Every finding on record at Care One at Redstone

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who required laboratory work for a urine culture and sensitivity test (test used to identify bacterial infection and determine the most effective antibiotic), the Facility failed to ensure nursing promptly notified the Physician, Physician Assistant, or Nurse Practitioner of the abnormal laboratory result, when Resident #1's laboratory results were sent to the facility on [DATE], but the provider was not made aware until 01/28/26, five days later resulting in a delay in treatment.Findings include:Review of the Facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, date revised November 2018, indicated the laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. The Policy indicated a Facility nurse will contact the Physician to report abnormal test results and document information about when, how and to whom the information was provided and the response in the Progress Notes section of the of the medical record.Resident #1 was admitted to the Facility in January 2026, diagnoses included metabolic encephalopathy (brain problem caused by a chemical imbalance), atherosclerotic heart disease (plaque buildup in heart artery walls), gastrostomy (G-tube-surgical opening through the skin of the abdomen to the stomach), and urinary retention.Review of Resident #1's Minimum Data Set (MDS) assessment, dated 01/13/26, indicated he/she had intact cognitive functioning, was dependent on staff for activities of daily living (ADL-eating, dressing, bathing, toileting and transfer), had a feeding tube and an indwelling urinary catheter.Review of Resident #1's Nurse Progress Note, dated 01/19/26, indicated an order for urinalysis with culture and sensitivity had been obtained.Review of Resident #1's Nurse Progress Note, dated 01/21/26, indicated urinalysis and preliminary culture results had been obtained and reported to the in-house Provider. The Note indicated the Provider wanted to wait for culture and sensitivity results (usually reported within two to three days).Review of Resident #1's Urine Culture and Sensitivity results, dated 01/23/26 indicated two types of bacteria had been detected in his/her urine and listed antibiotics that would be effective in treating his/her urinary tract infection.Review of Resident #1's Nurse Progress notes, dated 01/21/26 through 01/28/26 indicated there was no documentation to support that the Physician, Physician Assistant or Nurse Practitioner had been notified of his/her urine culture and sensitivity report.Review of Resident #1's Physician Orders for the month of January 2026 indicated his/her new orders included the following:01/28/26-Ciprofloxacin Hydrochloride (antibiotic) oral tablet 500mg, give 500mg via G-tube two times a day for urinary tract infection for seven days.01/28/26-Nitrofurantoin Monohydrate Macro (antibiotic) capsule 100mg, give one capsule via G-tube, two times a day for urinary tract infection for seven days, take with food.Review of Resident #1's Medication Administration Record (MAR) for the month of January 2026 indicated the first dose of Ciprofloxacin Hydrochloride 500mg and Nitrofurantoin Monohydrate Macro 100mg had been administered on 01/28/26 at 5:00 P.M., five days after the abnormal culture and sensitivity result had been available to the facility.During a telephone interview on 04/1/26, at 10:45 A.M., the Physician Assistant (PA) said Facility Nurses are responsible for notifying the Provider of abnormal laboratory results. The PA said she was not notified of Resident #1's urine culture and sensitivity result.During a telephone interview on 04/01/26, at 2:00 P.M., the Nurse Practitioner (NP) said she had examined Resident #1 on 01/26/26 at the facility and that nursing staff did not notify her of his/her culture and sensitivity result at that time.During an interview on 03/31/26 at 4:15 P.M., the Director of Nurse (DON) said she was aware that that had been a prolonged period between when Resident #1's urine culture results had been available and when treatment for a urinary tract infection had started. The DON said it was the Nurse's responsibility to follow-up with laboratory results but that this had not happened causing a delay in treatment for Resident #1. On 03/31/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 02/11/26, which addressed the area(s) of concern as evidenced by:A. Resident #1 no longer resides in the Facility.C. On 02/03/26, the Director of Nurses and/or designee developed a Performance Improvement Plan including audits, re-education of nurses, and reporting to Quality Assurance Performance Improvement Committee.B. On 02/03/26, the Director of Nurses and/or designee initiated a facility wide audit of urine specimen results for the prior 30 days to ensure lab values were received at the facility and reported to the Provider timely.D. On 02/03/26, the Assistant Director of Nurse and/or designee completed an in-service for Nurses regarding their responsibility for obtaining laboratory results, notifying the Provider, and documentation in the medical record.E. The Director of Nursing and Administrator met with the Medical Provider team to address the concern.F. The Concern will be discussed at the facility monthly QAPI meetings, until the facility determines substantial compliance has been achieved.G. The Director of Nursing and/or designee are responsible for compliance.

Based on records reviewed, interviews, and observations for one of three sampled residents, (Resident #1) who had a known food allergy to onions, the Facility failed to ensure his/her diet was free from allergens, when on 09/15/25, Resident #1 was served a meal that contained onions, Resident #1 consumed some of the meal, developed signs and symptoms of an allergic reaction, and was transferred to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment.Findings include:Review of the Facility's Policy titled Food Allergies and Intolerances, dated as revised August 2017, indicated the following:- Food allergies are immune system responses to allergens (foods).- Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment.- Severe food allergies are noted on the face of the chart (in the form of a sticker or permanent marking indicating Severe Food Allergy: (name of food) and communicated in writing directly to the dietitian and the director of food and nutrition services.- Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur.- Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.Review of the Facility's Policy titled Tray Identification, dated as revised April 2007, indicated the following:- Appropriate identification/coding will be used to identify various diets.- To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification (e.g. color coded or computer-generated diet cards) to identify various diets.- Nursing staff shall check each food tray for the correct diet before serving the residents.- If there is an error, the nurse supervisor will notify the dietary department immediately by phone so the appropriate tray can be served.Resident #1 was admitted to the Facility in August 2024, diagnoses included COPD (chronic obstructive pulmonary disease, a lung condition characterized by ongoing inflammation and narrowing of the airways, leading to difficulty breathing), Anxiety, and a history of Anaphylactic Shock.Review of Resident #1's Allergy Report, dated 08/30/24, indicated he/she had the following allergies: bee pollen, royal jelly (moderate severity) and onions (severe, with anaphylactic reaction, including airborne exposure).Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 08/26/25, indicated he/she was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact).Review of Resident #1's current Physician's Orders indicated he/she had an allergy to bee pollen, royal jelly and onions.Review of Resident #1's weekly menu selection as provided by the Facility's Administrator indicated that on 09/15/25, the main dinner meal consisted of Beef Taco Salad, Salsa and Cantina Corn, and the alternate meal consisted of Grilled Chicken Salad with Dressing and Chef's Breadbasket.Further review of Resident #1's weekly menu selection indicated that for the dinner time meal on 9/15/25, he/she circled that he/she wanted the alternate meal of Grilled Chicken Salad and that he/she crossed out the with Dressing line indicating he/she did not want the dressing added to the salad.Review of Resident #1's dinner Meal Ticket (form used to notify kitchen staff and nursing staff the residents' meal choices, preferences, special devices needed, dislikes, and allergies), dated 09/15/25, indicated he/she was to be served the alternate meal with no dressing, that he/she has an onion allergy (indicated under the allergy section of the ticket) and under the notes section. The Ticket indicated that Resident #1 had an allergy to all onion products, including anything with a hint of onion, as well as including instructions not to serve mustard, mayonnaise, relish, barbeque sauce, salad dressings, ketchup, teriyaki and Worcestershire sauce to him/her.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/16/25, indicated that on 09/15/25, at approximately 6:00 P.M., staff responded to Resident #1's call bell and observed him/her to be sitting on the edge of his/her bed with his/her meal tray in front of him/her.The Report indicated Resident #1 was experiencing shortness of breath, that he/she pointed to his/her dinner tray, and that upon nursing assessment he/she was tachycardic (higher than normal heart rate) with low oxygen saturation, altered mental status and appeared to have symptoms of anaphylaxis, requiring Nursing to administer an EpiPen (Epinephrine, a hormone medication used for emergency treatment of life-threatening allergic reactions) and that he/she was transferred to the Hospital ED for evaluation. The Report further indicated that Resident #1 was inadvertently served taco salad, which contained small, diced onions that were within the ready-made salsa that was mixed in with the ground beef.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented (on 09/15/25) to the Hospital with anaphylaxis following accidental ingestion of onions (severe onion allergy), required two doses of Epinephrine, supplemental oxygen, was given intravenous (administered through the veins) Dexamethasone and will be discharged back to the facility on Prednisone (both Dexamethasone and Prednisone are steroid medications that work on the immune system to help treat allergic reactions).During an interview on 10/22/25 at 10:55 A.M., Resident #1 said he/she was severely allergic to onions and that he/she cannot eat or have them anywhere near him/her, nor could he/she ingest onion powder which is in many dressings, condiments, spice mixes, and sauces. Resident #1 said the Facility staff know very well that he/she has a severe onion allergy because he/she had an anaphylactic reaction requiring hospitalization approximately a year ago, and that his/her allergy was documented in his/her chart, care plan and on his/her meal ticket.Resident #1 said that on 09/15/25, a Certified Nurse Aide (CNA) brought dinner to his/her room and removed the lid from the plate. Resident #1 said the plate contained a deconstructed taco salad, which included seasoned ground beef, lettuce, and tomato on a dish in separate piles. Resident #1 said when he/she looked at the meal, he/she did not think there was salsa mixed in with the meat. Resident #1 said that he/she took a forkful of lettuce and beef then immediately noticed that his/her tongue felt funny and he/she began to have difficulty breathing.Resident #1 said he/she pressed his/her call bell, that a CNA came to his/her room, noticed he/she was having difficulty breathing and immediately summoned the nurse, who arrived and wheeled him/her into the hallway in his/her wheelchair. Resident #1 said the last thing he/she remembered was that he/she began to slide out of his/her wheelchair, and that the nurse gave him/her Epinephrine in the form of an EpiPen. Resident #1 said when he/she began to rouse, the Paramedics arrived to bring him/her to the Hospital where he/she received a second dose of Epinephrine.During an interview on 10/22/25 at 3:34 P.M., with CNA #1 and CNA #2, CNA #1 said she responded to Resident #1's call bell on 09/15/25 during dinnertime. CNA #1 said when she arrived at Resident #1's room, he/she was having difficulty breathing and that he/she pointed to his/her food tray, which contained taco salad. CNA #1 said she immediately called out for a nurse to come to help Resident #1.CNA #1 and CNA #2 both said they were aware of Resident #1's severe allergy to onions, that it was documented in his/her care plan. CNA #2 said Resident #1's allergy is so severe that he/she cannot even be near onions. CNA #1 and CNA #2 said they had not delivered Resident #1's dinner tray to him/her that night and did not know who had.During an interview on 10/22/25 at 1:53 P.M., Dietary Aide #1 said there is a process Dietary staff have to follow when preparing residents' meal trays. Dietary Aide #1 said the first person in the tray line is supposed to call out each resident's meal ticket information, which includes their meal preferences and any special instructions, including allergies. Dietary Aide #1 said this practice continues throughout the line where Kitchen staff are supposed to double check the meal tickets multiple times during the food plating process. Dietary Aide #1 said the final check is at the end of the line just prior to placing the residents' trays inside the meal cart for transport up to the units. Dietary Aide #1 said Resident #1 should not have received a meal containing onions because his/her allergy was clearly listed on his/her ticket. During an interview on 10/22/25 at 12:50 P.M., [NAME] #1 said she functions as the Kitchen Night Supervisor and Cook, comes in at 12:30 P.M., and covers the dinner service. [NAME] #1 said she was cooking the evening of 09/15/25 when Resident #1 received the incorrect meal, resulting in him/her consuming onions that caused him/her to experience an allergic reaction. [NAME] #1 said that afternoon upon arrival, she checked the menu to see what she needed to prepare for dinner, that the main meal was taco salad, the alternate meal was listed as grilled chicken salad, however they did not have the ingredients needed for the chicken salad, therefore the alternate would have been cheeseburgers, which was something Resident #1 was able to eat, and had chosen to order in the past. [NAME] #1 said when she prepared the taco salad, she placed unseasoned ground beef into a pan, cooked it in the oven, and when it was finished, she asked the Food Service Director (FSD) for assistance in finishing the preparation of the taco salad.Cook #1 said the FSD told her the ground beef needed to be seasoned, and that the FSD proceeded to add taco seasoning, garlic powder, chili powder and cumin to the meat. [NAME] #1 said she added salsa [which contained onions] to the ground beef mixture per the direction of the FSD. [NAME] #1 said there was supposed to be a process in place where each resident's meal ticket is called out at the beginning of the tray line prior to meals being plated (to include the meal preference, allergies, and any other pertinent information), then the P.M. [NAME] Assistant (PCA), who works alongside the [NAME] plating the food, will call out the ticket again, and a third and final person check the meal tickets before the residents' trays are placed in the meal cart and transported to the Nursing Units.Cook #1 said from where she was standing on the line, she was unable to visualize Resident #1's meal ticket. [NAME] #1 said both she and the PCA were plating the meals, and said if she had heard Resident #1's name called out, she would have known not to put taco salad on his/her tray because she knew Resident #1 was allergic to onions and onion products and the taco salad contained onions. [NAME] #1 said she had no explanation as to why he/she received this meal. During an interview on 10/22/25 at 8:15 A.M., the Food Service Director Assistant (FSDA) said everybody in the Dietary department was aware of Resident #1's severe onion allergies and that the allergies, along with other foods he/she is unable to eat are all listed on his/her food ticket.During a follow up interview on 10/22/25 at 4:21 P.M., the FSDA said there is a process that Dietary staff are supposed to adhere to that included Dietary Aides actually reading/calling the residents' meal tickets out loud, and that the meal tickets are supposed to be checked repeatedly by multiple Dietary staff members while serving the food, with a final check just prior to the meal tray being placed on the meal cart for delivery.The FSDA said on 09/15/25, Resident #1's meal ticket indicated he/she requested the alternate meal, that he/she received taco salad in error, and that multiple staff members failed to ensure the correct meal was delivered to him/her.During a telephone interview on 10/23/25 at 4:45 P.M., the Food Service Director (FSD) said she helped [NAME] #1 prepare the main meal of taco salad on 09/15/25, left the Facility at 4:30 P.M., and was not present when the Dietary staff accidentally sent taco salad, which contained onions, to Resident #1.The FSD said Resident #1 was well-known to the Dietary department because of his/her severe onion allergy and that his/her allergy was well documented in both his/her medical record as well as within the Dietary department. The FSD said Resident #1's meal ticket clearly indicates that he/she has an onion allergy and indicated specific foods that contain onion that he/she was unable to eat.The FSD said the meal times service was set up in such a way that the residents' meal tickets are reviewed at least three separate times [in the kitchen] at the beginning of the tray line before food is plated, during the tray line when the food is actually being plated, and at the end of the tray line prior to the tray being placed into the meal cart for delivery to the nursing units. The FSD said that Nursing staff serves as the final safeguard, and they are also supposed to check the trays prior to the CNAs delivering the trays to the residents.The FSD said Resident #1's dinner meal ticket on 09/15/25 indicated he/she chose the alternate meal, which was listed as the grilled chicken salad, and that he/she should never have received taco salad.During an interview on 10/22/25 at 5:05 P.M., the Administrator said Resident #1 had a severe onion allergy and he/she cannot ingest them in any form, nor can they be in his/her presence. The Administrator said Resident #1's onion allergy is well documented in his/her medical record and within the Dietary department and is documented on his/her meal tickets.The Administrator said Resident #1 chose the alternate meal of grilled chicken salad without dressing for dinner on 09/15/25, that his/her meal ticket indicated he/she requested the alternate meal for dinner, that he/she erroneously received the main meal of taco salad, which contained onions, causing him/her to develop an allergic reaction necessitating emergency intervention and transfer to the Hospital. The Administrator said Resident #1 should never have received taco salad and that multiple systems failed on 09/15/25.On 10/22/25, the Facility was found to be in Past Non-Compliance with an effective date of 09/20/25, and presented the surveyor with a plan of correction that addressed the area(s) of concern as evidenced by:A) On 09/15/25, Resident #1 received emergency treatment while at the Facility and sent to the Hospital for evaluation.B) On 09/16/25, the Administrator conducted a Facility-wide audit to determine whether any residents have food allergies, and for those who were identified to have food allergies to ensure the allergies were documented in the Medical Record and on the Meal Ticket.C) On 09/16/25 (and ongoing) the Administrator educated the Dietary, Nursing, CNAs, and Rehabilitation departments outlining a new procedure that all residents with documented food allergens should be receiving a tray card/meal ticket on bright pink paper for visibility.D) On 09/16/25 (and ongoing) the Administrator educated the Dietary staff on the topic of Resident Allergy and Food Preparation (with policy review), understanding the importance of allergen awareness and checking trays to ensure residents with allergies are receiving the appropriate meal, and preparing food specific for residents with allergies are to be prepared and stored separately than other food, labeled accordingly, ensure tray tickets are checked for allergens and that the appropriate food is taken from appropriately labeled containers.E) On 09/16/25 (and ongoing) the Administrator educated the Dietary staff on the topic of identifying preferred meal choice to include meal selections are to provided weekly to residents every Monday by the Food Service Director or Designee, meal selection sheets will be picked up weekly every Wednesday by the Food Service Director or Designee, meal choice will be written on the meal ticket of a resident is ordering a meal other than the main meal, and meal choice will be highlighted by the Food Service Director or Designee on meal ticket with highlighting marker.F) On 09/16/25 (and ongoing), the Administrator or Designee began conducting daily audits to ensure allergen food was prepared and stored separately, labeled appropriately and plated according to tray ticketG) On 09/16/25 (and ongoing), the Administrator or Designee began conducting daily audits that pink meal tickets were utilized for residents with food allergies.H) On 09/17/25 (and ongoing), the Administrator inventoried and compiled a list of in-stock food products in the Dietary department that contains onions, this list is updated with every delivery and is hanging up in the food preparation area.I) On 09/19/25, an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted, and the Plan of Correction was reviewed and approved by the Interdisciplinary Team. J) The Administrator and/or their Designee are responsible for overall compliance of this plan of correction.

Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for three Residents (#1, #2 and #3), out of a total sample of 33 residents. Specifically, the facility failed: 1. For Residents #1 and #3, to ensure staff followed the Physician's orders relative to the Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications; and 2. For Resident #2, to ensure the Resident's Foley catheter was secured with a securement device to reduce friction and movement at the insertion site. Findings include: Review of the facility's policy titled Catheter Care, Urinary, dated 2001, indicated: -Purpose is to prevent urinary catheter-associated complications including urinary tract infections. - Review the resident’s care plan to assess any special needs of the resident. - Ensure the catheter remains secured with a securement device to reduce friction and movement at the insertion site. - Review and document the clinical indications for catheter use prior to inserting. 1A. Resident #1 was admitted to the facility in August 2025 with diagnoses of Chronic Kidney Disease, Chronic Respiratory Failure with Hypoxia, and Infection and Inflammatory reaction due to Indwelling Urethral Catheter. Review of the Minimum Data Set (MDS) Assessment, dated 8/17/25, indicated that Resident #1: - Was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15; - Had an indwelling urinary catheter; and - Needed assistance for activities of daily living (ADLs- basic skills such as bathing, dressing, eating, etc.). Review of Resident #1’s August 2025 Physician’s Orders indicated: -Foley catheter, every night shift, every Saturday, Change the catheter secure tube holder - as needed for breakage/soilage Change the Foley catheter bag 18 French (Fr) (unit measurement used to indicate the diameter of the catheter) 10 milliliters (ml) - as needed Flush the Foley catheter with 10 ml Sterile Saline - every shift, provide Foley catheter care - every shift Document urinary Output - as needed for blockage/leakage change Urinary catheter with French size:18 Fr Balloon size: 10 ccs (cubic centimeters). Start date 8/11/25. On 8/18/25 at 8:58 A.M., Unit Manager (UM) #1 observed Resident #1’s Foley catheter with the surveyor. UM #1 said Resident #1’s Foley catheter size was 16 Fr with 10 cc’s balloon. UM #1 reviewed Resident #1’s Physician’s order with surveyor as said the Resident had the wrong Foley catheter size. UM #1 said Resident #1’s Foley catheter size should have been 18 Fr and not 16 Fr. B. Resident #3 was admitted to the facility in April 2025 with diagnoses of Sepsis, Heart Failure, Difficulty Walking, Urinary Tract Infection, and Bladder Neck Obstruction. Review of the MDS Assessment, dated 7/10/25, indicated that Resident #3: - Was cognitively intact as evidenced by a BIMS score of 14 out of 15. - Had an indwelling urinary catheter. Review of Resident #3’s August 2025 Physician's Orders indicated: -Foley catheter as needed for blockage/leakage change Urinary catheter with French size:18 FR and Balloon size:10cc - Start Date 04/15/2025. - Foley catheter every night shift, every Saturday, Change the catheter secure tube holder - as needed for breakage/soilage Change the Foley catheter bag - every 8 hours as needed Flush the Foley catheter with 10 cc Sterile Saline - every shift provide Foley catheter care - every shift Document urinary Output - as needed for blockage/leakage change Urinary catheter with French size: 18 Fr and Balloon size: 10cc - Change Foley catheter on 5/16/25 and every 4 weeks. Order start date 05/15/25 On 8/15/25 at 8:09 A.M., Nurse #2 observed Resident #3’s Foley catheter with the surveyor. Nurse #2 said Resident #3’s Foley catheter size was 16 Fr with 10 cc’s balloon. Nurse #2 said Resident #3’s physician's order indicated the Resident’s catheter size should be 18 Fr and 10 cc’s balloon, and that the Resident did not have the right size as ordered by the Physician. During an interview on 8/15/25 at 8:15 A.M., UM #1 reviewed Resident #3’s physician’s order with surveyor and said the Resident had the wrong Foley catheter size. UM #1 said Resident #3’s Foley catheter size should have been 18 Fr and not 16 Fr. 2. Resident #2 was admitted to the facility in October 2024 with a diagnosis of retention of urine. Resident #2’s MDS Assessment, dated 8/4/25, indicated the following: -the Resident was cognitively intact as evidenced by a BIMS score of 15 out of a possible score of 15. -the Resident used an indwelling urinary catheter Review of Resident #2’s August 2025 Physician's Orders indicated: -an active order dated 7/30/25 for Foley Catheter: change the catheter secure tube holder every night shift on Saturday During an interview on 8/19/25 at 9:37 A.M., the surveyor observed Resident #2 lying in bed with catheter tubing and lower ¾ of the thigh exposed. There were no catheter securement devices observed in place. The Resident stated he/she had never had a device that secured the catheter tubing in place. On 8/20/25 at 8:10 A.M., UM #2 and the surveyor observed Resident #2’s indwelling urinary catheter together. No securement device was observed to be in place on the indwelling urinary catheter. During an interview on 8/20/25 at 8:13 A.M., UM #2 said that there was not a securement device in place on Resident #2 but that she would apply one. UM #2 further said that she believed the Resident had a history of removing the device and would look for evidence of this. At the time of survey exit, no additional information was provided to the survey team.

Based on observations, record reviews, and interviews, the facility failed to ensure one Resident (#157), out of total sample of 33 residents, was free from the use of physical restraints. Specifically, the facility failed to ensure Resident #157's Velcro self-releasing seatbelt was released during supervised activities and failed to evaluate Resident #157's ability to self-release the Velcro seatbelt every shift, restricting his/her ability to move freely when the Resident had a history of attempting to stand up from a seated position. Findings include:Review of the facility's policy titled Use of Restraints, revised April 2017, indicated the following: -Restraints should only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. -When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. Resident #157 was admitted to the facility in February 2025 with diagnoses that included metabolic encephalopathy, repeated falls, and unspecified dementia. Review of the Care Plan for the use of a Velcro alarming seatbelt, initiated on 2/25/25, indicated the following: -Resident #157 had impulsivity, motor restlessness, impaired cognition, poor safety awareness, poor spatial awareness, weakness and unsteady gait. -Restraint Release: FYI- with supervised activities, meals and on rounds, initiated 2/25/25. Review of the active Physician's Orders, initiated 4/23/25, indicated the following: -Velcro alarming seatbelt- prompt for ability to release seatbelt on command. (ensure they document ability in nurse's notes) every shift. Review of the Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated the following for Resident #157: -Brief Interview for Mental Status (BIMS) score of 5 out 15 indicating a severe cognitive impairment. -used a manual wheelchair for mobility. -a history of two or more falls since admission. -does not utilize a restraint. Review of the Nursing Progress notes from 2/23/25 through 8/15/25, did not show evidence of every shift documentation regarding Resident #157's ability to self-release the Velcro Alarmed seatbelt. During a continuous observation on 8/15/25 at 8:04 A.M.- 8:32 A.M., Resident #157 was assisted into the supervised dining room and positioned at a dining room table and remained seated in the wheelchair with the Velcro Seatbelt secured around his/her waist. A breakfast tray was delivered to the Resident and the Velcro seatbelt remained secured at Resident #157's waist throughout the entire breakfast meal while a staff member was supervising the dining room. During a continuous observation on 8/15/25 at 1:46 P.M. - 2:16 P.M., Resident #157 was sitting in a wheelchair with a Velcro Seatbelt secured around his/her waist in the activities room while being supervised by two activities staff members and one Certified Nursing Assistant (CNA). Resident #157 did not attempt to self-rise and did not display any signs of agitation or impulsivity but was smiling and happy while speaking nonsensically to another Resident. Two activity staff members were performing manicures and hand massages to the residents sitting on each side of Resident #157. The Velcro seatbelt remained secured around Resident #157's waist during the supervised activity. During an observation on 8/15/25 at 2:16 P.M., Resident #157 was removed from the activity and brought to the nurse's station where maintenance staff were performing maintenance on the alarmed seatbelt. The seatbelt remained secured at this time. During an interview on 8/19/25 at 12:12 P.M with Unit Manager (UM) #5 and the Director of Nurses (DON)., UM #5 said Resident #157 used a Velcro Alarmed seatbelt due to multiple falls in the facility, agitation, and impulsivity. The DON said that the facility should assess any potential restraint quarterly and that a quarterly restraint assessment should have been completed according to the MDS scheduled for 8/6/25, but that did not happen. The DON said that if the Resident was in a supervised activity or at a supervised meal, then the restraint should have been removed if the Resident was not having impulsive behaviors. The DON further said that nurses should have been documenting Resident #157's ability to self-release the Velcro Seatbelt in the nursing progress notes every shift but could not show evidence this occurred. During an interview on 8/19/25 at 1:35 P.M., the DON said that Resident #157's mental status varied daily and his/her ability to self-release the seat belt was inconsistent, therefore the Self-releasing Velcro Alarmed seatbelt should have been considered a restraint.

Based on observations, interviews, and records reviewed, the facility failed to maintain infection control practices to provide a safe, sanitary, and comfortable environment and to prevent the potential spread of infection on two Units ([NAME] and [NAME]), out of five Units observed. Specifically, on the [NAME] Unit, the facility failed to ensure:1. Staff wore appropriate personal protective equipment (PPE) when providing incontinence care to a resident who was on contact precautions; [NAME] the [NAME] Unit, the facility failed to ensure:2. Contaminated gloves were disposed of properly and appropriate hand hygiene was performed after removal of contaminated gloves, increasing the potential spread of healthcare-associated infections.Findings include: Review of the facility's policy titled Isolation- Categories of Transmission Based Precautions, last revised September 2022, indicated the following: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection; or has laboratory confirmed infection; and is at risk for transmitting the infection to other residents. - Contact Precautions: < Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident’s environment. < Contact precautions are also used in situations when a resident is experiencing…incontinence or diarrhea…that cannot be contained and suggest an increased potential for extensive environmental contamination… < Staff and visitors wear gloves (clean, non-sterile) when entering the room… < Staff and visitors wear a disposable gown upon entering the room and remove gown before leaving the room… Review of the Handwashing/Hand Hygiene policy, revised October 2023, indicated the following:-This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. -All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. -Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene. -Residents, family members and/or visitors are encouraged to practice good hand hygiene. -Hand hygiene is indicated: >Immediately after glove removal -The use of gloves does not replace hand washing/hand hygiene. 1. Resident #33 was admitted to the facility in August 2022 with a diagnosis of Enterocolitis due to Clostridium difficile (C-diff). Review of Resident #33’s August 2025 Physician’s Orders indicated the following: -Maintain contact precautions for C-diff, every shift; initiated 7/16/25. On 8/14/25 at 9:23 A.M., the surveyor observed signage outside of Resident #33’s room indicating contact precautions and instructions for staff on handwashing, and PPE use of gown and gloves. The surveyor observed Unit Manager (UM) #2 providing the Resident with incontinence care at the bedside. UM #2 was wearing gloves only and was not observed wearing a gown. UM #2 exited the room at 9:31 A.M. and was not observed removing a gown. During an interview on 8/14/25 at 9:31 A.M., UM #2 said Resident #33 was on contact precautions due to active C-diff infection. UM #2 said that she provided Resident #33 with incontinence care and that she should have been wearing a gown and had not been. She said that contact precautions are important to prevent the spread of infection to others. During an interview on 8/20/25 at 8:56 A.M., the Infection Control Nurse (ICN) said that the expectation for staff when caring for residents on contact precautions is that staff don gowns and gloves prior to entering the room and remove gowns and gloves prior to exiting the room. The ICN said that signage outside of resident rooms will indicate which PPE staff should use. The ICN further said staff should preform hand hygiene prior to donning gloves at any time. 2. On 8/15/25 at 8:52 A.M., the surveyor observed Hospice Staff Member #1, walk out of a resident room, into the hallway wearing gloves on both hands and holding three plastic bags of soiled material. Hospice Staff Member #1 entered the soiled utility room and disposed of the three plastic bags, while holding the door open with her foot and remaining visible to the surveyor. Hospice Staff Member #1 removed her gloves and put the dirty gloves in her shirt pocket; they fell out of the pocket and Hospice Staff Member #1 picked the gloves off the floor and put the dirty gloves back into her shirt pocket before re-entering the same resident room. During an interview on 8/15/25 at 9:01 A.M., Hospice Staff Member #1 said that when she disposed of the bags holding soiled linen and briefs, she should have removed her gloves, thrown them in the trash and washed her hands right away but did not. Hospice Staff Member #1 said she had turned the dirty gloves inside out and put them into her pocket and did not sanitize her hands but should have. Hospice Staff Member #1 said she should have thrown the gloves into a trash can and sanitized her hands to reduce the chances of cross contamination to a resident. During an interview on 8/15/25 at 9:11 A.M., UM #5 said staff should not be wearing dirty gloves in the hallway and that Hospice Staff Member #1 should have disposed of the gloves properly then washed her hands. During an interview on 8/15/25 at 12:03 P.M., the Director of Nursing (DON) said it is the facility’s responsibility to educate outside providers on facility infection control policies, such as hospice agencies before they provide care in the building, but this did not happen. The DON said that Hospice Staff Member #1 should have disposed of the dirty gloves into a trash can and should have performed hand hygiene right away.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#95), out of a total sample of 33 residents, had the ability to make choices about their daily preferences. Specifically, for Resident #95, the facility failed to ensure the Resident's preference to receive a peanut butter and jelly sandwich for dinner was honored. Findings include:Review of the Resident's Right Policy and Procedure, dated February 2021, indicated that federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -self-determination. -be informed of, and participate in, his or her care planning and treatment. Resident #95 was admitted to the facility in April 2024 with diagnoses that included Glaucoma and Gastric Esophageal Reflux Disease (GERD). Review of the Minimum Data Set (MDS) Assessment, dated 7/3/25, indicated Resident #95: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. -was able to make him/herself understood -was able to understand others -required set-up assistance from staff for eating. Review of the Dietary slip for Resident #157 indicated he/she had a preference to receive a peanut butter and jelly sandwich with every dinner meal. During an interview on 8/14/25 at 10:41 A.M., Resident #95 said he/she had spoken with the dietitian a few months prior and requested to receive a peanut butter and jelly sandwich with the dinner meal. Resident #95 said that he/she cannot eat a regular dinner meal because it upsets his/her stomach. Resident #95 said the peanut butter and jelly sandwich only comes on the dinner tray once or twice a week and when it does not come on the tray, he/she does not eat. Resident #95 said he/she does not like to bother staff for the sandwich, since the request has already been made for it to arrive on the dinner tray. During an interview on 8/15/25 at 7:45 A.M., Resident #95 said that a peanut butter and jelly sandwich did not come on the dinner tray on 8/14/25, and as a result he/she did not eat dinner. Resident #95 said he/she did not request a sandwich on 8/14/25 and wanted to avoid asking for items repetitively and has asked several times for a peanut butter and jelly sandwich to arrive on the dinner tray. During an interview on 8/15/25 at 11:24 A.M., the Dietitian said that she meets with the residents regarding food preferences/dislikes and passes that information onto the dietary team. The Dietitian showed the surveyor Resident #95's dietary slip that included a preference for him/her to receive a peanut butter and jelly sandwich with dinner. During an interview on 8/15/25 at 11:26 A.M., the Food Service Director (FSD) said that if a resident has food preferences listed on the dietary slip, those preferences should be honored. The FSD said that dietary staff are supposed to refer to the dietary slip when preparing meal trays and Resident #95 should have been receiving a peanut butter and jelly sandwich on every dinner tray. During an interview on 8/15/25 at 11:28 A.M., the Dietitian said it would be important for Resident #95 to receive a peanut butter and jelly sandwich for dinner to avoid nutritional complications such as weight loss and malnutrition. The Dietitian said that Resident #95 was continuously monitored for weight loss and should have been receiving the sandwich as requested. During an interview on 8/15/25 at 1:36 P.M., with the Dietitian and Resident #95, the Resident told the Dietitian that he/she has not been receiving the peanut butter and jelly sandwich and does not eat dinner if it does not come on the tray because he/she cannot eat a heavy meal at dinner. The Dietitian informed Resident #95 that he/she should have been receiving the sandwich as requested.

Based on interview and record review, the facility failed to provide nursing services consistent with professional standards of practice for two Residents (#175 and #4) out of a total sample of 33 residents. Specifically, for Resident #175 and Resident #4, the facility failed to reorder the Residents' medications resulting in the facility staff borrowing other Residents' medications to administer the prescribed dosages. Findings include: Review of the facility's policy titled Medication Ordering and Receiving from Pharmacy, revised January 2018, indicated: -Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. - If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form, by placing a re-order portion of the prescription label in the appropriate area on the order form provided by the pharmacy for that purpose. - The nurse who re-orders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. - The re-order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. - Delivery records are retained for one (1) year. Review of the facility's policy titled Pharmacy Services Overview, dated 2001, indicated: -Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. - Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice. - Pharmacy services are available to residents 24 hours a day, seven days a week. - Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. - Borrowing medications from other residents or from the emergency medication supply because of a failure to order or reorder a medication in time for a resident to receive scheduled medication is not acceptable practice. 1. Resident #175 was admitted to the facility in June 2025 with diagnoses including Adrenocortical Insufficiency (a condition where the hormones do not produce enough cortisol leading to symptoms of fatigue and muscle weakness). Review of Resident #175's August 2025 Physician's Order indicated: - Prednisone Tablet 5 milligram (mg), give 1.5 tablet by mouth one time a day for Adrenocortical Insufficiency total dose=7.5mg. Start date 6/4/25. Review of Resident #175's August 2025 Medication Administration Record (MAR) indicated: -Prednisone 7.5 mg had been administered from 8/1/25 to 8/14/25. On 8/15/25 at 8:41 A.M., the surveyor observed Nurse #1 prepare to administer medications to Resident #175. The surveyor did not observe Nurse #1 administer Prednisone 7.5 mg as ordered by the Physician. During an interview immediately following the observation, Nurse #1 said Resident #175's Prednisone 7.5 mg was not available from the medication cart or the Omnicell (back-up automating and managing medication and supply dispensing in healthcare settings) to be administered as ordered by the physician. Nurse #1 said that it appeared someone attempted to reorder the Prednisone 7.5 mg medication but did not follow through, so the re-order was not transmitted to the pharmacy on 8/5/25. 2. Resident #4 was admitted to the facility in July 2025 with diagnoses including restless leg syndrome. Review of Resident #4's Physician's Orders for August 2025 included but was not limited to: - Ropinirole HCl Oral Tablet 0.5 MG (Ropinirole Hydrochloride) Give 1 tablet by mouth two times a day for restless leg syndrome. Start date 7/9/25. Review of Resident #4's August 2025 MAR indicated: - Ropinirole 0.5 mg by mouth twice a day medication had been administered 22 times from 8/1/25 to 8/15/25. - Ropinirole 0.5 mg by mouth twice a day medication had been documented as not available six times from 8/1/25 to 8/15/25. - Ropinirole 0.5 mg by mouth twice a day medication had been documented as not applicable one time from 8/1/25 to 8/15/25. On 8/15/25 at 9:00 A.M., the surveyor observed Nurse #1 prepare to administer medications to Resident #4. The surveyor did not observe Nurse #1 administer Ropinirole 0.5 mg as ordered by the Physician. During an interview immediately following the observation, Nurse #1 said Resident #4's Ropinirole 0.5 mg medication was not available to be administered. The Resident had run out of the Ropinirole 0.5 mg medication, and the medication was not available in the Omnicell. Nurse #1 said there was no indication that the Ropinirole 0.5 mg medication had been re-ordered. During an interview on 8/15/25 at 9:05 A.M., Unit Manager (UM) #1 said she had no record of Resident #4's Ropinirole medication or Resident #175's Prednisone 7.5 mg medication being ordered and or received from the pharmacy. During an interview on 8/15/25 at 10:15 A.M., the Director of Nursing (DON) said a 10-day supply of the Prednisone medication was last delivered from the pharmacy on 7/28/25 and would have been completed on 8/7/25. There was no evidence that the Prednisone medication was reordered after 8/7/25. The DON further said she was not aware that Resident #175 and Resident #4 had run out of their medications. During an interview on 8/15/25 at 10:51 A.M., the Pharmacy Consultant said the Prednisone 7.5 mg medication was last ordered by the facility on 7/28/25 for a 10-day supply. The Pharmacy Consultant said the Ropinirole 0.5 mg medication was last ordered on 7/18/25 by the facility and a 10-day supply was delivered. The Pharmacy Consultant further said the facility had not re-ordered the Ropinirole 0.5 mg medication since it was last delivered on 7/18/25 and the Prednisone 7.5 mg since it was last delivered on 7/28/25. During an interview on 8/15/25 at 1:58 P.M., Nurse #1 said she had borrowed the Prednisone and Ropinirole medications from other residents and administered the medications. Nurse #1 said she had not reordered the medications. Nurse #1 said she was a float Nurse and would fill in when the regular nurses were off. Nurse #1 further said she should not have borrowed medications, but she did. During an interview on 8/19/25 at 7:52 A.M., Nurse #3 said she worked as a regular nurse on the unit. Nurse #3 said whenever the residents were out of medications she would borrow from other residents. Nurse #3 further said she knew it was not an acceptable practice to borrow medications from other residents, but she did.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#14) received proper treatment and care to maintain mobility and good foot health, out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #14 received timely foot care and treatment in order to prevent potential and actual complications when Resident #14 was identified as being high risk due to a diagnosis of Diabetes, having elongated toenails that were affecting his/her balance and mobility, experiencing discomfort during physical therapy treatments, and received toenail care on 8/15/25, 73 days after the initial identification of need on 6/3/25.Findings include:Review of the facility's policy titled Nursing Care of the Older Adult with Diabetes, revised November 2020, indicated the following:-Complications associated with Diabetes can be attributed to: (1) uncontrolled hyperglycemia and subsequent damage to vasculature; over treatment of diabetes resulting in hypoglycemia; or (3) common co-morbidities of diabetes.-Hyperglycemia and vascular damage can lead to.<Foot complications- neuropathy, dry skin, calluses, poor circulation, ulcers;<Skin problems- fungal/bacterial infections, itching, diabetic dermopathy.-Skin and Foot Care:<Toenails should only be trimmed by personnel qualified to do so (this can be regular associates, and does not have to be a podiatrist). Resident #14 was admitted to the facility in May 2025 with diagnoses including Vascular Dementia with Agitation and Diabetes Mellitus Type II. Review of the Minimum Data Set (MDS) Assessment, dated 5/28/25, indicated the following relative to Resident #14:-he/she was moderately cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15.-rejected care 1-3 days out of the last 7.-fell in the past month prior to facility admission.-was at risk for developing pressure ulcers/injuries. -did not have dressing or medications to feet. Review of the comprehensive plan of care for Activities of Daily Living (ADLs), last revised 8/7/25, indicated the Resident was at risk for self-care deficits related to physical limitations, incontinence, cognitive loss, and decreased communication. The plan of care included the following:-Goal: Resident to be clean, dressed, and well-groomed daily to promote dignity and psychosocial well-being.-Intervention for Physical Therapy and treatment.-Interventions:>provide assist of one staff with transfers to/from toilit (sic)>Setup to assist of 1 with daily hygiene, grooming, dressing, oral care, and eating.>Supervised to assist of one staff with bed mobility, transfers, and ambulation using front wheeled walker. During a telephone interview on 8/14/25 at 1:37 P.M., Resident Representative (RR) #1 said Resident #14's toenails were very bad, affected the Resident's balance, and that this concern had been discussed with the facility staff previously. RR #1 said he/she had been in touch with the facility and understood that the facility was attempting to get the Resident seen by a Podiatrist, but he/she was unsure of when the next visit would be. During an interview on 8/15/25 at 9:57 A.M., Nurse #6 said Resident #14 was new to her unit, needed to be seen by the Podiatrist, and she was unsure if the Resident was on the list to be seen. During an interview and observation on 8/15/25 at 10:08 A.M., the Surveyor and Nurse #6 observed Resident #14's feet and toenails. All ten toenails were observed to be hard, thick, elongated, yellow, and discolored with ridges. The large toe toenails on both feet were observed to be 2 inches in length beyond the skin, textured, curling at the tips, and overlapping onto the next toenail. Resident #14 verbalized ow when the Nurse manipulated the right great toe to for examination. Resident #14 said that he/she wanted to see the Podiatrist and have his/her toenails cut. Nurse #6 said the Resident's toenails had been elongated like this since the Resident transferred to the unit. Review of the Physical Therapy Treatment Encounter Note, dated 6/3/25, indicated but was not limited to the following:-Care plan meeting was held with the Resident, Therapy staff, Unit Manager, Case manager, Healthcare Proxy (HCP), and RR #1.-Education was provided regarding concerns of the lengths of the Resident's toenails which affected his/her ability to utilize toe muscles effectively.-Resident was a high risk for falls. Review of the Case Management Note, dated 6/3/25, indicated but was not limited to the following:-Physical Therapist reported the Resident's toenails were too long and were affecting his/her ability to walk and his/her balance.-Resident agreed to all services available. Review of Resident #14's medical record indicated a Request for Service form with consent for Podiatry services was signed by the Resident's Representative on 6/26/25. During an interview on 8/15/25 at 11:52 A.M., the Medical Record Staff said the last Podiatry visit occurred on 6/7/25 and Resident #14 had not been seen because a consent had not been signed or submitted until 6/26/25. During an interview on 8/15/25 at 12:59 P.M., the Medical Record staff said the facility was between contracted Podiatrists and that another date and provider had not yet been scheduled since the last visit on 6/7/25. Review of the Physical Therapy Encounter Note, dated 8/9/25, indicated:-The Resident was unable to complete the session due to reports of toenail pain.-The Resident stated that he/she needed the toenails to be cut.-A message was left for request to have the Resident seen by Podiatry on the Unit Manager's phone. During an interview on 8/15/25 at 2:21 P.M., the Director of Nursing (DON) said that she observed and evaluated Resident #14's toenails and determined that they needed to be trimmed urgently. She said she had the facility Nurse Practitioner (NP) and the Medical Doctor (MD) trim Resident #14's toenails today. The DON said she had been aware there had been concerns in obtaining Podiatry services for Resident #14 in the past. The DON further said she was not aware of how severe Resident #14's toenails were until she evaluated them today. Review of Resident #14's Progress Note by Nurse Practitioner (NP), dated 8/15/25, indicated:-Resident had bilateral (on both sides) foot pain caused by extremely large thick fungal nails.-Nails were cut with the MD present.-Great care taken since the Resident was diabetic.-The Resident's toes had very large, thick curling toenails bilateral. During an interview on 8/19/25 at 10:03 A.M., Unit Manager (UM) #2 said when a resident transferred to the Unit, she reviews if the resident or their representative would want to access services like Podiatry and she would complete the Request for Service form and send to the Podiatrist group. UM #2 said if a resident needed services like Podiatry outside of the services group scheduled visits, the facility would make arrangements with an outside services and the resident's family, and if those were not options, she would coordinate with the DON. UM #2 said she recalled having Resident #14's representative HCP sign the Request for Services form, and that she faxed the completed form on 6/26/25 to the Podiatry service group. UM #2 said that she was not aware of how severe Resident #14's toenails were until 8/15/25. UM #2 said residents with diabetes were considered high risk and a Podiatrist or medical professional needed to trim their toenails. During an interview on 8/19/25 at approximately 11:00 A.M., UM #3 said Resident #14 was initially admitted to the facility for short-term rehabilitation services on the Unit she managed and transitioned to long term care placement where the Resident resided currently. UM #3 said she participated in the care plan meeting on 6/3/25 and spoke with the Resident to provide education on the risk of infection, pain, and how toenails could affect his/her ambulation during the meeting. UM #3 said when she approached the Resident after providing the education, and the Resident still declined to consent to Podiatry services. UM #3 said Resident #14's Representative was invoked later on 6/17/25 and then the Resident transferred to another unit for long term care placement. UM #3 said she did not recall contacting the medical provider to review alternative options when the Resident declined Podiatry services after she approached the Resident on 6/3/25. During a telephone interview on 8/19/25 at 1:16 P.M., the NP said Resident #14's toenails were extremely long and thick, one was curled around the toe itself and the toenails were in very poor condition and difficult to remove. The NP said if Resident #14's nails had not been addressed, the Resident would be at risk for additional complications. The NP said that when a resident has an urgent need for podiatry services, the facility would make outside arrangements to meet the resident needs. Further review of the medical record indicated Resident #14 was identified as needing specialized foot care services on 6/3/25 and did not receive foot care services for toenail trimming until 8/15/25, 73 days after the initial identification of need.

Based on observations, interview, and record review, the facility failed to maintain a homelike environment for one Resident (#15), out of a total sample of 33 residents. Specifically, the facility failed to ensure timely repair of a cracked second floor bedroom window for Resident #15 when it had been reported to the facility 84 days prior.Findings include:Review of the facility's policy titled Homelike Environment, revised February 2021, indicated the following:-Residents are provided with a safe, clean, comfortable, and homelike environment.-The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.Resident #15 was admitted to the facility in August 2024 with diagnoses including Non-Alzheimer's Dementia, Depression, and Post-Traumatic Stress Disorder (PTSD). During a telephone interview on 8/14/25 at 4:16 P.M., Resident Representative (RR) #2 said that Resident #15 had a large crack in their bedroom window on the second floor. RR #2 further said he/she had asked the facility staff in prior care plan meetings to repair the window and had been told a window needed to be ordered, but he/she was unsure if this occurred and the window remained cracked.During an interview on 8/14/25 at 4:36 P.M., the Administrator said she was aware of a cracked window for Resident #15 and that maintenance was in the process of replacing the window. On 8/14/25 at 4:40 P.M., the surveyor observed Resident #15's room which included a large crack in the lower half of the window across four windowpanes.During an interview on 8/14/25 at 4:56 P.M., Nurse #5 said she was not aware of a cracked window in Resident #15's room. The Nurse said any maintenance requests were put in the book on the unit, and the Nurse demonstrated where and how the request book was kept. Further review of the unit Maintenance Request book did not provide evidence of maintenance requests made for Resident #15's room.Review of Resident #15's Care Conference Note, dated 5/27/25, indicated the following attendees: -Social Services,-Nursing,-Recreation, and- RR #2 via telephone call. During an interview on 8/15/25 at 1:35 P.M. Social Worker (SW) #1 said that she participated in Resident #15's care plan meeting on 5/27/25 and recalled that RR #2 had voiced a concern about the Resident's cracked window. SW #1 said that she notified the administrative team about the Resident's window on 5/27/25 during the afternoon wrap-up meeting.During an interview on 8/15/25 at 12:23 P.M. with the Maintenance Director, Administrator, and Maintenance Worker #1, the Maintenance Director stated he was new in the role and was training with Maintenance Worker #1. Maintenance Worker #1 said that he was made aware by the Administrator in July of a cracked window in Resident #15's room. Maintenance Worker #1 said he had initiated the process of obtaining a glass vendor to repair the Resident's window once he was notified, and payment for the repair had been made on 8/15/25, but they do not have an estimated timeframe for the repair to occur.During an interview at the same time on 8/15/25 at 12:23 P.M., the Administrator said the facility had been made aware of RR #2's concern of a cracked window in Resident #15's room earlier than July but she was unable to provide evidence prior to July addressing the cracked window.On 8/19/25 at 9:42 A.M., the surveyor observed that the window in Resident #15's room remained cracked and unrepaired, 84 days after being reported to the facility.

Based on record review and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant (used to treat seizures) medications, the Facility failed to ensure the resident was free from significant medication errors when he/she was not administered the medication as prescribed, placing him/her at risk for seizures. Findings include: Review of the Facility policy titled, Administering Medication, revised 2019, indicated the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medications are administered within one (1) hour of their prescribed times, unless otherwise specified (for example, before and after meal orders). Resident #1 was admitted to the Facility in February 2025, diagnoses included but were not limited to Epilepsy. Review of Resident #1's Physician's Orders for the Month of April 2025, indicated it included orders for, but not limited to the following: A) 8:00 A.M.-Oxcarbazepine (anti-convulsant) oral tablet, 300 milligrams (mg) give one tablet in the morning. B) 6:00 P.M.-Oxcarbazepine 300mg, give two tablets in the evening. C) 2:00 P.M.-Lamotrigine (anti-convulsant) 100 mg oral tablet, give 400 mg by mouth one time a day. Review of Davis's DRUG GUIDE FOR NURSES®, 19th edition (2025) indicated the following: Oxcarbazepine: Take missed doses as soon as possible but not just before next dose; do not double dose. Notify health care professional if more than 1 dose is missed. Medication should be gradually discontinued to prevent seizures. Lamotrigine: should be discontinued gradually over at least 2 weeks, unless safety concerns require a more rapid withdrawal. Abrupt discontinuation may cause increase in seizure frequency. A) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300 mg, one tablet in the morning on the following dates: 04/02/24 at 8:00 A.M. 04/03/25 at 8:00 A.M. 04/18/25 at 8:00 A.M. 04/19/25 at 8:00 A.M. 04/21/25 at 8:00 A.M. B) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300mg, two tablets in the evening on the following dates: 04/01/25 at 6:00 P.M. 04/02/25 at 6:00 P.M. 04/03/25 at 6:00 P.M. 04/14/25 at 6:00 P.M. 04/15/25 at 6:00 P.M. C) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Lamotrigine 400 mg by mouth one time a day at 2:00 P.M. on the following dates: 04/12/25 at 2:00 P.M. 04/21/25 at 2:00 P.M. During an interview on 06/25/25 at 11:35 A.M., Nurse #1 said that she had not administered to Resident #1, his/her prescribed Oxcarbazepine 300 mg on 04/02/25 or 04/03/25 at 8:00 A.M., and she had not administered Oxcarbazepine 300 mg, 2 tablets, on 04/03/25 at 6:00 P.M. because it was not available. Nurse #1 said that when Resident #1's Oxcarbazepine was not available on 04/02/25 for his/her 8:00 A.M. dose, she had called the pharmacy and was told that it was going to be delivered, but that it was still not available on 04/03/25 for his/her 8:00 A.M., or 6:00 P.M. dose. Nurse #1 said that missing doses of anti-convulsant mediation could lead Resident #1 to have a seizure. During an interview on 6/25/25 at 12:00 P.M., the Unit Manager said that she was aware that Resident #1 had missed some doses of his anti-convulsant medication and that missed doses of anticonvulsant medication could lead to a seizure. During a telephone interview on 06/27/25 at 9:00 A.M., Nurse #3 said that she had not administered Resident #1 his/her Lamotrigine 400 mg on 04/12/25 at 2:00 P.M. because it was not available. Nurse #3 said that she had called the pharmacy for a STAT (immediate) delivery because she knew that a certain blood level of the medication was required to prevent seizures. Nurse #3 said that a STAT delivery takes four hours for the medication to be delivered and that she was not able to give the 2:00 P.M. dose on 04/12/25. During an interview on 6/25/25 at 2:00 P.M., the Director of Nursing (DON) said the medication errors had occurred because Resident #1's medications were not being delivered to the facility on time for them to be administered as prescribed. The DON said that the facility utilized two additional pharmacies to fill residents prescriptions and that the issue of medication availability had been corrected. On 06/25/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A. Resident #1 no longer resides at the Facility. B. On 04/21/25, the Facility Educator completed re-education of licensed nurses on the policy titled, Change in a Residents Condition or Status, including that the nurse will notify the residents' provider when there had been a need to alter the resident's medical treatment significantly or refusal of treatment or medication two or more consecutive times. C. On 04/21/25 the Facility Educator completed re-education of licensed nurses on the policy titled, Pharmacy Services Overview, including that residents have a sufficient supply of their prescribed medications, receive medication in a timely manner, that nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. D. The facility initiated the use of a local pharmacy on 04/22/25, and a back-up pharmacy on 04/24/25, to obtain mediations. E. On 04/24/25 the Unit Managers and/or designee completed an initial audit of current residents with prescribed medications to ensure sufficient supply of medications. F. The Unit Manager and/or designee completed an initial audit of provider notification of unavailable medications on 05/02/25. G. The Unit Managers or designee discuss missing medications daily in morning meetings. H. The Unit Manager or designee notifies the pharmacy electronically or via telephone daily for any missing medications. I. The Director of Nursing and /or designee completed ongoing audits of provider notification of unavailable medications for three weeks on 05/09/25, 05/16/25 and 05/23/25. J. The Director of Nursing and /or designee completed ongoing audits of current residents with prescribed medications to ensure a sufficient supply of medications on 05/05/25, 05/16/25 and 05/23/25. K. Physician notification, medication availably, and medication errors have been reviewed in Quality Assurance Performance Improvement (QAPI) committee meetings. L. The Director of Nursing and/or designee is responsible for compliance.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant (used to treat seizures) medications, the Facility failed to ensure they obtained, and Resident #1 was provided the medication as ordered by his/her Provider. Findings include: Review of the Facility's policy titled, Pharmacy Services Overview, revised April 2019, indicated but was not limited to: -Residents have a sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. -Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. -Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice. Resident #1 was admitted to the Facility in February 2025, diagnoses included but were not limited to Epilepsy. Review of Resident #1's Physician's Orders for the Month of April 2025, indicated it included orders for, but not limited to the following: A) 8:00 A.M.-Oxcarbazepine (anti-convulsant medication used to treat epilepsy) oral tablet, 300 milligrams (mg) give one tablet in the morning. B) 6:00 P.M.-Oxcarbazepine 300 mg, give two tablets in the evening. C) 2:00 P.M.-Lamotrigine (anti-convulsant medication used to treat epilepsy) 100 mg oral tablet, give 400 mg by mouth one time a day. A) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300 mg, one tablet in the morning, and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/02/24 at 8:00 A.M. 04/03/25 at 8:00 A.M. 04/18/25 at 8:00 A.M. 04/19/25 at 8:00 A.M. 04/21/25 at 8:00 A.M. B) Review of Resident #1's MAR for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300 mg, two tablets in the evening, and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/01/25 at 6:00 P.M. 04/02/25 at 6:00 P.M. 04/03/25 at 6:00 P.M. 04/14/25 at 6:00 P.M. 04/15/25 at 6:00 P.M. C) Review of Resident #1's MAR for the Month of April 2025 indicated he/she did not receive the ordered Lamotrigine 100 mg oral tablet, give 400 mg by mouth one time a day and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/12/25 at 2:00 P.M. 04/21/25 at 2:00 P.M. A) Review of Resident #1's Nursing Progress Notes indicated it included notes titled, Administration Note, for Oxcarbazepine 300mg, one tablet in the morning, at 8:00 A.M., indicated the following: 04/02/25-9:49 A.M.-on order 04/03/25 9:23 A.M.-med is on order 04/18/25-8:31 A.M.-the pharmacy has indicated that the order will not be filled because it has been rejected. 04/19/25-9:12 A.M.-med on order 04/21/25-8:01 A.M.-the pharmacy has indicated that the order will not be filled because it has been rejected. There was no documentation to support what additional steps were taken by nursing, and therefore the facility, in order to obtain the medications from the pharmacy. B) Review of Resident #1's Nursing Progress Notes indicated it included notes titled, Administration Note, for Oxcarbazepine 300 mg, two tablets in the evening, at 6:00 P.M, indicated the following: 04/01/25-7:14 P.M.-on order. 04/02/25-7:55 P.M.-on order 04/03/25-7:04 P.M.-on order 04/14/25-6:41 P.M.-med on order 04/15/25-6:40 P.M.-on order There was no documentation to support what additional steps were taken by nursing, and therefore the facility, in order to obtain the medications from the pharmacy. C) Review of Resident #1's Nursing Progress Notes indicated it included notes titled, Administration Note for Lamotrigine 100 mg oral tablet, give 400 mg by mouth one time a day at 2:00 P.M., indicated the following: 04/12/25-2:09 P.M.-reordered 04/21/25-1:20 P.M.-reordered medical aware During an interview on 06/25/25 at 11:35 A.M., Nurse #1 said that she had not administered Resident #1, his/her prescribed Oxcarbazepine 300 mg on 04/02/25 or 04/03/25 at 8:00 A.M., and she had not administered Oxcarbazepine 300 mg, 2 tablets, on 04/03/25 at 6:00 P.M. because it was not available. Nurse #1 said that when Resident #1's Oxcarbazepine was not available on 04/02/25 for his/her 8:00 A.M. dose, she had called the pharmacy and was told that it was going to be delivered, but that it was still not available on 04/03/25 for his/her 8:00 A.M., or 6:00 P.M. dose. Nurse #1 said when the medication was still not available on 04/03/25 she documented 9 on the medication administration record and added a note that indicated it was on order. During a telephone interview on 06/27/25 at 9:00 A.M., Nurse #3 said that she had not administered Resident #1 his/her Lamotrigine 400 mg on 04/12/25 at 2:00 P.M. because it was not available. Nurse #3 said that she had called the pharmacy for a STAT (immediate) delivery but that a STAT delivery takes four hours for the medication to be delivered and that she was not able to give the 2:00 P.M. dose. During a telephone interview on 06/27/25 at 11:00 A.M., Nurse #2 said that getting medications from the pharmacy had been and big, big problem. Nurse #2 said that the pharmacy will say the medication is coming, but they will only send one- or two-days' worth of medication and that she would have to start re-calling for medication again as soon as it arrives at the facility. Nurse #2 said that she had waited for 20-30 minutes for the pharmacy to answer the phone when she has called for medications. During an interview on 06/25/25 at 2:00 P.M., the Director of Nursing (DON) said that Resident #1 was not administered his/her doses of Oxcarbazepine and Lamotrigine as prescribed by the Provider because it was not available from the Pharmacy. On 06/25/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A. Resident #1 no longer resides at the Facility. B. On 04/21/25, the Facility Educator completed re-education of licensed nurses on the policy titled, Change in a Residents Condition or Status, including that the nurse will notify the residents' provider when there had been a need to alter the resident's medical treatment significantly or refusal of treatment or medication two or more consecutive times. C. On 04/21/25 the Facility Educator completed re-education of licensed nurses on the policy titled, Pharmacy Services Overview, including that residents have a sufficient supply of their prescribed medications, receive medication in a timely manner, that nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. D. The facility initiated the use of a local pharmacy on 04/22/25, and a back-up pharmacy on 04/24/25, to obtain mediations. E. On 04/24/25 the Unit Managers and/or designee completed an initial audit of current residents with prescribed medications to ensure sufficient supply of medications. F. The Unit Manager and/or designee completed an initial audit of provider notification of unavailable medications on 05/02/25. G. The Unit Managers or designee discuss missing medications daily in morning meetings. H. The Unit Manager or designee notifies the pharmacy electronically or via telephone daily for any missing medications. I. The Director of Nursing and /or designee completed ongoing audits of provider notification of unavailable medications for three weeks on 05/09/25, 05/16/25 and 05/23/25. J. The Director of Nursing and /or designee completed ongoing audits of current residents with prescribed medications to ensure a sufficient supply of medications on 05/05/25, 05/16/25 and 05/23/25. K. Physician notification, medication availably, and medication errors have been reviewed in Quality Assurance Performance Improvement (QAPI) committee meetings. L. The Director of Nursing and/or designee is responsible for compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant medications (used to treat seizures), the Facility failed to ensure nursing notified the Provider when he/she did not receive the anti-convulsant medication as ordered. Findings include: Review of the Facility's policy titled, Change in a Resident's Condition or Status, revised February 2021 indicated: -The nurse will notify the resident's attending physician or physician on call when there has been a (an): -need to alter the resident's medical treatment significantly. -refusal of treatment or medication two (2) or more consecutive times. Resident #1 was admitted to the Facility in February 2025, diagnoses included but was not limited to Epilepsy. Review of Resident #1's Physician's Orders for the Month of April 2025, indicated it included orders for, but not limited to the following: A) 8:00 A.M.-Oxcarbazepine (anti-convulsant medication used to treat epilepsy) oral tablet, 300 milligrams (mg) give one tablet in the morning. B) 6:00 P.M.-Oxcarbazepine 300 mg, give two tablets in the evening. C) 2:00 P.M.-Lamotrigine (anti-convulsant) 100 mg oral tablet, give 400 mg by mouth one time a day. A) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300 mg, one tablet in the morning, and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/02/24 at 8:00 A.M. 04/03/25 at 8:00 A.M. 04/18/25 at 8:00 A.M. 04/19/25 at 8:00 A.M. 04/21/25 at 8:00 A.M. B) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Oxcarbazepine 300 mg, give two tablets in the evening, and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/01/25 at 6:00 P.M. 04/02/25 at 6:00 P.M. 04/03/25 at 6:00 P.M. 04/14/25 at 6:00 P.M. 04/15/25 at 6:00 P.M. C) Review of Resident #1's Medication Administration Record (MAR) for the Month of April 2025 indicated he/she did not receive the ordered Lamotrigine 100 mg oral tablet, give 400 mg by mouth one time a day, and that the nurses had documented the code 9 (other, see nursing note) on the following dates and times. 04/12/25 at 2:00 P.M. 04/21/25 at 2:00 P.M. Review of the Nurse Progress Notes indicated there was no documentation to support nursing notified the Provider on 04/01/25, 04/02/25, 04/3/25, 04/14/25, 04/15/25, 04/18/25, 04/19/25 and 04/21/25 of missed doses of Oxcarbazepine, or notified the Provider on 04/12/25 and 04/21/25 of missed doses of Lamotrigine. During an interview on 06/25/25 at 1:40 P.M., the Nurse Practitioner said that she had not been notified by nursing that Resident #1 had not been administered Oxcarbazepine and Lamotrigine as prescribed. During an interview on 06/25/25 at 11:35 A.M., Nurse #1 said that she had not administered to Resident #1, his/her prescribed Oxcarbazepine 300 mg on 04/02/25 or 04/03/25 at 8:00 A.M., and she had not administered Oxcarbazepine 300 mg, 2 tablets, on 04/03/25 at 6:00 P.M. because it was not available. During a telephone interview on 06/27/25 at 9:00 A.M., Nurse #3 said that she had not administered to Resident #1 his/her Lamotrigine 400 mg on 04/12/25 at 2:00 P.M. because it was not available. During an interview on 06/25/25 at 2:00 P.M., the Director of Nurses said when medication is not available the nurse is expected to notify the Provider, document the notification and the Provider's response in the Nurses Notes and that this had not been done as required. On 06/25/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction is as follows: A. Resident #1 no longer resides at the Facility. B. On 04/21/25, the Facility Educator completed re-education of licensed nurses on the policy titled, Change in a Residents Condition or Status, including that the nurse will notify the residents' provider when there had been a need to alter the resident's medical treatment significantly or refusal of treatment or medication two or more consecutive times. C. On 04/21/25 the Facility Educator completed re-education of licensed nurses on the policy titled, Pharmacy Services Overview, including that residents have a sufficient supply of their prescribed medications, receive medication in a timely manner, that nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. D. The facility initiated the use of a local pharmacy on 04/22/25, and a back-up pharmacy on 04/24/25, to obtain mediations. E. On 04/24/25 the Unit Managers and/or designee completed an initial audit of current residents with prescribed medications to ensure sufficient supply of medications. F. The Unit Manager and/or designee completed an initial audit of provider notification of unavailable medications on 05/02/25. G. The Unit Managers or designee discuss missing medications daily in morning meetings. H. The Unit Manager or designee notifies the pharmacy electronically or via telephone daily for any missing medications. I. The Director of Nursing and /or designee completed ongoing audits of provider notification of unavailable medications for three weeks on 05/09/25, 05/16/25 and 05/23/25. J. The Director of Nursing and /or designee completed ongoing audits of current residents with prescribed medications to ensure a sufficient supply of medications on 05/05/25, 05/16/25 and 05/23/25. K. Physician notification, medication availably, and medication errors have been reviewed in Quality Assurance Performance Improvement (QAPI) committee meetings. L. The Director of Nursing and/or designee is responsible for compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and a Physician's order for Potassium Sodium Sulfate (a supplement that can help maintain a therapeutic potassium level in the body), the facility failed to ensure they obtained and Resident #3 was provided the medication, as ordered by his/her Provider. Findings include: Review of the Facility's policy titled, Pharmacy Services Overview, revised April 2019, indicated but was not limited to: - Residents have a sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. - Nursing staff communicate Prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. Resident #3 was admitted to the Facility in March 2025, diagnoses included Hypokalemia, Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Influenza, and Respiratory Syncytial Virus (RSV, a virus that causes infections of the respiratory tract). Review of Resident #3's Physician's Orders for March 2025, indicated it included an order for (but was not limited to) the following: - Potassium and Sodium Phosphate Oral Packet 280-160-250 milligrams (mg), give one packet two times per day for low potassium levels, initiated 3/13/25. Review of Resident #3's Medication Administration Record (MAR), indicated Resident #1 did not receive the ordered Potassium and Sodium Phosphate Oral Packet and that nurses documented code 9 (other, see nursing note) for the following dates and times:. - 03/13/25: 8:00 A.M., 5:00 P.M. - 03/14/25: 8:00 A.M., 5:00 P.M. - 03/15/25: 8:00 A.M. Review of Resident #3's Nurse Progress Notes, indicated it included notes titled, Administration Note (for Potassium and Sodium Phosphate) with nursing documenting: - 03/13/25 8:59 A.M., Medication not available, on order. - 03/13/25 4:34 P.M , Medication not available, pharmacy called. - 03/14/25 9:11 A.M., Medication not available, pharmacy contacted. - 03/14/25 4:15 P.M., No reason given as to why the medication was not given or what steps nursing took after they were unable to administer the medication. - 03/15/25 8:53 A.M., No reason given as to why the medication was not given or what steps nursing took after they were unable to administer the medication. During an interview on 04/02/25 at 12:00 P.M., Nurse #2 said the particular potassium supplement that was prescribed to Resident #3 was not available in the Facility's emergency medication supply. Nurse #2 said the Facility has had a lot of issues with their Pharmacy related to the medications taking a long time to be delivered, medications being out of stock, and medications being on backorder. Nurse #2 said they make a list of medications that were not available at the end of the day shift (the shift she primarily works) and call the Pharmacy to find out the status of the missing medication(s). Nurse #2 said the Facility had not received Potassium and Sodium Phosphate timely from the Pharmacy and that it should have been delivered to the Facility before Resident #3 was due to be administered his/her 5:00 P.M. dose on 03/15/25. During an interview on 04/02/25 at 1:00 P.M., Unit Manager #1 said they often have trouble obtaining medications from the Pharmacy and when they call, the Pharmacy gives them various reasons for why the medications were not delivered. Unit Manager #1 said the Pharmacy will give reasons such as, the medication is on backorder, they (the Pharmacy) need to obtain the medication from another pharmacy, or the medication will be on the next delivery. Unit Manager #1 said she has sent emails to the Pharmacy about medications that are not delivered and sometimes she receives no reply at all or other times she will receive a reply with the previously stated reasons. Unit Manager #1 said the Pharmacy email address the Facility utilizes is a generic customer service email address and the responses, when they receive them, are from various Pharmacy staff and they do not have a consistent customer service person to contact. Unit Manager #1 said that Resident #3 should have received his/her Potassium and Sodium Sulfate prior to 03/15/25. Review of Resident #3's Medical Record indicated there was no documentation to support Nursing communicated with the Pharmacy on 03/13/25 and 03/14/25 to inquire about when the medication would be delivered. During a telephone interview on 04/09/25 at 1:08 P.M., the Pharmacy Manager said he reviewed Resident #3's prescriptions, that the Potassium and Sodium Phosphate was considered an over the counter (OTC) medication and said the Facility should be aware the Pharmacy does not send OTC medications unless they get a signed OTC form from the Facility. The Pharmacy Manager said they never received a signed OTC form from the Facility, and according to their records, the medication order was never sent to the Facility. The Pharmacy Manager said he did not know if the Facility contacted anyone directly (via telephone) at the Pharmacy regarding the medication not being delivered. During a telephone interview on 04/09/25 at 2:03 P.M., the Director of Nursing (DON) said Potassium and Sodium Phosphate packets are not a medication the Facility stocks in the emergency medication supply. The DON said the Pharmacy has sent OTC medications to the Facility without needing an OTC form in the past. The DON said the Pharmacy has been inconsistent with their communication. The DON said that their current Pharmacy has had ongoing problems and are in the process of being acquired by another Pharmacy. During a follow up telephone interview on 04/10/25 at 2:45 P.M., the DON said other than the Administration Notes on 03/13/25 and 03/14/25 which indicated that nursing staff contacted the Pharmacy, there was no further documentation of the details of the conversation with the Pharmacy that indicated a reason as to why there was no Potassium and Sodium Phosphate available for the nursing staff to administer to Resident #3.

Based on records reviewed and interviews for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and had a Physician's Order for potassium supplements, the Facility failed to ensure nursing notified the Provider when he/she did not receive the supplement as ordered. Findings include: Review of the Facility's policy titled, Change in a Resident's Condition or Status, revised February 2021 indicated: - The nurse will notify the resident's attending physician or physician on call when there has been a(an): - need to alter the resident's medical treatment significantly. - refusal of treatment or medication two (2) or more consecutive times. Review of Resident #3's Hospital Discharge/Transfer Note, dated 03/12/25, indicated his/her medication orders included (but was not limited to) the following: - Potassium Phosphate-Sodium Phosphate 250 milligrams (mg) -280 mg-160 mg oral powder, administer by mouth two times per day for 14 days. Further review of Resident #3's Hospital Discharge/Transfer note indicated lab work was performed on 03/12/25 and his/her serum (blood) potassium level was 3.6 milliequivalents per liter (mEq/L, a unit of measurement that expresses the chemical equivalence of a substance's concentration in a solution). The normal range for potassium levels in adults is typically between 3.5 and 5.2 mEq/L). Resident #3 was admitted to the Facility in March 2025, diagnoses included Hypokalemia, Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Influenza, and Respiratory Syncytial Virus (RSV, a virus that causes infections of the respiratory tract). Review of Resident #3's Physician's Orders for March 2025 indicated he/she had an order for Potassium and Sodium Phosphate Oral Packet 280-160-250 mg, give one packet by mouth two times per day for low potassium levels with a start date of 03/13/25 and discontinuation date of 03/17/25. Review of Resident #3's Medication Administration Record (MAR), indicated Resident #1 did not receive the ordered Potassium and Sodium Phosphate Oral Packet and that nurses documented code 9 (other, see nursing note) for the following dates and times:. - 03/13/25: 8:00 A.M., 5:00 P.M. - 03/14/25: 8:00 A.M., 5:00 P.M. - 03/15/25: 8:00 A.M. On 03/16/25, Resident #3 was transferred to the Hospital Emergency Department (ED) due to new onset mental status changes, and was subsequently admitted to the Hospital for treatment of a urinary tract infection (UTI, a bacterial infection that affects the urinary tract). Review of Resident #3's Hospital Admission Note, dated 03/16/25 indicated his/her potassium level was 2.9 mEq/L (below normal range for an adult) upon arrival to the ED and he/she required 40 mEq of intravenous (through the vein) Potassium Chloride (KCl, a medication used in the management and treatment of Hypokalemia). During an interview on 04/02/25 at 12:00 P.M., (which included review of Resident #3's March 2025 MAR) Nurse #2 said that Resident #3 did not receive any Potassium and Sodium Phosphate on 03/13/25, 03/14/25 and did not receive his/her morning dose on 03/15/25. Nurse #2 said the code 9 corresponding to these dates and times on the MAR indicated the medication was not received from the Pharmacy. Nurse #2 said she did not notify Resident #3's Provider that the Potassium and Sodium Phosphate was unavailable when she went to administer it on 03/15/25, and she said was not aware of a policy or protocol in place as to when to notify the Provider if a medication was not available and/or if a resident missed multiple doses of a prescribed medication. Further review of Resident #3's medical record indicated there was no documenation to support nursing notified the provider on 3/13/25 or 3/14/25, after they were unable to administer the medication because it was unavailable. During an interview on 04/02/25 at 1:00 P.M., Unit Manager #2 said nursing staff should notify the Provider if a resident misses two doses of a medication in order for the Provider to determine what the next steps would be, such as ordering an alternative medication or to obtain a medication from the Facility's emergency supply. During an interview on 04/02/25 at 2:21 P.M., (which included a review of her provider notes and documentation related to Resident #3) the Nurse Practitioner (NP) said she could not see where nursing staff notified her that Resident #3 missed multiple doses of Potassium and Sodium Phosphate due to the medication not being delivered from the Pharmacy. The NP said that she would have liked to have been notified because Resident #3 was known to have repeated instances of Hypokalemia, and the medication was intended to maintain a normal potassium level in his/her blood. The NP said if that particular medication was unavailable from the Pharmacy, she could have prescribed something different, including one that was available in the Facility's emergency medication supply. During a telephone interview on 04/09/25 at 2:03 P.M., the Director of Nursing said that it is their expectation that nursing staff attempt to obtain any prescribed medications from the Pharmacy, and if they are unable to obtain the medication, the expectation is that they notify the resident's Provider.

Based on observation, interview and policy review, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure resident food was prepared and distributed to prevent potential for cross contamination. 2. Ensure beard nets were worn in the food preparation area. Findings include: Review of the facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised December 2008, indicated Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy also included the following: -Employees must wash their hands: >after handling soiled equipment or utensils >during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks >after engaging in other activities that contaminate the hands -Gloves are considered single-use items and must be discarded after completing the task for which they were used. -Food service employees will be trained in the proper use of utensils as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness -Hair restraints or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens On 6/5/24 at 4:46 P.M., the surveyor observed the following during dinner service in the facility kitchen: -three Dietary Aides (#1, #2 and #3) with facial hair that was not covered with a beard restraint during dinner preparation. During an interview with Dietary Aide #3 at the time, Dietary Aide #3 said that beard restraints are not required if the facial hair was less than 1/2 inch in length. During an interview on 6/5/24 at 4:50 P.M., the Food Service Director (FSD) said he thought that beard restraints were only required for facial hair that is longer than 1/4 inch in length. The surveyor requested to review the facility policy relative to hair restraints at this time. From 4:58 P.M. through 5:17 P.M., the surveyor observed the dinner service and observed the following: -Dietary Aide #3, without a beard restraint, preparing grilled cheese sandwiches. -Dietary Aide #1 serving the food, using gloved hands, to scoop tuna tortellini salad onto plates that had cut up lettuce on them. Dietary Aide #1 used his gloved hands to arrange the tuna tortellini salad and then used the same gloved hands to pick up unwrapped dinner rolls and place them on the plate without changing his gloves and performing hand hygiene. -At 5:08 P.M., Dietary Aide #1 left the serving line, walked through the kitchen, and into the dry storage room, got a box containing bags of chips, exited the storage room, put the open box of chips on a utility cart placed by the serving line, moved the utility cart using the handle and then resumed serving dinner with the same gloved hands used previously. The surveyor stopped Dietary Aide #1 prior to him plating the food and instructed him to remove the gloves and perform hand hygiene, which he did. -At 5:13 P.M., the FSD provided tongs to serve the dinner rolls. During an interview on 6/5/24 at 5:17 P.M., the FSD said that Dietary Staff should be using serving utensils for food items to prevent potential cross contamination. The FSD said this could occur when touching handles and other items and then touching ready to eat foods. During a follow-up interview on 6/6/24 at 7:47 A.M., the FSD said that hair and beard restraints should be worn in the kitchen and serving utensils should be utilized when serving food to prevent potential for food contamination.

Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for two Residents (#66 and #71), out of a total sample of 29 residents. Specifically, 1. For Resident #66, the facility failed to: a)complete PICC device dressing changes as ordered by the Physician, b)complete external catheter length measurements as ordered, c)notify the Provider timely when changes in external catheter length and arm circumference measurements were identified for a Resident with a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. The PICC is a type of CVAD [Central Vascular Access Device] catheter) placing Resident #66 at risk for undiagnosed infiltration (when fluid or medication given by an intravenous [IV] device exits the vein and enters the soft tissues) and/or deep vein thrombosis (DVT: a blood clot in a deep vein). 2. For Resident #71, the facility failed to ensure that: a) required steps were taken when scheduled medication was unavailable from the pharmacy for 24 days, including notifying the Physician of the continued medication non-availability b) administer medication via the right route as prescribed by the Physician. Findings include: 1. Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, undated, indicated the following: -Perform site care and dressing change at established intervals . -Change the dressing if it becomes damp, loosened, or visibly soiled and: -at least every seven days . -Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. -Report any signs and symptoms of complications to Physician, supervisor, and oncoming shift. According to Lippincott Nursing Procedures-9th Edition (2023), to ensure to ensure the PICC line has not migrated (moved out of the appropriate location for safe use): -the Nurse should measure the external length of the catheter during dressing changes. Resident #66 was admitted to the facility in May 2024, with diagnoses of Pneumonia with Lung Abscess (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] with abscesses resulting from necrosis [death of body tissue] of the pulmonary tissue and formation of cavities) and Sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Review of the June 2024 Physician's orders indicated the following: -Dressing-PICC .24 hours after insertion, then weekly and PRN. >Change needless connector with weekly dressing change and after blood draw. >If securement device is used, change at time of dressing change, every day shift, every seven days, > measure external catheter length in centimeters (cm), with a start date of 5/20/24. -PICC Baseline Assessment Total Catheter Length 43 cm, External Length 0 centimeters (cm). >Document changes in external length in nurses notes. >Baseline arm circumference 38 cm, no routine interval, check PRN only, with a start date of 5/21/24. -Ceftriaxone Sodium Injection Solution Reconstituted (antibiotic) 2 grams (gm), use two gram intravenously one time a day for Sepsis until 6/12/24, with start date of 5/17/24. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15. During an interview on 5/30/24 at 1:52 P.M., Resident #66 said he/she had to ask for his/her PICC dressing to be changed as it had not been done since it was originally changed at the time of his/her admission to the facility. Resident #66 said the staff at the facility were not regularly changing the dressing, and were not measuring the catheter length. The Resident further said that a Nurse came in very early this morning and changed the dressing for him/her because the dressing was falling off and he/she asked for it to be changed. During an observation of the Resident's PICC line dressing on his/her right upper arm, the surveyor observed that the dressing was changed at 12:15 A.M., but there was no date documented on the bandage. Review of the IV Insertion Company Record for IV Placement dated 5/7/24, indicated the external catheter length was 0 cm. Review of the May 2024 Treatment Administration Record (TAR) indicated the Resident's PICC dressing was changed on 5/21/24, but no measurement of the external catheter length was recorded. Further review of the TAR indicated on 5/28/24 the Resident was supposed to have the PICC dressing changed and external catheter length measured, but the documentation was left blank on the TAR. Review of the Nursing Progress Note dated 5/30/24, indicated the Resident's PICC dressing was changed and the external catheter length measured at 2 cm (which was a change from the 5/7/24 external catheter length of 0 cm). Review of the June 2024 TAR indicated that on 6/4/24 the Resident's PICC dressing was changed and the external catheter length measured at 11 cm (which was a change from the 5/30/24 external catheter length of 2 cm). During an interview and observation on 6/4/24 at 2:45 P.M., two surveyors observed Nurse #1 demonstrate how she would measure the external catheter length of Resident #66's PICC line. Nurse #1 demonstrated and measured from the PICC line insertion site (the site at which the catheter tubing enters under the skin) down to the top of the clamp (device used to keep the catheter tubing closed when not in use). Nurse #1 stated she had no recent facility specific training on PICC line measurements and had only been working at the facility for a couple months. Nurse #1 further said she had not compared her external catheter length measurement to the previously documented external catheter length measurements and she was unsure if there had been changes since the external catheter length was last measured. During an interview on 6/4/24 at 2:55 P.M., Unit Manager (UM) #1 said the facility used the initial external catheter measurements obtained from the hospital as a baseline, then would measure the external catheter length every seven days following admission. UM #1 said the order for measuring the external length should be obtained at the time of admission. UM #1 said the order for Resident #66 was not obtained until 5/20/24, several days after the Resident had been admitted to the facility. The surveyor and UM #1 reviewed the Resident's TAR and UM #1 said the PICC line dressing was changed on 5/21/24 but there was no documentation to indicate if the external catheter length was measured, per the Physician's order. UM #1 also said on 5/28/24 there was no documentation to indicate the PICC line dressing change was performed or the external catheter length was measured as ordered. UM #1 further said she was unable to find any documentation that on 5/30/24 and 6/4/24 the Physician had been notified that there were changes in the external catheter length. UM #1 said it was important to update the Physician regarding changes in external catheter length because the changes could indicate that the catheter may have moved out of place and the Resident could be ask risk for the medication not being delivered correctly and the Physician would need to give orders on how the facility should proceed. 37400 2. Resident #71 was admitted to the facility in October 2021, with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Delirium (disturbed state of mind or consciousness, characterized by symptoms of confusion, disorientation, agitation, and hallucinations), Psychotic Disturbance (mental disorder characterized by a disconnection from reality), Mood Disturbance (disorder where long periods of extreme happiness, sadness, anger and/or irritability are experienced), Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), and Insomnia (sleep disorder with persistent problems falling and/or staying asleep). Review of the Resident's clinical record included specific care plans to address the following: -Verbal/physical agitation/aggression due to diagnoses of Dementia and Depression, initiated 10/25/21 -Episodes of combativeness with staff, throwing things, and refusals of care and medications, initiated 10/25/21 -Behavior management, initiated 10/25/21 -Cognition/communication loss related to dementia with behavioral disturbance, initiated 10/25/21 and revised 10/28/21 -At risk for adverse effects related to use of .antipsychotic medications (medications that treat symptoms of psychosis), initiated 10/25/21 and revised 8/15/22 Review of the Minimum Data Set (MDS) Assessment, dated 1/1/24, indicated Resident #71: -was severely cognitively impaired as obtained by staff interview, -was dependent on staff for activities of daily living (eating, bathing, dressing, toileting activities), -had physical behaviors and rejection of care that occurred 4-6 days of the assessment period. 2a.) Review of the facility policy titled Unavailable Medications, effective February 2019, indicated medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion and included the following: -The facility must make every effort to ensure that medications are available to meet the needs of each resident: a. The pharmacy staff shall: >Call or notify nursing staff that the ordered product(s) is/are unavailable. >Notify nursing when it is anticipated that the drug(s) will be available >Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available, which is covered by the resident's insurance. b. The nursing staff shall: > Notify the attending Physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. >If the facility Nurse is unable to obtain a response from the attending Physician, the Nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction. >Obtain a new order and cancel/discontinue the order for the non-available medication. >Notify the pharmacy of the replacement order. Review of the Physician's orders for Resident #71 dated January 2024, included the following orders: -ABH gel (combination of Ativan (antianxiety medication), Benadryl (antihistamine used to treat pain, itchiness and also used to aid in sleep) and Haldol (antipsychotic medication used to treat mental disorders), 1/25/1 milligram (mg)/milliliter (ml), apply to inner wrist topically twice daily for anxiety related to major depressive order, initiated 8/23/23. Review of the January 2024 Medication Administration Record (MAR) indicated the ABH gel was documented as administered to Resident #71 twice daily from 1/1/24 through 1/7/24. Further review of the January 2024 MAR indicated 9 was documented from 1/8/24 through 1/31/24, with the exception of 1/29/24 at 5:00 P.M. where there was no documentation (left blank). Review of Resident #71's Medication Administration Notes from 1/8/24 through 1/31/24 indicated the following relative to the ABH gel administration: -1/8/24 at 9:07 A.M. medication was unavailable, Physician was notified for the script (prescription) to be sent and call out to the pharmacy to verify -medication not available, awaiting delivery from the pharmacy on: >1/8/24 at 4:07 P.M., >1/12/24 at 5:34 P.M., >1/15/24 at 4:09 P.M., >1/16/24 at 4:25 P.M., >1/17/24 at 4:22 P.M., >1/20/24 at 4:38 P.M., >1/21/24 at 4:29 P.M., >1/22/24 at 4:26 P.M., >1/25/24 at 4:27 P.M., >1/26/24 at 4:26 P.M., >1/30/24 at 4:33 P.M., >1/31/24 at 4:35 P.M. -medication not available: >1/9/24 at 7:30 A.M., >1/11/24 at 7:51 A.M., >1/11/24 at 4:06 P.M., >1/11/24 at 10:11 P.M., >1/18/24 at 8:13 A.M., >1/22/24 at 9:51 A.M., >1/23/24 at 7:43 A.M., >1/24/24 at 7:44 A.M., >1/25/24 at 9:06 A.M., >1/26/24 at 8:00 A.M., >1/29/24 at 8:04 A.M., >1/30/24 at 8:03 A.M. -not available from the pharmacy: >1/9/24 at 4:08 P.M. -not available: >1/10/24 at 9:39 A.M.,>1/13/24 at 10:53 A.M., >1/14/24 at 9:06 A.M., -waiting for pharmacy to deliver: >1/10/24 at 5:26 P.M. -awaiting delivery: >1/12/24 at 10:17 A.M. -on order: >1/13/24 at 4:52 P.M., >1/14/24 at 5:57 P.M., >1/18/24 at 6:55 P.M., >1/19/24 at 4:32 P.M., >1/23/24 at 5:32 P.M., >1/24/24 at 5:26 P.M., >1/27/24 at 7:13 P.M., >1/28/24 at 6:20 P.M. -awaiting pharmacy: >1/15/24 at 8:17 A.M. -awaiting medications: >1/16/24 at 9:15 A.M. -unavailable: >1/17/24 at 9:10 A.M., >1/28/24 at 9:39 A.M. -no documentation noted: >1/19/24 at 8:42 A.M., >1/20/24 at 8:11 A.M., >1/21/24 at 9:43 A.M., >1/27/24 at 10:05 A.M., >1/31/24 at 8:13 A.M. Review of the clinical record indicated no documented evidence that the Physician and/or other Medical Provider (Nurse Practitioner/Physician Assistant) was notified that the ABH gel was not available to administer to the Resident, so that additional orders could be obtained after the request for the prescription was sent to the pharmacy on 1/8/24. During an interview on 6/5/24 at 10:33 A.M., the surveyor asked Unit Manager (UM) #3 about the January 2024 MAR documentation for the ABH gel which indicated 9 from 1/8/24 through 1/31/24. UM #3 said that she could recall a period of time when the medication needed to be made at the pharmacy and the facility was unable to obtain the medication. When the surveyor asked what happened when a medication was not available as ordered by the Physician for administration, UM #3 said the Physician would be notified and additional orders would be obtained for alternate medications. During an interview on 6/5/24 at 12:00 P.M., the Director of Nursing (DON) said there have been issues with the pharmacy that the facility utilized. The DON said if a medication was not available, the Physician would be notified and additional orders for medication change would be obtained. The DON said there should be documentation in the Resident's clinical record that this communication occurred, that she would look into the documentation, and get back to the surveyor. During a follow-up interview on 6/5/24 at 1:12 P.M., the DON said she was unable to find evidence that the Physician was notified of the ABH gel not being available from the pharmacy from 1/8/24 through 1/31/24. 2b) Review of the Journal of the American Medical Directors Associations Article titled ABH Gel ., dated January 2021, indicated the following areas for administration: -Application of ABH gel is typically to the volar (pertaining to the palm or sole) or palmar (inner) surface of the wrists, rubbed behind the ears or the bottoms of the feet. Review of the Lippincott Nursing Procedures 9th Edition (2023) manual for safe medication administration included but was not limited to the following: -Follow the five rights of medication administration: >the right patient, >the right medication, >the right dose, >the right time >and the right route. -Some literature indicates use of nine rights which adds the right documentation, the right action, the right form and the right response. -Identify high alert medications, examples of these include opioid medications and precautions may include having a second Nurse independently verify the medication and dose before administration Review of the Physician's orders from December 2023 through June 2024 included the following order: -ABH gel: 1/25/1 mg/ml, apply to inner wrist topically (application to body surfaces such as skin or mucous membranes) twice daily for anxiety related to major depressive order, initiated 8/23/23. Review of the December 2023 through June 2024 MARs indicated the ABH gel was administered to the following locations (other than the inner wrist as ordered by the Physician): -left or right inner ankle: on 51 occurrences -left or right outer ankle: on six occurrences -right or left forearm: on two occurrences -top of left foot: on two occurrences -right or left arm: on one occurrences -front of thigh: on one occurrence -right leg: on one occurrence During an interview on 6/5/24 at 10:13 A.M., UM #3 said Resident #71's Physician's orders indicate to apply the ABH gel to his/her inner wrist, if the nurses were applying the gel elsewhere, they would need to contact the Physician and have the order clarified. Nurse #6, who was present during the interview, said that she applies the ABH gel to the Resident's inner ankle. During an interview on 6/5/24 at 12:00 P.M., the DON said that she had only ever seen ABH gel applied to patients' inner wrists. The DON further said she would follow-up with the Provider about the application of the ABH gel to other locations on Resident #71's body. During a follow-up interview on 6/5/24 at 12:39 P.M., the DON said the Provider was contacted and indicated that the ABH gel could be applied to other specified locations, but it was usually ordered to be applied to the inner wrist because the medication was better absorbed. The DON said if the nurses had concerns about applying the medication to the Resident's inner wrist as ordered, the Physician/Provider should have been notified to request to change the Resident's administration order for the ABH gel to allow application to other areas.

Based on observation, interview, record and policy review, the facility failed to provide pain management consistent with professional standards of practice for two Residents (#130 and #72), of two applicable Residents reviewed for pain, out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to provide pain medication as ordered for severe pain reported by the Resident. The facility also failed to contact the Physician/ Provider for an emergency order and/or alternative pain medication to aid in managing the Resident's pain when the ordered pain medication was unavailable from the pharmacy to be administered. 2) For Resident #73, the facility failed to appropriately monitor the Resident for effectiveness of prescribed pain medication, and notify the Physician/ Provider for evaluation and modification of the pain medication regimen as needed. Findings include: Review of facility policy titled Pain Assessment and Management, with an edit date of 11/10/22, indicated but was not limited to the following: -Pain management is a multidisciplinary care process that includes the following: monitoring for the effectiveness of interventions; and modifying approaches as necessary. -The medication regime is implemented as ordered. -Results of the interventions are documented and communicated directly to the provider when appropriate. -Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medication. -Contact the prescriber immediately if the resident's pain or medications side effects are not adequately controlled. -Report the following information to the physician or practitioner: .prolonged, unrelieved pain despite care plan interventions. 1) Resident #130 was admitted to the facility in April 2024 with diagnoses including Fracture of the Right Patella with surgical repair (broken bone in the knee that required surgery to fix), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #130 was cognitively intact as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. Review of the April 2024 Physician's orders, included the following: -Morphine Sulfate (opioid medication used to reduce moderate to severe pain) oral tablet, 22.5 milligrams (mg) every 6 hours for pain (on a scale of 7-10 out of 10), with an order date of 4/6/24. -Scheduled Tylenol (medication used for mild/minor pain) 650 mg every 6 hours (at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.) with an order date of 4/6/24. -Ativan (medication to treat anxiety), 0.5 mg every 12 hours as needed (PRN) for anxiety with an order date of 4/7/24 Review of Resident #130's Nursing Evaluation Note dated 4/6/24 at 8:25 P.M., indicated a pain assessment score of 8 out of 10 (severe pain on a scale where 0 is no pain and 10 is the worst pain). Review of the Medication Administration Note dated 4/7/24 at 3:00 A.M., indicated that Nurse #5 administered Ativan to the Resident for right knee pain per the Resident's request. Review of the Nursing Clinical Note dated 4/7/24 at 7:28 A.M., indicated that Nurse #5 contacted the pharmacy several times about the pending delivery of the Resident's Morphine Sulfate immediate release medication (a strong medication used to relieve pain) with no answer. Further review of the Nursing Clinical Note indicated that the Resident was offered and accepted ice applied to the knee which helped the pain a little and he/she was able to sleep after the administration of Ativan from 3:50 A.M. until 6:00 A.M. on 4/7/24. Review of Resident #130's April 2023 Medication Administration Records (MAR) indicated: -Tylenol was documented as administered to Resident #130 on 4/7/24 at 12:00 A.M. (3.5 hours after the Resident expressed an 8 out of 10 pain scale). -Morphine Sulfate oral tablet was documented as administered to the Resident on 4/7/24 at 11:26 A.M. (approximately 15 hours after the Resident expressed a severe 8 out of 10 pain scale) Further review of the clinical record indicated no documented evidence that the Physician/ Provider was notified that the Resident had expressed severe pain and that the ordered Morphine Sulfate pain medication was not available to be administered for pain management. During an interview on 5/31/24 at 11:57 A.M., Resident #130 said he/she went a long time without any pain medications upon admission to the facility. During an interview on 6/4/24 at 3:01 P.M., Nurse #5 said that Ativan was not a medication used to treat pain. Nurse #5 further said that if a resident was admitted to the facility with pain, and was awaiting delivery of their own supply of pain medication from the pharmacy, that she would contact the on-call Provider (Physician, Nurse Practitioner [NP], or Physician Assistant [PA]) to obtain an order for narcotic medication (strong pain medication such as morphine) from the emergency kit (supply the facility maintains on site to minimize gaps in medication administration of essential medications). During an interview on 6/4/24 at 3:15 P.M., the surveyor and UM #2 reviewed the Resident Evaluation Note dated 4/7/24 at 8:25 P.M. UM #2 said the pain scale indicated that the Resident's pain was an 8 out of 10 at the time of assessment, and a strong pain medication should have been offered. The surveyor and UM #2 also reviewed the Nursing Clinical Notes dated 4/7/24 at 3:00 A.M., and 4/7/24 at 7:28 A.M. UM #2 said that Ativan was not a pain medication and should not have been administered for pain. UM #2 said if the appropriate pain medication was not immediately available, the Nurse should have contacted the on-call Provider to get an order to administer a pain medication that was available in the facility emergency kit. During an interview on 6/5/24 at 9:22 A.M. Nurse Practitioner (NP) #1 said with the Resident's pain scale being an 8 out of 10, the on-call Provider should have been called for an order to administer the same or similar pain medication from the facility emergency kit to manage the Resident's pain until his/her supply of pain medication arrived from the pharmacy. NP #1 said Ativan medication was not used for pain management. During an interview on 6/5/24 at 4:19 P.M., the Director of Nursing (DON) said the Nurse should have contacted the on-call Provider to obtain a one-time dose from the emergency kit when Resident #130 had severe pain and the prescribed medication was not available to be administered. The DON further said that because Resident #130 regularly took narcotic pain medication prior to admission, there would be concern for both withdrawal from the pain medication as well as pain becoming harder to manage effectively due to the lapse in administering the medication. 2) Resident #73 was admitted to the facility in April 2024, with diagnoses including Osteomyelitis of Vertebra, Sacral Region (infection of the bone(s) in the lower spine in the area of the low back and buttocks), Stage 4 Pressure Ulcer (a wound caused by pressure extending down into the muscle, tendon or to the bone) of the Sacral Region (in the area of the buttocks), Stage 3 Pressure Ulcer of the Right Buttock (a wound caused by pressure extending past the surface skin into fat tissues but not to the muscle), and a Stage 4 Pressure Ulcer of the Right Hip. Review of Resident #73's MDS assessment dated [DATE], indicated that the Resident: -was cognitively intact as evidenced by a BIMS score of 14 out of 15. -His/her pain assessment indicated pain was almost constant with the worst pain rating at 9 out of 10 on the pain scale (severe) and had an almost constant effect on his/her sleep and activities of daily living (ADLs: dressing, bathing, getting in out of bed, mobility). Review of the Resident's Pain Care Plan, revised 4/29/24, indicated the following goal: -Resident will express pain management was within acceptable limits. Review of Resident #73's Physician's orders, from April 2024 through May 2024 included the following medications for pain: -Morphine Sulfate extended release (ER: a type of Morphine Sulfate that works over a longer period of time than traditional Morphine Sulfate tablets for a more controlled effect on pain) 15 mg scheduled twice a day at 8:00 A.M. and 8:00 P.M., initiated 4/21/24 -Dilaudid (opioid analgesics used to manage pain) 2 mg every 4 hours as needed (PRN), initiated 4/21/24 and hold dates (dates the medication could not/should not be administered) from 5/15/24 through 5/22/24 -Morphine Sulfate oral tablet 15 mg every 6 hours as needed (PRN) for pain before dressing change, initiated 5/11/24 and discontinued on 5/16/24 -Morphine Sulfate oral solution (liquid version of morphine pain medication) 5 mg every 4 hours as needed (PRN) for pain, initiated 5/17/24 and discontinued on 5/17/24 -Morphine Sulfate oral tablet 7.5 mg every 4 hours as needed (PRN) for pain, initiated 5/15/24 Review of the April 2024 and May 2024 Medication Administration Records (MARs) indicated that the Resident received his/her scheduled Morphine Sulfate ER 15 mg twice daily as ordered. Review of Resident #73's clinical record indicated the following PRN pain medications were administered and the follow-up pain assessments conducted by the Nurse indicated the medication was ineffective on the following dates/times: > Dilaudid 2 mg: -4/22/24 at 8:43 A.M.: initial pain scale was 6 out of 10, follow-up pain scale was 10 out of 10 -4/24/24 at 11:27 A.M.: initial pain scale was 6 out of 10, follow-up pain scale was 10 out of 10 -4/25/24 at 10:28 A.M.: initial pain scale was 8 out of 10, follow-up pain scale was 10 out of 10 -4/29/24 at 10:52 A.M.: initial pain scale was 10 out of 10, follow-up pain scale was 8 out of 10 -5/1/24 at 11:46 A.M.: initial pain scale was 10 out of 10, follow-up pain scale was 10 out of 10 -5/2/24 at 10:48 A.M.: initial pain scale was 9 out of 10, follow-up pain scale was 10 out of 10 >Morphine Sulfate 15 mg: -5/12/24 at 4:53 A.M.: initial pain scale of 8 out of 10, follow-up pain scale was 10 out of 10 -5/15/24 at 4:00 A.M.: initial pain scale of 8 out of 10, follow-up pain scale was 10 out of 10 >Morphine Sulfate 7.5 mg: -5/29/24 at 3:15 P.M.: there was no documentation that pain was assessed using the pain scale at the time of medication administration and the follow-up pain assessment. Review of the clinical record indicated no documented evidence that additional interventions were offered to Resident #73 to manage and relieve pain, or that the on-call Provider was contacted and notified that the pain medication was ineffective in managing the Resident's pain. During an interview on 5/31/24 at 8:34 A.M., Resident #73 said he/she has issues with constant pain, that the pain medication helps some, but he/she still had to deal with a lot of pain. During a follow-up interview on 6/4/24 at 10:10 A.M., Resident #73 said when his/her pain medication had been ineffective, neither medication or non-medication interventions were offered to help with his/her unrelieved pain. The Resident said that he/she had asked for Tylenol at times but was not given or offered anything to assist with the unrelieved pain. Review of the clinical record indicated no documented evidence that Tylenol medication was ordered or had been administered for Resident #73. During an interview on 6/4/24 at 11:22 A.M., with Nurse #4, who said she was a regular staff member and familiar with providing care for Resident #73. Nurse #4 said if she assessed the Resident after pain medication was administered and it was not effective, she would offer him/her another dose if he/she was due, but she had not documented offering another dose and should have. Nurse #4 said that if pain medication was ineffective in managing pain, the Provider should be notified for additional orders and/or to reassess the Resident. During an interview on 6/4/24 at 3:22 P.M., the surveyor and UM #2 reviewed the clinical record. UM #2 said the Medication Administration Note dated 5/2/24 at 10:48 A.M., indicated that the Resident's follow-up pain scale after the Dilaudid administration was 10 out of 10 (severe pain). UM #2 said the Nurse should have contacted the Provider after completing the follow-up assessment for Resident #73 to obtain additional pain medication orders. When the surveyor asked UM #2 if there was documented evidence that the Provider was contacted relative to Resident #73's pain documented on 5/2/24, UM #2 said she was unable to provide any evidence the 5/2/24 occurrence had been communicated to the Provider or that additional pain control measures had been offered to the Resident. During an interview on 6/5/24 at 9:13 A.M., NP #1 said her expectation would be for staff to contact her or the on-call Provider relative to a resident who was experiencing unrelieved pain so an order for an additional dose of medication could be obtained. NP #1 further said that if notified, the Provider would know to review whether the pain medication regimen needed to be changed for improved pain management. NP #1 said she was not notified that Resident #73 was having unrelieved pain. During an interview on 6/5/24 at 4:13 P.M., the DON said if a follow-up assessment indicated a resident's pain medication was ineffective, the staff would be expected to contact the Provider to obtain additional orders. The DON further said that unrelieved pain would be concern that could indicate a larger issue and that the Provider would need to determine if a medical workup could be managed in-house or if it would have required the Resident to be transferred to the hospital for further evaluation.

Based on observation, interview, record and policy review, the facility failed to notify the Physician of a need to alter treatment for two Residents (#130 and #73), out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to notify the Physician/ Provider timely for an emergency order and/or alternative pain medication when the ordered pain medication was unavailable from the pharmacy to address the Resident's pain. 2) For Resident #73, the facility failed to notify the Provider when the ordered pain medication regimen was determined to be ineffective in managing the Resident's pain. Findings include: Review of facility policy titled Pain Assessment and Management, with an edit date of 11/10/22, indicated but was not limited to the following: -Pain management is a multidisciplinary care process that includes the following: >monitoring for the effectiveness of interventions >and modifying approaches as necessary. -The medication regime is implemented as ordered. -Results of the interventions are documented and communicated directly to the provider when appropriate. -Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medication. -Contact the prescriber immediately if the resident's pain or medications side effects are not adequately controlled. -Report the following information to the physician or practitioner: .prolonged, unrelieved pain despite care plan interventions. 1) Resident #130 was admitted to the facility in April 2024 with diagnoses including Fracture of the Right Patella with surgical repair (broken bone in the knee that required surgery to fix) and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review of the Minimum Data Set (MDS) Assessment, dated 4/10/24, indicated Resident #130 was cognitively intact based on a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15. Review of the Resident's Physician's orders for April 2024 indicated: -Morphine Sulfate (opiate medication that works by changing the way the brain and nervous system respond to pain) oral tablet, 22.5 milligrams (mg) every 6 hours for pain (on a scale of 7-10), initiated 4/6/24 at 11:30 P.M. Review of Resident #130's Nursing Evaluation Note dated 4/6/24 at 8:25 P.M., indicated the Resident had a pain assessment score of 8 out of 10 (severe pain on a scale where 0 is no pain and 10 is the worst pain). Review of Resident #130's Nursing Note dated 4/7/24 at 7:28 A.M., indicated that Nurse #5 contacted the pharmacy several times regarding the pending delivery of the Resident's Morphine Sulfate immediate release medication with no answer from the pharmacy. Further review of the clinical record indicated no documented evidence that the Physician and/or covering Provider was notified of Resident #130's complaint of severe pain (8 out of 10) on 4/6/24 and that the Morphine Sulfate ordered for the Resident was not available to be administered. During an interview on 6/4/24 at 3:01 P.M., Nurse #5 said if a resident was admitted to the facility with pain, and was awaiting delivery of their own supply of pain medication from the pharmacy, she would contact the on-call Provider (a Physician, Nurse Practitioner[NP], or Physician Assistant[PA]) to obtain an order for narcotic medication (strong pain medication such as morphine) from the emergency kit (supply the facility maintains on site to minimize gaps in medication administration of essential medications). During an interview on 6/4/24 at 3:15 P.M., the surveyor and Unit Manager (UM) #2 reviewed the Resident's Evaluation Note dated 4/7/24 at 8:25 P.M. UM #2 said the pain scale indicated the Resident's pain was an 8 out of 10 at the time of evaluation and a strong pain medication should have been offered. UM #2 said if the appropriate pain medication was not immediately available, the Nurse should have contacted the on-call Provider to get an order to administer a pain medication that was available in the facility emergency kit. During an interview on 6/5/24 at 9:22 A.M., NP #1 said with the Resident's pain scale being an 8 out of 10, the on-call Provider should have been called for an order to administer the same or similar pain medication from the facility emergency kit to manage the Resident's pain until his/her supply of pain medication arrived from the pharmacy. During an interview on 6/5/24 at 4:19 P.M. the Director of Nursing (DON) said the expectation relative to pain medication administration for Resident #130 was that the Nurse should have contacted the on-call Provider to obtain a one-time dose of pain medication from the emergency kit. 2) Resident #73 was admitted to the facility in April 2024 with diagnoses including Osteomyelitis of Vertebra, Sacral Region (infection of the bone(s) in the lower spine in the area of the lower back and buttocks), Stage 4 Pressure Ulcer (a wound caused by pressure extending down into the muscle, tendon or to the bone) of the Sacral Region (in the area of the buttocks), Stage 3 Pressure Ulcer of the Right Buttock (a wound caused by pressure extending past the surface skin into fat tissues but not to the muscle), and a Stage 4 Pressure Ulcer of the Right Hip. Review of the MDS Assessment for Resident #73 dated 4/27/24, indicated the Resident: -was cognitively intact as evidenced by a BIMS score of 14 out of 15. -his/her pain assessment indicated pain was almost constant with the worst pain rating at 9 out of 10 on the pain scale (severe) and had an almost constant effect on his/her sleep and activities of daily living (ADLs: dressing, bathing, getting in out of bed, mobility). Review of Resident #73's Physician's orders, from April 2024 through May 2024 included the following medications for pain: -Morphine Sulfate extended release 15 mg (a type of Morphine Sulfate that works over a longer period of time than traditional Morphine Sulfate tablets for a more controlled effect on pain) scheduled twice a day at 8:00 A.M. and 8:00 P.M., initiated 4/21/24 -Dilaudid (Hydromorphone: opioid analgesic medication prescribed for pain) 2 mg every 4 hours as needed (PRN), initiated 4/21/24 and hold dates (dates the medication could not/should not be administered) from 5/15/24 through 5/22/24 -Morphine Sulfate oral tablet 15 mg every 6 hours as needed (PRN) for pain before dressing change, initiated 5/11/24 and discontinued 5/16/24 -Morphine Sulfate oral solution (liquid version of Morphine pain medication) 5 mg every 4 hours as needed (PRN) for pain, initiated 5/17/24 and discontinued 5/17/24 -Morphine Sulfate oral tablet 7.5 mg every 4 hours as needed for pain, initiated 5/15/24 -No order for Tylenol medication Review of the Resident#73's clinical record indicated the PRN medications were used to treat pain and were documented as ineffective after administration on the follow-up pain assessment on the following dates/times: >Dilaudid 2 mg on: -4/22/24 at 8:43 A.M. with a 10 out of 10 pain, follow-up pain assessment -4/24/24 at 11:27 A.M. with a 10 out of 10 pain, follow-up pain assessment -4/25/24 at 10:28 A.M. 10 out of 10 pain, follow-up pain assessment -4/29/24 at 10:52 A.M. with an 8 out of 10 pain, follow-up pain assessment -5/1/24 at 11:46 A.M. with a 10 out of 10 pain, follow-up pain assessment -5/2/24 at 10:48 A.M. with a 10 out of 10 pain, follow-up pain assessment >Morphine Sulfate 15 mg on: -5/12/24 at 4:53 A.M. with a 10 out of 10 pain, follow-up pain assessment -5/15/24 at 4:00 A.M. with a 10 out of 10 pain, follow-up pain assessment >Morphine Sulfate 7.5 mg on: -5/29/24 at 3:15 P.M. with no documented follow-up pain assessment Further review of the clinical record for Resident #73 indicated no documented evidence that the on-call Provider was contacted and notified that the Resident's pain medication regimen was not managing his/her pain effectively. During an interview on 5/31/24 at 8:34 A.M., the Resident said he/she has had issues with constant pain, that the pain medication helps some, but he/she still had to deal with a lot of pain. During an interview on 6/4/24 at 11:22 A.M., Nurse #4 said that if pain medication was ineffective in managing pain, the Provider should be notified for additional orders and/or to have the Provider reassess the Resident. During an interview on 6/4/24 at 3:22 P.M., the surveyor and UM #2 reviewed the clinical record for Resident #73. UM #2 said if the follow-up pain assessment indicated the Resident's medication to treat pain was ineffective, she would expect the Nurse to contact the Provider for additional orders. When the surveyor asked UM #2 if there was evidence that the Provider was contacted relative to Resident #73's pain documentation, UM #2 was unable to provide any documented evidence that the ineffectiveness of the Resident's pain medication was communicated to the Provider. During an interview on 6/5/24 at 9:13 A.M., NP #1 said her expectation would be for staff to contact her or the on-call Provider relative to a resident who was experiencing unrelieved pain so that an order for an additional dose of medication could be obtained. NP #1 said she was not notified that Resident #73 was experiencing unrelieved pain. During an interview on 6/5/24 at 4:13 P.M., the DON said if a follow-up assessment indicated a resident's pain relief was ineffective, the staff would be expected to contact the Provider to obtain additional orders. Please Refer to F697

Based on record review, policy review, and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for one Resident (#112), out of a total sample of 29 total residents. Specifically, for Resident #112 the facility failed to accurately complete a Level I PASRR indicating that the Resident had a diagnosis of Bipolar Disorder, and received Behavioral Health Services within the last two years in the community, resulting in a Level II PASRR Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services) not being completed as required. Findings include: Resident #112 was admitted to the facility in February 2023 with the following diagnoses: Bipolar Disorder (a mental illness that causes extreme mood swings, from high to low, that affect your energy, thinking and behavior) and Adjustment Disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) with mixed anxiety and depressed mood. Review of the facility policy titled Admission Criteria, edited on 6/23/22, indicated the following: -If the Level I screen indicates that the individual may meet the criteria for a MD, ID (or RD [related disorders], he or she is referred to the state PASARR [SIC] representative for the Level II (evaluation and determination) screening process. Review of the Hospital Admission Information referral dated 2/11/24, indicated Resident #112 had a history of Bipolar Disorder. Review of the Social Service Admission Evaluation dated 2/21/24, indicated the Resident had a history of Bipolar Depression and utilized outside Behavioral Health Services. Review of the PASRR Level I Screening, dated 2/20/23 indicated No to the following questions: -Does the applicant have a documented diagnosis of a mental illness or disorder (MI/D) or substance use disorder (SUD) that may lead to chronic disability? -Within the past two years, is the applicant known to have required one of the treatments or interventions listed below, that is, or may be due to a mental illness or disorder (MI/D) .Association with mental health agency. During an interview on 6/4/24 at 12:12 P.M., the surveyor and Social Worker (SW) #2 reviewed Resident #112's Social Service Admission Evaluation dated 2/21/24 and the PASRR that was completed upon admission. SW#2 said that the PASRR was not completed correctly upon admission. SW #2 said that the PASRR should have indicated the Resident had a diagnosis of Bipolar Disorder, and that the Resident received Behavioral Health Services within the last two years in the community. SW #2 said that if the information had been completed accurately the Resident would have been reviewed and prompted a Level II PASRR evaluation to be completed. SW #2 further said that a Level II PASRR had not been completed as required.

Based on interview and record review, the facility failed to ensure that one Resident (#24) out of a total sample of 29 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #24, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures that can be taken when a person's heart stops or they fail to breathe on their own) and ancillary services that could be provided while at the facility. Findings include: Resident #24 was admitted to the facility in August 2022 with a diagnosis including Cerebral Infarction (Stroke: occurs when the blood flow to the brain is disrupted causing tissue damage) without residual effects. Review of the Resident's clinical record included the following: -Request for Services Form for consent or declination for audiology (hearing services), eye care, podiatry (foot care services), dental, and behavioral health, which was completed, all services were declined and was signed by the Resident's Representative on 8/17/22. -Advanced Directive Care Plan, initiated on 8/18/22, which included the intervention to discuss Advanced Directives with the patient, family or legal representative, and to honor the Medical Orders for Life-Sustaining Treatment (MOLST: indicates preferences for life sustaining measures) form. -MOLST form completed and signed by the Resident's Representative on 10/20/22. Further review of Resident #24's clinical record indicated that Resident #24 was not invoked (put into effect, was not dependent on a designated person to make medical and health care decisions) by the Physician/Medical Provider since his/her admission. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #24 was cognitively intact as evidenced a Brief Interview of Mental Status (BIMS) score of 15 out of 15. On 6/4/24 at 3:55 P.M., the surveyor and Unit Manager (UM) #3 reviewed the Resident's clinical record. During an interview at the time, UM #3 said Resident #24 was not invoked relative to decision making. After review of the Resident's MOLST form, which was signed by the Resident's Representative, UM #3 said that she would have a new MOLST form completed because the Resident did not sign the MOLST form and was able to make his/her own decisions. During an interview on 6/4/24 at 4:02 P.M., Resident #24 said that he/she would like to sign his/her own paperwork. The Resident further said that because of visual deficits, the paperwork would need to be reviewed with him/her but that he/she was capable and able to sign it once reviewed. During a follow-up interview on 6/5/24 at 5:32 P.M., Resident #24 said he/she could not recall if ancillary services like dental, eye/vision care and foot care were discussed/offered to him/her and was not aware if his/her Representative had previously signed paperwork for this. The Resident said that he/she would like someone from the facility to review the options for services with him/her, and possibly look into receiving new eyeglasses and dental care. The Resident further said that if this information was discussed on admission and he/she was out of it, it was possible that his/her Representative signed for him/her but did not recall anyone from the facility reviewing the services with him/her.

Based on observation, interviews, record and policy review, the facility failed to ensure that staff identified, addressed and monitored significant weight loss of one resident (#82) with unplanned, significant weight loss, out of a sample of 37 residents. Specifically, the facility failed to notify a Physician or Nurse Practitioner of Resident #82's change in condition, recheck weights timely, weigh resident at the frequency ordered by the Physician and implement nutritional interventions to prevent further significant weight loss. Findings include: Resident #82 was admitted to the facility in [DATE], with multiple diagnoses including Alzheimer's Disease, Insulin Dependent Diabetes, and Dysphagia. Review of the most recent Minimum Data Set (MDS) Assessment, dated [DATE], indicated: -Resident #82 was rarely/never understood -non-ambulatory -dependent with eating -was 60 inches tall (5 feet) and weighed 76 pounds The MDS further indicated that Resident #82 had a significant weight loss and was not on a Physician prescribed weight loss regime. Further review of the medical record indicated that Resident #82's Health Care Proxy (HCP) was invoked in June of 2020. Physician's orders for Advanced Directives indicated the Resident was a Full Code/CPR (Cardiopulmonary Resuscitation), use Non-Invasive Ventilation (NIV-administering ventilatory support without using an artificial airway), may transfer (to hospital if needed for medical care), use dialysis (procedure used to remove waste and excess fluid when the kidneys stop functioning), use artificial nutrition and hydration. During an interview on [DATE] at 12:46 P.M., with Family Member #1, she said she was also the Resident's Health Care Proxy (HCP). Family Member #1 said she comes in at least once per day at mealtimes to assist with feeding Resident #82 because they do not have the staff to do it. She said she brings in Glucerna (a high-calorie nutritional drink) from home because they won't give it to him/her. Family Member #1 said she's not happy with the care because the Resident has lost weight. At the time of the interview, the Family Member was at the Resident's bedside feeding him/her lunch, which he/she was eating. Review of the facility policy, titled Weight Assessment and Intervention, last edited [DATE], indicated but was not limited to the following: - A weight change of five pounds or more in a patient weighing more than 100 pounds or of a two pound in a patient weighing less than 100 pounds since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the dietitian. - The dietitian will respond within one week. - Weights will be reviewed by the 10th of the month to follow individual weight trends overtime. Negative trends will be evaluated to determine significant, unplanned and undesired weight loss. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight-actual weight) / (usual weight x 100)]: a. One month - Five percent weight loss is significant: greater than five percent is severe. b. Six months - Ten percent weight loss is significant: greater than ten percent is severe. Review of the facility policy titled, Change in Resident's Condition or Status, dated February 2021, indicated but was not limited to the following: - Our facility promptly notifies the resident, his or her attending Physician, and the Resident Representative of changes in the resident's medical/mental condition and/or status. - The nurse will notify the resident's attending Physician or Physician on-call when there has been a(an): significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly. - A significant change of condition is a major decline or improvement in the resident's status that: - will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions - impacts more than one area of the resident's health status - requires interdisciplinary review and/or revision to the care plan Review of the Physician's Orders for Resident #82 indicated the following: -weigh weekly in the morning every Tuesday for dietary recom (recommendations), dated [DATE]. - Nutritional juice drink four times per day for dietary recom (recommendations), dated [DATE] During observation on [DATE] at 8:26 A.M., the surveyor arrived to the Unit. Resident #82 was observed sleeping in bed with his/her breakfast tray on the bedside table, covered and untouched. At 8:44 A.M., CNA #10 entered the Resident's room, took the bedside chair out of the room, but did not assist the Resident with his/her meal. The tray remained on the bedside table, untouched. At 9:37 A.M., the CNA was observed again entering the room, collected the roommate's tray and did not assist Resident #82 with his/her meal. The tray remained at the bedside, untouched. At 9:39 A.M., CNA #10 was observed re-entering the room, repositioned Resident #82 and began assisting him/her with the breakfast meal, more than an hour after the breakfast tray was first observed in Resident #82's room. During an observation on [DATE] at 9:46 A.M., CNA #10 was observed leaving Resident #82's room with the breakfast tray in her hands. She placed the tray onto the food truck and said the Resident did not eat very much and only took a few bites. She said she did not feel the food needed to be warmed up despite being left in the Resident's room for over an hour. CNA #10 further said it took some time to assist the Resident with breakfast because she is responsible for feeding all the residents who require assistance on her assignment, about three to four residents. She said Resident #82 typically doesn't eat very much at meal times which is why it didn't take very long (feeding the Resident). During an observation on [DATE] at 12:40 P.M., Resident #82 was observed lying in bed with the lunch tray on the bedside, untouched. At 1:10 P.M., CNA #10 was observed entering the Resident's room and began assisting him/her with his/her meal, 30 minutes after the food tray was first observed in the Resident's room. Review of the medical record indicated the following weights were obtained for Resident #82: [DATE]: 90.0 lbs. (pounds) [DATE] 86.4 lbs. [DATE] 85.4 lbs. [DATE]: 80.4 lbs. [DATE] 76.1 lbs. [DATE]: 75.0 lbs. Further review of the medical record failed to indicate that the Resident was weighed weekly on Tuesdays per Physician's Order. Review of the Dietitian's Progress Note dated [DATE], two days after the [DATE] weight was obtained, indicated the following: -Re-weigh requested to verify weight of 80.4 lbs obtained on [DATE] as previous weight noted 85.4 lbs on [DATE]. Will follow for re-weight result. There was no indication in the medical record that Resident #82 was re-weighed, per facility policy or that the Physician was notified of the weight change. Further review of the Dietitian's progress note dated [DATE], 16 days after the [DATE] weight was obtained indicated the following: -Re-weight remains unavailable to assess - requested again There was no indication in the medical record that Resident #82 was re-weighed per facility policy, that the Physician or HCP was notified of the 5.85% significant weight loss, or that interventions were put into place to prevent further weight loss. Review of the Dietitian's Progress Note dated [DATE], 17 days after the [DATE] weight was obtained, indicated the following: -Re-weigh noted 76.1 lbs on [DATE]. -Resident is receiving pureed, CCHO (consistent carbohydrate) diet with thin liquids - appetite is fair to good. -Resident noted dependent at meals. -Resident is receiving and accepting nutritional juice drink supplement four times daily. -[DATE] labs reviewed: glucose-58, chloride-111, total protein-WNL (within normal limits), albumin-2.9, triglycerides-186, vitamin D-24, TSH cascade-WNL. -Resident's weight continues to show decline despite nutrition interventions. -Resident remains full code status. -Physician and IDT(Interdisciplinary Team) notified of continued weight loss. -Care plan updated. During an interview on [DATE] at 2:57 P.M., the Dietician said the re-weight for Resident #82 took over two weeks to obtain. She said the Resident was already receiving nutritional drinks four times per day but continued to lose weight despite this being put into place. The Dietician said she did not put additional interventions in place after the re-weight of 76.1 pounds was obtained. Review of the medical record failed to indicate interventions were put into place for Resident #82 for the 10.89% significant weight loss on [DATE]. During an interview on [DATE] at 2:30 P.M., with the Registered Dietitian (RD), she said that she reviews weights as part of her assessment. If a weight is not available or is out of expected range, she will ask nursing for a re-weight using the communication form. If re-weight is not done within a few days she will request re-weight from Unit Manager again. She said that sometimes getting weights and re-weights completed is a challenge because of turnover of Unit Managers. She further said completing assessments are hard when weights are not being obtained. During an interview on [DATE] at 2:00 P.M., with Unit Manager (UM) #3, she said that weights are documented in the Electronic Medical Record (EMR) under the Weights/Vitals Tab. UM #3 said there is no where else the weights would be documented. She said that weekly weights are usually documented by the Nurse in the MAR. This will populate into the Weights/Vitals Tab. She said that re-weights are requested by the RD on the Dietary Communication Form. Nurses or the Unit Manager will tell the assigned Certified Nursing Assistant (CNA) or write it onto the daily Assignment if a weight is needed and the Nurse will follow up to ensure it gets done. She said the Physician and Dietitian should be notified of a weight variance.

Based on observations, interviews, and record review, the facility failed to ensure its staff prevented one Resident (#58), of 10 applicable residents, from developing two pressure injuries/ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), out of a total sample of 37 residents. Specifically, the facility staff failed to: a) accurately assess the Resident's risk for developing pressure injuries while at the facility for post-operative care after spinal surgery, and b) also accurately assess, document and treat the Resident's pressure injuries. Findings include: Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, indicated the following: - The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. - The nurse shall describe and document/report the following: >full assessment of pressure sore including location, stage, length, width and depth, presence of exudate (drainage) or necrotic (dead) tissue >pain assessment >mobility status >current treatments including support surfaces and all active diagnoses - The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. a) Resident #58 was admitted to the facility in January 2023 with diagnoses of status post laminectomy (a surgical procedure that removes a portion of a vertebra (series of small bones which form the backbone) called the lamina which is the roof of the spinal canal - a major spine operation) of L4-L5 (the two lowest vertebrae in the lower spine) with bilateral microdiscectomy (surgery to remove part or all of a bulging or damaged disc (soft pad between the vertebrae of the spine) in the lower spine. Review of the Minimum Data Set (MDS) Assessment, dated 1/17/23, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated: -the Resident required extensive assistance of two plus persons for bed mobility and transfers -was at risk for developing pressure ulcers/injuries -did not currently have a pressure injury -was not on a turning and positioning program. Review of the Resident's Care Plan included: - At Risk for Skin Alteration Care Plan, initiated 1/11/23, indicated the Resident was at risk due to impaired mobility and included the following interventions: -observe skin condition with care daily, report abnormalities -provide preventative skin care routinely and as needed -refer to therapy plan of treatment in the medical record for any more details Review of the Hospital Discharge Summary dated 1/10/23, indicated: Given the severity of the patient's condition, he/she was told along with family members the probability of him/her regaining control of his/her bowel and bladder function is very low. Review of the Resident Evaluation (admission assessment completed by Nurse #8), dated 1/10/23 indicated the following: - On page 8, the assessment indicated the Resident was incontinent of bowel. - On page 10, the skin evaluation included a Norton Plus Skin Risk Assessment score of 17 indicating the Resident was at minimal risk for pressure injuries. [The Norton Plus Scale consists of five subscale scores that range from five to 20. A lower score indicated higher levels of risk for pressure injuries. A score of 14 or less indicated at-risk status]. Scores included the following: -Physical Condition - scored as good (free of major health problems - score of four instead of Poor (chronic serious health conditions and/or major surgery - score of two). -Incontinence - scored as not incontinent - score of four instead of a possible score of one indicating the Resident lacked control of both bowel and bladder (which contradicted the information Nurse #8 recorded on page eight, and ultimately affected the total Norton risk score). -On page 11, the Nurse indicated there was no current skin breakdown or skin conditions present. Review of the January 2023 Physician's Orders indicated: -Norton Plus Skin Risk Assessment on admission, times (x) three weeks post admission every night shift, every Tuesday for three weeks, initiated 1/10/23. -Weekly skin checks - complete skin observation tool every day shift, every Wednesday, initiated 1/11/23. Review of the Resident's medical record indicated that Norton Plus Skin Assessments were started on 1/12/23 and 1/18/23 but were not completed for either date and the remaining two weeks, as ordered. Review of the Nursing Skin Observation Tool, dated 1/17/23 and completed by Nurse #8, indicated the following: Nurse #8 checked boxes that indicated both a previously identified area and newly identified area was observed. The location of the previously identified area(s) was documented as the Resident's left and right gluteal fold (horizontal crease between the bottom of the buttocks and top of the thighs), and the area(s) was described as shearing (a combination of downward pressure and friction). There was no information (location, description) under the newly identified area on the assessment and there were no measurements of the identified areas to the Resident's gluteal folds. Review of the Medical Record indicated no evidence the Norton Plus Skin Assessment was completed on 1/17/23, as ordered. Review of an Occupational Therapy Progress Note, dated 1/22/23, indicated the following: -Resident #58 had a left heel pressure area which was round, dark in color and was non-blanchable (discoloration of skin does not turn white when pressed - a clinically significant skin abnormality). The nurse was notified and recommended to apply a layer of skin prep prior to applying the Resident's socks, which was done. Review of a Physical Therapy Assistant (PTA) Progress Note, dated 1/22/23, indicated the PTA inspected and palpated (examined by touch) the Resident's left heel due to increased deep tissue injury (DTI, an injury to a person's underlying tissue below the skin's surface that results from prolonged pressure in an area of the body, restricting blood flow in the tissue causing tissue to die) and applied skin prep to prevent further injury. The PTA indicated that the assigned Physical Therapist (PT) and nursing staff were notified and recommended the Resident wear no socks unless he/she was standing. Review of Physical Therapy Progress Note dated 1/22/23 indicated the writer was notified by the PTA that Resident #58 had a darkened area on his/her left heel. The heel was inspected and appeared to have a DTI on the bottom of the Resident's foot measuring 4.3 centimeters (cm) long x 3.5 cm wide with a deep purple non-blanchable center and slight blanchable peri-wound (area surrounding wound). The Physical Therapist (PT) indicated that care partners were notified about the area on the Resident's left heel and therapy made the following recommendations: -avoid footwear/socks during non-weight bearing activity -to wear non-skid socks only during weight bearing activities -as well as to eliminate pressure to heels when in bed to optimize healing Review of a Physician Assistant (PA) progress note dated 1/23/23, indicted: Resident stated buttocks were sore and burned when he/she had stool in his/her briefs. Buttock soreness discussed with nursing to apply barrier cream and prompt brief changes as well as position changes to prevent breakdown. Review of an Occupational Therapy (OT) Progress Note, dated 1/24/23, indicated: -Resident #58 was observed in bed and was wearing bilateral TEDS stockings (tight stockings that help reduce the risk of developing blood clots in the lower leg) and non-skid socks. The OT indicated that PT recommended Resident #58 was not to have socks when in bed, however after a discussion with the Nurse and Unit Manager, who were aware of the patient's heels pressure areas, that the TEDS/non-skid socks were to be worn at all times except during hygiene. b) Review of the Nursing Skin Observation Tool, dated 1/25/23, completed by Nurse #8 indicated the following: No skin breakdown (despite the documented DTI on the Resident's left heel that was discussed with Nursing by both PT and OT staff). Review of the PA progress note dated 1/25/23, indicated: buttocks raw and erythematous (red). Further review of the Resident's Care Plan, updated 1/26/23 indicated: Actual skin breakdown related to: (reason for skin breakdown was left blank). Review of the PA progress note dated 1/27/23, indicated: buttocks raw and erythematous. Review of the PA progress note dated 1/30/23, indicated: buttocks wound, local treatment, keep clean, pressure relief and consult in house wound Nurse Practitioner (NP). Review of the PA progress note dated 2/1/23, indicated: coccyx (triangular bone at the base of the spine), wound base is fibrinous and left side eschar (meaning devitalized/dead tissue). Continue local treatment and will consult wound clinic. Review of the Nursing Skin Observation Tool dated 2/1/23, completed by Nurse #8 indicated the following: the Nurse checked the box indicating there was a previously identified area and indicated the location of the area to be both the right and left buttocks (not the gluteal fold as indicated on the Skin Observation Tool completed by Nurse #8 on 1/17/23), and that the areas to the buttocks were larger and there was drainage with new orders being implemented for treatment. The assessment did not include measurements of the area of concern (buttocks), and still did not include any documentation of the DTI to the Resident's left heel. Review of the Norton Plus Skin assessment dated [DATE], indicated the Resident was at high risk for pressure injuries as indicated by a score of 9, indicating the Resident's physical condition was poor and lacked control of both bowel and bladder. During an observation and interview on 2/1/23 at 9:43 A.M., with Resident #58 and family members at the Resident's bedside, the surveyor observed the Resident lying on his/her back in bed with an air mattress in use. The Resident was wearing an incontinence brief and between the brief and the air mattress the surveyor observed a sheet and a thick bath blanket folded up underneath the Resident's buttocks. Family Members #2 and #3 were present and told the surveyor the Resident has a wound to his/her left foot and to his/her backside. The surveyor observed the Resident's heels were resting directly on the air mattress. Both family members and Resident #58 said the Resident was supposed to be toileted regularly and that he/she had been feeling the sensation to have bowel movements but when he/she rings his/her call bell for help, no one responds timely and the Resident winds up having a bowel movement in the bed. Family member #3 said that sometimes there were pillows under the Resident's legs to keep his/her heels off the bed and sometimes there were not. Family Member #3 said this was the second day in a row when she came to visit that the Resident's heels were laying directly on the bed mattress. The surveyor observed the Resident's left heel and noted a non-blanchable purple area measuring approximately 4 cm x 3 cm to the plantar (sole) aspect of the heel. There was a pillow underneath the Resident's calves, however not high enough to keep the Resident's heels off the bed surface. Family member #3 said the Resident also had an open area on his/her buttocks. At this time a Certified Nursing Assistant (CNA) #4 entered the room to let the Resident know that they would be back in to clean him/her up, adjusted his/her blanket and found the cap to a bottle of ointment underneath the Resident, however, could not find the ointment at that time. After the CNA left the room, Family Member #2 moved the Resident to his/her left and found the tube of ointment that was underneath the Resident's thigh. During this time, the Nursing Supervisor, CNA #4 and Nurse #8 entered the Resident's room to provide care. CNA #4 and Nurse #8 rolled the Resident to his/her side to provide personal care. Both Family Member's #2 and #3 gasped and became tearful saying, they told us this was getting better .this looks bad! The Nursing Supervisor said the area to the Resident's buttocks appeared to be due to pressure and the PA was changing the wound care treatment because the wound had worsened. She further said the Resident should not be laying on a bath blanket due to the blanket causing increased heat and moisture, and the fact that air mattress manufacturers caution against putting layers between the air mattress and the body because the air mattress cannot effectively function to prevent skin breakdown. She also said she was not aware the Resident had a wound to his/her left heel, that she had just started in her position. During an interview on 2/1/23 at 12:20 P.M., CNA #4 said when the Resident arrived, his/her skin was completely intact although his/her entire buttock area was darker than the rest of his/her skin. Nurse #8 said she had noticed the Resident's buttocks wound had worsened this past Sunday (1/29/23), she then attempted to describe the wound to surveyor, then said, I don't know, I'm not good with wound stuff and was unable to describe the wound characteristics she had observed. During an interview on 2/1/23 at 3:54 P.M., the Director of Nursing (DON) said when any alteration in skin integrity was discovered, an incident report should be completed. She further said there was no evidence the Norton Plus Skin Assessments for 1/12/23 and 1/18/23 were completed as required, there were no incident reports completed relative to the Resident's buttocks wound or his/her left heel DTI and no evidence of any nursing documentation at all relative to the Resident's left heel DTI, as required. During an interview on 2/2/23 at 9:23 A.M., Nurse #8 said wounds should be measured upon discovery and weekly thereafter and this did not happen for Resident #58, as required. She further said if there was no documentation, there was no way to know if the wounds have improved or worsened. She said she was off for a few days and when she worked on Sunday, the Resident's buttocks wounds were much worse, that she was surprised at how bad they had gotten, and felt this could have been prevented. In addition, she said she did not recall ever having competencies or training relative to wound care at this facility. During an observation on 2/2/23 at 8:57 A.M., the surveyor observed the Resident lying on his/her back in bed with a pillow under his/her legs, his/her right heel was floated (elevated) off the bed but his/her left heel was resting directly on the pillow and not floating, as ordered. Review of a Wound Care Progress Note dated 2/3/23 indicated the following: I am asked to see the Resident today to evaluate reported in-house acquired two wounds to his/her coccyx (triangular bone at the base of the spine) and left heel. Nursing has been applying Santyl to his/her coccyx wound for the last four days, started with triad paste when they noticed skin breakdown and placed him/her on a LAL (low air loss) mattress. -Wound #1 - Coccyx extending to bilateral buttocks is an unstageable pressure injury (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough in the wound bed). Initial measurements are 10cm length x 5cm width x 0.2 cm deep with an area of 50 square cm and a volume of 10 cubic cm. There is a large amount of serosanguinous-sanguineous (exudate composed of red blood cells and serous fluid) drainage noted with mild odor. The wound bed has 1-25% eschar (dead tissue) and 51-75% slough. -Wound #2 - Left Heel is a DTI. Initial wound measurements are 4.5 cm length x 4.5 cm width with an area of 20.25 square cm. -Recommendation: -Nursing to perform dressing changes with skin prep to peri-wound (area surrounding wound), -Apply Santyl, followed by Calcium Alginate (an absorbent dressing used for heavily draining wounds), followed by foam dressing, changing twice per day (2x/Day) to the coccyx wound due to large serosanguinous drainage. -Apply skin prep to bilateral heels every shift for protection and offload. -Turn and position every two hours and as needed. -Dietary consult for protein supplementation. -Low air loss mattress and gel cushion for wheelchair to remain in place. During an interview on 2/6/23 at 9:10 A.M., the Nursing Supervisor reviewed the Resident's medical record with the surveyor. She said the Resident should have been turned and positioned every two hours, and should have been reflected in the CNA documentation and was not, as required. She further said the Resident's care plan was incomplete relative to what the impairment in his/her skin integrity was related to (body areas). The Nursing Supervisor further said the Norton Plus Skin Assessment in the initial Resident Evaluation (Nursing Admission Assessment) should have indicated the Resident's physical condition at the very least coded as fair due to his/her surgery prior to admission, and that he/she was incontinent. She said by not answering these questions correctly, it ultimately impacted the score which would have put the Resident at risk for pressure injuries versus minimal risk, as was initially coded. When the surveyor asked how the Norton Scale was used, she said if a Resident was scored at risk for pressure injuries, immediate interventions would have been put into place to prevent such injuries, such as utilizing an air mattress which was not implemented until after the Resident's skin integrity had already been compromised. She further said that upon discovery, any alteration in skin should be documented in an incident report/assessment and the areas of concern should be measured every week on Tuesdays - which was not done, as required and there was no documentation at all for the Resident's left foot DTI, as required. During a telephone interview on 2/7/23 at 10:42 A.M., Physician Assistant (PA) #1 said she was aware of the Resident's pressure injury to his/her buttocks. PA #1 said that one day the Resident told her his/her bottom was sore and upon observation she noted redness. She further said that the Resident was at high risk for skin breakdown due to his/her incontinence and limited mobility. She said the buttocks wound progressed quickly from being a reddened, closed area one week where she ordered barrier cream and an air mattress, to a slight open area the following week, then grew to a large open area with fibrinous tissue and slough (dead tissue). She further said that she was not aware the Resident had a DTI to his/her left heel until this surveyor told her during this telephone interview.

Based on interview, policy review, and record review, the facility and its staff failed to ensure quality care and services were provided to one Resident (#161) out of a total sample of 37 Residents. Specifically, the facility failed to: A) monitor and notify the Physician of critical lab values consistent with hypernatremia and acute kidney injury resulting in a hospitalization , and B) identify, address and monitor an unplanned, significant weight loss by failing to re-check weights timely, monitor enteral (a liquid form of nutrition delivered into the digestive system) intake consistently, and implement nutritional interventions to prevent further significant weight loss. Findings include: Resident #161 was admitted to the facility in October 2022 with diagnoses including: Cerebral Infarction, Dysphagia with gastrostomy tube placement (g-tube: a surgically placed device used to give direct access to a resident's stomach for supplemental feeding, hydration or medicine). Review of the most recent Minimum Data Set (MDS), dated [DATE] indicated Resident #161 was rarely or never understood or understands others, was 65 inches (5 feet, 5 inches) tall, had a weight of 135 pounds and was dependent for nutritional intake through a feeding tube. The MDS further indicated the Resident had a 5% weight loss in the past month and was not on a prescribed weight loss regimen. A) Review of the facility policy titled, Change in Resident's Condition or Status, dated February 2021, indicated but was not limited to the following: - Our facility promptly notifies the resident, his or her attending Physician, and the resident representative of changes in the resident's medical/mental condition and/or status. - The nurse will notify the resident's attending Physician or Physician on-call when there as been a(an): significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly. - A significant change of condition is a major decline or improvement in the resident's status that: - will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions - impacts more than one area of the resident's health status; - requires interdisciplinary review and/or revision to the care plan Review of Resident #161's Physician's Orders for November 2022 indicated the following: - Enteral Feed Order at bedtime, bolus (given over a short period of time) feed: 240 ml prior to bedtime (10/11/22) - (Order did not indicate formula used for bolus feed) - Enteral Feed Order four times a day flush tube with 190 ml water (10/11/22) - Enteral Feed Order with meals: Glucerna 1.2 bolus feeds: 480 ml three times per day (10/11/22) Review of the medical record for Resident #161 indicated that labs were obtained on 1/2/23 and the following critical results were indicated: - WBC (white blood cells): 17.8 HIGH (normal 4.8-10.8) - Sodium: 152 (normal 135-145) - BUN (blood [NAME] nitrogen): 114 HIGH (normal 5-25) - Creatinine: 3.58 HIGH (normal 0.7-1.3) Comparatively, the previous lab obtained within the facility for Resident #161 on 11/17/22 indicated the following results: - WBC 11.3 (4.8-10.8) - Sodium: 137 (135-145) - BUN: 26 (5-25) - Creatinine: 1.0 (0.7-1.3) Review of the medical record failed to indicate the critical laboratory values obtained on 1/2/23 were reviewed and the Physician was notified. During an interview on 2/6/23 at 12:40 P.M., Nurse #10 said she was the nurse caring for Resident #161 on 1/2/23. She said she could not recall the labs being drawn on that day but would have documented if she called out to the Physician. She further said she could recall the Nurse Practitioner ordering additional labs later in the week but was unsure of the exact date. Review of the medical record indicated STAT labs were obtained on 1/5/23, three days after the critical lab values were obtained, and the following critical results were indicated: - WBC: 25.4 HIGH (4.8-10.8) - worse in comparison to the 1/2/23 results - Sodium: 160 (135-145) - worse in comparison to the 1/2/23 results - BUN (blood [NAME] nitrogen): 117 HIGH (5-25) - worse in comparison to the 1/2/23 results - Creatinine: 3.82 HIGH (0.7-1.3) - worse in comparison to the 1/2/23 results Further review of the medical record indicated the Resident was transferred to the hospital on 1/5/23. Review of the hospital discharge paperwork for Resident #161 indicated the following: - Acute Hypernatremia, free water deficit close to seven liters. -Unclear how he/she got so dry if his/her home regimen includes standing free water boluses. Most likely having increased insensible loses secondary to COVID infection and not meeting baseline needs with home regimen. Per nutrition, the 190 cc free water four times per day that he/she gets at home is not sufficient to cover his/her maintenance needs. Not clear who manages his/her G-tube outpatient. No reported GI losses (vomiting/diarrhea) from facility. During an interview on 2/6/23 at 11:50 A.M., with Nurse Practitioner (NP) #2 the medical record was reviewed with the surveyor. NP #2 said she saw Resident #161 on 1/12/23 when he/she returned from the hospital after laboratory results indicated he/she had hypernatremia and acute kidney injury likely from dehydration. She said the Resident had remained stable up until this recent hospitalization and felt the Resident was not receiving enough water. NP #2 said when you have a resident who is NPO (nothing by mouth) and completely dependent for all nutrition and hydration, you have complete control over keeping labs and weights stable. She said she was not in the facility on 1/2/23 due to the holiday and was not notified by the nursing staff of the critical labs obtained on the Resident. She said when she was reviewing the medical record on 1/5/23, the labs on 1/2/23 were identified and she ordered STAT labs and requested Resident #161 be sent out to the hospital (three days after the first set of labs were obtained and resulted). Nurse Practitioner #2 further said it is her expectation that the nursing staff review all labs obtained, compare them to the previous labs and call the on-call service to report changes. She said this was not done for Resident #161 on 1/2/23. During an interview on 2/6/23 at 1:20 P.M., Regional Nurse #1 said the nurses should be following up on all labs and notifying the Physician or Nurse Practitioner of any abnormal labs. Review of the Progress Note from Nurse Practitioner #2 indicated the following: - Hypernatremia: Concerns that patient may not have been receiving his/her free water boluses as directed - Discussed with Nurse Manager who is implementing system with nursing to ensure that patient is receiving his/her free water as ordered During an interview on 2/6/23 at 12:00 P.M., Nurse Practitioner #2 said she had concerns that Resident #161 was not receiving adequate water intake based on his/her recent labs. She said she spoke with Unit Manager (UM) #2 about putting a system in place to ensure that the Resident was receiving his/her bolus flushes as ordered. During an interview on 2/7/23 at 10:10 A.M., UM #2 said the Nurse Practitioner did have a conversation with her regarding Resident #161. UM #2 said she educated the staff on bolus flushes but could provide no documentation that the education was completed. She further said she was only tracking the Resident's output and did not have documented input for the Resident to track the total amount of food and fluid he/she was receiving. The Unit Manager could provide no further information or documentation regarding this and said monitoring Resident #161's total input might be a good idea. B) Review of the facility policy, titled Weight Assessment and Intervention, last edited 6/15/22, indicated but was not limited to the following: - A weight change of five pounds or more in a patient weighing more than 100 pounds or of a two pound in a patient weighing less than 100 pounds since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the dietician. - The dietician will respond within one week. - Weights will be reviewed by the 10th of the month to follow individual weight trends overtime. Negative trends will be evaluated to determine significant, unplanned and undesired weight loss. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight-actual weight) / (usual weight x 100)]: a. One month - Five percent weight loss is significant: greater than five percent is severe. b. Six months - Ten percent weight loss is significant: greater than ten percent is severe. Review of the Physician's Orders as of 11/1/2022 indicated the following: - Weekly weight on Tuesday x 4 weeks (10/17/22 through 11/15/22) - Weigh monthly (start date 12/1/22) Review of the medical record indicated the following weights were obtained for Resident #161: - 10/11/22: 149.7 pounds (lbs) - 10/22/22: 154.5 lbs - 10/25/22: 157.6 lbs - 11/1/22: 154.4 lbs - 11/7/22: 155 lbs - 11/8/22: 155.2 lbs - 11/9/22: 155 lbs - 11/16/22: 155 lbs - 12/7/22: 146 lbs - 1/15/23: 135 lbs Review of the Nutrition Follow-Up Assessment, dated 12/2/22, indicated the Resident weighted 155 pounds on 11/16/22, was NPO (nothing by mouth) and dependent for enteral nutrition/hydration, through the gastrostomy tube. Further review of Resident #161's medical record indicated a weight of 146 pounds was obtained on 12/7/22, which was a -5.81% weight loss. Review of the Nutrition Progress note, dated 12/9/22, indicated the following: - Reweigh requested to verify weight of 146.0 pounds obtained on 12/7/22 as previous weight noted 155.0 pounds on 11/16/22. Will follow for re-weigh results. Review of the Nutrition Progress note, dated 12/19/22, indicated the following: - Unable to verify current weight status - resident noted to have refused weight on 12/10/22 During an interview on 2/8/23 at 2:50 P.M., Unit Manager #3 said if a resident refuses to be weighed, the nursing staff should re-educate the resident, attempt a re-weigh again at a later time, and notify the Physician of the refusal. She said this should be documented in the medical record. There was no indication in the medical record that a re-weigh was re-attempted or the Physcian was notified of the Resident's refusal to be weighed. During an interview on 2/2/23 at 12:16 P.M., the Dietician said obtaining re-weighs within the building has been an ongoing struggle. She said if weight loss is identified she would review the medical record and put interventions in place for the Resident. During an interview on 2/2/23 at 3:12 P.M., the Director of Nurses said obtaining weights within the building as been an ongoing issue. She said re-weighs should be obtained if a significant weight change is identified. Review of the medical record failed to indicate that the Physician was notified and interventions were implemented for Resident #161 for the 5.81% weight loss between 11/16/22 and 12/7/22. During an interview on 2/6/23 at 3:56 P.M., the Dietician said she did not put interventions in place for Resident #161 because he/she had remained stable previously and since the weight of 146 lbs was not very different from his/her initial weight of 149.7 lbs in October 2022, the interventions did not change. Resident #161 was transferred to the hospital in January 2023. Review of the medical record indicated Resident #161 did not have another documented weight until 1/15/23, four days after he/she returned from the hospital, which was 135 pounds and indicated a significant weight loss of 12.90% in two months. Review of the Nutritional Evaluation following the recent hospitalization for Resident #161, dated 1/12/23, indicated the most recent weight for the Resident was 146 pounds, obtained on 12/7/22. However, the evaluation further indicated Readmission weight requested - weight of 155.0 lbs from 11/15/22 utilized to calculate estimated nutritional needs/BMI at this time. Re-admission weight was not obtained until 1/15/23, four days after the Resident's return from the hospital. Review of the Nutrition progress note, dated 1/16/23 indicated the following: - Resident with fluctuating weights/refusals making it difficult to assess weight trend. Re-weigh requested to verify weight of 135 pounds obtained on 1/15/23. A re-weight of 134 pounds was obtained on 1/18/23, two days after the re-weigh was requested by the Dietician. Review of the Nutrition Follow-up Assessment, dated 1/19/23 indicated the following: - Noted to have a weight loss; percentage of weight loss equals timeframe for weight change noted to be within three months; Weight loss is unplanned. - Re-weigh noted 134 pounds on 1/18/23 indicated a significant weight decline of 13.3% in three months.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure staff followed Resident #1's plan of care for safety requiring the use of a mechanical lift with two staff person assist to transfer Resident #1 from the bed to his/her wheelchair, when Certified Nurse Aide (CNA) #1 failed to follow Resident #1's care plan, transferred Resident #1 by herself and Resident #1 sustained a right [MEDICAL CONDITION]. Findings include: The Safe Lifting and Movement of Residents Policy, dated 07/2017, indicated in order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. The Policy indicated manual lifting of residents shall be eliminated when feasible. The Policy indicated staff will document resident transferring and lift needs in the care plan. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. An At Risk for Falls Care Plan, revised 04/20/18, indicated Resident #1 required a hoyer lift transfer with two staff persons. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required total dependence of two staff persons for transfers. A Licensed Nursing Summary, dated 09/19/18, indicated Resident #1 was dependent/hoyer (mechanical lift) for transfers. The Facility's Investigation, dated 10/22/18, indicated Resident #1 complained of pain and pointed to his/her right lateral thigh. The Investigation indicated Resident #1 was assessed by the Nurse, the Nurse Practitioner was notified, and an x-ray was ordered. The Investigation indicated CNA #1 transferred Resident #1 by herself from the bed to the wheelchair quickly and that after the transfer Resident #1 complained of right leg pain. The Investigation indicated Resident #1 sustained a right [MEDICAL CONDITION] and was transferred to the Hospital Emergency department for evaluation. A Nursing Home to Hospital Transfer Form, dated 10/22/18, indicated Resident #1 was being transferred to the Hospital Emergency Department for a [MEDICAL CONDITION]. A Hospital Discharge Summary, dated 10/25/18, indicated Resident #1 was admitted to the hospital with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 1:33 P.M. on 01/23/19. CNA #1 said that she transferred Resident #1 quickly from the bed to the wheelchair by herself. CNA #1 said she did not review Resident #1's plan of care prior to providing care to Resident #1 and said she was not aware Resident #1 was a mechanical lift transfer with a two staff person assist. The Surveyor interviewed the Director of Nurses (DON) at 3:23 P.M. on 01/23/19. The DON said CNA #1 transferred Resident #1 by herself and said CNA #1 did not follow Resident #1's plan of care for a mechanical lift with a two staff person assist. In response to the incident, the Facility took the following action: A) A Facility wide audit was completed on 10/25/18 for transferring status of all Residents by the DON or Designee. All areas of concern and or non-compliance were corrected. B) A Fall audit for the past 30 days was completed on 10/22/18 for compliance with transfers and care plan interventions by the DON or Designee. C) Education was completed by 10/25/18 on following Resident's plan of care and Resident transfers with the Nursing Staff by the Facility Educator or Designee. D) Transfer Care Plans audits up to five Residents weekly for three weeks then monthly for two months will be done by the DON or Designee. E) Nursing staff will be audited randomly up to five staff members on knowledge of transfer status weekly for three weeks then monthly for two months by the DON or Designee F) The DON or Designee will report the audit results to the QAPI monthly. The Monthly Quality Assurance Performance Improvement (QAPI) was held on 11/30/18 and on 12/21/18 and the results of the audits were reported to the Committee.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Certified Nurse Aide (CNA) #1 followed Resident #1's plan of care requiring the use of a mechanical lift and two staff members for all transfers. CNA #1 manually transferred Resident #1 out of bed to his/her wheelchair, unassisted by another staff member, and without the use of the mechanical lift. Resident #1 immediately complained of pain after the transfer and was diagnosed with [REDACTED]. Findings include: The Safe Lifting and Movement of Residents Policy, dated 07/2017, indicated in order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. The Policy indicated manual lifting of residents shall be eliminated when feasible. The Policy indicated staff will document resident transferring and lift needs in the care plan. Resident #1 was admitted to the Facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. An At Risk for Falls Care Plan, initiated 08/21/14 and revised 04/20/18, indicated Resident #1 required a hoyer lift transfer with two staff persons. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 required total dependence of two staff persons for transfers. A Licensed Nursing Summary, dated 09/19/18, indicated Resident #1 was dependent/hoyer (mechanical lift) for transfers. The Facility Investigation, dated 10/22/18, indicated Resident #1 complained of pain and pointed to his/her right lateral thigh. The Investigation indicated Resident #1 was assessed by the Nurse, the Nurse Practitioner was notified, and an x-ray was ordered. The Investigation indicated CNA #1 transferred Resident #1 by herself from the bed to the wheelchair quickly and that after the transfer Resident #1 complained of right leg pain. The Investigation indicated Resident #1 sustained a right [MEDICAL CONDITION] and was transferred to the Hospital Emergency department for evaluation. A Nurse Progress Note, dated 10/22/18, indicated Resident #1 had a change of condition related to pain to his/her upper right lower extremity and that the pain had gotten worse. The Note indicated the Nurse Practitioner was notified and an x-ray was ordered. A Physician's Interim/Telephone Order for Resident #1, dated 10/22/18, indicated to obtain a stat (immediate) x-ray of the right hip. A Radiology Report, dated 10/22/18, indicated Resident #1 had an acute right [MEDICAL CONDITION]. A Physician's Interim/Telephone Order, dated 10/22/18, indicated to send Resident #1 to the Hospital Emergency Department for evaluation and treatment for [REDACTED]. A Nursing Home to Hospital Transfer Form, dated 10/22/18, indicated Resident #1 was being transferred to the Hospital Emergency Department for a [MEDICAL CONDITION]. A Hospital Discharge Summary, dated 10/25/18, indicated Resident #1 was admitted to the hospital with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 1:33 P.M. on 01/23/19. CNA #1 said that she transferred Resident #1 quickly from the bed to the wheelchair by herself. CNA #1 said she was not sure if Resident #1 bumped his/her leg during the transfer because the transfer happened so quickly. CNA #1 said that after the transfer Resident #1 complained of leg pain. CNA #1 said she did not review Resident #1's plan of care prior to providing care to Resident #1 and said she was not aware Resident #1 was a mechanical lift transfer with a two staff person assist. The Surveyor interviewed the Director of Nurses (DON) at 3:23 P.M. on 01/23/19. The DON said CNA #1 transferred Resident #1 by herself and that she did not follow Resident #1's plan of care for a mechanical lift with a two staff person assist. In response to the incident, the Facility took the following action: A) A Facility wide audit was completed on 10/25/18 for transferring status of all Residents by the DON or Designee. All areas of concern and or non-compliance were corrected. B) A Fall audit for the past 30 days was completed on 10/22/18 for compliance with transfers and care plan interventions by the DON or Designee. C) Education was completed by 10/25/18 on following Resident's plan of care and Resident transfers with the Nursing Staff by the Facility Educator or Designee. D) Transfer Care Plans audits up to five Residents weekly for three weeks then monthly for two months will be done by the DON or Designee. E) Nursing staff will be audited randomly up to five staff members on knowledge of transfer status weekly for three weeks then monthly for two months by the DON or Designee F) The DON or Designee will report the audit results to the QAPI monthly. The Monthly Quality Assurance Performance Improvement (QAPI) was held on 11/30/18 and on 12/21/18 and the results of the audits were reported to the Committee.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at high risk for choking, had a history of [REDACTED]. - When on [DATE], a hospitality cart with food items was left unattended and accessible to residents for approximately 10.5 hours on Resident #1's unit, Resident #1 took a donut from the cart, ate it unsupervised, and was found choking on it. -The [MEDICATION NAME] maneuver (a first aide procedure for dislodging an obstruction from the windpipe) was performed, he/she became unresponsive, and Cardiopulmonary Resuscitation (CPR - a medical technique for reviving someone whose heart and or lungs have stopped working) was performed, the Emergency Medical Service (EMS) personnel arrived and continued CPR and he/she was intubated. Resident #1 was transported to the Hospital. - On arrival to the Emergency Department, Resident #1 was in cardiopulmonary arrest (unexpected loss of heart function, breathing and consciousness), CPR was in progress, a large amount of donut remnants were suctioned from the endotracheal tube, [MEDICATION NAME] (a heart stimulating medication) was administered and a pulse was regained with a blood pressure of ,[DATE] (normal is ,[DATE]), intravenous [MEDICATION NAME] (a medication to increase the blood pressure) was then administered. - Resident #1 was admitted to the Intensive Care Unit and died approximately six days later from an [MEDICAL CONDITIONS] (lack of oxygen to the brain) secondary to a [MEDICAL CONDITION] and [MEDICAL CONDITION] (an unexpected loss of heart function, breathing and consciousness) caused by choking. Findings include: The Facility Policy titled, Comprehensive Person-Centered Care Plans, dated ,[DATE], indicated that the comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychological and functional needs would be developed and implemented for each resident. Resident #1 was admitted to the Facility in ,[DATE], [DIAGNOSES REDACTED]. The Care Plan dated ,[DATE], indicated Resident #1 would attempt to obtain food and drinks from other resident's trays, if they are left unattended. Interventions dated [DATE] and [DATE], included: - Resident #1 would eat meals in the Dining Room with supervision to ensure he/she does not take other residents food or that other residents do not give him/her food. - Redirect Resident #1 when he/she attempts to obtain food and drinks from other resident's trays. The Social Work Note, dated [DATE], indicated Resident #1 was oriented to person and place but not to time, level of cognition fluctuated, he/she was impulsive, but continued to be responsible for self. The Significant Change Minimum Data Set, dated dated [DATE], indicated Resident #1 had moderate cognitive impairment, required a one person physical assist with transfers and locomotion on the unit, supervision with eating and had a [DIAGNOSES REDACTED]. The MDS indicated he/she had a swallowing disorder resulting in coughing and choking during meals and when swallowing medications, and that Resident #1 required a mechanically altered diet (this is a change in texture of food or liquids). The physician's orders [REDACTED].#1 was treated with a mechanically altered diet NDD2 (National Dysphagia Diet level 2 - moist food that needs some chewing) with thin liquids. The Change in Condition Note, dated [DATE], and timed at 5:35 A.M., indicated Resident #1 was observed choking at 4:44 A.M., had an obstructed airway, abdominal thrusts (the [MEDICATION NAME] maneuver) were performed until Resident #1 went unresponsive and did not have a pulse, CPR was initiated and Automated External Defibrillator (a portable electronic device that automatically [DIAGNOSES REDACTED].#1 was transported to the Hospital. The Emergency Medicine Note, dated [DATE] and timed at 5:54 A.M. indicated on arrival to the Emergency Department, Resident #1 was in cardiopulmonary arrest (an unexpected loss of heart function, breathing and consciousness), CPR was in progress, a large amount of donut remnants were suctioned from the endotracheal tube, [MEDICATION NAME] (a medication to stimulate the heart) was administered and his/her pulse was regained with a blood pressure of ,[DATE] (normal is ,[DATE]), intravenous [MEDICATION NAME] (a medication to increase the blood pressure) was administered and Resident #1 was admitted to the Intensive Care Unit. Resident #1 died six days later from an [MEDICAL CONDITIONS] (lack of oxygen to the brain) secondary to a [MEDICAL CONDITION] and [MEDICAL CONDITION] (an unexpected loss of heart function, breathing and consciousness) caused by choking. The Facility's Internal Investigation, dated [DATE], indicated on [DATE] at 4:44 A.M., Resident #1 was observed by a Certified Nurse Aide (CNA) with food in his/her mouth, was choking and communicated this by demonstrating the universal choking sign (hands clutched to the throat, which a person choking usually does). Abdominal thrusts were done unsuccessfully, Resident #1 then became unresponsive with no pulse, and CPR was initiated. The Surveyor interviewed Nurse #1 at 5:50 P.M. on [DATE]. Nurse #1 said that she saw the Hospitality cart unsupervised on [DATE] after 12 midnight in the Dining Room, and said this cart would normally have been removed from Resident common areas. The Surveyor interviewed CNA #2 at 3:30 A.M. on [DATE]. CNA #2 said that on [DATE], sometime after 3:00 A.M., Resident #1 was in the hallway wheeling him/herself around and sat in the hallway by the Nurses station near the Dining Room. The Surveyor interviewed CNA #1 at 2:30 P.M. on [DATE]. CNA #1 said that on [DATE] at approximately 4:44 A.M., Resident #1 was unsupervised at the entrance of the Dining Room, with food crumbs on the front of him/herself from a donut he/she had just eaten from the Hospitality cart. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on [DATE]. The DON said the findings from the investigation indicated that a Hospitality cart was left unsupervised with food pastries, and said the cart remained on Resident #1's Nursing Unit for approximately 10.5 hours. The DON said Resident #1's care plan was not followed when he/she was unsupervised, choked on a donut obtained from the Hospitality cart, when the cart was not removed from the Nursing Unit The DON said a donut was not part of Resident #1's mechanically altered diet and would pose a safety/choking risk for him/her. At the time of the Survey, on [DATE], the Facility provided the Surveyor with documentation to support that the deficient practices identified during this survey were corrected. The Facility took the following corrective actions: A) Identified all the residents on mechanically altered diets, residents at risk of choking and residents who required supervision at all times with eating. B) Completed audits of each resident, to assess physician diet orders, adaptive equipment, care plans, medication administrative records and any discrepancies were addressed and corrected. C) Monitoring and supervision of meals by the Unit Managers was implemented. D) Nursing and Dietary Staff were in-serviced on [DATE] regarding not leaving food items unattended on the units. E) Procedures were updated to include: meal trays to be picked up and placed in the food carts after meals; meal trays left over after the food carts have left are brought to the Kitchen; no meal trays were to be left in the kitchenettes or resident dining rooms. F) Hospitality carts for families replenished by Kitchen Staff are removed by the Kitchen Staff at the end of the day. G) All staff were educated and are required that any leftover trays or the hospitality cart that has not been picked up, they are to bring it down to the Kitchen as soon as it is discovered. H) Staff are not allowed to have food or drinks at the Nurse's Station or near the medication carts. I) The Facility conducted mock Code Blue Codes, for cardio-pulmonary arrests and choking. J) The Facility will continue to review the changes for effectiveness at QAPI, and the Director of Nurses is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), with a history of wandering, taking food items that did not belong to him/her, and who also had a history of [REDACTED].#1 from choking incident, that resulted in his/her death 6 days later. -When on [DATE] a cart with food items (Hospitality cart) was left unattended on Resident #1's unit, accessible to all residents including Resident #1, for approximately 10.5 hours, and Resident #1 was found by staff at approximately 4:44 A.M., choking on a donut he/she had taken from the food cart. - The [MEDICATION NAME] maneuver (a first aide procedure for dislodging an obstruction from the windpipe) was performed, he/she became unresponsive, and Cardiopulmonary Resuscitation (CPR - a medical technique for reviving someone whose heart and or lungs have stopped working) was performed, the Emergency Medical Service (EMS) personnel arrived and continued CPR and he/she was intubated. Resident #1 was transported to the Hospital. - On arrival to the Emergency Department, Resident #1 was in cardiopulmonary arrest (an unexpected loss of heart function, breathing and consciousness), CPR was in progress, a large amount of donut remnants were suctioned from the endotracheal tube, [MEDICATION NAME] (a heart stimulating medication) was administered and his/her pulse was regained with a blood pressure of ,[DATE] (normal is ,[DATE]), intravenous [MEDICATION NAME] (a medication to increase the blood pressure) was administered. - Resident #1 was admitted to the Intensive Care Unit and died approximately 6 days later from an [MEDICAL CONDITIONS] (lack of oxygen to the brain) secondary to a [MEDICAL CONDITION] and [MEDICAL CONDITION] (an unexpected loss of heart function, breathing and consciousness). Findings include: The Facility Policy titled, Assistance with Meals, dated ,[DATE], indicated Nursing Service and/or Feeding Assistants will pick up resident's food trays after each meal and will notify the Food Services staff to pick up food carts. Resident #1 was admitted to the Facility in ,[DATE], [DIAGNOSES REDACTED]. The Nutritional Care Plan dated ,[DATE], indicated Resident #1 would attempt to obtain food and drinks from other Resident's trays, if they are left unattended. The Change in Condition Note, dated [DATE], indicated that Resident #1 had choked on a sandwich, was slumped over in a wheelchair and required the [MEDICATION NAME] maneuver to dislodge the sandwich. The Nutritional Care Plan, updated [DATE] and [DATE], indicated additional interventions included: - Resident #1 would eat meals in the Dining Room with supervision to ensure he/she does not take other residents food or other residents do not give him/her food. - Redirect Resident #1 when he/she attempts to obtain food and drinks from other resident's trays. The Speech Therapy Note, dated [DATE], indicated Resident #1's current diet texture (mechanically altered diet) does not allow for sandwiches and he/she was on the most appropriate diet texture. Resident #1 had mild to moderate oropharyngeal dysphagia (difficulty swallowing and ate at a fast pace, which negatively impacted his/her safety. Resident #1 was only minimally responsive to verbal cues for safe swallowing strategies and a NDD2 (National Dysphagia Diet level 2), moist food that needs some chewing, was recommended by the Speech Therapist. Social Work Note, dated [DATE], indicated Resident #1 was oriented to person and place but not to time, cognition fluctuated, and he/she was impulsive. The Significant Change Minimum Data Set, dated dated [DATE], indicated Resident #1 had moderate cognitive impairment, required a one person physical assist with transfers and locomotion on the unit, supervision with eating and had a [DIAGNOSES REDACTED]. The MDS indicated he/she had a swallowing disorder resulting in coughing and choking during meals and when swallowing medications and he/she required a mechanical altered diet (this is a change in texture of food or liquids). The Physician's Note, dated [DATE], indicated that Resident #1 had dysphagia (difficulty swallowing) was to continue to eat orally (not a feeding tube) despite signs of aspiration on thin and thickened liquids and the family had accepted this risk of aspiration given his/her enjoyment of eating, but if Resident #1 runs into difficulty will need to reassess. The physician's orders [REDACTED].#1 was treated with a mechanically altered diet, NDD2 (National Dysphagia Diet level 2 - moist food that need some chewing with) thin liquids. The Change in Condition Note, dated [DATE], and timed at 5:35 A.M., indicated Resident #1 was observed choking at 4:44 A.M., had an obstructed airway, abdominal thrusts (the [MEDICATION NAME] maneuver) were performed until Resident #1 became unresponsive and did not have a pulse, CPR was initiated and Automated External Defibrillator (a portable electronic device that automatically [DIAGNOSES REDACTED].#1 was transported to the Hospital. The Ambulance Run sheet, dated [DATE] and timed at 5:00 A.M., indicated Resident #1 was unresponsive, pulseless and apneic (without respirations - not breathing). A laryngosopic (use of a device to visualize the airway) exam indicated copious (large) amounts of masticated (chewed) donut in Resident #1's airway, which was scooped out and suctioned to remove the donut. This was a [MEDICAL CONDITION] (an unexpected loss of heart function, breathing and consciousness) caused by choking. The Emergency Medicine Note, dated [DATE] and timed at 5:54 A.M. indicated on arrival to the Emergency Department, Resident #1 was in cardiopulmonary arrest (an unexpected loss of heart function, breathing and consciousness), CPR was in progress, a large amount of donut remnants were suctioned from the endotracheal tube, [MEDICATION NAME] (a heart stimulating medication) was administered, his/her pulse was regained with a blood pressure of ,[DATE] (normal is ,[DATE]), intravenous [MEDICATION NAME] (a medication to increase the blood pressure) was administered and Resident #1 was admitted to the Intensive Care Unit. Resident #1 died six days later from an [MEDICAL CONDITIONS] (lack of oxygen to the brain) secondary to a [MEDICAL CONDITION] and [MEDICAL CONDITION] (an unexpected loss of heart function, breathing and consciousness) caused by choking. The Facility's Internal Investigation, dated [DATE], indicated on [DATE] at 4:44 A.M., Resident #1 was observed by a Certified Nurse Aide (CNA) with food in his/her mouth, was choking and communicated this by demonstrating the universal choking sign (hands clutched to the throat, which a person choking usually does). Abdominal thrusts were done unsuccessfully, Resident #1 then became unresponsive with no pulse, and CPR was initiated. The Witness statement from CNA #3, dated [DATE], indicated during the 3:00 P.M. to 11:00 P.M. shift on [DATE] at supper time (approximately 6:00 P.M.), she saw donuts on the Hospitality cart next to the two resident food carts. The Witness statement from CNA #4, dated [DATE], indicated during the 3:00 P.M. to 11:00 P.M. shift on [DATE], the Hospitality cart was by the resident food carts, and she later saw this cart was near the elevator (not taken off the Nursing Unit). The statement indicated CNA #4 thought she would take the cart down to the Kitchen when she left the Unit at 11:00 P.M. but was in a hurry and left the cart on the unit. The Witness statement from CNA #1, dated [DATE], indicated at approximately 4:44 A.M., she came out of another Resident's room and noticed Resident #1 sitting at the entrance of the Dining Room, that Resident #1 was not responding to her questions, and then she noticed that Resident #1 had food in his/her mouth and crumbs on his/her lap. The statement indicated CNA #1 yelled for the Nurse, the Nurse started the [MEDICATION NAME] maneuver (a first aide procedure for dislodging an obstruction from the windpipe), nothing came out. Resident #1 was lowered to the floor, and CNA #1 went to get help. The Witness statement from Nurse #1, undated and un-timed, indicated at approximately 4:45 A.M., she was signaled by CNA #1 that a Resident was choking. Nurse #1 observed that food was lodged in the back of Resident #1's throat, so she attempted to suction the airway. The food was too big to remove, so she attempted to scoop the food out with the suction catheter. The Surveyor interviewed Nurse #1 at 5:50 P.M. on [DATE]. Nurse #1 said that she saw the Hospitality cart unsupervised on [DATE] after 12 midnight in the Dining Room, and said this cart would normally have been removed from Resident common areas. The Surveyor interviewed CNA #2 at 3:30 A.M. on [DATE]. CNA #2 said that on [DATE] after 3:00 A.M., Resident #1 was in the hallway wheeling him/herself around and sat in the hallway by the Nurses station near the Dining Room. The Surveyor interviewed CNA #1 at 2:30 P.M. on [DATE]. CNA #1 said that on [DATE] at approximately 4:44 A.M., Resident #1 was sitting, unsupervised at the entrance of the Dining Room, with food crumbs on the front of him/herself from a donut he/she had just eaten from the Hospitality cart. The Surveyor interviewed the Director of Nurses (DON) at 7:30 A.M. on [DATE]. The DON said the findings from the investigation indicated that a Hospitality cart with pastry items on it, remained Resident #1's Nursing Unit for approximately 10.5 hours. The DON said the hospitality cart was on Resident #1's unit from [DATE] at approximately 6:00 P.M. through [DATE] at 4:44 A.M. The DON said Resident #1 choked on a donut from the Hospitality cart. The DON said the donut was not part of Resident #1's mechanically altered diet and said Resident #1 was unsupervised while eating. At the time of the Survey, on [DATE], the Facility provided the Surveyor with documentation to support that the deficient practices identified during this survey where corrected. The Facility took the following corrective actions: A) Identified all the residents on mechanically altered diets, residents at risk of choking and residents who required supervision at all times with eating. B) Completed audits of each resident, to assess physician diet orders, adaptive equipment, care plans, medication administrative records and any discrepancies were addressed and corrected. C) Monitoring and supervision of meals by the Unit Managers was implemented. D) Nursing and Dietary Staff were in-serviced on [DATE] regarding not leaving food items unattended on the units. E) Procedures were updated to include: meal trays to be picked up and placed in the food carts after meals; meal trays left over after the food carts have left are brought to the Kitchen; no meal trays were to be left in the kitchenettes or resident dining rooms. F) Hospitality carts for families replenished by Kitchen Staff are removed by the Kitchen Staff at the end of the day. G) All staff were educated and are required that any leftover trays or the hospitality cart that has not been picked up, they are to bring it down to the Kitchen as soon as it is discovered. H) Staff are not allowed to have food or drinks at the Nurse's Station or near the medication carts. I) The Facility conducted mock Code Blue Codes, for cardio-pulmonary arrests and choking. J) The Facility will continue to review the changes for effectiveness at QAPI, and the Director of Nurses is responsible for overall compliance.

Based on interviews and record review for one of seven residents (Resident #1), the Facility failed to ensure Resident #1 received only those medications ordered. On 9/23/14, Nurse #5 administered [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (narcotic [MEDICATION NAME]) to Resident #1 in error. Resident #1 subsequently developed respiratory depression, received intranasal [MEDICATION NAME] (an antagonist that reverses the effect of narcotics), and was transferred emergently the hospital where Resident #1 received intravenous [MEDICATION NAME]. Findings include: The Facility's Policy/Procedure titled Administering Medications, revised December 2012, indicated the nurse administering the medication(s) must verify the right resident, right medication, right dosage, right time, and right method before administering medication using the resident's identification band, the photograph, or verifying resident identification with another staff member. Nurse #5's Medication Pass Audit, dated 10/18/13, Nurse #5 properly performed the five rights of medication administration; right resident, medication, dose, time, and method. The Physician Orders, dated 9/12/14, indicated Resident #2 was prescribed [MEDICATION NAME] 200 milligrams (mg) three times daily, to be administered at 9:00 A.M., 2:00 P.M., and 9:00 P.M. and [MEDICATION NAME] 40 mg twice daily, to be administered at 9:00 A.M. and 9:00 P.M. for chronic back pain. The Admission History and Physical, dated 9/17/14, indicated Resident #1's [DIAGNOSES REDACTED]. The Surveyor toured the Subacute/Rehabilitation Unit at 8:30 A.M. on 10/24/14. The Surveyor observed the rooms Resident #1 and Resident #2 resided in were located next to each other. The Staffing Schedule, dated 9/23/14, indicated during the 3:00 P.M. to 11:00 P.M. shift Nurse #5 was scheduled along with another nurse from 3:00 P.M. until 8:00 P.M. The Staffing Schedule indicated there was a free floating Evening Supervisor (Nursing Supervisor #1) scheduled to the Unit from 8:00 P.M. until 11:00 P.M. Nurse #5 did not respond to the Surveyor's requests for an interview. The Surveyor interviewed Nursing Supervisor #1 at 8:00 A.M. on 10/24/14. Nursing Supervisor #1 said after the nurse left at 8:00 P.M., he remained on the the unit as much as possible and offered to assist Nurse #5 who told him she was frustrated. Nursing Supervisor #1 said Nurse #5 declined assistance. The Surveyor interviewed the Director of Nurses (DON) at 8:15 A.M. on 10/24/14. The DON said she usually scheduled 2 nurses on the Subacute Unit during the evening shift, however, there was a vacancy and the second nurse could only work until 8:00 P.M. The Narcotic Drug Control Log/Book, pages 161 and 164 and dated 9/23/14, indicated at 9:00 P.M., a nurse removed one [MEDICATION NAME] 200 mg capsule and one [MEDICATION NAME] 40 mg tablet for Resident #2. The Narcotic Book indicated at 9:00 P.M. the nurse documented she "popped" in error and removed a second [MEDICATION NAME] for Resident #2 and at 10:00 P.M.; the nurse documented "popped in error" and removed a second [MEDICATION NAME] for Resident #2. The DON identified the initials as those belonging to Nurse #5. The Surveyor interviewed Unit Manager #1 at 11:50 P.M. on 10/24/14. Unit Manager #1 said on 9/23/14, she acted as the Nursing Supervisor for the night shift. Unit Manager #1 said Nurse #5 told her there might be a problem because Nurse #5 erroneously administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #1. Unit Manager #1 said she asked Nurse #5 if she had notified the physician to which Nurse #5 responded no. Unit Manager #1 said she assessed Resident #1 who was alert. Unit Manager #1 said she stayed with Resident #1 and sent Nurse #5 to call the physician. Unit Manager #1 said Resident #1 developed an itchy rash. Unit Manager #1 said Nurse #5 spoke with the physician then Unit Manager #1 reported Resident #1's rash, current status, and vital signs to the physician. Unit Manager #1 said the physician issued orders to treat the rash, to monitor vital signs, and to call if any changes. The Interim Physician order [REDACTED]. Unit Manager #1 said she sat with Resident #1 to closely monitor his/her mental status and take Resident #1's vital signs every 15 minutes as ordered. The Doctor's Progress Notes indicated Unit Manager #1 monitored Resident #1's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation levels) from 12:25 A.M. to 6:30 A.M. and monitored Resident #1's mental status until 6:30 A.M. Unit Manager #1 said she handed off care of Resident #1 to the Assistant Director of Nurses (ADON). The Surveyor interviewed the ADON at 9:00 A.M. on 10/24/14. The ADON said she continued to monitor Resident #1's vital every 15 minutes, which were stable, until 7:45 A.M. and during that time, Resident #1 was responsive and arousable. The Surveyor interviewed Nurse #3 at 9:55 A.M. on 10/24/14. Nurse #3 said she went in to take Resident #1's vital signs and found Resident #1 unresponsive. The Progress Note, dated 9/24/14, indicated that at 8:05 A.M., Resident #1 became unresponsive with very slow respirations of 8 and a critically low oxygen saturation level of 49% (normal was 90%). The Progress Note indicated a Physician Assistant present in the Facility went to assess Resident #1; the staff provided supplemental oxygen and ventilated with an Ambu bag. The note indicated emergency medical response system was activated and the Emergency Medical Technicians who responded, administered [MEDICATION NAME] (antagonist to opioids) and transported Resident #1 to the hospital. The Hospital Emergency Medicine Note, dated 9/24/14, indicated Resident #1 initially improved with oxygen therapy and intranasal [MEDICATION NAME] however, Resident #1 remained sleepy at the Emergency Department and was started on a [MEDICATION NAME] intravenously. The Emergency Medicine Note indicated the Physician admitted Resident #1 to the Hospital for a critically elevated potassium level. The DON said she interviewed Nurse #5 and Nurse #5 told her that when she prepared the medications for administration, she took the medications to Resident #1 instead of Resident #2 in error. The DON said Nurse #5 told her that when administering the medications, she did not take the Medication Administration Record [REDACTED]#1. The DON said Nurse #5 told her she did not know of the medication error until 11:00 P.M., when Resident #2 requested his/her medications.

Based on record review, observation and interview, the facility failed to ensure that 1 resident (#14) from a total sample of 30, received necessary care and services to promote wound healing, and prevent new wounds from developing, in order to attain or maintain the highest practicable physical well-being. Findings included: For Resident #14, the facility failed to ensure appropriate care and services were provided to prevent the development of open areas on the resident's thighs, one on the left posterior thigh, and three on the right posterior thigh. Resident #14 was admitted to the facility in 4/11. The resident's pertinent [DIAGNOSES REDACTED]. The 4/26/11 Initial/Admission MDS (Minimum Data Set) assessment revealed that the resident had no memory problem; scored a 15 on the BIMs (Brief Interview for Mental Status) indicating the resident has no cognitive problems; requires extensive assist for bed mobility, dressing, toilet use, hygiene and bathing; did not ambulate; has functional limitation in range of motion with impairment to both lower extremities; utilizes a w/c (wheelchair); utilizes an indwelling catheter; weight is 407 pounds; has four Stage II pressure ulcers (one ulcer was present on admission); has one open lesion (other than ulcers, rashes cuts); non-surgical dressings and ointments were applied other than to the resident's feet. The CAA (Care Area Assessment) summary, completed 5/2/11, revealed that this resident triggered for pressure ulcers due to a Shearing/Stage II pressure area (shearing is produced when adjacent surfaces slide across one another) on the abdominal fold. Additional "Shearing" areas have resolved. Also, the resident has an area on the right posterior thigh. The CAA revealed that the resident is at risk for further breakdown. The MD and wound nurse are to follow, as needed, and a decision was made to care plan. The 5/2/11 skin integrity care plans included the following interventions: - Mattress and chair pad. - Treatment as ordered. - Barrier cream to scrotum and buttocks. The 7/18/11 Quarterly MDS Assessment revealed that the resident's memory, cognitive status, bed mobility and ambulation status remained unchanged; required extensive assist with transfers; was now dependent for dressing; continues to require extensive assist for hygiene, bathing and toilet use; continues to have functional limitation in range of motion with impairment to both lower extremities; utilizes a w/c (wheelchair); has an indwelling catheter, is at risk for pressure ulcers, with no current pressure ulcers, and has no open [MEDICAL CONDITION]. According to the clinical record, Resident #14 underwent a "radical excision" 45 cm (centimeter) x 30 cm dermal flap closure called a "Charles Procedure (aggressive operation for severe [MEDICAL CONDITION])" of the right inner thigh, related to [DIAGNOSES REDACTED] on 7/25/11. The surveyor reviewed (on 9/28/11 at 8:00 A.M.) a Surgeon's Consultation report of 8/31/11, which revealed that the resident has a less than 1 cm open area on the posterior right thigh, and instructed that the facility apply [MEDICATION NAME] powder with EPC (Extra Protective Cream) as needed (EPC is a barrier cream which contains 30 % Zinc Oxide, as well as Vitamin E). "No Substitute." The 9/2/11 physician's orders [REDACTED]. This order did not identify that there was to be no substitute for the EPC cream, as the surgeon instructed in the 8/31/11 consult note. The 9/11 TAR (Treatment Administration Record) indicated that the aforementioned treatment would be completed daily on the 3:00 P.M. to 11:00 P.M. shift. The reverse side of the TAR revealed that on 9/4/11, the resident now has an open area on the posterior left thigh. During an interview with Resident #14 on 9/28/11 from 8:14 A.M. to 8:30 A.M., Resident #14 rested on an extra large/wide Pressure Guard Bariatric specialty mattress. There was a urinal on the resident's raised siderail. Resident #14 told the surveyor that the Foley Catheter (F/C) had been removed just yesterday. Resident #14 stated that he/she had a surgical procedure to the inside right thigh due to a [DIAGNOSES REDACTED], and was going to see the surgeon later today. Resident #14 said that he/she was "upset" because the facility had "not been applying the correct treatment" to the "areas" on the back of the right and left legs, as the surgeon requested. Resident #14 said that the facility "insisted" that the "DermaSeptin (protective barrier cream contains primarily Zinc Oxide, also has [MEDICATION NAME] to absorb moisture)" is the same as EPC (EPC cream does not contain the same ingredients as the DermaSeptin), and the facility insisted that it was appropriate to use, despite what the surgeon ordered EPC with no substitute for the open area on the back of his/her leg. Resident #14 identified a tube of the DermaSeptin barrier cream in the top drawer of the nightstand. Resident #14 said that the inner thigh area was draining a lot, but was steadily improving. Resident #14 indicated that he/she can "feel" the areas on the back of the legs are "not getting better." Resident #14 indicated that the areas on the posterior right and left thighs were from shifting weight, and constant sliding back and forth across the mattress (shearing) to the side of the bed. This resident was agreeable for the surveyor to observe the treatment to all areas on 9/29/11. The surveyor observed a treatment to the resident's right inner thigh surgical wound with Nurse #3 on 9/29/11 at 10:28 A.M.. CNA #2 indicated that A.M. care had just been completed and stood by while Nurse #3 prepared the dressing supplies. Nurse #3 removed the old dressing from the resident's inner right thigh, cleansed the area and applied the prescribed treatment. Nurse #3 indicated to Resident #14 that he/she was done. The surveyor questioned Nurse #3 with regards to the treatment to the resident's right posterior thigh. Nurse #3 indicated that this treatment is completed by the 3:00 P.M. to 11:00 P.M. shift and that the prescribed treatment was for a "crusting" technique to the "buttock area." The surveyor requested to look at the "area" in question. CNA #2 assisted with positioning Resident #14 onto the right side. The surveyor observed a horizontal, raw, moist, shallow cratered wound on the posterior upper left thigh (approximately 1.3 cm x 0.5 cm), and 3 horizontal open, shallow, raw cratered wounds on the right posterior thigh (approximately 1 cm long x 0.2 cm wide). There was a white cream surrounding the open raw areas on the resident's posterior thighs (also lower buttocks and scrotal area). The surveyor inquired if Nurse #3 applied this cream. Nurse #3 replied "No." CNA #2 stated "I put it on," then indicated a tube of protective barrier cream inside the resident's nightstand, along side a tube of the "DermaSeptin." Nurse #3 confirmed that the open areas were new, raw, and did not have a treatment provided. Review of the Surgeon Consult visit reports (9/7, 9/14 and 9/28/11) revealed that the areas on the back of the resident's left and right thighs were not addressed or identified by the surgeon for any of these visits. During an interview with UM (Unit Manager) #1 on 9/29/11 at 11:10 A.M., following what was observed with Nurse #3, UM #1 stated that he/she was not aware the resident had open areas on the posterior thighs, and that this was "news" to him/her. UM #1 said that the resident was "just seen by the surgeon yesterday," and that "any and all areas are managed by this surgeon." UM #1 stated that the "Wound Doctor" who visits the facility every "Tuesday" has not seen, or been consulted to see Resident #14, because Resident #14 is a "surgical patient." UM #1 stated that the facility's "Wound Nurse" is currently on vacation, and has not been following Resident #14. UM #1 indicated that each Unit Manager is covering their respective units in the Wound Nurse's absence. According to UM #1, the "Wound Doctor" was consulted briefly, "a week or so ago" regarding substituting the EPC for the DermaSeptin cream (despite the resident's surgeon indicated no substitute), and that the "Wound Doctor" said the DermaSeptin was the same as the EPC, and it was okay to use." The surveyor inquired to UM #1 what the facility has done to ensure appropriate care and services were provided, when the new open area was identified at the surgeon's visit on 8/31/11, and for the prevention and development of new areas on the resident's legs. UM #1 indicated that there was nothing in the clinical record to indicate that the right posterior thigh had been evaluated by the facility to ensure that appropriate treatments were ordered and rendered accordingly. UM #1 identified that he/she would complete an "incident report," measure all the areas and contact the physician for a prescribed treatment. UM #1 acknowledged that the facility failed to ensure appropriate care and services were provided in order to attain or maintain the highest practicable physical well-being, for Resident #14, relative to new open areas identified during a treatment observation on 9/29/11 at 10:28 A.M.. The surveyor was provided with a copy of the Surgeon's "office visit" reports (of 8/31, 9/7, and 9/14/11), by UM #1 on 9/29/11 at 12:30 P.M.. None of these reports identified any areas to the posterior right or left thighs (despite the Surgeon's consult report of 8/31/11 which indicated there was less than a 1 cm area on the resident's posterior right thigh, and prescribed a treatment). During interview with the DON (Director of Nursing) on 9/29/11 at 3:40 P.M., the DON acknowledged that he/she was not aware that Resident #14 had new open areas, and would ask that the "Wound Doctor" come in to see Resident #14 regularly to ensure that proper care and treatment was provided.

Based on record review and staff interview, the facility failed to ensure that 1 sampled resident (#1), in a sample of 1, had services provided which met professional standards of quality regarding [MEDICAL CONDITION] care. Findings included: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, Section 23R through 23BB, individuals are given the designation of Respiratory Therapist which includes the responsibility to provide respiratory care. Pursuant to the Code of Massachusetts Regulation (CMR) 261 Rules and Regulations 2.02 defines Respiratory Care. The regulation stipulates that the Respiratory Therapist utilizes the application of scientific principles for the identification, prevention, remediation, research and rehabilitation of acute or chronic cardiopulmonary dysfunction thereby producing optimum health and function. The regulations also stipulate that Respiratory Care is provided under the direction of a licensed physician. (Please refer to the Respiratory Services Policies and Procedures Manual referred to as the facility's Standards of Practice for Respiratory Services by the Director of Nurses). For Resident #1, the facility failed to ensure the Respiratory Therapist (RT) was qualified to perform respiratory procedures according to the facility's Standards of Practice. Resident #1 was admitted to the facility in 3/10. [DIAGNOSES REDACTED]. Review of the Respiratory Services Policies and Procedures for [MEDICAL CONDITION] Care indicated [MEDICAL CONDITION] kit contained pipe cleaners to be used to clean the inside of the inner cannula following removal from the resident's [MEDICAL CONDITION] and soaking it in hydrogen peroxide. Review of the clinical record indicated that on 9/11/10, at approximately 11:30 A.M., the RT was [MEDICAL CONDITION] on the resident. While cleaning the outer cannula of [MEDICAL CONDITION] a folded pipe cleaner, the pipe cleaner slipped into the resident's trach. Surveyor reviewed the RT's verbal statement on 9/21/2010 at 8:45 A.M. (transcribed by the Director of [MEDICAL CONDITION] Rehabilitation on 9/13/2010). This statement was also signed and witnessed by the Director of Nurses as well as the Assistant Director Nurses. The RT's statement indicated that while using a folded pipe cleaner to clean the inside of the outer cannula, the pipe cleaner slid into the resident'[MEDICAL CONDITION]. The statement also indicated that the RT "tried to take corrective action which was wrong and possibly could have been life threatening." According to the documentation, the RT then removed the entire [MEDICAL CONDITION] from the resident's trachea exposing the stoma (The facility's Standards of Practice pg. 86 regarding [MEDICAL CONDITION] Change states that, "If the [MEDICAL CONDITION] is being changed by a respiratory therapist the Physician's order must specify 'by RT.' The licensed caregiver will also have documented competency [MEDICAL CONDITION] and tracheal suctioning prior to attempting this procedure.") Interview with the Director of Nurses, on 9/21/10 at 2:15 P.M., acknowledged there was no Physician's order for the RT to remove or change the resident's [MEDICAL CONDITION]. During interview, the RT verbalized to the Director of [MEDICAL CONDITION] Rehab, that she attempted to remove the pipe cleaner through the stoma with tweezers. At this point, the resident started bleeding and was being suctioned for frank blood by the RT. When the pipe cleaner could not be retrieved with the tweezers, the RT reinserted [MEDICAL CONDITION] back into the trachea. Review of the RT's statement further indicated that while waiting for the EMTs (Emergency Medical Technicians) to arrive, the RT again removed [MEDICAL CONDITION] in an attempt to retrieve the pipe cleaner one last time without success. The RT then ventilated the resident with an Ambu-Bag (a medical device used to provide assisted ventilation to people who are either not breathing or are having trouble breathing). According to the Director of Respiratory Rehab, this was an unnecessary procedure because the resident's breathing and oxygenation levels were stable, and this action would only have pushed the object deeper into the resident's lungs. The Hospital's Discharge Summary of 9/13/10 revealed that an x-ray conducted on 9/11/10 confirmed the pipe brush was lodged in the resident's right main bronchus (part of the lung). Interview on 9/21/10 at 9:30 A.M., with the Director of Respiratory Rehab and the Director of Nurses, confirmed that the RT did not perform [MEDICAL CONDITION] care within Standards of Practice, and that the resident should have immediately been sent to the emergency room when the pipe cleaner had been inhaled by the resident. Please refer to F328.

Based on record review and staff interview, the facility failed to ensure that 1 sampled resident (#1), in a sample of 1 received the necessary care and services to attain the highest level of functioning and well-being possible regarding [MEDICAL CONDITION] care. Findings included: For Resident #1, the facility failed to ensure that the Respiratory Therapist (Accused): - Was competent as evidenced by Competency Evaluations in the facility's Standards of Practice manual; - Was registered or Certified by the National Board for Respiratory Care as required upon hire; - Was certified in Cardio [MEDICAL CONDITION] Resuscitation as required upon hire; - Could demonstrate the ability to function in a trauma and/or stressful environment; - Could perform all modes of therapy treatments as ordered by physicians according to departmental policies and procedures; - Could administer therapy as ordered according to departmental policies and procedures. Resident #1 was admitted to the facility in ,[DATE]. [DIAGNOSES REDACTED]. The plan of care addressing the resident's [MEDICAL CONDITION] (trach) was developed on [DATE]. Interventions included: - Respiratory Therapy evaluation and respiratory therapy; - Assess oxygen saturation as ordered and as needed; - Assess respiratory status as ordered and as needed; - Oxygen as ordered. physician's orders [REDACTED]. - [MEDICAL CONDITION] care every shift and as needed; - Suction as needed - Oxygen saturations every shift; - Oxygen at 3 liters with 28% humidification continuously via [MEDICAL CONDITION]; - Resident may use [MEDICATION NAME] (hand held suction tube) suction independently in room, - Head of bed up ,[DATE] degrees. The Initial MDS (Minimum Data Set) assessment dated [DATE] indicated the resident: had no memory deficits, and was able to make decisions independently; required extensive assistance from staff for bed mobility and toilet use; required total assistance from staff for transfers, dressing, eating, personal hygiene, and bathing; did not ambulate; received ostomy care, oxygen therapy, suctioning, and [MEDICAL CONDITION] care, and had received skilled respiratory care during the assessment reference period. Review of the Respiratory Services Policies and Procedures for [MEDICAL CONDITION] Care indicated that [MEDICAL CONDITION] kit contained pipe cleaners to be used to clean the inside of the inner cannula after removal from the resident's [MEDICAL CONDITION] and soaking it in hydrogen peroxide. A nurse's note of [DATE] indicated that during suctioning [MEDICAL CONDITION] conducted by a licensed Respiratory Therapist (RT), at approximately 11:30 A.M., Nurse #4, was alerted by the RT "to an emergent situation" in the resident's room. The note indicated that when this nurse entered the resident's room, the RT told the nurse that the resident had inhaled a pipe cleaner through [MEDICAL CONDITION], and that attempts to suction the object out were unsuccessful. The Physician was notified by Nurse #1 and 911 was called. Surveyor reviewed the RT's statement which was written by the Director of [MEDICAL CONDITION] Rehabilitation on [DATE] and also signed and witnessed by the Director of Nurses and the Assistant Director Nurses. The RT's statement indicated that while using a folded pipe cleaner to clean the inside of the outer cannula, the pipe cleaner slid into the resident'[MEDICAL CONDITION]. The statement went on to say that the RT "tried to take corrective action which was wrong and possibly could have been life threatening." The RT then removed the entire [MEDICAL CONDITION] from the resident's trachea exposing the stoma, and attempted to remove the pipe cleaner through the stoma with tweezers. At this point, the resident was being suctioned for frank blood. When the pipe cleaner could not be retrieved with the tweezers, the RT reinserted [MEDICAL CONDITION] into the trachea. Review of the statement further indicated that while waiting for the EMTs (Emergency Medical Technicians) to arrive, the RT attempted to ventilate the resident with an Ambu-Bag (a medical device used to provide assisted ventilation to people who are either not breathing or are having trouble breathing). Review of the written statement from the Director of Respiratory Rehabilitation (on [DATE] at 8:50 A.M.) indicated that during the incident, the resident was breathing spontaneously and oxygenation levels were safe, so that the use of the Ambu-Bag was unnecessary, and, "this could only of pushed the object again deeper into the pt's (patient's) lungs. Review of Witness #4's (Licensed Nurse) written statement dated [DATE], and interview on [DATE] at 1:35 P.M. indicated that upon entering the resident's room on [DATE], the resident's suction tubing was full of bright red blood. Nurse #4 also indicated that the RT suctioned the resident multiple times without success of retrieving the pipe cleaner. This nurse stated that at some point the RT removed [MEDICAL CONDITION] which this nurse did not observe. The RT continued suctioning the resident multiple times in hopes of retrieving the object. The RT suctioned a large amount of bright red blood. Nurse #4 indicated that Nurse #1 and Nurse #3 then came into the resident's room. Review of Witness #1's (Licensed Nurse) written statement dated [DATE], and interview on [DATE] at approximately 1:15 P.M. indicated, that upon entering the resident's room on [DATE] this nurse observed that the resident's suction catheter was "full of bright red blood...." Since the RT and Nurse #4 were in the room, this nurse left the room to prepare the necessary paperwork for the transfer to the hospital. Review of Witness #3's (Licensed Nurse) written statement dated [DATE], and interview on [DATE] at approximately 12:00 P.M. indicated that upon entering the resident's room on [DATE] at about 11:30 A.M., this nurse observed that the resident'[MEDICAL CONDITION] had been removed from the resident, and that the RT was utilizing the Ambu-Bag. This nurse suggested that the RT stop ventilating the resident (so as not to destabilize the resident by pushing the object deeper). This nurse could not recall if it was suggested to the RT by this nurse to reinsert [MEDICAL CONDITION], but the tube was then reinserted. Review of the RT's written statement, and interview with the RT on [DATE] at 8:50 A.M., indicated that when "debris" was observed on the inside of the inner cannula during [MEDICAL CONDITION], a folded in half pipe cleaner was used to clean the inside of the cannula. The folded pipe cleaner then slipped into the resident's trachea (visible, but just out of reach), and suctioning was performed in an attempt to remove the pipe cleaner which "slipped out of site...." During interview on [DATE], the RT also indicated that after suctioning the resident, the [MEDICAL CONDITION] was removed, and the RT suctioned again while yelling for help from nursing who called 911. When [MEDICAL CONDITION] was reinserted, the resident began to bleed. Review of the RT's written statement indicated that while waiting for the EMTs to arrive, suctioning was again performed to remove the blood. The RT then removed [MEDICAL CONDITION] a second time to determine if suctioning had moved the object to within reach. The object could be seen as stated by the RT, but was unable to reach it. The resident was coughing, "but only blood appeared." Review of the RT's written statement further indicated that an Ambu-Bag was used to assist the resident's respirations to assure adequate oxygenation, and that the resident's oxygenation levels remained ,[DATE]% during the incident (making the Ambu-Bag an unnecessary procedure, and probably projected the object into the resident's lungs). EMTs arrived, and transported the resident to the emergency room via ambulance. When questioned about the tweezers by the surveyor, the RT confirmed that she did have tweezers, but did not tell the surveyor why she happened to have them. The RT told the surveyor the tweezers were not used; however, the RT's statement on [DATE] to the Director of [MEDICAL CONDITION] Rehab, which was witnessed by the Director of Nurses and the Assistant Director Nurses, indicated that the tweezers were used on the resident. Review of the list of items in a [MEDICAL CONDITION] Kit on [DATE] at the facility revealed that tweezers were not part of the contents in the Kit. The resident was admitted to the hospital on [DATE] for observation of complications which may include shortness of breath, pain, hemorrhage, and/or increased secretions. The resident was discharged back to the facility on [DATE] without complications. The Hospital's Discharge Summary of [DATE] revealed that an x-ray confirmed the pipe brush was lodged in the resident's right main bronchus (part of the lung). While hospital staff were prepping the resident to go to special procedures to undergo an emergency [MEDICATION NAME], the resident was able to cough up the pipe cleaner. The Discharge Status Report from the hospital dated [DATE] indicated the resident'[MEDICAL CONDITION] was slightly reddened with a large amount of yellow/green/blood tinged secretions which were thick to frothy. The report indicated [MEDICAL CONDITION] was performed, and stated, "...Do not advance [MEDICAL CONDITION] items into trach, remove inner cannula to cleanse then replace...." During interview with the Director of [MEDICAL CONDITION] Services and the Director of Nurses on [DATE] at 9:30 A.M., the Respiratory Services Policies and Procedures packet was referred to as the facility's "Respiratory Standards of Practice" Manual by both of the above. The Manual's instructions were that the "packet must be completed within two weeks of receiving it. Read each section and complete the Self-Test (Competency Check Lists). Record the answers on the Answer sheet provided. When finished with the entire packet return it and your Answer sheet to your initiative Trainer." The Director of Nurses indicated that all Respiratory Therapists upon hire received this Standards of Practice manual. Review of the RT's Personnel and Education Files, and interview with the Director of Nurses on [DATE] at 12:40 P.M. confirmed that no competency evaluations/tests could be found, and that there was no evidence that the Standards of Practice packet had been given to the RT and/or completed. Further review of the Personnel File revealed that the facility's policy regarding the Education and Qualifications for a Respiratory Therapist was that it was required by the facility that the therapist be "certified or registered by the NBRC (National Board for Respiratory Care)", and "Needs to be certified in CPR (Cardio [MEDICAL CONDITION] Resuscitation)." Under Duties and Responsibilities the Respiratory Therapist must be able to "...Administer therapy as ordered according to departmental policies and procedures...." Interview with the Administrator and Director of Nurses on [DATE] at 2:00 P.M. confirmed that there was no evidence in the RT's Personnel and Education files that could substantiate that there were any competency evaluations completed, or that the RT was registered by the NBRC and certified in CPR as required. Please refer to F281.