Every finding on record at Care One at Concord

Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for two Residents (#6 and #10) out of 26 total sampled residents. Specifically:1.) For Resident #6, the nurse inaccurately documented a wound dressing change was completed multiple times when it was not.2.) For Resident #10, the nurses inaccurately documented a topical medication was applied multiple times when it was not.Findings include:Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1.) Resident #6 was admitted to the facility in December 2025 with diagnoses including heart failure and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/15/25, indicated Resident #6 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS also indicated Resident #6 had two stage three pressure ulcers and one stage four pressure ulcer. During an interview on 1/6/26 at 7:53 A.M., Resident #6 was unable to provide the surveyor information regarding his/her left buttock wound. On 1/7/26 at 11:27 A.M., The Assistant Director of Nursing (ADON) said she had been responsible for assessing Resident #6's left buttock wound every week. The ADON said Resident #6 used to have a wound on his/her left buttock, but it had healed in December. The surveyor observed Resident #6's left buttock with the ADON. There was no wound on Resident #6's left buttock. The ADON showed the surveyor the healed, discolored skin and said this was where the left buttock wound had been located but it healed on 12/29/25. There was no dressing located on this area on the left buttock during this observation. Review of Resident #6's active physician's order, initiated 12/11/25, indicated: -LEFT BUTTOCK: NORMAL SALINE CLEANSE/PAT DRY APPLY CALCIUM ALGINATE F/B BORDER FOAM DRESSING every day shift every 2 day(s), initiated 12/11/25. Review of Resident #6's Treatment Administration Record (TAR), dated 12/30/25 to 1/7/26, indicated the physician's order for LEFT BUTTOCK: NORMAL SALINE CLEANSE/PAT DRY APPLY CALCIUM ALGINATE F/B BORDER FOAM DRESSING was documented as completed by Nurse #1 with the following wound description of the left buttock: -12/31/25: left buttock dressing change completed, and Nurse #1 noted scant serous (a clear fluid which leaks out of wounds) drainage. -1/2/26: left buttock dressing change completed, and Nurse #1 noted scant serous drainage. -1/4/26: left buttock dressing change completed, and Nurse #1 noted scant serous drainage. -1/6/26: left buttock dressing change completed, and Nurse #1 noted scant serous drainage. Review of Resident #6's assessment titled 'Pressure Injury Record', completed by Assistant Director of Nursing, dated 12/8/25 to 12/29/25, indicated -left buttock pressure ulcer resolved on 12/29/25. During an interview on 1/7/26 at 12:16 P.M., the ADON said Nurse #1 should not have documented a dressing being applied because the left buttock pressure ulcer was healed. The ADON further said the physician's order for the wound treatment to Resident #6's left buttock should have been discontinued but wasn't. During an interview on 1/7/26 at 12:40 P.M., Nurse #1 said Resident #6's left buttock pressure ulcer had been healed since 12/29/25. Nurse #1 said there was no drainage. Nurse #1 said she did not apply any wound dressing to Resident #6's left buttock wound since it healed and should not have documented that she did. Nurse #1 said her documentation on the TAR indicating that Resident #6's left buttock wound dressing change had been completed and noting the presence of scant serous drainage was inaccurate. During an interview on 1/7/26 at 1:07 P.M., the Director of Nursing (DON) said the nurse should not have documented a dressing change was completed or that drainage was present if it was not. 2. Resident #10 was admitted to the facility in December 2025 with diagnoses including acquired absence of right leg below knee and muscle weakness. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored 12 out of 15 on the Brief Interview for Mental Status indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident required maximum assistance with activities of daily living. On 1/6/26 at 10:29 A.M., the surveyor observed Resident #10 sitting in his/her room, the Resident had a right prosthetic leg. Review of Resident #10's current physician order dated 12/7/25, indicated the following: -Skin prep to bilateral heels every day and evening shift. Review of Resident #10's Treatment Administration Record (TAR), dated 12/7/25 to 1/7/26 indicated the nurses had signed off the treatment of skin prep had been applied to bilateral heels twice a day. During an interview on 1/8/26 at 8:46 A.M., Nurse #1 said the Resident had a right below knee amputation and the application of skin prep to right heel was documented in error. During an interview on 1/8/26 at 8:54 A.M., Nursing supervisor #1 said documentation of skin prep to right heel was inaccurate as the Resident does not have a right heel. During an interview on 1/8/26 at 9:42 A.M., the Director of Nursing said if the nurses documented that skin prep was applied to the Resident's right heel that was inaccurate documentation.

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 stored in the original, labeled containers when two nurses stored multiple pre-poured medications in uncovered, unlabeled medication cups within the medication carts.Findings include:Review of the facility policy titled 'Medication Labeling and Storage', revised February 2023, indicated:-Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are labeled accordingly.-Controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments. On 1/7/26 at 8:25 A.M., the surveyor observed the Dove Unit medication cart with Nurse #2 which contained three uncovered and unlabeled medication cups containing pre-poured medications. Nurse #2 said she pre-poured these medications, even though she had not attempted to administer them to the residents. Nurse #2 said she pre-poured the medications so they would be ready when it was time to administer them later. Nurse #2 said the following were in each uncovered, unlabeled medication cup:-In the first medication cup, there was an ativan pill (a controlled substance) mixed with various other pills melting in applesauce, making it difficult to identify the pills. This was not in a separately locked compartment.-In the second cup, there was another ativan pill melting in apple sauce, making it difficult to identify the pill. Nurse #2 said this was for a different resident. This was not in a separately locked compartment.-In the third cup, there was a pink liquid medication. Nurse #2 said this was poured earlier because it's supposed to be refrigerated so she gets it early so it's in her cart when she needs it.Nurse #2 said she knew she shouldn't have pre-poured medications in advance because it was against the law. On 1/7/26 at 1:17 P.M., the surveyor observed the Cardinal Unit medication cart #1 with Nurse #3 which contained one uncovered and unlabeled medication cup containing four pills. Nurse #3 said she prepared the medications earlier in the shift, but the resident was not ready to take the medications, so she saved them to administer later. Nurse #3 said she should have discarded them because they shouldn't be stored this way in the medication cart but did not. During an interview on 1/7/26 at 1:30 P.M., the Director of Nursing (DON) said she would expect the nurses to follow their medication storage policy regarding how to store medications in the medication cart.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Policy when on 04/08/25, after Nurse #1 witnessed an incident of alleged physical abuse of the resident by staff member, Nurse #1 left Resident #1 and the accused staff member (Certified Nurse Aide (CNA) #1) alone together and did not immediately separate them. Findings include: Review of the Facility's Abuse Policy titled Recognizing Signs and Symptoms of Abuse, dated as revised April 2021, indicated all types of resident abuse are strictly prohibited and personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Review of the Facility's Policy titled Protection of Residents During Abuse Investigations, dated as revised April 2021, indicated residents are protected from harm, retaliation, reprisal, discrimination or coercion during investigations of abuse, neglect, exploitation and misappropriation of resident property. The Policy indicated that if the alleged perpetrator is an employee or staff member, the individual is immediately reassigned to duties that do not involve resident contact or are suspended until the findings of the investigation are reviewed by the administrator. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 04/08/25, indicated that on 4/08/25 at approximately 11:15 A.M., the Nurse Manager reported to the Director of Nursing that Nurse #1 perceived that CNA #1 slapped the left side of Resident #1's face with an open hand. Review of the Facility's Internal Investigation Summary Report, undated, indicated that after witnessing CNA #1 slap Resident #1, Nurse #1 left Resident #1's room without saying anything. During a telephone interview on 05/05/25 at 2:05 P.M., Nurse #1 said that on 04/08/25 at approximately 11:15 A.M., she entered Resident #1's room looking for his/her roommate and when she opened the door, she saw CNA #1 slap the left side of Resident #1's face with her right hand. Nurse #1 said she was shocked and immediately exited the room leaving Resident #1 and CNA #1 alone in the room. Nurse #1 said she went to the Nurse Manager and reported the incident that she witnessed. Nurse #1 said that when she and the Nurse Manager returned to Resident #1's bedroom door, Resident #1 was already ambulating out of the room on his/her own. During an interview on 05/05/25 at 11:30 A.M., the Director of Nursing (DON) said that on 4/08/25, Nurse #1 reported that she saw CNA #1 slap Resident #1 and initiated an internal investigation. The DON said when interviewing Nurse #1 about the incident she witnessed, Nurse #1 told her that she left CNA #1 alone in the room with Resident #1 after she witnessed the slap in order to go and speak with the Nurse Manager. The DON said Nurse #1 should have intervened, stayed with Resident #1 and asked CNA #1 to leave Resident #1's room after witnessing abuse. The Director of Nursing said that Nurse #1 was suspended as a result of her failure to intervene and received education before returning to work. On 5/05/25 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. On 4/08/25, Nurse #1 and CNA #1 were suspended pending the outcome of the Facility's Internal Investigation of the allegation. B. The Director of Nursing conducted Skin and Pain Assessments for Resident #1 on 4/08/25 and reviewed and updated interventions on his/her ADL deficit care plan. C. The Social Worker met with Resident #1 on 4/09/25 to offer support and assess for change in mood/behavior. D. Starting on 4/08/25 and on-going, the Facility Director of Education or designee trained all staff on the expectations of when to report abuse and steps to assure resident safety. E. On 4/09/25, the Facility Social Worker/designee initiated interviews of all Facility residents regarding staff treatment and comfort/safety in the Facility. F. On 4/11/25, the Director of Nursing/designee initiated interviews of all staff members regarding observations of staff treatment of residents, including response to incidents/allegations. G. Starting 4/11/25, the Director of Nursing/designee conducted audits with ten staff members weekly for three weeks and subsequently monthly for two additional months, of their understanding of the Facility Abuse Policies and Procedures. H. The Quality Assurance Committee reviewed the Facility Performance Improvement Plan on 4/08/25 and will review progress during the July 2025 meeting. I. The Administrator and/or designee are responsible for overall compliance.

Based on record review and interviews, the facility failed to develop personalized care plans for two Residents (#87 and #92) out of a sample of 26 residents. Specifically: 1. For Resident #87, the facility failed to develop personalized care plans after the Speech Therapist made recommendations after two speech evaluations. 2. For Resident #92, the facility failed to develop a personalized history of substance abuse care plan. Findings include: A review of the facility policy titled, 'Care Plans, Comprehensive Person-Centered' with a revision date of December 2016 indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive care plan will: -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Aid in preventing or reducing decline of the resident's functional status and or/functional levels. 1.) Resident #87 was admitted to the facility in October 2023 with diagnoses including dementia and dysphagia (difficulty swallowing). A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. A review of the Situation, Background, Assessment, and Recommendation (SBAR) dated 2/10/24 indicated the following: -Change in condition noted related to Around 1:35 pm, patient was in the hallway between his/her room and dining when staff notice his/her briefly unresponsive, mouth cyanotic (bluish coloring) and eyes fixed while trying to hand over a bottle of drink to that staff. While assessing him/her further, we notice he/she had something in his/her mouth which looks like smuchy blueberry muffins. Apparently, his/her family brought donuts to him/her and he/she must have eating it too fast and it did not go down the digestive track easily. This change in condition started on 2/10/24. Since this started, it has stayed the same. Other relevant information: Patient has a history of eating too fast [sic] A review of a speech evaluation dated 2/15/24 indicated the following: -Patient noted one time pocketing (holding food in one's mouth without swallowing it) and patient independently cleared with liquids. Discussed with nursing, continue to assist with cutting into small bites, encourage slow rate of intake and alternating with liquids and checking oral cavity at the end of PO (by mouth) intake. Suspected that a diet change will not make a difference with behaviors/pocketing, and patient appears to tolerate regulars with no overt signs and symptoms of aspiration. They (nursing) expressed understanding, agreement with the plan. Discussed to continue with regular thin, if they (family) are here during lunch, encourage washing all food down with liquids at the end of the meal, if they want to bring outside food from home, have the nurses store it in the kitchen for patient and then supervise when eating. [sic] A review of the SBAR dated 12/2/24 indicated the following: - Change in condition noted related to Resident was observed coughing/choking on a piece of waffle, residents' mouth was cleared of any food, but food was still lodged in throat, Heimlich maneuver (abdominal thrusts used as a first aid technique used to dislodge foreign objects that obstruct the upper airway) was performed with good effect. Residents 02 (oxygen) after incident was 86, but went up to 92% RA (Room Air) after a few minutes. This change in condition started on 12/2/24. Since this started, it has gotten better. Treatment for the last episode: resident sent out.[sic] A review of a speech evaluation dated 12/2/24 indicated the following: -Patient seen in the dining room today, speech therapist was initially sitting with a different patient at his/her table. Speech therapist noted patient with an overstuffed oral cavity of waffles. Speech therapist instructed patient to remove the waffles, which he/she followed, he/she then started pointing at his/her throat. When asked if he/she felt food was stuck in his/her throat, he/she nodded yes. Speech therapist called for help, Heimlich maneuver completed. At this time, downgraded diet, discussed diet change and incident with Nursing. [sic] During an interview on 1/23/25 at 9:28 A.M., the Speech Therapist said she completed a speech evaluation with Resident #87 on 2/15/24 after the Resident pocketed a muffin that was brought in by family. She said she met with the Resident's family and provided education, she said she made a verbal recommendation to the Unit Manager #1 that food brought in from family should be stored in the kitchen and the Resident should only eat it with staff supervision. The Speech therapist also said she verbally explained the following to Unit Manager #1, the Resident has a history of fast paced eating, and his/her mouth should always be checked for pocketing prior to exiting the dining area after meals. The Speech Therapist said she completed another speech evaluation with Resident #87 on 12/2/24 after he/she choked and received the Heimlich maneuver. She said she met with the Unit Manager #1 and made the following verbal recommendations, check for pocketing prior to leaving the dining area after meals, change the Resident's seating in the dining room so that the Resident is visible to all staff, and Resident #87 has a history of fast-paced eating. The Speech Therapist said she makes verbal recommendations to the Unit Manager and expects her to develop a personalized care plan, so all staff are aware of Resident #87's needs during meals. A review of Resident #87's care plan failed to indicate that the Speech Therapist's recommendations were developed and implemented into Resident #87's care plan after the evaluations on 2/15/24 and 12/2/24. During an interview and record review on 1/23/25 at 9:42 A.M., Unit Manger #1 said she was aware of the verbal recommendations made by the Speech Therapist on 2/15/24 and 12/2/24. She said she did not develop personalized care plans based on the recommendations but should have. Unit Manger #1 added that Resident #87 gets very anxious on Fridays before his/her family member visits and tends to eat in a very fast paced manner. She said the fast-paced eating could be triggered by anxiety. Unit Manager #1 said this information should also be added and personalized in Resident #87's care plan. During an interview on 1/23/25 at 1:20 P.M., the Director of Nurses said she expects all verbal recommendations from the Speech Therapist to be addressed by the Unit Manager and added in the care plan. The DON said the verbal recommendations and information provided by the Speech Therapist on 2/15/24 and 12/2/24 should have been care planned. 2.) A review of the facility policy titled, 'Substance Use Disorder' dated November 2022 indicated the following: -Residents who are admitted to the facility with substance use disorder (SUD) will receive the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being, provided by the facility and in accordance with the comprehensive assessment and care plan. -The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record. Resident #92 was admitted to the facility in August 2024 with diagnoses including alcohol abuse and schizoaffective disorder. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 indicating cognitive impairment. A review of Resident #92's Nutritional care plan initiated 8/28/24 indicated the following: -Diagnosis of encephalopathy and ETOH (alcohol) abuse. A review of the behavioral medication management progress notes dated 12/30/24 indicated the following: -Substance Use/Addiction History-History of ETOH (Alcohol) use disorder. During an interview and medical review on 1/23/25 at 10:30 A.M., the Social Worker reviewed the medical record and said a history of ETOH abuse care plan should be added even though Nutrition has addressed the ETOH abuse in the care plan. The Social Worker said a personalized ETOH abuse care plan should be developed and address the interventions from a mood and behavior perspective. During an interview on 1/23/25 at 1:20 P.M., the Director of Nurses said Resident #92 should have a personalized history of substance use care plan.

Based on record review and interview, the facility failed to ensure accurate documentation in the medical record for one Resident (#88) out of a total sample of 26 residents. Specifically, for Resident #88, nursing documentation in the Medication Administration Record (MAR) regarding the Resident's wanderguard was inaccurate. Findings include: Review of the facility policy titled Charting and Documentation, dated as revised July 2017, indicated the following: -Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Resident #88 was admitted to the facility in September 2023 and has diagnoses that include dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that on the Brief Interview for Mental Status exam Resident #88 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #88 had behavior of wandering 4-6 days in the previous 7 days. Review of Resident #88's current care plan indicated the following: Focus: Elopement/wandering risk related to cognitive impairment, initiated 1/2/24. Interventions include: -Check for placement and function of security bracelet as indicated, initiated 1/2/24. -Wanderguard to left ankle, initiate 1/2/24. Review of Resident #88's current Physician's orders indicated the following order: -Wanderguard, Expiration Date 5/26, every shift Wanderguard to left ankle. Check placement and function every shift. Start date of 11/13/24. Review of the January 2025 Medication Administration Record (MAR) indicated that in January 2025 nursing had documented 19 times no that Resident #88's wanderguard was not in place or functioning. During an interview on 1/23/25 at 10:00 A.M., with Nurse #2 she said that she is Resident #88's nurse on a regular basis. Nurse #2 said that Resident #88 wears a wanderguard due to behavior of trying to elope. She said that the Resident has no behavior of removing the wanderguard and that she should be documenting yes in the MAR, to indicate that the wanderguard is in place and functioning. Nurse #2 and the surveyor reviewed the MAR where Nurse #2 documented 15 of the 19 no entries that were in the MAR and she said that needed to be fixed. During an interview on 1/23/25 at 11:02 A.M., with the Director of Nursing she said that it is her expectation that the documentation in the MAR be accurate

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required the use of a mechanical lift with the assistance of two staff members for transfers later during the day or when he/she was fatigued or in pain, the Facility failed to ensure he/she was provided with an adequate level of safety from staff while being transferred via the mechanical in an effort to maintain his/her safety to prevent an incident/accident resulting in an injury. On 09/29/23, two Certified Nurse Aides (CNA's) attempted to transfer Resident #1 from a shower chair into his/her bed with the use of a mechanical lift, after positioning him/her in the mechanical lift sling required for use with a mechanical lift, as the CNA's raised him/her up, one of the straps (looped end of sling pad that staff manually connect to the lift) lifted up (slipped off) and became detached from the mechanical lift causing Resident #1 to fall backwards and hit his/her head on the floor. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, returned the same day, however, several days later he/she experienced a change in condition, was transferred back to the Hospital ED for further evaluation and was diagnosed with a concussion (brain injury caused by a blow to the head) related to the fall. Finding Include: The Facility Policy titled Mechanical Lift Use, dated as edited 08/24/22, indicated the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device and that it was not a substitute for manufacturer's training or instructions. The Policy indicated that step three in the procedure in use of a mechanical lift included measuring the resident for proper sling size and purpose, according to manufacturer's instructions. The Policy indicated that step twelve in the procedure in use of a mechanical lift included: -Make sure the sling is securely attached to the clips and that it is properly balanced. -Check to make sure the resident's head, neck, and back are supported. -Before resident is lifted, double check the security of the sling attachment. -Examine all hooks, clips, or fasteners. -Check the stability of the straps. Resident #1 was admitted to the Facility in April 2023, diagnoses included hemiparesis (partial paralysis on one side of body) following a cerebral infarction (stroke) affecting the left non-dominant side, diabetes mellitus, hypertension, dementia, anxiety and depression. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status score of 15 (13-15 indicates intact cognition), and was able to make his/her needs known. Review of Resident #1's Risk for Falls Care Plan, dated as revised 05/04/23, indicated that interdisciplinary staff may use a mechanical lift with the assistance of two staff members for transfers later in the day or when he/she was fatigued or in pain. Review of the Facility Incident Report, dated 09/29/23, indicated that Resident #1 fell from the mechanical lift when two Certified Nurse Aides (CNAs) were transferring him/her. The Report indicated Resident #1 hit his/her head, complained of pain to the back of his/her head and lower back, and that 911 was called. Review of the Hospital Discharge Instructions, dated 09/29/23, indicated Resident #1 was diagnosed with a head and back injury, and indicated to return to the Hospital for worsening headache, or unexplained nausea, vomiting, or mental status change. Review of the Facility to Hospital Transfer Form, dated 10/05/23, indicated Resident #1 was being transferred to the Hospital ED for complaints of nausea, vomiting and headache, and that he/she had a fall on 09/29/23 and had hit his/her head. Review of the Hospital ED Clinical Chart Document, dated 10/05/23, indicated Resident #1 had a fall from a mechanical lift on Friday (09/29/23) with a head strike and indicated that the Facility reported new onset of headache, nausea and vomiting. Review of the Hospital Discharge Instructions, dated 10/05/23, indicated that Resident #1's final diagnosis was a concussion. During an interview on 11/07/23 at 8:44 A.M., Resident #1 said that on the day he/she fell when staff attempted to transfer him/her with the mechanical lift, he/she had just taken a shower and said before the staff members attempted to transfer him back into bed that day, said it seemed to take them longer than it usually took other staff to hook up the straps to the hooks of the mechanical lift. Resident #1 said typically in the past, when staff had hooked him/her up to the mechanical lift while he/she was in the sling, one of the staff members would check to make sure that everything was alright. Resident #1 said that on the day he/she fell , he/she did not remember seeing staff do any checks on the straps. Resident #1 said as soon as they started to lift him/her up from the shower chair with the mechanical lift, he/she observed one of the straps start moving, and then things happened so fast, he/she fell and landed on his/her head. Review of Certified Nurse Aide (CNA) #1's written Witness Statement, dated 09/29/23, indicated that at approximately 2:00 P.M., another CNA called for his (CNA #1's) assistance with transferring Resident #1 back to bed from a shower chair with the use of a mechanical lift. The Statement indicated that during the middle of the transfer, the mechanical lift pad (also known as sling, which suspends resident in the mechanical lift during transfer) snapped out (slipped off) on one side and Resident #1 slid on the floor. During an interview on 11/07/23 at 10:54 A.M., CNA #1 said that on 09/29/23, CNA #2 asked him to assist her with transferring Resident #1 back into bed. CNA #1 said Resident #1 was seated in a shower chair at the end of his/her bed with the sling for the mechanical lift under him/her. CNA #1 said he helped hook up the two bottom straps (loops) of the sling to the hooks on the lower part of mechanical lift. CNA #1 said CNA #2 hooked the two upper straps of the sling to the hooks on the upper part of the mechanical lift, then he used the remote and began to lift Resident #1 with the mechanical lift. CNA #1 said he had not checked the two upper straps connections that CNA #2 had connected and put in place, because CNA #2 was not a new CNA. CNA #1 said as the mechanical lift slowly raised Resident #1 up off the chair, and he started to move the mechanical lift, with Resident #1 still suspended over the shower chair in the sling, the portion of the strap that was looped over and attached to one of the lift hooks on the upper part of the lift near Resident #1's shoulder snapped (slipped) off the hook. CNA #1 said it all happened so fast, that when the sling strap came off, Resident #1's body went to the side, he/she slid down and hit his/her head on the floor. Review of CNA #2's written Witness Statement, dated 09/29/23, indicated that after she (CNA #2) gave Resident #1 a shower, and called another CNA to assist with transferring him/her back to bed. The Statement indicated that while in the middle of transferring Resident #1, a strap of the sling, snapped (slipped) off the mechanical lift which caused him/her to hit his/her head on the floor. During an interview on 11/07/23 at 11:25 A.M., CNA #2 said that on 09/29/23 Resident #1 had been on her assignment and that after she gave him/her a shower, she asked CNA #1 to help her transfer him/her back into bed. CNA #2 said while Resident #1 was suspended above the shower chair in the sling attached to the mechanical lift, as CNA #1 started to move the lift, all of a sudden said she heard what sounded like a pop and observed Resident #1's legs go up, he/she fell backwards, his/her head went backwards, and he/she hit his/her head on the floor. CNA #2 said she observed that part of the sling, one of the straps had come off one of the hooks of the mechanical lift. CNA #2 said she did not know how or why the strap disconnected while they transferred Resident #1. CNA #2 said that the sling they used to transfer Resident #1 was wet and dripping at the time of the transfer and said that maybe that was the reason. During an interview on 11/07/23 at 11:51 A.M., the Unit Manager said that on 09/29/23, she was called by CNA #2 to come assist with Resident #1 and said when she went to Resident #1's room, she observed that he/she was on the floor by his/her bed. The Unit Manager said she assessed Resident #1, that he/she had a bump on his/her head, and 911 was called. During interview on 11/07/23 at 2:07 P.M., the Director of Nursing (DON) said she was notified by the Unit Manager of Resident #1's incident on 09/29/23 and said when she arrived at Resident #1's room she observed him/her lying on his/her back on the floor. The DON said she left the room to call 911. The DON said that after she investigated the incident, the only conclusion she could come to was that the strap (on the mechanical lift sling) was not positioned all the way down over the hook on the lift. On 11/07/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 10/03/23, Maintenance and Central Supply Coordinator completed audits (which included visual inspections of slings and straps) on all of the facility's mechanical lift slings to ensure they were in good condition. B) 10/04/23, DON and Central Supply Coordinator completed audits for all residents who required mechanical lift transfers to ensure the correct sling type was in use, that the appropriate sling size had been determined, and to ensure Care Plans were updated. C) 10/05/23, DON presented the area of concern and Plan of Correction at a Quality Assurance Performance Improvement Meeting. D) 10/06/23, Facility Educator completed education to Nursing Staff regarding: -Two care givers must assist with the use of a mechanical lift transfers. -Two care givers must inspect that the sling and hooks to ensure they are properly secured before any resident is moved. -Mechanical lift competencies were completed for nursing staff. E) 10/06/23, Maintenance Director and Central Supply Coordinator completed audit to ensure proper function of Facility mechanical lifts. F) 10/09/23, DON conducted follow-up observations of five mechanical lift transfers to ensure nursing staff compliance. G) Ongoing, DON will conducted weekly observations, then monthly follow-up observations of five mechanical lift transfers for continued compliance. H) November-December 2023, DON will present Plan of Correction, results of audits, follow-up Observations at the Quality Assurance Performance Improvement Meetings. I) DON and/or designee are responsible for overall compliance.

Based on observation, interview and record review the facility staff failed to ensure physician orders for oxygen administration were implemented accurately for 1 Resident (#62) out of a total sample of 21 residents. Findings include: Resident #62 was admitted to the facility in August 2020 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status exam (BIMS). The MDS further indicated that Resident #62 used oxygen. Review of Resident # 62's medical record indicated the following: -a physician order dated 8/22/20 for oxygen (O2) at 2 L (liters) via nasal cannula (NC) -a care plan initiated 8/22/20 with a focus of risk for respiratory impairment related to [MEDICAL CONDITION], obstructive sleep apnea with an intervention to administer oxygen per physician order. On 9/28/20 at 11:40 A.M., the surveyor observed Resident #62 using oxygen (O2) at 3 L (liters) via nasal cannula (NC). Resident #62 said he/she is not able to reach the oxygen to adjust settings and that the staff does it for him/her. On 9/30/20 at 8:35 A.M., Resident #62 was sitting in bed. Resident #62's O2 setting was 2.5 L via NC. Resident #62 said he/she had no shortness of breath. On 10/02/20 at 7:22 A.M., Resident #62 was observed lying in bed sleeping comfortably. Resident #62's O2 setting was at 2.5 L via NC. During an interview on 10/02/20 at 8:38 A.M., Nurse #2 said Resident #62 is unable to adjust his/her O2 settings independently and that nursing staff manages it for him/her. Nurse #2 acknowledged Resident #62's O2 was set to 2.5 L via NC. Nurse #2 said sometimes O2 may be adjusted for shortness of breath per nursing judgement but a progress note must be written and MD notification would occur. Nurse #2 said he had not received in report from the 11-7 shift that Resident #62 had increased shortness of breath that would warrant an increase in O2 setting. During an interview on 10/02/20 at 10:25 A.M., the Director of Nursing (DON) said adjusting oxygen settings can be a nursing intervention if a resident is symptomatic, but that if there were continued days of needing increased oxygen than the expectation would be that nursing would evaluate for a change in orders. Review of facility policy titled Oxygen Administration edited 4/02/2019 indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration.

Based on observation, interview, record review and facility policy review, the facility staff failed to implement the plan of care for one Resident (#86) out of a total of 21 sampled residents. For Resident #86 the facility failed to float the resident's heels when in bed, as ordered by the physician. Findings include: The facility policy titled Prevention of Pressure Injuries, revised April 2020, indicated for nursing staff to select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Resident #86 was admitted to the facility in December 2019, and had [DIAGNOSES REDACTED]. On the most recent Minimum Data Set (MDS) assessment Resident #86 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition. Further the MDS indicated that Resident #86 did not have behavior of refusing care and required extensive to total assistance of 2 people for Activities of Daily Living (ADL's), including bed mobility and transfers. On 10/01/20 at 9:20 A.M., the surveyor met with Resident #86. Resident #86 was lying in bed and he/she reported that he/she was experiencing a lot of pain in his/her feet. The surveyor observed that Resident #86's feet were lying flat on the mattress. Review of medical record of Resident #86 indicated the following: * A physician's orders [REDACTED]. * A skin care plan indicating Resident #86 was at risk for alteration in skin integrity related to impaired mobility, incontinence, chronic bilateral lower extremity [MEDICAL CONDITION] contributing to skin fragility, obesity, decreased mobility. Further, there was an intervention on the skin care plan, initiated 6/18/20, to float heels while in bed on a pillow. On 10/02/20 at 7:16 A.M., the surveyor observed Resident #86 lying in bed with his/her feet flat on the mattress. There was no pillow floating Resident #86's heels. The surveyor asked Resident #86 if the staff placed a pillow under his/her feet when he/she was in bed and Resident #86 replied no. On 10/02/20 at 7:19 A.M., the September and October 2020 Treatment Administration Records (TAR) was reviewed and the documentation indicated that Resident #86's heels were last floated on a pillow in bed at 8:00 P.M., on 10/1/20 and every night at 8:00 P.M., in September. Additionally, the clinical progress notes for the previous week were reviewed and there was no documentation that Resident #86 had refused care or the placement of the pillow. During an interview with the Certified Nursing Assistant (CNA #1) responsible for Resident #86, on 10/02/20 at 7:25 A.M., he said that Resident #86 did not refuse care and that he was not aware that his/her feet were supposed to be floated on a pillow while in bed. During an interview with the Nurse Unit Manager (UM#2) on 10/02/20 at 7:29 A.M., she said that Resident #86 had fluctuating behaviors, however, she was not aware of Resident #86 refusing care. The Surveyor and UM#2 observed Resident #86 together and his/her feet were lying flat on the mattress. UM#2 reviewed the clinical record and said that there was not any documentation that indicated Resident #86 refused the pillow placement. On 10/02/20 9:30 A.M., during an interview with the Director of Nursing (DON) he said that if someone had an order for [REDACTED].

Based on observation, interview and record review, the facility staff failed to ensure physician's orders for Prevlon boot (a pressure relieving device used to minimize pressure, friction and shear on the feet, heels and ankles) was applied as ordered to an area with a pressure ulcer for 1 resident (Resident #52) out of a total sample of 21 residents. Findings include: Resident #52 was admitted to the facility in August of 2020 with [DIAGNOSES REDACTED]. Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 had moderate cognitive impairment and scored an 11 out of 15 on the Brief Interview for Mental Status exam (BIMS). Resident #52's MDS further indicated that he/she had no behaviors, had no rejection of care and required an extensive assist with a one person physical assist for dressing. Resident #52's MDS further indicated that he/she had no pressure ulcer present upon admission and was at risk for pressure ulcer development. Review of Resident #52's medical record indicated a physician order dated 9/26/20 for the following treatment: -Ensure Prevlon boot is applied to left foot when in bed for Deep Tissue Injury (DTI) wound offloading every shift for DTI of left foot offloading (may remove for hygiene/ care). On 9/29/20 at 9:24 A.M., the surveyor observed Resident #52 lying in bed. Resident #52 said his/her left heel was painful and that he/she had a blister on his/her heel. Resident #52 further said that he/ she got the blister on his/her heel after being admitted to the facility. The surveyor observed that Resident #52 was not wearing a Prevlon boot. On 9/30/20 at 8:24 A.M., the surveyor observed Resident #52 lying in bed. Resident #52 was not wearing a Prevlon boot. During an interview on 10/01/20 at 8:52 A.M., Unit Manager (UM) #1 said Resident #52 is generally compliant and is not able to remove the Prevlon boots independently. UM#1 was unable to say why the Resident #52 did not have the Prevlon boot on during the surveyor's observations. During an interview on 10/01/20 at 11:10 A.M., Nurse #3 said Resident #52 is compliant with care and doesn't refuse care. During an interview on 10/01/20 at 12:57 P.M., the Director of Nursing (DON) acknowledged that Resident #52 had a physician order for [REDACTED].

Based on observation, interview and policy review, the facility failed to ensure that staff were 1.)actively screened upon entry to work for signs and symptoms of COVID-19 and 2.) properly performing hand hygiene while performing housekeeping duties while cleaning resident rooms. Findings include: 1. The facility failed to ensure that Social Worker #1 actively screened staff for symptoms of Covid-19 prior to their start of work. Review of Centers for Disease Control and Prevention (CDC) guidance,entitled, Preparing for COVID-19 in Nursing Homes, last reviewed 6/25/20, included the following: * Screen all Health Care Personnel at the beginning of their shift for fever and symptoms of COVID-19. * Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Review of the facility policy, entitled, Coronavirus Disease (Covid-19) Infection Prevention and Control Measures, revised 7/2020, indicated that anyone entering the facility (including staff) is screened and triaged for signs and symptoms of and exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection. Review of the facility form, entitled, Covid-19 Screening Questionnaire for Health Care Personnel, rev 7/16/20, indicated a Symptom Monitoring section which is used for one employee for six shifts. This section included yes/no boxes for the following symptoms: fever, cough, sore throat, new loss taste/smell, nausea/vomiting/diarrhea etc. On 9/28/20 at 7:10 A.M., during observation of the screening process, the surveyor observed Social worker #1 as she screened two staff members. Social Worker #1 took each of the staff members temperatures but did not conduct any further screening. She did not actively screen for symptoms of Covid-19. On 9/28/20 at 7:25 A.M., during interview, Social Worker #1 said that she just takes the staff temperatures. When the surveyor referred her to the symptom monitoring section of the screening questionnaire, Social Worker #1 said that maybe she should ask those questions. 2. The facility failed to ensure that Housekeeper #1 properly performed hand hygiene after cleaning a resident's room. Review of Centers for Disease Control and Prevention (CDC) guidance,entitled Hand Hygiene in Healthcare Settings, last reviewed 1/30/20, indicated that healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: * After touching a patient or the patient's environment. * After contact with blood, body fluids or contaminated surfaces. * Immediately after glove removal. On 9/28/20 at 10:42 A.M., the surveyor observed Housekeeper #1 in a resident room on the Dove Unit. Housekeeper #1 washed the floors and cleaned the bathroom. Once she left the resident's room, she removed her gloves and without performing hand hygiene, she donned another pair of gloves and moved on to the next resident room. Once in the next resident room, Housekeeper #1 cleaned the floor and the bathroom. Housekeeper #1 left the resident room and with the same gloves on, proceeded to go back to three other resident rooms and pick up the Wet Floor signs with her contaminated gloves and return the signs to her housekeeping cart. Housekeeper #1 removed her gloves and again, without performing hand hygiene, donned a new pair of gloves. On 9/28/20 at 10:53 A.M., during interview, Housekeeper #1 said she knows she should change her gloves and clean her hands before moving on to the next resident room, but did not remember to perform hand hygiene between glove changes.

Based on observation, interview and policy review, the facility staff failed to ensure that medications were secure and not left at the bedside of 1 Resident (#415) out of a total sample of 21 residents. Findings include: Resident #415 was admitted to the facility in September 2020 with [DIAGNOSES REDACTED]. Review of Resident #415's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #415 had severe cognitive impairment and scored a 5 out of 15 on the Brief Interview for Mental Status. On 9/28/20 at 11:55 A.M., the surveyor observed several loose medications on the bedside table in front of Resident #415. The surveyor also observed an empty medicine cup next to the medications. There was no nursing staff present in Resident #415's room. Resident #415 said that they were this morning's medications and that he/she had forgotten to take them. Review of Resident #415's medical record failed to indicate an order or consent for self administration of medication. During an interview on 10/02/20 at 8:20 A.M., Unit Manager (UM) #1 said Resident #415 should not have had medications left at his/her bedside. During an interview on 10/02/20 at 10:04 A.M., the Director of Nursing (DON) said Resident #415 is not cognitively intact. The DON further said Resident #415 is not safe to have medications left at his/her bedside table. Review of facility policy titled 'Storage of Medications' revised April 2019 indicated the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Based on observation, interview and Facility policy review, the Facility staff failed to ensure that proper hand washing was performed and food was served in accordance with professional standards for food service safety. Findings include: Review of the Facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices on 3/4/19, indicated: *Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. *Employees must wash their hands after handling soled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and/or after engaging in other activities that contaminate the hands. On 4/11/19, at 11:44 A.M., the Surveyor observed Cook #1 bring a rolling steam table to the dining room on the Dove Unit. He donned gloves and plugged the cord to the steam table into the electrical outlet, therefore contaminating his gloves. He further contaminated the gloves by touching the handles of drawers, the handle of the warming compartment and the tray tickets. With the contaminated gloves, he proceeded to pick up food items such as dinner rolls, pizza slices and grilled cheese sandwiches and place them on plates for residents to be served. During an interview on 4/11/19, at 2:32 P.M., Cook #1 said he should have sanitized his hands and change his gloves, after he touched the cord to plug in the steam table, but he thought the handles were clean and were okay to touch before handling food items. During an interview on 4/11/19, at 3:35 P.M., the Food Service Director said that Cook #1 contaminated his gloves when he touched the cord and the handles and should not have touched food with contaminated gloves.

Based on observations and interviews, the Facility staff failed to ensure that residents are treated with dignity and privacy, as evidenced by observations of the resident being transported around the unit in a wheel chair with several photos, depicting how the Resident should be positioned, attached to the back of the wheelchair. These photos were clearly observable to all residents, staff, and visitors, for 1 Resident (#31) out of a total sample of 21 residents. Findings include: 1) Resident #31 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Resident's Brief Inventory of Mental Status (BIMS) score was 3 out of 15 indicating severe cognitive impairment. The Resident was not interviewable. On 4/10/19, at 8:37 A.M., the Surveyor observed several laminated, front view photos of Resident #31 along with written directions regarding how she/he was to be positioned in the wheel chair, hanging on the back of the wheel chair - in full view of all persons who passed. The Resident did not respond when spoken to. The Resident was observed on 4/10/19, at 3:08 P.M., lying in bed asleep. The same pictures were hanging on the back of the wheelchair The Resident was observed on 4/11/19, at 1:41 P.M., with a Certified Nurse Assistant (CNA) wheeling the Resident down the hallway back to her/his room, with the pictures still on the back of her/his wheelchair, in full view of passersby. The Surveyor was informed that the pictures were placed there by the Rehabilitation staff to provide information to staff on the correct positioning of the Resident. During an interview on 4/11/19, at 4:30 P.M., The Director of Nursing (DON) said that she was not aware of the photos on the back of the Resident's wheelchair. The Surveyor showed her several photos of the back of the wheelchair where the photos were attached. The DON acknowledged that this was not appropriate.

Based on observations, interviews and record review, the Facility staff failed to ensure residents were assessed and reviewed by a multidisciplinary team to ensure that self-administration of medication was clinically appropriate for 1 Resident (#47) out of a total sample of 21 residents. Findings include: Review of the Facility Policy titled Self-Administration of Medications revised 12/2016 indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Point #1 indicated that as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Point #2 indicated that in addition to general evaluation of decision making capacity , the staff and practitioner will perform a more specific skill assessment including the resident's ability to: a. read and understand medication label. B. comprehension of the purpose and proper dosage and administration time for his or her medications. Point #6 indicated that for self-administering residents, the nursing staff will determine who will be responsible, the resident or nursing staff, for documenting that medications were taken. Point #8 indicated that medications must be stored in a safe and secure place, which is not accessible by other residents. Resident #42 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Resident was alert and oriented with mild cognitive impairment. During observation of the medication pass by the Surveyor on 4/11/19, at 8:31 A.M., on the Sparrow unit, Nurse #1 obtained a vial of [MEDICATION NAME] 15 MCG/2 ML nebulizer and a [MEDICATION NAME] 0.5 MG/2 ML inhaler (both medications are used to treat [MEDICAL CONDITION]) from the medication cart and proceeded to Resident #42's room to administer medications. After administering the oral medications, Nurse #1 handed Resident #42 the respiratory medications to self-administer, saying - and here's your meds for your breathing treatment. The resident replied, I know what to do, I have been doing it for years. Nurse #1 then left the room. Review of the physician's orders for Resident #42 indicated an order dated 12/05/18, for the [MEDICATION NAME] nebulizer to inhale orally two times a day for wheeze and shortness of breath and the [MEDICATION NAME] inhaler to inhale orally two times a day also for wheeze and shortness of breath. There were no orders for the resident to self-administer either medication and no evidence of a multi-disciplinary review of the Resident's ability to self-administer the medication and no care plan for self-administration of medications. Nurse #1 was interviewed on 4/11/19, at 8:30 A.M., Nurse #1 said she was not aware that this was considered self-administration of medications and that the Resident had to have an order to self-administer the medications. Nurse #1 said the Resident always does it him/herself.

Based on observation and interview the Facility staff failed to ensure medications and biologicals that were available for administration were at full potency and effective for the use intended in 3 of 4 medication carts inspected. Findings include: 1. During observation of the Sparrow Unit medication cart on 4/11/19, at 1:30 P.M., the Surveyor observed the following: a. 14 vials of single use [MEDICATION NAME] and [MEDICATION NAME] inhalation solution (used to treat asthma) open, exposed to light and without a date of when opened. Review of the manufacturer's directions indicated that they are to be used within 1 week of opening the foil pouch. b. 6 vials of single use Dorzolamide/[MEDICATION NAME] eye drops (used to treat [MEDICAL CONDITION]) removed from the protective foil pouch and or open and exposed to light without a date of opening. Review of the manufacturer label indicated to discard 1 week after opening the foil pouch and exposing to light. During an interview on 4/11/19, at 1:39 P.M. Nurse #3 acknowledged the expired medications. 2. During inspection of the(NAME)unit medication cart on 4/11/19, at 1:42 P.M., the surveyor observed the following: a. 1 bottle of Systaine lubricating eye drops open and without a date. During an interview on 4/11/19, at 1:45 P.M. Nurse #4 acknowledged the expired medications. 3. During observation of the Cardinal Unit medication cart on 4/11/19, at 1:48 P.M., the Surveyor observed the following: a. 10 vials of single use [MEDICATION NAME] and [MEDICATION NAME] inhalation solution open, exposed to light and without a date of when opened. b. 1 vial of [MEDICATION NAME] (used to treat diabetes) open and with an expiration date of 4/3/19. During an interview on 4/11/19, at 1:50 P.M. Nurse #2 acknowledged the expired medications.

Based on observations, record review and interviews, the Facility staff failed to meet professional standards of nursing practice during medication administration for 2 Residents (#47 and #450) by; 1. failing to obtain clarification from the physician as to what form of Aspirin should be administered for 2 Residents (#47 and #450). 2. by providing Resident #47 with medications to self-administer without first assuring that the Resident was assessed as clinically appropriate by a multi-disciplinary team and obtaining physician's orders for self-administration of medications. 3. by failing to follow a physician's order for oxygen administration for 1 Resident (#47) out of a total sample of 21 residents. Findings include: 1) During observation of the medication pass on 4/11/19, at 8:31 A.M., on the Sparrow unit, Nurse #1 obtained a vial of [MEDICATION NAME] 15 MCG/2 ML nebulizer and a [MEDICATION NAME] 0.5 MG/2 ML inhaler (both medications are used to treat [MEDICAL CONDITION]) from the medication cart and proceeded to the Resident's room to administer medications. After administering the oral medications, Nurse #1 handed the Resident the medications to self-administer, saying - and here's your meds for your breathing treatment. The Resident replied, I know what to do, I have been doing it for years. Nurse #1 then left the room. During an interview on 4/11/19 at 8:30 A.M. Nurse #1 said she was not aware that this was considered self-administration of medications and that the Resident had to have an order to self-administer the medications. Nurse #1 said the Resident always does it him/herself. Review of the Facility Policy titled Self-Administration of Medications revised 12/2016 indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.For Resident #47, Nurse #1 administered 81 milligrams (mg) of chewable Aspirin (used to treat pain or fever). 2. Review of the Physician's Orders, dated (MONTH) (YEAR), indicated that Resident #47 had an order to receive an Aspirin tablet 81 mg., no form such as tablet, liquid or chewable specified, one time a day. During observation of the medication pass on 4/11/19, at 8:31 A.M., on the Sparrow unit, Nurse #1 read the order correctly out loud, selected the chewable Aspirin bottle and administered the medication, without first clarifying what form of medication the physician ordered. Nurse #1 was interviewed on 4/11/19, at 8:35 A.M., Nurse #1 said that she didn't realize the physician's order was incomplete, but if the order was not specific, she just gave the chewable kind. 3. For Resident #450, Nurse #2 administered 81 mg of chewable Aspirin, no form such as tablet, liquid or chewable specified, one time a day, without first clarifying what form of medication the physician ordered. Review of the Physician's Orders, dated (MONTH) 2019, indicated that Resident #450 had an order to receive an Aspirin tablet 81 mg., no form such as tablet, liquid or chewable specified, one time a day. During observation of the medication pass on 4/11/19, at 9:27 A.M., on the Cardinal unit, Nurse #2 read the order correctly out loud and selected the chewable Aspirin bottle and administered the chewable Aspirin to the Resident. During an interview on 4/11/19, at 9:35 A.M., Nurse #2 said that he chooses chewable Aspirin if the physician does not specify what form it should be. According to professional standards of nursing practice, the Nurse must ensure that each medication order consists of the 7 rights of administration: right patient, right drug (which includes the form of the drug such as tablet, chewable, liquid, extended release, etc .), right dose, right time, right route and right reason and right documentation. Without a physician's order for the correct form of medications, the nurse is not professionally licensed to determine which form of the medication is medically appropriate. Only the physician is licensed to determine which form is medically appropriate for the resident. The Director of Nurses and the Assistant Director of Nursing were interviewed on 4/11/19, at 4:30 P.M. They said that the physician's order should have been clarified to make certain that the correct form of aspirin that the physician intended based on the resident's medical status was administered. During the interview, the Surveyor noted the pharmacy dispensed an incomplete order and this was observed on several units. They said that they were not aware of the problem. 4. Resident #47 was admitted to facility in 5/18 with [DIAGNOSES REDACTED]. Review of Resident #47's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status score of 6 out of a possible 15 which indicated moderate cognitive impairment. The MDS also indicated Resident #47 required supervision for activities of daily living. Review of Facility policy titled, Oxygen Administration, dated 4/2/19, indicated that the first two steps in preparing for oxygen administration are to: 1. verify that there is a physician order 2. review the physician's orders or facility protocol for oxygen administration Review of Resident #47's physician orders dated 4/1/19 listed an order for [REDACTED].#47 had received continuous O2 throughout all days of survey on all shifts. Resident #47 was observed on 4/10/19 at 7:45 A.M., 4/10/19 at 1:01 P.M., 4/11/19 at 7:58 A.M., 4/11/19 at 9:38 A.M., and 4/12/19 at 7:41 A.M., without Oxygen on. During an interview on 4/10/19 at 8:00 A.M., Resident #47 said that he/she wears oxygen when he/she is told by nursing that it is needed. Resident #47 said that he/she often wears oxygen at night. During an interview on 4/11/19 at 9:58 A.M., Nurse #1 said Resident #47's order for oxygen is as needed and does not need to be worn continuously. She said that Resident #47's O2 is monitored every shift and oxygen is only needed if his/her oxygen saturation level is lower than 90%. During an interview on 4/12/19 at 7:41 A.M., Nurse Manager #1 said that if a resident had an order for [REDACTED].#47's physician orders with the Surveyor, Unit Manager #1 confirmed that his/her orders are for continuous oxygen and that he/she should be wearing it at all times, not as just an as needed basis.

Based on observation, record review and interview the Facility staff failed to develop a comprehensive restraint care plan for 1 Resident (#60) and failed to implement a care plan for the use of air booties for 1 Resident (#450) out of a total sample of 21 residents. Findings include: 1. Resident #60 was admitted to the Facility in 11/2017 with [DIAGNOSES REDACTED]. Review of the doctor's order dated 1/10/19, indicated to apply an abdominal binder to [DEVICE] site, release during care and medications/flushes. Review of the care plan dated 12/7/19, indicated the following: a focus of; *Use of abdominal binder to secure [DEVICE] injury. a goal of; * Will reduce/eliminate restraint usage, will use least restrictive device. 3 interventions/tasks including: *Assist patient to ambulate/reposition as needed. *Physical restraint-use of abdominal binder to prevent her/him from pulling [DEVICE] out. *Report changes in skin integrity. Further review of the care plan failed to indicate any interventions to reduce the use of the restraint, how often to remove the restraint or to remove the restraint for specific lengths of time. Review of the Facility policy titled Physical Restraint Application and dated as revised (MONTH) 2010 failed to indicate a policy for the use of an abdominal restraint. Further review of the policy indicated that all restraints are to be checked every 30 minutes and are to be removed every 2 hours for 10 minutes. During an interview on 4/11/19, at 12:14 P.M., the Director of Nursing acknowledged that the current care plan was not comprehensive and the interventions in the careplan did not address the goal for reduction or elimination of the restraint. 2. Resident #450 was admitted to the Facility in 3/2019 with [DIAGNOSES REDACTED]. During initial tour on 4/10/19, at 8:20 A.M., the Surveyor observed Resident #450 lying in bed with bare feet, both heals pressing into the mattress and a pair of air booties on the top of Resident #450's dresser. On 4/10/19, at 11:27 A.M., the Surveyor observed Resident #450 lying in bed with bare feet, both heals pressing into the mattress and a pair of air booties on the top of Resident #450's dresser. On 4/11/19, at 8:24 A.M., the Surveyor observed Resident #450 lying in bed with bare feet, both heals pressing into the mattress and a pair of air booties on the top of Resident #450's dresser. Review of the doctor's note dated 4/2/19, indicated an order for [REDACTED]. During an interview on 4/10/19, at 11:27 A.M., Resident #450 said he/she never refuses to put them on. He/she also said that not all the Certified Nurse's Aides (CNA) put them on. On 4/11/19, at 8:19 A.M., and 2:17 P.M., the Surveyor observed Resident #450 lying in bed and a pair of air booties on the top of Resident #450's dresser. During an interview on 4/11/19, at 2:19 P.M., CNA #2 said that Resident #450 was on his assignment and was supposed to have booties on his/her feet at all times when in bed. He also said that the nurses will tell the CNA's when a Resident needs special booties. He then said that he should have put the booties on but forgot.

Based on observation, policy review and interview, the Facility staff failed to provide clean and sanitary environment for 1 Resident (#47) out of a total sample of 21 residents. Resident #47 was admitted to facility in 5/18 with [DIAGNOSES REDACTED]. Review of Resident #47's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status score of 6 out of a possible 15 which indicated moderate cognitive impairment. The MDS also indicated Resident #47 required supervision for activities of daily living. Resident #47's bed linens were observed on 4/10/19, at 7:45 A.M., 4/10/19, at 1:01 P.M., 4/11/19, at 7:58 A.M., 4/11/19, at 9:38 A.M., and 4/12/19, at 7:41 A.M., with red, blood-like stains in three different areas on the pillow case. Review of the Facility policy titled, Laundry and Bedding, Soiled, indicated that -personal clothing that becomes soiled with blood or body fluids is covered or removed and immediately laundered . -washable pillows are laundered in hot water when soiled with bodily substances and before exchange between residents. During an interview on 4/11/19, at 10:33 A.M., CNA #1 said that it is a Facility policy to immediately change linens if they are visibly soiled. During an interview on 4/12/19, at 7:56 A.M., Nurse Manager #1 confirmed linens that should be changed if visibly soiled.

Based on observation, record review and interview the Facility staff failed to assess 1 Resident (#60) for the use of a restraint out of a total sample of 21 sampled residents. Findings include: Resident #60 was admitted to the Facility in 11/2017 with [DIAGNOSES REDACTED]. On 4/11/19, at 10:04 A.M. the Surveyor observed resident #60 to have an abdominal binder around her/his waist, covering the gastric tube ([DEVICE]) exiting from the abdomen and preventing the Resident from having access to the [DEVICE]. Review of the doctor's order dated 1/10/19, indicated to apply an abdominal binder to [DEVICE] site, release during care and medications/flushes. Review of the care plan dated 12/7/19, indicated the following: a focus of; *Use of abdominal binder to secure [DEVICE] injury. a goal of; * Will reduce/eliminate restraint usage, will use least restrictive device. 3 interventions/tasks including: *Assist patient to ambulate/reposition as needed. *Physical restraint-use of abdominal binder to prevent her/him from pulling [DEVICE] out. *Report changes in skin integrity. Further review of the care plan failed to indicate any interventions to reduce the use of the restraint, how often to remove the restraint or to remove the restraint for specific lengths of time. Review of the Facility document titled Pre-Restraining Evaluation and dated 12/7/18, indicated that no alternatives were tried prior to the use of a restraint, no referrals were made to psychiatric services, physical or occupational therapy, the interdisciplinary team made no recommendations and there is no signature of who completed the form. Review of the Facility document titled Physical Restraint Elimination Review and dated 3/4/19, failed to indicate the Resident's name and failed to describe the least restrictive means of restraint that were to be used. Review of the Facility policy titled Physical Restraint Application and dated as revised (MONTH) 2010 failed to indicate a policy for the use of an abdominal restraint. Further review of the policy indicated that all restraints are to be checked every 30 minutes and are to be removed every 2 hours for 10 minutes. During an interview on 4/11/19, at 12:14 P.M., the Director of Nursing acknowledged that the current interventions in the careplan did not address the goal for reduction or elimination of the restraint. During an interview on 4/11/19, at 12:24 P.M., the Assistant Director of Nursing said that the Resident came back from the hospital with the abdominal binder on so no alternatives to the use of the restraint were attempted.

Based on observation, interview, Facility policy and procedures and review of the Resident's medical record, the Facility staff failed to ensure that proper legal consent for treatment (a Roger's Guardianship) was obtained for the administration of anti-psychotic medication for 1 Resident (#56), in a total sample of 21 residents. Findings include: Resident #56 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident #56 had a permanent Legal Guardian established based on incapacity to make medical decisions. Further review of the clinical record indicated that the legal paperwork for the guardianship was current, but failed to evidence any documentation in the medical record indicating a Roger's Guardianship was in place. (A Roger's Guardianship allows the Legal Guardian to make additional authorization for administration of anti-psychotic medications.) Review of the physician's orders for (MONTH) 2019 indicated that the Resident received the following [MEDICAL CONDITION] medications: [REDACTED] Review of the physician's orders indicated that the order for Klonapin was started on 8/1/18, [MEDICATION NAME] started on 1/29/19 and [MEDICATION NAME] 8/2/18 Review of the Facility policy titled Psychopharmocologic Medication Policy effective 10/1/12, revised 9/8/18, section on Massachusetts Consent Requirement applied to specified [MEDICAL CONDITION] medications indicated that: Residents who have a court appointed guardian must receive permission from the court (a Roger's hearing) prior to an antipsychotic drug being prescribed. A guardian may only act after the court has made a substituted judgement determination. This means that the guardian must obtain the court's approval of a designated medical treatment plan before the antipsychotic medication can be administered.