Every finding on record at Copley at Stoughton Nursing Care Center

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose family initiated a transfer to the Hospital Emergency Department (ED) for an evaluation after concerns he/she may have fallen, the Facility failed to ensure Resident #1 was able to return to the Facility following his/her evaluation and considered Resident #1 discharged at the time of transfer. Findings include:Review of the Facility Policy titled Bed-Holds and Returns, dated as last revised 10/2022, indicated all residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies either well in advanced of any transfer or at the time of transfer (or, if the transfer was an emergency, within 24 hours).The Policy further indicated the requirement that residents be permitted to return to the facility following a hospitalization or therapeutic leave applies to all residents regardless of payor source.Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 01/02/26, indicated that Resident #1's Family Member had voluntarily discharged him/her from the Facility because Family Member #1 had called the local Police Department (PD) and Emergency Medical Services (EMS).During a telephone interview on 01/13/26 at 2:13 P.M., Family Member #1 said that on 12/18/25, while visiting, after an incident occurred in Resident #1's bathroom with his/her nurse, (during which they heard a loud bang and he/she was found on the floor), they called the local Police Department (PD) and Emergency Medical Services (EMS) to transfer him/her to the Hospital Emergency Department (ED) for evaluation.Family Member #1 said Resident #1 recently had a fall and had just returned to the facility from the hospital, two days earlier (on 12/16/25) where it had been identified that he/she had chronic vertebral fractures, and they thought it would be best to have Resident #1 seen at the ED for an evaluation, after seeing him/her on the floor.Review of Resident #1's Facility Incident Report, dated 12/18/25, indicated that he/she had been involved in an incident with Nurse #1 in his/her bathroom and although Family Member #1 had not witnessed the incident, a loud bang was heard from the bathroom and Family Member #1 thought that Resident #1 had fallen to the floor. The Report indicated, despite Nurse #1 informing Family Member #1, the noise that Family Member #1 heard was his/her wheelchair hitting the wall, Family Member #1 called the local PD, EMS arrived and asked the Nurse for a Face Sheet and list of medications for transfer.The Report indicated the nurse informed the Police Officer that the Facility was not transferring Resident #1 to the ED, and he/she had no Physician's Order to do so.Resident #1 was admitted to the Facility in April 2024 diagnoses include dementia, history of urinary tract infections, anxiety, repeated falls, and anemia.Review of Resident #1's MassHealth Eligibility Form, dated 08/29/24, indicated that his/her Medicaid benefit was his/her primary payor source on the day of his/her transfer (12/18/25) and therefore a bed hold should have been in place.Review of Resident #1's Physician's Order dated,10/22/24, indicated his/her Health Care Proxy (HCP) had been invoked. Review of Resident #1's Care Plan titled Long Term Care Placement, dated as last reviewed on 12/17/25, indicated that he/she will remain long term care secondary to his/her medical diagnoses, care needs and that Resident #1 will be comfortably assured in a long-term care setting. Review of Resident #1's EMS Patient Care Report, dated 12/18/25, indicated, Family Member #1 had called EMS secondary to Resident #1 having a fall and requested to have him/her evaluated at the Hospital ED.The Report indicated that the Facility was requesting that Resident #1 not be sent back to the Facility and that the Facility said they will not be accepting his/her back.During a telephone interview on 01/21/26 at 9:56 A.M., Nurse #1 said on 12/18/25 while attempting to get Resident #1 off the toilet, his/her legs buckled and she had lowered Resident #1 to the floor.Nurse #1 said that Family Member #1 opened the bathroom door and observed Resident #1 on the floor and assumed he/she had fallen unassisted to the floor. Nurse #1 said that she had lowered him/her and he/she had not struck the floor with any force.Nurse #1 said by the time she had gotten Resident #1 back into bed, the Police and EMS had arrived. Nurse #1 said that EMS asked for transfer paperwork to send Resident #1 to the ED and that she told EMS that Resident #1 did not have a physician's order to be transferred. Nurse #1 said that she did not which Hospital EMS was transferring him/her to.Nurse #1 said that she had been told by Administration not to let Resident #1 back into the Facility and that he/she had been discharged .During a telephone interview on 01/23/26 at 10:54 A.M., the Nurse Practitioner (NP) said that she would have given a verbal order to transfer Resident #1 to the ED for evaluation, however the Supervisor had told her that he/she was a discharge from the Facility. Review of Resident #1's Police Report, dated 12/19/25, indicated that upon return to the Facility (on 12/18/25, only four hours after being transferred to the ED for an evaluation), that Facility Staff (later identified as the Nursing Supervisor) stated that because Resident #1 had been transferred to the ED Against Medical Advice (AMA), that he/she had discharged Resident #1 from the Facility.During a telephone interview on 01/14/26 at 4:01 P.M., the Nursing Supervisor said that on 12/18/25 Resident #1's Family had called Police and EMS, EMS asked the nurse for paperwork for transfer and when staff asked where they were transferring Resident #1, they responded with they would let us know. The Supervisor said she had called Resident #1's Nurse Practitioner but did not ask for any order to transfer and or discharge Resident #1 to the ED because Resident #1 had already left the building and was considered a discharge.The Supervisor said she informed the Administrator and Director of Nurses (DON), and they said Resident #1 had left against medical advice and that she was told that Resident #1 was considered discharged from the Facility and was not allowed to return.During an interview on 01/14/26 at 12:32 P.M., the DON said that Resident #1's Family discharged him/her when they called the Police, EMS, and initiated transfer to the ED for evaluation after an incident. The DON said that to the best of her knowledge, no discharge paperwork was provided to Resident #1 upon transfer and that nursing had not obtained a physician's order for him/her to be transferred to the ED.The DON said that the Administrator made the final decision regarding the discharge status of Resident #1.During a telephone interview on 01/20/26 at 1:10 P.M., the Administrator said that Family Member #1 had discharged Resident #1 from the Facility and Family Member #1 had not informed the Facility what the plan was. The Administrator said that there was no discharge/transfer order and that Resident #1 did not need to go to the ED. The Administrator said that because the Family initiated the discharge, the Facility did not have to readmit Resident #1 back to the Facility despite his/her payor source.

Based on observations and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was labeled and dated in the main kitchen and in three of three unit kitchenette refrigerators. Findings include: Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated, but was not limited to, the following:-Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of the undated facility policy titled Food Brought by Family/Visitors, revised July 2017, indicated, but was not limited to, the following:-Food brought in by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food.a. None-perishable foods will be stored in re-sealable containers with tight-fitting lids. Intact fresh fruits may be stored without a lid.b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use-by date. -The nursing staff will discard perishable foods on or before the use-by date. -The nursing and/or foodservice staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example mold growth, foul odor, past due package expiration dates). On 12/1/25 at 7:01 A.M., the surveyor made the following observations during the initial walkthrough of the main kitchen:-An opened bag of cooked, diced chicken wrapped but undated in the walk-in refrigerator.-Slices of ham wrapped but undated in the walk-in refrigerator.-A plastic container with 20 pre-portioned containers of cottage cheese in the walk-in refrigerator, there was tape on the container indicating a date of 11/17/25.-An opened tub of fruit salad mix in the walk-in refrigerator, 11/7 was written on the lid and the manufacturer-printed best-by date was 11/17/25.-Two tomatoes with significant signs of decomposition, including textural deterioration and the presence of a white wispy growth in the walk-in refrigerator.-Two opened but undated gallon containers of apple cider in a reach-in refrigerator.-One opened but undated container of orange juice in a reach-in refrigerator.-Three packages of sliced cheese opened, wrapped, but undated in a reach-in refrigerator.-A plate with a meat patty in a reach-in refrigerator; the plate was wrapped but undated.-Two pans containing leftover food, the pans were wrapped but undated.During an interview on 12/1/25 at 7:24 A.M., the Food Service Director (FSD) said food service staff check the walk-in refrigerators and reach-in refrigerators when food orders came in and that food orders came in several times per week. The FSD said prepared and open food should be labeled, dated and typically discarded after five days. The FSD said cottage cheese should be labeled and discarded after three days. The FSD said that the tub of fruit salad mix should be discarded and that she did not know when the apple cider or orange juice were opened. The FSD said the meat patty and other leftover food in the reach-in refrigerator should have been dated. On 12/1/25 at 7:37 A.M., the surveyor made the following observations in the [NAME] unit kitchenette refrigerator:-An undated container of food with a Resident room number written on it.-A container of orange juice opened but undated.-An undated pre-portioned dessert.-A jar of applesauce opened but undated.-An undated, pre-portioned container of food consistent in appearance with yogurt.-A sandwich in a plastic bag, the bag and sandwich were not dated.On 12/1/25 at 7:34 A.M. the surveyor made the following observations in the [NAME] unit kitchenette refrigerator:-A container of eggnog opened but undated.-A gallon container of apple cider open but undated.During an interview on 12/1/25 at 7:41 A.M., Nurse #5 said Resident food is kept for 48 - 72 hours and that she would expect Resident food to be dated. Nurse #5 said that the jar of applesauce and container of orange juice should have been dated when opened.On 12/2/25 at 9:15 A.M., the surveyor made the following observations in the [NAME] unit kitchenette refrigerator:-An undated container of food with a Resident room number written on it.-An undated pre-portioned dessert.-Two undated, pre-portioned containers of food consistent in appearance with yogurt.During an interview on 12/3/25 at 8:05 A.M., the FSD said that kitchen staff check the kitchenette refrigerators twice a day to ensure that everything is dated, and that they should dispose of any undated food. The FSD said the kitchen does not supply pre-portioned yogurts or desserts and that the pre-portioned yogurts and desserts must have been taken off trays and placed into the refrigerator by staff. The FSD said she would expect staff to date the pre-portioned desserts and yogurts when they place them into the refrigerator. The FSD said she would expect staff to date beverages when they were opened. The FSD said the undated food should have been discarded.

Based on record review and interviews, the facility failed to ensure one Resident (#41) was free from unnecessary psychotropic medication, out of a total sample of 24 residents.Findings include:Review of the facility policy titled Psychotropic Medication Use, dated July 2022, indicated the following:-Psychotropic medications are not prescribed or given on an as needed (PRN) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.-As needed medication for psychotropic medications are limited to 14 days.-For psychotropic medications that are not antipsychotic: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.Resident #41 was admitted to the facility in October 2025 with diagnoses including anxiety disorder and major depressive disorder.Review of Resident #41's most recent Minimum Data Set (MDS) assessment, dated 10/26/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she was cognitively intact.Review of Resident #41's physician orders indicated the following order with a start date of 10/20/25:-Alprazolam (an antianxiety medication) oral tablet 0.5 milligram (mg). Give one tablet by mouth every 8 hours as needed for anxiety.Review of Resident #41's Medication Administration Record (MAR) from 10/20/25 through 12/1/25, indicated the Resident received alprazolam 51 times as needed.Review of Resident #41's medical record failed to indicate a 14 day stop date had been initiated for the PRN alprazolam.During an interview with Nurse #4 on 12/2/25 at 8:17 A.M., she said a PRN psychotropic requires a stop date and then must be re-evaluated by the physician.During an interview with the Director of Nursing on 12/2/25 at 8:05 A.M., she said psychotropic medication should have a 14 day stop and be re-evaluated by the physician if to be continued and that this would be documented in the medical record.

Based on observations, interviews, and record review, the facility failed to maintain a safe environment for one Resident (#91) out of 24 total sampled residents. Specifically, the facility failed to implement socks with grips to prevent falls as indicated in plan of care for Resident #91.Findings include:Review of the facility policy titled Fall and Fall Risk, Managing, revised December 2007, indicated:-The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls.Resident #91 was admitted to the facility in August 2024 with diagnoses including a stroke, syncope (fainting), and history of fall. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/22/25, indicated Resident #91 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #91 required partial/moderate assistance with putting on and taking off socks.Review of Resident #91's plan of care related to falls, revised 8/19/25, indicated:-Ensure patient is wearing slip resistant shoes or socks with grips. On 12/1/25 at 8:22 A.M., the surveyor observed Resident #91 self-transfer out of bed wearing white socks, which did not have any grips. There was no staff within view of Resident #91. Resident #91 was tangled in his/her oxygen tubing and unsteady on his/her feet while standing. Resident #91 said he/she was going to the bathroom. On 12/2/25 at 7:03 A.M., 8:40 A.M., and 9:37 A.M., Resident #91 was observed in bed wearing white socks, which did not have any grips. During an interview and observation on 12/2/25 at 9:48 A.M., Certified Nurse Assistant (CNA) #1 said she would expect fall interventions, such as socks with grips, to be in place if indicated on the care plan. CNA #1 went into Resident #91's room with the surveyor and said the Resident was wearing socks without any grip. CNA #1 said they usually put socks without grips on when Resident #91 is in bed because he/she only needs socks with grips when he/she is sitting up during the day. CNA #1 said Resident #91 was unable to put on or remove his/her socks without staff assistance.Review of Resident #91's nursing progress note and plan of care, dated 11/3/25 to 12/3/25, failed to indicate Resident refused to wear socks with grips.During an interview on 12/2/25 at 11:31 A.M., Unit Manager #1 said she would expect fall interventions, such as socks with grips, to be in place if indicated on the care plan. Unit Manager #1 said staff should have ensured Resident #91 always had socks with grips on.During an interview on 12/2/25 at 1:10 P.M., the Director of Nursing (DON) said she would expect fall interventions, such as socks with grips, to be in place if indicated on the care plan. The DON said staff should have ensured Resident #91 always had socks with grips on.

Based on record review and interviews, the facility failed to implement pharmacy recommendations for one Resident (#41) out of a total sample of 24 residents.Findings include:Review of the facility policy titled Consultant Pharmacy Reports, dated 2024, indicated the following but was not limited to:-Recommendations are acted upon and documented by the facility staff and/or prescriber.-Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.Resident #41 was admitted to the facility in October 2025 with diagnoses including anxiety disorder and major depressive disorder.Review of Resident #41's most recent Minimum Data Set (MDS) assessment, dated 10/26/25, indicated the Resident scored a 15 out of a total possible 15 on the Brief Interview for Mental Status exam, indicating he/she was cognitively intact.Review of the consultant pharmacist recommendations to the medical doctor (MD), dated 10/23/25, indicated the following:-This resident has an order for a psychoactive PRN (as needed) alprazolam without a stop date recorded.-After 14 days, the use of this psychoactive PRN may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling this medication if necessary.-If this medication is continued as a PRN, we recommend that a stop date be added to the PRN order.-A reasonable amount of time between reviews (stop/evaluation dates) is required and will be determined by a prescriber (proper documentation validating this extension of therapy is required).Review of the medical record failed to indicate the physician addressed the pharmacy consultant recommendation.During an interview with the Director of Nursing on 12/5/25 at 8:05 A.M., she said pharmacy recommendations should be addressed by the physician and documented in the medical record.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, the facility failed to ensure expired medications were removed from medication room on 1 out 3 medication units and failed to ensure medications were dated once opened according to manufacturer's guidelines in one of three medication carts observed.Findings include:Review of facility policy titled Medication Storage policy and Procedure, undated, indicated:-Medications and biologicals labeled in accordance with currently accepted professional principles and include expiration date when applicable.On 12/2/25 at 11:35 A.M., the surveyor and Nurse #1 observed the following in the medication room on the [NAME] Unit.-1 bottle of GeriLanta (antiacid) expired 10/2025.During an interview with Nurse #1 on 12/2/25 at 11:35 A.M., she said nurses are responsible for ensuring no expired medications are in the medication room.On 12/2/25 at 11:49 A.M., the surveyor and Nurse #2 observed the following in the [NAME] Unit side A medication cart.-Two trelegy ellipta inhalers, opened and undated.-Two fluticasone propionate nasal spray, opened and undated.During an interview with Nurse #2 on 12/2/25 at 11:54 A.M., she said inhalers and nasal sprays should be dated once opened.During an interview with the Director of Nursing on 12/2/25 at 1:13 P.M., she said medication without expiration dates should be labeled and dated when opened and that nurses are responsible for checking expired medications in the medication carts and medication rooms.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two Residents (#39 and #72) out of 24 total sampled residents. Specifically, the facility failed to ensure healthcare personnel appropriately don (put on) a precaution gown while providing incontinence care for Resident #39 and Resident #72, who required enhanced barrier precautions (EBP).Findings include:Review of United States Centers for Disease Control and Prevention's (CDC) guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs), updated July 12, 2022, indicated:- Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: device care or use of urinary catheter. Review of the facility policy titled Enhanced Barrier Precautions, dated August 2022, indicated:-EBPs employ targeted gown and glove use during high contact resident care activity when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity.-Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: d. Providing hygiene, f. changing briefs or assisting with toileting.1.) Resident #39 was admitted to the facility in November 2022 with diagnoses including urinary retention and failure to thrive.Review of the most recent Minimum Data Set (MDS) assessment, dated 11/5/25, indicated Resident #39 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. This MDS also indicated Resident #15 had an indwelling urinary catheter.Review of Resident #39's active physician's order, initiated 2/7/24, indicated:-Maintain Enhanced Precaution r/t (related to) H/O (history of) VRE (vancomycin-resistant enterococcus, which is a multidrug-resistant organism) stool, every shift for infection control.Review of Resident #39's plan of care related to infection, revised 11/17/25, indicated:-Resident #39 is on enhanced precautions for VRE in stool.-Staff will wear gloves and gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs/assisting with toileting. On 12/1/25 at 9:19 A.M., the surveyor observed Resident #39 with a urinary catheter bag attached to his/her bed frame. Resident #39 said he/she was concerned about their urinary catheter care because the staff often does not wear a precaution gown when providing urinary catheter care and is afraid about getting an infection. During an observation on 12/2/25 at 7:09 A.M., the surveyor observed Certified Nurse Assistant (CNA) #1 changing Resident #39's incontinence brief. CNA #1 said she was providing incontinence care. CNA #1 was not wearing a precaution gown during this observation. There was a sign posted at the room's doorway that indicated the Resident was on enhanced barrier precautions (EBP) and that everyone must wear gloves and gown for high-contact resident care activities including providing hygiene, changing brief or assisting with toileting, and/or device care or use of urinary catheter. During a follow-up interview on 12/2/25 at 7:20 A.M., CNA #1 said Resident #39 required EBP because he/she had an indwelling urinary catheter. CNA #1 said she was not wearing a precaution gown because it is only required while providing urinary catheter care. CNA #1 said a precaution gown was not required to be worn during incontinence care.During an interview on 12/2/25 at 11:30 A.M., Unit Manager #1 said Resident #39 is on EBP. Unit Manager #1 said a precaution gown is required for any close contact activity for a Resident on EBP. Unit Manager #1 said CNA #1 should have been wearing a precaution gown while providing incontinence care to Resident #39. During an interview on 12/2/25 at 1:10 P.M., the Director of Nursing (DON) said a precaution gown is required during all high contact activities, including incontinence care, for residents on EBP. The DON said CNA #1 should have been wearing a precaution gown while providing incontinence care to Resident #39.During an interview on 12/2/25 at 1:18 P.M., the Infection Preventionist said a precaution gown is required during all high contact activities, including incontinence care, for residents on EBP. The Infection Preventionist said CNA #1 should have been wearing a precaution gown while providing incontinence care to Resident #39.2.) Resident #72 was admitted to the facility in April 2025 with diagnoses including vancomycin-resistant enterococcus (VRE).Review of the most recent Minimum Data Set (MDS) assessment, dated 10/29/25, indicated Resident #72 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 2 out of 15.Review of Resident #72's active physician's order, initiated 11/6/25, indicated:-Enhanced Barrier Precautions, every shift for MDRO (multidrug-resistant organism). Review of Resident #72's plan of care related to infection, revised 12/1/25, indicated:-Enhanced Barrier Precautions r/t MDRO.-Wear gloves and gown for high contact resident care activities Dressing, Providing Hygiene, Bathing/Showering, Changing Brief/Toileting, Transferring, Device Care.On 12/2/25 at 10:01 A.M., the surveyor observed Certified Nurse Assistant (CNA) #2 changing Resident #72's incontinence brief. CNA #2 said she was providing incontinence care. CNA #2 was not wearing a precaution gown during this observation. There was a sign posted at the room's doorway that indicated the Resident was on enhanced barrier precautions (EBP) and that everyone must wear gloves and gown for high-contact resident care activities including providing hygiene and/or changing brief or assisting with toileting.During an interview on 12/2/25 at 11:30 A.M., Unit Manager #1 said Resident #72 is on EBP. Unit Manager #1 said a precaution gown is required for any close contact activity for a Resident on EBP. Unit Manager #1 said CNA #2 should have been wearing a precaution gown while providing incontinence care to Resident #72. During an interview on 12/2/25 at 1:10 P.M., the Director of Nursing (DON) said a precaution gown is required during all high contact activities, including incontinence care, for residents on EBP. The DON said CNA #2 should have been wearing a precaution gown while providing incontinence care to Resident #72.During an interview on 12/2/25 at 1:18 P.M., the Infection Preventionist said a precaution gown is required during all high contact activities, including incontinence care, for residents on EBP. The Infection Preventionist said CNA #2 should have been wearing a precaution gown while providing incontinence care to Resident #72.

Based on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for one Resident (#1) out of 24 total sampled residents. Specifically, the use of antipsychotic medications was inaccurately coded in three MDS assessments for Resident #1.Findings include:Resident #1 was admitted to the facility in November 2013 with diagnoses including a psychotic disorder with delusions.Review of the most recent Minimum Data Set (MDS) assessment, dated 10/1/25, indicated Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. Review of Resident #1's medical record indicated:-Annual MDS, dated [DATE], indicated Resident #1 received antipsychotic medication.-Discharge MDS, dated [DATE], indicated Resident #1 received antipsychotic medication.-Quarterly MDS, dated [DATE], indicated Resident #1 received antipsychotic medication.Review of Resident #1's physician's orders indicated:-Abilify Tablet (an antipsychotic medication) 1 mg (milligram), initiated 3/18/22 and discontinued 6/4/25.Review of Resident #1's medication administration record, dated 6/5/25 to 12/2/25, failed to indicate any antipsychotic medications were administered since 6/4/25, when Abilify was discontinued.During an interview on 12/2/25 at 8:48 A.M., the MDS Nurse said Resident #1 used to be on an antipsychotic, but it had been discontinued a long time ago. The MDS Nurse said the MDS assessments, dated 7/2/25, 9/24/25, and 10/1/25, were coded inaccurately because Resident #1 did not receive any antipsychotic medications during that time.During an interview on 12/2/25 at 11:17 A.M., the Director of Nursing said she would expect all MDS assessments to be coded accurately according to the Resident Assessment Instrument (RAI) guidelines.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. For Resident #31, who has an indwelling urinary catheter, that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and 2. An effective water management program was in place from 7/31/23 to 9/18/24 to prevent the potential growth of Legionella (bacteria that can cause legionellosis [illness caused by Legionella] including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens. Findings include: 1. Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. - EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing - EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO - EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, indicated but was not limited to: - EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. - EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply a. gloves and gown are applied prior to performing the high contact resident care activity - Examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care - EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization - Signs are posted in the door or wall outside the resident room indicating the type of precaution and PPE required - PPE is available outside of the residents' rooms Resident #37 was admitted to the facility in August 2023 and had diagnoses including neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #37 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15, and had an indwelling urinary catheter. On 10/2/24 at 8:58 A.M., the surveyor observed an EBP sign posted at the door of Resident #37's room indicating the Resident was on EBP. During an interview with observation on 10/7/24 at 10:33 A.M., Nurse #12 confirmed that Resident #37 had a Foley catheter, but did not know the size of the catheter or the retention balloon and said she was going to look at the catheter itself to obtain that information. Nurse #12 removed two gloves from a box at the nursing desk and walked down the hallway to the Resident's room. The surveyor observed an EBP sign posted at the door of Resident #37's room and a hanging organizer mounted to the closet door inside the Resident's room that stored gowns. The surveyor observed Nurse #12 don gloves without first performing hand hygiene and did not put on a gown before entering the Resident's room and proceeded to reposition the Resident while he/she was reclined in bed. The surveyor observed the Nurse remove the Resident's pants and examine the Foley catheter. Following the observation, Nurse #12 said she did not perform hand hygiene before donning gloves and no one told her the Resident was on precautions. She said she didn't notice the EBP sign posted at the Resident's doorway, and the hanging PPE organizer that was mounted to the closet door just inside the Resident's room. Nurse #12 read the EBP sign posted at the Resident's doorway and said she should have worn a gown when providing high contact care and did not. During an interview on 10/7/24 at 10:55 A.M., Unit Manager #2 said that Nurse #12 should have performed hand hygiene prior to donning gloves and should have worn a gown when removing Resident #37's clothing and examining his/her Foley catheter because it is high contact care. During an interview on 10/8/24 at 1:35 P.M., the Infection Preventionist said Nurse #12 should have performed hand hygiene prior to donning gloves and followed EBP while providing high contact care for Resident #37. 49428 2. Review of the facility's policy titled Legionella Water Management Program, dated as revised September 2022, indicated but was not limited to: - As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. - The water management team consists of at least the following personnel: a. the infection preventionist; b. the administrator; c. the medical director (or designee); d. the director of maintenance; and e. the director of environmental services. - The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. - The water management program includes the following elements: a. an interdisciplinary water management team. b. a detailed description of and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; (5) Waste. c. the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. d. the identification of situations that can lead to Legionella growth, such as: (5) water temperature fluctuations; (6) water pressure changes; (7) water stagnation; and (8) inadequate disinfection. f. the control limits or parameters that are acceptable and that are monitored; h. a system to monitor control limits and the effectiveness of control measures; j. documentation of the program. - The water management program is reviewed at least once a year, or sooner, if any of the following occur: a. the control limits are consistently not met. During an interview on 10/4/24 at 3:42 P.M., the Director of Maintenance (DOM) said he was new to the facility and had been DOM for about one month. The DOM said he could not provide documentation that a water management program had been implemented prior to his hire. During an interview on 10/7/24 at 2:04 P.M., the Administrator provided a binder of the water management program that was to be in place from 7/31/24 to 9/18/24, but said he could not provide any testing or monitoring documentation during that time. During an interview on 10/7/24 at 3:41 P.M., the Infection Preventionist (IP) said she had not previously participated in the water management program.

Based on interview and record review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#93), out of a total sample of 22 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendation to add a stop date to the Resident's as needed Ativan (an antianxiety medication) order. Findings include: Resident #93 was admitted to the facility in February 2024 with diagnoses including dementia and anxiety. Review of Resident #93's medical record indicated he/she was seen by the Consultant Pharmacist in July 2024 and recommendations were made. The surveyor was unable to locate the July 2024 Consultant Pharmacist's recommendation in Resident #93's record. After inquiry, the facility provided Resident #93's July 2024 Summary of all Doctor Recommendations, dated 7/11/24, provided by the consultant pharmacist. The document indicated but was not limited to: -Resident #93 had an order for as needed Ativan without a stop date and that after 14 days, the use of the as needed psychoactive medication may be continued if it is determined that the benefit of treatment outweighs the potential/actual risk of continued as needed therapy. -The Consultant Pharmacist recommended that if the medication was continued as needed, a stop date should be added to the order. Further review of the July 2024 recommendation form indicated the physician/prescriber response section was blank. During an interview on 10/8/24 at 10:40 A.M., Unit Manager #2 said that she had not been aware of the pharmacist's recommendations from July. Unit Manager #2 said the July recommendations should have been addressed. During an interview on 10/9/24 at 8:42 A.M., the Consultant Pharmacist said that she had provided the facility with a recommendation in July 2024 regarding the lack of stop date on Resident #93's as needed Ativan order. The Consultant Pharmacist said that after a recommendation is made but not addressed when she returns for subsequent months' reviews, it goes on a list of pending recommendations that is given to the facility. The Consultant Pharmacist said that the recommendation she had made in July 2024 for Resident #93 was on the list of pending recommendations that had not been addressed and given to the facility in both August 2024 and September 2024.

Based on record review and interview, the facility failed to ensure one Resident's (#93) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 22 residents. Specifically, the facility failed to ensure as needed antianxiety medications were limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. Findings include: Review of the facility's policy titled Psychotropic Medication Use, dated July 2022, indicated but was not limited to the following: 12. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Resident #93 was admitted to the facility in February 2024 with diagnoses including dementia and anxiety. Review of Resident #93's Physician's Orders indicated but was not limited to the following: -Alprazolam (an antianxiety medication) Oral Tablet 0.25 milligrams (mg) Give 0.25 mg by mouth every 12 hours as needed for anxiety (start date 2/5/24, no end date) -Ativan (an antianxiety medication) Oral Tablet 0.5 mg Give 1 tablet sublingually every 4 hours as needed for anxiety (start date 7/7/24, no end date) Review of Resident #93's Medication Administration Record (MAR) indicated that as needed Ativan was administered on: -7/18/24 at 2:04 A.M. -7/20/24 at 1:15 A.M. -7/25/24 at 1:25 A.M. -7/30/24 at 1:42 A.M. -8/4/24 at 1:33 A.M. -8/10/24 at 5:04 P.M. -8/21/24 at 1:01 A.M. -8/22/24 at 12:58 A.M. -8/25/24 at 2:12 A.M. -9/4/24 at 1:07 A.M. and 3:44 P.M. -9/20/24 at 4:17 P.M. Review of the MAR for July through October 2024 did not indicate that Resident #93 was administered as needed Alprazolam. Review of Resident #93's medical record failed to indicate that the use of antianxiety medications on an as needed basis was limited to 14 days or extended beyond 14 days with a documented clinical rationale and duration. During an interview on 10/8/24 at 10:40 A.M., Unit Manager #2 said she was aware that the Resident's as needed psychotropic medication orders needed stop dates.

Based on record review and interview, the facility failed to ensure one Resident's (#93) representative, as designated by the Resident, was able to make medical decisions for the Resident, in a sample of 22 records reviewed. Specifically, the facility failed to ensure that the Resident's representative was able to formulate the Resident's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form. Findings include: Review of the facility's policy titled Advance Directives, revised September 2022, indicated but was not limited to the following: -Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. -The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents legal representative. -Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. -The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. Resident #93 was admitted to the facility in February 2024 with a diagnosis of dementia. Review of the medical record for Resident #93 indicated a Physician completed a Health Care Activation Form on 2/7/24. The form indicated the physician determined Resident #93 lacked the capacity to make and/or communicate health care decisions related to cognitive impairment dementia and the duration was undetermined. Review of Resident #93's Care Plan indicated but was not limited to the following: -Focus: Resident has a MOLST: DNR (do not resuscitate) DNI (do not intubate) Do not use invasive ventilation No CPAP (continuous positive airway pressure) DNH (do not hospitalize) No dialysis No artificial nutrition No artificial hydration -Interventions 1) Communicate with hospital/EMTs (emergency medical technician) code status 2) MOLST form/copy of MOLST form in front of chart 3) Review MOLST form quarterly with resident and/or HCP 4) If changes made by resident and/or HCP use new MOLST form. Review of the medical record indicated that the Resident signed a MOLST form on 5/14/24 indicating the Resident was not to be resuscitated, not to be intubated and ventilated, not to use non-invasive ventilation, not transferred to the hospital unless needed for comfort, and not to be treated with dialysis, artificial nutrition, or artificial hydration. The MOLST form was signed by the provider on 5/14/24, effecting the orders for life-sustaining treatment immediately as indicated on the MOLST form completed by the Resident. The record failed to indicate that the Resident's representative reviewed and signed the Resident's MOLST form. During an interview on 10/8/24 at 11:10 A.M., Unit Manager (UM) #3 and surveyor reviewed that Resident #93's HCP had been activated in February 2024 and that the Resident, not the HCP, had signed the MOLST form in May 2024. UM #3 said that hospice staff had assisted the Resident with completing the MOLST form but that the HCP should have reviewed and signed the MOLST form at that time since the Resident's HCP was activated.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for two Residents (#93 and #37), out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #93, to develop and implement interventions to address the Resident's risk for falls; and 2. For Resident #37, to ensure the care plan was updated when a Foley catheter (small flexible tube inserted into the urethra to drain urine from the bladder) used to manage the Resident's urinary retention was ineffective and changed to a larger size catheter in response following two episodes of urinary incontinence. Findings include: Review of the facility's policy titled Falls - Clinical Protocol, revised September 2012, indicated but was not limited to the following: -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. -If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. -If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated but was not limited to the following: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; e. reflects currently recognized standards of practice for problem areas and conditions -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The IDT reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. Review of the facility form titled Resident Incident/Accident Report indicated but was not limited to: -Identify what new intervention was put into to prevent a reoccurrence [sic]. The form indicates that the area must be completed. Resident #93 was admitted to the facility in February 2024 with diagnoses including repeated falls, concussion (a brain injury that occurs when the brain is forced to move rapidly within the skull), difficulty walking, weakness, and dementia. Review of Resident #93's Minimum Data Set (MDS) assessment, dated 8/28/24, indicated that the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of the medical record indicated Resident #93 sustained four falls after his/her admission to the facility: -On 4/24/24 at 5:30 P.M., the Resident fell from his/her wheelchair. -On 4/25/24 at 11:00 A.M., the Resident was found on the floor. -On 7/10/24 at 6:20 A.M., the Resident was found sitting on the floor. -On 8/3/24 at 11:10 P.M., the Resident was found sitting on the floor. Review of the facility's Resident Incident/Accident Reports for the falls occurring on 4/25/24, 7/10/24, and 8/3/24 did not indicate new interventions put into place to prevent falls. The Resident Incident/Accident Report for the fall occurring on 4/24/24 indicated the intervention put into place was Call for assistance. Review of Resident #93's Progress Notes indicated but was not limited to the following: -On 4/24/24 at 5:30 P.M., the Resident was found lying on the floor near his/her wheelchair. The Resident had been sitting in the wheelchair prior. When asked what happened, the Resident stated he/she leaned forward to pick up something and slipped out of the chair. -On 4/25/24 at 11:00 A.M., the Resident was found on the floor in his/her room and stated he/she had to use the bathroom. -On 7/10/24 just before 6:30 A.M., the Resident was found sitting on his/her buttocks next to his/her bed. -On 8/3/24 at 11:10 P.M., the Resident slipped from his/her bed with his/her buttocks on the floor. The Resident was confused and having hallucinations and Ativan (an antianxiety medication) was administered at 1:00 A.M. -On 8/4/24 at 6:29 A.M., the Resident was evaluated by a Nurse Practitioner (NP) via telemedicine visit. The NP indicated that the Resident's fall interventions were reviewed and additional fall prevention precautions were to be added per center protocol. Review of Resident #93's Care Plans indicated but was not limited to the following: -Focus: The resident has had an actual fall with serious injury poor balance and unsteady gait (2/5/24) -Goal: a) The resident will resume usual activities without further incident through the review date (2/5/24) b) The resident's Facial Concussion and bruises will resolve without complication by review date (2/5/24) -Interventions: a) Bed at lowest position. (2/5/24) b) Continue interventions on the at-risk plan. (2/5/24) c) Ensure call light is within reach. (2/5/24) d) Ensure patient is wearing slip resistant shoes or socks with grips. (2/5/24) e) Ensure proper use of assistive devices. (2/5/24) f) For no apparent acute injury, determine and address causative factors of the fall. (8/4/24) g) Keep residents [sic] personal possessions within reach. (2/5/24) h) Monitor/document/report PRN (as needed) x 72h (hours) to MD for s/sx (signs and symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. (2/5/24) i) Pharmacy consult to evaluate medications. (2/5/24) j) Provide activities that promote exercise and strength building where possible Provide 1:1 activities if bedbound. (2/5/24) k) PT consult for strength and mobility. (8/4/24). Further review of Resident #93's Care Plans failed to identify a separate at-risk plan as identified in the actual fall care plan interventions noted above. Review of the medical record failed to indicate that Resident #93's comprehensive care plan was reviewed/updated to identify and/or add additional fall prevention interventions after the Resident's falls on 4/24/24, 4/25/24, and 7/10/24. During an interview on 10/8/24 at 12:59 P.M., Nurse #11 said that when a resident has a fall, an incident report is done, the physician and family are notified, the resident is assessed, a fall assessment is completed in the electronic medical record. Nurse #11 said that the Charge Nurse usually updates the Resident's care plan and the completed incident report is given to the Director of Nursing (DON) for review. During an interview on 10/08/24 at 1:00 P.M., the surveyor and DON reviewed the Resident Incident/Accident Reports for Resident #93's falls. The DON said that the reports did not indicate interventions put into place after each fall but that the care plan should have been updated. During an interview on 10/08/24 at 1:25 P.M., MDS Nurse #1 said that no care plan updates were made to Resident #93's fall care plan after the Resident fell on [DATE] and 4/25/24. 34145 2. Resident #37 was admitted to the facility in August 2023 with diagnoses including neuromuscular dysfunction of the bladder. Review of the MDS assessment, dated 9/11/24, indicated Resident #37 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15, and had an indwelling urinary catheter. Review of the medical record indicated Resident #37 was admitted to the hospital in March 2024 and was treated for a urinary tract infection. The Resident had a Foley catheter in place at the time of admission to the hospital, but it was removed prior to discharge. Physician's orders upon return to the facility included, but was not limited to: -Post void residual (PVR) bladder scan every shift. Insert Foley catheter (FC) for greater than 350 milliliters (ml), every shift for 2 Days (4/1/2024) Review of a Skilled Nurse's Note, dated 4/2/24, indicated a bladder scan was performed with a post-void residual (PVR) volume of 438 ml. A Foley Catheter 16 French (Fr) 10 ml balloon was inserted. Review of Resident #37's comprehensive care plans indicated but was not limited to: -Focus: The resident has an indwelling Foley catheter related to neurogenic bladder (10/20/23) -Interventions: Catheter: The resident has 16 French catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door (4/12/24) -Goal: The resident will show no signs/symptoms of urinary infection through review date (4/12/24) Review of a Skilled Nurse's Note, dated 9/13/24, indicated Resident #37 was incontinent of a large amount of urine and the FC 16 Fr 10 ml balloon was changed (with the same size catheter). Review of a Skilled Nurse's Note, dated 9/30/24, indicated Resident #37 was incontinent of a large amount of urine and the FC was changed to a 22 Fr 30 ml balloon. During an interview with observation on 10/7/24 at 10:33 A.M., Nurse #12 confirmed that Resident #37 had a Foley catheter, but did not know the size of the catheter or the retention balloon as there was no physician's order and said she was going to look at the catheter itself to obtain that information. Nurse #12 walked down the hallway and entered Resident #37's room, and proceeded to reposition the Resident while he/she was reclined in bed, remove the Resident's pants and examine the Foley catheter. She said the catheter was a 22 Fr with a 30 ml retention balloon. Further review of comprehensive care plans indicated the care plan for indwelling catheter was not revised to reflect the discontinuation of the FC 16 Fr 10 ml balloon due to its ineffectiveness and initiation of the larger size Foley catheter 22 Fr 30 ml balloon. During an interview on 10/8/24 at 11:25 A.M., Unit Manager #2 said the care plan should have been updated when the 16 Fr Foley catheter failed to effectively manage the Resident's urinary retention and a new, larger catheter was inserted on 9/30/24.

Based on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#77 and #37), out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #77, to identify and provide care for an implanted central line catheter (port, type of central line that allows for long-term access to a patient's bloodstream); and 2. For Resident #37, to ensure physician's orders for insertion of indwelling Foley catheters, including the size of the device, was obtained/documented in the medical record on three occasions. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: 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's policy titled Admission Assessment and Follow Up: Role of the Nurse, last revised September 2012, indicated but was not limited to: - Purpose: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instructions, including the MDS (Minimum Data Set). -Steps in the Procedure: 7. Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission. b. Relevant medical, social, and family history. c. A list of active medical diagnoses and patient problems. - Documentation: The following information should be recorded in the resident's medical record: 3. All relevant assessment data obtained during the procedure. Review of the facility's policy titled Implanted Venous Port Flushing and Locking, last revised 2022, indicated but was not limited to: -Purpose: the purposes of this procedure are to maintain patency of the implanted port. -Frequency 4. Flush implanted venous ports not accessed for infusion at least 10 mL (milliliters) with preservative-free 0.9% sodium chlorine and 3-5 mL heparin (anticoagulant medication, used to prevent clots) every 3 months for maintenance flushing, or refer to manufacturer's instructions. Review of the National Library of Medicine (NLM), dated 5/15/23, indicated but was not limited to: - A central line is a thin, flexible, large-bore tube inserted into a client's large vein, also referred to as a central venous access device (CVAD). -CVADs are commonly guided into the superior vena cava so the distal tip is located in the superior vena cava near the junction with the right atrium. -Complications: -Occlusion due to clot formations: -Flush the catheter routinely as recommended and according to agency policy. -Skin erosion: -Assess the skin at and around the CVAD insertion site. Note any skin separation from the catheter exit site, drainage, contusions, or any indication of skin involvement. https://www.ncbi.nlm.nih.gov/books/NBK594495/ Resident #77 was admitted to the facility in June 2024 with diagnoses including ovarian cancer, colon cancer, and weakness. Review of Resident #77's hospital discharge paperwork, dated 6/11/24, indicated but was not limited to: -Patient Lines/Drains/Airway Status -Implanted Port Chest Wall Review of Resident #77's intial admission assessment, dated 6/11/24, failed to indicate he/she had an implanted central line catheter. Review of Resident #77's hospital discharge paperwork, dated 7/3/24, indicated but was not limited to: - Patient Lines/Drains/Airway Status - Single Lumen Implantable Port Right Chest Review of Resident #77's re-admission assessment, dated 7/3/24, failed to indicate he/she had an implanted central line catheter. Review of Resident #77's chest x-ray (obtained because of an elevated white blood cell count), dated 9/27/24, indicated he/she had a right implanted central line catheter. Further review of Resident #77's medical record failed to indicate he/she had orders for care and maintenance of the implanted central line catheter. During an interview on 10/7/24 at 3:00 P.M., Nurse #2 said she completed Resident #77's admission assessment on 7/3/24. Nurse #2 said she completed an admission assessment but had not reviewed Resident #77's hospital discharge paperwork because another nurse did. Nurse #2 said she did not identify Resident #77 had an implanted central line catheter but should have. During an interview on 10/8/24 at 10:49 A.M., Nurse #10 said she had completed Resident #77's admission assessment dated [DATE]. Nurse #10 said she was aware Resident #77 had an implanted central line catheter, but she did not mark it off on his/her admission assessment and did not pass it on. During an interview on 10/7/24 at 2:58 P.M., Unit Manager (UM) #3 said residents who have implanted central line catheters should have orders for care and maintenance of them. UM #3 said she was unaware Resident #77 had an implanted central line catheter. UM #3 said Resident #77 should have orders for care and maintenance of his/her implanted central line catheter but does not. During an interview on 10/8/24 at 11:32 P.M., the Director of Nursing (DON) said for any resident who had an implanted central line catheter the expectation is that he/she had orders for care and maintenance of it, but Resident #77 did not. 34145 2. Review of the facility's policies titled Medication and Treatment Orders, last revised July 2016, and Verbal Orders, last revised February 2014, indicated but was not limited to: - Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. - Text messaging is not an acceptable method of communicating an order. - The individual receiving the verbal order must write it on the physician's order sheet as v.o. (verbal order) or t.o. (telephone order). - The individual receiving the verbal order will: a. read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed; b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order. Resident #37 was admitted to the facility in August 2023 and has diagnoses including neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment, dated 9/11/24, indicated Resident #37 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15, and had an indwelling urinary catheter. Review of the medical record indicated Resident #37 was admitted to the hospital in March 2024 and was treated for a urinary tract infection. The Resident had a Foley catheter in place at the time of admission to the hospital, and it was removed prior to discharge. Review of the Physician's Orders upon return to the facility included but was not limited to: -Post-void residual (PVR) bladder scan every shift. Insert Foley catheter for greater than 350 milliliters (ml), every shift for 2 Days (4/1/24 - 4/2/24) The physician's order failed to identify the size of the Foley catheter and retention balloon to be inserted. Review of a Skilled Nurse's Note, dated 4/2/24, indicated a bladder scan was performed with a PVR volume of 438 ml and a Foley catheter 16 French (Fr) 10 ml retention balloon was inserted. Review of the medical record indicated the following physician's orders were initiated on 4/2/24: -Foley catheter care every shift -Maintain enhanced precautions related to Foley catheter every shift -Foley Catheter Output every shift Document amount -Change catheter drainage bag (CD) weekly and label/date every night shift every Wednesday Further review of the entire medical record failed to indicate a physician's order was obtained and documented that included the Foley catheter size and retention balloon size to be inserted. Review of a Skilled Nurse's Note, dated 9/13/24, indicated Resident #37 was incontinent of a large amount of urine and the Foley catheter 16 Fr 10 ml retention balloon was changed (with the same size catheter). Further review of the entire medical record failed to indicate a physician's order was obtained and documented to remove and insert a new Foley catheter 16 Fr 10 ml retention balloon. Review of a Skilled Nurse's Note, dated 9/30/24, indicated Resident #37 was incontinent of a large amount of urine, 100 ml in Foley drainage bag, and the Foley catheter was changed with a 22 Fr 30 ml retention balloon. Nurse Practitioner (NP #1) aware. Further review of the entire medical record failed to indicate a physician's order was obtained and documented to remove the Foley catheter 16 Fr 10 ml retention balloon and insert a new FC 22 Fr 30 ml retention balloon. During an interview on 10/7/24 at 10:33 A.M., Nurse #12 reviewed Resident #37's medical record and said she could not find any information about the size of the Foley catheter and retention balloon. Said there should be a physician's order that includes the type and size of the catheter and retention balloon and there is no order. She said there were only orders for catheter care every shift and to change the CD bag. Nurse #12 said it is important to have physician's orders with information about the size of the catheter and retention balloon available in the medical record because if something happens, they need to have that information to change the catheter with the proper size device. During an interview on 10/7/24 at 10:55 A.M., Unit Manager #2 reviewed Resident #37's medical record and said there should have been an order for insertion of the Foley catheter on 4/2/24 that included the size of the catheter and retention balloon and there is not. She said there should also have been orders obtained and documented for the catheter changes with sizes of the catheter on 9/13/24 and 9/30/24 and there were no orders documented as required. During an interview on 10/7/24 at 2:15 P.M., NP #1 said she doesn't recall getting any messages or hearing anything about Resident #37's Foley catheter insertions on 4/2/24, 9/13/24, and 9/30/24, but may have. During a subsequent interview on 10/7/24 at 2:31 P.M., NP #1 said she just reviewed her cell phone messages and found a message from a Nurse regarding Resident #27 dated 9/30/24. She read the message aloud to the survey team and it indicated the Resident was incontinent of urine and a 22 Fr catheter was inserted and it was working, draining clear yellow urine. She said she still did not recall giving an order for the new catheter, but she must have. During an interview on 10/8/24 at 11:25 A.M., Nurse #4 reviewed Resident #37's medical record and said on 9/13/24, the Resident was incontinent of a large amount of urine and she changed the Foley catheter. She said she couldn't remember who she spoke to and did not write/transcribe a telephone order for the Foley catheter change in the medical record. Nurse #4 said on 9/30/24, Resident #37 was incontinent and she notified NP #1 and was given a verbal order to change the catheter, but did not transcribe the order into the medical record. She said she should have written the order and included the size of the catheter and retention balloon and written a note documenting NP notification and that an order was given. During an interview on 10/8/24 at 1:35 P.M., the DON said the nurse should have documented contacting the NP and transcribed the orders for the Foley catheters, including the size of the catheter and retention balloon, when they were inserted on 4/2/24, 9/13/24, and 9/30/24.

Based on record review and interview, the facility failed to complete a discharge assessment to ensure timely coding and transmitting of a Minimum Data Set (MDS) assessment for two Residents (#25 and #42), out of two resident assessments reviewed, resulting in a delay in the encoding and transmission of an MDS post-discharge from the facility. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual Chapter 2: Assessments for the RAI, dated October 2023, indicated but was not limited to: -The MDS must be transmitted (submitted and accepted into iQIES) electronically no later than 14 calendar days after the care plan completion date (V0200C2 + 14 calendar days). 1. Resident #25 was admitted to the facility in April 2024 for short-term skilled rehabilitation services and discharged to the community in May 2024. Review of the medical record indicated the discharge MDS was not completed until 9/30/24 approximately four months following the Resident's discharge from the facility. During an interview on 10/8/24 at 10:08 A.M., MDS Nurse #1 reviewed Resident #25's medical record and said Resident #25's MDS assessment was not submitted for over 120 days and should have been submitted in a timely manner. 2. Resident #42 was admitted to the facility in May 2024 for short-term skilled rehabilitation services and discharged to the hospital in May 2024. Review of the medical record indicated the discharge MDS was not completed until 9/30/24 approximately four months following the Resident's discharge from the facility. During an interview on 10/8/24 at 10:08 A.M., MDS Nurse #1 reviewed Resident #42's medical record and said Resident #42's MDS assessment was not submitted for over 120 days and should have been submitted in a timely manner. During an interview on 10/8/24 at 2:32 P.M., the Director of Nursing (DON) said the expectation was for MDS assessments for Resident #25 and Resident #42 to have been encoded and transmitted in a timely manner.

Based on record review and interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments were completed for three Residents (#80, #93, and #76), out of a total sample of 22 residents. Specifically, the facility failed to: 1. For Resident #80, accurately code the Resident's prognosis of less than six months on the 9/4/24 MDS; 2. For Resident #93, a. Accurately code hospice care on the 3/1/24 MDS, b. Accurately code a fall with injury on the 5/29/24 MDS, and c. Accurately code the Resident's prognosis of less than six months on the 8/28/24 MDS; and 3. For Resident #76, accurately code the Resident's use of antipsychotic medication on the 8/21/24 MDS. Findings include: Review of the facility's policy titled Electronic Transmission of the MDS, revised October 2023, indicated but was not limited to the following: - All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the Resident Assessment Instrument (RAI) User's Manual, before being permitted to use the MDS information system. - The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. Review of the facility's policy titled MDS Error Correction, revised October 2023, indicated but was not limited to the following: - If an error is discovered after the encoding period and the record in error is an OBRA (Omnibus Budget Reconciliation Act, regulations that defined a schedule of assessments that will be performed for a nursing facility resident at admission, quarterly, annually, and whenever the resident experiences a significant change in condition) comprehensive or quarterly assessment, determine if the error is significant or minor. -A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to the iQIES system. -A significant error is one that inaccurately reflects the resident's clinical status and/or may result in an inappropriate plan of care. For major errors: (1) correct the original assessment to reflect the resident's status as of the original assessment reference date and submit the record; and (2) perform a new significant change in status (if this has occurred) or a new significant correction to a prior assessment with a current observation period and assessment reference date. 1. Resident #80 was admitted to the facility in December 2022 with diagnoses including heart failure, cerebral infarction, and dementia. Review of the Hospice Certification of Terminal Illness signed by the Hospice Physician on 9/5/24 indicated that the life expectancy for Resident #80 was less than six months and that hospice care was initiated on 8/26/24. Review of the 9/4/24 Significant Change MDS assessment for Resident #80 indicated that he/she received hospice care. The 9/4/24 MDS assessment failed to indicate that the Resident had a condition or chronic disease that may result in a life expectancy of less than six months. During an interview on 10/8/24 at 8:24 A.M., MDS Nurse #1 reviewed the MDS assessments for Resident #80. The MDS Nurse said that the facility has a difficult time getting a copy of the signed Hospice Certification of Terminal Illness in the time needed to complete the MDS accurately. The MDS Nurse said that if she does not have a copy of the signed Hospice Certification of Terminal Illness or a progress note from the physician indicating that a resident has a life expectancy of less than six months, then she cannot include that information on the MDS. 2. Resident #93 was admitted to the facility in February 2024 with diagnoses including heart failure and dementia. a. Review of the Hospice Certification of Terminal Illness signed by the Hospice Physician on 5/20/24 indicated that hospice care was initiated on 2/24/24 and the prognosis/life expectancy for Resident #93 was less than six months. Review of the 3/1/24 Significant Change MDS for Resident #93 failed to indicate that the Resident received hospice care. During an interview on 10/8/24 at 8:24 A.M., MDS Nurse #1 reviewed the MDS assessments for Resident #93. MDS Nurse #1 said that the facility has a difficult time getting a copy of the signed Hospice Certification of Terminal Illness in the time needed to complete the MDS accurately. MDS Nurse #1 said that if she does not have a copy of the signed Hospice Certification of Terminal Illness or a progress note from the physician indicating that a resident has a life expectancy of less than six months, then she cannot include that information on the MDS. b. Review of Resident #93's Progress Notes indicated that the Resident sustained a fall at the facility on 4/24/24 and 4/25/24. As a result of the fall sustained on 4/24/24, the Resident acquired an injury (skin tears to each elbow) which required treatment with dressings. Review of the 5/29/24 Quarterly MDS for Resident #93 indicated that since the prior assessment on 3/1/24, Resident #93 sustained only one fall with no injury. During an interview on 10/08/24 at 1:25 P.M., MDS Nurse #1 said that she obtains information about falls from multiple places in the Residents' medical records. MDS Nurse #1 said she must have missed the documentation indicating that Resident #93 sustained a fall with injury while completing her review. c. Review of the Hospice Certification of Terminal Illness signed by the Hospice Physician on 8/16/24 indicated that the prognosis/life expectancy for Resident #93 was less than six months. Review of the 8/28/24 Quarterly MDS indicated that the Resident received hospice services but failed to indicate that the Resident had a condition or chronic disease that may result in a life expectancy of less than six months. During an interview on 10/8/24 at 8:24 A.M., MDS Nurse #1 reviewed the MDS assessments for Resident #93. MDS Nurse #1 said that the facility has a difficult time getting a copy of the signed Hospice Certification of Terminal Illness in the time needed to complete the MDS accurately. MDS Nurse #1 said that if she does not have a copy of the signed Hospice Certification of Terminal Illness or a progress note from the physician indicating that a resident has a life expectancy of less than six months, then she cannot include that information on the MDS. 34145 3. Resident #76 was admitted to the facility in August 2021 with diagnoses including psychotic disorder. Review of the Physician's Orders indicated but was not limited to: -Olanzapine (antipsychotic) 2.5 milligrams (mg), give 2.5 mg by mouth one time a day (11/14/22) -Olanzapine 5 mg at bedtime (4/9/24) Review of the August 2024 Medication Administration Record (MAR) indicated Olanzapine was administered to Resident #76 as ordered by the physician. Review of the MDS assessment, dated 8/21/24, indicated that section N0450 Antipsychotic Medication Review A. Did the resident receive antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent. A check mark was noted in the box corresponding to the response: No- Antipsychotics were not received. During an interview on 10/8/24 at 10:08 A.M., MDS Nurse #1 said Resident #76's 8/21/24 MDS should have indicated he/she was receiving an antipsychotic medication daily, but it was not coded correctly.

Based on observation, record review and interview, the facility failed to 1.) develop and implement care plan interventions related to falls for one Resident (#76) resulting in a fall with injury and 2.) failed to implement a fall care plan for wearing the appropriate footwear for one Resident (#4), out of a total of 21 sampled Residents. Review of the facility's Managing Falls and Fall Risk policy, dated December 2007 indicated: *Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Findings include: 1. Resident #76 was admitted to the facility in June 2023 with a right hip fracture after falling in the community. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #76 scored an 11 out of a possible 15 indicating moderate cognitive impairment and that he/she required assistance with ambulation and transfers. On 7/28/23, at 8:15 A.M., Resident #76 was observed sitting in bed eating his/her breakfast meal. A floor mat was propped against the wall. Review of Resident #76's Activities of Daily Living care plan dated 6/15/23, indicated Resident #76 ambulates with physical assistance and requires one person assistance with transfers. Review of Resident #76's Fall care plan, effective 6/15/23 - 7/20/23 indicated only one intervention related to falls: [rehab] consult for strength and mobility. There were no other individualized interventions implemented for fall prevention. During an interview on 7/28/23, at 8:39 A.M., Unit Manager #3 said that when a resident is admitted to the facility after having a fall in the community, care plan interventions are implemented and include monitoring, the use of assistive devices, answering call lights timely, and de-cluttering the room, (none of which were indicated in Resident #76's plan of care). Unit Manager #3 said that interventions are added as time goes on and as the facility assesses the resident's status. Review of Resident #76's Nurse progress notes indicated: 6/17/23: Patient is alert and confused, multiple attempts to get out bed without calling for help. Resident walking without use of walker during the night. Encouraged calling for help when needed. 6/26/23: Patient is alert and confused awake off and on during the night. Patient hallucinating stating he/she was in another place and time.Multiple attempts out of bed. 6/29/23: No hallucinations during this night, close supervision for safety. 7/1/23: Patient remains alert and confused. Patient sat out in the chair. 7/5/23: Patient is alert and confused. Patient sat out in chair, brought out to dinning area after supper for safety as patient was found ambulating unsafely in [bedroom]. 7/6/23: Patient is alert and confused. Sat out in the chair, brought to dinning area for supper for safety. 7/7/23: Patient is alert and confused. Sat out in the chair, brought to the dinning area for supper for safety. Notes dated 7/10/23, 7/14/23, 7/17/23, 7/18/23 indicated Resident #76 was alert and confused and sat out on chair during the 3:00 P.M. - 11:00 P.M. shift. Despite the documentation of Resident #76's cognition, instances of ambulating alone without calling for assistance, making multiple attempts to get out of bed and being supervised in a sitting area during the 3:00 P.M. - 11:00 P.M. shift, there were no updates or interventions added to Resident #76's falls care plan. Review of the facility investigation dated 7/20/23, indicated that at approximately 12:15 A.M., Resident #76's roommate rang his/her call light and called for help after Resident #76 got out of bed unassisted. Resident #76 was found on the floor by the foot of his/her bed and complained of hip pain. Resident #76 was transferred to the hospital. The incident report failed to indicate where Resident #76's call light was located at the time of the fall. Review of the hospital paperwork dated 7/23/23, indicated Resident #76 was diagnosed with a left hip fracture. During an interview on 7/28/23, at 9:33 A.M., Nurse #5 said that on the night of Resident #76's fall, she and the assigned Certified Nurse's Assistant (CNA) were taking care of other residents, when she heard a call light going off. Nurse #5 said she then heard yelling in the hallway and poked her head out of the room and saw Resident #76's roommate in the hallway yelling that Resident #76 was on the floor. Nurse #5 said she then saw the nurse from the 3:00 P.M. - 11:00 P.M., at the nurses station documenting and called out for her to assist. Nurse #5 then said that the nurse supervisor heard Nurse #5 calling out for help and he went to Resident #76's room and found Resident #76 on the floor by the foot of the bed. Nurse #5 said when she arrived to his/her room, Resident #76 had been put back in bed and was wearing shoes. Nurse #5 said the nurse supervisor said that he thought Resident #76 may have broken his/her hip and was sent to the hospital. Nurse #5 said that Resident #76 was admitted to the facility after having a fall at home. Nurse #5 said Resident #76 was confused and known to ambulate by himself/herself when he/she needed assistance and would never use his/her call light. Nurse #5 said I don't think [he/she] even knows how to use the call light. Nurse #5 said that Resident #76 was at risk for falls and the overnight CNAs would usually station themselves outside of his/her room during the shift but can't always be there as they have other residents to attend to. During an interview on 7/28/23, at 11:00 A.M., the Director of Nursing said that when a resident with a history of falls is admitted to the facility, care plan interventions include monitoring for fall risks and safety and making sure their call light is within reach. The Director of Nursing said that the interventions are individualized and that resident's who are confused would need more monitoring. The Director of Nursing then said that more interventions could have been implemented to address Resident #76's fall risks. 45984 2. Resident #4 was admitted to the facility in October 2020 with diagnoses including diffuse traumatic brain injury, unspecified dementia, history of falling, difficulty in walking and weakness. Review of Resident #4's most recent Minimum Data Set (MDS) indicated that the Resident scored a 3 out of possible 15 on the Brief Interview for Mental Status exam indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that Resident #4 requires extensive assistance with dressing and supervision with walking. Review of Resident #4's Nursing Progress notes indicated the following: 4/5/23: Pt. (patient) sitting on buttocks on floor, legs out straight, head against upright walker. Heels out of Skecher shoes when pt. found on floor, had previously noted shoes on properly when ambulating with walker. Skecher shoes replaced with alternate pair of shoes. 5/19/23: Resident was pacing around in usual his/her state, went to another resident's room and fell . Review of Resident #4's Activities of Daily Living self-care performance care plan dated 10/6/2020, indicated the following intervention: *Dressing: The resident requires total dependence by staff Review of Resident #4's fall care plan, dated and revised 7/4/2023, indicated the following interventions: *Dated 4/6/23: Ensure resident has proper fitting footwear on at all time s/p (status post) fall 4/5/23 *Dated 5/23/23: Encourage resident not to wear slide shoes Review of Resident #4's quarterly fall risk assessments dated 1/9/23, 4/10/23 and 7/5/23, indicated that the resident is a high risk for falls. Review of the facility investigation dated 4/5/23, provided by Nurse #1 indicated that Resident #4 was found sitting on his/her buttocks with legs out in front, head upright against walker. His/her heels were out of shoes when pt. was found on floor. Further review of the investigation indicates the following: *Was appropriate footwear on resident? No was marked with a note reading slip on shoes, heel not in tight *Did they have appropriate footwear on? No was marked with a note reading perhaps loose fitted as heels out when found on floor *New intervention of check pt every shift for properly fitting footwear Review of the facility investigation dated 5/19/23, provided by Nurse #2 indicated Resident #4 paces around the unit and went to another resident's room and fell . Further review of the investigation indicates the following: *Was the appropriate footwear on resident? No was marked with a note reading slide shoes on *Additional comments: Resident's shoes was out (one) during fall, she/he may have tripped During a phone interview on 7/28/23, at 11:26 A.M., Nurse #1 said Resident #4 had worn slip on shoes and also had flip flops which lets his/her ankle go back, part of his/her new interventions was for proper footwear to be worn. During an interview on 7/28/23, at 11:36 A.M., Nurse #2 said Resident #4 wanders a lot and was not wearing his/her proper footwear when he/she fell on [DATE]. The shoe was not secured around his/her ankle and his/her foot was hanging out and he/she tripped and fell . During an interview on 7/28/23, at 11:58 A.M., Unit Manager #1 says Resident #4 is totally dependent, he/she wanders and recently fell in another resident's room. She said she believes it was due to the Resident wearing the incorrect shoes. During an interview on 7/28/23, at 12:10 P.M., Certified Nursing Assistant (CNA) #1 said Resident #4 is totally dependent on staff and gets help with being dressed which include putting on his/her shoes. She continued to say that the Resident used to wear slip shoes but now has regular sneakers. During an interview on 7/31/23, at 10:34 A.M., the Administrator said he would expect care plan interventions to be followed.

Based on record review, interview and observation, the facility failed to ensure professional standards of practice were followed for the changing of oxygen and nebulizer tubing for 5 Residents (#68, #16, #9, #22 and #67) in a total sample of 21. Findings include: Review of the facility form titled 11-7 nightly duties licensed nursing staff (undated) indicated to change and label oxygen [equipment] every Wednesday. Review of the facility policies titled Oxygen Administration, dated October 2010, and For the Set-Up, and Administration of Oxygen, and the Use of Oxygen Concentrators, undated, did not reference the changing or labeling of oxygen. Review of the facility policy titled Administering Medication through a Small Volume (Handheld) Nebulizer dated revised October 2010 indicated to change the equipment and tubing every seven days. 1. Resident #68 was admitted to the facility in September 2022, and had diagnoses which included chronic obstructive pulmonary disease (COPD) and history pf pneumonia. Resident #68's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required oxygen therapy. Resident #68's physician order dated 3/23/23, indicated: Oxygen at 1 liter via nasal cannula to maintain oxygen saturation above 88%. There was no reference to the frequency of changing oxygen tubing in Resident #68's physicians orders. Resident #68's care plan for respiratory distress, dated 9/22/23, indicated he/she had a diagnosis of COPD. Care plan interventions included: *Oxygen setting: oxygen via nasal cannula @1-2 liters at night for comfort. During an observation on 7/27/23 at 9:03 A.M., Resident #68 was lying in bed awake and wearing a nasal cannula. There was no label on the tubing to indicate the date of the most recent change. During an observation on 7/31/23 at 8:01 A.M., Resident #68 was lying in bed, awake and wearing a nasal cannula. There was no label on the oxygen tubing to indicate the date of the most recent change. Resident #68's progress notes dated the week of 7/25/23, did not reference the changing or labeling of oxygen tubing. The weekly treatment form dated 7/27/23, indicated staff did not change or label Resident #68's oxygen tubing. During an interview with the Director of Nursing (DON) on 7/28/23 at 1:41 P.M., she said the facility did not require a physician's order for the changing of oxygen tubing. The DON said it was facility policy to change oxygen tubing weekly, and as needed. The DON said that nurses maintained a binder containing a record of these weekly tubing changes. During an interview with Unit Manager (UM) #2 on 7/31/23 at 8:30 A.M., she said nurses documented weekly tubing changes in a binder kept at the nursing desk. UM #2 showed the surveyor this binder, which contained the form titled 11-7 PM nightly duties licensed nursing staff. The form indicated that every Wednesday staff are to change and label oxygen equipment. UM #2 said that oxygen equipment: was in reference to tubing. UM #2 reviewed these forms in the presence of the surveyor and said that staff did not indicate they had changed or labeled residents' oxygen tubing for the week of 7/25/23. UM #2 entered Resident #68's bedroom and told the surveyor their oxygen tubing was not labeled or dated 2. Resident #16 was admitted to the facility in March 2023, and had diagnoses which included chronic obstructive pulmonary disease (COPD. Resident #16's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required oxygen therapy. Resident #16's physician order dated 12/23/22, indicated: Administer oxygen between 1-3 liters nasal cannula if O2 [oxygen] sat (saturation) is below 89% room air. Document usage and liter flow q shift, related to chronic obstructive pulmonary disease. There was no reference to the frequency of changing oxygen tubing in Resident #16's physicians orders. Resident #16's care plan for Alteration in Respiratory Status dependent dated 12/3/20, indicated: *Oxygen therapy as ordered. During an observation on 7/31/23 at 8:04 A.M., Resident #16 was lying in bed and appeared to be asleep. Tubing was connected to his/her oxygen concentrator. There was no label to indicate the date of the most recent tubing change. Resident #16's progress notes dated the week of 7/25/23, did not reference the changing or labeling of oxygen tubing. The weekly treatment form dated 7/27/23, indicated staff did not change or label Resident #16's oxygen tubing. During an interview with the Director of Nursing (DON) on 7/28/23 at 1:41 P.M., she said the facility did not require a physician's order for the changing of oxygen tubing. The DON said it was facility policy to change oxygen tubing weekly, and as needed. The DON said that nurses maintained a binder containing a record of these weekly tubing changes. During an interview with Unit Manager (UM) #2 on 7/31/23 at 8:30 A.M., she said nurses documented weekly tubing changes in a binder kept at the nursing desk. UM #2 showed the surveyor this binder, which contained the form titled 11-7 PM nightly duties licensed nursing staff. The form indicated that every Wednesday staff are to change and label oxygen equipment. UM #2 said that oxygen equipment: was in reference to tubing. UM #2 reviewed these forms in the presence of the surveyor and said that staff did not indicate they had changed or labeled residents' oxygen tubing for the week of 7/25/23. UM #2 entered Resident #16's bedroom and told the surveyor their oxygen tubing was not labeled or dated 3. Resident #9 was admitted to the facility in November 2013, and had diagnoses which included emphysema, chronic obstructive pulmonary disease (COPD), asthma, and respiratory failure. Resident #9's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required oxygen therapy. Resident #9's physician order dated 2/14/23, indicated: May Administer Oxygen at 2 Liters via Nasal Cannula at Bedtime, related to chronic obstructive pulmonary disease. There was no reference to the frequency of changing oxygen tubing in Resident #9's physicians orders. Resident #9's care plan for Altered Respiratory Status, difficulty breathing/ shortness of breath related to COPD, dated 2/6/23, indicated: * oxygen at bedtime * Provide oxygen as ordered by the MD/NP. During an observation on 7/31/23 at 9:10 A.M., Resident #9 was lying in bed, awake. An oxygen concentrator was located near the foot of the bed. Oxygen tubing and nasal cannula were draped over the concentrator. There was no label to indicate the date of the most recent tubing change. Resident #9's progress notes dated the week of 7/25/23, did not reference the changing or labeling of oxygen tubing. Review of the weekly treatment form dated 7/27/23, indicated staff did not change or label Resident #9's oxygen tubing. During an interview with the Director of Nursing (DON) on 7/28/23 at 1:41 P.M., she said the facility did not require a physician's order for the changing of oxygen tubing. The DON said it was facility policy to change oxygen tubing weekly, and as needed. The DON said that nurses maintained a binder containing a record of these weekly tubing changes. During an interview with Unit Manager (UM) #2 on 7/31/23 at 8:30 A.M., she said nurses documented weekly tubing changes in a binder kept at the nursing desk. UM #2 showed the surveyor this binder, which contained the form titled 11-7 PM nightly duties licensed nursing staff. The form indicated that every Wednesday staff are to change and label oxygen equipment. UM #2 said that oxygen equipment: was in reference to tubing. UM #2 reviewed these forms in the presence of the surveyor and said that staff did not indicate they had changed or labeled residents' oxygen tubing for the week of 7/25/23. UM #2 entered Resident #9's bedroom and told the surveyor their oxygen tubing was not labeled or dated. 36797 4. Resident #22 was admitted to the facility in March 2014 with diagnoses including heart disease, dementia with psychosis and blindness secondary to macular degeneration and glaucoma. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #22 scored a 4 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #22 is totally dependent on staff for all activities of daily living. Review of the doctor's orders dated July 2023 failed to indicate an order for nebulizer treatments. On 7/27/23, at 7:47 A.M. the surveyor observed the nebulizer medication cup and tubing dated 2/15/23, On 7/31/23, at 7:42 A.M., the surveyor observed the nebulizer medication cup and tubing dated 2/15/23, During an interview on 7/31/23, at 7:42 A.M. Nurse #3 said that the nebulizer's should be changed every week on Tuesday 11-7 shift. Nurse #3 then looked at the date written on the nebulizer medication cup and tubing and said that she reads the date as 2/15/23. Nurse #3 said that Resident #22 doesn't always use the nebulizer but the tubing should have either been removed or changed. 45984 5. Resident #67 was admitted to the facility in March 2020 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus and unspecified dementia. Review of Resident #67's most recent Minimum Data Set (MDS) indicated that the Resident had a Brief Interview for Mental status score of 6 out of a possible 15 indicating that he/she has severe cognitive impairment. Further review of the MDS indicated that the Resident requires extensive assistance with activities of daily living and requires oxygen therapy. The surveyor made the following observations: On 7/27/23 at 11:58 A.M., Resident #67 was observed lying in bed receiving oxygen via nasal cannula, the oxygen tubing had a piece of tape on it with a date reading 7/12. On 7/28/23 at 7:45 A.M., Resident #67 was observed sleeping in bed receiving oxygen via nasal cannula, the oxygen tubing had a piece of tape on it with a date reading 7/12. Review of Resident #67's physician orders dated 8/15/20 indicated the following: *Oxygen at 1-3 L (liters) via N/C (nasal cannula) to maintain O2 (oxygen) sat (saturation) above 89% Review of the facility document titled, 11-7 Nightly Duties Licensed Nursing Staff indicated the following under Weekly Duties: *7/19/23 Wednesday: Change and label Foley bags and oxygen - this was not initialed as being completed *7/26/23 Wednesday: Change and label Foley bags and oxygen - this was not initialed as being completed During an interview on 7/31/23 at 8:09 A.M., Nurse #3 said oxygen tubing should be changed every Wednesday on the 11-7 shift and they will put a piece of tape on the tubing of the date it was changed. During an interview on 7/31/23 at 8:48 A.M., Unit Manager #1 said she just changed Resident #67's oxygen tubing as it was outdated and dated as 7/12. She said her expectations is that oxygen tubing should be changed weekly documented. The surveyor and Unit Manager #1 review the 11-7 Nightly Duties Licensed Nursing Staff document and she said 7/19/23 was signed off even though it was not completed and 7/26/23 was left blank and not completed. She further said if something is checked off it should be completed. During an interview on 7/31/23 at 10:16 A.M., the Infection Control Nurse said her expectations is for oxygen tubing to be changed weekly by the night staff and documented appropriately.

Based on observation, record review, interview and facility policy review, the facility failed to assess a scoop mattress as a potential restraint for one Resident (#80) out of a total sample of 21 residents. Findings include: Review of the facility policy titled Use of Restraints, dated revised April 2017, indicated that prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Further review indicated that restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. Resident #80 was admitted to the facility in December 2022 with diagnoses including stroke with left sided hemiparesis, dementia and dysphagia. Review of the Minimum Data Set assessment (MDS) dated [DATE], indicated that Resident #80 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated Resident #80 requires an extensive assist for all acitivities of daily living. On 7/27/23, at 7:51 A.M., and 10:32 A.M., the surveyor observed Resident #80 in bed on a full length scoop mattress. On 7/31/23, at 7:15 A.M., and 10:20 A.M., the surveyor observed Resident #80 in bed on a full length scoop mattress. Review of the facility document titled Documentation Survey Report v2 dated July 2023 indicated that Resident #80 was a limited assist for bed mobility on the night shift (11:00 P.M.-7:00 A.M.) 19 out of 21 days documented. Review of the medical record failed to indicate that a pre-restraining assessment was completed to determine if the use of a full length scoop mattress constituted a restraint for Resident #80, or had reviewed to determine if any changes had occurred. Review of the doctor's orders dated July 2023 indicated an order for nursing to ensure Fall No More mattress in place and secured when resident in bed. Review of the care plans failed to indicate the use of a full length scoop mattress as a potential restraint. During an interview on 7/27/23, at 7:53 A.M. Certified Nurses Aide (CNA) #2 said that the scoop mattress is in place because Resident #80 is always trying to get out of bed and has had many falls. CNA #2 then said that the mattress keeps Resident #80 from getting out of bed.

Based on observation, record review and interview, the facility failed to implement the plan of care for 3 Residents (#22, #5 and #80) out of a total sample of 21 residents. Findings Include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated revised March 2022, indicated that the comprehensive, person-centered care plan describes the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #22 was admitted to the facility in March 2014 with diagnoses including dysphagia (difficulty eating), dementia with psychosis and blindness secondary to macular degeneration and glaucoma. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #22 scored a 4 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #22 was totally dependent on staff for all activities of daily living. Review of the doctor's orders dated July 2023 indicated Resident #22 to wear foam boots to bilateral feet at all times while in bed every shift for skin prevention. Further review indicated: offload bilateral heels on pillow every shift and for nursing to ensure bed cradle in place at all times when resident in bed. Ensure blankets are over bed cradle. Ensure that mattress is properly inflated and functioning between 98 lbs (pounds) and 108 lbs. On 7/27/23, at 7:47 A.M. and 12:55 P.M., and on 7/31/23, at 7:49 A.M., the surveyor observed Resident #22 lying in bed without wearing foam boots on his/her feet. The surveyor also observed both of Resident #22's heels directly on top of a pillow, not offloaded and no bed cradle in place, with the blankets directly laying on top of Resident #22's feet. The surveyor also observed the mattress setting at 240 lbs. During an interview on 7/31/23, at 7:42 A.M. Nurse #3 said that the booties should be on and the heels should not be directly on the pillow. Nurse #3 then said that she had asked for a new bed cradle a while ago but hasn't been given one. During an interview on 7/31/23, at 7:59 A.M. Nurse #3 said the mattress setting was way too high and shouldn't be more than 130 lbs., but she wasn't sure of the exact doctor's order. 2. Resident #5 was admitted to the facility in June 2021 with diagnoses including dementia, psychotic disorder and diabetes. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #5 scored a 5 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #5 requires an assist of one person for supervision with eating. On 7/27/23, at 8:28 A.M., the surveyor observed Resident #5 sitting on the edge of the bed, eating with her/his fingers and searching the tray with her/his fingers for the location of the food. There was no staff in the room assisting the Resident. On 7/31/23, at 8:08 A.M., the surveyor observed Resident #5 sitting on the edge of the bed, eating with her/his fingers and searching the tray with her/his fingers for the location of the food. There was no staff in the room assisting the Resident. Review of the facility document titled Documentation Survey Report v2 dated July 2023 indicated that Resident #5 required continual supervision with eating. Review of Resident #5 nutrition care plan indicated a focus for swallowing difficulties related to dysphagia with need for modified textures. Further review indicated an Activities of Daily Living (ADL) care plan with an intervention of Resident #22 to eat out of her/his room, encourage if refuses. During an interview on 7/31/23, at 8:12 A.M. Certified Nurses Aide (CNA) #3 said, she knew who required assistance with eating, that if a resident can feed themselves then they are ok. CNA #3 then said that she was not aware that Resident #5 required supervision with eating. 3. Resident #80 was admitted to the facility in December 2022 with diagnoses including stroke with left sided hemiparesis, dementia and dysphagia. Review of the Minimum Data Set assessment (MDS) dated [DATE], indicated Resident #80 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated Resident #80 required an extensive assist for all acitivities of daily living. Review of the doctor's order dated July 2023 indicated to apply Prevlon boot to bilateral feet every shift. Further review indicated an order to offload his/her bilateral heels every shift while in bed. On 7/27/23, at 7:51 A.M., and 10:32 A.M. the surveyor observed Resident #80 in bed without Prevlon boots on and heels directly on the mattress. The surveyor observed one Prevlon boot on a chair in the Resident's room and did not see the other boot. On 7/27/23, at 12:58 P.M. the surveyor observed Resident #80 in the dining room without Prevlon boots on. On 7/31/23, at 7:32 A.M., and 10:20 A.M., the surveyor observed Resident #80 in bed without Prevlon boots on and his/her heels directly on the mattress. The surveyor observed one Prevlon boot in the dresser drawer and another on a chair. Review of the care plan dated 6/1/23, indicated to offload bilateral heels on pillow every shift while in bed. Further review indicated to apply Prevlon boots to bilateral feet while in bed. Right heel for DTI, left heel for protection. There was no documentation in the clinical record indicating that Resident #80 refused the booties. During an interview on 7/31/23, at 7:36 A.M. Certified Nurse's Aide (CNA) #3 and Nurse #3, said that Resident #80 should be wearing the booties at all times. CNA #3 said that Resident #80 doesn't refuse to wear them.

Based on interview, policy review, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent new ulcers from developing and provide ongoing assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility failed to effectively implement the facility's pressure injury prevention policy, ensure timely identification of a deep tissue injury (DTI), and document, monitor, and treat Resident #18's DTI resulting in a worsening of the DTI of the heels. Findings include: Review of the facility's policy titled Prevention of Pressure Injuries, revised April 2020, included but was not limited to the following: Risk Assessment - Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. (The facility's form is titled Licensed Weekly Nursing Skin Assessment) - Identify any signs of developing pressure injuries (i.e., non-blanchable [CONDITION(S)]) - Inspect pressure points (heels, buttocks ., etc.). Monitoring - Evaluate, report and document potential changes in the skin - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014, included but was not limited to the following: Assessment and Recognition - the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic tissue b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces; and e. All active diagnoses Review of the facility's policy titled Pressure Injuries Overview, revised March 2020, included but was not limited to the following: -Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Avoidable/Unavoidable Avoidable means the Resident developed a pressure ulcer/injury and that one or more of the following was not completed: -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. Review of the facility's policy titled Pressure Injury Risk Assessment, revised March 2020, included but was not limited to the following: Steps in Procedure - Conduct a structured pressure injury risk assessment using a facility-approved tool (facility uses the Weekly Skilled Nursing Skin Assessment). - Conduct a comprehensive skin assessment with every risk assessment. - Once inspection of skin is completed, document the findings on a facility approved skin assessment tool. - If a new skin alteration is noted, initiate a (pressure or non-pressure) for related to the type of alteration in skin. - Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition and the resident's stated wishes and goals. - The interventions must be based on current, recognized standards of care - The effects of the interventions must be evaluated - The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation The following information should be recorded in the resident's medical record utilizing facility forms: - The type of assessment (s) conducted - The condition of the resident's skin (i.e., the size and location of any or tender areas), if identified. - Any problems or complaints made by the resident related to the procedure. - Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted - Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated - Documentation in medical record addressing family, guardian, or resident notification if new skin alteration noted with change of plan of care if indicated Review of the National Pressure Injury Advisory Panel (NPIAP)Classification System includes but is not limited to the following: Stage 2 Pressure Injury: -Partial thickness skin loss with exposed dermis and partial thickness loss of skin. The wound bed is viable, pink, or red, moist and may also present as an intact/ruptured serum filled blister. Deep Tissue Pressure Injury (DTPI-DTI): -Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon or purple discoloration, or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss A partial thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the [MEDICATION(S)] layers only A full thickness wound indicates that damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc.). NPIAP-Off-loading Heels Effectively in Adults to Prevent Pressure injuries Interventions -Place a pillow vertically under each lower leg between the knees and ankles so that the heels are off-loaded in such a way as to distribute the weight of the leg along the calf without pressure to the popliteal space or Achilles' tendon. -Place pillow horizontally on top of vertical pillows. -Heel suspension devices can be used instead of a pillow to off-load [distribute the load to other areas which are not susceptible to pressure] the heels. Follow the manufactures guidelines and consider the implementation. Considerations in the Guidance when using these devices. Resident #18 was admitted to the facility in November 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 11/2021, indicated Resident #18 was frequently incontinent of bowel and bladder, required extensive assistance of two staff for dressing and bed mobility and totally dependent for bathing. The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Record review indicated the Resident had been seen by the Nurse Practitioner (NP) on 1/3/22 at 9:16 A.M. The visit note included but was not limited to: DTI- right heel, entire heel, approximately 4 centimeters (cm) x 4 cm, intact. Review of a Nurse's Note, dated 1/3/22 at 11:31 A.M., included but was not limited to: Has a DTI on right heel. Record review of the December 2021 and January 2022 Treatment Administration Records (TAR) indicated the following: -Apply Skin Prep (protective film on skin) to bilateral heels every day and evening shift for preventative skin care. Document what the site looks like in progress note. Further review of the TAR and Progress Notes for December 2021 and January 2022 indicated there was no documentation as to the appearance of the bilateral heels. Review of the Licensed Weekly Nursing Skin Assessment, dated 1/3/22 at 6:33 P.M., included but was not limited to the following responses: 5a. Any blisters? Answered NO 6a. Any open ulcers? (Indicate even if being treated) Answered NO 9a. Any impaired skin on heels and ankles? (Blisters, skin discoloration, boggy, opened area) Answered YES Comments-Dryness due to psoriasis. The weekly skin assessment failed to indicate a new 4 cm x 4 cm DTI on the Resident's right heel, as required, and did not initiate a pressure or non-pressure form as per facility policy. Review of the January 2022 TAR indicated a new treatment for: -Float heels all the time when in bed, every shift. (day/evening/night) Start date 1/3/22 -1500 (3:00 P.M.) Record review indicated no documentation by nursing that addressed the initial appearance, of the right heel with stage, length, width and depth, presence of exudates (drainage) or necrotic tissue, pain assessment, mobility status, current treatments, and the procedure/device that would be implemented to float Resident #18's heels. There was no documentation in the medical record as to physician notification, family/guardian, or Resident notification of the DTI. Review of Physician's Note, dated 1/4/22, indicated the Resident had a Decubiti right heel. On 1/4/22 the Resident was seen by the Wound Consultant. The initial visit note, included but was not limited to the following: Resident has a DTI of the right heel for at least 1 day's duration. There is no exudate or indication of pain. Etiology: Pressure Stage: Unstageable DTI with intact skin Wound size (L x W x D): 4 cm x 4 cm x not measurable. Exudate: None Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound consultant also applied [MEDICATION(S)] foam (Versatile padding that adheres well to a variety of surfaces. Pads, cushions, and protects skin from damage) to the area and indicated to keep the foam in place, apply once daily. Review of a Nurse's Note, dated 1/4/22 at 12:51 P.M., included but was not limited to: Wound MD wanted skin prep and ABD and Kling to blister right heel. Blister didn't break. There was no further documentation from 1/4/22 indicating the wound consultant had made a visit, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Skin prep to right heel, cover with ABD pad, wrap with Kerlix daily. (This order did not include the [MEDICATION(S)] foam which had been recommended by the wound consultant.) There was no order obtained or transcribed on the TAR for 1/4/22 and 1/5/22 for the above recommendations. Subsequently, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's Note, dated 1/5/22 at 2:03 P.M., indicated: -Right heel blister, applied skin prep, [MEDICATION(S)] foam, ABD, and Kling. Review of a Nurse's Note, dated 1/6/22 at 1:03 P.M., included but was not limited to: Blister right heel broke, small amount of serosanguinous (bloody and serous) drainage. Review of the Wound Consultant's telemedicine visit note, dated 1/6/22, included but was not limited to: Exudate: Moderate serous Wound progress: deteriorated Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] Add: Vaseline Gauze *Discontinue: Skin Prep Continue with the ABD pad and Kerlix. *Continue: Please keep the [MEDICATION(S)] foam in place. The order recommended by the Wound Consultant on 1/6/22 (telemedicine visit-wound care was not physically provided by the wound consultant) was not initiated until 1/7/22. Review of a Nurse's Note, dated 1/7/22 at 6:33 P.M., included but was not limited to: [MEDICATION(S)] foam removed, Normal Saline Wash (NSW), Vaseline gauze, ABD, Kling applied to right heel, Ace wraps on in am off in p.m. Some pain noted no drainage. Review of a Licensed Weekly Nursing Skin Assessment, dated 1/10/22 at 9:19 P.M., included but was not limited to: 5a. Any blisters? Answered NO 6a. Any open ulcers? (Indicate even if being treated) Answered NO 9a. Any impaired skin on heels and ankles? (Blisters, skin discoloration, boggy, opened area) Answered YES Comments-Dry, flaky due to psoriasis. The weekly skin assessment did not indicate/include in the assessment/documentation of the DTI on the Resident's right heel as required. Review of the Wound Consultant's Note, dated 1/11/22, included but was not limited to: Etiology: Pressure Stage: Unstageable -Necrosis (1/4/22 Unstageable DTI with intact skin, no necrotic tissue was present) Wound size (L x W x D): 4 cm x 4 cm x not measurable. Exudate: Moderate Serous Thick adherent black necrotic tissue (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black brown or tan in color and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound), 80% Granulation tissue: 20% The area was debrided to remove the necrotic tissue and establish the margins of viable tissue. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Add: Santyl ([MEDICATION(S)] is an enzyme. It works by helping to break up and remove dead skin and tissue). -Discontinue: Vaseline gauze Add: ACE bandage 6 inch Continue: Xeroform Sterile Gauze, followed by an abdominal pad (ABD), wrap with Gauze roll (Kerlix) 4.5 inch, and keep the [MEDICATION(S)] foam in place. Review of a Physician's Note, dated 1/11/22, included but was not limited to: -Decubiti right heel (seen by Wound MD -status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nurse's Note, dated 1/12/22 at 12:55 P.M., included but was not limited to: Right heel wound cleaned and changed per wound orders (There had been no orders obtained, transcribed, or entered in to the EMR on 1/12/22.) Review of a NP's Note, dated 1/13/22 at 11:52 A.M., included but was not limited to: -Right heel necrotic, approximately 3.5 cm x 3.5 cm. Seen with nursing. Wound care, including Santyl applied. Assessment and Plan: -off-load -Wound consultant following Review of a Nurse's Note, dated 1/13/22 at 12:36 P.M., included but was not limited to: Right heel, NSW, Santyl ointment, xeroform, ABD and Kling. NP looked at the wound and will continue to monitor. There was no documentation, nurse's note, approval obtained by the physician or NP or interim order/T.O. in the record that addressed the treatment recommendations by the wound consultant on 1/11/22. Further review of the medical record indicated the new treatment was entered into the EMR on 1/15/22, with no supporting documentation/progress note indicating why there was a delay in obtaining and entering the order into the EMR. Review of a Nurse's Note, dated 1/14/22 at 12:59 P.M., included but was not limited to: -right heel wound, healing well, NSW, Santyl ointment, xeroform, ABD, Kling. Seen by physician and followed by wound doctor. Off-loading as tolerated. Review of a late entry Nurse's Note, dated 1/11/22 at 11:24 A.M. and entered in the EMR on 1/18/22, indicated the following: -Resident seen by wound consultant for unstageable Right heel wound measuring 4 cm x 4 cm, moderate serous drainage, 80% necrotic tissue, 20% granulation tissue, continue treatment as ordered. The late entry note did not indicate there was a treatment change and that the physician or NP had approved the change. Record review of the January 2022 TAR indicated the Resident's heels were being floated while in bed. Review of the Nurse's Notes, dated 12/24/21 through 2/23/22, indicated the Resident frequently refused to go to bed, and his/her preference was to sleep in a recliner. The order to float the heels, when in bed, every shift, did not address the Resident's preference to sleep in a recliner. There was no documentation indicating that a review of the current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment order did not indicate what should be used or implemented to float the Resident's heels. Review of the January 2022 and February 2022 TARs indicated the Skin Prep to bilateral heels every day and evening shift for preventative skin care was still in effect, even though the wound consultant had discontinued the Skin Prep to the right heel on 1/6/22. There was no documentation in the progress notes as to the appearance of the area, specifically the left heel. During an interview on 2/28/22 from 8:40 A.M. to 9:24 A.M., the surveyor, the Director of Nursing (DON) and Unit Manager (UM) #1 reviewed the care and treatment concerns identified by the surveyor for Resident #18's pressure ulcer. The DON and Unit Manager #1 confirmed the lack of documentation, lack of implementation of effective off-loading, failure to implement the wound consultant's recommendations timely and correctly, failure to follow the facility's policies regarding care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, the DON spoke to UM #3 regarding the appearance of the DTI when it was initially identified and indicated that the area was a flat, dry dark area, brownish/purple in color; the area began filling with fluid and looked like a blood blister. The DON agreed that the initial appearance was never documented in the Resident's medical record and that the nursing staff were documenting the area as a blister (according to NPIAP classification- the area would be a Stage ll and not a DTI). The DON further said that when the wound consultant is not in the facility on any given week, the Unit Managers are responsible for performing a comprehensive assessment of the wounds on their assigned unit. The DON said the weekly wound documentation is a paper form which is located on the individual units. The DON said she did not have a policy regarding this, but the Unit Managers are aware of this expectation and are responsible for completing the comprehensive wound assessment. During an interview on 2/28/22 at 10:15 A.M, UM #3 confirmed the initial appearance of the DTI was described a flat, dry dark area, brownish/purple in color, that began filling with fluid and looked like a blood blister. Review of the Skin Impairment True Decubitus weekly log included but was not limited to: The documentation required for the wounds was to include measurements, drainage, odor, peri wound, pain, and status of the wound. The week of 1/18/22 (visit not made by wound consultant) indicated the measurement of the wound to be 4 cm x 4 cm. There was no comprehensive assessment of the wound as required. During an interview on 2/28/22 from 8:40 A.M. to 9:24 A.M., the surveyor asked how/what was used to float the heels and indicated that the Resident frequently refuses to go to bed, and that there were no documented interventions in place to float the heels when the Resident slept in the recliner. The DON and Unit Manager #1 said that the facility uses pillows to float heels and agreed that the intervention needed to address the Resident's preference to sleep in the recliner. The facility did not review the effectiveness/appropriate interventions with a resident centered approach for Resident #18 for the off-loading/floating of the heels, as per the facility policy. During an interview on 2/28/22 at 11:00 A.M., the DON said the pressure ulcer prevention and treatment policies that were previously given to the surveyor were all the facility had. The DON verified that from 1/4/22 to 1/11/22, Resident #18's heel area deteriorated and was debrided due to necrosis/eschar which covered 80% of the wound bed. The DON further said the facility failed to implement an effective program for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews, the Facility failed to ensure for one of two sampled residents (Resident #1) that the tea reheated in the microwave for Resident #1 was luke warm, per plan of care. On 11/6/10 during the 3:00 PM to 11:00 PM shift, Certified Nurse Aide (CNA) #1 reheated Resident #1's tea in the microwave for 30 seconds, gave the tea to Resident #1, and Resident #1 spilled the hot tea on Resident #1's right thigh. Nurse's notes, dated 11/13/10. indicated that upon inspection of the burn on Resident #1's thigh, Nurse #1 observed a layer of Resident #1's skin that had sloughed off. The nurse's note indicated the Physician was notified, the Physician ordered Silvasorb ointment and a dressing twice a day until healed. A nurse's note of 11/15/10, indicated that Resident #1 was transferred to the Hospital for evaluation of the burn on Resident #1's right thigh, which had developed yellow green slough, and redness around the burn.The Hospital Discharge Summary, dated 11/19/10, indicated that Resident #1's principal [DIAGNOSES REDACTED]. Findings included: Resident #1 was admitted to the Facility January of 2009 and [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 8/12/10, indicated that Resident #1: had long and short term memory deficits; was moderately impaired in daily decision making; and required assistance with meals. The incident report and nurse's note, dated 10/12/10, indicated that on the evening shift (no time specified), Resident #1 had spilled hot tea on the right outer foot, and Resident #1 sustained a reddened area which measured 2.3 cm by 2.0 cm. The incident report and the nurse's note indicated that the Physician was notified, and the Physician ordered Silvadene cream to the right foot twice a day until healed. The plan of care interventions updated on 10/12/10 included provide "luke warm" beverages to Resident #1. The nurse's note, dated 11/13/10 as a late entry for 11/6/10, indicated that on 11/6/10, Resident #1 was provided tea warmed in the microwave, Resident #1 spilled the hot tea on the right thigh and Resident #1 sustained a reddened thigh area, with sloughed off skin noted. The nurse's note indicated that the Physician was notified, and the Physician ordered Silvasorb ointment. CNA #1 was interviewed on 11/22/10 at 11:20 AM. CNA #1 said on 11/6/10 on the 3:00 PM to 11:00 PM shift, Resident #1 had requested that the tea be heated up because the tea was cool. CNA #1 said that CNA #1 heated up Resident #1's tea in the microwave for approximately 30 seconds. CNA #1 said CNA #1 was aware that Resident #1 was burned before on hot tea, but Resident #1 always asked for the tea to be reheated. CNA #1 said on 11/6/10, CNA #1 prepared Resident #1's tea the same way and CNA #1 said a few seconds after Resident #1 received the tea, Resident #1 yelled out, ow ow, and used words to the effect, I wasn't paying attention. CNA #1 said that Nurse #1 and CNA #1 brought Resident #1 into the room, removed Resident #1's pants, and observed a reddened area on Resident #1's right thigh. Nurse #2 was interviewed on 11/22/10 at 11:30 AM. Nurse #2 said the burn on Resident #1's right thigh was initially treated with Silvasorb ointment, but the burn worsened and on 11/14/10, Resident #1 was prescribed an anti- infective medication, Keflex, 500 milligrams twice a day for 7 days due to increased redness, and green yellow sloughing skin. Nurse #2 said on 11/15/10, the Nurse Practitioner assessed Resident #1's burn and ordered Resident #1 transferred to the Hospital for evaluation of the burn. The Director of Nurses (DON) was interviewed on 11/22/10 at 8:30 AM and 1:30 PM. The DON said that Resident #1 enjoyed hot tea, the nursing staff usually heated up Resident #1's tea in the microwave, and there was no intervention in place to identify how hot Resident #1's tea was after heating the tea. The DON said Resident #1 was supervised now with hot beverages, and wore a smoking vest for protection. The Hospital discharge summary, dated 11/19/10, indicated that Resident #1 was treated for [REDACTED].