Every finding on record at Fitchburg Rehabilitation and Nursing Center

Based on observation, record review and interview, the facility failed to meet professional standards of practice for three Residents (44, #29, and #1) out of a total of 20 sampled residents. Specifically, 1. For Resident #44, the facility failed to: a.) adequately assess, monitor, and implement a physician order for fluid restrictions (limiting the amount of fluid a person takes in) from August 2024 to March 2025. Subsequently, Resident #44 was hospitalized in February 2025, and admitted to ICU (intensive care unit) with diagnosis of acute hypoxic respiratory failure, acute renal failure and septic shock., b.) failed to follow up on physician recommendations for new prosthetic leg, and c.) failed to implement a physician order for bilateral shoulder X-ray. 2. For Resident #29, the facility failed to obtain labs as ordered by the physician. 3. For Resident #1, the facility failed to ensure the air mattress was set per the physician order. Findings include: 1. Resident #44 was admitted to the facility in August 2024 with diagnoses that include, chronic kidney disease stage 4 severe, retention of urine, type 2 diabetes mellitus, and congestive heart failure (CHF). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/17/25, indicated that Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Further review of the MDS indicated Resident #44 requires substantial/maximal assistance for self-care and mobility, has functional limitation in range of motion to lower the extremity and has an impairment on one side requiring the use of an orthotic/ prosthetic. a. Review of Resident #44's active physicians orders indicated: No Concentrated Sweets diet- Regular texture, Thin consistency, 1500 ml/day fluid restriction 1500 ml (milliliters) Total in 24 hrs (hours): Nursing 660ml/24hr, (240 ml on 7-3, 240ml on 3-11, 180 ml on 11-7) Dietary 840ml/24 hrs) 360ml @ breakfast, 240ml lunch, 240 ml @ Dinner). Dated 8/27/24. Review of Resident #44's MAR and TAR failed to indicate monitoring of fluids and did not contain any information related to fluid restrictions. Review of Resident #44's nutrition care plan indicated: - Resident is nutritionally at risk r/t (related to) CHF, diabetes, anemia, COPD, poor dentition. Dated as revised 8/28/24. Interventions included: - Record and monitor intakes. - Continue diet as ordered. Review of Resident #44's current dietary slip failed to indicate fluid restrictions. Review of Resident #44's Kardex, (a form indicating level of care needs) failed to indicate the Resident was on fluid restrictions. Review of the nursing progress note dated 8/30/24, indicated: fluid restrictions maintained. Review of the Nutritional Risk Evaluation dated 1/13/25 indicated: Nutritional Plan: Identified at-risk for weight loss and dehydration - Yes. - Resident is on 1500ml F/R (fluid restriction). Resident had been admitted to Hospital for acute on chronic CHF and acute on chronic Renal failure. Resident had diuretics for excess water. Note that he/she is on diuretic and may experience wt.(weight) fluctuations via fluid shifts. He/she knows his nutritional expectations while on a diabetic diet with F/R. Will continue to monitor ongoing trends and adjust needs accordingly. Review of the nursing progress note dated 1/31/25 indicated: This RN was notified by this patients significant other that he/she would like this patient to be sent out to hospital. When RN asked why, he/she stated that he/she thinks he/she has pneumonia. I went to assess the patient.BP slightly low, 90/56, o2 90% on RA (room air), pulse 54. Afebrile. Patient agreeable to send out to hospital. EMS was called and patient was transferred out. Review of Resident #44's medical record indicated the following Nursing progress note dated 2/11/25, Per discharge paperwork the Resident was found to be covid positive, was admitted to ICU (intensive care unit) for management of acute hypoxic respiratory failure, acute renal failure and septic shock. Review of the hospital discharge paperwork dated 2/11/25, indicated that Resident #44 was admitted to the hospital and diagnosed with acute renal failure superimposed on stage 4 chronic kidney disease, acute hypoxic respiratory failure, hypokalemia (low potassium level), hyponatremia (low sodium level), community acquired PNA (pneumonia), and sepsis. - Disease course complicated by worsening kidney function. - AKI (acute kidney injury), hyponatremia, urinary retention. During an interview on 3/6/25 at 9:48 A.M., Certified Nursing Assistant (CNA)#6 said Resident #44 is not on fluid restrictions and said the Resident can have anything he/she wants to drink to stay hydrated. During an interview on 3/7/25 at 11:02 A.M., the assistant Director of Nurses (ADON) said Resident #44 has an order for fluid restrictions and said staff should be following the orders as written. The ADON said the care plan should indicate fluid restrictions and the order should be on the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR) to track fluids. The ADON said the dietary slip should indicate the Resident is on fluid restrictions. During an interview on 3/10/25 at 10:17 A.M., Nurse Practitioner (NP) #1 said Resident #44 is very fragile and needs close monitoring due to his/her medical conditions and requires close monitoring of fluid restrictions. NP #1 said fluid restrictions should have been completed as ordered with ongoing monitoring of the fluid restrictions daily. NP #1 said staff should be following fluid restrictions as ordered especially after the recent hospitalization . b. During an observation on 3/4/25 at 9:45 A.M., Resident #44 was sitting in bed. There was a prosthetic leg on the floor next to the bedside table. During an observation on 3/7/25 at 8:40 A.M., Resident #44 was sitting in bed and said to the surveyor old leg not new one as he/she pointed to the prosthetic leg on the floor. When the surveyor asked if he/she was getting a new one, Resident #44 shook his/her head side to side and said I don't know. Review of the physician note dated 1/7/25, indicated: visit with patient today about new prosthetic. Patient stated old prosthetic is too heavy to ambulate, with increase fatigue and LE (left extremity) and low back pain. Would recommend new lighter fitting prosthetic to help increase ambulation distance and decrease pain with less caregiver asst. Review of the clinical record failed to indicate that Resident #44 had ever been evaluated for a new prosthetic leg. During an interview on 3/6/25 at 9:10 A.M., the Director of Rehab said Resident #44 may benefit from a new prosthetic leg because it is very old and he/she may have lost weight since admission and said he called the vendor last week, (approximately 2 months since the physician note recommending a newer prosthetic), but should call again to set up an evaluation. During an interview on 3/7/25 at 11:23 A.M. the Assistant Director of Nurses (ADON) said she would expect that an evaluation would be completed and said she was not aware of the recommendation. During an interview on 3/8/24 at 9:38 A.M., the Director of Nursing said that she would look into the consult for the prosthetic leg and said she would expect staff to follow up when the recommendation was made in January to start the process. During an interview on 3/10/25 at 10:28 A.M. Nurse Practitioner #1 said she would expect that recommendations would be implemented and documented in the medical chart to obtain a new prosthetic leg. c. Review of the Nurse Practitioner note dated 10/28/24, indicated, Chief complaint about shoulder pain. Assessment & Plan- bilateral shoulder pain: pt c/o (patient complained of) bilateral shoulder pain. Will order shoulder X-ray to assess for arthritis. Review of the nursing progress note dated, 11/1/24, indicated a physician order for Lidocaine patch for c/o pain to bilat (bilateral) shoulder. Review of the medical record indicated an imaging signature request form from an outside vendor dated 1/28/25, indicated, 4th request for ordering practitioner's signature. Exam date 10/29/24. Confirm this exam order by signing this document and faxing it back to imaging. The form was unsigned. During an interview on 3/7/25 11:23 A.M., the Assistant Director of Nurses (ADON) said Resident #44 should have had the X-ray completed as ordered and said she is not sure why it was not done. During an interview on 3/7/25 at 12:04 P.M., Nurse #7 said Resident #44 had an order for an X-ray but said she did not see that the X-ray was ever done. During an interview on 3/10/25 at 10:08 A.M., Nurse Practitioner #1 said Resident #44 was reporting shoulder pain and said she ordered an X-ray but was not aware that it was never done. NP #1 said the X-ray should have been obtained and followed up on and said Resident #44 has had pain in his/her shoulders and neck. 36876 2. Resident #29 was admitted to the facility in February 2023 with diagnoses including achondroplasia and hydronephrosis. Review of the Minimum Data Set (MDS) asssessment dated 12/4/24, indicated Resident #29 is cognitively intact as evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status exam. The MDS also indicated Resident #29 requires assistance for bathing, dressing and toileting. Review of Resident #29's physicians orders indicated: Sodium Chloride Oral Tablet 1 GM (Sodium Chloride) Give 1 tablet by mouth three times a day for Hyponatremia Repeat BMP every week until sodium level normalizes and adjust salt tablet, 10/18/24. Additional review of Resident #29's physicians orders indicated: November 2024: labs were not obtained the weeks of 11/10/24, 11/17/24 and 11/24/24. December 2024: no labs were obtained. January 2025: no labs were obtained. February 2025: labs were not obtained the weeks of 2/2/25, 2/9/25, and 2/16/25. During an interview on 3/7/25 at 11:25 A.M., the Assistant Director of Nursing (ADON) said staff should implement physicians orders. The ADON said that if the nursing staff had questions related to Resident #29's ordered weekly labs, they should have called the physician for clarification. 46339 3. Resident #1 was admitted to the facility in February 2023 with diagnoses including peripheral vascular disease and lymphedema. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was cognitively intact. The MDS further indicated the Resident had wounds. On 3/4/25 at 8:13 A.M., the surveyor observed Resident #1 lying in his/her bed. The air mattress was set at 10/380 lbs (pounds). On 3/6/25 at 7:59 A.M., the surveyor observed Resident #1 lying in his/her bed the air mattress was set at 10/380 lbs (pounds). On 3/6/25 at 11:00 A.M., the surveyor observed Resident #1 lying in his/her bed the air mattress was set at 10/380 lbs (pounds). Review of the medical record indicated the following physician order dated 4/18/24: - Low air loss mattress check settings and functions every shift - settings at 10/350 Lbs - every shift for preventative skin check proper function. Review of the current Treatment Administration Record (TAR) indicated the nurses had signed off that the air mattress was set at 10/350 Lbs. During an interview on 3/6/25 at 11:07 A.M., Nurse #6 said the physician order should match the air mattress setting and that nurses are responsible for ensuring the air mattress is checked for correct setting and proper functioning. During an interview on 3/7/25 at 11:10 A.M., the Assistant Director of Nursing (ADON) said the physician orders should match Resident #1's actual mattress pressure.

Based on observation, record review and interview, the facility failed to notify the Physician of critical labs for two residents (#12, and #44) out of a total of 20 sampled residents. Specifically: 1. For Resident #12, the facility failed to alert the Physician of critically high BUN (measures how much blood urea nitrogen is in your body and can may indicated a problem with kidneys or liver) and critically low potassium (measures the electrolyte potassium in the blood that is essential for proper muscle and nerve function) results, which resulted in a delay of treatment and hospitalization for acute hypokalemia and acute kidney injury. 2. For Resident #44, the facility failed to obtain laboratory services as ordered by the Physician. Findings include: 1. Resident #12 was admitted to the facility in August 2024 with diagnoses including dementia, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 is moderately cognitively impaired as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #12 requires assistance with bathing and dressing and utilizes oxygen therapy. Review of Resident #12's clinical record indicated that a blood draw was obtained on 2/26/25 at 12:20 P.M. with results reported to the facility on [DATE] at 4:52 P.M. that were critical: - BUN:106 (Reference range 10 - 24). Critically high. - Potassium: 2.7 (Reference range 3.3 - 5.1) Critically low. Resident #12's lab draw on 11/6/24 indicated his/her previous levels were as follows: - BUN: 19 - Potassium: 4.2 Review of the nurse progress note dated 2/26/25 at 9:09 P.M., written by Nurse #4, indicated: Resident continues on antibiotic azithromycin for PNA (pneumonia), no ill effect noted, VSS (vital signs stable). Resident compliant with meds and care, no s/sx (signs or symptoms) of hypo/hyperglycemia noted, safety maintained at all times. The nurse progress note failed to indicate Resident #12's lab results were reported to the Physician. Review of the nurse progress notes dated 2/27/25 at 10:50 A.M. written by the Director of Nursing (DON) indicated: Resident alert and able to make needs known. Continues on abx (antibiotic treatment) for pneumonia with no adverse effect. Critical lab results with BUN of 106 . Reported to provider, new order obtained from [Nurse Practitioner] to send resident to ED for evaluation. Review of the hospital paperwork dated 2/27/25 indicated the following lab results: BUN: 106 Potassium: 2.3 (a decrease from his/her potassium level on 2/26/25) Additional review of the hospital paperwork indicated Resident #12 was admitted to the hospital and diagnosed with acute hypokalemia, and acute kidney injury. During an interview on 3/6/25 at 8:14 A.M., Nurse #2 said that labs are obtained for residents on Wednesdays and Friday mornings. Nurse #2 said that labs do not usually come back until the afternoon so nurses will give report to the 3:00 P.M. - 11:00 P.M. shift to be aware of pending lab results for residents. Nurse #2 said that if labs are critical, the lab will call the facility and alert the nursing staff who will then alert the physician immediately. During an interview on 3/6/25 at 10:58 A.M., Nurse #3 said she worked the 7:00 A.M. - 3:00 P.M., shift on 2/26/25 and remembered that the lab tech arrived late that day. Nurse #3 said she told the incoming nurse (Nurse #4) that Resident #12 had pending labs. Nurse #3 said that staff would immediately call the physician if there were critical lab results for a resident. During an interview on 3/6/25 at 1:56 P.M., Nurse #4 said that he worked the 3:00 P.M. - 11:00 P.M., shift on 2/26/25. Nurse #4 said that he completely forgot to check Resident #12's labs and the DON called him on 2/27/25 and said that Resident #12's labs were critical and Resident #12 was being sent to the hospital. Nurse #4 said he did not receive a call from the lab company and he did not think that the lab faxes over results to the facility. During an interview on 3/6/25 at 11:26 A.M., the Lab Coordinator said that the lab will place three calls to the facility to alert them of any critical labs in addition to faxing over a copy of the lab results. The Lab Coordinator said that if the facility misses the call, they can still view the lab results online. The surveyor was unable to locate a physical copy of Resident #12's labs in his/her paper chart or the unit lab book. Review of the lab report indicated that calls were placed to the facility on [DATE] at 5:04 P.M., 5:37 P.M., and 6:29 P.M., which were unanswered. The DON was unavailable for interview. During an interview on 3/7/25 at 11:18 A.M., the Assistant Director of Nursing (ADON) said that staff should be alerting providers with critical lab results immediately. The ADON said that the DON had found that Resident #12's critical labs were not reported on 2/26/25 and she alerted Nurse Practitioner #1 on 2/27/25. During an interview on 3/10/25 at 9:36 A.M., the Nurse Practitioner said that nursing staff should immediately notify the provider with any critical lab results. The Nurse Practitioner said that she was not made aware until 2/27/25 of Resident #12's labs and she ordered the Resident be sent to the hospital. The Nurse Practitioner said that Resident #12's potassium level was too low and required hospitalization and he/she should have been sent out right away on 2/26/25. 48671 2. Resident #44 was admitted to the facility in August 2024 with diagnoses that include, chronic kidney disease stage 4 severe, retention of urine, type 2 diabetes mellitus, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure (CHF). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/17/25, indicated that Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Further review of the MDS indicated Resident #44 requires substantial/maximal assistance for self-care and mobility. Review of the physician lab orders for Resident #44 indicated: Add TSH (thyroid stimulating hormone), T4 (thyroxine), D3 (vitamin D), B12, FOLATE, Fe tibc (total iron binding capacity) ferritin, HgA1c (glucose blood levels in diabetic patients) and FLP (fasting lipid profile), dated 11/8/2024. Review of the electronic medical record for Resident #44 failed to indicate the ordered labs were obtained. The surveyor was unable to locate a physical copy of Resident #44's labs in his/her paper chart or the unit lab book. During an interview on 3/6/25 at 11:34 A.M., Nurse #6 said Resident #44 was in the hospital recently and should have orders for labs because he/she had elevated levels that needed to be checked and said the Resident has kidney issues. Nurse #6 reviewed Resident #44's medical record and said she did not see any of the labs ordered on 11/8/24. Review of Resident #44's medical record indicated a physician progress note dated 10/29/24, indicated the following: Patient was transferred off hospice care. Remains the same condition but we need to regulate meds (medication) and labs. Review of the physician progress note dated 11/15/24, did not include information related to the labs that were ordered on 11/8/24. During an interview on 3/6/25 at 12:30 P.M., the Director of Nursing said Resident #44 did not have labs drawn as ordered and said she would expect the orders to be followed and monitored. During an interview on 3/7/25 at 11:00 A.M., the Assistant Director of Nurses (ADON) said Resident #44 had an order for lab draws but did not see that they were done. The ADON said staff should have notified the doctor to obtain a new order for labs. The Physician was unavailable for interview. During an interview on 3/10/25 at 10:14 A.M., Nurse Practitioner (NP) #1 said Resident #44 is very fragile and needs close monitoring due to his/her medical conditions and requires labs to be followed and monitored. NP #1 said labs should have been completed as ordered in November and said labs are checked to see if the resident needs to be transferred to the hospital for treatment. NP #1 said she was not aware that the labs in November were not completed and said Resident #44 should have had labs ordered when he/she returned from the hospital.

Based on record review, interview and observation, the facility failed to provide respiratory care in accordance with professional standards of practice, for three of 20 sampled residents. Specifically: 1. For Resident #18, the facility failed to develop a care plan for post-traumatic stress disorder. 2. For Resident #11, the facility failed to develop a care plan for post-traumatic stress disorder. 3. For Resident #12, the facility failed to develop a care plan for suicidal ideation. 4. For Resident #44, the facility failed to develop care plans for the presence of a cardiac pacemaker. 1. Resident #18 was admitted to the facility in April 2024, with diagnoses including post-traumatic stress disorder (PTSD), anxiety and depression. Review of the Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status exam of 7, signifying severe cognitive impairment, and an active diagnosis of PTSD. Review of the current care plan for PTSD/mood care dated 5/10/24, indicated: - Resident #18 was at risk for alteration in mood related to: diagnosis of Depression, PTSD. - The care plan goal: Resident will display positive affect through next review period. - Care plan intervention was limited to: Staff to report any changes in resident's mood to Social Worker, Director of Nurses and supportive services immediately for evaluation. During an interview with the Regional Nurse on 3/6/25 at 10:13 A.M., she said Resident #18's care plan for PTSD should be individualized to include specific triggers and interventions, and that the current care plan is not individualized. The Regional Nurse said the PTSD care plan should give direct care staff direction on how to manage the Resident's PTSD and associated behaviors. 36797 2. Resident #11 was admitted to the facility in July 2023 with diagnoses including post-traumatic stress disorder (PTSD), anxiety and borderline personality disorder. Review of the current care plan failed to indicate a plan of care for the diagnosis of PTSD. During an interview on 3/6/25, at 10:11 A.M., the Regional Nurse said that residents with a diagnosis of PTSD should have a care plan in place that addresses the Resident's PTSD. 36876 3. Resident #12 was admitted to the facility in August 2024 with diagnoses including dementia, chronic obstructive pulmonary disease and suicidal ideation. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 is moderately cognitively impaired as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #12 requires assistance with bathing and dressing and utilizes oxygen therapy. Review of Resident #12's discharge paperwork from the hospital indicated that he/she had a history of suicidal ideation and had been transferred to the psychiatric unit during his/her hospital stay after reporting suicidal ideation with a plan. Review of Resident #12's care plans failed to include a care plan identifying Resident #12's history of suicidal ideation or methods or means for staff to monitor for his/her mental well-being and physical safety. During an interview on 3/6/25 at 10:37 A.M., the Social Worker said residents with a history of suicidal ideation or attempt history should have care plans implemented to reflect triggers signs/symptoms and to notify the physician/administration of any changes of behaviors. The Social Worker said she was not aware Resident #12 did not have a care plan related to his/her suicidal ideation. 48671 4. Review of the facility policy titled Pacemaker, Care of a Resident with, dated as revised December 2015, indicated the purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. - Pacemakers are electronic devices that artificially stimulate the heart muscle with electrical impulses when the heart rhythm is too low (bradycardia). - Pacemakers are programmed to sense the heart and respiratory rate and to administer electrical pulses when the heart rate falls below a set threshold. Complications -If the pulse generator or battery fails or if the leads become displaced the pacemaker may not work properly leading to [NAME] arrhythmias. Resident #44 was admitted to the facility in August 2024 with diagnoses that included: presence of cardiac pacemaker, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, unspecified atrial fibrillation (irregular heartbeat), essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (buildup of plaque restricting blood flow), and acute respiratory failure with hypoxia (lack of oxygen). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/17/25, indicated that Resident #44 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. Further review of the MDS indicated the presence of a cardiac pacemaker. On 3/4/25 at 9:43 A.M., the surveyor observed Resident #44 sitting in bed. A white box was located on the nightstand next to the Resident's bed. Resident #44 said he/she has a pacemaker and but did not know who manages it. Review of Resident #44's pacemaker care plan, dated 8/27/24, indicated the Resident has a pacemaker r/t (related to) A-fib (atrial fibrillation). - Will remain free from s/sx (signs /symptoms) of pacemaker malfunction or failure through the review date. - Obtain vital signs as ordered/per facility protocol and record. Notify MD of significant nursing abnormalities. Review of Resident #44's medical record failed to indicate information on the cardiac pacemaker. During an interview on 3/6/25 at 9:48 A.M., Certified Nursing Assistant #1 said Resident #44 does not have a pacemaker. During an interview on 3/6/25 at 11:36 A.M., Nurse #6 said Resident #44 does have a pacemaker and said the care plan should be completed with information related to the pacemaker and said she did not have any additional information regarding reports in the medical record. During an interview on 3/6/25 at 12:30 P.M., the Director of Nurses said the pacemaker care plan must be updated with information on how the pacemaker is monitored and specifics of the pacemaker and monitoring orders must be in place. During an interview on 3/10/25 at 10:08 A.M., Nurse Practitioner #1 said the medical record should indicate the presence of a pacemaker, so staff are aware.

Based on observation, record review and interview, the facility failed to notify the physician of a change in condition for one Resident, (#6), out of a total of 20 sampled residents. Specifically, the facility failed to notify the physician of a change in skin condition. Findings include: Review of the facility policy titled Change in a Resident's Condition or Status, dated revised December 2003 indicated that the facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and or status. Resident #6 was admitted to the facility in February 2023 with diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure and schizophrenia. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident #6 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. During an interview on 3/4/25, at 10:47 A.M., Resident #6 said he/she has a fungal infection in his/her right groin. Resident #6 said that he/she told the nurses, but no one has obtained a nystatin powder (antifungal) for it. Resident #6 said that he/she bought Gold Bond powder, but it doesn't work. Review of the physician's orders failed to indicate an order for antifungal powder. Review of the progress notes failed to indicate that the physician was notified of Resident #6 having a reddened groin and was requesting an antifungal powder to be applied. Review of the document titled weekly Skin Review dated 2/12/25, indicated groin is pink. antifungal powder applied, no new skin issues. Review of the document titled weekly Skin Review dated 2/19/25, indicated resident groin is pink, antifungal powder applied. Review of the document titled weekly Skin Review dated 2/25/25, indicated groin is pink, antifungal powder order is in place, no new skin issues noted. During an interview on 3/06/25, at 10:11 A.M., the Regional Nurse said that the physician should have been notified of Resident #6's reddened groin.

Based on observation, record review and interview, the facility failed to ensure quality of care for two Residents (#69, and #6), out of a total sample of 20 residents. Specifically, 1. For Resident #69, the facility failed to ensure for Resident #69, who is treated with anticoagulant medication (a medication that hinders clotting of the blood), that areas of discoloration consistent with bruising were identified. 2. For Resident #6, the facility failed to obtain a treatment for a change in condition related to skin management. Findings include: 1. Review of the Facility's policy titled Anticoagulation - Clinical Protocol, revision date November 2018, included but was not limited to the following: Monitoring and Follow-up 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. A. If an individual on anticoagulation therapy, shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Resident #69 was admitted to the facility in December 2024 and has diagnoses that include muscle wasting and atrophy, sepsis, chronic obstructive pulmonary disease, atherosclerotic heart disease and peripheral vascular disease. Review of the Minimum Data Set assessment, dated 12/25/25 indicated Resident #69 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having moderately intact cognition. During an observation and interview on 3/4/25 at 8:35 A.M., Resident #69 was in his/her bed. Resident #69's right arm had scattered red areas on the skin. Nurse #6 entered the room and said the Resident is on Lovanox (an anticoagulant) and administered the medication via an injection, and then she exited the room. Resident #69 said he/she transfers in out of bed with a slide board and can easily bump his/her arms. Review of Resident #69's physician's orders indicated the following: - Aspirin (a medication that can thin the blood) oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day for Arterial Insufficiency, start date 12/20/2024. - Lovenox (an anticoagulation medication that hinders the clotting of blood) Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium). Inject 0.4 ml subcutaneously one time a day for supplement related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) start date 12/20/24. - Clopidogrel Bisulfate Oral Tablet (an antiplatelet medication) 75 mg, give 75 mg by mouth one time a day for prophylactic use for 3 months. Start date 1/9/2025. - Monitor for Bleeding/Bruising r/t (related to) Lovenox use every shift, start 12/19/24 - Weekly skin check every shift every Thu (Thursday), start date 12/25/2024. Review of Resident #69's care plans indicated a care plan 'the Resident will not experience complications secondary to anticoagulation therapy', date initiated: 12/22/24. Goal - Resident will not develop bruising or abnormal bleeding from anticoagulant use through next review, dated initiated 12/22/24, revision date 2/28/2025. During an observation and interview on 3/6/25 at 8:48 A.M., and on 3/6/25 at 9:16 A.M., Resident #69 was in bed. His/her right arm had an increase in the number of areas of reddish discoloration on his/her right arm. Resident #69 said his/her left arm now had marks and held his/her arm up revealing red circular areas. Resident #69 said his/her arms have the areas because he/she is on a blood thinner and when he/she moves around or bangs them on the bed rail they just pop. Resident #69 said his/her right arm is worse than his/her my left arm. Resident #69's right arm had large, darker reddened discolorations, and close to his/her elbow was a small dark raised area, consistent with a scab. Resident #69 said it was a small cut. Resident #69 said the nurses knows about his/her skin. During an interview on 3/6/25 at 10:35 A.M., Certified Nursing Assistant (CNA) #1 said any changes in a resident's skin is reported to the nursing staff. CNA #1 said she is taking care of Resident #69 today and was not aware of any skin issues other than the dressings to his/her feet. The surveyor and CNA #1 went to Resident #69's room and observed both his/her arms. Resident #69 said the area on the right elbow observed with a scab has been there a few days after he/she hit it on his/her wheelchair. CNA #1 said the areas on his/her arms should be reported to nursing staff. Review of the Weekly skin review-V3, dated 3/6/25 indicated it failed to document areas of red discoloration on Resident #69's right or left arms. Review of the progress notes entered in Resident #69's medical record from 3/1/25 through 3/6/25 failed to indicate any nursing progress note related to changes in Resident #69's skin, specifically the areas of discoloration to his/her right and left arms. Nor were there any progress notes to indicate the physician was made aware of the resident's areas of discoloration on his/her right and left arms. Review of the March 2025, Medication Administration Record (MAR) indicated: Monitor for Bleeding/Bruising r/t (related to) Lovenox use every shift, start 12/19/24, and from 3/1/25 through day shift on 3/6/25, the day, evening and night shifts were checked off by nursing staff, and failed to indicate if any bleeding or bruising was noted. During an interview on 3/6/25 at 10:51 A.M., Nurse #6 said she just been informed of the bruises on Resident #69's right and left arms. Nurse #6 said the Resident is on three blood thinners and requires close monitoring to make sure he/she does not have any bruises or bleeding. Nurse #6 said the weekly skin check should include documentation of any skin changes including bruises. Nurse #6 said the MAR should include if bleeding or bruising is present due to the use of blood thinners. 36797 2. Resident #6 was admitted to the facility in February 2023 with diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure and schizophrenia. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #6 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. During an interview on 3/4/25 at 10:47 A.M., Resident #6 said he/she has a fungal infection in his/her right groin. Resident #6 said that he/she told the nurses but no one has obtained a nystatin powder (an antifungal) for it. Resident #6 said that he/she bought Gold Bond powder but it doesn't work. Review of the physician's orders failed to indicate an order for antifungal powder. Review of the progress notes failed to indicate that the physician was notified of Resident #6 having a reddened groin and was requesting an anti fungal powder to be applied. Review of the document titled weekly Skin Review dated 2/12/25, indicated groin is pink. antifungal powder applied, no new skin issues. Review of the document titled weekly Skin Review dated 2/19/25, indicated resident groin is pink, antifungal powder applied. Review of the document titled weekly Skin Review dated 2/25/25, indicated groin is pink, antifungal powder order is in place, no new skin issues noted. During an interview on 3/6/25, at 9:00 A.M., Nurse #5 said that she did not know the residents very well and did not know Resident #6 had a reddened groin. Nurse #6 then said that the physician should have been notified when Resident #6's groin became reddened.

Based on observation, record review and interview the facility failed to ensure for one Resident (#69) that a smoking assessment was completed and that a care plan was developed for smoking. Findings include: Review of the facility's policy titled Smoking Policy - Residents, revision date October 2023 indicted the following: The facility has established and maintains safe smoking practices. 1. Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption, b. method of tobacco consumption (traditional cigarettes electronic cigarettes, pipe, etc.) c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 9. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to those issues. Resident #69 was admitted to the facility in December 2024 and has diagnoses that include muscle wasting and atrophy, sepsis, chronic obstructive pulmonary disease, atherosclerotic heart disease and peripheral vascular disease. Review of the Minimum Data Set assessment, dated 12/25/25 indicated Resident #69 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having moderately intact cognition. Further, the MDS indicated no tobacco use. Review of the list, not dated, provided by the facility to the surveyors on 3/4/25, indicated Resident #69 was listed as a person who smoked, requiring supervised/monitoring. Review of Resident #69's medical record indicated the following: - No person-centered care plan for smoking including individualized interventions. - No Safe Smoking Evaluation. - A smoking agreement signed by Resident #69, dated 12/23/24. -The admission nursing assessment dated [DATE] indicated Resident #69 did not smoke. During an interview on 3/6/25 at approximately 8:37 A.M., Resident #69 said he/she smokes when his/her friend visits a few times a week, but he/she does not go out to the smoking area. During an interview on 3/6/25 at 8:19 A.M., Nurse #6 said that she was not aware that Resident #69 smoked, and that Resident #69 had told her that he/she did not smoke. During an interview on 3/6/25 at 3:02 P.M., the Social Worker said Resident #69 signed a smoking agreement upon admission. The Social Worker said at admission Resident #69 was ill and did not smoke, and when he/she began to feel better he/she resumed smoking. The Social Worker said Resident #69 may have began smoking around the end of January. The Social Worker said there was no safe smoking evaluation in Resident #69's medical record. The Social Worker said a care plan for smoking was initiated and discontinued. During an interview on 3/6/25 at 3:58 P.M., the Administrator said he added Resident #69 to the supervised smoking list because he saw him/her smoking outside with his/her friend. The Administrator said a care plan for smoking should be in place and a safe smoking evaluation should have been conducted when staff became aware that Resident #69 began to smoke.

Based on record review, interview and observation, the facility failed to provide respiratory care for three of 20 sampled residents. Specifically: 1. For Resident #18, the facility failed to implement the physician's order for oxygen use. 2. For Resident #6, the facility failed to implement the physician's order for oxygen, and did not change expired oxygen tubing. 3. For Resident #12, the facility failed to obtain a physician's order for oxygen used by the Resident. Findings include: 1. Resident #18 was admitted to the facility in [DATE] and had diagnoses which included chronic obstructive pulmonary disease (COPD). Review of Resident #18's Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status exam of 7, signifying severe cognitive impairment, and an active diagnosis of COPD. Review of Resident #18's respiratory care plan dated [DATE], indicated: - The Resident has oxygen therapy related to COPD. - Provide oxygen as ordered. Review of Resident #18's physician's order dated [DATE], indicated: - Oxygen via nasal cannula as needed at 2 liters per minute to maintain saturation at or above 90%. On [DATE] at 10:41 A.M., the surveyor observed Resident #18 lying awake in bed and wearing a nasal cannula. The cannula and tubing were attached to an oxygen concentrator, located on the floor by the side of the bed. The oxygen was running and set to 4 ,d+[DATE] liters per minute. On [DATE] at 7:58 A.M., the surveyor observed Resident #18 asleep in bed, and wearing a nasal cannula attached to the oxygen concentrator. The concentrator was running and set to 4 ,d+[DATE] liters per minute. During an interview with Nurse #2 on [DATE] at 8:05 A.M., the surveyor told her that Resident #18's oxygen was running at 4 ,d+[DATE] liters per minute. Nurse #2 reviewed the Resident's physician orders and said the oxygen delivery rate should be set to 2 liters per minute. Nurse #2 accompanied the surveyor to the Resident's room and observed the oxygen concentrator was running at 4 ,d+[DATE] liters per minute. During an interview with Resident #18 on [DATE] at 9:33 A.M., he/she said he/she does not adjust the oxygen level on the concentrator, and that only staff touch the concentrator. 36797 2. Resident #6 was admitted to the facility in February 2023 with diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure and schizophrenia. Review of the Minimum Data Set assessment date [DATE] indicated that Resident #6 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. On [DATE], at 8:09 A.M. the surveyor observed Resident #6 in bed receiving 4.5 liters/minute of oxygen via nasal cannula. The surveyor then observed the oxygen tubing to be dated [DATE]. Review of the physician orders dated [DATE] indicated an order for O2 via nasal cannula 1 to 3 liters/minute continuous. Review of the medication administration record dated [DATE] indicated that the oxygen tubing was changed on [DATE]. Review of the care plan indicated that Resident #6 is at risk for respiratory complications r/t COPD, respiratory failure and to provide O2 therapy as ordered. During an interview on [DATE], at 9:00 A.M., Nurse #5 said that the oxygen tubing was dated [DATE] and should have been changed on [DATE]. Nurse #5 then said that the oxygen was running at 4.5 liters/minute and was ordered to be running at no higher than 3 liters/minute. Nurse #5 then said that the medical record was inaccurate because a nurse had signed off that the O2 tubing was changed on [DATE]. 36876 3. Resident #12 was admitted to the facility in [DATE] with diagnoses including dementia, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 is moderately cognitively impaired as evidenced by a score of 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. The MDS also indicated Resident #12 requires assistance with bathing and dressing and utilizes oxygen therapy. On [DATE], the surveyor observed Resident #12 asleep in bed wearing oxygen via nasal cannula. The surveyor was unable to observe the oxygen concentrator due to its placement under the bed. Review of Resident #12's physicians orders failed to indicate a current order for the use of oxygen. During an interview on [DATE] at 8:20 A.M., Resident #12 was observed seated in the hallway outside his/her door, not wearing 02. Resident #12 and said he/she wears oxygen at night and gave the surveyor permission to view the concentrator. The surveyor then observed the 02 concentrator running with the nasal cannula on the floor. The concentrator was set at 3 liters. Resident #12 said it should be set at 2 liters. During an interview on [DATE] at 10:16 A.M., Nurse #2 said that Resident #12 wears oxygen at night when he/she is sleeping. Nurse #2 and the surveyor reviewed the physician' orders and Nurse #2 said she could not see an order for the use of oxygen for Resident #12. Nurse #2 said residents on oxygen need a physician's order. During an interview on [DATE] at 11:25 A.M., the Assistant Director of Nursing (ADON) said that she knew Resident #12 wore oxygen at night and did not know there was no order in place.

Based on observation, record review and interview, the facility failed to ensure medications were stored as required for one Resident (#26), out of a total sample of 20 residents. Specifically, the facility failed to ensure that medication was not left at the Resident's bedside unattended. Findings include: Review of the facility policy titled 'Medication Labeling and Storage' dated February 2023, indicated the following but was not limited to: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Resident #26 was admitted to the facility in April 2019 with diagnoses including gastro esophageal reflux disease without esophagitis. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was cognitively intact. The MDS further indicated the Resident did not reject care. On 3/4/25 at 8:09 A.M., the surveyor observed three medicine cups by the Resident's bedside table with 15 round various colored tablets, and appeared to be calcium carbonate Tums. Review of the medical record indicated the following physician order. - Calcium carbonate tablet 1250 (500 ca) mg (milligram). Give 2 tablets by mouth with meals for supplement. Review of medical record failed to indicate a resident self-medication administration assessment had been completed. During an interview on 3/6/25 at 11:04 A.M., Nurse #6 said the nurses are supposed to stay with the Resident during medication administration to ensure all medications are taken. During an interview on 3/7/25 at 11:08 A.M., the Assistant Director of Nursing (ADON) said nurses are to stay with the resident until all the medication is consumed and should not leave any medications by the bedside.

Based on record review and interview, the facility failed to ensure specialized rehab services were provided in a timely fashion for one Resident (#41) out of a total sample of 20 residents. Findings include: Resident #41 was admitted to the facility in November 2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side. Review of Resident #41's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had a moderate impaired cognition and scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam. Review of Resident #41's medical record indicated the following: - Nursing note dated 2/8/25: Patient continue to c/o (complain of) pain and stiffness of left-hand joints when he/she tries to use his/her hand and bend his/her fingers. No swelling, redness or signs of trauma noted. The doctor notified new order to start patient on Biofreeze gel every 8 hours, then refer patient to OT (Occupational Therapy) [sic]. During an interview on 3/7/25 at 11:41 A.M., the Assistant Director of Nursing (ADON) said the OT evaluation was done on Tuesday 3/4/25. She further said they have not had an OT on staff and the per diem (as needed) OT staff are here at the facility only once a month. The ADON said the expectation for a therapy screen to be completed should be no more than two weeks. During an interview on 3/7/25 at 12:03 P.M., the Rehab Director said they are made aware of residents requiring therapy evaluation either by nursing staff telling them verbally, filling out a slip or during morning meeting. He further said he has not had an occupational therapist on staff, and the expectation is a resident should be evaluated as soon as possible after the initial screen request.

Based on record review and interview, the facility failed to ensure the accuracy of its medical records for 3 of 20 sampled residents. Specifically: 1. For Resident #18, the facility failed to accurately document the oxygen delivery rate. 2. For Resident #6, the facility failed to accurately date oxygen tubing. 3. For Resident #1, the facility failed to accurately document wound dressing treatment. Findings include: 1. Resident #18 was admitted to the facility in April 2024 and had diagnoses which included chronic obstructive pulmonary disease (COPD). Review of Resident #18's Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status exam of 7, signifying moderate cognitive impairment, and an active diagnosis of COPD. Review of Resident #18's respiratory care plan dated 10/20/24, indicated: - The Resident has oxygen therapy related to COPD. - Provide oxygen as ordered. Review of Resident #18's physician's order dated 5/14/24, indicated: - Oxygen via nasal cannula as needed at 2 liters per minute to maintain saturation at or above 90%. On 3/4/25 at 10:41 A.M., the surveyor observed Resident #18 lying awake in bed and wearing a nasal cannula. The cannula and tubing were attached to an oxygen concentrator, located on the floor by the side of the bed. The oxygen was running and set to 4 1/2 liters per minute. On 3/6/25 at 7:58 A.M., the surveyor observed Resident #18 asleep in bed, and wearing the nasal cannula, attached to the oxygen concentrator. The concentrator was running and set to 4 1/2 liters per minute. Review of Resident #18's Medication Administration Record (MAR) indicated that on 3/4/25, 3/5/25 and 3/6/25, staff documented he/she received oxygen via nasal cannula as needed at 2 liters per minute. The MAR did not indicate the Resident's oxygen was set to and running at 4 1/2 liters per minute. Review of Resident #18's nursing notes dated 3/4/25, 3/5/25 and 3/6/25, did not indicate the Resident's oxygen was set to and running at 4 1/2 liters per minute. During an interview with Nurse #2 on 3/6/25 at 8:05 A.M., the surveyor told her that Resident #18's oxygen was running at 4 1/2 liters per minute, but the MAR indicated it ran at 2 liters per minute. Nurse #2 reviewed the Resident's physician orders and said the oxygen delivery rate should be set to 2 liters per minute and that the MAR was inaccurate. Nurse #2 accompanied the surveyor to the Resident's room and observed the oxygen concentrator was running at 4 1/2 liters. During an interview with Resident #18 on 3/6/25 at 9:33 A.M., he/she said he/she does not adjust the oxygen level on the concentrator, and that only staff touch the concentrator. 36797 2. Resident #6 was admitted to the facility in February 2023 with diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure and schizophrenia. Review of the Minimum Data Set assessment date 12/25/24 indicated that Resident #6 scored a 9 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. A. During an interview on 3/4/25, at 10:47 A.M., Resident #6 said he/she has a fungal infection in his/her right groin. Resident #6 said that he/she told the nurses but no one has obtained a nystatin powder (an anti fungal) for it. Resident #6 said that he/she bought Gold Bond powder but it doesn't work. Review of the physician's orders failed to indicate an order for fungal powder. Review of the progress notes failed to indicate that the physician was notified of Resident #6 having a reddened groin and was requesting an anti fungal powder to be applied. Review of the document titled weekly Skin Review dated 2/12/25, indicated groin is pink. antifungal powder applied, no new skin issues. Review of the document titled weekly Skin Review dated 2/19/25, indicated resident groin is pink, antifungal powder applied. Review of the document titled weekly Skin Review dated 2/25/25, indicated groin is pink, anti fungal powder order is in place, no new skin issues noted. During an interview on 3/6/25, at 10:11 A.M.,the Regional Nurse said that a doctor's order for an antifungal powder should be obtained before applying the powder. The Regional Nurse also said that the documentation should be accurate and not indicate a physician's order was in place when it was not. B. On 3/4/25 at 8:09 A.M., the surveyor observed Resident #6 in bed receiving 4.5 liters/minute of oxygen via nasal cannula. The surveyor then observed the oxygen tubing to be dated 2/24/25. Review of the physician orders dated March 2025 indicated an order for O2 via nasal cannula 1 to 3 liters/minute continuous. Review of the medication administration record dated March 2025 indicated that the oxygen tubing was changed on 3/2/25. Review of the care plan indicated that Resident #6 is at risk for respiratory complications r/t COPD, respiratory failure and to provide O2 therapy as ordered. During an interview on 3/06/25, at 9:00 A.M., Nurse #5 said that the oxygen tubing was dated 2/24/25 and should have been changed on 3/3/25. Nurse #5 then said that the oxygen was running at 4.5 liters/minute and it was ordered to be running at no higher than 3 liters/minute. Nurse #5 then said that the medical record was inaccurate because a nurse had signed off that the O2 tubing was changed on 3/3/25. 46339 3. Resident #1 was admitted to the facility in February 2023 with diagnoses including peripheral vascular disease and lymphedema. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she was cognitively intact. The MDS further indicated the Resident had wounds. On 3/4/25 at 8:13 A.M., the surveyor observed Resident #1 lying in his/her bed land the eft ankle had a border gauze dressing dated 3/2. Review of the medical record indicated the following physician order, dated 2/10/25: - Xeroform gauze, gauze island with border apply to left upper medial ankle once daily every day shift. Review of the current Treatment Administration Record (TAR) indicated the nurses had signed off that the wound dressing had been changed on 3/3/25. During an interview on 3/6/25 at 11:07 A.M., Nurse #6 said the treatment nurse does the wound treatments Monday through Friday and the floor nurses are responsible for the treatments when the wound treatment nurse is not available. She further said nurses should not document a treatment as complete if it was not completed. During an interview on 3/7/25 at 11:10 A.M., the Assistant Director of Nursing (ADON) said the floor nurses are responsible for ensuring the wound treatments are completed as ordered and document accurately.

Based on record review and interview, the facility failed to accurately execute an Advanced Directive for 1 Resident (#69), out of a total sample of 20 residents. Specifically, for Resident #69 the facility failed to ensure the Massachusetts Medical Order for Life Sustaining Treatment (MOLST) (An Advanced Directive that is reviewed and signed as an order by a Physician/Nurse Practitioner (NP), or Physician Assistant (PA) and confirms a Resident's decisions for life sustaining treatment), was valid and signed by the Resident. Findings include: Review of the Facility's policy titled Advanced Directives, revision date September 2022, indicated the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced Directives are honored in accordance with state law and facility policy. Resident #69 was admitted to the facility in December 2024 and has diagnoses that include muscle wasting and atrophy, sepsis, chronic obstructive pulmonary disease, atherosclerotic heart disease and peripheral vascular disease. Review of the Minimum Data Set assessment, dated 12/25/25 indicated Resident #69 scored an 11 out of 15 on the Brief Interview for Mental Status score, indicating he/she as having moderately intact cognition. Review of Resident #69's medical record indicated the following: - A MOLST form dated 12/23/24 indicating Do Not Resuscitate, and Do Not Intubate and Ventilate, signed by a nurse practitioner and signed by a person, not the resident. - Admission paperwork signed by Resident #69. Further review of the medical record failed to indicate a physician's order, or documentation to indicate Resident #69 had an invoked health care proxy agent, (an order/document that is signed by the physician, NP or PA that indicates the resident lacks the capacity to make their health care treatment decisions, allowing a designated health care agent to make informed decisions). During an interview on 3/6/25 at 12:19 P.M., the Social Worker said that Resident #69's health care proxy was not invoked, and that the person who signed the MOLST did not have the authority to make health care decisions for Resident #69, resulting in the MOLST not being valid.

Based on observations, interviews and records reviewed, for five out of thirteen resident rooms on one unit (Unit A) and for three out of three resident shower rooms, the Facility failed to ensure it provided a safe, clean, comfortable and homelike environment for its residents, when the condition of the resident shower rooms were found to be dirty and baseboard heaters in several resident rooms were in disrepair, with missing or damaged covers, both of which created potentially hazardous conditions. Findings include: Review of the Facility Policy titled Shower and Tub Room Cleaning, undated, indicated showers would be cleaned daily to remove soap scum, dirt and debris, providing a safe and sanitary place for residents to bathe. Review of a Department of Public Health (DPH) Consumer Complaint Form, dated 02/06/25, indicated the Complainant alleged that the resident showers were dirty and covered in mold and mildew. The Form further indicated the Complainant alleged that baseboard heaters in several resident rooms were broken and exposed. During an environmental tour of Unit C, on 02/20/25 at 7:54 A.M., Surveyor #2 observed the resident shower room had blackened areas in the grout between the tiles on the wall of the shower and did not appear to be cleaned on a routine basis. The shower room was poorly lit, and there were black mildew-like stains on the ceiling. During an environmental tour of Unit A, on 02/20/25 at 8:15 A.M., Surveyor #2 observed the following: - Resident shower room (near the nurses' station): The ceiling was covered with a black mildew-like substance. The air in the room was very humid, smelled musty, and the exhaust fan was not working. The base of the shower curtain was black. The air vent was caked with dust. - Resident shower room (near the Hair Salon): The shower curtain was dirty. The ceiling and the grout between the shower tiles were covered with a black mildew-like substance. - room [ROOM NUMBER]: The baseboard heater cover was hanging off. - room [ROOM NUMBER]: The baseboard heater cover was completely off, sharp edges and heating elements were exposed and accessible to residents. - room [ROOM NUMBER]: The baseboard heater cover was hanging off. - room [ROOM NUMBER]: The baseboard heater cover was hanging off. - room [ROOM NUMBER]: The baseboard heater cover was hanging off and sharp edges were exposed and accessible to residents. During an interview on 02/20/25 at 11:55 A.M., Resident #6 said the shower on Unit C was not kept clean. Resident #6 led Surveyor #3 to the shower room and showed her the black mildew-like substance that covered the grout between the shower tiles. During an interview on 02/20/25 at 9:40 A.M., the Director of Environmental Services said the expectation was for the housekeepers to clean the resident shower rooms daily. The Director of Environmental Services said that the exhaust fan in the Unit A Shower Room (near the nurses' station) was supposed to turn on automatically, but it did not operate consistently, and he had not been able to fix it. During an interview on 02/20/25 at 2:30 P.M., with the Administrator, Surveyor #2 requested copies of all Facility Policies that addressed overall general maintenance of the resident care areas and/or maintaining the baseboard heating equipment in resident rooms. The Administrator provided, and Surveyor #2 reviewed the following Facility Policies related to maintenance: - General Guidelines (Maintenance of Fire safety Equipment), October 2019 - Cleaning and Disinfection of Environmental Surfaces, August 2010 Review of Policies indicated there was no documentation to address general maintenance of the resident care areas and/or the upkeep of the baseboard heaters. The Administrator said the Facility had identified a problem with the covers on the baseboard heaters about a year ago and had planned to replace all the covers. The Administrator said that while some covers were purchased on 08/29/24, several baseboard heaters were still in need of replacement covers.

Based on observations, interviews and records reviewed, for the main kitchen where all food items are prepared and plated before being served to the residents, the facility failed to ensure; 1) they maintained a clean and sanitary environment in the facility's main kitchen, and 2) that kitchen (dietary) staff adhered to sanitary standards of practice during food handling when two of two cooks were observed handling food without wearing hair restraints. Findings include: Review of the Facility's policy, titled Sanitation/Infection Control, undated, indicated the following: -The Dietary Manager is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department. -The Dietary Manager and consultant dietician develop a cleaning schedule. -Light daily cleaning is required for the refrigerator .outside doors on steamers and freezers are wiped off. -All work and storage areas are clean, well lit, and orderly. Review of the Facility's policy, titled Personal Hygiene, undated, indicated the key to a safe and sanitary Dietary Department is healthy employees, properly trained in safe food handling, who practice good personal hygiene. The Policy indicated if hair was long and not covered properly with a cap, a hair net must be worn. On 02/20/25 at 11:15 A.M., the surveyor observed the following in the facility's main kitchen: 1) A wall of reach-in freezers adjacent to the steam table with large areas of fingerprints and smears along five out of five doors. -Four of the five reach-in freezer doors did not have a plastic protective piece along the door handle, leaving an exposed metal edge, which created a space for debris to collect. -The reach-in refrigerator located near the exit door of the kitchen had large areas of fingerprints and smears on both doors. 2) -Dietary staff were preparing to serve the lunch meal. -Cook #1 stood behind the steam table, in front of the uncovered food items to be served for lunch, without wearing a beard net. -Cook #1 plated all the food items to be served to the residents for lunch, without wearing a beard net. -Cook #2 set up a workstation at a preparation table behind the steam table, placing several pieces of bread on the table to make sandwiches for the residents, without wearing a cap or hair net. -Cook #2 made several sandwiches to be served to the residents for lunch, without wearing a cap or hair net. During an interview on 02/20/25 at 2:38 P.M., the Food Service Director (FSD) said she had a generic cleaning schedule but needed to develop a better one. The FSD said the freezer and refrigerator doors should be cleaned every shift and that the handles on the reach-in freezer doors had been missing for a long time. The FSD said all dietary staff were supposed to wear hair and beard coverings when they were in the kitchen. The FSD said both cooks should have worn appropriate hair coverings when in the kitchen and during lunch service. During a telephone interview on 02/21/25 at 9:31 A.M., the Administrator said he expected the kitchen appliances to be clean and he did not know that the plastic coverings for the handles on the reach-in freezers were missing. The Administrator said that all dietary staff were supposed to wear appropriate hair coverings when they were in the kitchen.

Based on records reviewed, interviews and observations, for one of three sampled resident care units (Unit A), the Facility failed to ensure food provided to the residents was served at safe and appetizing temperatures, when on 02/20/25, results of test tray observations indicated the food items were not served at appetizing temperatures and some of the food items were not palatable. Finding include: Review of the Facility's policy, titled Food Temperatures, undated, indicated foods will be maintained at proper temperature to ensure food safety. The point of service temperature to residents will be within the range of 120 degrees Fahrenheit (F) to 140 degrees (F) based on the resident's preference. The policy further indicated the following range of temperatures recommended for food at point of tray assembly: -Meat, portioned for service: 160 degrees (F) -Potatoes and vegetables: 160 degrees (F) Review of the Dining Committee Minutes, dated 12/16/24 and attended by 12 residents, indicated some residents stated that some meals were not up to temperature, but the residents did not specify which meal. Review of a Department of Public Health (DPH) Consumer Complaint Form, dated 02/06/25, indicated the Complainant alleged that breakfast was always cold, and dinner was inedible. During an interview on 02/20/25 at 8:08 A.M., Resident #7 (who resided on Unit A) said the food at the Facility was awful and always cold. Resident #7 said there was no variety, and the food quality was poor. During an interview on 02/20/25 at 8:15 A.M., Resident #3 (who resided on Unit A) said the quality of the food at the Facility was poor. Resident #3 showed the surveyor his/her breakfast meal which consisted of scrambled eggs and one piece of toast, which had been cut in half and toasted on only one side. On 02/20/25 at 11:31 A.M., Surveyor #1 observed the following in the facility's main kitchen: - [NAME] #1 took the temperature of the following food items in preparation to serve the lunch meal: -puree beef: 170 degrees (F) -puree carrots: 180 degrees (F) -mashed potatoes: 160 degrees (F) -hamburger: 160 degrees (F) -hot dog: 150 degrees (F) -chicken salad: 41 degrees (F) - At 11:37 A.M., the lunch line began. [NAME] #1 plated the food items and handed the plate to the Dietary Aide who put a cover over the plate and placed it in the food truck, to be delivered to the resident units. On 02/20/25 at 12:14 P.M., the second lunchtime truck for Unit A left the kitchen. At 12:14 P.M., the second lunchtime truck was observed to arrive on Unit A. Multiple staff members began passing the lunch trays out to the residents who were in their rooms. At 12:19 P.M., after the last resident meal tray was removed and served, the test tray was pulled from the truck by Nurse #1. A food test tray was then conducted on Unit A by Surveyor #1 accompanied by Nurse #1. Test Tray observations: The food temperatures were measured by Nurse #1, the food items were tasted by Surveyor #1 in the presence of Nurse #1, observations were as follows: - puree beef was 109.9 degrees (F) and tasted lukewarm - mashed potatoes were 104.4 degrees (F), were tepid, bland, and not palatable. - puree carrots were 103.6 degrees (F), were tepid and not palatable. - hot dog was 97.3 degrees (F), was cold and not palatable. - A hamburger was not provided on the test tray. - The chicken salad sandwich was dark in appearance; the portion of chicken salad in the sandwich was inadequate and did not meet the corners or edges of the bread and tasted bland. During an interview on 02/20/25 at 12:30 P.M., Resident #4 (who resided on Unit A) said the food was awful and that he/she got some kind of salad sandwich for lunch and it tasted awful. During an interview on 02/20/25 at 12:32 P.M., Resident #5 (who resided on Unit A) said the food was not good, so he/she usually requested hamburgers. During an interview on 02/20/25 at 2:38 P.M., the Food Service Director (FSD) said the hot food temperature at the time of service to residents should be 135 degrees (F). The FSD said she was not surprised that the food temperatures for the test tray were low, and she thought one of the wells in the steam table did not hold the appropriate temperature. The FSD said the food would not taste good at those temperatures (obtained during the test tray observation). During a telephone interview on 02/21/25 at 9:31 A.M., the Administrator said the facility needed a pellet system (provides an insulated base to hold the plated food ready for service). The Administrator said the plates were not kept warm because there was nothing under them.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who were assessed by nursing to be at risk for elopement, the Facility failed to ensure 1) nursing updated Resident #1's comprehensive plan of care with new interventions following an elopement on 07/07/24, and 2) nursing developed and implemented an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed Resident #2's risk for elopement. Findings include: Review of the Facility's policy titled Care Plans Comprehensive Person-Centered, dated 03/2022, included the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the Facility's policy titled Wandering and Elopements, dated 03/2019, indicated if a resident is identified to be at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 1) Resident #1 was admitted to the Facility in July 2023, diagnoses include hereditary ataxia (impaired balance or coordination), mild cognitive impairment, and repeated falls. Review of Resident #1's Elopement and Wander Risk Evaluation, dated 04/15/24, indicated he/she was assessed as being at high risk for elopement. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, indicated he/she scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests no cognitive impairment). Review of Resident #1's Elopement Care Plan, renewed and reviewed with his/her April 2024 MDS, indicated he/she was at risk for elopement with an intervention to make the receptionist and other staff aware of his/her risk for elopement. Review of Resident #1's Nurse Progress Note, dated 07/07/24 and signed by Nurse #3, indicated Resident #1 had an argument with his/her roommate and Resident #1 attempted to leave the Facility. The Note indicated staff were able to redirect Resident #1 back into the Facility, but he/she refused to go back to his/her room and Resident #1 was moved to a different room for the night. During an interview on 11/26/24 at 3:16 P.M., Nurse #3 said she was the nurse on duty for the evening shift (3:00 P.M. through 11:00 P.M.) on 07/07/24. Nurse #3 said staff found Resident #1 outside in the parking lot adjacent to the facility, that Resident #1 was crying and said that he/she wanted to go home. Nurse #3 said staff were able to redirect Resident #1 back into the Facility. Nurse #3 said she notified the Director of Nurses (DON), Assistant Director of Nurses (ADON) and the Administrator that Resident #1 spent that night in a different room. Nurse #3 said no changes were made to Resident #1's care plan. Review of Resident #1's Elopement Care Plan, initiated 04/12/24, indicated there was no documentation to support that new interventions were implemented after his/her elopement on 07/07/24. Review of an Employee Statement, undated and signed by Certified Nurse Aide (CNA) #1, indicated CNA #1 entered Resident #1's room at 7:40 P.M. on 09/21/24, to provide him/her care, and Resident #1's roommate said Resident #1 left the building to meet his/her spouse. During a telephone interview on 11/26/24 at 4:43 P.M., Nurse #1 said he worked through a staffing agency and was on duty the evening shift of 09/21/24 and he did not know how Resident #1 was able to leave the Facility that evening, unattended by staff. Nurse #1 said it was a busy time of night when Resident #1 left the Facility. Nurse #1 said when Resident #1 returned to the Facility, he/she had bruises on his/her face and abrasions to his/her knees and palms. Nurse #1 said the abrasions were all superficial. During an interview on 11/26/24 at 3:59 P.M., the Director of Nurses (DON) said had she realized that Resident #1 was found outside of the building in the facility's parking lot on 07/07/24, she would have revised the care plan at that time to add new interventions which would have included for Resident #1 to always wear a wander guard bracelet (triggers an alarm at the exit doors) and to increase safety checks performed by staff, in an effort to prevent his/her second elopement. 2) Resident #2 was admitted to the Facility in May 2024, diagnoses include Alzheimer's Disease, repeated falls, and unsteadiness on feet. Review of Resident #2's Nursing Elopement and Wander Risk Evaluation, dated 08/26/24, indicated he/she was assessed to be at high risk for elopement. Review of Resident #2's medical record indicated there was no documentation to support that an individualized comprehensive care plan with interventions, treatment goals and outcomes that addressed his/her risk of elopement, had been developed. During an interview on 11/26/24 at 3:59 P.M., the Director of Nurses (DON) said Resident #2 should have had a care plan related to his/her risk of elopement once the risk of elopement was identified.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for elopement, and was moderately cognitively impaired, the Facility failed to ensure he/she was provided an adequate level of staff supervision to prevent two incidents of elopement, when on 07/07/24, Resident #1 was found out in the parking lot adjacent to the facility (unescorted by a staff member) and, on 09/21/24, Resident #1 was able to exit the facility unbeknownst to staff, was found by staff a couple of blocks away from the facility with bruises on his/her face and abrasions on his/her bilateral knees and palms. Findings include: Review of the Facility Policy titled Wandering and Elopements, dated March 2019, indicated the following: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the Report submitted by the facility via the Health Care Facility Reporting System (HCFRS), dated 09/21/24, indicated that at approximately 7:40 P.M., during evening rounds, the staff were unable to locate Resident #1. Further review of the Report indicated Resident #1 was found at 7:50 P.M., by a staff member, two blocks away from the facility. The Report indicated that Resident #1 said that while he/she was walking outside, he/she fell down but was able to get back up and continue walking. Resident #1 was admitted to the Facility in July 2023, diagnoses include hereditary ataxia (impaired balance or coordination), mild cognitive impairment, difficulty in walking, and repeated falls. Review of Resident #1's Nursing Elopement and Wander Risk Evaluation, dated 04/15/24, indicated he/she was assessed as being at high risk for elopement. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, indicated he/she scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests no cognitive impairment). Review of Resident #1's Elopement Care Plan, reviewed and renewed with his/her April 2024 MDS, indicated he/she was at risk for elopement and included an intervention to make the receptionist (located at the building's entrance) and other staff aware of elopement risk. Review of Resident #1's Nurse Progress Note, dated 07/07/24 and signed by Nurse #3, indicated Resident #1 had an argument with his/her roommate and Resident #1 attempted to leave the facility. The Note indicated staff were able to redirect Resident #1 back into the facility, but he/she refused to go back to his/her room; Resident #1 was moved to a different room for the night. Further Review of the Note indicated the Director of Nurses (DON), Assistant Director of Nurses (ADON) and the Administrator were all notified. During an interview on 11/26/24 at 3:16 P.M., Nurse #3 said she was the nurse on duty for the evening shift (3:00 P.M. through 11:00 P.M.) on 07/07/24. Nurse #3 said staff found Resident #1 outside in the parking lot adjacent to the facility, that Resident #1 was crying and said that he/she wanted to go home. Nurse #3 said Resident #1 probably walked out of the facility's back door which was not alarmed until 8:00 P.M. Nurse #3 said staff were outside, possibly coming in at change of shift, when they saw Resident #1 in the parking lot. Nurse #3 said staff were able to redirect Resident #1 back into the facility. Nurse #3 said Resident #1 should not have been outside alone. During an interview on 11/26/24 at 3:59 P.M., the Director of Nurses (DON) said that she was notified by Nurse #3 of an incident related to Resident #1 on 07/07/24, but did not realize that Resident #1 was found in the facility's parking lot. The DON said no new interventions to prevent another elopement were added to Resident #1's care plan at that time but should have been. Review of an Employee Statement, undated and signed by Certified Nurse Aide (CNA) #1, indicated CNA #1 entered Resident #1's room at 7:40 P.M. [on 09/21/24] to assist with his/her care and Resident #1's roommate said Resident #1 left the building to meet his/her spouse. Review of an Employee Statement, dated 09/21/24 and signed by Nurse #2, indicated that around 7:40 P.M. a CNA reported to her that Resident #1 was not in his/her room and Resident #1's roommate had reported that Resident #1 left the facility to go home. The Statement indicated Nurse #2 drove down the road from the facility and found Resident #1 crossing a bridge and he/she had bruises to his/her forehead, lips, chin, and bilateral palms. During a telephone interview, which included review of his witness statement, on 11/26/24 at 4:43 P.M., Nurse #1 said he worked at the facility through a staffing agency and was on duty the evening shift of 09/21/24 and Resident #1 was on his assignment. Nurse #1 said a CNA told him that Resident #1 had left the facility alone. Nurse #1 said he began to search the inside of the building. Nurse #1 said he did not know how Resident #1 was able to leave the facility that evening, unattended by staff. Nurse #1 said it was a busy time of night when Resident #1 left. Nurse #1 said when Resident #1 returned to the facility, he/she had bruises on his/her face and abrasions to his/her knees and palms. Nurse #1 said the abrasions were all superficial. During an interview on 11/26/24 at 3:59 P.M., the Director of Nurses (DON) said if she had realized that Resident #1 was found outside of the building in the facility's parking lot on 07/07/24, she would have added new interventions which would have included for Resident #1 to always wear a wander guard bracelet (triggers alarms at the exit doors) and to increase safety checks performed by staff, in an effort to prevent future elopements.

Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP: Nurse Practitioner) of a significant change in medical condition and an elopement for two Residents (#60 and #62) out of a total sample of three closed records reviewed. Specifically, the facility staff failed to: 1. For Resident #60, identify a serious change in condition and acute decline in mental status, and notify the Physician/ NPP timely, resulting in the Resident further decompensating and being transferred to the hospital. 2. For Resident #62, notify the Physician/ NPP when the Resident with compromised medical status, and no access to prescribed medications eloped (left) the facility without a Leave of Absence (LOA) order and did not return to the facility. Findings include: 1. Review of the facility policy, Change in Resident's Condition or Status, Revised December 2023, indicated the following: The Nurse will notify the resident's attending Physician or Physician on call when there has been a (an): -Change in the resident's physical/ emotional /mental condition -Need to alter the resident's medical treatment significantly -Need to transfer the resident to a hospital/treatment center -Specific instruction to notify the physician of changes in the resident's condition Resident #60 was admitted to the facility in February 2024 with diagnoses including: Stage 4 (advanced Oxygen needs) Pulmonary Fibrosis (progressive lung disease where the lung tissue becomes damaged with fibrosis [scarring]. The thickened, stiff scar tissue makes breathing difficult for the individual, eventually resulting in shortness of breath [SOB], even at rest) and Acute on Chronic Respiratory Failure with Hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, that can trigger serious complications for the individual). Review of the February 2024 Physician's orders indicated the following: -Albuterol Sulfate (bronchodilator- relaxes and opens the airways) Nebulizer Solution (2.5 mg/3ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed (PRN) for SOB, start date 2/7/24. -O2 (Oxygen) via nasal cannula (NC) with humidification water at 3.5 liter per minute (LPM) to maintain saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) above 90% every shift related to Acute and Chronic Respiratory Failure with Hypoxia, start date 2/14/24. Review of the Occupational Therapy Treatment Encounter dated 2/20/24, indicated: -Resident had difficulty speaking -SpO2 was 95% on 4 LPM of Oxygen (O2) and heart rate (HR) was 50 -The head of bed (HOB) was elevated approximately 45 (degree) and respiratory rate (RR) was 28 bpm (breaths per minute). -When the Resident lifted his/her right foot to don (put on) their sock, the RR increased to 40, and the HR was 49 with activity. -Lying on Left side: vitals read 85% SpO2 with 1-minute recovery to 93% SpO2 on 4 LPM O2, and HR - 64. -Lying on Right side: 79% SpO2 with 5-minute recovery to 93% SpO2 [on 4 LPM O2] and non-productive cough. -Reported to nursing. Further review of the medical record did not indicate that the Physician/NP were notified of the change in the Resident's condition reported to the nursing staff by the Occupational Therapy staff on 2/20/24. Review of the Nursing Progress Notes dated 2/21/24 at 7:37 A.M., indicated the following: -Resident is alert and oriented with baseline [sic] confusion. -Resident c/o (complaint) shortness of breath, neb (Nebulizer) treatment given at 12:00 A.M., and 6:00 A.M., with good [sic] -Very anxious, increasing of respiration [sic] noted during care Review of the Nursing Progress Notes dated 2/21/24 at 8:48 A.M., indicated the following: -Resident very SOB. -Resident experiencing very shallow breathing, appears quite anxious, respirations fluctuating mid-high 20's. -Resident unable to clearly express needs. -Resident continues with O2 at 3.5 LPM via nasal cannula, SpO2 fluctuating low-high 90's -Resident's Nurse called NP and 911 for transport (to hospital). Review of the Nursing Progress Notes indicated the following medication was administered more frequently than (every 6 hours PRN) as ordered the Physician: -Albuterol Sulfate Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via Nebulizer every 6 hours PRN for SOB: > 2/21/24 at 00:51 A.M., > 2/21/24 at 2:27 A.M., PRN effective (Treatment repeated within 1 hour, 36 minutes) > 2/21/24 at 7:35 A.M. (Treatment repeated within 5 hours, 8 minutes) > 2/21/24 at 8:29 A.M., indicated the following: PRN was ineffective (Treatment repeated within 54 minutes) Review of the February 2024 Medication Administration Record (MAR) indicated an order for Albuterol Sulfate Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via Nebulizer every 6 hours PRN for SOB -was given on 2/21/24 at 12:51 A.M., with diminished lung sounds before and after the Albuterol treatment -was given at 2/21/24 at 7:35 A.M., with diminished lung sounds before and after the Albuterol treatment Review of the Oxygen Care Plan, initiated 2/7/24 indicated the following: -Monitor symptoms of respiratory distress and report to MD as needed (PRN) -Oxygen via nasal cannula at 3 liters (LPM) continuously (was implemented before a Physician order for 3.5 LPM of Oxygen was obtained on 2/14/24) -Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 ) Review of the Emergency Hospital Report, dated 2/22/24, indicated that Resident #60 was admitted with the following active diagnoses: -Sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection and the body's reaction causes damage to its own tissues and organs) -Failure to Thrive (a syndrome of global decline in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment) -Weakness and increasing Shortness of Breath (abnormal respiration often characterized by the feeling of suffocation) -Influenza (flu- contagious respiratory infection caused by influenza viruses that infect the nose, throat and lungs) -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) -Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing). -The patient is DNR/DNI, and the prognosis is poor. During an interview on 3/21/24 at 4:11 P.M., the Assistant Director of Nurses (ADON) said that if a resident is having a change in condition, nursing staff would perform an assessment of the resident including taking vital signs to rule out any issues with the lungs. The ADON said that a resident would need a Physician's order to titrate Oxygen to maintain the SpO2 level above a certain number. If someone got a nebulizer treatment and it did not work, the facility staff should notify the Doctor of the change in respiratory status and the results after the nebulizer treatment. During a telephone interview on 3/29/24 at 12:05 P.M., Rehabilitation Service Staff (RSS) #3 said that she provided therapy treatment to Resident #60 on the morning of 2/20/24 and documented on the Occupational Therapy Treatment Encounter. RSS #3 said that the Resident was more lethargic and seemed more deconditioned (having lost physical strength through being sick, injured, or not active) than he/she had been the previous day and could not even tolerate sitting on the edge of the bed without being SOB. RSS #3 said that Resident #60's SpO2 was 79% on 4 LPM O2 and there were no orders to increase the amount of Oxygen that could be given. RSS #3 said that she was concerned enough about the Resident's change in condition that she reported her findings to the Nurse assigned to take care of the Resident that morning. During a telephone interview on 3/29/24 at 12:15 P.M., Nurse #1 said that she was assigned to the care of Resident #60 on 2/20/24 (Day shift) and that the Resident was very anxious, his/her respiratory rate had increased with any activity and the Resident had new worsening, increased confusion and SOB. When the surveyor asked Nurse #1 if she was aware of the Occupational Therapy (OT) note from 2/20/24, Nurse #1 said that OT/RSS #3 had informed her that the Resident had increased SOB with activity during the therapy session, but she did not have access to read the OT notes. Nurse #1 said that the Resident's Oxygen was set to 4 LPM, and that was outside of the 3.5 LPM that was ordered, but she was not sure how the Oxygen got set to the 4 LPM. Nurse #1 said that she did not offer the Resident an Albuterol Nebulizer at that time or notify the Physician of the change in condition, and she should have done so based on the ongoing changes with the Resident. During a telephone interview on 3/29/24 at 12:58 P.M., Nurse # 4 said that she received the Resident shift report on 2/21/24 around 7:30 A.M., and upon entering Resident #60's room sometime later, she could tell that the Resident was in distress. Nurse #4 said that she called out for help and other staff members came to assist her. Staff also placed calls to the Physician and the family. Nurse #4 said that the Resident had SOB while talking and his/her SpO2 was around 85% and RR was 28-30 bpm, rapid and shallow. Nurse #4 said that she was unable to give an Albuterol Nebulizer as one had been given already that morning. Nurse #4 said that she went back into the MAR and documented that the (last given) Nebulizer Treatment was ineffective as the prior shift Nurse had not made any post treatment notes, as required. During an interview on 3/26/24 at 10:05 A.M., Physician #2 said that if someone required a breathing [Nebulizer] treatment and it is a change [in status] for them, she would expect to be updated. During an interview on 3/26/24 at 1:15 P.M., the DON reviewed the record for Resident #60 and said that he/she had an O2 order for 3.5 LPM and that there were no titration orders to increase the O2 and if the Resident needed more O2 the Physician should have been notified. The DON further said that it appeared the Resident had a change in status and that staff should have notified the Physician sooner. 2. Review of the facility policy titled Wandering and Elopement, revised March 2019, indicated the following: -The facility will identify Residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If a resident is missing, initiate the elopement/missing resident emergency procedure: >Determine if the resident is out on an authorized leave. >If the resident was not authorized to leave, initiate a search of the building and the premises, and >If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident legal representative, the attending physician, law enforcement officials and as necessary volunteer agencies. Resident #62 was admitted to the facility in December 2023, with diagnoses including Bipolar Disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), Alcohol Abuse, Opioid Use, Diabetes Type 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Osteomyelitis (Osteomyelitis is an infection in a bone.), left Diabetic foot ulcer (an open sore on the foot), Heart Failure (when the heart muscle doesn't pump blood as well as it should), muscle weakness and difficulty in walking. Review of the Absentee Register undated, indicated that Resident #62 signed out of the facility independently on 1/8/24. Review of the clinical record progress notes for Resident #62 indicated: -On 1/8/24 at 11:17 P.M., Patient left this morning to go visit family and has not return [sic]. -On 1/9/24 at 11:00 A.M., DON called Resident #62's family member and was informed that the Resident was currently with the family member and that Resident #62 would like to return to the facility. The DON informed the Resident that they would need a drug test from the Emergency Department before returning to the facility. -On 1/10/24 at 10:57 A.M., the DON informed the NP that Resident #62 had been discharged against medical advice (AMA) from the facility. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the medical record for Resident #62 and said that Resident #62 had no Physician's order for an authorized leave as required and should have had one prior to leaving the facility. The DON further said that there was no completed assessment to indicate that Resident #62 could leave the building independently or with a responsible party. The DON reviewed his/her elopement score on admission and said that the elopement assessment was not completed on admission as required. The DON reviewed the nursing progress notes and said that the staff did not notify the Physician that Resident #62 did not return to the building as expected on 1/8/24 and should have returned. The DON further said that if a resident leaves the building without Physician orders it is considered elopement, and the staff should have followed the facility Wandering and Elopement policy, and notified the Physician, the Police and reported it to the Department of Public Health (DPH) timely but this was not done. Please Refer to F684.

Based on interview and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#60) out of a total sample of three discharged residents, resulting in a decline in medical status and hospitalization with sepsis (a life-threatening medical emergency that occurs when an infection triggers the body's immune system to damage its own organs and tissues). Specifically, the facility staff failed to: 1. Recognize, assess, and manage pulmonary symptoms that indicated a significant change in condition for Resident #60 who had multiple pulmonary diagnoses that required immediate and appropriate interventions for symptom management. 2. Provide needed care and services for a nephrostomy tube and manage symptoms of a change in nephrostomy tube output as required. Findings include: Review of the facility policy, Change in Resident's Condition or Status, Revised December 2023, indicated the following: The Nurse will notify the Residents attending Physician or Physician on call when there has been a (an): -Change in the resident's physical/ emotional /mental condition -Need to alter the resident's medical treatment significantly Resident #60 was admitted to the facility in February 2024, with diagnoses including: Stage 4 (advanced Oxygen needs) Pulmonary Fibrosis (progressive lung disease where the lung tissue becomes damaged with fibrosis [scarring]. The thickened, stiff scar tissue makes breathing difficult for the individual, eventually resulting in shortness of breath [SOB], even at rest) and Acute on Chronic Respiratory Failure with Hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, that can trigger serious complications for the individual) and a Nephrostomy tube (tube used to drain urine directly from the kidneys to a collection bag outside of the body). Review of the February 2024 Physician's orders dated 2/7/24, indicated the following: -MOLST (Medical Orders for Life Sustaining Treatment - document of a patient's treatment preferences concerning life-sustaining treatment) Advanced Directive - Full Code (Resuscitate), start date 2/7/24. -Albuterol Sulfate (bronchodilator) Nebulizer Solution (2.5mg/3ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB), start date 2/7/24 Review of the Oxygen Care Plan, initiated 2/7/24 indicated the following: -Monitor symptoms of respiratory distress and report to MD as needed (PRN) -Oxygen via nasal cannula at 3 LPM continuously (was implemented before a Physician order for 3.5 LPM of Oxygen was obtained on 2/14/24) -Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 ) Review of the Nursing notes dated 2/7/24 indicated that Resident #60 was -Alert and oriented times (x) 3 [alert and oriented to person, place and time]. Review of Occupational Therapy Treatment Encounter dated 2/13/24 indicated a change in Resident #60's status from 2/7/24: -Patient was received in agitated mood and became increasingly agitated during encounter. -O2 set at 4 LPM Review of the February 2024 Physician's orders dated 2/13/24, indicated the following: -Oseltamivir Phosphate (antiviral medication) Oral Capsule 75 mg give one capsule by mouth one time a day once daily for 10 days prophylactic for flu (Influenza) for 10 administrations until finished, start date 2/13/24 -Glomerular Filtration Rate [(GFR) 71- is a measure of how well your kidneys are filtering.], start date 2/13/24 Review of Physical Therapy Treatment Encounter dated 2/14/24 indicated further decline in Resident #60's status from 2/13/24: -Patient presented with increased confusion, nursing notified. -Patient said they are feeling lethargic. Review of the February 2024 Physician's orders dated 2/14/24, indicated the following: -O2 (Oxygen) via nasal Cannula (NC) with humidification water at 3.5 liter per minute (LPM) to maintain saturation (SpO2 - measure of Oxygen in the blood as a percentage of the maximum Oxygen the blood could carry) above 90% every shift related to Acute and Chronic Respiratory Failure with hypoxia, start date 2/14/24. Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/14/24 indicated the following: -Resident makes self-understood -Resident has clear comprehension to understand verbal content -Resident had a Brief Interview for Mental Status (BIMS) of 12 out of a total 15, indicating moderate cognitive impairment -No evidence of an acute change in mental status -Respiratory Failure (a serious condition that makes it difficult to breathe on your own. Develops when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body) and a Urinary Tract Infection (UTI: bacterial infection of the urinary tract) within the last 7 days -Shortness of breath (SOB) while lying flat -Resident has an HCP- [not invoked - put into effect] Review of Physical Therapy Treatment Encounter dated 2/15/24 indicated continued decline in Resident #60's status from 2/14/24: -Multiple standing brakes [sic] due to fatigue, shortness of breath, and global weakness -Vital monitor: SP02 ranging from 80% to 97% after activity and heart rate ranging from 80 to 90 beats per minute (bpm) after all interventions. Review of the Nursing Progress Notes dated 2/17/24 indicated continued decline in Resident #60's status from 2/15/24: -Was awake at 2:30 A.M., and was confused -Pox (Pulse Oximetry/ SpO2) was 90-92% on O2 - 4 LPM via nasal cannula (higher liter flow than the 3.5 LPM ordered on 2/14/24). Review of the Nursing Progress Notes dated 2/19/24 indicated a significant change in condition for Resident #60 from 2/17/24: -Had an occasional nonproductive cough -Lung sound diminished (LSD) bilaterally -Episodes of SOB with exertion -Nephrostomy is patent 75 cubic centimeters (cc-standard unit in measuring volume), slightly dark yellow output Review of the Occupational Therapy Treatment Encounter dated 2/20/24, indicated continued decline in condition for Resident #60 from 2/19/24: -Resident had difficulty speaking -SpO2 was 95% on 4 LPM of Oxygen (O2) and heart rate (HR) was 50 -The head of bed (HOB) was elevated approximately 45 (degree) and respiratory rate (RR) was 28 bpm (breaths per minute). -When the Resident lifted his/her right foot to don (put on) their sock, the RR increased to 40, and the HR was 49 with activity. -Lying on Left side: vitals read 85% SpO2 with 1- minute recovery to 93% SpO2 on 4 LPM O2, and HR - 64. -Lying on Right side: 79% SpO2 with 5- minute recovery to 93% SpO2 [on 4 LPM O2] and non-productive cough. -Reported to nursing. Review of the Nursing Progress Notes dated 2/20/24 indicated: -The Resident was confused and wanted to get out of bed and go to his/her car. -Respirations noted to increase when getting help with morning care. Further review of the Nursing Progress Notes dated 2/20/24 indicated: -no evaluation and/or revision of interventions related to symptoms and conditions documented in the medical record from 2/13/24 - 2/20/24. -no Physician communication for alternative care options for Resident #60. Review of the Documentation of Resident Incapacitation pursuant to Massachusetts Health Care Proxy Act M.G.L.C201D, dated 2/20/24, indicated that Resident #60's HCP was invoked (allowing someone else to make healthcare decisions) due to a diagnosis of Dementia, with lifelong extent. Review of Resident #60's medical record failed to indicate any history, current or new of a diagnosis of Dementia. Review of the Nursing Progress Notes dated 2/21/24 at 7:37 A.M., indicated the following: -Resident c/o shortness of breath, neb treatment given at 12am and 6am with good [sic] -Very anxious, increasing of respiration noted during care Review of the Nursing Progress Notes dated 2/21/24 at 8:48 A.M., indicated the following: -Resident very SOB. Resident experiencing very shallow breathing, appears quite anxious, respirations fluctuating mid-high 20's. -Resident unable to clearly express needs. -Resident unable to swallow -Resident continues with continuous O2 at 3.5 liters applied via nasal cannula. -O2 sats fluctuating low to high 90's however resident still appearing very SOB, unable to get words out. -Residents' Nurse called Nurse Practitioner (NP) and 911 for transport. Review of the February 2024 Physician's orders dated 2/21/24, indicated the following: -DNR (Do Not Resuscitate)/ DNI (Do Not Intubate), may hospitalize - Health Care Proxy (HCP - an appointed individual to legally make medical decisions on a person's behalf if he/she became unable to do so) - Wife, start date 2/21/24 Review of the February 2024 Medication Administration Record (MAR) indicated the following: -Albuterol Sulfate Nebulizer Solution (2.5 mg/3 ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB was documented as administered on 2/21/24 at 12:51 A.M., and again at 7:35 A.M. -May send to emergency room (ER) for eval STAT (immediately) for SOB, start date of 2/21/24 at 8:17 A.M. Review of the Nursing Progress Notes dated 2/21/24 at 11:30 A.M., indicated the following: -Patient noted with increased SOB at rest and with talking, -RR 28-30 which are rapid and shallow, pox on 3.5 LPM 02 via nasal cannula (NC) - 85% -HR 102 and irregular, BP 90/58; LSD (lung sounds diminished) bilat; patient c/o SOB; -previous shift had given Albuterol nebulizer two times at 12:00 A.M., and at 6:00 A.M. -Patient having difficulty producing an effective cough Review of the Nursing Progress Notes indicated the following medication was administered more frequently than ordered: -(Albuterol Sulfate Nebulizer Solution (2.5 mg/3 ml) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB). > 2/21/24 at 00:51 A.M. > 2/21/24 at 2:27 A.M., PRN effective (given within 1 hour (hr) 36 minutes (mins) of the 00:51 A.M. treatment) > 2/21/24 at 7:35 A.M. (given within 5 hrs 9 mins of the 2:27 A.M. treatment) > 2/21/24 at 8:29 A.M., indicated the following: PRN was ineffective (given within 54 mins of the 7:35 A.M treatment). Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/21/24 indicated the following: -Evidence of an acute change in mental status from the Resident's baseline -Behavior present, fluctuates (comes and goes, changes in severity) -Inattention -Disorganized thinking -Shortness of breath while lying flat, while sitting at rest, and with exertion -The Resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. During an interview on 3/21/24 at 4:11 P.M., the Assistant Director of Nurses (ADON) said that if a resident is having a change in condition nursing staff would perform an assessment of the resident including taking vital signs to rule out any issues with the lungs. The ADON said that a resident would need a Physician's order to titrate Oxygen to maintain the SpO2 level above a certain number. The ADON said if a resident got a nebulizer treatment and it did not work, the facility staff should notify the Physician/Doctor of the change in respiratory status and the results after the nebulizer treatment. During an interview 3/22/24 at 9:20 A.M., Nurse #4 said that if a resident was having any changes in respiratory status, she would look for SOB, including listening to the lung sounds checking their pulse oximetry and checking the orders for O2 to see if the liter flow can be increased. Nurse #4 further said that she would call the Physician for any change in respiratory status as the resident could have over exertion, or they could have Pneumonia, which is why the assessment piece is so important. During a follow-up interview on 3/22/24 at 9:59 A.M., Nurse #4 said if a Resident had a change in mental status and was no longer alert and oriented, the nursing staff would complete a nursing assessment and would contact the Physician to inform them about the change and then the Physician may give the order to invoke the Health Care Proxy (HCP). During a telephone interview on 3/26/24 at 10:05 A.M., Physician #2 said that if someone required a breathing (Nebulizer) treatment and it is a change for them, she would expect to be updated on the Resident's condition. During a follow-up interview on 3/26/24 at 12:58 P.M., Physician #2 reviewed Resident #60's medical record and said that the facility staff did not speak to her about a change in condition and they did not ask to increase Resident #60's oxygen from 3.5 LPM to 4 LPM. Physician #2 further said that she does not recall invoking Resident #60's HCP for a change in mental status or Resident #60 having a diagnosis of Dementia. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the record for Resident #60 and said that he/she had an O2 order for 3.5L and no titration order was noted, so if the Resident required more Oxygen the Physician should have been notified. The DON further said that staff should have notified the Physician when Resident #60 had a change in condition on 2/20/24 and they did not. During a telephone interview on 3/29/24 at 12:05 P.M., Rehabilitation Service Staff (RSS) #3 said that she provided therapy treatment to Resident #60 on the morning of 2/20/24 and documented the Resident's status on the Occupational Therapy Treatment Encounter form. RSS #3 said that the Resident was more lethargic and seemed more deconditioned (having lost physical strength through being sick, injured, or not active) than he/she had been the previous day and could not even tolerate sitting on the edge of the bed without being SOB. RSS #3 said that Resident #60's SpO2 was 79% on 4 LPM O2 and there were no orders to increase the amount of Oxygen that could be given. RSS #3 said that she was concerned enough about the Resident's change in condition that she reported her findings to the Nurse assigned to take care of the Resident that morning. During a telephone interview on 3/29/24 at 12:15 P.M., Nurse #1 said that she was assigned to the care of Resident #60 on 2/20/24 (Day shift) and that he/she was very anxious, and his/her respiratory rate had increased with any activity and the Resident had new worsening increased confusion and shortness of breath. When the surveyor asked Nurse #1 if she was aware of the Occupational Therapy (OT) note from 2/20/24, Nurse #1 said that OT had informed her that the Resident had increased SOB with activity during the therapy session, but she did not have access to read the OT notes. Nurse #1 said that the Resident's Oxygen was set to 4 LPM, and that was outside of the 3.5 LPM that was ordered, but she was not sure how the Oxygen got set to the 4 LPM. Nurse #1 said that she did not offer the Resident an Albuterol Nebulizer at that time or notify the Physician of the change in condition, and she should have done so based on the ongoing changes noted with the Resident. During a telephone interview on 3/29/24 at 12:58 P.M., Nurse #4 said that she received the Resident shift report on 2/21/24 around 7:30 A.M., and upon entering Resident #60's room sometime later, she could tell that the Resident was in distress. Nurse #4 said that she called out for help and other staff members came to assist her and placed calls to the Physician and the family. Nurse #4 said that the Resident had SOB while talking and his/her SpO2 was around 85% and RR was 28-30 bpm, rapid and shallow. Nurse #4 said that she was unable to give an Albuterol Nebulizer as one had been given already that morning. Nurse #4 said that she went back into the MAR and documented that the Albuterol Treatment given was ineffective, as the prior shift Nurse had not made any post treatment notes, as required. Review of the Emergency Hospital Report, dated 2/22/24 indicated that Resident #60 had active diagnoses of -Sepsis -Failure to Thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol.) -Weakness and increasing Shortness of Breath (SOB: abnormal respiration often characterized by the feeling of suffocation). -Influenza (flu -contagious respiratory infection caused by influenza viruses that infect the nose, throat and lungs) -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) -Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing). -The patient is DNR/DNI and the prognosis is poor. 2. Review of the facility policy Nephrostomy Tube, Care of revised October 2010, indicated the following: -Check the placement of the tubing and integrity of the tape during assessments. -Drainage should be below the level of the kidneys. -There should be no kinks in the tubing. -Empty drainage bag once per shift and as needed. -Measure output every 8 hours. -Record urinary and nephrostomy output separately. -Change dressings every one to three days as ordered. -Use sterile technique during dressing changes. Review of the February 2024 Physician's orders, date 2/8/24 indicated the following: -Sodium Chloride solution 0.9% use 5 ml via irrigation in the afternoon for Nephrostomy tube -flush Nephrostomy tube with 5 ml Sodium Chloride solution 0.9% daily. Review of the Medical Record did not indicate that Physican's orders were in place for Nephrostomy site dressing changes or monitoring of the output from the Nephrostomy tube. Review of the February 2024 Medication Administration Record (MAR) indicated the following: -Sodium Chloride solution 0.9% use 5 ml via irrigation in the afternoon for Nephrostomy. -flush nephrostomy with 5 ml daily -was documented as administered from 2/9/24 through 2/20/24 Review of the Care Plan, indwelling Foley catheter and nephrostomy tube, initiated 2/7/24 indicated: -Check tubing for kinks each shift per policy -Monitor and document output as per facility policy -Nephrostomy tube dressing change as ordered. -Observe for document pain discomfort due to catheter Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/14/24 indicated the following: -Urinary Tract Infection (UTI: bacterial infection of the urinary tract) within the last 7 days -Shortness of breath (SOB) while lying flat Review of the Physician Progress Note dated 2/15/24 indicated: -Nephrostomy tube draining yellow clear urine. Review of the Nursing Progress Note dated 2/17/24, indicated: -Nephrostomy tube draining yellow urine. Review of the Nursing Progress Note dated 2/19/24 indicated: -Nephrostomy is patent 75 cubic centimeters (cc-standard unit in measuring volume), slightly dark, yellow output Review of the Nursing Progress Note dated 2/21/24 indicated: -Nephrostomy tube draining 200 ml of amber urine. During an interview on 3/22/24 at 9:20 A.M., Nurse #4 said that if a resident has new or increased confusion, she would complete an assessment which would include vital signs and asking if they had burning with urination or frequency. If the resident had a Foley catheter or a Nephrostomy tube, they should be assessed for patency, drainage, sediment, cloudy urine, foul odor, and blockage by looking at their output. During a follow-up interview on 3/22/24 at 9:59 A.M., Nurse #4 said if a Resident had a change in mental status and was no longer alert and oriented, the nursing staff would complete a nursing assessment and would contact the Physician to inform them about the change and then the Physician may give the order to invoke the Health Care Proxy (HCP). During a telephone interview on 3/26/24 at 10:09 A.M., Physician #2 said that a Resident might have Dementia, or they may be sick and that could be why they were having a mental status change. When the surveyor asked about invoking the HCP for Resident #60, Physician #2 said that she would not invoke a HCP right away and that she would wait until the patient is totally incompetent, but if they are sick and are going to get better, she would not invoke the HCP as the Medical Orders for Life-Sustaining Treatment (MOLST (is one way of documenting a patient's treatment preferences concerning life-sustaining treatment) was in place already. During an interview on 3/26/24 at 1:15 P.M., the Director of Nurses (DON) reviewed the record for Resident #60 and said that Resident #60 had a nephrostomy tube in place and that she would expect to see orders for monitoring output and for administering dressing changes. She further said that she could not find evidence that there was a Physician's order for the nephrostomy tube site dressing changes or to monitor output, as expected and required. The DON further said that staff should have notified the Physician when Resident #60 had a change in condition on 2/20/24 and they did not.

Based on observation, interview, record and policy review, the facility failed to provide necessary care and services to treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#22 and #4), out of two applicable residents, out of a total sample of 17 residents. Specifically, the facility staff failed to: 1. Offload Resident #22's heels per the Physician's Order for treatment of an existing right heel ulcer, and prevent skin decline in his/her left heel. 2. Implement a turning and repositioning schedule and apply specialized boots and/or pillows to offload Resident #4's heels per the plan of care. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown, revised April 2018, indicated the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). -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 (any fluid that has been forced out of the tissues or blood vessels because of inflammation or injury) or necrotic (the death of most or all organs or tissue due to disease, injury or lack of blood supply) tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses -The Physician will identify medical interventions related to wound management. 1. Resident #22 was admitted to the facility in October 2022 with diagnoses including Diabetes (condition that results in too much sugar in the blood resulting in high blood glucose[sugar]), Cerebral Vascular Accident (CVA: stroke-interruption of the blood supply to the brain resulting in damage), Protein-calorie Malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and need for assistance with personal care. Review of the Resident's clinical record indicated that he/she was transferred to the hospital on 12/3/23 and returned on 12/25/23. Further review of the clinical record indicated the Resident was identified as having a Deep Tissue Injury (DTI-purple or maroon localized area of discolored intact skin or fluid filled blister due to damage of underlying soft tissue from pressure) after the hospitalization , and was at increased risk for pressure ulcers related to his/her mobility status and medical conditions. Review of the Nursing assessment dated [DATE], indicated Resident #22 had a DTI to his/her right heel. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated: - Resident #22 had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of a total possible 15 - had range of motion impairments affecting bilateral (both) lower extremities - required assistance from staff with upper and lower dressing, rolling side to side, lying to sitting and with transfers - was at risk for pressure ulcers - had an unstageable [full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (yellow/white material in the wound bed) or eschar (dry/dry scab or dead skin)] pressure ulcer that was present on admission. Review of the March 2024 Physician's orders, included the following: - float heels when in bed every shift for DTI, initiated 1/4/24 - low air low mattress set at 150 every shift, initiated 3/8/24 Review of the March 2024 Treatment Administration Record (TAR) indicated the order and treatment to float Resident #22's heels while in bed every shift was administered every day, every shift from 3/1/24 through 3/21/24. Review of the current Activities of Daily Living (ADLs - tasks of everyday life including eating, bathing, dressing) Care Plan, initiated 10/5/22, indicated Resident #22 required assistance with ADLs and required the following: -Dependent on staff for grooming and hygiene -Assistance of 1-2 staff with positioning Review of the Weekly Wound assessment dated [DATE], indicated Resident #22 had the following: -Right heel DTI wound, unstageable -Preventative interventions included: > pressure distribution mattress > turning and repositioning program > elevate legs > float heels in bed and offload On 3/21/24 at 9:07 A.M., the surveyor observed Resident #22 lying in bed with the head of the bed elevated. The surveyor observed that an air mattress was in place and set to 150. During an interview at the time, Resident #22 said that he/she had an open area on the right heel which was uncomfortable when the heel was touched or moved. The Resident further said there was nothing special in place for his/her heel wound, but there was a treatment that was completed by nursing. On 3/21/24 at 9:13 A.M., Certified Nurses Aide (CNA) #6 entered Resident #22's room and showed the surveyor Resident #22's feet, which were covered with blankets. When CNA #6 lifted the bottom blankets, the surveyor observed that the Resident's heels were not offloaded, and there were no pillows or specialty devices in place to prevent the Resident's heels from laying directly on the mattress. The surveyor further observed that the Resident's feet were positioned on top of each other, that non-skid socks were in place and a gauze wrap was observed extending above the Resident's non-skid sock on the right foot. On 3/22/24 at 7:38 A.M. and 8:09 A.M., the surveyor observed Resident #22 lying in bed and the Resident's left foot was observed laying on the mattress, was not offloaded, and was further observed pressed against the foot board at the end of the bed. The surveyor observed that the Resident's right foot had a dressing wrapped around it and the right foot was laying on the mattress. On 3/22/24 at 11:38 A.M., the surveyor observed the wound dressing change of the Resident's right heel with Nurse #1 and Nurse #6. Prior to the dressing change treatment, Resident #22 was observed lying in bed on his/her right side with legs slightly bent. The Resident's left foot was bare and pressed against the foot board of the bed. Both of the Resident's feet were observed to be laying on the mattress and were not offloaded. Nurse #1 and Nurse #6 were observed to assist the Resident by shifting him/her up in bed so his/her feet were away from being positioned against the foot board of the bed, to access and complete the treatment to the right heel wound. When the surveyor asked Nurse #1 to provide an assessment of the Resident's left heel, Nurse #1 said the Resident's left heel was reddish in color compared to the bottom of his/her foot, and that the skin on the foot was dry. Nurse #6, who was still present during this time, said the Resident's heels should be offloaded and a treatment should be initiated to his/her left heel to prevent skin breakdown. Nurse #1 and Nurse #6 were observed to search the Resident's room to locate a pillow or device to offload the Resident's heels and Nurse #6 said there were no pillows present and that she would have to get one. On 3/22/24 at 12:42 P.M., the surveyor observed Resident #22 lying in bed with his/her eyes closed. The surveyor did not observe any pillows or devices offloading the Resident's heels. During an interview on 3/22/24 at 1:54 P.M., the Assistant Director of Nurses (ADON), who completed scheduled wound rounds with the Physician, said Resident #22's heels should be offloaded while in bed to prevent pressure on his/her heels. The surveyor relayed previous observations of the Resident's heels not being offloaded with the ADON who said that she would look into the matter. Review of the Weekly Wound Assessment, dated 3/22/24, indicated Resident #22 had a new suspected DTI to his/her left heel. During a follow-up interview on 3/22/24 at 3:51 P.M., the ADON said she assessed the Resident's heels, and at the time of her observation there were pillows under his/her feet to offload but that both of the Resident's feet were pressed against the foot board of the bed. The ADON said the Resident was repositioned in bed, so his/her feet were not against the foot board and a spacer was placed between the mattress and the footboard to prevent this from re-occurring. The ADON further said that the Resident's left heel was discolored and was boggy (abnormal texture of tissues characterized by sponginess), so the Physician was updated and an order was obtained for a treatment to the Resident's left heel and to implement heel protectors to both of the Resident's feet. During a follow-up interview on 3/26/24 at 1:53 P.M., the ADON said Resident #22 was unable to independently offload his/her heels when in bed and required assistance from staff to do this. 2. Resident #4 was admitted to the facility in March 2016, with diagnoses including hemiplegia (paralysis on one side of the body) affecting the left non-dominant side, CVA, abnormal posture, Adult Failure to Thrive (syndrome of weight loss, decreased appetite, poor nutrition and inactivity), pressure ulcer of the left buttock Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), and need for assistance with personal care. Review of the MDS Assessment, dated 2/28/24, indicated: -Resident #4 had significant cognitive impairment as evidenced by a BIMS score of 4 out of a possible 15 -had no rejections of care -had range of motion impairments of upper and lower extremities on one side -was dependent on staff for dressing, personal hygiene, rolling side to side -was at risk for pressure ulcers -had one unhealed Stage 4 Pressure Ulcer which was not present on admission. Review of the ADL Care Plan, initiated 3/9/16, indicated Resident #4 required assistance with ADLs related to hemiplegia and hemiparesis and included the following interventions: -Dependent on staff for transfers and positioning, initiated 12/18/23 Review of Potential for Skin Integrity Care Plan, initiated 3/9/16, included the following interventions: -Offload Resident heels using pillows/heels up on cushion ., revised 3/9/16 -Provide 2 assist with positioning and transfers .reposition at least every 2 hours while in bed ., revised 6/30/20 Review of the Actual Skin Integrity Impairment Care Plan, initiated 8/17/20, included the following interventions initiated 9/27/21: -Encourage Resident to turn and change position every 2 hours -Offload heels Review of the Wound Evaluation and Management Summary, dated 2/1/24, indicated the following: -Resident has wounds including a Stage 4 full thickness area on his/her left ischium (curved bone forming the base of each half of the pelvis) . -The plan of care included to offload the wounds, reposition per facility protocol . turn side to side and front to back in bed every 1-2 hours if able and elevate his/her legs Review of the March 2024 Physician's orders, initiated 3/17/21, included the following: -prevalon boots (type of specialized boots to offload feet) to bilateral heels -check for placement and check skin every evening and night for DTI Review of the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include documented evidence that the prevalon boots were ordered and applied from 3/1/24 through 3/21/24. Review of the current CNA Care Card included the following: -Encourage Resident to turn and change position 2 hours -Offload heels using pillows/heels up on cushions as Resident allows -Dependent of two staff with positioning On 3/20/24 at 4:19 P.M., the surveyor heard the Resident calling out and observed him/her lying in bed on his/her back. The surveyor observed that an air mattress was in place and set at 200. During an interview at the time, the Resident said he/she was uncomfortable and had some pain on his/her left side. The surveyor did not observe that the Resident's heels were offloaded. The surveyor exited the Resident's room and notified Nurse #1 of the Resident's concerns, and Nurse #1 responded that she would assess Resident #4. On 3/21/24 at 7:14 A.M. through 8:58 A.M., the surveyor observed the Resident lying in bed, positioned on his/her back with eyes closed. The air mattress was observed set at 200 and the head of the bed was slightly elevated. At 8:20 A.M., two CNA's entered the Resident's room and boosted him/her up in the bed prior to breakfast. The surveyor observed the Resident's feet as he/she was being boosted, and both feet were lying on the mattress, with no devices (pillows or boots) in place to offload. On 3/22/24 at 7:25 A.M. through 7:52 A.M., the surveyor observed Resident #4 lying in bed, on his/her back with eyes closed. During an interview at 7:31 A.M., the Resident said that his/her feet bothered him/her and were uncomfortable. The surveyor did not observe offloading boots in the Resident's room and when asked, the Resident said he/she was not aware of having anything for his/her feet. The surveyor requested assistance from the ADON, who was assisting with beverage pass at the time. The ADON uncovered the Resident's feet, and the surveyor observed that both of the Resident's feet were bare and lying on the mattress. The surveyor observed that a pillow was placed under the Resident's left knee. When the ADON assisted the Resident with moving his/her left foot, the Resident cried out in discomfort and said his/her left heel hurt. The ADON assessed the Resident's left heel and said there were no open areas on the Resident's left heel, and that she was going to position the pillow under the Resident's left heel so that it was offloaded and off the mattress. When the surveyor asked the ADON if the Resident was able to move the pillow which was observed previously positioned under his/her left knee, and the ADON said the Resident was unable to move his/her left side due to hemiplegia. After the Resident's left leg was repositioned with his/her left heel elevated, the Resident smiled and said that he/she felt better. The surveyor observed that the Resident's right foot remained on the mattress and was not offloaded. On 3/22/24 from 8:39 through 11:27 A.M., the surveyor observed the following: -At 8:39 A.M., the surveyor observed Resident #4 lying upright in bed, positioned on his/her back eating breakfast -At 8:52 A.M., the breakfast tray was removed, and the Resident remained in the same position -At 10:15 A.M., the Resident remained lying on his/her back in bed with eyes closed -At 11:27 A.M., two staff members entered the Resident's room, greeted the Resident and said that the wound dressings were going to be completed and then staff would get him/her out of bed. On 3/22/24 at 12:06 P.M. through 12:45 P.M., the surveyor observed Resident #4 lying in bed, and remained positioned on his/her back with eyes closed. During an interview on 3/22/24 at 12:47 P.M., CNA #2 said that she regularly worked with Resident #4 and knew him/her very well. CNA #2 said the Resident required full care, was incontinent of both urine and bowels, and was changed at 6:30 A.M.,10:30 A.M., and around 11:15/11:30 A.M., when he/she was assisted out of bed. CNA #2 said the Resident refused to get out of bed today because of complaints of pain which was reported to the Nurse. CNA #2 said the Resident was unable to move his/her left side and was unable to move about when in bed. CNA #2 further said that the Resident required the assistance of two staff for repositioning, that the staff will change his/her position when he/she calls out but staff had no schedule for repositioning. CNA #2 said if the Resident was lying in bed without yelling out or was observed to be sleeping, that indicated he/she was comfortable so staff would not move or reposition him/her. CNA #2 said that she puts a pillow under the Resident's heels when her shift was over to elevate his/her heels, but when she returns to work in the morning for her shift, she would find that the Resident's heels are not offloaded most of the time. When the surveyor asked whether the Resident had specialized boots to offload his/her feet, CNA #2 said she did not remember. On 3/26/24 at 12:10 P.M., the surveyor and Nurse #3 reviewed the Resident's clinical record and Nurse #3 said the Resident had an order for prevalon boots since 3/17/21, but the order was just added to the TAR on Friday 3/22/24. Nurse #3 said that unless the order was designated to the MAR or the TAR, it would not show up for the nursing staff to administer and sign off. When the surveyor asked about how the repositioning of residents was documented, Nurse #3 said that the CNAs document that information. Review of the CNA documentation indicated no documented evidence that repositioning had occurred every 1-2 hours per the Resident's plan of care. During an interview on 3/26/24 at 1:44 P.M., the ADON said the Resident should be repositioned every two hours or as needed and that the CNA's would document that this occurred in the medical record. The ADON said that there has been an order for the specialized boots to offload the Resident's heels for a long time, the ADON thought that she remembered seeing the boots, but would have to check. The ADON further said that the Resident was unable to reposition him/herself and was dependent on facility staff to do this for him/her. During a follow-up interview on 3/26/24 at 3:15 P.M., the ADON said she was unable to find any indication that Resident #4 was repositioned as per his/her plan of care since October 2023.

Based on review of the facility's Licensed Nurse staff schedule, Daily Census list provided to the survey team, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, the facility staff failed to: 1. Provide at least eight consecutive hours of RN services in the facility over one 24-hour period on 12/23/23, when no nurse staffing waivers were in place. 2. appropriately schedule the services of a RN when the facility scheduled the Director of Nurses (DON) as a charge nurse, providing direct resident care and the average facility resident occupancy was above 60 residents. Findings include: 1. Review of the Nursing Staff Schedule 'as worked' provided by the facility, dated 12/23/23, included no evidence that a RN worked at the facility for 8 consecutive hours on 12/23/23. During an interview on 3/26/24 at 10:53 A.M., the surveyor and the DON reviewed the schedule for 12/23/23, and the DON said there was no RN coverage scheduled until 11:00 P.M. on 12/23/23. The DON further said that she would expect to be notified by the Scheduler if there was no RN coverage in the facility so that another RN could be assigned to work and she was not aware there was no RN in the building until 11:00 P.M. on 12/23/23 until the surveyor brought it to her attention. During an interview on 3/26/24 at 11:30 A.M., Regional Nurse #1 reviewed the Nursing Staff Schedule dated 12/23/23 and said that the facility did not have a RN working for 8 consecutive hours as required on 12/23/23. 2. Review of the Nursing Administration schedule dated 2/8/24, indicated that the DON worked an assignment providing direct resident care. Review of the Daily Census dated 2/1/24 through 2/29/24 indicated that the average daily census was above 60 in February 2024. During an interview on 3/20/24 at 8:12 A.M., the Administrator said the facility had no nurse staffing waivers in place. During an interview on 3/26/24 at 10:45 A.M., the DON said that she works full-time, 40 hours a week or more as a DON. The DON further said that if the facility has staffing needs, she will have an assignment providing direct resident care. The DON said that she has taken direct resident care assignments providing medications and treatments to residents on several occasions. During an interview on 3/26/24 at 12:15 P.M., The facility Scheduler reviewed the nurse staffing schedules and said that the DON worked an assignment providing direct resident care on 2/8/24 from 3:30 P.M. until 7:30 P.M.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the assistance of two staff members while being repositioned in bed, the Facility failed to ensure that Resident #1 was provided with an adequate level of staff assistance during care to prevent an accident that resulted in an injury, which required Resident #1 to be transferred to the Hospital Emergency Department for treatment, where he/she received three sutures to close a facial laceration. Findings include: Resident #1 was admitted to the Facility in (MONTH) 2013 with [DIAGNOSES REDACTED]. Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that he/she required the assistance of two staff persons for activities of daily living, including the assistance of two staff persons for bed mobility and repositioning. Review of Resident #1's Certified Nurse Aide (CNA) care card, dated 10/20/19, indicated that he/she was totally dependent on staff for repositioning and required two staff to assist with repositioning and turning in bed. Resident #1's care plan related to activities of daily living indicated that he/she has self-care performance deficits due to trauma and required the assistance of two staff persons for transfers and bed mobility. Nurse #1's Progress Note, dated 11/11/19, indicated that CNA #1 came to get him at 2:00 P.M. and stated that when he rolled Resident #1 over in bed to provide incontinent care, and that Resident #1 had hit his/her face above the left eye on the bedside chest of drawers. The Note indicated that Resident #1 was observed to have a 3 centimeter (cm) laceration to the left eyebrow with bruising, that first aid was administered and a dressing was applied. The Note indicated that an order was obtained to transfer Resident #1 to the Hospital Emergency Department for evaluation and treatment. The Hospital Discharge Summary, dated 11/11/19, indicated that the CT imaging did not show any sign of facial fracture and that three sutures were applied to Resident #1's facial laceration. During an interview on 11/26/19 at 10:16 [NAME]M., Nurse #1 said that at 2:00 P.M., CNA #1 came to him and asked him to check on Resident #1. Nurse #1 said that as he entered Resident #1's room, he noted that Resident#1 was lying on his/her back and there was a laceration above the left eyebrow and a large bruise in the eyebrow and forehead area. Nurse #1 said he asked CNA #1 what happened and CNA #1 said that when he rolled Resident #1 over during care, he/she hit his/her head on the bedside chest of drawers. During an interview on 11/26/19 at 10:39 [NAME]M., the Assistant Director of Nursing (ADON) said that she asked CNA #1 how the injury occurred and that CNA #1 said that he was turning Resident #1 while performing incontinent care and he/she hit his head on the bedside chest of drawers. The Facility's policy titled, Turning a Resident on his/her side Away From You. Level II., dated as revised (MONTH) 2010, section on preparation, indicated that staff are to: Review the resident's care plan to assess for any special needs of the resident. The Facility's Internal Investigation, undated, indicated that Resident #1 was injured while CNA# 1 was providing care to him/her while in bed. The Investigation indicated that Resident #1 required two staff persons assistance with care and that CNA#1 did not ask for or obtain assistance from another staff member when providing care to Resident #1. During an interview on 11/26/19 at 11:41 [NAME]M., with the Director of Nursing (DON), the DON said that there were two administrative staff on the day shift for 11/11/19 in addition to two CNAs and two nurses. The DON said that there was no reason for CNA #1 to provide care to a resident that required a two person assist alone when anyone would help, including herself and the ADON. The DON said that when she interviewed CNA #1 during the investigation, he admitted that he was caring for Resident #1 alone and said he was aware that Resident #1 required the assistance of two staff for care. During an interview on 11/26/19 at 1:21 P.M., CNA #1 said he had been working alone the day of the incident, that he had looked for help because Resident #1 was a heavy person, but said at the moment he looked for help, nobody was around.

Based on records reviewed and interviews for one of three sampled residents (Resident #2), the facility failed to ensure that nursing adequately assessed and appropriately treated Resident #2, who experienced a significant change in status, which resulted in Resident #2 requiring transfer and admission to the Hospital. Findings include: The Facility Policy titled Acute Condition Changes-Clinical Protocol, dated (MONTH) 2012, indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make a detailed observation and collect pertinent information to report to the physician. The Policy indicated staff will monitor and document the resident's progress and responses to treatment. Resident #2 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A Nurse Progress Note, timed 1:38 P.M. dated 06/30/18, written by Nurse #6, indicated Resident #2 had a temperature of 99.4 degrees Fahrenheit (average range is 98.6 degrees Fahrenheit) and Tylenol (an [MEDICATION NAME] medication) 650 milligrams (mg) was administered. A Nurses Progress Note, timed 2:48 P.M., dated 06/30/18, written by Nurse #6, indicated Resident #2 had been in bed throughout the shift, ate little breakfast and lunch, vital signs were; blood pressure was 110/68 (normal range is 90/60 to 120/80), pulse 111 beats per minute (bpm, normal range is 60 to 100 bpm), temperature was 99.2 degrees Fahrenheit, and oxygen saturation was 94% (normal range for adults is 94% to 99%) on room air. The Note indicated Resident #2 complained of a headache and Tylenol was administered with pending results. The Note indicated Resident #2 was encouraged to take fluids but remained lethargic, with continuous monitoring. Review of Resident #2's medical record indicated there was no documentation to support that the nursing staff notified the Physician of Resident #2's significant change of condition. Review of Resident #2's medical record indicated there was no documentation to support that the nursing staff continued to monitor Resident #2 during the 3:00 to 11:00 P.M. shift on 06/30/18 and into the 11:00 P.M. to 7:00 A.M. shift on 07/01/18. The Nurse Progress Note, dated 07/01/18, indicated Nurse #7 went to Resident #2 in the morning to find him/her hot and clammy and unresponsive. The Note indicated Resident #2's temperature was 102.6 F, blood pressure was 140/86, pulse was 98 bpm, respirations were 22 (normal range is 12 to 18 breaths per minute), and oxygen saturation was 90%. The Note indicated Resident #2 was able to take Tylenol 650 mg and answer yes or no questions. The Note indicated the Physician was called and ordered Resident #2 be transferred to the hospital emergency department for evaluation. The Note indicated Resident #2's HCP arrived and also requested Resident #2 to be transferred to the hospital. The Situation, Background, Appearance, Review (SBAR) and Notify Form, dated 07/01/18, indicated Resident #2 was unresponsive, had labored, rapid breathing, his/her vital signs were: blood pressure was 141/77, pulse was 110 bpm, respirations were 22 breaths per minute, temperature was 102.6 degrees, and oxygen saturation was 88% with oxygen. The Surveyor interviewed Nurse #6 at 12:06 P.M. on 09/17/18. Nurse #6 said he did not notify Resident #2's Physician of his/her change in condition. Nurse #6 said he said he informed Nurse #3 about Resident #2's condition and thought Nurse #3 notified the on-call Physician. The Surveyor interviewed Nurse #3 at 11:35 A.M. on 09/17/18. Nurse #3 said she believes she notified the on-call Physician of Resident #2's change of condition. Nurse #3 said she thinks the on-call Physician said to monitor Resident #2. Nurse #3 said she should have documented that she called the Physician. Nurse #3 said she did not write an order to monitor Resident #2. Review of Resident #2's medical record indicated there was no documentation to support that Nurse #3 notified the Physician. The Surveyor interviewed Physician #1 at 1:29 P.M. on 09/17/18. Physician #1 said he does not recall receiving a phone call on 06/30/18 regarding Resident #2. The Surveyor interviewed Nurse #7 at 12:23 P.M. on 09/17/18. Nurse #7 said she did not receive report from the 11:00 P.M. to 7:00 A.M. shift nurse that Resident #2 was sick. Nurse #7 said that a Certified Nurse Aide had reported to her at about 9:00 A.M. on 07/01/18 that Resident #2 was not acting right. Nurse #2 said she obtained vital signs, notified the Physician, and obtained an order to transfer Resident #2 to the hospital emergency department for evaluation.

Based on record review and interview for 2 of 3 Residents (#1 and #2), the Facility failed to ensure they were free from accidental hazards. Resident #1 had a heroin overdose at the facility and Resident #2 smoked a cigarette in his/her bedroom with continuous oxygen prescribed for Resident #2 (in the next bed), thus creating a fire hazard for the other residents, who resided at the facility. In addition, the Facility failed to develop care plans for Resident #1's and Resident #2's, active heroin usage and for Resident #2 for cigarette smoking. Findings include: 1. Resident #1 was admitted to the Facility in 10/2015. This Resident's pertinent [DIAGNOSES REDACTED]. Review of the Facility's Hospital Liaison Sheet for Resident #2 indicated this Resident had been living in a crack house in 10/2015 and last used heroin on 10/6/15 (the day before hospitalization at the Community Hospital) and was admitted to this Facility on 10/23/15. The Facility's Resident Room Assignment policy, dated 4/28/10, stated, the center promotes care for its resident in a manner in an environment that promotes maintenance of enhancement of each resident's quality of life. For compliance guidelines, a resident's room assignment will be determined by the resident's individual: medical, nursing and service needs. Interview with the Regional Nurse and Unit Manager #1 at 8:15 A.M. and at 2:27 P.M. on 1/5/16 indicated that assigning Resident #1 and Resident #2, who both had heroin addictions with recent heroin usage and without substance abuse rehabilitation (prior and during this admission), was not well thought out. The Facility investigation and Nurse's note of 11/17/15 at 9:20 A.M., indicated that the Business Office Manager entered Resident #1's room and Resident #1 did not look like him/herself. Resident #1 told the Business Office Manager that he/she snorted (inhaled through the nose) heroin and that Resident #1 received the heroin from Resident #2 (his/her roommate). Resident #1 had a decline in his/her mental status, had an ashen color of the skin, and had an oxygen saturation of 72 % (normal 90% or greater). Resident #1 was then transferred to the Community Hospital. The Situation Background Assessment Recommendation (SBAR) note of 11/17/15 at 3:50 P.M., indicated Resident #2 was lethargic and twitching was noted. Resident #2 was also transferred to the Community Hospital. Interview with the Business Office Manager at 10:20 A.M. on 1/5/16 indicated that on 11/17/15 at 9:20 A.M., Resident #1 looked gray when she entered Resident #1's room. She asked this Resident to come clean, and he/she admitted that he/she snorted heroin in his bedroom. Resident #1 said that he/she had snorted 3 lines of heroin on 3 different days at this facility. The hospital physician's admission of 11/17/15 at 4:20 P.M., indicated that Resident #1 presented from the Facility with a change in mental status and hypoxemic (low oxygen levels) respiratory failure. Resident #1 had a heroin overdose. Resident #1 had been sniffing heroin and responded to Narcan (a medication to reverse the effects of heroine). Resident #1 was critically ill with circulatory failure, neurologic failure, respiratory failure and an overwhelming infection and was admitted to critical care. Interview with Resident #1 at 10:20 A.M. on 1/8/16, (who was identified as an accurate historian by the Facility) said that his/her roommate Resident #2 obtained the heroin from a person who delivered packages to their bedroom window. Resident #1 said the window to their room could be easily opened to receive the packages. Resident #1 said that he/she saw Resident #2 snort heroin 4 to 5 times while he/she was a resident at this Facility. Resident #1 said that Resident #2 gave the heroin to him/her and he/she did not buy it from Resident #2. In addition. Resident #1 said that Resident #2 frequently snorted heroin with him/her in the facility. When Resident #1 was asked if the staff was aware that they was both snorting heroin, Resident #1 then said words to the effect of, evidently not until I was sent out to the hospital with a heroin overdose. Interview with Social Worker #1 at 1:35 P.M. on 1/5/16 indicated that Resident #1 and Resident #2 should not have been admitted to this Facility. Social Worker #1 said that Resident #1 and Resident #2 should have gone to a substance abuse hospital for rehabilitation. Social Worker #1 said that the staff did not have the skill and knowledge to take care of Resident #1 and Resident #2. Social Worker #1 said that the former Administrator did not agree to accept Resident #1 and #2, the facility was words to the effect of, overruled by Corporate. There was no specific care plan to address Resident #1's heroin abuse and current usage. This resident's addiction and rehabilitation needs were not addressed. Interview with the Regional Nurse and Unit Manger # 1 at 8:15 A.M. and at 2:27 P.M. on 1/5/16, both said prior to Resident #1's heroin overdose there were no policies, protocols, or staff education, for substance abuse, prior to Resident #1's heroin overdose. Interview with Unit Manager #1 at 2:27 P.M. on 1/5/16, Unit Manager #1 stated that the Facility failed to develop a care plan for Resident #1's and Resident #2's current heroin usage and rehabilitation needs. 2. The facility failed to adequately supervise Resident #2 to prevent him/her from smoking a cigarette in his/her bedroom, with a supply of oxygen at his/her roommate's (Resident #1's) bedside. In addition, the facility failed to develop a care plan for Resident #2's cigarette smoking. Resident #2 was admitted to the Facility in 10/2015. This Resident's pertinent [DIAGNOSES REDACTED]. The Smoking policy, dated 4/28/10, stated that, the care plan of a resident who smokes reflects the smoking designation (independent, dependent) and identifies the assistance the resident needs. Smoking is not permitted in close proximity to oxygen storage areas. The Investigation and Nursing note of 11/10/15 indicated that during the 3:00 P.M. to 11:00 P.M. shift a Nurse smelled an odor of smoke coming from Resident #1 and Resident #2's room and the bedroom door was closed. Resident #2 had tried to smoke a cigarette in his/her room. His lighter was taken out of his/her room that evening. After Resident #2 was found to be unsafe with smoking in his/her room, Resident #1's cigarettes remained stored in his/her room. The Nurse's note of 11/11/15 at 12:02 A.M., indicated that Resident #2 was smoking in his/her room last night and his/her lighter was removed from the room. This morning cigarettes were requested by the staff and he gave them to the Nurse. Interview with Resident #1 at 10:20 A.M. on 1/8/16, (who was identified as an accurate historian by the facility) said that he received continuous oxygen due his lung disease while a Resident at this facility. He said that his/her Roommate smoked cigarettes in the room they shared, despite the oxygen and potential for a hazard. Resident #1 said that later during his/her stay at the facility he/she did not feel safe with Resident #2 in the same bedroom. Interview with Unit Manager #1 at 2:27 P.M. on 1/5/16, indicated that the Facility failed to develop a care plan for Resident #2's cigarette smoking and heroin usage.

Based on record review, interviews for 2 of 3 Residents (#1 and #2), the facility failed to develop care plans as needed for both Resident #1's and Resident #2's continued heroin abuse, for Resident #2 for cigarette smoking, and for the treatment and care of an infected [MEDICAL CONDITION]. Findings include: 1. Resident #1 was admitted to the Facility in 10/2015. This Resident's pertinent [DIAGNOSES REDACTED]. The Hospital record of 11/12/15 indicated Resident #1 was injecting heroin between May 2015 and September 2015, one month prior to the facility's admission 10/23/15. The Admission Nursing form, dated 10/23/15 indicated Resident #1 smoked 20 cigarettes a day. There was a no specific care plan to address Resident #1's heroin abuse and current usage. This Resident's addiction and rehabilitation needs were not addressed. There was no care plan for tobacco addiction, which can be a precipitator/trigger for Resident #1's [MEDICAL CONDITION] and history of [MEDICAL CONDITION]. Interview with Unit Manager #1 at 3:20 P.M. on 1/5/16, indicated that the facility failed to develop a care plan for Resident #1's recent heroin usage and tobacco addiction. The Facility investigation and Nurse's note of 11/17/15 at 9:20 A.M., indicated that the Business Office Manager entered Resident #1's room and Resident #1 did not look like his/herself. Resident #1 told the Business Office Manager that he/she snorted (inhaled through the nose) heroin and that Resident #1 received the heroin from Resident #2 (his/her roommate). Resident #1 had a decline in his/her mental status, had an ashen color of the skin, and had an oxygen saturation of 72 % (normal 90% or greater). Resident #1 was then transferred to the Community Hospital. The hospital physician's admission of 11/17/15 at 4:20 P.M., indicated that Resident #1 presented from the Facility with a change in mental status and hypoxemic (low oxygen levels) [MEDICAL CONDITION]. Resident #1 had a heroin overdose. Resident #1 had been sniffing heroin and responded to [MEDICATION NAME] (a medication to reverse the effects of heroine). Resident #1 was critically ill with circulatory failure, neurologic failure, [MEDICAL CONDITION] and an overwhelming infection and was admitted to critical care. Interview with Resident #1 at 10:20 A.M. on 1/8/16, (who was identified as an accurate historian by the Facility) Resident #1 was asked if the staff were aware that both Resident #1 and Resident #2 had snorted heroin on numerous occasions, Resident #1 then said words to the effect of, evidently not until I was sent out to the hospital with a heroin overdose. 2. Resident #2 was admitted to the Facility in 10/2015. This Resident's pertinent [DIAGNOSES REDACTED]. The Hospital's admission records dated 10/7/15 indicated Resident #2's last heroin usage was 10/6/15. The Facility's Hospital Liaison notes indicated Resident #2, last used 10/06/15-heroin-sniffed per pt. (patient) . The Facility's Admission Nursing form, dated 10/23/15 indicated Resident #2 smoked 1 pack per day of cigarettes The Admission progress note of 10/23/15 indicated Resident #2 had a scalp abscess and [MEDICAL CONDITION] infected [MEDICAL CONDITION]. The care plans indicated there was no care plan for the following: heroin usage, tobacco addition and the scalp abscess and [MEDICAL CONDITION] infected [MEDICAL CONDITION]. Interview with Unit Manager #1 at 2:27 P.M. at 1/5/16, indicated that the Facility failed to develop a care plan for Resident #2's heroin usage, tobacco addiction [MEDICAL CONDITION] infected scalp abscess with a [MEDICAL CONDITION].

Based on record review and interview for 2 of 3 Residents (Resident #1 and #2), the facility failed to assess and identify each resident's needs related to heroin abuse, an infected scalp abscess with [MEDICAL CONDITION], and cigarette smoking. Findings include: 1. Resident #1 was admitted to the Facility in 10/2015. This Resident's pertinent diagnoses included alcohol [MEDICAL CONDITION], heroin addiction, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The admission Minimum Data Set (MDS) assessment of 10/30/15 identified that Resident #1 had a brief interview for mental status of 15, cognitively intact. Under Section I Active Diagnoses there were no diagnoses of heroin and [MEDICAL CONDITION]. The record review indicated this Resident was at risk for heroin and tobacco abuse secondary to the following: - The Physician's admission history and physical had current diagnoses of alcohol and heroin addiction. - Recent heroin abuse (Hospital records of 11/12/15 indicated Resident #1 was injecting heroin between May 2015 and September 2015, one month prior to the facility admission). - The Admission Nursing evaluation indicated this Resident smoked 20 cigarettes a day. The Admission Nursing Evaluation form of 10/23/15 indicated that under section D, psychosocial: Resident smoked 20 cigarettes per day. There is no information on this Admission form to assess for heroin use (when last used) and no alcohol usage. This information is valuable in order to monitor for current usage and screening, withdrawal signs and symptoms and/or substance abuse rehabilitation. Interview with Unit Manager #1 at 2:27 P.M. on 1/5/16 indicated that the Facility failed to identify and assess Resident #1 had active heroin usage. The Facility investigation and Nurse's note of 11/17/15 at 9:20 A.M., indicated that the Business Office Manager entered Resident #1's room and Resident #1 did not look like his/herself. Resident #1 told the Business Office Manager that he/she snorted (inhaled through the nose) heroin and that Resident #1 received the heroin from Resident #2 (his/her roommate). Resident #1 had a decline in his/her mental status, had an ashen color of the skin, and had an oxygen saturation of 72 % (normal 90% or greater). Resident #1 was then transferred to the Community Hospital. The hospital physician's admission of 11/17/15 at 4:20 P.M., indicated that Resident #1 presented from the Facility with a change in mental status and hypoxemic (low oxygen level) [MEDICAL CONDITION]. Resident #1 had a heroin overdose. Resident #1 had been sniffing heroin and responded to [MEDICATION NAME] (a medication to reverse the effects of heroine). Resident #1 was critically ill with circulatory failure, neurological failure, [MEDICAL CONDITION] and an overwhelming infection and was admitted to critical care. Interview with Resident #1 at 10:20 A.M. on 1/8/16, (who was identified as an accurate historian by the Facility) Resident #1 was asked if the staff were aware that both Resident #1 and Resident #2 had snorted heroin on numerous occasions, Resident #1 then said words to the effect of, evidently not until I was sent out to the hospital with a heroin overdose. 2. Resident #2 was admitted to the Facility in 10/2015. This Resident's pertinent diagnoses included a [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) infected scalp wound, [MEDICAL CONDITION], chronic pai[DIAGNOSES REDACTED] and history of substance abuse which includes opiates and cocaine. The admission Minimum Data Set (MDS) assessment of 10/30/15, identified that Resident #2 had a brief interview for mental status of 11, moderately cognitively impaired. Under Section I Active Diagnoses were depression, [MEDICAL CONDITION] staphylococcus infection, cutaneous abscess of the head, [MEDICAL CONDITION] of the head, and [MEDICAL CONDITION] with intoxication, tobacco use and poisoning by heroin. The medical record indicated Resident #2 was at risk for substance abuse and tobacco addiction, and a head wound infected [MEDICAL CONDITION] secondary to the following: - History of polysubstance abuse; intravenous heroin (Hospital admission records indicated last heroin usage 10/6/15 - the day before the hospital admission on 10/7/15) - History of smoking 1 pack per day of cigarettes -Scalp abscess [MEDICAL CONDITION] - 10/23/15 After heroin and tobacco usage diagnoses were identified there were no assessments or identification of strategies or interventions for screening current abuse, promoting cessation and rehabilitation. After the scalp abscess [MEDICAL CONDITION] was identified there was no assessment or identification to address treatment and preventing the spread [MEDICAL CONDITION]. The Admission Nursing Evaluation form of 10/23/15 indicated that under section D, psychosocial: Resident #2 smoked one pack per day and occasionally has alcohol. There is no information on this Admission form to assess cocaine and heroin use (when last used). This information is valuable in order to monitor for current usage, withdrawal signs and symptoms and/or substance abuse rehabilitation. Interview with Unit Manager #1 at 2:27 P.M. on 1/5/16, indicated that the Facility failed to identify and assess Resident #2 for the scalp abscess infected [MEDICAL CONDITION], polysubstance and tobacco abuse.

br>Based on record review and interviews for 1 of 3 sampled residents (Resident #1), the facility failed to follow acceptable standards of practice when Charge Nurse #1 did not immediately assess and provide emergency care to Resident #1 who experienced a sudden change in condition. Findings include: The Facility's policy on Notification of Resident Change in Condition, dated 2/2015, it states, All staff will communicate any information about resident change in condition to appropriate licensed personnel immediately upon observation. The resident's change in condition will be reported immediately to the Unit Manager (The Charge Nurse title is used for the Unit Manager) or shift Nursing Supervisor. The licensed nurse will assess the resident for signs and symptoms of physical or mental change of condition. The Charge Nurse's (CN) job description states that, the primary purpose of the job position was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and be required to ensure that the highest degree of quality care is maintained at all times. The Investigation Report, dated 9/14/15, indicated that on 7/28/15, Resident #1 was found in their bedroom by Certified Nursing Assistant (CNA) #1, Resident #1 was tipping to the side and not acting like him/her self. Resident #1's change in condition was reported by CNA #1 to CN #1, who was at the Nurses' Station. CNA #1 asked CN #1 to evaluate Resident #1 but CN #1 did not assess Resident #1, at CNA #1's request, but instead told CNA #1 to contact the Respiratory Therapist (RT). CNA #1 checked the RT's office and the RT was not there. CNA #1 returned to the Nurses' Station and asked CN #1 to overhead page the RT, which CN #1 did not do. The Report indicated CNA #1 then asked Nurse #1 for assistance and CNA #1 shared concerns regarding Resident #1, and Nurse #1 responded immediately. The Report indicated Nurse #1 went concurrently with the RT (who had just arrived on the unit) to Resident #1's room and assessed Resident #1. Resident #1 was initially alert and verbal, but pale. Resident #1 then stopped talking, had a blank stare, and was found to be without a pulse. A code was called (an emergency for a cardiac/pulmonary arrest) and the Emergency Medical Service (EMS) was called. EMS arrived and transported Resident #1 to the community hospital. Upon arrival, Resident #1 was pronounced dead. The Surveyor interviewed the Administrator at 1:00 P.M. on 9/16/15, the Administrator said that at 7:10 A.M. on 7/28/15, Resident #1 had a change in his/her condition; CNA #1 and CNA #2 found Resident #1 in bed leaning to the side and Resident #1 did not look right. The Administrator said CN #1 was informed of Resident #1's change in condition, but CN #1 did not respond to CNA #2's request to evaluate Resident #1. CN #1 was asked to page the RT, but did not do so. The Administrator said CN #1 was terminated based on the investigation findings of negligence. The Surveyor interviewed CNA #1 and CNA #2 at 9:36 A.M., on 9/17/15 and at 10:07 A.M. on 9/17/15. CNA #2, stated that on 7/28/15 at approximately 7:30 A.M., Resident #1 was huffing and buffing and did not look right. CNA #1 and CNA #2 tired twice to get CN #1 to evaluate Resident #1's change in condition, but CN #1 remained sitting at the Nurses' Station and instructed CNA #1 and CNA #2 to notify the Respiratory Therapist. When asked how long was there a delay in having Resident #1 assessed by a Nurse, CNA #1 and CNA #2 said it was an approximate 5 minute delay. The Surveyor interviewed CN #1 at 12:35 P.M., on 9/17/15; CN #1 was asked, Did CNA #2 ask you to evaluate Resident #1? CN #1 said that she did but then she called for the RT, so they could go in together. The Surveyor said, But the RT was not there initially. CN #1 said that he wasn't. The Surveyor asked, Did you respond the 1st time CNA #2 requested you to see Resident #1? CN #1 said, I got up immediately from the desk and took the Resident's pulse oximetry and brought a blood pressure cuff. The Surveyor asked CN #1, Who was in Resident #1's room at that time? CN #1 said, I don't know. The Surveyor asked, Do you recall CNA #1 and CNA #2 requesting you to evaluate Resident #1 for the second time? CN #1 said, No. The Surveyor asked, Didn't CNA #1 and CNA #2 come out to the Nurses' Station again to get you (CN #1) to come into Resident #1's Room? CN #1 said, No. The Surveyor interviewed Nurse #1 at 2:30 P.M. on 9/17/15. He said that on the morning of 7/28/15, CNA #2 approached the CN and asked her to come and assess Resident #1. She was instructed to find the RT (which CNA #2 could not find). Nurse #1 said that when CNA #2 said that the CN would not leave the Nurses' Station to evaluate Resident #1, then Nurse #1 went right away to evaluate Resident #1. The Surveyor asked Nurse #1, Did the CN take Resident #1's pulse oximetry or vital signs? He said that the CN did not, and the only thing he saw her bring to Resident #1's room was the AED (automated external defibrillator) and then she left the Room. When Nurse #1 was asked, Did the CN assess Resident #1? Nurse #1 said that she did not assess Resident #1, and that it was at least a 10 minute delay from when the CN was first asked to evaluate Resident #1 by CNA #2.