Every finding on record at Care Village at West Roxbury

Based on record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed for two Residents (#59, #) out of a total sample of 19 residents. Specifically,For Resident #46, the facility failed to ensure a resident- centered personalized care plan was developed for a pacemaker.For Resident #59, the facility failed to ensure a resident-centered personalized care plan was developed for a pacemaker. Findings include: Review of facility policy titled Pacemaker, care of a Resident with a, undated, indicated the following: -Documentation: For each resident with a pacemaker, document the following in the medical record upon admission: 1. The name, address and telephone number of the cardiologist. 2. Type of pacemaker c. Date of implant. d. Paced rate. 1. Resident #46 was admitted to the facility in March 2025 with diagnoses that included Parkinson's, adult failure to thrive, bradycardia and presence of a cardiac pacemaker. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. Review of Resident #46's care plan, initiated 5/7/25 indicated the following: -I have a pacemaker r/t (related to) bradycardia (low heart rate), palpations, HTN (hypertension). -Interventions for the care plan included: follow up with cardiology as needed, pacemaker checks as needed, vital signs as ordered and as needed, report abnormalities to MD if noted. Review of the Resident's care plan failed to indicate a comprehensive person-centered care plan around the care of his/her pacemaker including the name of the cardiologist, the type of pacemaker, implant date and the paced rate. Review of Resident #46's progress notes failed to indicate information regarding his/her pacemaker, including paced rate or appointments for pacemaker checks. Review of Resident #46's physician's orders failed to indicate monitoring orders for the pacemaker or specific pacemaker settings. Review of the unit appointment book since Resident #46's admission and through the end of the year, failed to indicate a scheduled appointment for a pacemaker check. During an interview on 9/25/25 at 7:50 A.M., Nurse #2 said that she does not know what the paced rate for Resident #46's pacemaker is. She said she is not sure if there needs to be a care plan or physician's orders addressing the care of the pacemaker. She also said she is not sure what the schedule is for pacemaker checks for Resident #46. During an interview on 9/25/25 at 8:03 A.M., the Director of Nurses (DON) said that when residents are admitted to the facility, they contact the cardiologist for pacemaker information and information about last and next appointments. The DON said that he would expect the Resident to have a comprehensive care plan and physician's orders regarding the management of the pacemaker to include monitoring the paced rate. He said he was not sure when the Resident's next appointment was, but he was trying to find out. 2. Resident #59 was readmitted to the facility in March 2021 with diagnoses that included hemiplegia and hemiparesis, cerebral infarction, heart failure, and aphasia. Review of Resident #59's Minimum Data Set (MDS) assessment, dated 7/4/25, indicated he/she was assessed by nursing staff to have severe cognitive impairment. Review of Resident #59's physician order, dated 9/15/25, indicated Please check Pacemaker monitor at bedside for functioning every shift. Review of Resident #59's hospital discharge paperwork, dated 1/11/21, indicated Pacemaker Pacer Mode: DDD (01/10 0000). Review of Resident #59's pacemaker care plan failed to indicate paced rate, cardiologist information, frequency of checks or the cardiologist information. Review of Resident #59's Medical Doctor and Nurse Practitioner progress notes since admission in 2021 failed to indicate the Resident had a pacemaker or any details of the pacemaker. During an observation and interview on 9/25/25 at 8:02 A.M., Nurse #2 said there should be a care plan in place that has all of the pacemaker information in it including the paced rate but is not sure what that rate is. During an interview on 9/25/25 at 8:03 A.M., the Director of Nurses (DON) said that when residents are admitted to the facility, they contact the cardiologist for pacemaker information and information about last and next appointments. The DON said that he would expect the Resident to have a comprehensive care plan and physician's orders regarding the management of the pacemaker to include monitoring the paced rate.

Based on observations, record review and interview, the facility failed to provide a dignified dining experience for one Resident (#46) out of a total sample of 19 Residents. Specifically, facility staff stood over the Resident in bed while assisting with meals. Findings include: Review of facility policy titled Dignity/ Quality of Life, dated as revised 12/6/21, indicated the following:-Purpose: To ensure residents are cared for in a manner that enhances quality of life.-1. Residents shall be always treated with dignity and respect.-2. Treated with dignity means that resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.-11. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed. Resident #46 was admitted to the facility in March 2025 with diagnoses that included Parkinson's, adult failure to thrive, bradycardia and presence of a cardiac pacemaker. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS further indicated that the Resident required substantial/ maximal assistance with eating. On 9/22/25 at 8:30 A.M., the surveyor observed a staff member standing over the Resident in bed to assist with the breakfast meal. On 9/24/25 at 8:26 A.M., the surveyor observed a staff member standing over the Resident in bed to assist with the breakfast meal. During an interview on 9/25/25 at 8:12 A.M., Certified Nurse Aide (CNA) #1 said that when a resident is being assisted with eating, the staff should be seated next to the Resident. She said it doesn't matter if the Resident is in a chair or in the bed, staff should not stand over them. During an interview on 9/25/25 at 9:56 A.M., the Director of Nurses said that staff should be sitting with residents and making them feel comfortable while they are assisting them with their meals to provide a dignified dining experience.

Based on observations, interview and record review the facility failed to assess the use of a seat belt as a potential restraint for one Resident (#17) out of a total sample of 19 Residents. Findings include: Review of facility policy Physical Restraints, dated as reviewed December 2022, indicated the following:-The facility recognizes the necessity of maintaining a systemic method of evaluating and monitoring restraint use.-The policy includes an interdisciplinary process of assessment and reassessment in order to ensure that when a restraint is necessary to treat a resident's medical condition the least restrictive is utilized for the least amount of time to treat the resident's medical condition with a plan for continued assessment and reduction.-components of restraint use: interdisciplinary assessment, MD (Physician) order, consent, care planning, CNA (Certified Nurse Aide) care card, reduction plan, reassessment.-Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets the following criteria: is attached to adjacent to the patient's body, cannot be removed easily by the patient and restricts the patient's freedom of movement or normal access to his/her body.-All potentially restraining devices require assessment to determine if the device constitutes a restraint. If the assessment of the device reveals that it meets the criteria for restraint the policy for restraint use will be utilized.-Device evaluation- any resident who is utilizing a device that could constitute a restraint will be evaluated to determine if the device is a restraint.-b. if the evaluation determines that the device does not meet the guidelines for physical restraint, the device will be addressed on the plan of care. Resident #17 was admitted to the facility in November 2024 with diagnoses including cerebral infarction and major depressive disorder.Review of Resident #17's most recent Minimum Data Set (MDS) Assessment, dated 9/3/25, indicated a Brief Interview for Mental Status score of 15 out of 15 indicating that the Resident was cognitively intact. The MDS failed to indicate that any type of restraint was used.On 9/22/25 at 7:45 A.M. the surveyor observed Resident #17 sitting in his/her motorized wheelchair. The surveyor observed Certified Nurse Aide (CNA) #2 buckle a seatbelt around the Resident's abdomen while the resident sat in the chair.On 9/25/25 at 7:53 A.M., the surveyor observed Resident #17 in his/her wheelchair in the hallway. The Resident had a seat buckle around his/her abdomen as well as across his/her thighs. Resident #17 said that he/she utilizes both belts when up in his/her chair. Resident #17 said that he/she has left sided weakness and cannot keep his/her legs in the chair without the buckle. Resident #17 said that he/she has been utilizing the buckles since admission to the facility. Resident #17 said that he/she needs assist to apply and remove the buckles. Review of the medical record failed to indicate a restraint or device assessment addressing the use of the seat belt/buckle had been completed.Review of Resident #17's physician's orders failed to indicate orders for the use of a restraint/device, or specifically a seat belt.Review of the Resident's care plan failed to indicate the use of a seat belt while in his/her wheelchair.Review of progress notes dated 3/23/25- 9/24/25 failed to indicate the use of a seat belt or any type of restraint.Review of the UDA Packet, specifically, the device assessments completed on 3/5/25, 6/8/25 and 9/9/25 indicated the resident was assessed for the use of side rails but no other devices. During an interview on 9/24/25 at 1:45 P.M., CNA #2 said that he takes care of Resident #17 every day. He said that when Resident #17 is up in his/her wheelchair, the seatbelt is in place at all times. He said the Resident is unable to remove it or apply it on his/her own. CNA #2 said that whenever the Resident is up on his/her wheelchair, the seatbelt is utilized. During an interview on 9/24/25 at 1:46 P.M., Nurse #2 said that Resident #17 utilizes a seat belt while up in his/her wheelchair. She said that she would not consider it a restraint. She said that she would not complete a restraint assessment because it does not have the potential to be a restraint. During an interview on 9/24/25 at 1:54 P.M., the Director of Nurses said that staff should have reported to him that the Resident was utilizing a seat belt so that a restraint assessment could have been completed to assess for the use of a potential restraint. The Director of Nurses said he was not aware that the Resident was utilizing the buckle. He said that there should be a physician's order for use of the seat belt and a care plan initiated for the use.

Based on record review and interview the facility failed to ensure that for one Resident's (#46) out of a total sample of 19 residents, their drug regime was free from unnecessary antipsychotic drugs. Specifically, the facility failed to adequately monitor the use of quetiapine (an antipsychotic medication) and evaluate whether a Gradual Dose Reduction (GDR) was indicated. Findings include:Review of facility policy titled Psychotropic Medication Treatment in Long Term Care Centers, dated as January 2021, indicated the following:-It is the [facility's] policy to abide by state and federal regulations when requesting consent and administering psychotropic medications.-GDR: Tapering of a Medication Dose/ Gradual Dose Reduction (GDR). The requirements underlying this guidance emphasize the importance of seeking an appropriate dose and duration for each medication and minimizing the risk for adverse consequences. The purpose of tapering medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident.-There are various opportunities during the care process to evaluate the effects of medications on the resident's function and behavior, and to consider whether the medications should be continued, reduced or discontinue, or otherwise modified. Examples of these opportunities include:-During the monthly medication regimen review, the pharmacist evaluates resident- related information for dose, duration, continued need, and the emergence of adverse consequences for all medications.-When evaluating the resident's progress, the practitioner reviews the total plan of care, orders, the resident's response to medications, and determines whether to continue, modify, or stop a medication; and-During the quarterly MDS review, the facility evaluates mood, function, behavior, and other domains that may be affected by medications. Resident #46 was admitted to the facility in March 2025 with diagnoses that included major depressive disorder and visual hallucinations. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS further indicated the use of antipsychotic and antidepressant medications. The MDS further indicated that antipsychotics were received on a routine daily basis and that no Gradual Dose Reduction (GDR) had been attempted. The MDS indicated that there was no documentation from the physician indicating that a GDR was clinically contraindicated. Review of Resident #46's active physician's orders indicated the following:-Quetiapine (an antipsychotic medication) 25 mg, give 0.5 tablet by mouth at bedtime for hallucinations, give with Quetiapine 25 mg tab = 37.5 mg, dated as 3/31/25. (Originally dated 3/7/25 but rewritten for clarification).-Quetiapine 25 mg give 1 tablet by mouth at bedtime for hallucinations, give with quetiapine 25 mg 1/2 tab = 37.5 mg, dated 3/31/25. (Originally dated 3/7/25 but rewritten for clarification). Review of the medical record indicated that the Resident had been receiving the same dose of Quetiapine since admission to the facility. Review of Resident #46's active care plan, dated as initiated 3/7/25, indicated, I am taking psychotropic medication related to depression and anxiety, with interventions that include the following:-Please give me the lowest dose possible to control my situation/ behavior and prevent adverse side effects as my MD/NP (physician or nurse practitioner) as ordered.-Please review the need for this medication quarterly and as needed. Review of Physician and Nurse Practitioner progress notes failed to indicate that a GDR was attempted or clinically contraindicated.Review of the medical record failed to indicate any behavioral health visits had occurred since Resident #46 was admitted to the facility in March 2025. During an interview on 9/24/25 at 2:01 P.M., the Director of Nurses said that behavioral health services manage GDRs in the facility, and the Resident had not been seen by behavioral health services since admission. He said that a GDR had not been attempted but should have been attempted or documented in the medical record that it was contraindicated for the Resident.

Based on record review and interview, the facility to ensure that services provided met professional standards for one Resident (#46) out of a total sample of 19 residents. Specifically, for Resident #46 the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission and at the initiation of an antipsychotic medication. Findings include:Resident #46 was admitted to the facility in March 2025 with diagnoses that included Parkinson's, adult failure to thrive, bradycardia and presence of a cardiac pacemaker. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS further indicated the use of antipsychotic and antidepressant medications and that antipsychotic medications were received on a routine daily basis. Review of Resident #46's physician orders indicated the following:-Quetiapine (an antipsychotic medication) 25 mg give 0.5 tablet by mouth at bedtime for hallucinations give with Quetiapine 25 mg tab = 37.5 mg, dated as 3/31/25. (originally dated 3/7/25 but rewritten for clarification).-Quetiapine 25 mg give 1 tablet by mouth at bedtime for hallucinations, give with quetiapine 25 mg 1/2 tab = 37.5 mg, dated 3/31/25. (originally dated 3/7/25 but rewritten for clarification). Review of the summary for recommendations for DNS (Director of Nurses)/ Medical Director from the Monthly Medication Regime Review, completed by the consultant pharmacist, dated as recommendations made between 4/1/25 and 4/18/25, indicated the following for Resident #46:Nursing Recommendation: This resident is receiving the antipsychotic medication Quetiapine. Please perform AIMS testing now and every 6 months to monitor for tardive dyskinesia. Thank you.Review of the medical record failed to indicate that an AIMS assessment was completed prior to the one completed on 5/27/25, 81 days after admission and initiation of the antipsychotic medication and 40 days after the recommendation to complete it was made (on 4/17/25). The score of the AIMS test when completed was 2, indicating that tardive dyskinesia movements have been identified, but are not severe enough for interventions, and do not interfere with activities of daily living. During an interview on 9/24/25 at 1:53 P.M., Nurse #2 said that an AIMS assessment should be completed on admission if the resident is admitted on antipsychotic medications, or upon the initiation of an antipsychotic medication. She said, however, she was not sure who was responsible to complete the assessment. During an interview on 9/24/25 at 2:01 P.M., the Director of Nurses said that he had asked the psychiatric nurse practitioner to complete an AIMS assessment on Resident #46 in April following a pharmacy recommendation. He said that he noticed that the Resident hadn't been seen by behavioral health services to have the assessment completed, so he completed the assessment in May. He said the assessment should have been completed on admission and then every 6 months thereafter.

Based on record review and interviews the facility failed to develop person centered trauma informed care plans accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for two Residents (#10 and #34) out of a sample of 19 Residents. Specifically, the facility failed to develop person centered (Post Traumatic Stress Disorder) PTSD care plans.Findings include:Review of the facility policy tilted, 'Trauma Informed Care', effective [DATE] indicated the following:-The facility ensures that residents who are trauma survivors receive culturally competent, trauma informed care decisions in accordance with professional standards of practice and account for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.-Trauma-the result of an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.-Trauma-informed care-an approach to delivering care that involves understanding recognition and response to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporated knowledge about trauma into policies, procedures and practices to avoid re-traumatization.-Upon admission, the center will assess each resident with a PTSD screen and Traumatic events checklist. Social service personnel will conduct the assessment to identify whether a resident has experienced trauma and PTSD as well as to gather trauma triggers. The information re3ceived from the assessment will be used to identify appropriate services and assist with preventing re-traumatization of the resident. Additional information may be obtained from the medical record, physical and emotional assessments completed with the residents and/or family members who have share this information.Review of the facility policy titled 'Comprehensive Care Plan' with no revision date indicated the following:-An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.1.Resident #10 was admitted to the facility in [DATE] with diagnoses including PTSD.Review of the Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition.Review of behavioral health notes dated [DATE] indicated the following:-History of present illness-endorses continues PTSD symptoms including nightmares and flashbacks relating to past exposure to trauma.-Past living arrangements-resident cannot live with spouse due to a question of domestic violence.-Other trauma/loss-sexual assault, miscarriage at 20 weeks.Review of the care plan initiated [DATE] indicated a PTSD care plan that failed to identify the Resident's specific history of trauma, identify the specific triggers, the signs and symptoms of the Resident's trauma to avoid re-traumatization.During an interview on [DATE] at 9:30 A.M., the Social Worker said PTSD care plans should not be generic, they should be person centered, including the resident's specific trauma, identify the specific triggers based on the trauma to avoid re-traumatization. The Social Worker said a trauma informed assessment should be completed at admission to identify the residents' trauma and triggers.During an interview and medical record review on [DATE] at 10:15 A.M., the Director of Nurses (DON) said the Resident's PTSD care plan was in place, but it was not person centered. The DON said the PTSD care plan should identify the resident's specific trauma, identify the specific triggers to prevent the resident from getting retraumatized.During an interview on [DATE] at 12:06 P.M., the Chief Operating Officer said the interdisciplinary team could not locate any trauma informed assessment completed for the Resident.2. Resident #34 was admitted to the facility in [DATE] with diagnoses including PTSD.Review of the Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition.Review of the behavioral health notes dated [DATE] indicated the following:-Other trauma loss-childhood abuse, was in foster care, physically abused by ex-husband, daughter was murdered at age [AGE].Further review of the hospital discharge paperwork, psychiatry service dated [DATE] indicated the following:-Resident describes finding his/her mother overdosing at the age of five and performing (cardiopulmonary resuscitation) CPR on her. Resident was sent to foster care where he/she was physically assaulted, locked in a cupboard for three days.Review of the care plan initiated [DATE] indicated a PTSD care plan that failed to identify the Resident's specific history of trauma, identify the specific triggers, the signs and symptoms of the Resident's trauma to avoid re-traumatization.During an interview on [DATE] at 9:30 A.M., the Social Worker said PTSD care plans should not be generic, they should be person centered, including the resident's specific trauma, identify the specific triggers based on the trauma to avoid re-traumatization. The Social Worker said a trauma informed assessment should be completed at admission to identify the residents' trauma and triggers. During an interview and medical record review on [DATE] at 10:15 A.M., the Director of Nurses said the Resident's PTSD care plan was in place, but it was not person centered. The DON said the PTSD care plan should identify the resident's specific trauma, identify the specific triggers that may cause the resident from getting re-traumatized.During an interview on [DATE] at 12:06 P.M., the Chief Operating Officer said the interdisciplinary team could not locate any trauma informed assessment completed for the Resident.

Based on record review and interview, the facility failed to provide behavioral health services for one Resident, (#46) out of a total of 19 sampled Residents. Specifically, the facility failed to ensure behavioral health services were provided for Resident #46 who received antipsychotic medication, antidepressant medication and has diagnoses of anxiety and major depressive disorder. Findings include:Review of facility policy, titled Behavioral Health Services, dated as revised 12/6/21, indicated the following:-The facility will ensure that, a resident who displays or is diagnosed with mental disorder or psychological adjustment difficulty, or who has a history of trauma and / or post-traumatic stress disorder, receives appropriate treatment and services. Resident #46 was admitted to the facility in March 2025 with diagnoses that included anxiety disorder, dementia, major depressive disorder and unspecified psychosis not due to a substance or known physiologic disturbance. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS further indicated the use of antipsychotic and antidepressant medications. Review of physician's orders indicated the following:-May be seen by psych as needed, dated 3/7/25.-Quetiapine (an antipsychotic medication) 25 mg (milligrams) give 0.5 tablet by mouth at bedtime for hallucinations give with Quetiapine 25 mg tab = 37.5 mg, dated as 3/31/25. (originally dated 3/7/25 but rewritten for clarification).-Quetiapine 25 mg give 1 tablet by mouth at bedtime for hallucinations, give with quetiapine 25 mg 1/2 tab = 37.5 mg, dated 3/31/25. (originally dated 3/7/25 but rewritten for clarification).-Mirtazapine (an antidepressant medication) 7.5 mg give one tablet at bedtime for depression, dated 3/7/25.-Sertraline (an antidepressant medication) 50 mg give one tablet one time a day for major depressive disorder, dated 3/7/25. Review of Resident #46's active care plan indicated: I am taking psychotropic medication related to depression and anxiety, dated as 3/7/25, with interventions that included:-Please provide [me] with a psych consult as needed. Resident #46's active care plan, dated 3/7/25, further indicated: Sometimes I don't feel happy and get depressed. I feel frustrated over my medical situation and my social situation, I have depression depressive mood, (sic) with interventions that included:-Please provide me with psych services as needed, if my MD/NP (Physician or Nurse Practitioner) thinks this will help. Review of the Nurse Practitioner progress note, dated 3/13/25, indicated the following: Assessments/Plans:-Unspecified psychosis not due to a substance or known physiological condition -Does not appear agitated or delusional in any way -Will have psychiatry follow along with us. Appears comfortable and calm at this time. Review of the Nurse Practitioner progress note, dated 9/11/25, indicated the following:Assessments/Plans:-Unspecified psychosis not due to a substance or known physiological condition - Patient is on Seroquel (another name for Quetiapine) mood is stable. Patient is followed along with psychiatry. Review of the medical record indicated a signed and dated Request for services, indicating that the Resident/ or their health care proxy had consented to receive counseling or behavioral health services. This request for service was signed and dated 5/9/25, two months after admission to the facility. Review of the medical record failed to indicate that the Resident had been evaluated by behavioral health services since admission to the facility. During an interview on 9/24/25 at 2:01 P.M., the Director of Nurses said that Resident #46 had not been seen by psych services, but he/she should have been seen. The Director of Nurses said that residents who take antipsychotic medications and antidepressant medications should be followed by psych for monitoring. He said that the Resident was registered to be seen but never was. During an interview on 9/25/25 at 9:21 A.M., the Social Worker said that all residents who have a signed consent to see behavioral health services and are on psychotropic medications should be provided with psych or behavioral health services.

Based on record review and interview the facility failed to ensure for two Residents (#46 and #2), out of a total sample of 19 residents, that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician/nurse practitioner response to the recommendations. Specifically,For Resident #46, the facility failed to implement recommendations timely to complete an AIMS (abnormal involuntary movement scale) Assessment, clarify the frequency of administration for as needed orders, and the pharmacist failed to recommend a Gradual Dose Reduction (GDR) for an antipsychotic medication.For Resident #2 the facility failed to clarify the frequency of administration for an as needed order.Findings include: Review of facility policy titled Psychotropic Medication Treatment in Long Term Care Centers, dated as January 2021, indicated the following:-It is the [facility's] policy to abide by state and federal regulations when requesting consent and administering psychotropic medications.-GDR: Tapering of a Medication Dose/ Gradual Dose Reduction (GDR). The requirements underlying this guidance emphasize the importance of seeking an appropriate dose and duration for each medication and minimizing the risk for adverse consequences. The purpose of tapering medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident.-There are various opportunities during the care process to evaluate the effects of medications on the resident's function and behavior, and to consider whether the medications should be continued, reduced or discontinue, or otherwise modified. Examples of these opportunities include:-During the monthly medication regimen review, the pharmacist evaluates resident- related information for dose, duration, continued need, and the emergence of adverse consequences for all medications. 1a. Resident #46 was admitted to the facility in March 2025 with diagnoses that included Parkinson's, adult failure to thrive, bradycardia and presence of a cardiac pacemaker. Review of Resident #46's most recent Minimum Data Set (MDS) Assessment, dated 9/11/25, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS further indicated the use of antipsychotic and antidepressant medications. The MDS further indicated that antipsychotics were received on a routine daily basis and no Gradual Dose Reduction (GDR) had been attempted. The MDS indicated that there was no documentation from the physician indicating that a GDR was clinically contraindicated. Review of the summary for recommendations for DNS (Director of Nurses)/ Medical Director from the Monthly Medication Regime Review, completed by the consultant pharmacist, dated as recommendations made between 4/1/25 and 4/18/25, indicated the following for Resident #46:Nursing Recommendation: This resident is receiving the antipsychotic medication Quetiapine. Please perform AIMS testing now and every 6 months to monitor for tardive dyskinesia. Thank you. Review of the medical record failed to indicate that an AIMS assessment was completed prior to the one completed on 5/27/25, 81 days after admission and initiation of the antipsychotic medication and 40 days after the recommendation to complete it was made (on 4/17/25). The score of the AIMS test when completed was 2, indicating that tardive dyskinesia movements have been identified, but are not severe enough for interventions, and do not interfere with activities of daily living. 1b. Review of the pharmacist progress note, dated 9/16/25, indicated the following:-NURSE REC (recommendation)-Please clarify frequency of MOM (milk of magnesia), Bisacodyl suppository, and Fleet enema PRN (as needed) orders. Review of Resident #46's active physician orders as of 9/24/25 indicated the following:- Milk of Magnesia Oral Suspension 400 mg/5 ml give 30 ml by mouth as needed for constipation, dated 3/7/25.-Dulcolax suppository 10 mg (bisacodyl) Insert 1 suppository rectally as needed for Constipation If Milk of Magnesia is ineffective give Dulcolax 10mg Suppository via rectum, dated 4/21/25-Fleet Enema Enema 7-19 GM/118ML (Sodium Phosphates) Insert 1 applicatorful rectally as needed for Constipation If no bowel movement after Dulcolax suppository give Fleet Enema via rectum, dated 4/21/25Review of the above physician orders failed to indicate a frequency for administration as recommended by the consultant pharmacist. 1c. Review of Resident #46's physician's orders indicated the following:-Quetiapine (an antipsychotic medication) 25 mg give 0.5 tablet by mouth at bedtime for hallucinations give with Quetiapine 25 mg tab = 37.5 mg, dated as 3/31/25. (originally dated 3/7/25 but rewritten for clarification).-Quetiapine 25 mg give 1 tablet by mouth at bedtime for hallucinations, give with quetiapine 25 mg 1/2 tab = 37.5 mg, dated 3/31/25. (originally dated 3/7/25 but rewritten for clarification). Review of the progress notes since Resident #46's admission to the facility pertaining to Monthly Medication Regime Reviews completed by the consultant pharmacist failed to indicate any recommendations for a Gradual Dose Reduction (GDR) of an antipsychotic medication. Review of Provider progress notes failed to indicate any review for a GDR was completed For Resident #46, or that a GDR was clinically contraindicated for the Resident. During an interview on 9/24/25 at 1:52 P.M., Nurse #2 said that she is not sure who addresses pharmacy recommendations, there is a specific nurse, but she is not sure who it is. She said that they are not brought to the floor for the staff nurses to address. During an interview on 9/24/25 at 2:01 P.M., the Director of Nurses said that all of the pharmacist's recommendations come to him and he addresses a majority of them. He said that they should be addressed right away. The Director of Nurses said that the AIMS assessment was completed on 5/27/25 by him, and it was not completed at the time of the recommendation. He said that he noticed it was never done so he completed it. He said that initially when the recommendation came in in April, he realized that behavioral health services had not seen the Resident and asked for him/her to be seen, and the AIMS completed. The Director of Nurses said that behavioral health services not being in place also contributed to the lack of a GDR attempt or documentation that it was not indicated, but it should have been picked up on. He further said that the frequency of the as needed orders should have been clarified when the recommendations were received. 2. Resident #2 was admitted to the facility in September 2019 with diagnoses that include dementia, persistent mood disorder and lower back pain. Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 9 out of a possible 15, indicating moderate cognitive impairment. Review of the pharmacist progress note pertaining to the Monthly Medication Regime, dated 9/16/25, indicated the following:-MD (physician) REC (recommendation)- please consider ordering a lipid panel/ Atorvastatin-Nurse REC- Please clarify strength and frequency of PRN (as needed) Fleet enema order. Review of Resident #2's active Physician's orders as of 09/24/25 indicated the following:-Fleet enema Insert 1 application rectally as needed for Constipation, dated 9/1/2020. (The order failed to indicate a strength/ dose or frequency for administration). During an interview on 9/24/25 at 1:52 P.M., Nurse #2 said that she is not sure who addresses pharmacy recommendations, there is a specific nurse, but she is not sure who it is. She said that they are not brought to the floor for the staff nurses to address. During an interview on 9/24/25 at 2:01 P.M., the Director of Nurses said that pharmacy recommendations come to him first and he usually addresses them. He said they should be addressed right away. He said the physician's orders should indicate a dose and frequency of administration.

Based on observation and interview the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the medications on one of two units.Findings include:Review of the facility policy titled storage of Medications, not dated, indicated that medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. On 9/22/25, at 6:56 A.M. the surveyor observed a medication cart open, and the surveyor opened the drawer without interference. The surveyor also observed several residents and staff members in the hall. On 9/22/25, at 8:28 A.M., the surveyor observed 2 capsules in a medication cup on a resident's bedside table. The surveyor observed that the resident was in bed asleep. The surveyor also observed that the resident's roommate was awake. During an interview on 9/25/25 at 7:57 A.M., Nurse #1 said that medications should not be left at bedside and medication carts should not be left open.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#52) did not self-administer medications out of a total sample of 17 residents. Specifically, Resident #52 was not assessed to be able to safely self-administer medication and was observed self-administering medication. Findings include: Review of the facility policy titled, Self Administration of Medications/ Treatments, dated as reviewed 12/21/22, indicated that residents who wish to self-administer medications/treatments will be assessed for ability and allowed to self-administer if deemed capable. 1. Upon admission, residents will be informed of their right to self-administer medications. 2. If a resident wishes to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self-Administration of Medication Evaluation. 3. The nurse will interview the resident to determine their ability to identify, prepare and administer medications/treatments. 4. Based on the interdisciplinary team assessment, a decision is made as to whether or not the resident is a candidate for self-administration. This will be documented in the medical record. 5. The nurse will obtain a physician's order for each resident conducting self-administration of medications/treatments. 6. The nurse will evaluate accuracy and compliance of self-administration by periodic observation and counting doses. 7. Assessment of compliance and safety will be documented on a weekly basis in the resident's medical record. 8. Storage of self-administered medications/treatments will comply with state/federal requirements for medication storage. Resident #52 was admitted to the facility in April 2023 with diagnoses including hypothyroidism. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/21/24, indicated that Resident #52 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. On 10/29/24 at 8:31 A.M., the surveyor observed Resident #52 in bed and asleep. The surveyor observed a small white round pill in a medication cup with L 15 written on it. Resident #52 awoke and said to the surveyor that the medication was his/her morning thyroid pill and the nurse who usually works leaves it for me to take on my own. Resident #52 then swallowed the medication. Review of Resident #52's physician's order, dated 11/27/23, indicated: - Levothyroxine Sodium Oral Tablet 50 micrograms (mcg) (Levothyroxine Sodium), give 1 tablet by mouth one time a day for hypothyroidism. Further review of the order indicated the medication was ordered as administer by clinician and was scheduled daily at 6:30 A.M. Review of Resident #52's form titled, new admission self-administration of medications, dated as 4/13/24, indicated: - administration by nursing staff. Review of Resident #52's plan of care in the electronic health record, dated 10/31/24, failed to indicate nursing staff assessed Resident #52 for self-administering medications. On 10/31/24 at 10:15 A.M., the surveyor and Nurse #7 reviewed Resident #52's medication supply and noted Resident #52 is prescribed levothyroxine a small white pill with L 15 written on it. During an interview on 10/30/24 at 4:13 P.M., Nurse #4 said that Resident #52 takes a thyroid pill in the morning at 6:00. A.M. Nurse #4 said she should stay with the Resident until he/she takes the medication. Further Review of Resident #52's Medication Administration Record dated 10/29/24 indicated Nurse #4 administered the thyroid medication to Resident #52. During an interview on 10/31/24 at 11:22 A.M., the Director of Nursing (DON) said nursing staff should stay with Resident #52 when he/she takes his/her medications.

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status of one Resident (#25) out of a total sample of 17 residents. Specifically, for Resident #25 the facility failed to code the correct pressure ulcer stage, when there was documentation of granulation. Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated the following: Coding Instructions for M0300B Coding Tips: Stage 2 pressure ulcers by definition have partial thickness loss of the dermis. Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers. Resident #25 was admitted to the facility in May 2024 with diagnoses including diabetes and nutritional anemia. Review of the Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that Resident #25 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #25 had one stage 2 (M0300B1) pressure ulcer that was present on admission (M0300B2). Review of Resident #25's hospital discharge summary, dated 5/23/24, indicated: - Pressure Injury to the Coccyx, dated 5/21/24. Review of Resident #25's assessment titled [NAME]-Admission/ Readmission Nursing Assessment (Premier) dated 5/23/24 indicated: - Section C 10. Coccyx, Pressure. Review of Resident #25's clinical nursing note, dated 5/23/24, indicated: - Note Text: pressure ulcer to coccyx. Review of Resident #25's nurses note, dated 5/24/24, indicated: - Sacral area with superficial open area from admission measuring 2.5 cm (centimeters) x 2 cm granulation to wound bed. During an interview on 10/30/24 at 1:22 P.M., Nurse #2 reviewed admission assessment, and said Resident #25 was admitted with a pressure ulcer. During an interview on 10/30/24 at 1:37 P.M., the Director of Nursing said he assessed Resident #25 the day after his/her admission, and he/she had a pressure wound with granulation. During an interview on 10/30/24 at 2:38 P.M., MDS Nurse #2 said a stage 2 pressure ulcer should not be coded when there is presence of granulation. MDS Nurse #2 said the MDS was not completed accurately. During a follow up interview on 10/31/24 11:20 A.M., the Director of Nursing (DON) said that the MDS Nurse should use the RAI manual to ensure accurate coding is complete.

Based on observation, record review, and interviews, for two Residents (#217 and #62) of 17 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, 1.) For Resident #217, the facility failed to ensure nursing implemented a physician's ordered urinary catheter drainage bag change as ordered by the physician. 2.) For Resident #62, the facility failed to follow physician's orders to apply offloading booties to bilateral heels while in bed. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1.) Review of the facility policy titled, Foley Catheter Care, dated May 1, 2022, indicated, it is the policy of this facility to maintain physician's (MD) orders for the care and maintenance of a Foley catheter. The MD orders will include: 7. MD order will indicate when to change the collection bag. Note: there is no specific timeframe for changing the collection bag. Resident #217 was admitted to the facility in October 2017 with diagnoses including urinary retention and benign prostatic hyperplasia with lower urinary symptoms. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/14/24, indicated that Resident #217 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #217 required an indwelling catheter. On 10/28/24 at 8:08 A.M., the surveyor observed Resident #217 in his/her bed. He/she had a urinary catheter bag that was dated 10/20/24. Review of Resident #217's plan of care related to urinary retention, dated 10/8/24, indicated: - Please change my catheter drainage (CD) bag weekly. Review of Resident #217's physician's order, dated 10/8/24, indicated: - Change catheter bag weekly Monday and Thursdays 11:00 P.M. to 7:00 A.M., every night shift. Further review of the physician's order indicated nursing only scheduled the order to completed on Thursdays. Review of Resident #217's TAR, dated October 2024, indicated nursing (Nurse #5) implemented the physician's order on 10/24/24. However, based on the surveyor's observation on 10/29/24, nursing completed the catheter drainage bag on 10/20/24. During an interview on 10/31/24 at 7:07 A.M., Nurse #5 said she couldn't recall changing Resident #217's urinary catheter drainage bag on 10/24/24. She said she would verify the physician's order for the bag changes and write her initials and date the bag on the day she changed it. During an interview on 10/31/24 11:24 A.M., the Director of Nursing said nursing should implement the physician's order and change the urinary catheter drainage bag as ordered by the physician. 46339 2.) Resident #62 was admitted to the facility in October 2024 with diagnoses including right femur fracture, pressure ulcer and local infection of the skin and subcutaneous tissues. Review of Resident #62's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 13 out of possible 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. The MDS further indicated that the Resident had pressure and surgical ulcers. The MDS did not indicate behaviors of refusal of care. Review of the Resident's current physician orders indicated the following: -Boots to bilateral feet at all times every shift. Dated 10/3/24. On 10/29/24 at 8:05 A.M., the surveyor observed Resident #62 lying in bed with his/her heels directly on the mattress. The blue offloading boots were at the foot of the bed. On 10/29/24 at 1:34 P.M., the surveyor observed Resident #62 lying in bed with his/her heels directly on the mattress. On 10/30/24 at 6:59 A.M., the surveyor observed Resident #62 lying in bed with his/her heels directly on the mattress. The blue offloading boots were on the Resident's bedside table. Review of Resident #62's Treatment Administration Record (TAR) indicated the Resident had been wearing the boots during the times of the observations, and only three episodes of documented refusals. During an interview on 10/30/24 at 9:42 A.M., Nurse #1 said per the physician orders the Resident should always have the boots on. She further said that the Resident does refuse the boots and it is their responsibility to ensure the Resident has the boot on. Nurse #1 said the nurses are to document refusal in the medical records. During an interview on 10/31/24 at 11:15 A.M., the Director of Nursing said the Resident doesn't like the boots, he/she will kick them off. Nurses are responsible to make sure they are on.

Based on observations, record review, and interview the facility failed to provide respiratory care services in accordance with professional standards of practice for one Residents (#61) out of a total sample of 17 residents. Specifically, for Resident #61, the facility failed to ensure nursing consistently implemented his/her physician's ordered continuous positive airway pressure machine (CPAP, a machine that uses mild pressure to keep the breathing airways open during sleep, used to treat obstructive sleep apnea). Findings include: Review of the facility policy, CPAP (continuous positive airway pressure machines) and BiPAP (Bilevel positive airway pressure machines), dated as May 1, 2022, indicated it is the policy of this facility to provide respiratory support through the use of a CPAP and BiPAP machine when ordered by the resident's physician. CPAP and BiPAP machines require humidification. The water in the chamber should be kept filled to the indicator line using distilled water. MD orders will be obtained and include the following: - When the CPAP/BiPAP machine is to be used. - Pressure settings for the CPAP/BiPAP - Supplemental oxygen (if used) - Orders for cleaning the machine. - CPAP/BiPAP machine should be wiped down weekly with a damp cloth. Warm soapy water may be used if there is visible debris on the machine. - The water chamber should be washed weekly with 1/2 strength Vinegar and Water and replaced if there are signs of wear or loss of integrity. - Orders for cleaning the mask and replacement of the hoses. - The CPAP/ BiPAP mask should be washed with warm soapy water once a week or whenever it is soiled. - The CPAP/BiPAP mask should be discarded if it is soiled to the point that it cannot be easily cleaned, or it has lost its integrity. - The hoses of the machine should be cleaned weekly with warm soapy water and replaced if there are signs of wear or debris that cannot be easily dislodged. Resident #61 was admitted to the facility in October 2024 with diagnoses including obstructive sleep apnea, heart failure, and shortness of breath. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/7/24, indicated that Resident #61 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #14 required non-invasive mechanical ventilator. During an interview on 10/29/24 at 7:34 A.M., Resident #61 said that staff do not offer of apply his/her CPAP at bedtime. The CPAP was observed on the nightstand wrapped in a plastic bag. The water chamber was dry. On 10/30/24 at 6:43 A.M., Resident #61 was observed sleeping in his/her bed not wearing the CPAP. The CPAP was wrapped in plastic bag on the nightstand. The water chamber was dry. During an interview on 10/30/24 at 12:27 P.M., Resident #61 said that nursing did not apply his/her CPAP last night. Resident #61 said when his/her family member comes in he/she would ask them to move it onto his/her bedside table so that nursing would remember to put it on him/her at night. On 10/31/24 at 6:20 A.M., Resident #61 was observed sleeping in his/her bed not wearing the CPAP. The CPAP was wrapped in a plastic bag on the bedside table. Review of Resident #61's physician's order, dated 10/4/24, indicated: - CPAP to be used at nighttime setting 5.5, at bedtime. Scheduled daily at 9:00 P.M. Further review of the physician's orders failed to include a removal schedule or cleaning schedule. Review of Resident #61's plan of care, dated 10/30/24, failed to include the use of CPAP. Review of Resident #61's Treatment Administration Record (TAR), dated October 2024, indicated nursing implemented the CPAP on 10/28/24, 10/29/24, and 10/30/24. However, based on observations and interviews the application was not documented accurately by nursing staff. During an interview on 10/31/24 at 6:34 A.M., Certified Nurse Assistant #2 (who was working the overnight shift) said Resident #61 doesn't wear a CPAP at night. During an interview on 10/31/24 at 6:31 A.M., Nurse #6 said she was the overnight nurse, and she said Resident #61 did not wear a CPAP during the night. Nurse #6 said that Resident #61 doesn't have an order to wear or to monitor for the CPAP during the night shift. During an interview on 10/31/24 at 11:19 A.M., the Director of Nursing (DON) said nursing should follow the physician's orders and apply Resident #61's CPAP. The DON said that Resident #61 knows when to put the CPAP on and take it off, and he/she aware of his/her needs. The DON said Resident #61's CPAP requires cleaning orders and a care plan.

Based on record review and interview, the facility failed to develop plans of care for their diagnoses of post-traumatic stress disorder for two Residents (#17 and #29) out of a total sample of 17 residents. Findings include: 1. Resident #17 was admitted to the facility in August 2020, and had diagnoses which included post-traumatic stress disorder (PTSD). Review of Resident #17's quarterly behavioral assessment dated [DATE] indicated a diagnosis of PTSD. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] indicated an active diagnosis of PTSD. Review of Resident #17's electronic medical record and paper chart indicated a PTSD care plan had not been developed. During an interview with the MDS Nurse on 10/30/24 at 2:28 P.M., she said that if the MDS assessment indicated a diagnosis of PTSD then a PTSD care plan should be developed. The MDS Nurse and the surveyor reviewed Resident #17's medical record and determined he/she had an active diagnosis of PTSD and that a nursing care plan for PTSD had not been developed. 46339 2. Resident #29 was admitted to the facility In November 2023 with diagnoses including Post-Traumatic Stress Disorder (PTSD). Review of Resident #29's Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Review of Resident #29's behavior assessment dated [DATE] indicated the Resident had a diagnosis of PTSD. Review of the Resident's plan of care failed to indicate a personalized PTSD care plan identifying any triggers. During an interview on 10/31/24 at 11:27 A.M., the Director of Nursing said the Resident's PTSD care plan was integrated with his/her psychotropics plan of care. He further said the PTSD care plan should identify triggers which may exacerbate his/her symptoms.

Based on observation, record review and interview the facility failed to ensure that bed rails were implemented in accordance with the bed rail assessment and physician's order, for one Resident (#28) out of a total sample of 17 residents. Findings include: Review of the facility policy, Use of Side Rails, undated, indicated the following the purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints. 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; and b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including proper assessment and care planning. While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request.) 10. The resident will be checked periodically for safety relative to side rail use. Resident #28 was admitted to the facility in June 2024 with diagnoses including hemiplegia, diabetes, brain disorder and encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated that Resident #28 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS indicated Resident #28 required assistance with bed mobility and he/she did not utilize physical restraints. On 10/29/24 at 8:19 A.M., 10/29/24 at 11:20 A.M., 10/30/24 at 6:42 A.M., 10/30/24 at 11:44 A.M., 10/30/24 at 4:19 P.M., and on 10/31/24 at 9:14 A.M, 10/31/24 at 9:53 A.M, and on 10/31/24 at 10:00 A.M, the surveyor observed Resident #28 in his/her bed. Resident #28 had bilateral side rails that measured 25 inches long each, these side rails were positioned in the middle of the bed and there was a gap that measured 30 inches from the top of the bed to the side rail, and there was 27.5 inches from the bottom of the side rail to foot board on both sides. Review of Resident #28's physician's order, dated 6/19/24, indicated: - (2) 1/4 bedrails up when in bed for mobility and transfers. Review of Resident #28's, bed rail assessment and consent form, dated 6/19/24, indicated the following. - 1/4 partial rails, left side upper and right side upper. Further review of the assessment failed to include the use of 1/2 partial rails. Review of Resident #28's, assessment titled, BEAR -- 00) UDA PACKET, dated 9/22/24, indicated the following: A. Please specify device, coded as 1) Side Rails (used in and/or out of bed) A1. SPECIFY, coded as a) 1/4 side rails. A1-a1. 1/4 SIDE RAIL, coded as a) 2 side rails UPPER ONLY Review of Resident #28's plan of care related to activities of daily living, dated as revised on 7/24/24, indicated: - Please utilize side rails as assessed and ordered if I choose, initiated 6/19/24. - I am dependent on staff to get me dressed and undressed, grooming, and bathing needs, initiated 6/19/24. During an interview and observation on 10/30/24 at 12:33 P.M., Certified Nurse Assistant (CNA) #1 said that Resident #28's side rails are always in the same position, positioned in middle of the bed. During an interview and observation on 10/30/24 12:34 P.M., Nurse #3 said that Resident #28's side rails are always in the same position, positioned in middle of the bed. During an interview, observation, and demonstration on 10/31/24 at 9:14 A.M., Director of Nursing (DON) observed the side rails on Resident #28's bed, the DON said that Resident #28 is utilizing 1/4 rails. The DON said even in the down position the side rails are still quarter rails. The DON moved Resident #28's bed rails into a 1/4 rail position and the rails were no longer in the middle of the bed and the rails were now in the upper 1/4 of Resident #28's bed. During an interview on 10/31/24 at 9:53 A.M., the Director of Operations said Resident #28's bed rails are quarter rails in the up position but when they are down in the other position, as they are on Resident #28's bed they are no longer quarter rails.

Based on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed by the facility in a timely manner for one Resident (#28) out of a total sample of 17 Residents. Findings include: Review of the facility policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, dated as January 1, 2021, indicated the consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion. C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Resident #28 was admitted to the facility in June 2024 with diagnoses including hemiplegia, diabetes, brain disorder and encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/24/24, indicated that Resident #28 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #28's pharmacist notes, dated 9/21/24 and 10/21/24 indicated the following: -Nursing recommendation to clarify two Tylenol as needed (prn) pain orders. Review of Resident #28's form titled summary of pharmacy recommendations for Director of Nursing (DNS)/Medical Director, dated 9/22/24 and 10/22/24, indicated: - This resident has two orders for as needed (PRN) Tylenol. One order is for 1 gram (gm) three times daily as needed for pain and the other order is for 650 mg every 6 hour as needed for pain. - Please clarify which order should remain active and discontinue the other order. Thank you for helping avoid a medication error. Review of Resident #28's physician's order, dated 8/21/24, indicated: - Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 6 hours as needed for pain. Review of Resident #28's Medication Administration Record (MAR), dated September and October 2024, indicated nursing administered Resident #28's as needed acetaminophen (325 mg), give 2 tablets) on 9/26/24, 10/1/24, and twice on 10/4/24, 10/22/24, and 10/30/24. Review of Resident #28's physician's order, dated 8/21/24, indicated: Tylenol Extra Strength Oral Tablet 500 milligrams (mg) (Acetaminophen), give 2 tablets by mouth as needed for pain, give 3 x daily as needed. Review of Resident #28's Medication Administration Record (MAR), dated September 2024, indicated nursing administered Resident #28's as needed acetaminophen (500 mg give 2 tablets) on 9/24/24. During an interview on 10/31/24 at 11:24 A.M., the Director of Nursing (DON) said the pharmacy recommendations should be reviewed and acted upon. The DON said the recommendation from 9/22/24 was repeated on 10/22/24 and was not acted upon but should have been.

Based on observations and interviews, the facility failed to ensure all medications used in the facility were stored in accordance with accepted professional principles of practice. Specifically, the facility failed to ensure nursing properly stored medications on one of two nursing units observed ([NAME] Unit). Findings include: Review of the facility policy titled, Storage of Medications, dated January 1, 2021, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 10/30/24 at 9:09 A.M., 10/30/24 at 1:01 P.M., 10/30/24 at 3:57 P.M., 10/31/24 at 6:41 A.M., and on 10/31/24 at 7:58 A.M., the surveyor observed at the [NAME] Unit nurses station a plastic container that was unlocked and unattended by nursing staff, that contained vials of ampicillin sulbactam (intravenous (IV) antibiotic medication). During an interview on 10/30/24 at 1:01 P.M., Nurse #1 said that the medications in the plastic container at the nurse's station is Resident #62's IV antibiotics. During an interview on 10/31/24 at 6:40 A.M., Nurse #6 said that nursing staff is storing Resident #62's IV medications at the [NAME] Unit nursing station. On 10/31/24 at 8:02 A.M., the surveyor and nursing staff counted the contents of the plastic container. There were 30 vials of ampicillin sulbactam that were currently inside the plastic container and that were left unlocked and unattended at the [NAME] Unit. During an interview on 10/31/24 at 8:03 A.M., the Director of Nursing said that Resident #62's IV antibiotics should not have been unlocked and unattended.

Based on observation and interview, the facility failed to date refrigerated foods and dispose of expired refrigerated food as required. Findings include: Review of the facility policy titled Food Receiving and Storage (undated) indicated: - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). On [DATE] at 7:25 A.M., the surveyor toured the kitchen with the Food Service Director (FSD). The surveyor observed in the refrigerator: - Three undated plastic containers covered in plastic wrap: one labeled pasta sauce, one unlabeled and containing a reddish-brown liquid, and one unlabeled and containing an opaque liquid. - One pan labeled caramel sauce, dated as expired [DATE]. During an interview with the FSD on [DATE] at 7:30 A.M., she said all refrigerated foods must have a written expiration date and that foods past the expiration date must be removed and discarded.

Based on record review, interview, and observation for two Residents (#47 and #25), the facility failed to ensure they maintained complete and accurate documentation in the medical record. Specifically, the facility failed to: 1.) For Resident #47, the facility failed to accurately document a treatment for steri strips. 2.) For Resident #25 the facility failed to ensure nursing completed a wound description on an admission assessment and weekly skin check. Findings include: 1.) Resident #47 was admitted to the facility in July 2024 and had diagnoses which included psychosis and dementia. Review of Resident #47 Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6, signifying severe cognitive impairment. Review of Resident #47's physician orders dated 10/15/24 indicated: - Monitor right forearm steri strips. Secure every shift. Steri strips are adhesive bandages used to pull together the edges of small wounds. Review of Resident #47's Treatment Administration Record dated 10/31/24, 7:00 A.M. to 3:00 P.M. shift, indicated Nurse #8 signed off as having completed the right forearm steri strip treatment. On 10/31/24 at 11:42 A.M., the surveyor observed Resident #47's exposed right forearm. There were no steri strips present. A small, scabbed wound, approximately 1 centimeter (CM) x 0.5 CM, was located on the right forearm. During an interview with Nurse #8 on 10/31/24 at 11:45 A.M., he said Resident #47's right forearm wound had healed and no longer required steri strips. Nurse #8 said he was unaware he had signed that he provided the treatment this morning. 44095 2.) Review of the facility policy, Skin Body Audit, dated as reviewed 5/9/22, indicated to identify changes in skin integrity through weekly skin audits (head to toe) on all residents. - Licensed nurses will perform skin body audits on a weekly basis, preferably on shower days. 1. The Licensed Nurse performs a weekly head to toe check of the resident's skin, paying particular attention to: - The surfaces of the skin that come in contact with the bed and chair, - Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.), - The surfaces of the skin that come in contact with any orthotic device, tube, brace or positioning device, - Skin folds. Review of the facility policy, Pressure Ulcer Prevention, dated as revised 12/22/22, indicated the facility will identify residents at risk for pressure ulcer development upon admission and throughout their stay. The facility will implement interventions to minimize and/or eliminate contributing factors for pressure ulcer development on patients/residents at risk. 1. Residents will be evaluated by the nurse for risk of skin breakdown using the Norton Scale or other approved skin assessment tool on admission, upon a significant change in condition, and quarterly. 5. A weekly body audit will be completed on residents. 6. Wounds will have weekly assessment and documentation on each area until healed. 9. The facility will provide education for treatment and prevention of pressure ulcers to caregivers. Additional education will be provided to residents and family as applicable. Resident #25 was admitted to the facility in May 2024 with diagnoses including diabetes and nutritional anemia. Review of Minimum Data Set (MDS) assessment, dated 5/28/24, indicated that Resident #25 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #25 had one stage 2 (M0300B1) pressure ulcer that was present on admission (M0300B2). Review of Resident #25's hospital discharge summary, dated 5/23/24, indicated the following: - Pressure Injury to the Coccyx, dated 5/21/24. Review of Resident #25's hospital RN shift note, dated 5/23/24, indicated: - Assessment: DTI (deep tissue injury) to coccyx, discolored purple area. Mepilex (absorbent wound dressing) changed overnight. Review of Resident #25's assessment titled [NAME]-Admission/ Readmission Nursing Assessment (Premier) dated 5/23/24 indicated: - Section C 10. Coccyx, Pressure. Further review of the assessment failed to include a description of the pressure ulcer. Review of Resident #25's clinical nursing note, dated 5/23/24, indicated: - Note Text: pressure ulcer to coccyx. Further review of the note failed to include a description of the pressure ulcer. Review of Resident #25's assessment titled SECTION Cust. [NAME]-Weekly Skin Checks (Premier - Triggered), dated 5/27/24, indicated: 1. Does the resident have any open areas or marks on skin? 2. If yes, list all marks on body and open areas with sizes and descriptions Site: 53) Sacrum, Description: pressure ulcer. Further review of the assessment failed to include a description of the wound. During an interview on 10/30/24 at 1:22 P.M., Nurse #2 reviewed admission assessment, and she said Resident #25 was admitted with a pressure ulcer. Nurse #2 said based on the admission assessment she was unable to determine a description of the wound. During an interview on 10/30/24 at 1:24 P.M., Nurse #1 said she completed the admission assessment and skin check on 5/27/24. Nurse #1 said she did not document the appearance of the pressure ulcer but should have. Nurse #1 said it was really hard to remember what Resident #25's wound looked like because it has been months since she admitted Resident #25. During an interview on 10/30/24 at 2:38 P.M., MDS Nurse #2 that skin assessments are not always accurately completed and should be so she can review the documentation for MDS completion. During an interview on 10/31/24 at 11:21 A.M., the Director of Nursing (DON) said nursing should complete the description section in skin assessments including descriptions of wounds.

Based on observations and interviews, for two of two resident units, the Facility failed to ensure they maintained a clean and homelike environment for resident use, when the showers rooms on both units were found to have dirty tile grout, the shower room on one unit had missing floor tiles, the drain cover was missing, and there were flying insects hovering around the open drain. Findings include: The Facility Policy, titled Homelike Environment, undated, indicated the Facility would provide residents with a safe, clean, comfortable, and homelike environment that reflected a homelike setting including cleanliness and order. During a tour of the Facility on 08/27/24 at 09:00 A.M., the shower room on the [NAME] Unit the Surveyor observed the following: - There were dark colored stains in the grout on the tiled shower walls from the floor to four feet up the walls; - 12 small tiles were missing around the floor drain; - The drain did not have an appropriate drain cover, and in place of a drain cover a metal mesh sink strainer had been put in place over the drain; - Several dead, small winged insects were observed on the shower chair and on the walls of the shower room; - Live small flying insects were observed flying around the shower room. The Shower room on the [NAME] Unit the Surveyor observed the following: - Dark colored stains in the grout on the tiled shower walls from the floor to two feet up the walls. During interview on 08/27/24 at 1:26 P.M., the Regional Maintenance Director said the grout in the shower rooms, the drain cover, and tiles in the [NAME] Unit shower room needed to be repaired. During interview on 08/27/24 at 09:08 A.M., the Director of Nurses (DON) said the shower rooms should not be that way, that the walls should be kept clean, that the tiles and drain cover in the [NAME] Unit shower room should be replaced, and the small flying insects should be removed.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as having and was indicated on his/her meal ticket, that he/she had extensive food allergies which included milk, it was alleged that the Facility failed ensure that Resident #1 was not served food that contained items he/she was allergic to, when on 09/14/20, Resident #1 was served hot cereal for breakfast, which kitchen staff prepared using milk, shortly after consuming half of the hot cereal, Resident #1 complained of not feeling well, was lightheaded, had a scratchy throat, felt he/she could not breathe, 911 was initiated, and Resident #1 was transferred to the Hospital Emergency Department where he/she was treated with steroids via intravenous (IV) for suspected allergic reaction. Findings include: The Facility's Investigation, dated 9/14/20, indicated that Resident #1, who was assessed as having multiple food allergies which included milk, had been served hot breakfast cereal made with milk prepared by the kitchen staff. The Investigation indicated that the Nurse Supervisor checked Resident #1's meal tray and his/her meal ticket prior to serving his/her breakfast. The Investigation indicated that Resident #1's meal ticket indicated milk as an allergy. The Investigation indicated that Resident #1 had become hypotensive (low blood pressure) and required an emergency transfer to the hospital for an evaluation. Review of the Hospital Admission Record, dated 9/14/20, indicated that Resident #1, who had an allergy to dairy, had been served hot cereal made with milk, which he/she ingested for breakfast. The Record indicated that Resident #1 reported to staff that he/she felt lightheaded, had an itchy throat, and felt he/she could not breath. The Record indicated Resident #1 was assessed as having signs and symptoms that included shortness of breath, throat closing and hives. The Hospital Record indicated Resident #1 had a history of [REDACTED]. The Hospital Record indicated that Resident #1 was treated in the Emergency Department with 100 milligrams of [MEDICATION NAME] (steroid) intravenously (IV) for suspected allergic reaction. The Facility's Policy, titled Food Allergies and Intolerance's, undated, indicated the following: - residents with food allergies and/or intolerance's will be identified upon admission, -steps will be taken to prevent resident exposure to the allergies, -meals well be specifically prepared for residents with severe food allergies so that cross-contamination with allergens does not occur. Review of Resident #1's medical record indicated he/she was admitted to the Facility in September 2020, he/she was alert, oriented, able his/her own health care decisions and had an extensive list of specific food allergies, which included many fruits, most types of nuts, eggs and milk. Review of Resident #1's Initial Care Plan, dated 9/09/20, indicated that although nutritional status and diet were checked off as a care area concern, there was no documentation to indicate what the concern was and did not reference his/her extensive food allergies. Resident #1's Comprehensive Nutrition Assessment , dated 9/12/20, indicated that he/she had a long list of food allergies. The Assessment indicated the following; -Resident #1 was at nutritional risk as evidence by extensive food allergy list, [MEDICAL CONDITION] (insufficient healthy red blood cells) and leukopenia (low white blood cell count). -Nutritional goals were to provide adequate nutrition, calories, protein and hydration. -Nutritional interventions included specific menu choices will be provided, large portions will be provided and appropriate supplements will be provided. However, there were no interventions identified in nutritional assessment, regarding Resident #1's extensive list of food allergies, to indicate how the facility would ensure Resident #1 would not served food that contained items he/she was allergic to. Review of the Nurse Progress Note, dated 9/14/20, indicated that Resident #1 reported not feeling well and his/her blood pressure decreased to 68/44. The Note indicated staff called 911 and Resident #1 was transferred to the Hospital Emergency Department for evaluation. Resident #1's Plan of Care, dated 9/15/20, indicated he/she had a lot of food allergies and staff were to monitor for an allergic reaction. During an interview on 10/15/20 at 3:30 P.M., Resident #1 said that during his/her admission to the facility, he/she was frequently served food items that he/she was allergic to. Resident #1 said that after eating his/her breakfast on 9/14/20, his/her throat began to close up and he/she was surprised that he/she made it to the nursing station to report not feeling well due to the severity of his/her allergic reaction. During an interview on 10/15/20, at 12:00 P.M., the Cook said he was not really trained by anyone specific at the facility, but said he was trained to make the hot cereal with milk, that it was the way he and other kitchen staff always made it. The Cook said the kitchen has recipe instructions for food items but said he did not reference the material prior to cooking the hot cereal and he was unsure if there is a specific recipe for hot cereal. During an interview on 10/14/20 at 12:52 P.M., the Food Service Manager (FSM) said he had only been employed at the Facility for about two months. The FSM said he was working at the Facility on 9/14/20, the day of the incident. The FSM said that after the incident involving Resident #1, the Director of Nurses (DON) came into the kitchen to speak with the food service staff and that was when it was discovered that the Cook made Resident #1's hot breakfast cereal with milk. The FSM said that residents can request milk as an option with their hot breakfast cereal but said hot cereal should not be made standard that way for all residents. The FSM said he was unaware that the Cook had been trained to make the hot breakfast cereal with milk until he had a conversation on 9/14/20 with the Cook and the DON. The Facility's Investigation indicated kitchen staff were re-educated on checking for food allergies prior to preparing food to be served to residents. During an interview on 10/15/20 at 2:50 P.M., the Nurse Supervisor said that on 9/14/20, she checked Resident #1's meal slip and breakfast to ensure that his/her diet orders were followed. The Nurse Supervisor said that Resident #1's hot cereal was prepared by the kitchen and said she did see any visible signs that it contained milk or cream. During an interview on 10/15/20 at 12:17 P.M., the Nurse Practitioner said that on 9/14/20, Resident #1 walked up to the nursing station where she was standing with the Nurse Supervisor. The Nurse Practitioner said Resident #1 reported not feeling well and upon assessment, he/she had a low blood pressure and 911 was called. The Nurse Practitioner said she was aware that Resident #1 had several food allergies, but he/she did not display any signs of an allergic reaction that morning at the Facility. During an interview on 10/14/20 at 9:30 A.M., the Director of Nursing (DON) said that nursing staff checks residents meal tickets and trays to ensure the safety of the residents. The DON said that Resident #1's hot cereal was made with milk, but it was not visible to the Nurse Supervisor or Resident #1 prior to him/her ingesting the food item he/she had an allergy to.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as having multiple food allergies, it was alleged that the Facility failed accommodate Resident #1's food allergies, when on 09/14/20, Resident #1, who was allergic to milk, had eaten hot cereal for breakfast which the kitchen staff had prepared with milk, after consuming half of the hot cereal, he she complained of not feeling well, was lightheaded, had a scratchy throat, felt like he/she could not breathe, 911 was initiated, and he/she was transferred to the Hospital Emergency Department where he/she was treated with steroids via intravenous (IV) due suspected allergic reaction. Findings include: The Facility's Investigation, dated 9/14/20, indicated that Resident #1, who was assessed as having multiple food allergies including milk, had been served hot cereal for breakfast that had been made with milk, prepared by the kitchen staff. The Investigation indicated that the Nurse Supervisor checked Resident #1's meal tray and his/her meal ticket prior to serving his/her breakfast. The Investigation indicated that Resident #1's meal ticket indicated milk as an allergy. The Investigation indicated that Resident #1 had become hypotensive and required an emergency transfer to the hospital for an evaluation. Review of the Hospital Admission Record, dated 9/14/20, indicated that Resident #1, who had an allergy to dairy, had been served hot cereal made with milk, which he/she ingested for breakfast. The Record indicated that Resident #1 reported to staff that he/she felt lightheaded, had an itchy throat, and felt he/she could not breath. The Record indicated Resident #1 was assessed as having signs and symptoms that included shortness of breath, throat closing and hives. The Hospital Record indicated Resident #1 had a history of [REDACTED]. The Hospital Record indicated that Resident #1 was treated in the Emergency Department with 100 milligrams of [MEDICATION NAME] (steroid) intravenously (IV) for suspected allergic reaction. The Facility's Policy, titled Food Allergies and Intolerance's, undated, indicated that residents with food allergies and/or intolerance's will be identified upon admission and steps will be taken to prevent resident exposure to the allergies. The Policy indicated that all residents allergies and intolerance's will be incorporated into the resident's care plan. The Policy indicated that the Attending Physician will be notified of the resident's food allergies and standing orders for emergency medications (e.g., [MEDICATION NAME]) and interventions will be taken. Review of Resident #1's medical record indicated he/she was admitted to the Facility in September 2020, he/she was alert, oriented, able his/her own health care decisions and had an extensive list of specific food allergies, which included many fruits, most types of nuts, eggs and milk. Resident #1's Comprehensive Nutrition Assessment , dated 9/12/20, indicated that he/she had a long list of food allergies. The Assessment indicated the following; -Resident #1 was at nutritional risk as evidence by extensive food allergy list, [MEDICAL CONDITION] (insufficient healthy red blood cells) and leukopenia (low white blood cell count). -Nutritional goals were to provide adequate nutrition, claries, protein and hydration. -Nutritional interventions included specific menu choices will be provided, large portions will be provided and appropriate supplements will be provided. However, there were no interventions identified in the nutritional assessment, regarding Resident #1's extensive list of food allergies, to indicate how the facility would ensure Resident #1 would not be served food that contained items he/she was allergic to. Resident #1's Plan of Care, dated 9/15/20, indicated he/she had a lot of food allergies and staff were to monitor for an allergic reaction, however there were no interventions identified to how the Facility would ensure he/she was not served foods prepared with items he/she was allergic to. During an interview on 10/15/20 at 3:30 P.M., Resident #1 said that during his/her admission to the Facility, staff would frequently serve him/her food items that he/she was allergic to. Resident #1 said that after eating his/her breakfast on 9/14/20, his/her throat began to close up and he/she was surprised that he/she made it to the nursing station to report not feeling well due to the severity of his/her allergic reactions. During an interview on 10/15/20, at 12:00 P.M., the Cook said that he was trained to make the Facility's hot cereal with milk, that it was the way he and other kitchen staff had always made it. The Cook said the kitchen has recipe instructions for food items but said he did not reference the material prior to cooking the hot cereal and said he is unsure if there is a specific recipe for hot cereal. At the time of the Survey, the Facility was unable to provide a recipe for the kitchen staff to reference when making hot cereal for the residents, including a recipe for resident with allergies, including but not limited to an allergy to milk. During an interview on 10/14/20 at 12:52 P.M., the Food Service Manager (FSM) said he had only been employed at the Facility for about two months. The FSM said he was unaware that the Cook had been trained to make the hot cereal with milk until he had a conversation on 9/14/20 with the Cook and the DON. The FSM said as a standard of practice, hot cereal being prepared to be served to all residents, should not be made milk. The FSM said there is a list in the kitchen for all residents diets, that he updates it as needed and said he checks with nursing daily or every other day for changes. During an interview on 10/14/20 at 9:30 A.M., the Director of Nursing (DON) said that nursing staff checks residents meal tickets and trays to ensure the safety of the residents. The DON said that Resident #1's hot cereal was made with milk, but it was not visible to the nurse or Resident #1 prior to him/her ingesting the food item he/she had an allergy to. Although nursing staff verified and checked Resident #1 meal against the meal ticket, as required, prior to serving him/her the hot cereal, because there would be no way for staff visualize or know it had been prepared with milk, the Facility was unable to demonstrate how they would safely accommodate a residents' nutritional needs, especially in the case of Resident #1 who had such an extensive list of food allergies.

Based on record review, interviews and observations for 5 of 10 sampled residents (Resident #1, #2, #3, #4 and #9), who were identified at risk for aspiration and were prescribed a pureed diet, the Facility failed to ensure that adequate supervision and assistance with feeding was provided in accordance with the plan of care. On [DATE], Resident #1 was left alone and unsupervised in his/her room, eating a peanut butter sandwich, which was not consistent with his/her diet orders. Resident #1 choked and attempts at clearing his/her airway were unsuccessful. Resident #1 died . On [DATE], [DATE] and [DATE], during 6 meal observations served in the dining room, the Surveyor observed Resident #2, #3 #4 and #9, who required supervision and/or assistance with feeding, eating pureed food, independently, without direct supervision and/or assistance from staff. At 4:50 P.M. on [DATE], the Surveyor observed 12 residents, including Resident #9, eating supper independently in the dining room, for a period of approximately 2 minutes, at which time no staff were present. Findings include: 1. The Facility's Policy titled Aspiration Precautions (undated), indicated Residents who have been identified at high risk for choking, who have difficulty with swallowing, or who are receiving thickened liquids, will be placed on aspiration precautions. The Policy indicated that any resident who meets this criteria will be out of bed at meal times, will be seated up right and positioned properly, and will be supervised during meals. 2. An Annual Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 had a history of [REDACTED]. A Nutritional Assessment, dated [DATE], indicated Resident #1 had fractured teeth, was unable to communicate his/her needs, he/she ate slowly and required extensive assistance with feeding. The Plan of Care, dated [DATE], indicated Resident #1 had difficulty chewing and required continuous assistance with meals. The Physician's diet order, dated as renewed on [DATE], indicated Resident #1 was prescribed a pureed diet. A Nurse Progress Note, dated [DATE], indicated at approximately 8:00 P.M. Resident #1 was given an evening snack. At 8:30 P.M. staff responded to the sound of Resident #1 coughing in his/her room and upon arrival, Resident #1 was observed pointing at his/her throat, with saliva drooling from the side of his/her mouth, but was unable to say what happened. The Note indicated staff performed a mouth sweep on Resident #1 and removed some brown food, the [MEDICATION NAME] maneuver was performed and Resident #1 spat out a small bolus (chewed mass) of food. The Note indicated Resident #1 became unconscious, Code Blue (activation of 911 emergency medical services) was activated, and minutes after the EMS crew arrived, Resident #1 stopped breathing. The Emergency Medical Service (EMS) Report indicated EMS was dispatched to the Facility at 8:59 P.M. (29 minutes after Resident #1 was discovered choking) on [DATE], incident choking, Priority 1. The EMS Report indicated on arrival, patient found supine (lying on his/her back) on floor in cardiorespiratory arrest. Per staff, they came in to feed patient, and upon placing liquid in her mouth, noted patient not responding and called 911. Upon EMS arrival, patient noted to have liquid in her oropharynx (back of throat) that was suctioned out (by EMS). Cardiopulmonary Resuscitation (CPR) was initiated (by EMS) by bed (beside the bed on the floor). An Automatic External Defibrillator (AED) was applied (by EMS) and oxygen was delivered. Staff were poor historians that could not state last time patient was spoken to, but patient was noted to be cool with mottled skin. No sign of rigor of lividity. AED advised no shock after 2 minutes of CPR, at which time staff produced a valid Do Not Resuscitate (DNR) order. CPR terminated and Resident #1's death was declared at 9:08 P.M. on [DATE]. At the request of staff, patient was placed back in bed. Staff stated that they would contact their Physician to handle further. Referred to Facility staff . The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said she was aware that Resident #1 was to receive a pureed diet and eat soft foods. CNA #1 said Resident #1 usually fed him/herself and most nights ate a snack, which was sent up from the kitchen, in his/her room. CNA #1 said on the evening of [DATE], at approximately 8:00 P.M. she removed a bag containing a sandwich, which to the best of her recollection had a hand written label with Resident #1's name, from the snack tray which had been sent up earlier in the evening from the kitchen. CNA #1 said she brought the sandwich into Resident #1's room, she sat Resident #1 up on the edge of the bed, and placed the overbed table in front of Resident #1. CNA #1 said she opened the bag and removed a peanut butter sandwich which she gave to Resident #1. CNA #1 said she gave Resident #1 a drink of juice and left Resident #1 alone in his/her room eating the peanut butter sandwich. CNA #1 said approximately 20 minutes later she went back to check on Resident #1 and he/she was still eating the peanut butter sandwich. CNA #1 said she left the unit, without letting other staff know, and went downstairs to the basement bathroom where she remained for quite a long period of time, or words to that effect. CNA #1 said when she returned to the Unit, other staff told her Resident #1 had choked and was dead. The Surveyor interviewed Nurse #1 at 4:00 P.M. on [DATE]. Nurse #1 said Resident #1 required 1 person physical assist with feeding, and was prescribed a pureed diet. Nurse #1 said all snacks sent up from the kitchen were supposed to be labeled with each resident's name. Nurse #1 said Resident #1 was to have applesauce with his/her evening snack, and he/she should not have been given a peanut butter sandwich and should not have been left alone in his/her room while eating. The Surveyor interviewed Dietary Aide #1 at 4:35 P.M. on [DATE]. Dietary Aide #1 said that on [DATE], she made peanut butter sandwiches (she had no jelly available) and ham and cheese sandwiches for the evening snack. Dietary Aide #1 said she placed preprinted labels with each resident's name on each of the sandwiches and sent these up on a tray, to the unit, via a dumb waiter. Dietary Aide #1 said she could not recall what she made for Resident #1 on the evening of [DATE]. On [DATE], the Facility was unable to provide a copy of Resident #1's dietary preprinted labels utilized by kitchen staff. On [DATE] at 5:30 P.M., the Surveyor observed Dietary Aide #1 leave an unlabelled brown paper bag containing 2 yogurts, 2 cartons of juice, and peanut butter crackers, at the Nurses' Station. Dietary Aide #1 said she did not know who the food was for but to the best of her knowledge it was for a resident going out to [MEDICAL TREATMENT] the next day. 3. An Annual MDS Assessment, dated [DATE], indicated Resident #2 had a history of [REDACTED]. A Nutritional Assessment, dated [DATE], indicated Resident #2 was prescribed a pureed diet and required assistance with eating. The Plan of Care, dated [DATE], indicated Resident #2 required a mechanically altered diet and staff were to monitor for problems with chewing and difficulty swallowing. A Significant Change in Condition MDS Assessment, dated [DATE], indicated Resident #2 had a significant change in cognition and had a 4 lb weight loss since his/her Annual MDS completed in July, 2015. On [DATE], the Surveyor observed Resident #2 in the dining room during the breakfast time meal. At 8:20 A.M. the Director of Nurses (DON) brought Resident #2's breakfast tray to his/her table and set up the tray (she removed the lids covering the plate and cups on the tray). The DON then walked away and started to assist other residents. The Surveyor observed Resident #2 feeding him/herself a pureed diet without direct supervision or physical assistance from staff in accordance with his/her plan of care. Resident #2 spilled food on his/ her clothing as he/she attempted to bring food to his/her mouth on a spoon. Resident #2 continued to feed him/herself, for 13 minutes, until 8:33 A.M. at which time Unit Manager #1 approached him/her and asked if he/she needed help, and Resident #2 replied yes. At 12:10 P.M. on [DATE], during the lunch time meal, the Surveyor observed Resident #2 feeding him/herself in the main dining room without direct supervision or physical assistance from staff which was not in accordance with his/her plan of care. 4. A Physician Order, dated [DATE], indicated Resident #3 required a speech evaluation secondary to a history of pneumonia, recent cough, question of silent aspiration, and special accommodations, which included a tilt-in space wheelchair. A Speech Pathology Evaluation Record, dated [DATE], indicated Resident #3 had a history of [REDACTED]. The Evaluation recommendations included staff were to ensure Resident #3 was positioned upright, provide cues for strategies to prevent aspiration, encourage small bites and sips, reduce distractions and supervise feeding. A Quarterly MDS Assessment, dated [DATE], indicated Resident #3 was cognitively impaired, required supervision and oversight with encouragement and cueing for feeding, and was prescribed a mechanically altered diet. A Nutritional Assessment, dated [DATE], indicated Resident #3 had a significant weight loss of 9.9% secondary to inadequate oral intake in the past 6 months, he/she required double portions at meal time and continual supervision from staff with feeding. The Plan of Care, dated [DATE], indicated Resident #3 required continuous supervision at meal time and staff were to observe for signs and symptoms of aspiration. The Plan of Care did not identify how staff were to position Resident #3 while eating, what cues to provide while eating or how to ensure Resident #3 took small bites with sips of fluid between each bite. The Physician's diet order, dated as renewed on [DATE], indicated Resident #3 was prescribed a pureed diet with nectar thickened liquids. On [DATE] at 5:00 P.M., the Surveyor observed 6 residents and 1 Certified Nurse Aide (CNA) in the dining room. Resident #3 was seated in a high back Broda chair (type of tilt in space wheelchair), which was tilted backwards and facing the wall. The CNA was at the far end of the dining room passing trays to other residents. Resident #3 reached forward and removed food from the tray, which was placed on a table in front of him/her. Resident #3 spilled food on his/her clothing as he/she brought the food to his/her mouth, and quickly shoveled a large spoon of pureed food into his/her mouth. Resident #3 continued to feed him/herself in this manner throughout his/her meal, eating 100% of the pureed food on his/her plate. Resident #3 did not take any sips of fluid between each bite, and no offer of assistance or cuing was provided by the CNA seated at the far end of the dining room. On [DATE], at at 5:15 P.M. the Surveyor observed Resident #3 seated in his/her high back Broda Chair, which was tilted backwards. Resident #3, who was right handed, was reaching over to the left and was scooping downwards with a spoon to get food from his/her supper tray which was placed on a table to the left of Resident #3. Staff present in the dining room at that time did not attempt to reposition Resident #3 to an upright position, or offer assistance or cuing with feeding. 5. An Annual MDS Assessment, dated [DATE], indicated Resident #4 was cognitively impaired, required 1 person physical assistance with feeding, and was on a mechanically altered diet. A Nutritional Assessment, dated [DATE], indicated Resident #4 was edentulous (toothless), required a pureed diet with thin liquids, and required assistance from staff during meals. The Plan of Care, dated [DATE], indicated Resident #4 required a mechanically altered diet secondary to dyshagia (difficulty swallowing) and required physical assistance with meals. The Physician's diet order, dated as renewed on [DATE], indicated Resident #4 was prescribed a pureed diet with nectar thickened liquids. On [DATE], at 5:20 P.M. the Surveyor observed Resident #4 seated at a table in the the dining room during the suppertime meal. At that time, 12 residents where present in the dining room and staff were observed both entering and leaving the dining room. The Surveyor observed Resident #4 pick up a bowl of tomato soup from the meal tray of the resident seated beside him/her. Resident #4 lifted the bowl to his/her head and drank the soup out of the bowl. No staff were in the immediate area, therefore no staff member intervened or assisted Resident #4. 6. A Quarterly MDS Assessment, dated [DATE], indicated Resident #9 was fed via a gastric tube (feeding tube) in addition to a mechanically altered diet, and he/she was dependent on staff for feeding, requiring physical assistance from 1 person. A Speech Language Pathology Screen Form, dated [DATE], indicated Resident #9 had a significant history of aspiration and was not appropriate for skilled speech therapy at that time. A Nutritional Assessment, dated [DATE], indicated Resident #9's tube feedings were discontinued on [DATE], and he/she required continuous supervision with feeding. The Plan of Care, dated [DATE], indicated Resident #9 was at risk for aspiration and required continual oversight from staff with all meals and used a built up spoon (type of adaptive device) when eating. The Physician's diet order, dated as renewed on [DATE], indicated Resident #9 was prescribed a pureed diet with nectar thickened liquids, he/she was on aspiration precautions, and staff were to encourage slow rate, small bites, sips and occasional throat clear, and suction his/her mouth as needed for increased secretions. On [DATE], at 5:21 P.M. the Surveyor observed Resident #9 eating independently in the dining room. Resident #9 did not have a built up spoon but was feeding him/herself with a regular spoon. As Resident #9 brought the spoon to his/her mouth, food was spilling off the spoon and on to the table. Staff present did not offer any assistance or cues to Resident #9. On [DATE], at 4:50 P.M. the Surveyor observed 12 residents, including Resident #9, eating supper independently in the dining room, for a period of approximately 2 minutes, at which time no staff were present. During this 2 minute time period, the Surveyor observed non-sampled Resident D, whose [DIAGNOSES REDACTED]. The Surveyor observed non-sampled Resident D having difficulty making his/her way around two other tables and chairs that were between him/her and the dining room exit. Non-sampled Resident D reached out his/her hands in front of him/her grasping at air at which time another resident offered to help him/her get out of the dining room.

Based on record review, interviews, and observation, for 1 of 10 sampled residents (Resident #1), the Facility failed to ensure that emergency equipment was readily available and in working order when on [DATE], Resident #1 choked on a peanut butter sandwich and died . Staff interviewed said when Resident #1 was found choking at 8:30 P.M. the emergency cart was brought to Resident #1's room, however, it was not properly stocked with Oxygen, and suction equipment was missing. Resident #1 was placed on the floor and positioned on his/her side. Staff took Oxygen from another resident's room, which they administered to Resident #1 and then called 911 Emergency Medical Services (EMS). When EMS arrived, approximately 30 minutes after staff first observed Resident #1 choking, Resident #1 was noted to be cool with mottled skin. An Automatic External Defibrillator (AED) was applied by EMS and advised no shock after 2 minutes of Cardiopulmonary Resuscitation (CPR), at which time staff produced a valid Do Not Resuscitate (DNR) order. CPR was terminated and Resident #1's death was declared at 9:08 P.M. on [DATE]. At approximately 6:20 P.M. on [DATE], the Surveyor observed the Facility's only Emergency Code Cart. The Oxygen cylinder was empty, and a suction machine was not equipped with a suction canister or suction tubing. At that time 47 residents out of a total census of 58 residents were full codes (in the event of cardiac or respiratory arrest, attempts at resuscitation will be made), including sampled Residents #2, #3, #4, #5, #7 and #8. Findings include: The Facility's Policy and Procedure (P&P) for Checking Code/Emergency Carts (undated), indicated the emergency cart will be inspected daily on the 11:00 P.M. to 7:00 A.M. shift to ensure that drawers are secured with a red plastic lock, the suction machine is operational and plugged in, the oxygen tank is in place and full, and a back board is present. The P&P indicated staff are to visually inspect the cart to verify the suction machine has tubing attached properly and is operational, and that a high flow regulator is attached to the oxygen tank capable of administering 15 liters of oxygen per minute. A Nurse Progress Note, dated [DATE], indicated at approximately 8:00 P.M. Resident #1 was given an evening snack. At 8:30 P.M. staff responded to the sound of Resident #1 coughing in his/her room and upon arrival, Resident #1 was observed pointing at his/her throat, with saliva drooling from the side of his/her mouth, but was unable to say what happened. The Note indicated staff performed a mouth sweep on Resident #1 and removed some brown food, the Heimlich maneuver was performed and Resident #1 spat out a small bolus (chewed mass) of food. The Note indicated Resident #1 became unconscious, Code Blue (activation of 911 emergency medical services) was activated, and minutes after the EMS crew arrived, Resident #1 stopped breathing. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said on the evening of [DATE], at approximately 8:00 P.M. she gave Resident #1 a peanut butter sandwich and left him/her alone in his/her room. CNA #1 said approximately 20 minutes later she went back to check on Resident #1 and he/she was still eating the sandwich. CNA #1 said she left the Unit, without letting other staff know, and went down stairs to the basement bathroom. The Surveyor interviewed CNA #2 at 6:00 P.M. on [DATE]. CNA #2 said that on [DATE], she was sitting in a chair in the hallway completing documentation in the Activity of Daily Living (ADL) book, when at approximately 8:30 P.M. she heard coughing coming from the direction of Resident #1's room. CNA #2 said when she looked up she saw CNA #1 open the door of the stairwell leading to the basement. CNA #2 said she called out to CNA #1 but CNA #1 exited through the door and did not answer her. CNA #2 said she continued to hear coughing and a choking sound and when she went into Resident #1's room, she saw Resident #1 trying to stand up. CNA #2 said Resident #1 appeared to be choking and was pointing at his/her throat. CNA #2 said she called out to Nurse #1 for help. The Surveyor interviewed Nurse #1 at 4:00 P.M. on [DATE] and at 6:15 P.M. on [DATE]. Nurse #1 said when she went into Resident #1's room, Resident #1 was sitting on the edge of the bed with his/her bedside table in front of him/her, and there was a half uneaten peanut butter sandwich on the table. Nurse #1 said Resident #1 was coughing and brown liquid was drooling form the side of his/her mouth. Nurse #1 said she grabbed a pair of disposable gloves, from the glove box located on the wall inside Resident #1's room, which she put on as she walked towards Resident #1. Nurse #1 said she positioned herself in front of Resident #1, and with the overbed table separating her from Resident #1, she bent forward and did a finger sweep of Resident #1's mouth. Nurse #1 said she took a small piece of bread out of Resident #1's mouth but Resident #1 continued coughing. Nurse #1 said she moved the overbed table out of the way, she climbed on to the bed and knelt behind Resident #1. Nurse #1 said she put her arms around Resident #1's waist and thrust upwards. Nurse #1 said Resident #1 coughed up a small piece of bread. Nurse #1 said at that point, she left CNA #2 in the room with Resident #1 and she ran out to the Nurses' station and called Code Blue over the telephone to Nurse #2 and Nurse #3 who where on the opposite Unit. Nurse #1 said she returned to Resident #1's room and shook Resident #1 by his/her shoulders, called out his/her name, but Resident #1 did not respond. The Surveyor interviewed Nurse #2 at 1:30 P.M. on [DATE] and at 9:10 A.M. on [DATE]. Nurse #2 said when she entered Resident #1's room, Resident #1 was sitting on the side of the bed with his/her legs dangling over the edge, he/he appeared very sluggish, he/she was turning blue in the face, and he/she was having difficulty breathing', or words to that effect. Nurse #2 said that Nurse #1 was standing beside Resident #1, and was leaning side ways with her arms around Resident #1's waist. The Surveyor interviewed Nurse #3 at 5:40 P.M. on [DATE]. Nurse #3 said when she entered the room, to the best of her recollection Nurse #1 was kneeling on the bed beside Resident #1, and Resident #1's face was blue. Nurse #3 said she took over from Nurse #1 and performed a back thrust on Resident #1. Nurse #3 said a lump of food came out of Resident #1's mouth. Nurse #3 said at that point someone moved everything out of the way and made a clear space on the floor beside Resident #1's bed. Nurse #3 said Resident #1 was not relaxing so they threw her on the floor to get some air, or words to that effect. Nurse #3 said she placed a pillow under Resident #1's head, covered him/her with a blanket, positioned him/her on his/her side, and rubbed his/her back, or words to that effect. Nurse #1 said she left Nurse #2 and Nurse #3 with Resident #1, who was lying on the floor, and went to get the emergency code cart. Nurse #1 said when she brought the code cart into Resident #1's room, she discovered the Oxygen tank was empty and and there was no canister on the suction machine. Nurse #1 said she went back and searched in other resident rooms until she found an Oxygen tank which she brought back to Resident #1's room. The Emergency Medical Service (EMS) Report indicated EMS was dispatched to the Facility at 8:59 P.M. (29 minutes after Resident #1 was discovered choking) on [DATE], incident choking, Priority 1. The EMS Report indicated on arrival, patient found supine (lying on his/her back) on floor in cardiorespiratory arrest. Per staff, they came in to feed patient, and upon placing liquid in her mouth, noted patient not responding and called 911. Upon EMS arrival, patient noted to have liquid in her oropharynx (back of throat) that was suctioned out (by EMS). Cardiopulmonary Resuscitation (CPR) was initiated (by EMS) by bed (beside the bed on the floor). An Automatic External Defibrillator (AED) was applied (by EMS) and oxygen was delivered. Staff were poor historians that could not state last time patient was spoken to, but patient was noted to be cool with mottled skin. No sign of rigor of lividity. AED advised no shock after 2 minutes of CPR, at which time staff produced a valid Do Not Resuscitate (DNR) order. CPR terminated and Resident #1's death was declared at 9:08 P.M. on [DATE]. At the request of staff, patient was placed back in bed. Staff stated that they would contact their Physician to handle further. Referred to Facility staff . At approximately 6:20 P.M. on [DATE], the Surveyor observed the Facility's only Emergency Code Cart, in the presence of Nurse #3 and the Director of Nurses (DON). The Oxygen cylinder was empty, and a suction machine was not equipped with a suction canister or suction tubing. Neither Nurse #3, or the DON were able to tell the Surveyor where extra supplies of emergency equipment and Oxygen were stored. At that point the Administrator called a Consultant Nurse from a sister Facility who on arrival to the Facility at approximately 7:35 P.M. she found a suction machine with tubing located in the Administrators office in the basement of the Facility. The Consultant Nurse then found 9 oxygen cylinders, 3 empty and 6 with intact seals, located in a respiratory closet on the Hawthorne Unit. The Surveyor reviewed the Facility's Code List which identified 47 out of a total census of 58 residents were full codes, including sampled Residents #2, #3, #4, #5, #7 and #8.

Based on record review and interviews, for 1 of 10 sampled residents (Resident #1) the Facility failed to ensure that he/she received received food in the proper consistency in accordance with his/her physician orders [REDACTED]. Resident #1 was assessed at risk for aspiration and was prescribed a pureed diet. On [DATE], Resident #1 was given a peanut butter sandwich, which was not consistent with his/her diet orders. Resident #1 started to choke but attempts at resuscitation were unsuccessful and he/she died . Findings include: The Facility's Dietary Manual titled Healthcare Services Group, Inc. Diet Manual Third Edition 2011, indicated a pureed diet must consist of foods in a pudding like or mousse consistency to ensure a cohesive quality without lumps. A Nutritional Assessment, dated [DATE], indicated Resident #1 had fractured teeth, was unable to communicate his/her needs, he/she ate slowly and required extensive assistance with feeding. The Plan of Care, dated [DATE], indicated Resident #1 had difficulty chewing and required continuous assistance with meals. The Physician's diet order, dated as renewed on [DATE], indicated Resident #1 was prescribed a pureed diet. A Nurse Progress Note, dated [DATE], indicated at approximately 8:00 P.M. Resident #1 was given an evening snack. At 8:30 P.M. staff responded to the sound of Resident #1 coughing in his/her room and upon arrival, Resident #1 was observed pointing at his/her throat, with saliva drooling from the side of his/her mouth, but was unable to say what happened. The Note indicated staff performed a mouth sweep on Resident #1 and removed some brown food, the [MEDICATION NAME] maneuver was performed and Resident #1 spat out a small bolus (chewed mass) of food. The Note indicated Resident #1 became unconscious, Code Blue (activation of 911 emergency medical services) was activated, and minutes after the EMS crew arrived, Resident #1 stopped breathing. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:55 P.M. on [DATE]. CNA #1 said she was aware that Resident #1 was on a pureed diet and ate soft foods. CNA #1 said Resident #1 usually fed him/herself and most nights ate a snack, usually a peanut butter sandwich, which was sent up from the kitchen, in his/her room. CNA #1 said on the evening of [DATE], at approximately 8:00 P.M. she gave Resident #1 a peanut butter sandwich and 20 minutes later she went back to check on Resident #1 and he/she was still eating the peanut butter sandwich. CNA #1 said she left the Unit, without letting other staff know, and went down stairs to the basement bathroom where she remained for quite a long period of time. CNA #1 said when she returned to the Unit, other staff told her Resident #1 had choked and was dead. The Surveyor interviewed Nurse #1 at 4:00 P.M. on [DATE]. Nurse #1 said Resident #1 was prescribed a pureed diet and he/she should not have been given a peanut butter sandwich. The Surveyor interviewed the Dietitian at 1:50 P.M. on [DATE]. The Dietitian said a peanut butter had a dense consistency, was difficult to swallow, and was not allowed as part of a pureed diet. The Facilities Education Records, titled Diet Orders, dated [DATE], indicated a resident on a puree diet can never ever have a peanut butter and jelly sandwich.

Based on record review and staff interview, the facility failed to obtain a laboratory test in a timely manner and the resident developed symptoms of [MEDICATION NAME] toxicity, for 1 resident (#2) in a total sample of 13 residents. Findings include: Resident #2 was cognitively impaired with [DIAGNOSES REDACTED]. The resident was admitted on [DATE] and had been receiving [MEDICATION NAME] (antipsychotic) since admission. A hospital discharge summary dated 3/24/11, indicated the resident had a history of [REDACTED]. The resident had an admission order for a monthly [MEDICATION NAME] level. The monthly [MEDICATION NAME] level was done on 4/14/11 (normal range) and not done mid-May 2011 when it was due. On 5/30/11, nurse's notes indicated the resident developed the following symptoms: somnolence, intermittent confusion with non-sensical phrases, intermittent tremors to lower extremities and incoordination to left hand and mouth. According to an excerpt from the Nursing 2011 Drug Handbook, the following are symptoms of [MEDICATION NAME] overdose: Diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination, giddiness, ataxia, blurred vision, confusion, tinnitus, large output of dilute urine, slurred speech, loss of consciousness, myoclonic limb movements, agitation, urinary and fecal incontinence, [MEDICAL CONDITION], arrhythmias, [MEDICAL CONDITION], peripheral vascular and coma. On 5/30/11, nursing notes indicated that the Nurse Practitioner (NP) was called and ordered to check [MEDICATION NAME] level. The lab results came in on 5/31/11 and indicated an abnormally high [MEDICATION NAME] level of 2.24 (normal range .50 - 1.50). On 5/31/11, the NP ordered to hold the [MEDICATION NAME] for 2 days then repeat the lab test. The [MEDICATION NAME] was within the normal range on 6/2/11. On 6/3/11, the NP ordered the level to be checked weekly for the next 4 weeks and restarted the [MEDICATION NAME] at a lower dose. Also, the NP ordered to monitor for signs of [MEDICATION NAME] toxicity. The [MEDICATION NAME] level has remained normal since that date. During interview on 7/27/11 at 11:30 p.m., the Hawthorne Unit Nurse Manager confirmed that the [MEDICATION NAME] laboratory test had not been done on a monthly basis as ordered by the physician and that the resident had developed symptoms of [MEDICATION NAME] toxicity on 5/30/11. See F502.

Based on record review and staff interview, the facility failed to obtain laboratory tests in a timely manner for 1 resident (#2) in a total sample of 13 residents. Findings include: Resident #2 was cognitively impaired with [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. The resident had an admission order for 3 laboratory tests monthly: a) CBC, CMP and b) [MEDICATION NAME] level. a) The CBC and CMP were done on 4/14/11 and were not done again. On 7/25/11, this surveyor brought this to the Unit Manager's attention. The physician was called and ordered the labs be done that day. The results on 7/26/11 indicated an abnormally high white blood count (WBC) of 13.5 (normal range is 4.8 - 10.8) The physician ordered to repeat the WBC the next day and ordered a urinalysis, culture & sensitivity (UA/C&S). b) The monthly [MEDICATION NAME] level was done on 4/14/11 (normal) and was not done mid-May 2011. On 5/30/11, nurse's notes indicated the resident developed the following symptoms of [MEDICATION NAME] toxicity: somnolence, intermittent confusion with non-sensical phrases, intermittent tremors of the lower extremities and incoordination of the left hand and mouth. On 5/30/11, nursing notes indicated that the Nurse Practitioner (NP) was called and ordered to check [MEDICATION NAME] level. The lab results came in on 5/31/11 and indicated an abnormally high [MEDICATION NAME] level of 2.24 (normal range .50 - 1.50). During interviews on 5/25/11 at 3:30 p.m. and 5/27/11 at 11:30 p.m., the Hawthorne Unit Nurse Manager confirmed that the laboratory tests had not been done on a monthly basis as ordered by the physician. See F309.