten Influenza Vaccine (Afluria) pre-filled syringes, Manufacture's guidelines indicate to store in refrigerator at temperature between 36 degrees F and 46 degrees F. -eight Trulicity (dulaglutide injection) pens, Manufacture's guidelines indicate to store in refrigerator at temperature between 36 degrees F and 46 degrees F. - two bottles of liquid Lorazepam Oral Concentrate, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F, to maintain stability and potency. -one Emergency Medication Kit containing: one injection vial of Insulin Glargine, one injection vial of NPH Insulin, and one injection vial of Insulin Lispro. Sticker from pharmacy indicated Maintain Temperature Between 36 degrees F and 46 degrees F. On 5/6/26 at 7:35 A.M., the surveyor and Unit Manager #2 observed the temperature reading of 52 degrees F. Unit Manager #2 said she is not sure why it is warm and said the Maintenance Director changed out the thermometer last week because it was not working. Unit Manager #2 reviewed the daily refrigerator logs, and she said she was not sure why it was warm. During an interview on 5/6/26 at 7:43 A.M., Nurse #5 said sometimes the thermometer does not work and the temperature will read higher than it should and said the temperature was high last weekend, but she does not know why. Review of the documented Refrigerator Temperature Log for May 2026 was left blank and contained no documented temperatures on 5/1/26 and 5/4/26. Further review indicated 11 undocumented temperatures out of 30 days during the month of April. During an interview on 5/6/26 at 7:49 A.M., the Director of Maintenance said this is the first he has been notified of any issues with the refrigerator on the first-floor unit and said he was just asked to put a new thermometer into the refrigerator as it is not working. On 5/6/26 at 11:32 A.M., the surveyor along with Unit Manager #2 observed in the first-floor medication room a medication refrigerator with a temperature reading as 50 degrees Fahrenheit (F). During an interview 5/6/26 at 11:34 A.M., Unit Manager #2 said the temperature should not be that high and said the temperature should be below 50 degrees Fahrenheit. Unit Manager #2 said she would remove the medications to a different refrigerator. During an interview on 5/6/26 at 11:40 A.M., Nurse Practitioner (NP) #1 said medications requiring refrigeration must be within the recommended safe range and said 52 is not a safe range for medications storage. NP #1 said the medications must be thrown away as they are unsafe to administer if not kept in a safe temperature range. During an interview on 5/6/26 at 11:49 P.M., the Director of Nursing (DON) said that the medication room refrigerators must be checked and documented daily, and any unsafe range must be reported. The DON said medication manufacture's guidelines must be followed and said 52 degrees is not within a safe range. During an interview on 5/6/26 at 11:50 A.M., the Regional Clinical Nurse said the medications must be removed and discarded as they were not stored in a safe temperature range. On 5/6/26 at 12:05 P.M., the surveyor observed Unit Manager #2 bringing the medications removed from the first-floor refrigerator over to the second-floor refrigerator. 2. On 5/6/26 at 11:07 A.M., the surveyor and Nurse #2 observed in the second-floor medication room a medication refrigerator with an internal temperature reading as 28 degrees Fahrenheit (F). Inside the refrigerator were the following medications that were cold to touch: - seven Tresiba flex pens, manufacture's guidelines indicate to store unused Tresiba pens in the refrigerator at 36 degrees F to 46 degrees F. - five Humalog flex pen, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F. - four Lantus flex pen, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F. - one NovoLog flex pen, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F - one bottle of liquid lorazepam, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F, to maintain stability and potency. - one vial of Humalog insulin, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F - one vial of Novolin N insulin, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F. - one vial of glargine insulin, manufacture's guidelines indicate to store in a refrigerator at a temperature between 36 degrees F and 46 degrees F. On 5/6/26 at 11:14 A.M., the surveyor and Unit Manager #1 observed the temperature reading of 28 degrees F. Unit Manager #1 said she was not sure why the medication refrigerator was so cold to touch. Unit Manager #1 reviewed the daily refrigerator logs, and she said she was not sure what happened today and she said that they recently received a new refrigerator. During an interview on 5/6/26 at 12:01 P.M., the Director of Nursing (DON) said that the medication room refrigerators temperatures should be set to the medication manufacture's guidelines. The DON and the surveyor went to the second-floor medication room. On 5/6/26 at 12:03 P.M., the surveyor and the DON observed the second-floor medication room refrigerator thermometer reading 32 degrees F. The temperature dial was set to the max setting. The DON said that she would review the manufacture's recommendations with nursing.

Based on observation and interview, the facility failed to ensure food is stored in accordance with professional standards of food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically, the facility failed to ensure available food was not expired or showing signs of decompensation, and that food was dated and stored appropriately in the main kitchen refrigerator second-floor kitchenette.Findings include:Review of facility policy titled Storage and Labeling of Food Brought in by Family/ Visitors, dated as effective 6/25/25 indicated the following:-Properly stored and labeled refers to both the dating of all newly opened food and drink items provided by the facility as well as all food items brought in by family members for the residents and food items belonging to and brought in by staff members. All food and drink items are required to have proper labeling for easy identification.-The Kitchen Department will clean and inspect labeled food items in all unit refrigerators on a weekly basis. Any outdated items will be immediately discarded.On 5/4/26 at 6:55 A.M., the surveyor made the following observations in the fridge in the emergency food storage room with the Food Service Director.-A tray of plastic cups containing Coleslaw, dated 4/14/26.-An undated cup of pudding.-An undated bag containing a head of cabbage with brown leaves and signs of decompensation.-An open bin of green peppers, undated, with signs of decompensation and a white fuzzy substance on them.-A covered and undated bin of brown and wilting celery with signs of decompensation.-An undated bucket of gelatin.On 5/4/26 at 7:51 A.M., the surveyor observed, in the second-floor kitchenette fridge two pitchers of cranberry juice, one was labeled with a use by date of 5/2/26 and one was labeled with a use by date of 5/3/26.During an observation and interview on 5/4/26 at 6:57 A.M., the Food Service Director along with the surveyor observed the contents of the fridge in the emergency food storage room. The Food Service Director said that all food should be dated upon receiving, and or with an expiration date. She said all prepared foods should be labeled with a prepared date and expiration date. She said the peppers had mold on them and the celery and cabbage had signs of decompensation and should have been removed from the fridge.During an interview on 5/6/26 at 7:37 A.M., the Administrator said that the expectation is that the kitchen staff are checking the food daily and getting rid of anything that is expired. Further, he said that when food is prepared and stored in the fridge it should be labeled with the date it was prepared on, and the date it expires so that it can be disposed of on or before the expiration date.

Based on observation, record review and interviews, the facility failed to ensure that one Resident (#52) was free from significant medication errors out of a total sample of 18 residents. Specifically, for Resident #52, nursing staff failed to administer scheduled two units of Lispro insulin, and failed to administer 24 units of Insulin Glargine in accordance with the physician's order. Findings include: Review of the facility policy titled Administering Medications, dated 4/2024, indicated but was not limited to the following: Medications are administered in a safe and timely manner, and as prescribed. 2. Medications are administered in accordance with prescriber orders, including any required time frame. 3. Medication administration times are determined by resident need and benefit and as per MD (Medical Doctor) order. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. 5. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 7. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate this on the MAR (Medication Administration Record) space provided for that drug and dose and will inform the MD/NP (Nurse Practitioner). Resident #52 was admitted to the facility in September 2025 with diagnoses including type one diabetes mellitus, multiple sclerosis, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The MDS indicated Resident #52 received insulin. During an interview on 5/6/26 at 7:20 A.M., Nurse #4 Resident #52 is diabetic and has orders for scheduled and sliding scale insulin in the morning and said she was going to administer the Residents insulin. Nurse #4 said she did not take Resident #52's blood sugar this morning. Review of Resident #52's plan of care related to diabetes, dated 9/19/25, indicated: - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. - Fasting Serum Blood Sugar as ordered by doctor. Review of Resident #52's active physician orders, indicated the following: -Insulin Glargine Subcutaneous Solution 100 units per milliliter (Unit/ml) (Insulin Glargine) Inject 24 unit (s) subcutaneously (under the skin) one time a day for diabetes, hyperglycemia (high glucose/sugar levels in the blood) no parameter needed. Start Date: 3/4/26. Scheduled for 8:00 A.M. -Insulin Lispro Injection Solution (Insulin Lispro) Inject 2 unit(s) subcutaneously one time a day for diabetes with breakfast. Start Date: 5/5/26. Scheduled for 8:00 A.M. -Insulin Glargine Subcutaneous Solution 100 Unit/ml (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for diabete [SIC] related to type 1 diabetes mellitus without complications. Start Date: 3/3/26. Scheduled for 10:00 P.M.During an observation and interview on 5/6/26 at 8:27 A.M., Resident #52 was observed in bed, a breakfast tray was on the overbed table, and Resident #52 was eating his/her breakfast meal. Resident #52 said he/she had not received his/her insulin that was due to be administered before breakfast. Resident #52 said he/she should have received the insulin this morning. Review of the Physician progress note dated 5/4/26 indicated Resident has difficult to control diabetes. Diabetes mellitus ranges from 70-400's over the past few weeks. Currently on Lantus 24 u (units) qAM (every morning) and 10 (units) qHS (every night) with Lispro sliding scale. Reviewed trends in EMR (Electronic Medical Record). I can't discern obvious temporal pattern; 6am glucose ranging from 74-393 in the last week. Pre-lunch, no lows range 130-448. Pre-dinner 2 readings in 70's last week, range 70's-280. 9pm (P.M.) glc (glucose) ranging from 89-372. -Start Lispro 2 units with breakfast only. -Continue Lispro sliding scale, and change times to before meals only.-Discontinue qHS Lispro sliding scale, risk for hypoglycemia. -Continue Lantus 24 units qAM, 10 units qPM for now. -If qHS coverage needed, would use regular insulin not lispro. -Repeat A1C in July On 5/6/26 at 8:40 A.M., Nurse #4 was observed sitting in a Residents room down the hall assisting another resident to eat. During an interview on 5/6/26 at 8:47 A.M., Nurse #4 said she had not checked Resident #52's blood sugar and had not administered insulin to Resident #52 because she had to stop the medication pass to check the breakfast cart and to help feed other residents with breakfast. Nurse #4 said when she is finished, she will continue with her medication pass. Nurse #4 said she should have administered the scheduled insulin this morning when it was scheduled but did not. Review of Resident #52's Medication Administration Record (MAR), dated May 2026, indicated on 5/6/26 at 9:25 A.M., failed to indicate any insulin was administered, was left blank and contained no documentation. Review of the Electronic Medical Record indicated the last documented blood sugar level was on 5/5/26. Review of Resident #52's Medication Administration History Report dated 5/6/26 at 11:57 A.M., indicated: -Nurse #4 administered the 8:00 A.M., scheduled 24 units of Insulin Glargine a 9:43 A.M., 1 hour and 43 minutes after the scheduled time. -Nurse #4 did not administer the 8:00 A.M., scheduled 2 units of Insulin Lispro with the breakfast meal. The documentation code was 11 indicating it was not administered. During an interview on 5/6/26 at 11:15 A.M., Nurse #4 said she did not administer the scheduled 2 units of Lispro insulin because she used her nursing judgement and said she did not notify the Nurse Practitioner or Physician and said she would only call if the Residents blood sugar dropped below 75. Nurse #4 said she did not give the Resident the scheduled Lispro because the Residents blood sugar was stable. Nurse #4 said she checked the Residents' blood sugar at 9:43 A.M., and it was 148. During an interview on 5/6/26 at 11:34 A.M., Unit Manager #2 said Resident #52, should have received the insulin as ordered by the physician. Unit Manager #2 said Resident #52 should have had his/her blood sugar obtained in the morning and insulin administered with the breakfast meal as ordered by the physician. During an interview on 5/6/26 at 11:37 A.M., Nurse Practitioner (NP) #1 said Resident #52 should have had his/her blood glucose levels checked in the morning before breakfast and said the scheduled insulin should have been administered as ordered with breakfast and said she was not notified that the scheduled 2 units of insulin was not given. During an interview on 5/6/26 at 11:45 A.M., the Director of Nursing (DON) said that nursing should obtain blood sugars and administer insulin as ordered. The DON said Resident #52 should have had his/her insulin administered before breakfast because that was the physician's order and said Nurses are expected to contact the provider if a medication is not given. During an interview on 5/6/26 at 11:47 A.M., the Regional Clinical Nurse said morning blood sugar checks and insulin administration need to be a priority and said the medications should have been administered as ordered with breakfast and not administered almost 1.5 hours late. The Regional Clinical Nurse said Nurse #4 is a new nurse who should have checked Resident #52's blood sugar level in the morning and should not have withheld the scheduled insulin without contacting the provider. The Regional Clinical Nurse said nurses should not stop a medication pass when critical medications like insulin are ordered and need to be administered.

Based on observation, record review and interview, the facility failed to ensure staff implemented infection control practices to decrease the risk of infection and contamination for three Residents (#59, #6 and #49) out of a total of 18 sampled residents. Specifically:1. The facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) for Resident #59 and Resident #6.2. For Resident #49 the facility failed to a. change and label oxygen and nebulizer tubing as indicated in the physician's orders and b. properly store a Bi-level positive airway pressure (BiPAP, a noninvasive ventilation device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) mask.Findings include: 1a. Review of the facility policy titled Enhanced Barrier Precautions, dated April 2026 indicated: The enhanced barrier precautions (EBP) require the use of gown and gloves during high contact care activities. Examples of high contact resident care activities requiring gown and glove use among residents that trigger EBP include: dressing, bathing or showering, performing transfers, providing hygiene, changing linens, device care. Resident #59 was admitted to the facility in December 2025 with diagnoses including stroke and aphasia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #59 is severely cognitively impaired as evidenced by a score of four out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated that Resident #59 utilizes a feeding tube. Review of the physician orders indicated: Enhanced barrier precautions 2/2 (secondary to) wound, tube feeding site; every shift, dated 12/23/25.Review of Resident #59's Care plans indicated: Focus: Resident is on enhanced barrier precautions 2/2 abdominal wound, g tube site, 12/23/25. Interventions: Maintain Enhanced Barrier Precautions at all times. Use gown and gloves when performing high contact activities including toileting/incontinence care, dressing, bathing and showering, transferring, care of device, wound care, changing linens or any activity with close contact. Post signage outside resident's door. On 5/4/26 at 7:49 A.M., the surveyor observed Resident #59 resting in bed and with his/her tube feeding connected and running. There was a sign outside of his/her door indicating EBP. Resident #59 said he/she was uncomfortable and the surveyor alerted the nurse.On 5/4/26 at 7:50 A.M., the surveyor observed a nurse and a Certified Nursing Aide (CNA) repositioning Resident #59 in bed without wearing gowns. On 5/5/26 at 7:58 A.M., the surveyor observed Nurse #1 enter resident #59's room and adjust his/her blankets over his/her body. Nurse #1 did not wear a gown or gloves.On 5/5/26 at 9:18 A.M., Nurse #1 was observed wearing gloves and positioning Resident #59 in bed. Nurse #1 touched the buttons on the tube feed pump, adjusted Resident #59's blankets and then adjusted Resident #59's shoulder in bed. Nurse #1 was not wearing a gown. On 5/5/26 at 10:26 A.M., the surveyor observed CNA #1 providing Resident #59 a bed bath without wearing a gown.During an interview on 5/5/26 at 10:28 A.M., Nurse #1 said that she only needs to wear a gown while taking care of Resident #59's tube feeding.During an interview on 5/5/26 at 10:53 A.M., CNA #1 said that she does not have to wear a gown while bathing Resident #59, only gloves.During an interview on 5/5/26 at 10:52 A.M., Unit Manager #1 said that staff should wear a gown and gloves while providing high contact care to residents on Enhanced Barrier Precautions.During an interview on 5/5/26 at 12:12 P.M., the Director of Nursing said that staff should wear a gown and gloves while providing direct care to residents on enhanced barrier precautions. 1b. Resident #6 was admitted to the facility in April 2019 with diagnoses including stroke and cognitive communication deficit. Review of the Minimum Data Set assessment (MDS) dated [DATE] indicates that Resident #6 is severely cognitively impaired as evidenced by a score of 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam.On 5/4/26 at 7:52 A.M., the surveyor observed Resident #6 lying in bed. Resident #6 did not respond to the surveyors' questions. A sign outside the door indicated Enhanced Barrier Precautions. Review of Resident #6's physician order indicated: Enhanced barrier precautions, dated 2/26/26. Review of Resident #6's Wound Visit Note dated 4/29/26 indicated he/she had an abscess wound on his/her left hip, and skin tears on his/her left and right heels. Review of Resident #6's care plans indicated: Focus: Resident is on Enhanced Barrier Precautions 2/2 (secondary to) abscess on the left hip, 3/24/36. Interventions: Maintain Enhanced Barrier Precautions at all times. Use gown and gloves when performing high contact activities including toileting/incontinence care, dressing, bathing and showering, transferring, care of device, wound care, changing linens or any activity with close contact. Post signage outside resident's door.Focus: Resident has infection r/t (related to) abscess of the left hip, 3/24/26. Intervention: Maintain enhanced barrier precautions when providing resident care.On 5/5/26 at 10:26 A.M., the surveyor observed Certified Nursing Aide (CNA) #2 giving Resident #6 a bed bath. CNA #2 was not wearing a gown.During an interview on 5/5/26 at 10:44 A.M., CNA #2 said she does not have to wear a gown while providing care to Resident #6. During an interview on 5/5/26 at 10:52 A.N., Unit Manager #1 said that staff should wear a gown and gloves while providing high contact care to residents on Enhanced Barrier Precautions. During an interview on 5/5/26 at 12:12 P.M., The Director of Nursing (DON) said that staff should wear a gown and gloves while giving direct care to residents on enhanced barrier precautions. 2. Review of the facility policy titled Oxygen Tubing Safety and Infection Control, dated as 3/7/22, indicated the following:-Frequency of tubing change- a. Nasal Cannula tubing: changed weekly or sooner if visibly soiled. b. Nebulizer tubing (if applicable) changed according to respiratory therapy protocol or every week if in use.-Oxygen equipment must be stored in a clean, dry location when not in use.Resident #49 was admitted to the facility in October 2023 with diagnoses that included chronic obstructive pulmonary disease and obstructive sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/26, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS failed to indicate the use of non-invasive ventilation (Bipap or CPAP) On 5/4/26 at 7:59 A.M., the surveyor observed Resident #49 sitting up in bed. There was a nebulizer mask stored in a bag labeled with a date of 4/20/26. There was an oxygen concentrator with tubing wrapped around it, unbagged, and labeled 4/20/26. The Resident also had a BiPAP machine with the tubing and mask stored inside the bedside table drawer with other belongings. During an interview on 5/4/26 at 7:59 A.M., Resident #49 said that he/she is supposed to use oxygen at night with his/her BiPAP but that he/she hasn't been able to because the concentrator hasn't been working correctly. The Resident further said he/she is using the BiPAP and nebulizers regularly. On 5/4/26 at 12:45 P.M., the surveyor observed a new concentrator had been provided to the Resident. Both the oxygen and nebulizer tubing were now labeled as 5/3/26, which was inconsistent with the surveyor's initial observation at 7:59 A.M. On 5/6/26 at 7:25 A.M. and 7:58 A.M., the surveyor observed the Resident's BiPAP mask stored on top of the bedside table, not in a bag. Review of the Resident's active plan of care indicated the following: CPAP / BiPAP Therapy- DX (diagnosis) of Obstructive Sleep Apnea, dated as revised 5/29/25. Review of physician's orders indicated the following:-Change O2 (oxygen) Tubing and Clean Filter every week on Sunday 11-7, dated 6/1/25.-BIPAP to wear at bedtime and as needed. DX: Obstructive Sleep Apnea, dated 5/29/25.-Oxygen 1-4L/min (liters per minute) (can titrate to achieve O2 sat>90%) PRN (as needed) for SOB (shortness of breath) or O2 sat<90%, dated 12/17/23.-Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 ml inhale orally four times a day related to acute respiratory failure, dated 11/10/25. Review of Resident #49's April 2026 and May 2026 Treatment Administration Record indicated nursing changed the oxygen tubing as ordered on 4/27/26 and 5/3/26, however, this was inconsistent with the surveyor's observations. During an interview on 5/6/26 at 8:05 A.M., Nurse #2 said that respiratory tubing should be changed weekly and all respiratory equipment should be stored in a bag. During an interview on 5/6/26 at 8:44 A.M., the Regional Clinical Nurse said that tubing is changed weekly. She said if it is signed off as changed, she would expect that it is completed. She further said that respiratory equipment should be stored in a bag. During an interview on 5/6/26 at 11:26 A.M., the Director of Nurses said that tubing should be changed weekly as indicated in physician's orders. She further said that respiratory equipment should be properly stored.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that resident food and supplemental drinks were dated in two out of two unit kitchenettes. Findings include: Review of the facility's policy titled Storage & labeling of food brought in by family/visitors, effective June 2018, indicated, but was not limited to, the following: - Definitions: - properly stored and labeled refers to both the dating of all newly opened food and drink items provided by the facility as well as all food items brought in by family members for the residents and food items belonging to and bought in by staff members (sic). All food and drink items are required to have proper labeling for easy identification. - Perishable foods must be stored in re-sealable containers with lids or sealable bags in the refrigerator. All containers will be labeled with the resident's name and date. These items are good for 48 hours only and will be discarded after such time. - The housekeeping staff are responsible for discarding perishable foods after 48 hours. - Items with expiration dates such as milk, condiments, yogurts, cheeses, etc. should still be dated upon opening and discarded by the expiration date on the item. These items should be clearly labeled and easily identifiable. On 6/17/25 at 7:22 A.M., the surveyor made the following observations in the first-floor unit kitchenette refrigerator: - A green bag containing food, the food and bag were undated. - A plastic container of food which was undated. On 6/17/25 at 7:30 A.M., the surveyor made the following observations in the second-floor unit kitchenette refrigerator: - A container of food labeled with a resident name but undated. - A bag containing two containers of food, the bag was dated 6/11/25. - A container of thickened water which was dated opened 6/1/25. - A bag containing a container of soup, both the bag and the container of soup were undated. - A container of food labeled with a resident name and dated 6/10/25. - A bag containing watermelon with tajin which had a best-by date of 6/15/25 and an undated container of food. - Two 32 ounce containers of a nutritionally fortified supplemental drink opened but undated. During an interview on 6/17/25 at 1:03 P.M., the Food Service Director (FSD) said staff check the kitchenette refrigerators between 6:30 A.M. and 6:45 A.M. each morning. The FSD said that when resident families bring food in the nurses are supposed to date and label leftover food before placing it in the kitchenette refrigerator and that leftover food should be discarded after three days. The FSD said that nursing has to bring the leftovers into the kitchenette because the kitchenette is locked, and that nurses should label and date any open drinks including nutritionally fortified supplemental drinks. The FSD said the food dated 6/11/25 should have been discarded. During an interview on 6/17/5 at 1:10 P.M., Nurse #3 said all resident food items and leftover food should be dated and discarded after two days. Nurse #3 said nurses should date the nutritionally fortified supplemental drinks when opened.

Based on observation, record review, and interview, the facility failed to accurately document in the medical record for one Resident (#24), out of 33 total sampled residents. Specifically, the facility failed to ensure the nurses accurately documented that Resident #24's insulin lispro (an injectable hormone that lowers the level sugar in the blood) was administered. Findings include: Review of the facility's policy titled 'Documentation of Medication Administration', dated 3/7/22, indicated: - Policy: The facility shall maintain a medication administration record to document all medications administered. - A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). Resident #24 was admitted to the facility in June 2020 with diagnoses including hypertension and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 6/5/25, indicated Resident #24 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. This MDS also indicated Resident #24 received insulin daily and did not exhibit any behaviors of rejection of care during the look back period. On 6/20/25 at 7:41 A.M., Resident #24 said he/she was not aware of his/her insulin routine and the nurses managed it. Review of Resident #24's active Physician's Orders indicated: - Check blood sugar 3 (three times a day), three times a day, scheduled for 7:30 A.M., 11:30 A.M., and 5:00 P.M., initiated 2/3/22. - Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro), Inject as per sliding scale: if 200 - 250 = 2 lispro 2 units; 251 - 300 = 4 lispro 4 units; 301 - 350 = 6 lispro 6 units ; 351 - 400 = 8 lispro 8 units call NP (nurse practitioner)/MD (physician) for FS (fasting sugar) <60 or >400, subcutaneously every 8 hours as needed for diabetes SS, initiated 6/18/24. Review of Resident #24's Medication Administration Record (MAR), dated 6/1/25-6/19/25, indicated: - 6/1/25 at 7:30 A.M., blood sugar: 204 - 6/1/25 at 11:30 A.M., blood sugar: 222 documented by Nurse #2 - 6/2/25 at 11:30 A.M., blood sugar 250 - 6/2/25 at 5:00 P.M., blood sugar 280 - 6/3/25 at 5:00 P.M., blood sugar 200 - 6/4/25 at 7:30 A.M., blood sugar 265 - 6/4/25 at 5:00 P.M., blood sugar 355 - 6/6/25 at 5:00 P.M., blood sugar 300 - 6/7/25 at 5:00 P.M., blood sugar 316 documented by Nurse #2 - 6/8/25 at 5:00 P.M., blood sugar 201 documented by Nurse #2 - 6/9/25 at 5:00 P.M., blood sugar 210 - 6/11/25 at 7:30 A.M., blood sugar 210 - 6/15/25 at 5:00 P.M., blood sugar 389 documented by Nurse #2 - 6/16/25 at 5:00 P.M., blood sugar 204 - 6/17/25 at 5:00 P.M., blood sugar 218 - 6/18/25 at 5:00 P.M., blood sugar 295 - 6/19/25 at 5:00 P.M., blood sugar 345 Review of Resident #24's Medication Administration Record (MAR), dated 6/1/25-6/19/25, indicated: - Insulin lispro was never documented as administered during the month of June 2025 following the as-needed sliding scale, even though the physician's order indicated it should have been administered. Review of Resident #24's entire medical record, dated 6/1/25 to 6/19/25, failed to indicate any refusal of insulin and/or any rationale his/her insulin lispro was not administered. During an interview on 6/20/25 at 7:43 A.M., Nurse #2 said insulin should always be documented as administered at the time of administration. Nurse #2 said she did not remember giving Resident #24 sliding scale insulin lispro during the month of June 2025 but should have because his/her sugars were higher than 200. Nurse #2 said if she didn't document it as administered then she did not administer it. Nurse #2 said Resident #24 does not refuse insulin. During an interview on 6/20/25 at 8:50 A.M., Unit Manager #2 said he was not aware of Resident #24 refusing insulin during the month of June. Unit Manager #2 said if Resident #24 had refused the insulin, it should have been documented as refused in the medical record and the provider should have been notified. The surveyor and Unit Manager #2 reviewed Resident #24's June 2025 MAR and he said it looked like the as-needed sliding scale insulin lispro should have been given multiple times but was not. Unit Manager #2 said Resident #24 should have gotten as-needed insulin lispro whenever his/her blood sugar was higher than 200 to prevent risks from hyperglycemia. During an interview on 6/20/25 at 11:02 A.M., the Director of Nursing (DON) said insulin should be documented when administered. The surveyor and the DON reviewed the 17 times the insulin lispro was not documented as administered even though the physician order indicated it should have been administered. The DON said she could not determine if the insulin was actually administered based on the MAR and would have to interview each nurse because the MAR must be inaccurate. The DON said the physician's order was transcribed incorrectly as an as needed (PRN) order, so it did not pop up to alert the nurses to administer it with the scheduled blood sugars. The DON declined to comment on the risks for not giving insulin lispro according to the physician's order, and said only that it should have been administered and documented according to the physician's order. On 6/23/25 at 2:29 P.M., the surveyor received follow-up electronic correspondence from the facility which included 12 statements from nursing, including Nurse #2, indicating that the nurses did administer Resident #24's as needed sliding scale insulin lispro on the 17 times in June 2025 that it should have been, but had forgotten to document it as administered in the MAR.

Based on observations, interviews, and record review, the facility failed to ensure one Resident's (#74) personal care choices were honored, out of a total sample of 33 residents. Specifically, the facility failed to provide showers for Resident #74 per his/her request and preference. Findings include: Review of the facility policy titled 'Dignity and Resident Preferences', dated 3/7/22, indicated: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - When assisting with care, residents are supported in exercising their rights. Resident #74 was admitted to the facility in October 2024 with diagnoses including a history of stroke with right-sided hemiplegia (one-sided muscle weakness). Review of the Minimum Data Set (MDS) assessment, dated 4/3/25, indicated Resident #74 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #74 was dependent of staff for tub/shower transfers and shower/bathing. On 6/17/25 at 12:56 P.M., the surveyor observed Resident #74 in his/her room visiting with family members. Resident #74 said he/she was very upset because he/she had not had a shower since they were admitted in October 2024. Resident #74 said the staff provided bed baths, but he/she finds them degrading. Resident #74 said he/she always feels cleaner after a shower. Resident #74 and his/her family members said the staff is unable to wash his/her long hair thoroughly during bed baths and used dry shampoo. The surveyor observed Resident #74's hair to appear greasy and covered in a white powder-like substance, which the family member said was from the dry shampoo. Resident #74 and their family members said they have told many different staff members multiple times since October that the Resident would like to have a shower but are continually told there was not a safe shower chair. Review of Resident #74's physician progress note, dated 1/15/25, indicated Resident #74's mother was worried about him/her not getting a real shower. Review of Resident #74's plan of care related to activities of daily living, dated as reviewed 4/16/25, indicated Resident #74 was dependent on staff to get in and out of the tub/shower. Review of Resident #74's current care card (a form certified nursing assistants (CNAs) used to determine each resident's specific care needs) indicated: - Transfer to/from tub or shower: Dependent - Hoyer (a mechanical lift used to transfer residents) to shower chair. Review of care tracker sheet (a form containing CNA documentation for activities of daily living), dated 4/1/25 to 6/18/25, indicated Resident #74 was dependent on staff for bathing/showering, but failed to specifically indicate if Resident #74 received a shower or a bed bath. Review of Resident #74's nursing progress note, dated 10/1/24 to 6/18/25, failed to indicate Resident #74 ever received a shower. During an interview on 6/18/25 at 6:35 A.M., the surveyor and Certified Nurse Assistant (CNA) #1 observed all shower rooms on Resident #74's unit and four different types of shower chairs, including one that reclined. CNA #1 said all residents who prefer showers should have showers and that there are safe shower chairs available for all residents on the unit, even residents with poor trunk control or require a mechanical lift transfer. CNA #1 showed the surveyor the shower schedule and said CNA #2 is Resident #74's primary CNA on shower days. During an interview on 6/18/25 at 6:58 A.M., CNA #2 said she is the primary CNA responsible for Resident #74 and was usually the one assigned for his/her scheduled shower. CNA #2 said Resident #74 had not had a shower since his/her admission in October 2024 because there was no safe shower chair for him/her. CNA #2 said the facility administration had been aware for months. CNA #2 said sometimes Resident #74 complained that bed baths made him/her feel too cold and needed to be bundled up quickly to warm up. During an interview on 6/18/25 at 7:03 A.M., the Corporate Director of Clinical Operations said she was aware Resident #74 had been unable to have a shower, instead of a bed bath, because there was not a safe shower chair for him/her. The Corporate Director of Clinical Operations said the facility had been working on obtaining one for him/her and that therapy would have more information regarding this. Review of Resident #74's occupational therapy (OT) discharge summary completed by Occupational Therapist (OT) #1, dated 3/10/25, indicated OT worked on bathing tasks with the Resident and upon discharge from therapy services he/she was unsafe for shower at this time due to TD (total dependence) support from CNA for bathing supine. During an interview on 6/18/25 at 10:51 A.M., OT #1 said she was the therapist responsible for treating Resident #74. OT #1 said showering was always a goal for him/her, but he/she was unable to shower himself/herself or able to sit upright in the shower because of poor trunk control and right-sided weakness. OT #1 said even though Resident #74 was unable to shower himself/herself, a safe shower chair needed to be obtained because it was Resident #74's preference to have a shower instead of a bed bath. OT #1 said she told her supervisor that there wasn't a safe chair for him/her to shower in approximately four months ago and she was under the impression they were going to order one. OT #1 said a shower chair came Friday (6/13/25) but had not evaluated him/her for its use yet. During an interview on 6/18/25 at 10:59 A.M., the Regional Director of Rehab said he was aware Resident #74 wanted to shower and that there was not a safe shower chair available. The Regional Director of Rehab said about a month after the Resident was admitted (approximately November 2024) the facility borrowed a shower table from another facility, but it didn't fit into the facility's shower rooms. The Regional Director of Rehab said at that point it was determined a safe shower chair needed to be ordered and that it required research. The Regional Director of Rehab said that on 5/20/25 (approximately six months later) the facility ordered a shower chair for Resident #74. The Regional Director of Rehab said six months was not an acceptable time frame for research to be completed, and one should have been ordered within a month but was not. The Regional Director of Rehab said when the new shower chair arrived shortly after it was ordered on May 20th it was determined it needed modifications prior to being used. The Regional Director of Rehab said these modifications were not made until 6/13/25. The Regional Director of Rehab further said this was also not an acceptable time frame and the modifications should have been made by the end of May. The Regional Director of Rehab said the facility dropped the ball and the Resident should have been able to shower, instead of only having bed baths. During an interview on 6/18/25 at 11:09 A.M., the Director of Nursing (DON) said all residents in the facility should be able to choose between having a bath or a shower. The DON said if there was not a safe shower chair for a Resident who wished to have a shower, the facility expects that one be obtained timely. The DON said a safe shower chair should have been obtained for Resident #74 but was unaware of the timing surrounding when it was requested and originally ordered.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#33), out of a total sample of 33 residents. Specifically, the facility failed to initiate a referral to provide Resident #33 with occupational therapy (OT) services for the treatment of his/her upper extremity contractures as recommended by the Nurse Practitioner (NP). Findings include: Review of the facility's policy titled Rehabilitation Services - General, revised 3/7/24, indicated, but was not limited to, the following: a. Referrals and Evaluation 1. Referrals for rehabilitation services may originate from: - The Provider MD/NP - inputs orders into the electronic medical record under orders. - Nursing staff based on change in condition 2. Upon referral, the appropriate licensed therapist shall complete a comprehensive evaluation within 48 hours (or sooner if clinically indicated). 3. The evaluation shall include baseline functioning, clinical diagnosis, therapy needs, and resident goals. f. Documentation 1. Therapy screens, evaluations, treatment notes, progress reports, and discharge summaries are to be completed timely in accordance with CMS documentation requirements. Resident #33 was admitted to the facility in February 2024 and had diagnoses including stroke, traumatic brain injury, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 5/1/25, indicated that Resident #33 was unable to complete a Brief Interview for Mental Status (BIMS) as the Resident was rarely/never understood. Further review of the MDS indicated that Resident #33 had impairment of range of motion on both sides impacting his/her upper extremities. On 6/17/25 at 8:13 A.M., the surveyor observed Resident #33 in his/her room lying in bed. Both of Resident #33's hands were closed, and his/her arms were held closely up to his/her chest; the Resident was unable to participate in an interview. Review of Resident #33's care plans indicated, but was not limited to, the following: Resident #33 has potential for acute/chronic pain related to history of bilateral (both sides) upper extremity contractures with the following intervention: -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care, initiated on 2/9/24. Review of Resident #33's initial wound evaluation and management summary, dated 6/19/24, indicated Resident #33's right and left upper extremities were contracted. Review of Resident #33's nursing annual/quarterly assessment, dated 4/25/25, indicated Resident #33 had contractures. Review of Resident #33's NP progress note, dated 4/30/25, indicated that both of the Resident's upper extremities were contracted with a recommendation to refer to occupational therapy services in order to work with his/her muscle contracture. Review of Resident #33's occupational therapy evaluation and plan of treatment, signed 6/18/25, indicated the Resident was evaluated by occupational therapy services 49 days after the NP had referred the Resident to occupational therapy, and after the surveyor had brought the concern to the attention of the facility. Further review of the evaluation indicated that the Resident had contractures of both upper arms and left hand. The occupational therapy evaluation indicated the Resident was referred to skilled occupational therapy services for contracture management to decrease risk of skin breakdown and increase range of motion and that occupational therapy services were required to improve bilateral upper extremity contracture management, increase range of motion, and determine appropriate orthotic care. The evaluation indicated a recommendation for the Resident to wear an elbow extension splint and a hand roll on both hands as tolerated and that the Resident demonstrated good rehabilitation potential. During an interview on 6/18/25 at 11:34 A.M., Resident #33's health care proxy said that she had last seen the Resident on 5/10/25 and believes the Resident's upper extremities had become tighter recently. During an interview on 6/18/25 at 10:44 A.M., the Director of Rehab (DOR) said that when the NP determines that therapy needs to evaluate a resident that the NP would notify nursing and nursing would put in a referral which would then be sent to rehab services; the DOR said Resident #33 was last seen by an OT in 2024. During an interview on 6/18/25 at 12:09 P.M., the NP said Resident #33's upper extremities were getting more contracted because of the Resident's history of a stroke so she had decided to refer to therapy. The NP said the Resident's elbow contractures were getting more severe so she had told somebody from the therapy department to evaluate the Resident; the NP said she had assumed the Resident had already begun therapy because of her recommendation. During follow-up interviews on 6/18/25 at 1:55 P.M. and 6/20/25 at 10:51 A.M., the DOR said that an OT evaluated Resident #33 on 6/18/25, that the Resident had contractures and that the facility was planning on getting the Resident carrots to help open the Resident's hands and an elbow splint to get the Resident's arms to return to 90 degrees. The DOR said he would expect an evaluation to be done within 48 hours of the referral being made. The DOR said he had seen the NP's recommendation for an occupational therapy referral today for the first time, and that he would have expected the Resident to be evaluated by occupational therapy services sooner. The DOR said he did not know why the Resident had not been evaluated by therapy earlier. During an interview on 6/18/25 at 2:28 P.M., the OT said that Resident #33 would be able to participate in gentle passive range of motion exercises and that the carrots would be beneficial for range of motion. The OT said that she was the only OT in the facility and that she was made aware of the NP's recommendation/referral to therapy for the first time today by the DOR after the surveyor had brought the concern to the attention of the facility. The OT said that if the Resident was not seen by occupational therapy, it could put the Resident at risk for a decrease in range of motion. During an interview on 6/18/25 at 4:16 P.M., the Director of Nursing (DON) said management, including the Unit Manager and a rehab representative, reviews progress notes daily at morning meeting. The DON said the process for therapy referrals was that staff filled out a referral form for therapy evaluations and that she would expect therapy to follow-up on the referral/recommendation within one to two days of the referral/recommendation being made. During an interview on 6/18/25 at 3:01 P.M., Unit Manager #2 said she did not recall the last time therapy worked with Resident #33 and that a few months ago she had told the NP that it had become harder to move the Resident's extremities as they have become stiffer than usual. During an interview on 6/20/25 at 11:30 A.M., the Corporate Director of Clinical Operations said she would have expected the NP to place an order for Resident #33's occupational therapy evaluation and that the Resident would have been evaluated if an order was placed. The Corporate Director of Clinical Operations said she did not know why the Resident had not been evaluated by an OT earlier and that any contraindications for therapy would be documented. Review of Resident #33's medical record failed to indicate that the NP placed an order for Resident #33 to be seen by occupational therapy services for upper extremity contractures following her recommendation on 4/30/25. The facility was unable to provide evidence that a paper referral form was completed for Resident #33 after the NP's recommendation for therapy services on 4/30/25 or documentation of contraindications for therapy services.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were dated once opened according to manufacturer's guidelines in one of two medication carts observed. Findings include: Review of the facility policy titled 'Storage - Labeling - Maintenance of Medications', revised 11/8/22, indicated: - Medications with shortened expiry dates (i.e. insulins, injections, ophthalmic drops, etc.) must be dated when opened. On 6/18/25 at 9:33 A.M., the surveyor and Unit Manager #1 observed the following in the second floor side two medication cart: - One fluticasone propionate and salmeterol inhaler, opened and undated. - Two incruse ellipta inhalers, opened and undated. - One lantus solostar insulin pen, opened and undated. During a follow up interview on 6/18/25 at 9:34 A.M., Unit Manager #1 said the fluticasone propionate and salmeterol inhaler, two incruse ellipta inhalers, and lantus solostar insulin pen were all opened. Unit Manager #1 said these medications have shortened expiry dates once opened and should have been dated but were not. During an interview on 6/18/25 at 11:09 A.M., the Director of Nursing (DON) said the fluticasone propionate and salmeterol inhaler, two incruse ellipta inhalers, and lantus solostar insulin pen have shortened expiry dates once opened and should have been dated once opened.

Based on observation, policy review and interview, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure medication/treatment carts on two of two units. Findings Include: Review of facility policy titled Storage- Labeling- Maintenance of Medications, dated 11/8/22, indicated the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. -1. All drugs and biologicals are to be stored in the locked designated cabinets for this purpose and shall be stored under proper temperature controls. Only Authorized licensed personnel are to have access to the keys and the medications. -4. Medication carts must be locked at all times when not in use, including during medication passes when the nurse steps away from the cart. On 7/1/24 at 8:38 A.M., during a medication storage observation on the first- floor unit, Nurse #1 opened the medication cart for the surveyor, checked that the narcotic draw was locked, and walked away from the medication cart. Nurse #1 was out of site of the surveyor but was observed walking to the other end of the hallway. At 8:41 A.M., Nurse #1 returned to the medication cart. During an interview on 7/1/24 at 8:57 A.M., Nurse #1 said she should not leave her medication cart unlocked and unattended. She said, I had to do something quick, and I knew that you weren't going to take anything. During an interview on 7/1/24 at 10:12 A.M., the Corporate Director said that if a nurse leaves his or her medication cart, they should lock it. During observation of medication pass on the second- floor unit on 7/1/24 at 9:46 A.M., Nurse #2 walked away from her medication cart to administer medications to a resident, leaving it unlocked and unattended. During an interview on 7/1/24 at 9:46 A.M., Nurse #2 said that she should not have left her medication cart unlocked and should have locked it when she walked away. During an interview on 7/1/24 at 10:12 A.M., the Corporate Director said that if a nurse leaves his or her medication cart, they should lock it. 48990 On 7/2/24 at 6:48 A.M., the surveyor observed an unlocked treatment cart on the first- floor unit with no licensed nurse within view of the cart. On 7/2/24 at 6:51 A.M., the surveyor opened the unlocked treatment cart, which was filled with prescription creams. During an interview on 7/2/24 at 6:53 A.M., Unit Manager #1 came down the hall and said the treatment cart should always be locked when unattended because a resident could get into it. During an interview on 7/2/24 at 7:01 A.M., Nurse #6 said the treatment cart should be locked when not within view of the nurse. During an interview on 7/2/24 at 9:02 A.M., the Corporate Director said the nurse had forgotten to lock the treatment cart, but should have locked it since it was not within her view. During an interview on 7/2/24 at 12:07 A.M., the Director of Nursing (DON) said treatment carts should be locked if not within view of the nurse.

Based on observation, interviews, and policy review, the facility failed to ensure transmission-based precautions were followed to prevent the spread of infections. Specifically, the facility failed to ensure a nurse appropriately donned (put on) a precaution gown while caring for a Resident on enhanced barrier precautions (EBP). Findings include: Review of the facility policy titled Enhanced Barrier Precautions - Multidrug-Resistant Organisms (MDROs), dated 4/1/24, indicated the following: -Enhanced Barrier Precautions (EPB) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. -Enhanced barrier precautions should be followed for any resident in the facility with: an open wound requiring a dressing change. -Signage must be posted on the door or wall outside of the resident's room indicating enhanced barrier precautions and required PPE (personal protective equipment). On 7/2/24 at 7:25 A.M., the surveyor observed a pressure ulcer wound with Unit Manager #1. Upon entry into the resident room, there was a sign posted at the doorway that indicated the resident was on EBP and that everyone must wear gloves and gown for high-contact resident care activities including wound care. Unit Manager #1 did not put on a precaution gown, and only put on gloves. Unit Manager #1 removed the dressing on the Resident's right lateral foot revealing an open quarter sized circular wound with a bright red wound bed. Unit Manager #1 placed the dressing in her gloved hand and rested the right lateral foot back into a blue off-loading bootie without a new dressing on it and left the room. During an interview on 7/2/24 at 7:17 A.M., Certified Nurse Assistant (CNA) #1 said a precaution gown and gloves must be worn if the surveyor wanted to look at the foot wound of the resident because he/she was on EBP. During an interview on 7/2/24 at 11:06 A.M., Unit Manager #1 said the resident with the foot wound we observed was on enhanced barrier precautions and a precaution gown and gloves should be worn when changing his/her right foot pressure ulcer wound dressing. Unit Manager #1 said that she did not wear a gown when she removed the resident's dressing from their right foot. During an interview on 7/2/24 9:02 A.M., the Corporate Director said Unit Manager #1 should have worn a precaution gown, in addition to gloves, when removing a dressing from an open wound for the resident because he/she was on EBP. During an interview on 7/2/24 at 12:07 P.M., the Director of Nursing (DON) said a precaution gown, in addition to gloves, should have been worn by Unit Manager #1 for all wound procedures, even if she was just removing the right foot pressure ulcer wound dressing because the resident was on EBP.

Based on observation, record review, and interviews, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#16), out of a total sample of 19 residents. Specifically, the facility failed to revise and update Resident #16's Activities of Daily Living (ADL) care plan. Findings include: Resident #16 was admitted to the facility in November 2022 with diagnoses including irritable bowel syndrome. Review of the Minimum Data Set (MDS) assessment, dated 2/7/24, indicated that Resident #16 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #16 required: B. Oral hygiene: the ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment, coded as independent. C. Toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment, coded as independent. F. Toilet transfer: the ability to get on and off a toilet or commode, coded as independent. Review of Resident #16's plan of care related to activities of daily living, dated as current 6/28/24, indicated the following: - PERSONAL HYGIENE: The resident requires supervision/assist by (1) staff with personal hygiene and oral care, dated as revised 6/23/23. - TOILET USE: The resident is assist with toileting, dated as revised 9/13/23. - TRANSFER: The resident requires supervision by (1) staff with rollator to move between surfaces. Chair/ bed transfer supervision/ touching assist, dated as revised 1/18/24. - BATHING/SHOWERING/GROOMING: The resident requires partial/moderate assistance by (1) staff with bathing/showering/grooming, dated as revised 1/18/24. Further review of this care plan failed to include any revisions were made to the above focus areas after the revision dates stated above. Review of Resident #16's Activities of Daily Living (ADLs) flow sheets, dated February 2024, indicated Certified Nursing Assistants consistently coded Resident #16 on the day, evening, and night shifts between 2/4/24 to 2/7/24, the following: - Oral hygiene, coded as independent. - Toileting hygiene, coded as independent. - Toilet transfer, coded as independent. During an interview on 7/2/24 at 12:03 P.M., the Director of Nursing said the interdisciplinary team who completes section GG under the MDS is responsible for updating the care plan after each comprehensive assessment. The DON said that the care plan should have been updated after Resident #16's MDS assessment completed on 2/7/24 but was not.

Based on observation, record review, and interview, the facility failed to maintain professional standards in the managing and care for urinary catheter devices for one Resident (#28) out of a total sample of 19 Residents. Specifically, the facility staff failed to ensure the correct size suprapubic indwelling urinary catheter (a flexible tube that passes through the abdomen and into the bladder to drain urine) was in place for Resident #28 as ordered by the physician. Findings include: Review of the facility policy, titled suprapubic catheter insertion, dated as 10/2017, indicated: Purpose: The purpose of this procedure is to ensure the proper and safe insertion of suprapubic catheters to relieve urine retention in residents who require a permanent or long-term catheter. Policy: All nursing staff performing suprapubic catheter insertion must adhere to this policy to ensure safe and effective care for residents. This procedure outlines the steps, preparation, and documentation required for the insertion of suprapubic catheters. 1. Preparation a. verify there is a physician's order for the procedure. 5. Documentation: Record the following information in the resident's medical record f. Type of catheter inserted, balloon size, French size, and composition. Resident #28 was admitted to the facility in February 2019 with diagnoses including Parkinson's disease, urine retention, and legal blindness. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/22/24, indicated that Resident #28 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #28 required an indwelling catheter (suprapubic catheter). On 7/1/24 at 6:56 A.M., the surveyor and Unit Manager #1 observed Resident #28 bed. Resident #28 had a 16 French (F) with a 5 cubic centimeter (cc) balloon catheter inserted into his/her abdomen. Review of Resident #28's physician's order, dated 3/28/24, indicated: - suprapubic catheter active change suprapubic tube with 16 F/10 cc catheter one time a day every 1 month(s) starting on the 1st for 28 day(s). - suprapubic catheter, change monthly in the facility per physician (MD) and as needed. Review of Resident #28's physician's order, dated 6/30/24, indicated: - Change suprapubic tube with 16 French 10 cc catheter monthly, one time a day, every 1 month(s) starting on the 1st for 28 day(s). Review of Resident #28's nursing progress note, dated 6/13/24, indicated: Patient is alert and oriented, suprapubic catheter replaced with 16 F/10 ml (milliliter) and patent. During an interview on 7/2/24 at 3:03 P.M., Nurse #8 said that on 6/13/24, she and Unit Manager #1 changed Resident #28's suprapubic catheter. Nurse #8 said that prior to inserting a suprapubic catheter you need to verify the correct size. Nurse #8 said that Unit Manager #1 replaced the catheter. Review of Resident #28's Treatment Administration Record (TAR), dated June 2024, indicated on 6/28/24 nursing implemented the physician's ordered suprapubic catheter change. During an interview on 7/1/24 at 7:00 A.M., Unit Manager #1 said staff should implement the physician's order for the correct catheter size. During an interview on 7/1/24 at 2:44 P.M., Resident #28 said nursing changed his/her catheter a few weeks ago (6/13/24) because it was leaking. Resident #28 said the catheter was not changed on 6/28/24 and he/she would only allow staff to change it every four to six weeks. During an interview on 7/1/24 at 7:56 A.M., the Director of Nursing said nursing should implement the physician's order and Resident #28 should have a 16 French 10 cc balloon indwelling catheter.

Based on record review, policy review and interviews, the facility failed to implement their abuse prohibition policy for one Resident (#69) out of a total sample of 19 residents. Specifically, for Resident #69, the facility failed to ensure nursing immediately reported an allegation of potential abuse (bruise of unknown origin) to the Director of Nursing or Administrator, as required. Findings include: Review of the facility policy titled Accident/Incident - Investigating and Reporting, dated as revised 6/2022, indicated to provide the guidelines for the completion, investigation, care plan intervention and regulatory reporting of all Accidents & Incidents; to ensure the timeliness of such reporting, and to ensure the appropriate follow-up and monitoring post-incident occurs. PROCEDURE: Upon the discovery of an accident/incident immediately report the occurrence to the Charge Nurse and/or the Nursing Supervisor. All accidents and incidents require an assessment and an accident/incident report form to be completed in following order: 3. If the incident is an elopement, an alleged physical abuse or any other incident that meets the criteria of a reportable incident per the DPH regulations, the Nursing Supervisor/Nurse Manager will immediately notify the Administrator and Director of Nursing regardless of the time in which the incident was discovered. If the (sic) is not in the building, the Administrator will give the Nursing Supervisor/Nurse Manager direction to initiate the investigation until he/she arrives. The Administrator will conduct the required investigation. Review of the facility policy titled Abuse, Investigating and Reporting, dated as 4/23/19, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Resident #69 was admitted to the facility in April 2023 with diagnoses including dementia and psychosis. Review of the Minimum Data Set (MDS) assessment, dated 1/10/24, indicated that Resident #69 was rarely/never understood. This MDS indicated Resident #69 required total assistance with activities of daily living. Review of Resident #69's alert note, dated 3/3/24 at 8:56 A.M., indicated: This writer was told resident has a bruise on the left side of his/her eyes. I can't recall seeing the bruise and Resident is un unable to explain what happen. During an interview on 7/1/24 at 1:58 P.M., Nurse #4 said she worked the 3:00 P.M. to 11:00 P.M. shift and the 11:00 P.M. to 7:00 A.M. shift on 3/2/24 into 3/3/24, and she was not sure how Resident #69 got a bruise on his/her face. Nurse #4 said she did not notify the Director of Nursing of the new bruise. Review of Resident #69's progress note, dated 3/3/24 at 2:52 P.M., indicated: The assigned resident assistant (RA) to the supervision group reported that this Resident was found with a bruise on the left eye. During an interview on 7/2/24 at 11:19 A.M., Nurse #5 said she worked on 3/3/24 during the 7:00 A.M. to 3:00 P.M. shift, and said she was not sure what caused the bruise on Resident #69's face. Nurse #5 said she notified the Director of Nursing. Review of the health care facility reporting system, dated 3/4/24 at 4:31 P.M., indicated the facility reported the injury of unknown to the state agency, 30 hours after facility staff were first aware of the injury of unknown. During an interview on 7/2/24 at 12:04 P.M., the Director of Nursing (DON) said she became aware of the new bruise while reading the nursing note on 3/4/24. The DON said nursing should have notified administration about the injury of unknown but did not. During an interview on 7/2/24 at 1:08 P.M., the Administrator said that he became aware of the bruise by the Director of Nursing on 3/4/24. The Administrator said that direct care staff should have reported the injury of unknown to the Director of Nursing or Administrator but did not.

Based on observation, policy review, record review and interview the facility failed to provide necessary respiratory care consistent with professional standards of practice for one Resident (#3) out of a total sample of 19 residents. Specifically, the facility failed to implement Resident #3's physician ordered oxygen flow rate. Findings include: Review of the facility policy titled Oxygen Therapy, dated 2/22/22, indicated that the purpose of the policy was intended to ensure that high quality of care is delivered to residents regarding administration of oxygen to and the appropriate monitoring of resident's receiving oxygen and included the procedure that a physician's order is required to initiate oxygen therapy. Resident #3 was admitted to the facility in February 2019 with diagnoses including chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems), stroke, dysphagia (difficulty swallowing), and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 4/24/24, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 which indicated moderate cognitive impairment. This MDS further indicated Resident #3 required oxygen. On 6/28/24 at 7:50 A.M. and 8:04 A.M., the surveyor observed Resident #3 sitting in a wheelchair in his/her room. The Resident was receiving oxygen via nasal cannula at three liters per minute. On 6/28/24 at 2:07 P.M., the surveyor observed Resident #3 in the day room receiving oxygen via nasal cannula at three liters per minute. Review of Resident #3's physician orders indicated: -Oxygen two liters (L) per minute via nasal cannula (NC) continuously every shift, initiated 4/18/21. Review of the Medication Administration Record (MAR) indicated on 6/28/24 during the 7:00 A.M. to 3:00 P.M. shift and on 7/1/24 during the 11:00 P.M. to 7:00 A.M. nursing implemented the physician's order. Review of the plan of care related to oxygen therapy, dated 6/6/24, indicated: -OXYGEN (O2) SETTINGS: O2 continuously as ordered. During a phone interview on 07/02/24 at 10:41 A.M., Nurse #3 who worked the 11 P.M. to 7 A.M. shift on 7/1/24 said Resident #3 should be on continuous oxygen at two liters per minute which he verified by reviewing physician's order, and that Resident #3 does not adjust the settings. During an interview on 07/02/24 at 3:44 P.M., the Director of Nursing (DON) said nursing should implement the physician's order for oxygen flow rate. The DON said on 7/2/24 she observed Resident #3's oxygen set to three liters per minute and she had to adjust it.

Based on observation, record review, policy review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#38) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of a total of 19 sampled residents. Specifically, the amount of tube feeding infused did not correspond with the rate of infusion and the hours infused as ordered by the physician for Resident #38. Findings include: Review of the facility policy titled Gastrostomy Tube Feeding, dated 10/20/22, indicated that the purpose of the policy was intended to administer nourishment into the stomach via gastrostomy (G-tube) and decisions to continue use of tube feeding (TF) will be reviewed quarterly at a minimum and documented through continued care planning for intervention and renewal of physician orders. If any time the tube feeding is not administered per physician order, the physician must be notified for further instruction or orders. Resident #38 was admitted to the facility in February 2024 with diagnoses including stroke, dementia, dysphagia (difficulty swallowing), and post-traumatic stress disorder. Review of Resident #38's most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #38 had a feeding tube. Review of Resident #38's active physician's orders, dated 6/21/24, indicated the following: -Jevity (calorie dense therapeutic nutrition for tube feeding) 1.5 calorie (cal) administer via pump every shift, 60 mL (milliliters) per hour, hold at 5:00 A.M. and resume at 7:00 A.M. Review of the physician's progress note, dated 6/21/24, indicated: - concern tube feeding (TF) frequently turned off or forgotten to be turned on after providing personal care and at several follow up visits tube feeding have been off or stopped. On 7/1/24 at 7:00 A.M., the surveyor observed a 1500 mL bottle of Jevity 1.5 cal hanging in Resident #38's room. The Jevity 1.5 cal bottle was dated 7/1/24 at 7:00 A.M. and was visibly running through the tubing and was connected to resident at a rate of 60 mL per hour. On 7/1/24 at 1:25 P.M., the surveyor observed the tube feeding (TF) hanging, connected to Resident #38 and the pump read 60 mL per hour. The 1500 mL bottle of Jevity 1.5 cal, dated 7/1/24 at 7:00 A.M., contained 1500 mL of tube feeding. On 7/1/24 at 3:52 P.M., the surveyor observed the tube feeding hanging, connected to Resident #38 and the pump read 60 mL per hour. The 1500 mL bottle of Jevity 1.5 cal, dated 7/1/24 at 7:00 A.M., contained 1500 mL of tube feeding, which remained unchanged since the 7/1/24 at 7:00 A.M. observation. On 7/1/24 at 3:55 P.M., Unit Manager #1 observed the tube feeding infusing for Resident #38 with the surveyors, the tube feeding bottle was dated 7/1/24 and contained 1500 mL of Jevity 1.5 cal tube feeding. Unit Manager #1 said she was unsure why the tube feeding did not infuse all day, but it should have. Review of progress note dated 7/1/24 at 10:34 P.M., Nurse #7 documented Patient not getting full amount of Jevity 1.5 d/t (due to) machine, only got 400 cc (cubic centimeter and mL are different names for the same metric unit of volume). (sic.) Nurse #7 obtained an order from the physican to administer one time order Jevity 1.5 200cc bolus. (sic.) During phone interview at 7/2/24 at 12:57 P.M., Nurse #7 (who worked on 7/1/24 from 7:00 A.M. to 3:00 P.M. and 7/1/24 from 3:00 P.M. to 11:00 P.M.) said that she noticed a defect in the machine on 7/1/24 in the afternoon after 4:00 P.M., she said she tried to flush the tubing and reset the machine. Nurse #7 said that Resident #38 should have received tube feeding at 60 mL per hour but did not. Nurse #7 said that she did not check on enteral feeding routinely during her shift. Nurse #7 said she was not aware of any staff pausing or turning off the tube feeding machine during care. Nurse #7 called the physician and received an order at 6:00 P.M. to deliver a bolus feeding of 200mls. During interview 7/2/24 at 3:56 P.M., the Director of Nursing (DON) said she would expect tube feeding to be assessed and monitored to make sure enteral feed is infusing. The DON said she was aware that the physician had multiple concerns that the tube feeding had been stopped and would expect the physician to have notified her prior to leaving the facility.

Based on observations, record review and interviews, the facility failed to meet professional standards of quality for one Resident (#50) out of a total sample of 19 residents. Specifically, for Resident #50, the facility failed to follow physician's orders to apply offloading booties to bilateral heels while in bed. Findings include: Resident #50 was admitted to the facility in May 2024 with diagnoses that include adult failure to thrive and repeated falls. Review of Resident #50's most recent Minimum Data Set (MDS) Assessment, dated 6/4/24, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating that Resident #50 had severe cognitive impairment. The MDS further indicated that Resident #50 was at risk for the development of pressure ulcers. The MDS further indicated that rejection of care was not a behavior exhibited by the Resident. Review of Resident #50's physician's orders indicated the following: -Apply booties to bilateral heels while in bed, dated 5/31/24. Review of Resident #50's active skin risk care plan indicated that the resident had potential for skin breakdown related to fragile coccyx areas and left heel with DTI (deep tissue injury, a type of pressure ulcer) as evidenced of observation of eschar, dated 5/31/24. On 6/28/24 at 8:59 A.M., the surveyor observed Resident #50 laying in bed on his/her back with his/her heels directly on the mattress. On 6/28/24 at 11:40 A.M., the surveyor observed Resident #50 laying in bed on his/her back with his/her heels directly on the mattress. On 7/1/24 at 6:44 A.M., the surveyor observed Resident #50 sleeping in bed on his/her back with his/her heels directly on the mattress. The surveyor observed two offloading booties the wheelchair across the room from the Resident. On 7/1/24 at 9:30 A.M., the surveyor observed Resident #50 sleeping in bed on his/her back with his/her heels directly on the mattress. The surveyor observed two offloading booties the wheelchair across the room from the Resident. On 7/2/24 at 9:24 A.M., the surveyor observed Resident #50 laying in bed on his/her back with his/her heels directly on the mattress. The surveyor observed two offloading booties the wheelchair across the room from the Resident. During an interview on 7/2/24 at 9:32 A.M., the surveyor and Certified Nurse Assistant (CNA) #2 observed Resident #50 in bed without offloading boots on his/her bilateral feet. CNA #2 said Resident #50 should wear offloading booties at all times when he/she is in bed, but somebody must have forgotten to put them on. During an interview on 7/2/24 at 9:36 A.M., Nurse #9 said Resident #50 should have offloading booties on both feet at all times when he/she is in bed. Nurse #9 said Resident #50 never refuses to wear the offloading booties, but if he/she did it would be documented in the Treatment Administration Record (TAR) or in a progress note. Review of Resident #50's Treatment Administration Record (TAR) indicated that Resident #50 had heel booties on in bed as ordered on 6/28/24 and 7/1/24. Further review of TAR and progress notes failed to indicate Resident #50 refused offloading booties in the last month. During an interview on 7/2/24 at 12:07 A.M., the Director of Nursing (DON) said if the booties were refused it would be indicated in TAR or a progress note. The DON said offloading booties should have be worn following the physician order. 48990

Based on record review and interviews for one Resident (#3) out of a total sample of 19 residents, the facility failed to ensure staff adequately identified a significant change in Resident's status and complete a comprehensive Significant Change of Status Assessment Minimum Data Set (MDS) as required. Specifically, the facility failed to identify and complete a Significant Change of Status MDS when Resident #3 experienced significant weight loss and a decline in his/her ability to transfer in and out of bed. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated a Significant Change of Status must be completed by the end of the 14th calendar day following determination that significant change has occurred. It defines a significant change as a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Resident #3 was admitted to the facility in February 2019 with diagnoses including chronic obstructive pulmonary disease (COPD), which is a common lung disease causing restricted airflow and breathing problems, stroke, dysphagia (difficulty swallowing), and malnutrition. Review of Resident #3's MDS, dated [DATE], indicated: -a documented weight of 129 pounds. -supervision chair/bed-to-chair transfer. Review of Resident #3's MDS, dated [DATE], indicated: -a documented weight of 109 pounds. -significant weight loss (loss of five percent or more of the Resident's total body weight in the last month or a loss of ten percent or more in six months). -dependent chair/bed-to-chair transfer. Review of Resident #3's dietary progress notes, dated 3/26/24, indicated he/she had significant weight loss (6.5% in 30 days) based on documented weight of 115.5 pounds, and an increase in Med Pass (nutritional supplement) to 120 milliliters (mL) three times a day was ordered. Review of Resident's #3's dietary progress notes, dated 4/4/24, indicated he/she had significant weight loss (12.8% in 30 days) based on documented weight of 109 pounds, and an increase in Med Pass to 120 mL four times a day was ordered. Review of Resident #3's dietary progress notes, dated 4/11/24, indicated he/she had significant weight loss (6% in 30 days) based on documented weight of 108.5 pounds. Review of Resident #3's Certified Nursing Assistant (CNA) documentation, dated 1/18/24 to 1/24/24, indicated he/she required supervision for transfer to and from bed to chair. Review of Resident #3's CNA documentation, dated 4/18/24 to 4/24/24, indicated he/she was totally dependent on staff for transfer to and from bed to chair. The MDS Nurse was unable to be interviewed because she no longer worked at the facility. During an interview on 7/2/24 at 4:01 P.M., the Director of Nursing (DON) said a Significant Change of Status MDS should have been completed.

Based on interviews and record reviews the facility failed to 1.) develop a care plan for one Resident (#24) with a history of Suicidal Ideation and 2.) follow physicians' orders for pre- and post-dialysis weights for one Resident (#45) out of a total sample of 21 residents. 1. For Resident #24, who has a significant history of Suicidal Ideation (SI) and actual suicide attempts, the facility failed to develop a care plan for SI monitoring. Resident #24 was admitted to the facility in January 2022 with diagnoses including major depressive disorder, post-traumatic stress disorder and schizoaffective disorder. Review of the most recent Minimum Data Set Assessment, dated 2/1/23, indicated a Brief Interview for Mental Status exam score of 14 out of possible 15 indicating intact cognition. Review of Resident #24's medical record indicated the following: * A physician visit note for readmission in May 2022 indicated Resident #24 had a history of SI attempts with the most recent in July 2020. * A social service note, dated 5/6/22, indicated Resident #24 had a psychiatric admission this quarter. * A psychiatry consult note, dated 5/19/22, indicated: recent hospitalization for SI-reported he/she wanted to use a cord to hang self. History of suicidal behavior with attempted self-injury. * A psychiatry consult note, dated 3/31/23, indicated: Resident #24 had diagnoses including suicidal behavior with attempted self-injury. Notes indicate, recently expressed SI but stated, I have no way to do it. * A physician visit note, dated 4/4/23, indicated Resident #24 recently went to the Emergency Department and reported not feeling safe. The assessment indicates Resident #24 has a history of SI attempts the most recent in July 2020. * A shift level note, dated 5/7/23, indicated Resident #24 came back from the hospital at 3:30 A.M., secondary to fall and Suicidal Ideation. During an interview on 5/25/23 at 8:43 A.M., Nurse Unit Manager (#2) said staff recently found out about Resident #24's history of SI and that Resident #24 should have a care plan in place for Suicidal Ideation. Nurse Unit Manager #2 said the Assistant Director of Nursing is responsible for that. During an interview on 5/25/23 at 11:03 A.M., the Social Worker said she would expect an SI care plan to be in place for someone who has had numerous psychiatric admissions and suicide attempts. The social worker said she was unsure if there was a care plan in place and is not responsible for care plans. 2. For Resident #45 the facility failed to follow physicians orders for obtaining pre- and post- dialysis weights. Resident #45 was admitted to the facility in December 2019 with diagnoses including dependence on renal dialysis, chronic kidney disease stage 5 and dementia. Review of Resident #45's most recent Minimum Data Set assessment, dated 3/22/23 , indicated Resident #45 was unable to complete a Brief Interview for Mental Status. Review of Resident #45 medical record indicated the following: * A physician's order, dated 6/15/21, indicated an order to obtain a pre dialysis weight on Tuesday, Thursday and Saturday. * A physician's order, dated, 6/15/21, indicated an order to obtain a post dialysis weight on Tuesday, Thursday and Saturday. * A nursing progress note, dated 5/4/23, indicated Resident #45's weight was checked at the dialysis center. No documented weight was available at the facility. * A nursing progress note, dated 5/9/23, indicated Resident #45's weight was checked at the dialysis center. No documented weight was available at the facility. Review of Resident #45's weight record indicated weights were obtained on the following dates: -1/5/23 x1 -2/6/23 x1 -3/1/23 x1 -4/9/23 x1 -4/18/23 x2 -4/22/23 x2 -4/25/23 x2 -4/27/23 x1 -5/5/23 x1 -5/20/23 x1 During an interview on 5/25/23 at 8:59 A.M., Nurse Unit Manager (#2) said it was the expectation that physician orders be followed and confirmed that Resident #45 was not getting weighed as ordered by the physician pre- and post-dialysis.

Based on interview and record review, the facility failed to report an allegation of abuse within 2 hours to the State Survey Agency for one Resident (#19) out of a total sample of 21 residents. Findings include: Review of the facility policy titled Abuse Prevention Manual, last revised October 2022, indicated the following: *An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury Resident #19 was admitted to the facility in April 2022 with diagnoses including dementia without behaviors. Review of the Minimum Data Set (MDS) assessment, dated 4/26/22, indicated that Resident #19 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. During an interview on 5/23/23 at 8:07 A.M., Resident #19 said staff are rough with him/her when providing care, and that the Resident has not told the staff about this concern. The Surveyor immediately informed the Resident #19's Nurse (#1) of the allegation. Review of the Health Care Facility Reporting System (HCFRS) on 5/23/23 indicated that the allegation of abuse had been reported at 1:05 P.M. by Nurse #2, 5 hours after the facility was made aware of the allegation of abuse. During an interview on 5/3/23 at 1:48 P.M. Nurse #2 said she shares the responsibility of filing reports for allegations of abuse with the administrator. Nurse #2 said she would consider a report of rough handling as an allegation of abuse which would need to be reported to the State Agency, as a thorough investigation would need to be completed prior to determining whether or not abuse had occurred. Nurse #2 also said she was made aware of the allegation around 12:00 P.M., and that she should have been notified of the allegation immediately as all allegations of abuse must be reported to the State Survey Agency within 2 hours.

Based on interview and records reviewed for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free from physical abuse when at 11:30 A.M. on 12/25/18, Certified Nurse Aide (CNA) #1 was witnessed slapping Resident #1's face and arm. Findings include: The Facility Abuse Policy, dated 11/01/8, indicated that each resident will be free from, which includes verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Resident #1's clinical record indicated his/her medical [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set assessment, dated 01/07/19, indicated he/she had intact cognitive functioning, verbal behavioral symptoms directed towards others and required extensive assistance with one person for transfers. Resident #1's Plan Of Care, updated (MONTH) 2019, indicated he/she required assistance using a sliding board for transfers and had a history of [REDACTED]. The Surveyor interviewed Resident #1 at 12:10 P.M. on 01/29/19. Resident #1 said CNA #1 began slapping him/her after he/she told CNA #1 that he/she wanted the soiled floor cleaned before being transferred out of bed. Resident #1 said CNA #1 slapped his/her face. Resident #1 said he/she lifted his/her hands up to block additional slaps by CNA #1. Resident #1 said CNA #1 slapped his/her left arm. Resident #1 said although not he/she was not physically harmed, he/she was angry at CNA #1 for slapping him/her. Resident #1 said Visitor #1 and Resident #2 were in the bedroom during the incident. Resident #2's Annual Minimum Data Set assessment, dated 01/07/19, indicated his/her cognitive function was intact and he/she presented without mood or behavioral symptoms. The Surveyor interviewed Resident #2 at 11:35 A.M. on 01/29/19. Resident #2 said he/she heard Resident #1 refusing to be transferred out of bed. Resident #2 said Resident #1 yelled at CNA #1 to leave the bedroom. Resident #2 said he/she saw Resident #1 put his/her hands up to his/her own face. Resident #2 said he/she saw at least one of CNA #1's slaps directed at Resident #1, make contact with Resident #1's face. The Surveyor interviewed Visitor #1 at 12:45 P.M. on 01/29/19. Visitor #1 said Resident #1 refused to be transferred out of bed. Visitor #1 said Resident #1 pulled his/her arm away from CNA #1. Visitor #1 said she witnessed CNA #1 slap the left side of Resident #1 face and then slap the right side of Resident #1's face. Visitor #1 said Resident #1 covered his/her own face with his/her hands. Visitor #1 said CNA #1 kept slapping Resident #1. The Surveyor interviewed Nurse #1 at 11:30 A.M. on 02/08/19. Nurse #1 said at approximately 11:30 A.M. on 12/25/18 she told CNA #1 to wait for housekeeping to clean the floor before transferring Resident #1 out of bed. Nurse #1 said she proceeded out of the bedroom with the intent of call housekeeping when she heard Resident #1 screaming to someone to get out of his/her bedroom. Nurse #1 said she immediately proceeded back into Resident #1's bedroom. Nurse #1 said Resident #1, Visitor #1, and Resident #2 (who were present in the bedroom) indicated that CNA #1 hit Resident #1. Nurse #1 said CNA #1 immediately left Resident #1's bedroom and Unit as instructed, pending investigation.

Based on interview and record review, for one of three sampled residents (Resident #1), the Facility failed to provide Resident #1 with adequate supervision to prevent Resident #1's elopement despite indicators of increased risk, which occurred throughout the day on 1/4/15. - At 9:40 A.M. on 1/4/15, Resident #1 broke a window in the dayroom. Staff failed to investigate and identify Resident #1's role in breaking the window. - Staff failed to make an effective repair to the broken window or adequately supervise the hazard. - Resident #1 eloped from the smoking area at 10:46 A.M. and subsequent physician orders [REDACTED].#1's whereabouts every fifteen minutes, but they were not consistently completed during the 11:00 P.M. to 7:00 A.M. shift, which started on 1/4/15 and ended on 1/5/15. - Resident #1 climbed through the broken, second floor window at 1:48 A.M. on 1/5/15, and staff failed to recognize or react to his/her absence for about 90 minutes. Resident #1's whereabouts were unknown for 14 hours, during which outdoor temperatures ranged from 30 to 45 degrees Fahrenheit. Resident #1 sustained a fractured finger which was attributed to the fall. Findings include: The clinical record indicated the Facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1's Admission Assessment indicated he/she was alert, confused, oriented only to person and had impaired judgment and decision making. The Admission Assessment indicated Resident #1 wandered and disrobed. The Elopement Risk Assessment, completed 12/30/14, indicated Resident #1 was at risk to elope and his/her care plan interventions included Wanderguard placement, constant supervision and escort when off of the unit. Video surveillance footage of the day room on Resident #1's unit showed that on 1/4/15 at about 9:40 A.M., Resident #1 broke a window in the second floor day room. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 1/21/14. Nurse #1 said he noticed the broken window while passing medications, covered the opening with cardboard and plastic and reported it to the Nurse Supervisor and later in the day, to the Director of Nurses. Nurse #1 said he did not know how the window came to be broken and did not investigate. Nurse #1 said he checked the hands of the residents who frequented the dayroom during the day, but did not find any injuries likely to have occurred when breaking a window. The Surveyor interviewed the Director of Nurses at 10:00 A.M. on 1/12/15. The Director of Nurses said that she made rounds in the Facility around 3:00 P.M. on 1/4/15, saw the broken window, and spoke to Nurse #1. The Director of Nurses said it was unclear whether a resident broke the window or there was an external environmental cause. The Director of Nurses said she did not think to review surveillance footage to determine how the window was broken because she just thought it was an accident. Video surveillance footage of the smoking area showed that, on 1/4/15 at 10:46 A.M., Resident #1 walked away from the smoking area. The Surveyor interviewed Certified Nursing Assistant (CNA) #3 at 2:00 P.M. on 1/12/15. CNA #3 said that she supervised the smoking area on 1/4/15 and saw Resident #1 walk away. CNA #3 said she followed Resident #1 and asked him/her to come back inside and he/she said no. CNA #3 said another staff member went back inside for help while she followed Resident #1. CNA #3 said she and Resident #1 were intercepted by other staff members and Resident #1 returned to the Facility. Video surveillance footage at 10:50 A.M. on 1/4/15 showed Resident #1 returned to the Facility at 10:50 A.M. Nurse #1 said that he notified the physician of Resident #1's elopement from the smoking area and the physician ordered that Resident #1's whereabouts be checked every fifteen minutes. The 15 Minute Safety Checklist Forms for 1/4/15 and 1/5/15 contained documentation of Resident #1's whereabouts from 10:45 A.M. on 1/4/14 until 1:45 A.M. on 1/5/15. Video surveillance footage at 1:48 A.M. on 1/5/15, showed Resident #1 climb through the window in the second floor dayroom that he/she broke the previous day. Video surveillance footage from outside the Facility shows Resident #1 dropped two jackets from the window and then lowered him/herself from the second floor window to the pavement below. The footage showed Resident #1 gathered his/her things and walked away. Video surveillance footage of day room on Resident #1's unit showed Nurse #2 discovered the broken window in the dayroom at 3:17 A.M. and the police report indicated that the police were notified at 3:29 A.M. that Resident #1 was missing. The Surveyor interviewed Nurse #2 at 3:00 P.M. on 2/12/15. Nurse #2 said when she arrived at work at 11:00 P.M. on 1/4/15, Nurse #2 told her that Resident #1's physician order [REDACTED]. Nurse #2 said that she made the fifteen checks until about 1:30 A.M. when Resident #1 was sitting in the day room with his/her jacket because he/she said that it was cold. Nurse #2 said that between 3:00 A.M. and 3:15 A.M., she noticed that Resident #1 was not in the day and, when she checked his/her room, he/she was not there. Nurse #1 said a search of the floor was conducted, Resident #1 was not found and the police were notified. Resident #1's whereabouts were unknown for 14 hours, during which outdoor temperatures ranged from 30 to 45 degrees Fahrenheit. Resident #1 had cognitive impairment, but a reasonable person would experience psychological harm as a result of the incident. The Surveyor interviewed Family Member #1 at 11:30 A.M. on 1/12/15. Family Member #1 said Resident #1 was dropped off at her home, 5 miles from the Facility around 5:00 P.M. on 1/5/15, fifteen hours after he/she eloped. Family Member #1 said Resident #1 was unable to explain how he/she got to his/her home and he/she was transported to the hospital from her home for evaluation. Family Member #1 said the emergency department diagnosed Resident #1 with a fractured finger which he/she attributed to the jump from the window. The X-ray report, dated 1/6/15, indicated x-ray of Resident #1's fingers revealed a non-displaced fracture of the middle finger.

Based on interview and record review, for one of three sampled residents (Resident#1), the Facility failed to ensure that staff implemented Resident #1's plan of care. On 1/4/15, Resident #1's plan of care included for staff to ensure Resident #1's whereabouts were checked every fifteen minutes to prevent elopement. Video surveillance footage showed that Resident #1 jumped from a Facility second floor window and eloped at 1:48 A.M. on 1/5/15, and his/her absence was not discovered by Nurse #2 until 3:17 A.M. Resident #1 sustained a fractured finger as a result of jumping from the window. Findings include: The clinical record indicated the Facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1's Admission Assessment indicated he/she was alert, confused, oriented only to person and had impaired judgment and decision making. The Admission Assessment indicated Resident #1 wandered. The Elopement Risk Assessment, completed 12/30/14, indicated Resident #1 was at risk to elope and his/her care plan interventions included Wanderguard placement (a type of exit alert device), provide constant supervision and escort when off of the unit. Video surveillance footage of the second floor day room on Resident #1's unit showed that on 1/4/15 at about 9:40 A.M., Resident #1 broke a window. Video surveillance footage of the smoking area showed that, on 1/4/15 at 10:46 A.M., Resident #1 walked away from the smoking area followed by a staff member. Video surveillance footage at 10:50 A.M. on 1/4/15 showed Resident #1 returned to the Facility at 10:50 A.M. accompanied by five staff members. The Surveyor interviewed Nurse #1 at 11:00 A.M. on 1/21/14. Nurse #1 said that he notified the physician of Resident #1's elopement from the smoking area and the physician ordered that Resident #1's whereabouts be checked every fifteen minutes. The 15 Minute Safety Checklist Forms for 1/4/15 and 1/5/15 contained documentation of Resident #1's whereabouts from 10:45 A.M. on 1/4/14 until 1:45 A.M. on 1/5/15. Video surveillance footage at 1:48 A.M. on 1/5/15, showed Resident #1 climb through the window in the dayroom that he/she broke earlier in the day. Video surveillance footage from outside the Facility shows Resident #1 dropped two jackets from the window and then lowered him/herself from the second floor window to the pavement below. The footage showed Resident #1 gathered his/her things and walked away. The Surveyor interviewed Nurse #2 at 3:00 P.M. on 2/12/15 and reviewed her nurse's note for the 11:00 P.M. to 7:00 A.M. shift which started on 1/4/15 and ended on 1/5/15. Nurse #2 said and her documentation indicated, she completed Resident #1's fifteen minute checks until 1:30 A.M. Nurse #1 said that Resident #1 was asleep at 11:00 P.M. and for a short while afterward. Nurse #1 said that Resident #1 woke up and spent a short while in the day room before telling Nurse #1 that he/she was going to go back to bed. Nurse #1 said that Resident returned to the day room from his/her bedroom, with his/her jacket around 1:30 A.M. and told Nurse #1 that he/she could not sleep and needed the jacket because it was cold in the day room. Nurse #1 said that between 3:00 A.M. and 3:15 A.M., she walked passed the day room and saw that Resident #1 was not seated in there. Nurse #1 said that she checked Resident #1's and could not find him. Nurse #1 said that a search of the Facility ensued and the police were notified. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 2:00 P.M. on 1/21/15. CNA #1 said she saw Resident #1 in bed asleep at 11:30 P.M. on 1/4/15. CNA #1 said she and CNA #2 made rounds together around 1:00 A.M. on 1/5/15, but CNA #2 went into Resident #1's room and she did not. CNA #1 said she was off the unit from 2:30 A.M. to 3:00 A.M. on a break and when she returned, CNA #2 told her everything on the unit was okay. CNA #1 said CNA #2 went on break at 3:00 A.M. and a few minutes later, Nurse #1 asked whether she had seen Resident #1, and they started a search for him/her. CNA #1 said she and Nurse #1 could not find Resident #1 and the police were called. CNA #1 said she was aware that Resident #1 required checks every 15 minutes. CNA #1 said although Nurse #1 was responsible to completed the paperwork documenting the checks were performed, she and CNA #2 were required to check Resident #1 throughout the shift as well. The Surveyor interviewed Family Member #1 at 11:30 A.M. on 1/12/15. Family Member #1 said Resident #1 was dropped off at her home, 5 miles from the Facility around 5:00 P.M. on 1/5/15, fifteen hours after he/she eloped. Family Member #1 said Resident #1 was unable to explain how he/she got to his/her home and he/she was transported to the hospital from her home for evaluation. Family Member #1 said the emergency department diagnosed Resident #1 with a fractured finger, which he/she attributed to the jump from the window. The X-ray report, dated 1/6/15, indicated x-ray of Resident #1's fingers revealed a non-displaced [MEDICAL CONDITION] finger.

Based on record review, observation and staff interview the facility failed to promote the healing of a pressure ulcer for one Resident (Resident #6), in a total sample of 15. Findings include: For Resident #6, the facility failed to re-evaluate the plan of care for the effectiveness of current interventions for a right heel pressure ulcer and revise the interventions as indicated to promote wound healing from 4/4/13 to 10/23/13. Resident #6 was admitted in 3/2012 with [DIAGNOSES REDACTED]. On 4/4/13 the facility staff identified a new pressure ulcer on the Resident's right heel. On 4/4/13 the wound was documented as Stage II (a partial thickness loss of dermis). On 8/22/13 the Resident was sent out for a podiatry visit/wound evaluation for non-healing pressure on right heel. Following wound debridement of fibrotic tissue (a surgical procedure to remove dead tissue from a pressure ulcer), the wound measured 1.5 X 2.5 X .3 cm. in depth with minimal sanguinous drainage. Review of the 9/1/13 through 9/30/13 physician's orders [REDACTED]. 1. shake supplement 120 milliliters (mls) or approximately 4 ounces by mouth, three times per day, between meals. 2. off-load heels with pillows or heel protectors (heels are not to be in contact with the mattress). Review of the Resident's Care Plan for Pressure Ulcer on 9/23/13, indicated the following: change heel dressing every other day; rinse with sterile saline followed by application of [MEDICATION NAME] (to the wound, provide diet as ordered, evaluate progress of treatment skin breakdown weekly, pressure relieving mattress at all times and encourage fluids. Further review of the careplan indicated that the Resident was non-compliant with the Prevalon Booties, however no revised interventions were in place to ensure that the Resident's heels were off-loaded. On 9/23/13 at approximately 9:00 A.M., 9/24/13 at approximately 12 noon, 9/26/13 at approximately 6:00 P.M. and 9/30/13 at approximately 12:30 P.M. (observations were made during breakfast, lunch and dinner meals), Surveyor #2 observed the Resident with his/her heels rubbing against the sheets (friction and shearing are important contributing factors to the development of pressure ulcers) and an unfinished strawberry shake. The shake supplement was ordered to be given between meals and not with meals on the Resident's tray. During meal observations Surveyor #2 interviewed Resident #6 and asked why he/she was not keeping the heel booties on his/her feet as ordered by the physician. Resident #6 said that the booties were heavy, hot and uncomfortable and that he/she will never wear them. The Surveyor asked if he/she would be willing to try another heel protector to which he/she replied "sure". The Resident was in bed (by choice) most of the day and therefore, exposed to increased shearing/friction against the bed sheets. The Surveyor also asked the Resident why he/she was not taking the shake supplements as ordered by the physician. Resident #6 said "I don't like strawberry. I like vanilla." Resident #6 also said that the staff bring the shake with meals (physician's orders [REDACTED]. The Surveyor asked the Resident if he/she had communicated this to the staff. The Resident shook her head no and said that no one had ever asked. Review of the facility's "Skin Management Program Manual" (effective date 3/2008) indicated the following wound management principles be considered in the development of the plan of care: 1.) Control or eliminate causative factors a) Pressure b) Shear c) Friction d) Moisture Review of the "Individualized Care Plan" section of the Skin Management Program Manual indicated: 2) State measurable goal clearly 3) Specify target date 7) Provide ongoing evaluation of resident response to treatments and intervention. On 9/26/13 review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. After Surveyor observation of the Resident's refusal to accept shake supplements and communication with the nursing and dietary staff, the nursing staff indicated that shakes were not accepted with a circled nursing initial in the MAR. On 9/26/13 Surveyor #2 interviewed the Dietician. The Dietician said that the nursing staff had not informed her that the Resident was not accepting the strawberry shakes and also stated that the staff was supposed to notify the dietician if a resident had refused a supplement for 3 days or more. The dietician said that the shakes were recommended to provide extra calories and nutrients for wound healing. Surveyor #2 observed the Resident's right heel dressing change on 9/30/13 at 1:00 P.M. with staff nurse #2. The Surveyor observed the old dressing (dated 9/28/13) with moist, yellow drainage (approximately 2.5 cm. x 2.5 cm). Staff Nurse #2 removed the old dressing. The Surveyor observed a wound bed which was approximately 2.5 cm x 2.5 cm in diameter and width and approximately 0.3 cm in depth. Staff Nurse #2 cleansed the wound with normal saline (according to physician's orders [REDACTED]. Surveyor #2 observed that the staff nurse did not bring a measuring tape or sterile q-tip with her as part of her dressing change supplies. The Surveyor asked the staff nurse how she would measure the wound without a tape measure. The staff nurse said that she approximates the measurement at 2.5 cm. x 2.5 cm. and did not provide a depth measurement. Review of the "Measurement/Dimensions" section of the Skin management Program Manual indicated: Wounds will be measured on a weekly basis. Size is determined by measuring length, width and depth in centimenters. Depth is to be measured with a sterile q-tip. On 9/23/13, review of the Pressure Ulcer Record indicated the following heel measurements which only included length and width, but no depth (wound documentation should include size including length, width and depth, according to acceptable standards of practice): 5/7/13: 2.5 cm. X 2 cm. no depth recorded Stage II 5/9/13: 1.5 cm. X 2 cm. no depth recorded Stage II 6/4/13: 1.3 cm. X 2 cm. no depth recorded Stage II 6/18/13: 1.2 cm X 1.5 cm. no depth recorded Stage II 6/25/13: 1.1 cm. X 1.0 cm. no depth recorded Stage II 7/2/13: 1.5 cm. X 0.8 cm. no depth recorded Stage II 7/9/13: 1.0 cm. X 1.0 cm. no depth recorded Stage II 7/23/13: 1.0 cm. X 0.5 cm. no depth recorded Stage II 8/30/13: 2.7 cm. X 3 cm. no depth recorded Stage III (per physician) 9/4/13: 2.5 cm. X 2.6 cm. depth= .01 (yellow drainage) Stage III 9/18/13: 2.0 cm. X 2.5 cm. depth= .01 (yellow drainage) Stage III (According to the State Operations Manual, if a pressure ulcer fails to show evidence of progress toward healing within 2-4 weeks, the pressure ulcer and the resident's overall clinical condition should be reassessed). On 10/8/13 at 10:00 A.M. the Surveyor conducted a follow-up interview with the Unit #2 Manager (UM). The UM said that the Resident's wound had increased yellow drainage and that a nursing note of 10/2/13 indicated an increase in slough (necrotic/avascular tissue in the process of separating from the viable portions of the body which is usually light colored, soft moist and stringy, at times). The Surveyor asked if the Resident's Podiatrist was notified about the increase in drainage for a possible change in therapy. The UM said that the Resident was going to be evaluated on 10/17/13, but the staff had not notified the Podiatrist. The Surveyor interviewed the Resident's physician on 10/8/13 at 1:30 P.M. The physician said that the staff had not told him, nor was he aware that the Resident was not accepting his/her supplemental shakes. The physician said that he was aware of the Resident's non-compliance with off-loading heels. The Surveyor asked what Stage the pressure ulcer was. The physician said that the Resident's pressure ulcer was now a Stage III (full thickness tissue loss). On 10/9/13 at 9:00 A.M. the Surveyor interviewed the covering Podiatrist. The covering Podiatrist said that Resident #6 was first seen for a wound evaluation on 8/22/13 (approximately 5 months after the wound was first identified as a Stage II). The covering Podiatrist also said that the facility had not notified the office with any recent changes (increased drainage) to the Resident's pressure ulcer.