Every finding on record at Guilford House, The

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were at risk for falls, the facility failed to ensure Resident #1's family was notified on the same day when the resident sustained a fall. The findings include:Resident #1's diagnoses included heart failure, muscle weakness, difficulty in walking and cellulitis. The admission record dated 6/7/25 identified family members were Resident #1's emergency contact. The admission nurse's note dated 6/7/25 at 6:10 PM identified Resident #1 was admitted to the facility from the hospital at 5:00 PM. The note indicated Resident #1 was alert, forgetful, anxious, calling out occasionally wanting to go home and redirected to place and time. The nurse's note dated 6/8/24 at 2:07 AM identified Resident #1 was found lying on his/her side next to his/her bed. The note identified Resident #1 appeared confused pupils were equal, round, and reactive to light, there was no internal or external rotation or lengthening or shortening of all extremities, and no new skin redness or open areas. The note identified the provider was notified and a new order was obtained to perform safety checks for three (3) days every two (2) hours. The note identified Resident #1's family needed an update in the morning. Review of the clinical record from 6/8/25 through 6/14/25 failed to reflect documentation Resident #1's family was updated regarding the 6/8/25 fall. The facility Accident and Investigation dated 6/8/25 identified the physician was notified on 6/8/25 at 2:20 AM of the fall however Resident #1's family was not notified regarding the fall until 6/14/24, six (6) days later. Interview and clinical record review with the Director of Nursing (DON) on 9/22/25 at 12:06 PM identified Resident #1's family should have been notified at the time of the fall. Review of the facility policy titled Fall-Unwitnessed directed, in part, notify family and provider of occurrence and re-notify if any changes. Review of the facility policy titled Resident's Change in Condition, directed, in part, any changes in condition must be reported to the family/responsible party along with any new orders from the provider.

Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #2) who was reviewed for misappropriation of personal property, the facility failed to ensure staff did not remove the resident's jewelry from the facility. The findings include:Resident #2's diagnoses included anemia, atrial fibrillation, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely made decisions regarding tasks of daily life, and required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. The Resident Care Plan dated 7/14/25 identified impaired activities of daily living as evidenced by need for assistance with washing, dressing, transfers, and walking. Interventions directed for nursing to witness denture removal at hour of sleep and place in denture cup with tablet, 1/4 side rails can be used to facilitate self-repositioning and transfers, set up for self-care will be provided with encouragement to do as much as able and assistance as needed to perform the task, and assistance with activities of daily living as recommended by occupational therapy. The nurse's note dated 7/25/25 at 3:28 PM identified Resident #2 reported to a 7AM-3PM nurse aide, Nurse Aide (NA) #1, that his/her wedding band and engagement ring were missing. The note indicated the room, linen and garbage were searched, and the police and family were notified. The grievance log dated 7/25/25 identified NA #1 reported at 9:30 AM Resident #2 stated his/her rings were missing. The report indicated the charge nurse and NA #1 went into Resident #2's room at which time Resident #2 stated someone in pink took me into the bathroom, washed my hands and took my ring. The report identified the unit manager was notified. The Facility Reported Incident form dated 7/25/25 identified NA #1 informed the charge nurse that Resident #2 stated his/her rings were missing, stating someone in pink took me to the bathroom, washed my hands and took my rings. In a written statement dated 7/25/25 NA #1 indicated at approximately 9:30 AM while in the bathroom with Resident #2, she washed Resident #2's face, under the breasts, arms and bottom. NA #1 wrote once she was finished, she put Resident #2 in the wheelchair with the table and remote and began providing care to Resident #2's roommate, at which time Resident #2 yelled out hey have you seen my rings. NA #1 wrote she informed Resident #2 that she had not seen the rings and immediately reported the incident to the nurse. Interview with the Director of Nursing (DON) on 9/18/25 at 2:04 PM identified on 7/25/25 she was informed by the charge nurse Resident #2's rings were missing. The DON identified that she immediately initiated an investigation that consisted of interviews with Resident #2 as well as staff. The DON identified Resident #2 reported to her that his/her hands were sticky and the girl went in to wash his/her hands in the bathroom and while washing his/her hands, took the rings off. The DON identified in an interview with NA #1, she reported she had not noticed the rings that morning. The DON identified the investigation by the town police (a report was not available as the case was not complete), Resident #2's rings were found in a local pawn shop in a different city with NA #1's information. The DON identified she spoke with the police officer on 9/17/25, who informed her a warrant had been issued for NA #1's arrest. The DON identified her investigation substantiated the misappropriation of Resident #2's rings and NA #1 was terminated from employment. Review of the facility policy titled Abuse, Assault and Neglect, undated, directed, in part, each resident will be free from verbal, sexual, physical abuse, involuntary seclusion and neglect. The policy further directed, in part, misappropriation of resident property-means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further directed, in part, any employee guilty of resident abuse will be terminated and the reason for such action will be part of his/her personal record. Review of the facility policy titled Resident Rights, undated, directed, in part, the resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion.

Based on a review of clinical records, facility documentation and interviews for one (1) of three (3) residents (Resident #1) at risk for falls, the facility failed to provide adequate supervision to the resident with a history of not requesting assistance with transfers and ambulation resulting in falls with a significant injury. The findings include: Resident #1's diagnoses included progressive supranuclear ophthalmoplegia (neurodegenerative disease, causing gradual deterioration and death of specific volumes of the brain), subdural hemorrhage, repeated falls and anxiety disorder. A physician's order dated [DATE] directed Resident #1 was a contact guard assist of one with a rolling walker for ambulation (caregiver places hands on the resident to help with balance or stability). The Resident Care Plan (RCP) dated [DATE] identified that Resident #1 was at risk for falls, had 4 falls within the past 6 months with interventions that included to encourage the resident to utilize the call bell for assistance, a sensor alarm to the bed and chair, a low bed, video monitoring at the hour of sleep, provide toileting every two hours, provide close supervision when needed, and to ensure staff respond promptly to alarms. Review of the Fall Evaluation dated [DATE] identified that Resident #1 was a high risk for falls. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of six (6) indicative of severely impaired cognition, had limited range of motion to the lower extremities, required assistance of another person for ambulation with a walker, and had multiple falls with injury in the past six (6) months. a. Review of the reportable event report dated [DATE] identified Resident #1 self transferred to the bathroom, fell and hit head against the shower wall. The nurse's note dated [DATE] at 7:15 PM identified that the resident had a fall in the bathroom witnessed by administrative staff. The resident was noted with slight redness and swelling to the right temple measuring 1 centimeter (cm) in length and 2 cm in width, and a skin tear to the right knee. Initial neurological checks were within normal limits and the resident denied pain. The resident was brought to the nurse's station for observation and within fifteen (15) minutes the resident was noted to have reduced motor control and an altered mental status and was transferred to the hospital for evaluation. Review of the hospital record dated [DATE] identified that a CT scan of the head was obtained, and Resident #1 had sustained an acute/chronic left holohemispheric subdural hematoma, with a midline shift (when the brain tissue moves across the brain's center line). The subdural hematoma was operable, however, the family expressed that surgery was not within Resident #1's goals of care and they wished to transition him/her to comfort measures only. A nurse's note dated [DATE] at 6:20 PM identified that the resident was re-admitted at 6:20 PM and was placed on one-to-one observation to prevent any further falls. An Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified that the resident was re-admitted on [DATE] from the hospital after a fall and diagnosis of subdural hematoma. The resident was admitted under comfort measures only and was receiving morphine (a narcotic pain medication) for comfort. Nurse's notes during the period of 9/20- [DATE] identified that the resident was on hospice services related to a subdural hematoma with a mid-line shift and was receiving morphine and ativan around the clock for comfort. A nurse's note dated [DATE] at 8:30 PM identified that the resident had no respirations or heart rate and was pronounced deceased . Interview with Receptionist #1 on [DATE] at 12:24 PM identified on [DATE] at around 7:00 PM she was sitting at the front desk, heard a bed alarm going off, and found Resident #1 sitting on the edge of the bed trying to get his/her wheelchair. She encouraged the resident to stay seated because she knew Resident #1 required assistance with ambulation, she yelled for help with no response from staff. The resident then stood up and began to push the wheelchair with his/her left hand and hug the wall near the bathroom with his/her right side. She identified that she yelled for help again, and then went out into the hallway again and saw no staff, so she went back into the room, where the resident was now inside the bathroom shower when she witnessed Resident #1 fall, hitting his/her head on the shelf in the shower. She yelled out that Resident #1 had fallen, and LPN #1 and NA #4 responded to assist. She identified that she should have stayed with the resident, however, no-one was responding when she yelled so she didn't know what to do besides getting assistance. Interview with NA #2 on [DATE] at 12:45 PM identified that Resident #1 was on her assignment on [DATE]. NA #2 stated that she heard bed alarm sounding, however, she was toileting a resident that could not be left alone in the bathroom for safety reasons. Interview with NA #4 on [DATE] at 12:53 PM identified that she was working on Resident #1's unit on [DATE] and did not hear a bed alarm sounding or Receptionist #1 yelling for help prior to the fall. Receptionist #1 came up to her and reported that Resident #1 was on the floor, she then responded immediately to Resident #1's room to assist. Interview with NA #3 on [DATE] at 1:07 PM identified that on [DATE], she had been sitting at the table by the nursing station when she heard Receptionist #1 yell that Resident #1 had fallen. She identified that prior to that she had just come out of a resident's room and did not hear a bed alarm going off and did not hear Receptionist #1 yelling for assistance. Interview with LPN #1 on [DATE] at 3:16 PM identified that she was on her dinner break in the dining room across from the nursing station on [DATE] when she heard someone yell, he fell. She reported that she ran down the hall and saw Receptionist #1 and NA #4 in Resident #1's bathroom, alongside Resident #1 who was laying on the floor of the shower LPN #1 identified that she did not hear the bed alarm or Receptionist #1 yelling for assistance prior to that. Interview with LPN #4 on [DATE] at 3:31 PM identified that he was down the other end of the hall doing treatments in a resident's room at the time of Resident #1's fall on [DATE]. He identified that he did not hear Receptionist #1 yelling, nor did he hear a bed alarm and did not know the resident had a fall until other staff notified him when the resident was in the dining room. Interview with RN #1 (Nursing Supervisor) on [DATE] at 1:19 PM identified she assessed Resident #1, who was alert and verbal, with neurological checks within normal limits and was not complaining of pain at that time. Staff got the resident off the floor into the wheelchair and placed the resident in a common area that was visible to all of the staff. RN #1 reported that shortly after, the resident started to have a change in neurological status, and he/she was sent to the ED for evaluation. Interview with the DNS on [DATE] at 1:38 PM identified that the bed alarm is loud and can be heard at the nursing station and through closed resident doors. She identified that although Receptionist #1 reported she yelled for assistance twice prior to yelling that Resident #1 sustained a fall on [DATE], she was unsure why NA #1, 2, 3, 4 and LPN #1 or #4 did not hear either the bed alarm or Receptionist #1's request for assistance. She reported that Receptionist #1 was not licensed to touch the residents but identified that Receptionist #1 should have stayed with Resident #1 once Resident #1 got out of bed unassisted and should not left have the room and continue to encourage the resident to wait for assistance or offer him/her a chair for safety. b. A facility incident report dated [DATE] at 9:45 AM identified that Resident #5 (roommate) reported that Resident #1 was getting up to go to the bathroom and fell. The report identified that the alarm was going off and Resident #1 had already gotten himself/herself back up and into the wheelchair. Upon assessment, the resident was noted with a small bump to the back of his/her head. Resident #1 was sent to the Emergency Department (ED) and returned to the facility the same day with no new orders. Upon return a new intervention was added to the fall care plan ensure that the sensor alarm is answered promptly. Review of the hospital record dated [DATE] identified that Resident #1 had a Computer Tomography (CT) scan (a diagnostic test that can identify abnormalities) of the head completed which revealed no overt fracture or new hemorrhage. Interview with Nurse Aide (NA) #4 on [DATE] at 12:53 PM identified that she worked the 7:00 AM to 3:00 PM shift on [DATE] and recalled that NA #5 was assigned to Resident #1 that shift but had disappeared off the floor and could not be located prior to Resident #1 falling. She identified that NA #5 never notified her that she was leaving the floor, NA #4 identified that if she had known that NA #5 was leaving the unit, she would have kept an eye on Resident #1, as he/she had a history of falls and not calling for assistance prior to getting up. Interview with NA #6 on [DATE] at 9:30 AM identified that she worked the 7:00 AM to 3:00 PM shift on [DATE] and recalled finding Resident #1 standing independently in his/her room. She toileted the resident and then put the resident back to bed. Resident #1 was on NA #5's assignment and was unable to find her to notify her. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 2:53 PM identified that he was the charge nurse assigned to Resident #1 on the 7:00 AM to 3:00 PM shift on [DATE]. He identified that when working with NA #5, he always had to search for her and reported the acuity of the unit was high at that time, and there were several residents that were fall risks. He identified he expects all NA's to report to him when they are leaving the unit so that the remaining staff can work together to ensure safety and care of the residents and identified that NA #5 did not report to him on [DATE] that she was leaving the unit. Interview with Registered Nurse (RN) #3 (Nursing Supervisor) on [DATE] at 2:06 PM identified that at around 9:38 AM on [DATE], he observed NA #5 socializing on another unit and urged her to return to her assigned unit. RN #3 stated at 9:45 AM, he received a call that Resident #1 sustained a fall, noted that the resident was on NA #5's assignment and when NA #5 left the unit, her assignment was not accounted for because she didn't tell anyone. Interview with NA #5 on [DATE] at 1:02 PM identified that she worked the 7:00 AM to 3:00 PM shift on [DATE] and was assigned to Resident #1. NA #5 stated the resident's roommate (Resident #5) informed her that Resident #1 had fallen in the room. NA #5 denied leaving her assigned unit and if she left the unit, would inform her coworkers. Interview with the Director of Nursing Services (DNS) on [DATE] at 1:38 PM identified she was unaware that NA #5 was unable to be found on the unit prior to Resident #1's fall on [DATE]. She reported she expects all staff to report to the charge nurse and their direct co-workers prior to leaving the unit so that all remaining staff can watch over that assignment. She identified that NA #5 should have been on the unit prior to the fall with Resident #1 and reported that NA #5 was no longer employed at the facility due to other concerns.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #1's diagnoses included degenerative disease of the nervous system, cerebellar ataxia (inability to coordinate muscle movement due to disease or injury to the cerebellum/brain), and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert, oriented, and was dependent with assist of two (2) with transfers. The Resident Care Plan (RCP) dated 11/15/2023 identified Resident #1 required assistance with activities of daily living (ADL) related to degenerative disease of nervous system. Interventions directed the use of a Hoyer Lift for transfers, encourage to express care needs, setup for self-care with encouragement to do as much as possible, and assistance as needed to perform tasks. The facility incident report dated 12/11/2023 6:00 PM identified Resident #1 was alert and oriented and was upset with a statement a NA made when going to provide care for Resident #1. The report indicated, upon NA #1 (agency NA) entering the room and standing behind a pulled privacy curtain, NA #1 made a comment that Resident #1 heard (not directed toward Resident #1). The facility incident summary dated 12/20/2023 identified Resident #1 was upset about a comment that was made by NA #1 when she entered the room (and the comment was not made directly to Resident #1). NA #2 was with Resident #1 at the time NA #1 made the comment, and NA #2 told Resident #1 that the comment was directed at Resident #1. The facility immediately removed NA #1 from work, and would not have NA #1 back in the facility. A nursing note dated 12/11/2023 11:01 PM by RN #2 identified an allegation of verbal abuse by staff. The local police, the physician, DNS and responsible party were notified. The note indicated Resident #1 was initially upset but calmed quickly after the interview and support given with no further issues. Interview with Resident #1 on 1/8/2024 at 10:15 AM identified that on 12/11/2023 NA #1 stated Resident #1 doesn't look happy, is fat--- ready? NA #2 confirmed to Resident #1 that she would report the incident. Resident #1 identified at the time, he/she was upset, but the facility staff handled the situation immediately and Resident #1 was very satisfied with the outcome. Interview with NA #2 on 1/8/2024 at 10:55 AM identified she was Resident #1's NA during the 3 to 11 PM shift on 12/11/2023. At about 6:45 PM, NA #2 requested NA #1 to assist with the Hoyer lift transfer. NA #2 went into Resident #1's room and began preparing Resident #1 for the transfer while waiting for NA #1 to arrive. NA #2 indicated the privacy curtain we pulled prior to NA #1's arrival in the room. Upon NA #1 entering the room, NA #1 spoke with NA #2 from behind the curtain and stated she liked Resident #2 better than Resident #1, and then using foul language, asked is fat--- ready to go to bed? Resident #1 heard the comment and NA #2 gave reassurance that she would report the incident. Interview with NA #1 on 1/8/2024 at 11:10 AM identified on 12/11/23, NA #2 had requested her to assist with Resident #1's transfer. NA #1 identified while putting on gloves, she was talking to another nurse aide (unable to identify who) and indicated during this conversation she asked you already got a fat--- and indicated she was referring to herself during the conversation. NA #1 identified she would never insult a resident. Interview with the DON on 1/9/2024 at 1:20 PM identified the facility investigation substantiated that NA #1 spoke inappropriately to Resident #1, and should not have made the comment. The facility requested the nursing agency not to send NA #1 to the facility in the future. Review of the facility Abuse, Assault, and Neglect Policy identified verbal abuse as the oral, written, or gestured language that includes derogatory terms to describe residents. Name calling and/or swearing at a resident is verbal abuse.

Based on a tour of the Dietary Department and staff interview, the facility failed to ensure stored food was dated when opened, expired food was discarded, and that food was stored in a clean manner and not stored on the floor. The findings included: Tour of Dietary Department on [DATE] at 10:40 AM with the Director of Dining Services identified the following: 1. In the walk-in refrigerator: a. ,d+[DATE]-ounce containers of Greek plain yogurt expired [DATE]. b. 2 trays full of chicken in boxes on a tray on the floor. c. 10 boxes which contained 24 loaves of wheat bread and 24 loaves flat bread was noted on the floor. 2. In the alcove by the dry storage area: a. box of 36 China brand cups stored on the floor. b. 1 box of 30 thermal coffee mugs stored on the floor. 3. In the dry storage room: a. A 2.6-ounce pack of Jello expired [DATE]. b. A 24-ounce pack of lemon Jello dated [DATE], no expiration date identified. c. A 3.5-ounce vanilla pudding, 12 packs per case, 2 cases expired [DATE]. d. A 5 pound muffin mix, 6 bags (2 chocolate, 8 vanilla), no expiration date. e. ,d+[DATE] pound bags of marshmallows dated [DATE]. (The Director of Dining Services was unsure what that date meant.) f. A 10 quart container of penne pasta ,d+[DATE] full opened, undated. g. A 10 quart container Tri color pasta, ,d+[DATE] full opened, undated. h. A 6 quart container of elbow macaroni labeled ,d+[DATE]. (The Director of Dining Services was unsure what that date meant.) i. Spaghetti box that was opened but undated. j. A 2.5 quart container of [NAME] pasta with no expiration date. k. A 2 pound bag of couscous expired [DATE]. l. A container of cocoa powder ,d+[DATE] full expired [DATE]. m. A 1 pound bag of lentils dated [DATE]. n. ,d+[DATE]-ounce packages of gluten free pancake mix best by date [DATE]. o. A 4 pound container of mint jelly best by [DATE]. p. ,d+[DATE] pound bags of tri colored pasta opened, one ,d+[DATE] filled, the second is ,d+[DATE] full, undated. q. A 10 pound bag of penne pasta opened, ,d+[DATE] full undated. r. A 6-quart container of elbow macaroni dated [DATE]. s. A bag of pasta wrapped in plastic, undated. Additionally, there was a 1.35-gallon white plastic container that had a heavy accumulation of dirt, debris, and crumbs on the lid. Interview with Director of Dining Services on [DATE] at 12:20 PM identified that he instructs his staff to use a piece of tape and a sharpie marker to write the date the product was opened as well as the expiration date on the label according to a chart located on refrigerator. The Director of Dining Services stated that it was the facility policy to date any product that was opened. Although requested, a written policy for food storage and labeling was not provided.

Based on record review, interviews, and review of facility policy for 1 of 3 residents, (Resident #5), reviewed for nutrition, the facility failed to ensure timely identification and evaluation of a significant weight loss to address a 5 percent (%) loss in one month. The findings include: Resident #5's diagnosis included atrial fibrillation (irregular heartbeat), high blood pressure, and adjustment disorder (mood, behavior, or functioning condition). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 was cognitively intact and required extensive assistance with bed mobility, transfers, and personal hygiene. Additionally, Resident #5 was independent with eating after set-up assistance and had no prior weight loss or swallowing disorder identified. The Resident Care Plan dated 8/28/23 indicated that Resident #5 had a potential for changes in nutritional status. Interventions included providing preferences and alternatives as needed, monitoring intakes, weights, and bloodwork, and updating the provider with problems or concerns. A review of documented weights identified that on 8/29/2023 Resident #5 weighed 219.8 pounds, and on 9/19/2023, the resident weighed 208.8 pounds, indicating an 11 pound weight loss (5% weight loss in one month). An APRN progress note dated 9/20/23 indicated that Resident #5 was evaluated for a fever and decreased oxygen. The progress note failed to reflect weight loss or nutritional concerns. An APRN provider progress note dated 10/17/23 indicated that Resident #5 was evaluated for a weight loss of 5% in 30 days. The provider progress note identified that the resident remained above ideal body weight, was recently treated with antibiotics for pneumonia, and that a dietary evaluation would be ordered. A Dietician note dated 10/17/23 indicated that no weight loss intervention was required as the Resident #5's weight was above his/her ideal body weight and had good food intake. An interview with the Dietician on 10/19/23 at 10:50 AM indicated that she was usually notified of a resident's weight loss through the electronic record's communication board and that on 9/19/23 she had not received a notification regarding Resident #5's weight loss. The Dietician indicated she would expect that when a significant weight loss is suspected, staff would reweigh the resident to ensure the weight loss was accurate and then put the information in the communication board for review. An interview with the Unit Manager (LPN #2) on 10/19/23 at 1:00 PM indicated that nurse aids obtain weights, and the charge nurse inputs the value into the electronic health record. LPN #2 further stated that nurses get a notification in the electronic health record when inputting a weight qualifying as a significant weight loss. LPN #2 identified that a nurse could report a significant weight loss by sending a message in the communication board of the electronic health record or handwriting the concern in the APRN book (a book used to notify providers of concerns with residents) so that the provider could evaluate the resident. An interview with LPN #1 on 10/19/23 at 1:35 PM indicated that she was unsure if an alert was shown in the electronic health record when a significant weight loss was inputted. LPN #1 indicated that if weight loss was suspected, she would write it in the APRN book but does not remember if she placed a notification for Resident #5 in the book on 9/19/23. An interview with APRN #1 on 10/23/23 at 9:30 AM indicated that she was never notified of Resident #5's significant weight loss on 9/19/23. APRN #1 identified that she was first notified of Resident #5's weight loss on 10/17/23 through an entry in the the APRN communication book. APRN #1 indicated that if she had been notified of the weight loss on 9/19/23, she would have evaluated the resident and assessed the need for labs, supplements, and necessary consultations. If the weight loss did not require immediate interventions, she would still have referred Resident #5 to dietary and written a note. A review of the facility's Weight loss- Unintended policy indicated that residents were weighed weekly and that staff needed to report an unintended weight loss of 3% or more from the previous week to the house MD or APRN.

Based on observations, facility policy, and interviews for 4 of 5 sampled residents, (Resident #8, #35, #45, and #50), reviewed for oxygen use/respiratory conditions, the facility failed to properly store, label, and date required respiratory equipment. The findings include: 1. Resident #8's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and altered mental status. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 was moderately cognitively impaired and required extensive assistance with transfers, bed mobility, and dressing. The Resident Care Plan dated 6/2/23, identified Resident #8 had COPD. Interventions included monitoring for difficulty breathing, rapid, shallow breathing, and cough. A physician's order dated 9/23/23 directed Formoterol Fumarate Inhalation Nebulization Solution (a breathing treatment) 20 Micrograms/2 Milliliters, 2 times a day. Observation on 10/16/23 at 11:15 AM, identified that Resident #8 had a nebulizer machine on his/her bedside table with the nebulizer mask sitting on top of the machine. Additionally, the tubing was not labeled or dated. Interview with LPN #2 on at 10/17/23 at 9:00 AM identified that nebulizer masks must be cleaned after each use, placed in a plastic bag that is dated/labeled, and placed in the resident's drawer of the bedside table when not in use. Subsequent to surveyor inquiry, LPN #2 placed the nebulizer mask in a plastic bag and dated/labeled the bag. 2. Resident #35 had a diagnosis that included heart failure and prostate cancer. The annual Minimum Data Set assessment dated [DATE] identified that Resident #35 had moderately impaired cognition and required extensive assistance with bed mobility and dressing. A Resident Care Plan dated 9/18/23 indicated Resident #35 had a positive chest x-ray and was ordered antibiotics for pneumonia. Interventions included monitoring respiratory status and administering respiratory medications as ordered. A Review of the Medication Administration Record for September and October indicated that the resident was ordered an Albuterol Sulfate Nebulizer (medication for shortness of breath) and that the last dose had been given on 9/22/23. Observation and Interview with Resident #35 on 10/16/23 at 1:50 PM identified a nebulizer mask and tubing undated and stored on the bedside stand without the benefit of being covered. Additionally, winter gloves had been placed on top of the mask. Interview with the Resident #35 identified that s/he did not remember when the last nebulizer treatment had been administered, but mentioned it was when s/he had pneumonia (in September). Observation and interview with LPN #3 on 10/17/23 at 8:58 AM identified a nebulizer mask and tubing undated was stored on the bedside dresser without the benefit of being covered. LPN #3 indicated that a nebulizer mask and oxygen tubing should be dated, the shift indicated, and the nurse's signature as well as covered. LPN #3 indicated that there is usually an order in the medication administration record that prompts the nurse to change the oxygen tubing and that the nurse must then sign off on that task. LPN #3 was unable to find the order for Resident #35's oxygen tubing change and was unable to identify the last time the nebulizer mask had been changed. 3. Resident #45's diagnosis included leukemia, pneumonia, coronary artery disease, and pulmonary embolism. The admission Minimum Data Set assessment dated [DATE] identified Resident #45 was cognitively intact, required extensive assistance of 2 staff with transfers, and toileting, and extensive assistance of 1 staff for bed mobility, dressing, and personal hygiene. The Resident Care Plan dated 7/16/23 indicated that Resident #45 was new to oxygen use. Interventions directed to change the oxygen tubing weekly as scheduled in the Treatment Administration Record (TAR). A readmission physician order dated 7/16/23 directed to provide oxygen at 2 Liters Per Minute (LPM) via nasal canula. Review of the physician progress note dated 7/16/23 identified Resident #45 was on oxygen via nasal canula at 2 LPM. Review of Resident #45's Treatment Administration Record from 7/1/23 to 10/17/23 failed to reflect a physician order to provide supplemental oxygen and failed to direct that the oxygen tubing be changed weekly. Interview and observation with the Registered Nurse Supervisor, (RN #3) On 10/17/23 at 11:10 AM identified that Resident #45's oxygen tubing had been dated as last changed on 10/5/23 (12 days prior). RN #3 checked the oxygen order and stated that the order was written incorrectly and should have identified that tubing is to be changed every week. Subsequent to surveyor inquiry, RN#3 updated Resident #45's oxygen order to include changing oxygen tubing weekly. 4. Resident #50's diagnosis included heart failure, atrial fibrillation (irregular heartbeat), and diabetes. The annual Minimum Data Set assessment dated [DATE] identified that Resident #50 had moderately impaired cognition and required extensive assistance with bed mobility, dressing, and personal hygiene. The Resident Care Plan dated 8/29/23 identified Resident #50 as being at risk for an ineffective breathing pattern related to shortness of breath. Interventions included monitoring respiratory status, administering respiratory medications, and titrating oxygen. Review of the Medication Administration Record for September and October 2023, indicated the resident had an order for an ipratropium-albuterol nebulizer (a medication to treat shortness of breath). Observation on 10/16/23 at 3:10 PM identified a nebulizer mask on top of the Resident #50's bedside stand without the benefit of being covered. A second observation on 10/17/23 at 8:55 AM identified the nebulizer mask remained on top of the resident's bedside stand without the benefit of being covered. An interview with LPN #3 on 10/17/23 at 8:58 AM indicated that nebulizer masks are stored in the resident's bedside drawer or on the nightstand. An interview with Unit Manager (RN#3) on 10/17/23 at 10:50 AM identified that the facility policy directed oxygen tubing and nebulizer masks be changed every week, dated, and stored in a bag. RN #3 also indicated that a physician's order to replace oxygen tubing weekly was usually written at the same time nebulizer orders were placed. A review of the facility's Oxygen and Nebulizer equipment - Infection control procedures policy indicated that nasal and mask tubing were to be changed every week, labeled with the date, and nurse initials, and stored in a sealed container. 48881 48950

Based on observation, clinical record review, review of facility policy, and staff interview for the only sampled resident (Resident #13), reviewed for dialysis, the facility failed to ensure emergency medical equipment was stored at the bedside. The findings include: Resident #13's diagnosis included dependence on renal dialysis, anemia in chronic kidney disease, and End Stage Renal Disease (ESRD). A physician order dated 6/8/23 directed that emergency medical equipment related to Resident #13's access device for dialysis remain at the bedside. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #13 was moderately cognitively impaired and required extensive assistance of 1 staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 9/20/23 identified Resident #13 was at risk for potential complications related to dialysis and ESRD. Interventions included to monitor Resident #13's dressing condition for the external access device and report to the MD/APRN signs and symptoms of worsening condition and/or complications, and monitor for signs and symptoms of infection/shock/fluid excess. Interview and observation with LPN #2 and Resident #13 on 10/19/23 at 2:00 PM, failed to identify that dialysis access emergency medical equipment was located anywhere in Resident #13's room. LPN #2 indicated that the emergency medical equipment for Resident # 13 should have been hanging on the bulletin board at Resident #13's bedside. Resident #13 indicated that s/he was unaware of any emergency equipment for his/her dialysis access device. Subsequent to surveyor inquiry, the emergency medical equipment was placed on the bulletin board in Resident #13's room. Review of the facility policy for Care of Residents with End-Stage Renal Disease directed monitoring of the dialysis access site for residents on dialysis and that residents with an AV graft/fistula access device have an emergency fistula/graft dressing kit at the bedside.

Based on observation, staff interviews, and facility policy, the facility failed to ensure 1 of 2 medication storage rooms was free from expired medications. The findings include: 1. Resident #24's diagnosis included pulmonary fibrosis, hypoxemia, and hypertension. Active physician orders as of 9/1/23 directed 3 milliliters (ml) of albuterol sulfate nebulization solution 0.63 milligrams (mg)/3 ml, (prescribed for breathing problems) to be inhaled orally via nebulizer every 4 hours as needed for wheezing and shortness of breath. 2. Resident #49's diagnosis included atrial fibrillation, hypertension, and sick sinus syndrome. Observation of the 100 Unit medication storage room with LPN #2 on 10/23/23 at 1:12 PM identified house stock of two unopened bottles of aspirin, 325 mg, 100 tablets, with an expiration date of 09/2023, two boxes of albuterol sulfate 0.63 mg/3ml, 25 units per box, prescribed to Resident #24, both with expiration dates of 6/2023 and, in the medication refrigerator, although Resident #49's order had been discontinued, a bag of promethazine suppositories prescribed to Resident #49 with an expiration date of 9/2023 was noted. Interview with LPN #2 on 10/23/23 at 1:20 PM failed to identify that she was aware that the medications had expired. Further, LPN #2 indicated that the facility policy was to discard expired medications immediately. Subsequent to surveyor inquiry, LPN # 2 disposed of the expired medications identified in the medication storage room on Unit 100. Interview with the Director of Nursing on 10/23/23 at 2:50 PM identified that it is the responsibility of the Unit Manager to review the medication storage room on the unit and discard expired medications. The DNS further indicated that this process should be completed monthly and was unable to indicate why the expired medications remained in the medication room. Review of the facility Medication Storage policy identified expired medications should not be used and that expired medications should be discarded.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #32) reviewed for food, the facility failed to honor food preferences. The findings include: Resident #32's diagnoses included diabetes mellitus, malnutrition, and chronic kidney disease. The admission Resident Care Plan dated 9/8/23 identified potential for changes in nutritional status/risk for malnutrition. Interventions included providing preferences and offer alternatives as needed, resident requested liberalization of diet, consumption of 75-100% of meals, and encourage snacks. The admission Minimum Data Set assessment dated [DATE] identified Resident #32 as cognitively intact, required setup help for eating, and 2 staff physical assistance for bed mobility, transfers, and personal hygiene. An APRN note dated 9/12/23 identified that Resident #32 was at risk for malnutrition secondary to diagnosis, and had a history of decreased oral intake and wounds. Observation and interview with Resident #32 on 10/17/23 at 10:32 AM, identified Resident #32 had a breakfast tray on his/her over bed table with less than 25% consumed. Resident #32 indicated that s/he had not been receiving the meal choices that had been requested on his/her weekly menu choice form, and although s/he completed the form and left it on the meal tray that was taken away by staff, his/her preference were frequently not honored. Interview with the Dietary Manager on 10/19/23 at 1:20 PM, identified that the practice for facility menu choices was to hand out menus on Mondays for submission back to the Dietary Department by Wednesday, but currently, there was no process in place to collect the weekly menus. The Dietary Manager indicated that some residents had been leaving their menu choices on their returned meal trays and although he thought that the Nurse Aids had collected menus, they only received about 40 menus back for the current week (Census of 78). Further, the Dietary Manager indicated that there were no dietary or nursing staff assigned to go room to room to fill out any missing menus and there was no centralized location for residents or staff to return menu preferences. The Dietary Manager was unable to locate a meal preference menu for Resident #32 stating that the Dietary Department must not have received Resident #32's menu preferences for the week. Review of the facility Resident Centered Care Policy identified that they focus on the resident experience, and to the best of their ability, will strive to maintain a resident's individuality including choosing an option for meals. Review of the facility Nutrition-Dining Services policy identified that menus and individualized dietary plans will continuously be monitored for quality and to ensure maximum nutrient intake.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents, Resident #17, reviewed for accidents, the facility failed to update the Resident Care Plan following falls. The findings include: Resident #17's diagnosis included dementia with psychotic disturbance, anxiety, and left femur fracture. The significant change Minimum Data Set assessment dated [DATE] identified Resident #17 was severely cognitively impaired and required the assistance of 1 staff with transfers and dressing. Review of facility Reportable Event and Quality Improvement Investigation form dated 4/19/23 identified that the post fall intervention directed to bring Resident #17 to the nursing desk for the remainder of the shift. Review of the facility Reportable Event and Quality Improvement Investigation form dated 4/21/23 fall intervention directed to place Resident #17 in a room with a roommate and have a NA sit outside the room on the 11-7 shift for a quicker response time. Review of Resident #17's Resident Care Plan dated 7/26/23 failed to indicate the new care plan interventions following the falls that occurred on 4/19/23 and 4/21/23. Interview and review of Resident #17's care plan with the DNS on 10/23/23 at 11:09 AM failed to identify that the new interventions listed on the investigation form had been added to the care plan. The DNS indicated that facility staff would be unable to identify and implement the new interventions as the Resident Care Plan did not include the updated information. Subsequent to surveyor inquiry, the DNS updated Resident #17's care plan. Review of the facility Care Plan policy identified the facility will provide each resident with an individualized and interdisciplinary plan of care, to provide effective communication among nursing staff and other disciplines regarding resident care.

Combined F880 Based on observation, review of the clinical record, facility policy, and interviews for 2 of 9 sampled residents (Resident #6 and Resident #15) reviewed for infection control practices on the 100 Unit, the facility failed to utilize appropriate Protective Personal Equipment (PPE) while providing care to COVID-19 positive residents, for 1 of 3 sampled residents (Resident #10) on the 200 Unit, failed to ensure handwashing following PPE removal, and for the Infection Control program review, failed to ensure quarterly environmental surveillance rounds had been conducted. The findings include: 1. A. Resident #6's diagnoses included Dementia, Atrial Fibrillation (irregular heartbeat), and personal history of tuberculosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 was cognitively intact and required limited assistance of 1 staff with dressing, toileting, and personal hygiene. The Resident Care Plan dated 9/23/23 identified potential signs and symptoms and/or complications related to COVID-19. Interventions included using droplet precautions, encouraging frequent hand washing with soap and water, and ensuring proper PPE use each time staff entered the resident's room. A nurse's note dated 10/13/23 at 12:46 PM identified a COVID swab was performed due to complaints of body aches. A physician's order dated 10/13/23 directed that Resident #6 was to be maintained on contact/ droplet precautions due to a diagnosis of COVID-19 and any person entering the room should wear PPE including a mask, gown, and gloves and to remove the items prior to leaving the room. All services would remain in the room, every shift, for 10 days. B. Resident #15's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes, and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required limited assistance of 1 staff with transfers, dressing, toileting, and personal hygiene. The Resident Care Plan dated 9/26/23 identified potential signs and symptoms/ complications related to COVID-19. Interventions included using droplet precautions, encouraging frequent hand washing with soap and water, and ensuring proper PPE use each time staff entered the resident's room. A nurse's note dated 10/13/23 at 4:46 PM identified resident was swabbed for COVID due to exposure. A physician's order dated 10/13/23 directed that Resident #15 be maintained on contact/droplet precautions due to a diagnosis of COVID-19, any person entering the room should wear PPE including mask, gown, and gloves, and remove the items prior to leaving the room. Observation on 10/19/23 at 7:15 AM identified signage on Resident #6 and #15's shared room door indicating the requirement for use of PPE, as well as a PPE storage bin below the signs. RN #1 was observed walking around in and coming out of Resident #6 and #15's COVID-19 positive room without the benefit of wearing appropriate PPE (gown, gloves, and N95 mask). RN #1 was noted to be wearing a blue surgical mask that was observed to be worn improperly, below her nose, and failed to sanitize or wash her hands after existing the isolation room. Observation and interview with RN#1 identified that COVID-19 was a respiratory virus, therefore, full PPE (gown, gloves, and N95 mask) was optional. The Unit Manager, LPN #2, intervened indicating that RN#1 was incorrect, and full PPE was required when caring for both Resident #6 and Resident #15. RN #1 further stated that she was an agency nurse and was unaware of the facility policy, but when redirected to read the isolation signs outside of Resident #6 and #15's door, RN #1 then stated, my bad, indicating that she had not used appropriate PPE. Interview with the Director of Nursing Services (DNS) on 10/23/23 at 9:50 AM indicated that the facility provided agency nurses with a generalized education about the facility, including infection prevention measures. Review of the Guildford House Orientation for Agency Staff indicated Infection control training was provided to agency staff and included that staff would be required to utilize full PPE, (mask, shield, gown, and gloves) for designated isolation rooms. Additionally, gown and gloves will be changed between any interaction from 1 resident to another with proper hand hygiene before and after. 2. Resident #10's diagnosis included chronic kidney disease, atrioventricular block, and enterocolitis due to clostridium difficile. The admission Minimum Data Set assessment dated [DATE] identified Resident #10 as cognitively intact and required extensive assistance of 1 staff for bed mobility, dressing, and toileting. The Resident Care Plan dated 10/17/23 indicated Resident #10 was isolated due to having a positive COVID-19 diagnosis. Interventions included education for Resident #10, staff, and visitors on COVID-19 signs and symptoms, and necessary precautions. A physician order dated 10/17/23 directed Resident #10 to remain in his/her room in isolation for 10 days due to a positive COVID-19 diagnosis. Review of the nursing progress note dated 10/19/23 at 1:02 AM indicated Resident #10 remained COVID-19 positive and on isolation. Observations on 10/19/23 at 6:20 AM indicated a sign posted outside Resident #10's room that read, Did you wash your hands? Sanitize when coming out and that entrance to the room required PPE. A bin of PPE was also located outside of Resident #10's door. NA #2 was observed coming out of Resident #10's room and proceeded to remove and dispose of her PPE. NA #2 failed to wash or sanitize her hands following the PPE removal. Continued observation of NA #2 identified her to proceed down the hall to the soiled linen room, obtain a plastic bag, go to the nursing station, pick up a clean pair of disposable gloves and place the gloves on her hands. NA #2 was not observed to have washed or sanitized her hands at any time prior to clean glove placement. Interview with NA #2 at 6:23 AM on 10/19/23 identified that she had not washed or sanitized her hands upon exiting Resident #10's room or prior to placing clean disposable gloves. NA #2 indicated that she had just cared for Resident #10, and it was her intention to go back to pick up Resident #10's dirty linen from his/her room. NA #2 stated that she was going back to pick up Resident #10's dirty linen as the reason she had not washed or sanitized her hands after removing her PPE. NA# 2 indicated that the facility policy was to wash or sanitize hands her hands after taking off PPE, before touching clean items, and prior to placing on clean disposable gloves. 3. Interview and review of facility documentation with the Director of Nursing Services (DNS) on 10/23/23 at 11:38 AM of the infection prevention program identified that the last time environmental rounds were completed was in June of 2023. The DNS indicated that environmental rounds should be conducted on a quarterly basis by the Infection Control Nurse, but the role had been vacant since 6/23. The DNS identified that she was currently acting as the Infection Preventionist and, therefore, responsible for the environmental rounds but had not kept up with the completion. The DNS stated that the environmental rounds should have been completed in September of 2023, but she had overlooked the date due. Review of the facility Environmental Rounds policy directed, in part, that the Infection Preventionist, or designee would perform quarterly environmental rounds to ensure that supplies are adequate, and to monitor that appropriate cleaning and disinfecting procedures are being used. 49021 49100

Based on a tour of facility grounds, staff interview, and facility policy the facility failed to ensure that cigarette butts were properly disposed of and failed to ensure the smoking policy was enforced. The findings include: During a tour of the facility grounds on 10/16/2023 at 11:30 AM with the Dining Services Director, a large number of cigarette butts were identified in the mulch near the employee entrance. A goose neck ashtray was noted approximately 50 feet away, across from the mulch area, and contained cigarette butts. The Administrator was notified on 10/16/23 at 2:33 PM of the presence of cigarette butts in the mulch. Observation on 10/17/23 at 10:45 identified cigarette butts remained present in the mulch. Interview and review of the facility smoking policy with Administrator on 10/23/23 at 2:30 PM identified that he was unsure why the smoking policy was not being enforced and that the smoking policy should be in the employee handbook. Additionally, the Administrator indicated that the Maintenance Department was responsible for cleaning up the cigarette butts off the grounds. Review of the facility Smoking/Non-Smoking Policy indicated, in part, that smoking is strictly prohibited in all areas within the facility and on the facility property. Further, the policy directed that residents, families, and staff shall receive and be informed on the smoking policy.

Based of review of the clinical record, facility policy, and interviews for one sampled resident (Resident #45) reviewed for hospitalization , the facility failed to provide the required notification of transfer/discharge to the state Ombudsman's office, and failed to provide the Notice of Transfer to the resident/responsible party. The finding include: Resident #45's diagnosis included leukemia, pneumonia, and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was cognitively intact, required extensive assistance of 2 staff with transfers, and toileting, and extensive assistance of 1 staff for bed mobility and dressing. Review of the nurses noted dated 7/11/23 at 10:37 PM identified Resident #45 was having pain, shortness of breath, and had an increased blood pressure. The physician directed to send Resident #45 to the hospital, and the resident representative was notified. Review of the nurses note dated 7/11/23 at 11:21 PM indicated that Resident #45 had been admitted to the hospital. Interview and review of the clinical record with Social Worker #1 on 10/18/23 at 2:05 PM identified that she had not notified the Ombudsman's office of any resident transfers or discharges. Social Worker #1 was unaware of the requirement for notification to the state Ombudsman's office for resident transfers/discharges, or that there was a portal for notification. Re-interview with Social Worker #1 on 10/18/23 at 2:30 PM failed to identify that a Notice of Emergency Transfer could be located in Resident #45's clinical record. Interview and review of the clinical record on 10/18/23 at 2:40 PM with RN #2 identified that a Notice of Emergency Transfer form should be sent with any resident when they are transferred to the hospital, a copy was to be left in the clinical record, and a written notification sent to the resident representative as the responsible party. RN #2 indicated that she was unable to locate the Notice of Emergency Transfer in Resident #45's clinical record, therefore the notice must not have been provided. Review of the facility Notice of Emergency Transfer to the hospital policy identified that the family was to sign the form as written notification of transfer and that the Ombudsman's office was to be sent a copy of this form once filled out.

Based on review of the clinical record, facility policy, and interviews for one sampled resident (Resident#45) reviewed for hospitalization , the facility failed to provide the required notification of a bed hold to the resident and the resident representative. The finding include: Resident #45's diagnosis included leukemia, pneumonia, coronary artery disease, and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was cognitively intact, required extensive assistance of 2 staff with transfers, and toileting, and extensive assistance of 1 staff for bed mobility and dressing. Review of the nurses note dated 7/11/23 at 10:37 PM identified Resident #45 was having pain, shortness of breath, and had an increased blood pressure. The physician directed Resident #45 be sent to the hospital and the resident representative was notified. Interview and review of facility documentation on 10/19/23 at 10:00 AM with Admissions Person #1 identified that the facility policy was to provide the bed hold policy to every resident upon admission to the facility. Admission Person #1 indicated she was unaware that every time a resident was discharged to an acute care hospital the resident and resident representative was to be given the Bed Hold form. Review of the Bed hold policy identified that the bed hold form was to be sent with the resident when they were discharged to the hospital and to send an additional copy of the bed hold paperwork to the resident's representative.

Based on interviews and employee record review, the facility failed to complete annual performance evaluations for 3 of 3 sampled nurse aides (NA #4, 5, and 6). The findings include: 1. NA #4's date of hire was 4/6/11. Two performance evaluations were identified in the employee's personnel file dated 12/7/11 and 5/3/17. Although requested, the facility could not provide additional annual evaluations for NA #4. 2. NA #5's date of hire was 1/30/20. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #5. 3. NA #6's date of hire was 9/9/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #6. An interview with the Director of Nursing on 10/23/23 at 1:23 PM indicated that performance evaluations would be located in each employee's personnel file and that it would most likely be her or the Unit Managers who would complete performance evaluations. The DNS indicated she did not remember when the last time a performance evaluation was completed. An interview with the Administrator on 10/23/23 at 1:35 PM indicated that the facility does not complete yearly performance evaluations. The Administrator indicated that the facility uses real-time education and the disciplinary process to address employee concerns. The Administrator identified that there is no written facility policy for performance evaluations. Although the Administrator identified no facility policy for yearly performance evaluations, he indicated that the personnel handbook stated that employees would receive a performance evaluation once a year near the employee's anniversary date. It was requested that the Administrator review the regulatory requirement for yearly NA performance evaluations.

Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #2) who was reviewed for an allegation of abuse, the facility failed to ensure a resident was free from misappropriation of prescribed controlled medication. The findings include: Resident #2's diagnoses included attention deficit hyperactivity disorder (ADHD). The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had some difficulty with decision making skills regarding tasks of daily life. The Resident Care Plan dated 9/20/21 identified Resident #1 had a diagnosis of ADHD and had problems staying awake during the day. Interventions directed to administer medications according to physician's orders. A physician's order dated 11/12/21 directed to administer a medication to treat ADHD, Adderall 5 milligrams (mg) twice daily. The Controlled Drug Disposition Form with a delivery date of 11/12/21 identified two (2) blister packs with thirty (30) tabs each of Amphetamine/Dextroamphetamine 5mg tabs (generic for Adderall) were signed for on 11/12/21 by the nursing staff. The Facility Reportable Event form dated 1/6/22 identified the assigned charge nurse, Licensed Practical Nurse (LPN) #4, reported finding tape on the backs of several bubbles holding them closed of Resident #2's Adderall. LPN #4 stated she had noticed a #10 stamped on one (1) of the medications within the taped blister pack and reported her observations to the unit manager. LPN #4 and the unit manager looked up the tablet on pill identifier and discovered that the pill inside the card was a Lexapro 10 mg tablet. Upon further evaluation of the two (2) medication cards, out of the thirty-four (34) remaining available pills not including the one (1) already popped, twenty-four (24) bubbles were taped down with medications inside that were not Adderall, it appeared that the taping of the blister pack began on 1/2/22, therefore Resident #2 received approximately eight (8) doses of medications that were not Adderall. Resident #2 had been exhibiting increased lethargy since the weekend. The report indicated The Drug Enforcement Agency (DEA) was notified, assisting with further investigation of this event, took possession of the tampered cards and would be coming back to the facility for staff interviews. A photograph of the tampered blister pack(s) identified thirty (30) of the sixty (60) individual blisters were covered with tape, one (1) medication blister card contained four (4) white, round tablets, and one (1) medication blister card contained thirty (30) white, round tablets. An interview with the Director of Nursing (DON) on 6/20/23 at 1:48 PM identified she was made aware of Resident #2's medication misappropriation by LPN #4 on 1/6/22 where it was noted beginning 1/2/22, the blister pack(s) containing the Adderall had been tampered with by replacing the prescribed medication with alternate medications later identified as Lexapro (a medication used to treat depression). The DON indicated neither she nor the DEA were able to confirm which nurse was responsible for the misappropriation but that she did substantiate Resident #2 was a victim of misappropriation. A review of the facility policy for abuse directed that each resident would be free from abuse. A review of the facility policy for misappropriation directed that the facility was committed to protect a resident from misappropriation of property.

Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident # 1) who had possession of personal medications, the facility failed to implement policies to ensure a controlled substance was properly secured and a reconciliation of the controlled substance occurred by the licensed staff when the resident surrendered the mediation to their spouse to take home. The findings include: Resident #1's diagnoses included pyogenic arthritis (infection of a joint), acute kidney failure, and infection of the left knee. The hospital discharge summary dated 6/6/23 identified Resident #1 was prescribed the controlled substance Methadone 10 milligrams (mg) three 3) times daily for severe nerve pain with recommendations to continue the dosage upon discharge to the facility. The admission clinical record identified Resident #1 was self-responsible. The Nursing Admission note dated 6/6/23 identified Resident #1 was oriented times four (4) to person, place, time, and situation, had pian and received narcotic and antipsychotic medications. The Resident Care Plan dated 6/6/23 identified Resident #1 had a history of poly substance abuse. Interventions directed to follow physician orders and monitor for effectiveness and side effects. A physician's order dated 6/6/23 directed to administer Methadone 10 milligrams (mg) three (3) times daily for severe nerve pain. The nurse's note dated 6/6/23 at 6:58 PM identified the Medical Director was contacted due to Resident #1 wanting to keep a bottle of Methadone in his/her room and the Medical Director said it was ok to give Resident #1 his/her home bottle as the facility would be supplying the medication. The nurse's note dated 6/7/23 at 10:30 PM written by Registered Nurse (RN) #1 identified Resident #1 was found unresponsive in his/her room at 10:30 PM, Resident #1 was diaphoretic pale with a low blood pressure 70/40 (normal 120/80), oxygen was applied and three (3) doses of Narcan (emergency treatment of opioid overdose) was administered with Resident #1 becoming more responsive after the third dose and when the emergency medical responders arrived. The note indicated the Advanced Practice Registered Nurse (APRN) and a family member were notified and the family member verified there were fifty (50) tablets of Methadone in the bottle that was taken home earlier in the day. The hospital emergency room note dated 6/7/23 identified Resident #1 was reported to have an altered mental status with an unverified use of methadone and unclear medication compliance with the use of antibiotics in the setting of recent sepsis with a plan for hydration and sepsis workup. An interview with the Director of Nursing (DON) on 6/20/23 at 10:58 AM identified Resident #1 was admitted to the facility for intravenous (IV) antibiotic therapy and physical therapy, Resident #1 was prescribed Methadone for nerve pain according to the hospital paperwork. The DON indicated prior to 6/7/23, Resident #1 had demanded to safeguard his /her home stock of Methadone, the Medical Director was contacted and gave approval indicating Resident #1 would have been self-responsible for his/her medications at home, therefore able to keep the medications in a private room and the understanding was Resident #1 was to return the medication once the pharmacy delivered the medication to the facility. The DON identified the investigation showed Resident #1 had sixty-eight (68) pills that were counted with nursing staff on admission with one (1) dispensed by nursing on 6/6/23 and on 6/7/23 the remainder of the Methadone was returned to a family member on 6/7/23 however the Methadone was not counted at the time the medication was returned to the family member. The DON identified the investigation indicated the nurses were not counting the Methadone shift to shift and they should have been according to policy. The DON indicated after Resident #1 was transferred to the emergency room , the balance of the Methadone tablets was reported as fifty (50) according to a family member, reflecting a decrease of seventeen (17) pills. The DON identified the event was reported to the hospital and according to hospital paperwork, Resident #1 was being treated for possible sepsis and required surgical intervention for infection. The DON indicated the controlled medication should have been locked in Resident #1's room, counted by nursing staff every shift, and counted at the time the medication was returned to a family member. An interview with Licensed Practical Nurse, LPN #1 on 6/20/23 at 12:10 PM identified there were instances when an alert and oriented resident was permitted to safeguard medications in his/ her room, in these instances the medications should be locked in a drawer and counted by nursing staff shift to shift and if a medication was no longer needed the medication would be counted with nursing staff when removed from the resident. LPN #1 indicated on 6/7/23 she did not count the remainder of medications when returning the medication to a family member and she should have. An interview with the Medical Director on 6/20/23 at 12:46 PM identified he was notified Resident #1 wanted to safeguard his/her own medications. The Medical Director indicated he evaluated the situation and determined it was fine as Resident #1 would have been self-responsible for his/her own medication in the community so it would be permissible. The Medical Director identified he would expect staff to ensure controlled substances were safeguarded and managed in a safe and secure manner according to protocols. A review of the facility policy for Reconciliation of Narcotics directed that a narcotic be counted at the beginning and the end of each shift/or nurse change for each medication or locked box. Narcotics will be counted with the resident/responsible party upon bringing into the facility or removing from the facility.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for cardiopulmonary resuscitation (CPR), the facility failed to follow professional standards of practice to ensure CPR was provided on a hard, firm surface, and the facility failed to ensure staff performing CPR had current CPR certifications, and the facility policy failed to direct staff CPR certifications. The findings include: Resident #1's diagnoses included myotonic muscular dystrophy, hypertension, and muscle weakness. Physician order dated [DATE] directed to provide a 2 Gram sodium regular texture diet and to provide CPR/full code. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, was independent with transfers, eating, and had no difficulty swallowing. The Resident Care Plan (RCP) dated [DATE] identified an Advanced Directive of Full Code. Interventions directed to honor residents wishes and perform CPR, full code. Review of the clinical record identified Resident #1 weighed 214 pounds and had no history of dysphagia. The nurse's note written by LPN #2 dated [DATE] at 7:24 PM identified at 5:10 PM, NA #1 called LPN #2 into Resident #1's room as the resident did not look right. LPN #2 entered the room and found Resident #1 partially reclined in his/her chair with his/her left hand holding a partially eaten cheeseburger to his/her chest, unresponsive to name and shaking, no respirations and no pulse. Additionally, the note identified Resident #1's code status was verified, Code Blue was called, and Cardiopulmonary Resuscitation (CPR) was initiated by LPN #1 and #2. The nurse's note written by RN #1 (Supervisor) dated [DATE] at 7:39 PM identified RN #1 responded to the Code Blue and arrived at Resident #1's room at 5:15 PM with CPR in progress. The note further indicated Emergency Medical Service (EMS) transferred Resident #1 to the hospital. Review of facility incident report dated [DATE] at 5:15 PM identified Resident #1 was independent with meals/eating, transferred with extensive assist of one and had a physician's order for a regular texture diet. The report indicated a family member visited (signed in at 4:57 PM) and brought Resident #1 a McDonald's dinner. Resident #1 was found unresponsive in his/her recliner by a NA passing out dinner trays, the charge nurse entered the room and saw Resident #1 sitting back in his/her recliner which was partially reclined and his/her eyes were closed with his/her hand resting on his/her left side of the chest holding a half of cheeseburger. No signs of a struggle were observed, the call bell was not ringing, and a full cup of soda (undisturbed) was on the overbed table in front of Resident #1. Resident #1's face was pale, and lips were dusky colored. The code status verified by the charge nurse and a Code Blue called just before 5:15 PM. The report further indicated staff initiated CPR with an Automated External Defibrillator (AED) in place (no shock advised), and CPR included chest compressions and rescue breaths via ambu bag. Resident #1's positioning in the recliner made rescue breaths challenging and although cyanosis in Resident #1's lips improved it was difficult to visualize if chest movements occurred with the breaths. Staff CPR continued until arrival of Emergency Medical Technicians (EMT). EMTs took over CPR in the recliner where Resident #1 was found. The facility report further indicated EMTs had difficulty with intubation due to a large tongue which made it difficult to see, and food particles getting onto the camera of their Endotracheal (ET) blade which they suctioned to remove. EMTs continued CPR in Resident #1's recliner where Resident #1 was found, and then after about five (5) minutes Resident #1 was transferred onto the floor and a LUCAS chest compression machine was applied. EMTs gave two (2) shocks and multiple injections, and Resident #1 was transferred to the hospital while still receiving CPR. The Report further identified the facility had been updated that Resident #1 expired at the hospital. Review of Emergency Medical Services (EMS) run sheet dated [DATE] identified a call was received at 5:22 PM, and EMS was at the resident at 5:29 PM. The run sheet identified cardiac arrest and staff continued chest compressions while EMS moved items around in the room so Resident #1 could be transferred onto the floor. After the room was reorganized, EMS was able to put on Lifepack15; Lifepack confirmed asystole (no heartbeat) and Resident #1 was able to be transferred onto the floor with a [NAME] device applied and started chest compressions. A second medic attempted to intubate but the airway was full of chewed food; additional attempts to clear airway were unsuccessful and a Basic Life Support (BLS) airway was inserted. The report indicated Resident #1 was transported to the hospital and received a total of seven (7) doses of epinephrine and shocked three (3) times enroute to the hospital. Interview with LPN #1 on [DATE] at 11:15 AM identified Resident #1 was found to be purple in color and slumped in his/her recliner. LPN #1 identified after checking Resident #1's code status, CPR was initiated for Resident #1 in the recliner, a Code Blue was called, and EMS was called. Additionally, LPN #1 identified CPR was performed in Resident #1's recliner chair with the chair reclined as far back as it was able to be reclined. With Resident #1 positioned in the recliner, LPN #1 further identified attempts at providing rescue breaths while Resident #1 was in the recliner were not successful. Interview with the DNS on [DATE] at 12:38 PM identified when she heard the Code Blue called overhead, she instructed a staff member to bring the crash cart and she went to Resident #1's room to find LPN #1 and LPN #2 performing CPR with the RN supervisor present in the room. The DNS identified CPR was being performed while Resident #1 was in his/her recliner because Resident #1 was a larger person, and although four (4) staff responded to the code (LPN #1, LPN #2, RN #1 and the DNS), staff did not attempt to move Resident #1 out of the recliner. The DNS identified Resident #1 did have a draw sheet underneath him/her but it was inaccessible to staff, and facility staff did not attempt to get Resident #1 out of the recliner as it was not safe for them to attempt a transfer without EMS personnel, due to the way the recliner was set up tight against the wall, it was a big soft chair and Resident #1 was a bigger person. Additionally, the DNS indicated she did not want to attempt to transfer Resident #1 out of the recliner and possibly injure Resident #1. The DNS identified that she assisted in the CPR by going to the area behind the recliner in an attempt to provide rescue breaths. The DNS identified that the Automatic External Defibrillator (AED) pads were applied to Resident #1 and the device did not alert staff to provide a shock to Resident #1. The DNS further identified EMS personnel arrived quickly and took over CPR and attempted to intubate Resident #1 without success stating the resident's tongue was swollen. Additionally, the DNS identified EMS personnel reorganized the room to move the bed and bedside table to create space and then were able to get Resident #1 out of the recliner and on to the floor to provide CPR. Interview with LPN #2 on [DATE] at 2:44 PM identified on [DATE] at around dinner time NA #1 stated Resident #1 did not look good, at which point she went in to find Resident #1 unresponsive to his/her name or shaking, no pulse and no respirations. LPN #2 identified at that time she verified Resident #1's code status as Full Code, she called a Code Blue and immediately started CPR while Resident #1 remained in his/her recliner chair. Additionally, LPN #2 identified staff were unable to transfer Resident #1 out of the recliner chair; LPN #2 indicated Resident #1 was over 200 pounds (weight was 214), and staff could not transfer Resident #1 out of the chair. LPN #2 further identified the crash cart was brought in by another staff member, rescue breaths were attempted, and when EMS arrived, staff were directed to continue with CPR as EMS set up their equipment and then took over. LPN #2 identified EMS initiated their CPR while Resident #1 remained in the recliner chair, then transferred Resident #1 to the floor. LPN #2 further identified that she could not recall being directed by any facility staff to clear the room to make space to transfer Resident #1 onto the floor before EMS arrived and they cleared the room. Interview with RN #1 (Supervisor) on [DATE] at 3:09 PM identified she was the supervisor on duty during second shift on [DATE] when the Code Blue was called for Resident #1. RN #1 indicated she went to Resident #1's room to ensure staff were performing CPR and then went to call 911 and Resident #1's family member. RN #1 identified there was not one specific staff member directing the code, but staff were self-directed and performing CPR. Additionally, RN #1 identified there was no way to get Resident #1 on to the floor to perform CPR (there was not space on the floor) and staff attempted to put the backboard under Resident #1 but was unable to place the backboard while Resident #1 was in the recliner. Interview with LPN #2 on [DATE] at 10:44 AM identified she performed a mouth sweep with no results, prior to initiating CPR on Resident #1. Interview with Person #1 (CPR Trainer for the facility) on [DATE] at 12:07 PM identified he was certified as a CPR trainer through the American Heart Association (AHA). Additionally, Person #1 identified that CPR should not be performed in a recliner and that when CPR is performed, it should be done using a backboard or on a hard surface, i.e. in this case the floor, if the resident is in a recliner. Person #1 further identified it is his expectation when CPR is performed, if a resident is in a recliner, the resident should be brought to the floor, or a backboard should be placed behind the resident. Interview with MD #1 on [DATE] at 9:09 AM identified the standard for performing CPR is to have the resident on a hard surface or use a backboard. A review of the facility undated Cardiopulmonary Resuscitation Policy, directed in part, equipment needed for CPR: a hard, flat surface or backboard. A review of CPR steps guidance taken from the American Red Cross website directed in part, Step 4: place the person on their back on a firm, flat surface. A review of 2010 American Heart Association Guidelines for CPR directed in part, it is recommended to perform CPR on a firm, hard surface. a. Interview and record review with the DNS on [DATE] at 10:00 AM identified LPN #2 had a CPR certification card with an issue date of [DATE] and an expiration date of ,d+[DATE] (8 months prior to the incident). The DNS indicated although LPN #2 renewed her CPR certification in March of 2022, she was unable to provide documentation that LPN #2 had a current CPR certification. Additionally, the DNS was unable to provide a CPR certification card for RN #1. The DNS provided an expired CPR certification card for his/herself and indicated that his/her CPR certification had expired in February 2022 (8 months prior to the incident) and he/she was overdue for a renewal. The DNS indicated although staff were required to maintain CPR certification, she was unable to explain why LPN #2, RN #1 and she did not have current CPR certification. Review of the facility undated Cardiopulmonary Resuscitation Policy, identified in part, the Policy failed to direct staff requirements pertaining to maintaining staff CPR certification. Review of the American Red Cross Basic Life Support (BLS) guidance identified BLS cards are valid for two years from the date of certification. Additionally, the guidance identified if the American Red Cross BLS certification is about to expire (or has expired and you're within 30 days of its expiration), you can enroll in an abbreviated recertification BLS course (a review course) and get recertified for two more years. If your certification expired more than 30 days prior to your review course, you'll have to complete the full BLS certification course in order to regain your certification.

Based on review of the clinical record and interview, the facility failed to maintain the IV log. The findings include: Interview with Pharmacy Consultant #1 on 9/27/21 indicated 79 orders of IV antibiotics were dispensed to the facility between 3/2021 to current. A review of the IV therapy log indicated between 3/2021 to current, identified 3 entries on 8/31/21, 9/4/21 and 9/17/21. The log failed to reflect the symptoms, medication prescribed, and the outcome of the antibiotic therapy. Interview with the DNS on 9/23/21 identified there were no additional IV logs.

Based on review of the clinical record and interview for one of six sampled resident's reviewed for pressure ulcers (Resident #69), the facility failed to prevent the development of a pressure ulcer. The findings include: Resident # 69's [DIAGNOSES REDACTED]. The Admission Nurse's assessment dated [DATE] identified the resident was without pressure sores and had blanchable redness on the coccyx. Physician orders [REDACTED]. A Preliminary Care Plan dated 3/21/15 identified the potential for impaired skin integrity due to decreased mobility. Interventions directed a pressure relieving mattress and chair cushion, note skin condition during care, and assist with repositioning every two hours. The nurse's note dated 3/26/15 identified an open area on the resident's coccyx was found by a NA during care. The area was assessed by the nurse and was identified as an unstageable pressure ulcer that measured 1.5 cm by 1.5 cm by 1.0 cm with 90% slough. The physician was notified and a physical therapy request was sent for a wheelchair cushion. The treatment order dated 3/26/15 directed the staff to cleanse the wound with Normal Saline, followed by the application of Santyl and a clean dressing daily. The Admission MDS dated [DATE] identified the resident was without cognitive impairment, required extensive assistance of two for ADL's including bed mobility and transfers, was continent of bowel and bladder, and had one unstageable pressure ulcer. An APRN wound assessment dated [DATE] identified that the unstageable coccyx wound measured 1.6 cm by 1.0 cm with 100% slough. On 4/7/15, the wound measured 2.6 cm by 1.0 cm by 0.1 cm with 50% slough. The treatment record for March 2015 directed to conduct body/skin audits every week. The 3/25/15 skin assessment had not been completed as ordered. [MEDICATION NAME] ointment was signed off by licensed staff indicating that they had applied it to the coccyx every shift. Interview and review of the clinical record on 7/23/15 at 9:45 AM with the DNS identified that the NA's are allowed to apply [MEDICATION NAME] ointment under the supervision of the nurse who signs it off in the treatment record. The DNS noted that any change in the resident's skin should be reported immediately. Interview and review of the clinical record on 7/23/15 at 10:00 AM with RN # 1 identified the pressure ulcer was not visible by just looking and that staff had failed to visualize the skin between the buttocks during care resulting in a wound that wasn't identified until it was unstageable. Additionally, RN #1 noted that the resident's skin should be thoroughly checked during care to identify wounds at an earlier stage. Further review failed to provide documentation that the resident's skin had been assessed on 3/25/15 by licensed staff as directed.