Every finding on record at Hancock Park Rehabiliation and Nursing Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose diagnoses included Congestive Heart Failure (CHF) with Physician's Orders in place for management of that condition, the Facility failed to ensure they maintained a completed and accurate medical record when there was no documentation to support nursing obtained his/her weights daily or monitored signs and symptoms associated with CHF.Findings include:Review of the Facility Policy titled Nursing Service Documentation and Charting, dated as last reviewed September 2025, indicated that the Director of Nurses (DON) is responsible for overseeing the maintenance of the clinical records that are delegated to the Health Information Management.Resident #1 was admitted to the Facility in May 2026, diagnoses include status post Right Total Knee Replacement (TKR) secondary to osteoarthritis, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage three (3), and mitral valve insufficiency.During a telephone interview on 07/15/26 at 10:37 A.M., Family Member # 1 said the Physician informed her that nursing was to weigh Resident # 1 daily and said she knew he/she was not being weighed according to what the Physician had told her and did not know if he/she was ever weighed at all.Review of Resident #1's Physician's Orders, dated 06/02/26 through 06/14/26, indicated his/her orders included the following;-Obtain admission weight, 2 times to establish a baseline weight (reweight for gain or loss of three (3) lbs;-No Added Salt Diet (NAS); and-Encourage 250 milliliters (ml) every 3 hours while awake.Review of Resident #1's Physician Progress Notes, dated 06/02/26, 06/04/26, 06/09/26, and 06/11/26, indicated he/she was admitted related to a subacute level of service, and his/her plan was to include monitoring of his/her clinical needs.The Progress Notes all indicated the following interventions;-Daily weights; notify the Medical Doctor/Nurse Practitioner (MD/NP) if gains are equal to or more than two (2) pounds (lbs) or five (5) lbs in one week;-Continue with 2 gram (gm) Sodium (Na) diet and 2 Liter (L) fluid restriction; and-Monitor signs and symptoms of fluid overload, increased weights, crackles, and increased lower extremity edema.Review of Resident #1's Medical Record, dated from 06/02/26 through 06/14/26, including but not limited to physician's orders, Medication Administration Records (MAR), and nurse progress notes, indicated there was no documentation to support he/she had physician's orders to weigh Resident #1 daily while notifying provider of gains, specific restricted diet with a fluid restriction, or monitoring signs and symptoms of fluid overload.Review of Resident #1's MAR, dated 06/02/2026 through 06/14/26, indicated there was no documentation to support he/she had physician's orders to weigh him/her daily, to notify the provider of weight changes, provide a 2gm Na diet with a 2L fluid restriction, or monitor for fluid overload.During an interview on 07/14/26 at 10:39 A.M., the Physician said she enters her own orders into Point Click Care (PCC, Electronic medical record) and will follow up with an e-mail to the Unit Manager informing her of her orders.The Physician said that she was under the impression the nurses would know that a resident with Congestive Heart Failure (CHF) should be weighed daily and said she never entered the specific orders of weighing Resident #1 daily or to provide a 2gm Na diet with a 2L fluid restriction.During an interview on 07/14/26 at 3:51 P.M., the Unit Manager said that she was unaware the Physician had put interventions in her progress note indicating to weigh Resident #1 daily and to administer a specific diet with a fluid restriction.The Unit Manager said there are different ways to enter Physician's Order's into PCC and said the Physician can enter the orders into the system themselves, they can verbally give a nurse an order to be transcribed, or utilize Tiger Connect (text communication) to provide nurses with an order to enter into PCC.During a telephone interview on 07/22/26 at 3:51 P.M., the Director of Nurses (DON) said that she was not aware that Resident #1's Physician had documented in multiple progress notes to weigh him/her daily or he/she required a 2gm Na diet with a 2L fluid restriction.The DON said the Physician's will enter the resident's orders into PCC themselves, physically write them down to be transcribed by a nurse, or will provide the nurse with a verbal order to be entered into the PCC system.The DON said nursing typically does not read Physician's progress notes and depends on the Physician to provide the nurse accurate orders and complete accurate documentation. The DON said the Facility's expectation is that interventions put in a Physician's progress note are to be entered into PCC by the Physician or the Physician is to inform the Nurse of the orders needed.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #48, who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), a bacterium that is resistant to several antibiotics, to ensure staff implemented precautions after entering and exiting a room identified as being on contact precautions, and2. To implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.Findings include:1. Review of the facility's policy titled Infection Control- Personal Protective Equipment, dated as reviewed September 2025, indicated the following:This facility requires that all employees determined to have occupational exposure use appropriate personal protective equipment whenever risk of exposure is anticipated.-Gloves will be worn whenever it is reasonably anticipated that an employee may have hand contact with blood, other potentially infectious material, mucous membranes, non-intact skin, and when handling contaminated items or surfaces.-Disposable gloves will be replaced as soon as practical when contaminated or as soon as possible when torn, punctured, or when their ability to function as a barrier is compromised.-Masks and disposable face shields will be discarded after each patient contact or whenever soiled with blood or potential infectious material may be generated and the eye, nose or mouth contamination can be reasonably anticipated.-Protective body clothing, i.e., gowns and/or aprons, that will not permit blood or other potentially infectious material to reach an employee's work clothing, undergarments or skin will be worn whenever skin and/or clothing contamination is reasonably anticipated.Resident #48 was admitted to the facility in June 2024 with diagnoses including dementia, muscle weakness, morbid obesity, and repeated falls.Review of Resident #48's medical record indicated a physician's order for MRSA Precautions was started on 11/17/25.On 12/4/25 at 11:31 A.M., the surveyor observed a precaution bin located outside Resident #48's room. The precaution bin was filled with personal protection equipment (PPE) masks, gowns, and gloves. There was a contact precaution sign hanging on the door outside of the room. The door to the room was open and Housekeeping Staff #1 could be seen standing in the room. The staff member was not wearing any PPE. Housekeeping Staff #1 was observed touching items on the overbed table with her ungloved hand. Housekeeping Staff #1 was then observed exiting the room and picked up a box of gloves that were on top of the housekeeping cart located just outside Resident #48's room, with her bare contaminated hand, she then put on the gloves and re-entered room without additional PPE. The staff member was not wearing PPE aside from the gloves. Housekeeping Staff #1 was observed touching items on the overbed table, wiping a bureau with a towel and walking back to the housekeeping cart located outside the room. Using her contaminated gloved hands, she then picked up a spray bottle with pink liquid with her gloved hand and was observed touching the bathroom door handle and proceeded to clean the bathroom.On 12/4/25 at 11:35 A.M., Housekeeping Staff #1 used the same contaminated gloves to touch items on the overbed table and was observed exiting the room and touching items on the housekeeping cart outside the door. Housekeeping Staff #1 then removed her contaminated gloves touching the outside surface of the contaminated gloves with her bare hands and proceeded to walk across the hall into room [ROOM NUMBER], without performing hand hygiene. Housekeeping Staff #1 was observed touching the door handle to the bathroom with her contaminated hand and touched items located in the bathroom. Housekeeping Staff #1 was then observed exiting room [ROOM NUMBER] without preforming hand hygiene and walked across the hall back into Resident #48's room without wearing PPE and was observed touching the bathroom door handle with her bare hand and then exited Resident #48's room and proceeded to touch items on the housekeeping cart including a box of gloves, spray bottles, and a mop.At 11:37 A.M., Housekeeping Staff #1 used her contaminated hands and picked up the mop and walked into Resident #48's room and proceeded to mop the floors and was observed touching items within the room with her bare contaminated hands. Housekeeping Staff #1 was not wearing PPE and did not perform hand hygiene during the observations. During an interview on 12/4/25 at 11:43 A.M., Housekeeping Staff #1 said she was sorry and pointed to the contact precaution sign and said she should have put on PPE because the Resident is on precautions. The staff member pointed to the PPE cart and said she should not have entered the room without wearing the PPE. When the surveyor asked about handwashing the Housekeeping Staff member said yes and proceeded to use the hand sanitizer located on the wall.During an interview on 12/4/25 at 2:28 P.M., the Infection Preventionist (IP) said she would expect staff to follow the appropriate precautions and wear PPE as indicated. The IP said hand hygiene must be done before and after glove use.During an interview on 12/4/25 at 2:41 P.M., the Director of Nurses (DON) said she expects all staff to follow infection control protocols and wear PPE when entering a precaution room. The DON said staff must perform hand hygiene appropriately and remove gloves correctly and wash hands when contaminated.2. Review of the facility's policy titled Surveillance Procedure, dated as reviewed September 2024, indicated the following:-The purpose of surveillance is to identify single cases of healthcare associated and/or cluster infections, occurring within the facility. Trending should be done for significant organisms and healthcare associated infections to guide appropriate interventions to prevent/reduce further transmissions.-Surveillance will be performed by the Infection Control Coordinator, for healthcare associated infections within the facility.-Infection reports/information will be completed/collected on affected resident/patients.-Infection control coordinator will collect and coordinate data from nursing personnel. Repots of any resident suspected of having an infection according to infection criteria and by developing computerized reports of MD orders, antibiotic reviews, lab data, conducting rounds with nursing staff.-The Infection Control Coordinator will collect reports/information, review daily logs, and make rounds on regular basis to ensure complete data collection.-The Infection Control Coordinator will keep a running log of residents with a positive Mantoux, a positive MRSA, a positive C.difficile and other multiple-resistant organisms.-The facility routinely audits (monitors and documents) adherence to HH (hand hygiene) and PPE (personal protective equipment). Hand Hygiene and PPE surveillance goal will consistent of minimum, of once per month on each shift will be required. During outbreak situation, the unit will need a minimum of once per week per shift surveillance.Review of the facility's infection control line listings failed to indicate the monitoring, tracking, and analyzing of current infections in the facility and failed to have an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility.Review of the December 2025 line listing failed to include current infections within the facility including one resident with confirmed MRSA, one resident with confirmed C. difficile infection (an infection from a bacterium that causes colitis, an inflammation of the colon, causing diarrhea), and one case of active eye infection.During an interview on 12/4/25 at 2:20 P.M., the surveyor asked the IP to provide her with the facility's infection control line listings. The IP said she has line listings that she reviews at the end of the month, and she will review reports for new antibiotics, but she does not track clinical signs, symptoms or trending of infections unless antibiotics are prescribed. The IP said she does not evaluate the infections until the end of the month when she counts the antibiotics prescribed. The IP was unable to provide documentation of current ongoing infection control surveillance, including a system for recording infections, monitoring and any actions taken by the facility.During an interview on 12/4/25 at 2:44 P.M., the DON said she expects the facility to follow infection control guidelines for tracking and evaluating infections as well as document surveillance of signs and symptoms of communicable diseases. The DON said the facility should be aware of the infection control rates in the facility and should be identifying clusters and monitoring for increases in infections.

Based on observations and interviews, the facility failed to maintain comfortable and safe temperature levels on the third floor of the East Dining Room.Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents. Findings include:The following observations were made on the third-floor dining room:12/2/25 at 9:18 A.M., two out of four residents reported feeling cold and one resident had his/her jacket on. 12/3/25 8:41 A.M., three out of five residents reported feeling cold and one resident had his/her jacket on.12/3/25 at 8:49 A.M., one resident left the dining room and said, I need to go get my coat, it's freezing and wheeled him/herself out of the dining room and returned with a winter coat on.During an observation and interview on 12/3/25 at 9:07 A.M., the surveyor and the Assistant Maintenance Director observed the third-floor dining room, and the following thermal temperatures were taken by the Assistant Maintenance Director: Room temperature had a low of 60 degrees and a high of 67 degrees. Areas scanned/checked included center of the room, above the floor, interior walls. Thermal temperatures did not go above 67 during the observation. The Assistant Maintenance Director said the two vents located in the dining room are turned off and the switches to turn them on were removed over two years ago so residents would not adjust the air flow. He also said that the thermostat on the fourth floor controls the heat to the third-floor dining room but will not blow heat in if the vents are closed. The surveyor and Assistant Maintenance Director then observed the fourth-floor dining room, and the vents were open, and thermal readings were between 71 degrees and 76 degrees.During an interview on 12/4/25 at 1:02 P.M., the Administrator said we addressed it and opened the vents to allow for the heat and added in a vent system as the temperature should remain above 71 degrees.During an interview on 12/4/25 at 1:17 P.M., the Corporate Nurse #1 said she would expect the heat to be functioning and warm in the dining areas and said we are checking the temperatures now and we have put in heaters in the dining areas.During an interview on 12/4/25 at 2:03 P.M., Maintenance Technician said the ceiling roof opens and closes to allow outside air in because the outside roof had a gap it was letting in cold air blowing above window into room. He said the two vents in the dining room should be open and not in the off position to allow for warm heat to blow into the room.

Based on observation, record review and interview, the facility failed to implement the plan of care for one Resident (#121) out of a total of 28 sampled Residents. Specifically, the facility failed to ensure Resident #121's call light was within reach and accessible per his/her fall care plan. Findings include:Resident #121 was admitted to the facility in March 2022 with diagnoses including cerebral infarction (stroke) and aphasia. Review of the Minimum Data Set (MDS) Assessment, dated 9/3/25, indicated Resident #121 is severely cognitively impaired as evidenced by a score of 00 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). On 12/3/25 at 7:34 A.M., the surveyor observed Resident #121 resting in bed. Resident #121 did not respond to the surveyor's questions. The surveyor observed Resident #121's call light out of reach and inaccessible on his/her bedside table. Review of Resident #121's Fall Care Plan, dated 3/6/22, indicated: Problem: Resident #121 is at risk for fallsIntervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation with interview on 12/4/25 at 9:12 A.M. and 10:53 A.M., the surveyor observed Resident #121's call light on the floor and out of reach and inaccessible to Resident #121. When asked how he/she calls for help when he/she needs assistance, Resident #121 said, I don't need help right now and was unable to engage in further conversation. During an interview on 12/4/25 at 10:53 A.M., Nurse #1 said that Resident #121 does utilize his/her call light and it should be within reach. Nurse #1 said she was unaware that Resident #121's call light was inaccessible and out of reach. During an interview on 12/4/25 at 12:58 P.M., the Director of Nursing said resident call lights should be within reach and accessible.

Based on observation, record review, and interview, the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one Resident (#15), out of a total sample of 28 residents. Specifically, for Resident #15, the facility failed to provide assistance and/or supervision with meals as per the plan of care.Findings include:Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, dated 9/22, indicated the following:-Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).-Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Policy Interpretation and Implementation-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Dining (meals and snacks).Resident #15 was admitted to the facility in November 2015 with diagnoses that included adult failure to thrive, unintentional weight loss, gastro-esophageal reflux, and vascular dementia. Review of the Minimum Data Set (MDS) assessment, dated 9/10/25, indicated the Resident was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #15 is dependent for all self-care activities and requires substantial/maximal assistance for self-feeding.On 12/2/25 at 9:25 A.M., 9:31 A.M., and 9:35 A.M., and 12/3/25 at 8:52 A.M., 8:54 A.M., 9:04 A.M., 9:17 A.M and 9:27 A.M., the surveyor observed Resident #15 seated upright in his/her bed eating breakfast. There was no staff observed providing supervision or assistance, the Resident was not visible from the hallway, and the Resident ate less than 50% of his/her breakfast. During these observations, the surveyor observed Resident #15 coughing while eating his/her breakfast and no staff passed by the Resident's room or stopped to check on or assist Resident #15.During a record review on 12/4/25 at 7:23 A.M., Resident #15's activities of daily living and nutrition care plans indicated the following:-Eating: Resident #15 is dependent of 1 for meals. Last revised 9/25/25.-Nutrition: Monitor/document/report PRN any s/sx (signs and symptoms) of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Last revised 8/21/25.During an interview on 12/4/25 at 9:37 A.M., Nurse #3 said we setup Resident #15's meal and he/she can feed him/herself and we will check on him/her and if assistance is needed, we will provide it. Nurse #3 said Resident #15 does not normally refuse care.During an interview on 12/4/25 at 9:43 A.M., the Director of Nursing said she would expect Resident #15 would be provided with the level of assistance and/or supervision indicated on his/her care plan for self-feeding and any refusals should be documented. Review of the medical record failed to indicate Resident #15 refused assistance with self-feeding.

Based on observation, record review, and interview, the facility failed to ensure one Resident (#43) with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM, out of a total of 28 sampled residents. Specifically, the facility failed to implement the discharge plan of care made by rehab services for daily ROM with care and the use of a carrot (a device utilized to position the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture injuries while helping to prevent bacteria build up and protect against increased spasticity).Findings include:Review of the facility's Restorative Nursing Policy, dated September 2025, indicated: 3. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident centered and are outlined in the resident's plan of care.Review of the facility's Range of Motion (ROM) policy, dated September 2025, indicated: Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM as much as possible. Residents with limited mobility will receive services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Resident #43 was admitted to the facility in February 2022 with diagnoses including unspecified dementia and legal blindness.Review of the Minimum Data Set (MDS) Assessment, dated 11/19/25, indicated he/she was unable to participate in the Brief Interview for Mental Status exam (BIMS) and is cognitively impaired. The MDS also indicated Resident #43 is dependent on staff for all activities of daily living and has no functional limitation in range of motion in his/her upper extremities. A diagnosis of contracture, unspecified joint was added to his/her diagnosis list on 6/5/25. On 12/2/25 at 8:28 A.M., the surveyor observed Resident #43 asleep in bed and his/her right hand was balled into a fisted position. A hand carrot was observed on his/her nightstand.Review of the nurse progress note, dated 5/3/25, indicated: OT consult for possible carrot that pt (patient) can hold in his/her right hand to help with contractures. Review of the Occupational Therapy (OT) Discharge summary, dated [DATE], indicated: Progress & Response to TX (treatment): Pt made gains with skilled OT services since eval (evaluation) with orthotic use and ROM program.Pt has demonstrated ability to use carrot orthotic up to 5 hours per day to prevent further loss of ROM and maintain skin integrity. Staff ed (education) provided on ROM during care and utilization of carrot orthotic as tolerated throughout the day. Review of Resident #43's physician's orders failed to indicate the use of a hand carrot.Resident #43's care plans failed to indicate the presence of a contracture or methods and means for facility staff to monitor Resident #43's hand contracture.During an interview on 12/3/25 at 7:48 A.M., certified nurse aide (CNA) #1 said she was unsure how long Resident #43's hand had been contracted and that the rehab department works with Resident #43 and is responsible for placing the carrot in Resident #43's hand. CNA #1 then attempted to range Resident #43's hand, and he/she grimaced in pain and pulled his/her hand away.During an interview on 12/3/25 at 7:53 A.M., Nurse #1 said that Resident #43 was working with rehab services, but they ended the use of the carrot.During an interview on 12/3/25 at 8:21 A.M., CNA #2 said that Resident #43 wears the hand carrot every day.During an interview on 12/3/25 at 12:22 P.M., Occupational Therapist (OT) #1 said that he had worked with Resident #43 to assess his/her range of motion and use of the carrot orthotic. OT #1 said that at the end of services, Resident #43 could tolerate the use of the carrot for up to five hours with no redness or skin irritation. OT #1 said that the expectation is for staff to follow the education provided by the OT to implement the recommendations, obtain physician's orders and update the care plan. OT #1 said he spoke with nursing staff about utilizing the hand carrot and performing range of motion with Resident #43.On 12/3/25 at 12:27 P.M., the surveyor observed Resident #43 in his/her wheelchair resting and the hand carrot was placed on his/her side, not in his/her hand.During an interview on 12/3/25 at 12:41 P.M., CNA #1 said she was not sure who was responsible for placing the carrot in Resident #43's hand and the surveyor should ask Nurse #1. During an interview on 12/3/25 at 12:42 P.M., Nurse #1 said that OT was working with Resident #43 and it would be nursing or the CNA's responsibility to implement the use of orthotics, like the hand carrot. Nurse #1 said she was not aware that Resident #43 had not received rehab services since 11/18/25 and there should be orders and a care plan in place related to Resident #43's contracture management and use of a hand carrot. During an interview on 12/3/25 at 1:30 P.M., Unit Manager #1 said that when a resident comes off rehab services, the rehab staff will communicate with the nursing staff what interventions need to be implemented. Unit Manager #1 said nursing staff are responsible for obtaining physician's orders for recommended equipment and updating resident care plans. Unit Manager #1 said she was not aware there were no physician's orders related to the use of the hand carrot or performing ROM with Resident #43 per his/her OT discharge summary.Review of the equipment logbook indicated an in-service regarding the use of a hand carrot and performing ROM care took place with nursing staff on 12/3/25, approximately 15 days after Resident #43 had been discharged from rehab services. During an interview on 12/4/25 at 12:58 P.M., the Director of Nursing (DON) and Regional Nurse #1 said that residents with contractures should have a care plan indicating his/her contracture and methods of managing and monitoring the resident's range of motion. The DON said that when residents come off rehab services, an in-service with the nursing team is provided and placed in the red binder on the unit and that nursing staff updates the care plans and obtains physicians orders. The DON and Regional Nurse #1 said they were made aware upon the surveyor's inquiries on 12/3/25 that Resident #43 was missed and interventions related to the hand carrot and ROM as tolerated were not implemented upon his/her discharge from rehab services on 11/18/25.

Based on observation, record review, and interview, the facility failed to maintain accurate medical records for two Residents (#45, #43), out of a total of 28 sampled residents. Specifically, the facility failed:1. For Resident #45, to accurately document the presence of three new skin areas during weekly skin evaluations; and 2. For Resident #43, to accurately document the onset of a contracture. Findings include: 1. Review of the facility's policy titled Skin Integrity Guideline, revised 2019, indicated the following: -Purpose: To provide a systemic approach and monitoring process for skin. -Residents will be observed by the CNA (Certified Nurse Assistant) daily for reddened/open areas, edema of feet or sacrum. Changes will be reported to the licensed nurse and documented. -The facility develops a routine to review residents with wounds or at risk on a weekly basis and will document as needed. -Newly identified skin areas will have a skin event report completed. -If identified risk present, the interventions will be documented in the Care Plan. -Documentation of Weekly skin Evaluation/Observations: Licensed nurse will be responsible for performing this skin evaluation/observation. Review of the facility's policy titled Health Information Management, dated September 2025, indicated the following: -Policy: The clinical record shall serve as a tool in the planning for resident care and provide a means of communication among all members of the health team. -Procedure: All records shall be complete, accurate, current, available, and shall be maintained in an approved manner. Resident #45 was admitted to the facility in July 2024 with diagnoses including vascular dementia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/16/25, indicated Resident #45 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. This MDS also indicated that Resident #45 was at risk for pressure ulcers/injuries and had no presence of any ulcers, wounds, skin problems or pressure ulcers. On 12/2/25 at 8:28 A.M., the surveyor observed Resident #45 sleeping in his/her bed with both lower legs visible. Resident #45's left lateral (to the side, away from the middle) leg was noted with a raised area that was purple/black in color. The area appeared to look like a hematoma (a collection of blood outside of a blood vessel that appears as a swollen area of blood). Review of Resident #45's active Physician's Orders indicated the following: -Document weekly skin check in the weekly skin check assessment every day shift every Mon, dated 7/15/24. -Monitor right side hematoma every shift, dated 11/21/25. Review of the most recent skin assessments for Resident #45 indicated the following: -An assessment, dated 11/21/25, indicating a new skin issue to the Resident's right side of head described as a hematoma. -An assessment, dated 11/25/25, that failed to indicate Resident #45 had any skin issues. Further review of Resident #45's recent skin assessments indicated an assessment, dated 12/2/25 at 12:13 P.M., documented by staff after the surveyor's observation. This entry failed to indicate the Resident had a skin injury on the left lower leg. Review of Resident #45's plan of care related to skin, dated 7/16/24, indicated the Resident had potential for pressure ulcer development and required weekly skin inspection for redness, open areas, scratches, cuts and bruises. The plan of care failed to indicate the Resident had any open areas or skin injuries. Review of Resident #45's progress notes failed to indicate any documentation regarding an open area or skin injuries to Resident #45's left lower leg. On 12/4/25 at 10:22 A.M., the surveyor observed Resident #45 sitting up on the side of his/her bed with both lower legs visible. The left lower leg looked as though fluid inside had been drained. An open area was present, the surrounding skin yellowish in color, with a pink wound bed (the base of a wound, consisting of tissue exposed after an injury). During an interview on 12/4/25 at 12:11 P.M., Certified Nurse Assistant (CNA) #3 said she was assigned to Resident #45 and if she noticed any new skin areas, redness, scratches or bruises during resident care, she would notify the nurse. During an interview and observation on 12/4/25 at 12:14 P.M., the surveyor and CNA #3 observed Resident #45 sitting on his/her bed. CNA #3 observed with the surveyor the open area on Resident #45's left lower leg. CNA #3 said that she did not notice the area on the Resident's left lower leg this morning during care. CNA #3 said she did know that Resident #45 had swelling to her legs but did not know about the open area, and if she noticed the area she would have reported it to the nurse. During an interview on 12/4/25 at 12:19 P.M., Nurse #4 said she would expect the CNAs to report any new areas on a resident during ADL (activities of daily living) care. Nurse #4 said when a new area is noted, the area should be accurately documented in the skin assessment. During an interview and observation on 12/4/25 at 12:23 P.M., the surveyor and Nurse #4 observed Resident #45 sitting on the side of his/her bed. Nurse #4 observed with the surveyor the open area on Resident #45's left lower leg. Nurse #4 said the area looked new and the Resident could have scratched the area because it was open. Nurse #4 lifted Resident #45's pant leg, exposing the front and upper part of Resident #45's left leg. The surveyor and Nurse #4 observed two additional open areas that were similar in appearance to the open area on the Resident's left lower leg. Nurse #4 said Resident #45 had a total of three open areas and she was going to notify the doctor and consult the wound doctor. During an interview on 12/4/25 at 12:36 P.M., the Director of Nursing (DON) said she expects the CNAs to report to the nurses with any new skin concerns regarding all residents. The DON said when a new area is noted, it is the nurse's responsibility to go assess the new area. The DON said she expects nurses to accurately document findings on the weekly skin assessments and notify the physician of findings. During an interview on 12/4/25 at 3:06 P.M., the DON said she expects medical records to be accurately documented. 2. Resident #43 was admitted to the facility in February 2022 with diagnoses including unspecified dementia and legal blindness. Review of the MDS Assessment, dated 11/19/25, indicated he/she was unable to participate in the BIMS exam and is cognitively impaired. The MDS also indicated Resident #43 is dependent on staff for all activities of daily living and has no functional limitation in range of motion in his/her upper extremities. A diagnosis of contracture, unspecified joint was added to his/her diagnosis list on 6/5/25, however the diagnosis was listed as present upon admission. Review of Resident #43's admission paperwork failed to indicate the presence of a contracture upon admission. Review of the OT Discharge summary, dated [DATE], indicated an onset of a contracture to Resident #43's right hand on 8/13/23, and that he/she was unable to tolerate the use of a splint at that time. During an interview on 12/4/25 at 3:06 P.M., the DON said she expects medical records to be accurately documented.

Based on records reviewed and interviews for one of three sample residents (Resident #1), whose Hospital Discharge Summary included treatment orders related to his/her surgical incision staple removal, the Facility failed to ensure nursing provided care and services that met professional standards of practice, when nursing removed his/her staples two weeks prematurely, Resident #1 wound dehisced (partially or completely reopened along the incision line) and he/she was transferred to the Hospital Emergency Department for evaluation of the wound.Findings include:Review of the Facility Policy titled, Physician's Orders, dated as last reviewed 09/2025, indicated that Physician's Orders will be transcribed by licensed nurses only. The order is entered into the electronic medical record (Point Click Care, PCC) and Medication and Treatment Administration Records will be updated as required.The Policy further indicated that if there is any question concerning interpretation of the Physician's Order, the nurse will contact the physician for verification of the order and nursing treatment orders must include specific treatment.Resident #1 was admitted to the Facility in October 2025, diagnoses include status post left iliac angioplasty (invasive procedure to treat narrowed or blocked iliac artery) and Percutaneous Transluminal Angioplasty (PTA) stent placement followed by a right femoral-popliteal bypass (surgical procedure that reroutes blood flow around a blockage in an artery) due to Peripheral Arterial Disease (PAD), Diabetes Mellitus (DM), and anemia.Review of Resident #1's Hospital Discharge Summery, dated 10/16/25, indicated that he/she required an outpatient follow up appointment two (2) weeks from discharge (on 10/30/25) with the vascular surgeon to reassess the surgical site and to remove his/her staples.Review of the Vascular Surgeon Note, dated 10/16/25, indicated that the surgeon would see Resident #1 in 2 weeks from 10/16/25 (on 10/30/25) at 9:00 A.M. to remove his/her staples.Review of Resident #1's Physician's Orders, dated 10/16/25, indicated that Nursing Supervisor #1 transcribed the order as follows, left groin thigh is status post vascular surgery and to remove staples every shift.The Orders also indicated a second transcribed order from Nursing Supervisor #1, staples needed to be removed, monitor surgical site every shift.Review of Resident #1's Medical Record, including but not limited to physician's orders, medication reconciliation form, nurse progress notes and Treatment Administration Record (TAR) indicated that there was no documentation to support nursing clarified the orders related to staple removal with the physician, to ensure they accurately reconciled an order that indicated that the surgeon would remove Resident #1's surgical staples on 10/30/25.During an interview on 11/18/25 at 3:20 P.M., Nursing Supervisor #1 said that on 10/16/25, she had transcribed and reconciled Resident #1's admission physician orders upon entry to the Facility from the Hospital DC summary. Nursing Supervisor #1 said that she recalled informing the provider that Resident #1 had a surgical incision, but that she could not recall seeing or getting an order for a treatment for the surgical incision or a specific order that the surgeon was going to remove his/her staples.Nursing Supervisor #1 said the two orders regarding his/her staples/incision she had entered into the computer were meant to merely inform the nursing staff that Resident #1 had a surgical wound with staples, and not to actually remove the staples at that time. Nursing Supervisor #1 said typically staples in a surgical wound are not removed until the resident is seen by the surgeon at a follow up appointment, where the staples are removed by the surgeon. Nursing Supervisor #1 said she should have clarified the treatment order for Resident #1's surgical wound and staple removal with the physician before entering it into the PCC system.Review of Resident #1's Nurse Progress Note, dated 10/20/25 indicated that Nurse #1 removed the staples to his/her left groin per physician's order with some bleeding noted, the bleeding stopped by applying pressure, this nurse applied steri-strips and the bleeding subsided.Review of Resident #1's admission Nurse Practitioner (NP) Note, dated 10/20/25, indicated that his/her staples had been removed by the nursing staff, however according to the post-op orders, he/she was to follow up with vascular surgeon in 2 weeks for staple removal and reassessment of the wound. The NP Note indicated that the wound had been bleeding, and the wound had dehiscence. The Vascular Surgeon was notified and ordered to have Resident #1 transported to the Hospital Emergency Department for evaluation.Review of Resident #1's Hospital Emergency Department (ED) Note, dated 10/20/25, indicated that the staples had been removed prematurely and there had been significant drainage and bleeding from the wound.The ED Note further indicated that the surgical wound at the medial (midline) aspect of the left thigh appears to be partially dehisced, a dressing was placed and Resident #1 required intravenous antibiotics as a precaution.During an interview on 11/18/25 at 12:45 P.M., Resident #1's Physician said that she did not get a detailed report for Resident #1 upon admission when the Facility called to reconcile Resident #1's medications and treatment orders and said that she was unaware that Resident #1 had a surgical wound at that time.The Physician said that no provider, including herself, would have given such an incomplete treatment order [surgical wound care and staple removal] for a resident.During a telephone interview on 11/18/25 at 1:06 P.M., Nurse #1 said that on 10/19/25 she had worked a double shift (7:00 A.M.-11:00 P.M.), she said she saw the physician's order to remove Resident #1's staples from his/her surgical wound and had noted that the previous shifts nurses had not yet removed the staples.Nurse #1 said during the evening shift, she removed Resident #1's staples from his/her incision and that there had been some bleeding noted, she applied pressure along with steri-strips and the bleeding stopped. Nurse #1 said that she should have looked at the original physician's order and reviewed the hospital discharge summary before removing Resident #1's staples and should have questioned why the previous nurses had not removed his/her staples. During an interview on 11/18/25 at 2:24 P.M., the Director of Nurses (DON) said that she was not aware that Resident #1 had an incomplete physician's order related to the removal of his/her staples and said she was not aware that his/her staples were removed almost 2 weeks prior to what had been indicated on his/her Hospital DC summary.The DON said Nursing Supervisor #1, who reconciled Resident #1's orders upon admission wrote an incomplete and vague order to remove his/her staples and said that Nurse #1 never should have removed his/her staples without clarifying the order.The DON said that it is the Facility's expectation to clearly reconcile all medications and treatments upon admission with the resident's provider and if any physician's order is incomplete call the provider for clarification. On 11/18/25, the Facility was found to be Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 10/25/25, which addresses the area(s) of concern as evidence by:A) On 10/20/25 Resident #1 was immediately assessed by the DON and Nurse Practitioner, the vascular surgeon was notified, and Resident #1 was sent to the Hospital Emergency Department for evaluation and treatment.B) On 10/20/25, the DON/designee began re-education for both the Nursing Supervisor and Nurse #1 including but not limited to reading a hospital discharge summary, physician's orders and clarification of orders.C) On 10/22/25, 11/13/25, and 11/22/25, the facility held Ad [NAME] QAPI meetings to review and implement the Facility POC.D) On 10/21/25 the SDC/DON/ADON began Facility wide education for Nursing staff including, but not limited to reading a discharge summary, transcription, physician's orders, change in condition, documentation, clarification of orders, and new three step admission process.E) On 10/23/25 Management Clinical Staff began auditing all admissions for the past 30 days to ensure no transcription errors were identified and if found, were addressed immediately.F) The Nurse Management Team will complete audits all new admissions and readmissions for 60 days and 2 times a week until compliance is achieved.G) Audit results will be reported to the DON or designee weekly and brought to Quality Assurance and Performance Improvement (QAPI) meeting monthly until 100 percent compliance is achieved for three consecutive months.H) The Director of Nurses and/or designee are responsible for overall compliance.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain a safe and clean ice machine on three out of three floors. Findings include: Review of the 2022 Food Code, a model for safeguarding public health and ensuring food is safe for consumption, indicated but was not limited to: 4-602.11 Equipment Food-Contact Surfaces and Utensils: Surfaces of utensils and equipment contacting food that is not time/temperature control for safety such as ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. On 10/3/24 at 3:50 P.M., the surveyor observed the 5-East unit to have a small automatic ice machine. The inside of the ice machine had black speckles on the cover and a brown slimy substance on the inside of the door. The surveyor observed a brown, slimy substance on the top section that was making ice. The machine was full of ice. On 10/3/24 at 3:55 P.M., the surveyor observed the 5-West unit to have a small automatic ice machine. The surveyor observed the inside of the ice machine with a brown substance along the edge and the top section with running water and a brown film. The machine had a couple of ice cubes in it. On 10/4/24 at 8:45 A.M., the surveyor and the Food Service Director observed the following: -3 [NAME] ice machine (large) with a section of black specks on the inside and additional brown and black specks where the ice comes out. The machine was full of ice. -4 [NAME] ice machine (large) with multiple black areas along the inside wall. The machine was full of ice. -5 East ice machine (small) with a black and brown slimy substance inside. The machine was full of ice. -5 [NAME] ice machine (small) with a brown substance inside. The machine was full of ice. During an interview on 10/4/24 at 8:50 A.M., the Food Service Director said he thought the ice machines had been recently cleaned and he was not sure why there was black substance inside. He said the small ice machine on 5 [NAME] was not working and should not have been running the day prior. He said the dietary staff added ice to the 5 [NAME] ice machine this morning. During an interview on 10/4/24 at 9:20 A.M., the Director of Maintenance said he uses a cleaner provided by the vendor for the ice machines and cleans the machines every two weeks by emptying them and wiping down the inside. He said the vendor for the ice machines comes to the facility to clean, fix machines and change filters. He said the machines are cleaned by the vendor every three months. Review of the invoices for the ice machine vendor indicated the vendor provided repairs to a machine in May 2024 and August 2024. Review of the invoices indicated the last preventative maintenance for the ice machines was completed in March 2024 (seven months prior). During an interview on 10/4/24 at 2:00 P.M., the Maintenance Director said the last preventative maintenance on the ice machines was in March 2024. He said it was supposed to be done every quarter and he was not sure why the cleaning was missed in July 2024.

Based on record review and interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#102), out of a total sample of 24 residents. Specifically, the facility failed to provide diabetic foot care treatments and skin checks as ordered by the physician. Findings include: Review of the facility's policy titled Skin Integrity Guidelines, dated as last revised 2019, indicated but was not limited to the following: -All residents will be assessed/observed for risk of skin breakdown within 24 hours of admission, quarterly, and as necessitated by change in condition. -Wound will be documented on weekly measuring tools such as weekly measuring assessment. -Interventions will be documented in the Resident Care Plan. -Licensed nurse will be responsible for performing skin evaluation/observation. Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, dated as last revised December 2015, indicated but was not limited to the following: -Recognize, manage, and document the treatment of complications commonly associated with diabetes. -Complications Associated with Diabetes: Foot Complications-neuropathy, dry skin, calluses, poor circulation, ulcers. -Skin and Foot Care: skin should be kept as dry and clean as possible, apply lotion to dry skin as needed. -Documentation: -Assessment of the skin including the following: color, moisture, temperature, and any redness, ulcers, irritation, abrasions, and/or pruritus (itching). -Assessment of the feet should include the following: hygiene, temperature, color, circulation, any abrasions, sores, or injuries, any corns or calluses, and the condition of the toes and toenails. Resident #102 was admitted to the facility in July 2024 with diagnoses which included bacteremia (infection in the blood), End-Stage Renal Disease (ESRD) on hemodialysis, osteomyelitis (infection to the bone), diabetes mellitus with neuropathy (nerve damage affecting sensation), foot ulcer, toe amputations, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment, dated 8/5/24, indicated Resident #102 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. He/she had ESRD and was on dialysis, had pneumonia, a pressure ulcer, and a diabetic ulcer. Review of the medical record indicated Resident #102 was admitted to the facility in July with a coccyx pressure ulcer and diabetic foot ulcer and was at high risk for skin breakdown as evidenced by a score of 10 on the Norton Plus Pressure Ulcer Risk Scale. Review of the Comprehensive Care Plan indicated the following: -The Resident has potential for pressure ulcer development: Administer treatments as ordered; Follow facility policies/protocols for the prevention/treatment of skin breakdown. (7/31/24-care plan closed on 9/19/24) -The Resident has potential for pressure ulcer development: Administer treatments as ordered; Follow facility policies/protocols for the prevention/treatment of skin breakdown. (9/28/24) -The Resident has Diabetes Mellitus: Wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting powder or lotion. Do not apply lotion or powder between the toes. (7/31/24- care plan closed on 9/19/24) -The resident has a behavior problem. Refuses to reposition to offload wound, refuses for daily dressing changes, refuses insulin. (9/12/24- care plan closed on 9/19/24) -The Resident has potential/actual impairment to skin integrity related to decreased/impaired mobility or function- coccyx, left heel ulcer, right heel ulcer, left toe amputations, right butt: Educate resident of causative factors and measure to prevent skin injury, follow facility protocols for treatment of injury, keep skin clean and dry, use lotion on dry skin, do not apply to site of injury, weekly skin check by licensed nurse. (9/28/24) Review of the Physician's Orders indicated the following: -Diabetic Foot Care (DFC): Bathe feet daily with warm water, do not soak, dry well especially between toes, apply a thin layer of lotion to feet but not between toes every evening shift. (7/30/24) -Document weekly skin check in the Weekly Skin Check Assessment (start 8/6/24) -Truvue boots (boot to offload heel pressure) while in bed. (7/30/24) Review of the Treatment Administration Record (TAR) indicated the following: -August 2024: DFC was signed (N or NA) indicating it was not administered 18 out of 23 opportunities. (Resident was at the hospital (MLOA) 8/13-8/21) and the Weekly Skin check was signed as administered one out of two opportunities. -Resident returned from MLOA on 8/21/24 and no re-admission skin check was done. -September 2024: DFC was signed (N or NA) indicating it was not administered 13 out of 17 opportunities. (MLOA 9/13-9/26). Further review of the TAR indicated the treatment for DFC as not coded as refused in the opportunities listed above. Review of the progress notes failed to indicate Resident #102 had been routinely/repeatedly refusing treatments. Review of the nursing progress notes indicated the following: -9/11/24: Resident #102 had refused nursing and wound care. -9/12/24: Resident #102 had new bilateral heel ulcers. -9/13/24: Resident #102 had been transferred to the hospital (unrelated to wounds). Review of the Wound Physician Evaluation and Management Summary, dated 9/12/24, indicated Resident #102 had an unstageable deep tissue injury (DTI) with intact purple/maroon skin to the left heel measuring 2 x 1.5 x depth not measurable centimeters (cm) and an unstageable DTI to the right heel with moderate drainage measuring 0.5 x 0.6 x 0.2cm. Treatments were initiated. In summary, Resident #102 had a complex medical history and was at high risk for pressure ulcer development. Heels were offloaded to prevent breakdown, DFC was not completed as ordered, and weekly skin checks were not completed as ordered. Despite offloading heels, Resident #102's heels both developed a DTI. During an interview on 10/3/24 at 11:30 A.M., Resident #102 said last night the nurse did a skin check. He/she said it was the first time since admission, someone came in and looked at his/her entire body and was writing things down. Additionally, he/she said they only get out of bed for dialysis as it is not very comfortable to sit in the wheelchair, but the air mattress and repositioning helps, and they wear the booties all the time. Resident #102 said no one has done DFC, specifically he/she said no one washes and dries his/her feet or applies lotion to his/her feet, they only change the dressings. During observation of wound rounds on 10/3/24 at 12:15 P.M., with the Wound Physician he said both heels were clean and dry and only needed skin prep applied and they could be left open to air. He said the facility is doing all the right things overall with offloading, the air mattress, and repositioning and Resident #102 is very compromised. During an interview on 10/4/24 at 9:52 A.M., the Director of Nurses (DON) said she did not know why the only skin check in the system was from 8/6/24 as the other dates when he/she was not at the hospital there should have been one done, and they were not done. She said the re-admission assessment on 8/21/24 was not done and it should have been done and included a skin check. Additionally, she said her expectation is that staff are following the physician's order and she did not know why DFC was not being done as ordered. She said if he/she refuses, then the treatment should be coded as refused and a note written, but that was not done. During an interview on 10/4/24 at 12:35 P.M., Nurse #1 said she cleans his/her feet when she does wound care but does not wash and dry them or apply lotion per the physician's order for DFC. She said she did not know why she documented on the TAR (NA) indicating not applicable. During an interview on 10/4/24 at 12:45 P.M., the DON said she called two of the nurses regarding their documentation and they said they did not do the DFC sometimes because of the dressing on the foot and other times he/she refused. Additionally, she said prior to the DTIs developing on both heels, the heels would not have had a dressing on them and should have been looked at during DFC each evening and they were not.

Based on interviews and review of facility menus, the facility failed to ensure a repetitive menu was not provided to the residents resulting in complaints about the lack of variety in food options. Specifically, the facility failed to offer a variety of the main meal to residents on a renal diet (a diet that limits sodium, potassium, phosphorus, and sometimes protein to help people with kidney disease or limited kidney function). Findings include: Review of the facility's policy titled Menu Development, dated as last reviewed September 2023, indicated nutritional needs of individuals will be provided in accordance with the established standards, as needed adjusted for age, gender, disability, and through nourishing diets, unless contraindicated by medical needs. Review of the facility's policy titled Menu Review, dated as last reviewed September 2023, indicated menus would be reviewed by the Registered Dietitian, Food Service Director or designated staff on an as needed basis and updated according to the needs of the population served. Review of the Resident Dining Committee Meeting Minutes for the months of June and September 2024 indicated discussions regarding repetitive meals served back-to-back and concerns with variety. During a group meeting held on 10/2/24 at 2:00 P.M., with 15 residents in attendance, the residents said they were sick and tired of getting repetitive meals including pork and chicken. Review of the 4-week cycle of menus for the Spring/Summer 2024 indicated the following: Week 2 Renal Diet- Tuesday Dinner: Fish Sandwich Wednesday Lunch: Baked Fish Thursday Lunch: Baked Fish Friday Lunch: Baked Fish Week 3 Renal Diet- Monday Lunch: Herb Baked Chicken Wednesday Lunch: Baked Chicken Wednesday Dinner: Baked Chicken Thursday Dinner: Chicken Salad Plate Review of a complete list of resident's therapeutic diets indicated 16 residents had an order for a Renal diet. During an observation with interview on 10/2/24 at 11:40 A.M., the surveyor observed the lunch meal service in the kitchen, the current menu was Week 2, Wednesday. [NAME] #1 said the baked fish was for the Renal Diet. During an interview on 10/3/24 at 12:00 P.M., the Registered Dietitian said the process was for the regional Registered Dietitian to review and approve all menus (regular and therapeutic menus). She said no one had noticed until this morning that the menu for the Renal Diet had fish four times this week. She said the fish was already prepped for lunch today, so the residents on a Renal Diet would get the fish again. During an observation with interview on 10/3/24 at 12:35 P.M., the surveyor observed the lunch meal service in the kitchen, the current menu was Week 2, Thursday. [NAME] #1 said the baked fish was for the Renal Diet. During an interview on 10/3/24 at 1:40 P.M., Resident #32, who was on a Renal Diet, said they did not eat their lunch today because they did not want fish again. He/she said they had fish yesterday, had sent their lunch tray back and was waiting for soup. During an interview on 10/4/24 at 8:23 A.M., Resident #42, who was on a Renal Diet, said they receive fish for a meal two to three times per week. He/she said they do not like fish but had learned to tolerate it. He/she said they had told the Certified Nursing Assistants that they do not like the fish but have not been offered any substitutes. During an interview on 10/3/24 at 2:30 P.M., the Food Service Director said the process was for the Regional Registered Dietitian to review and make the menus. He said there was a Spring/Summer menu and a Fall/Winter menu. He said each menu repeats a four-week cycle for six months. He said the facility was currently using the Spring/Summer menu and had been since the Spring. He said residents had voiced concerns at the Resident Dining Committee about variety of foods and these particular menus had not been addressed on the Spring/Summer menu but had tried to address them on the upcoming Fall/Winter menu. He said he had just noticed the repetition of meals on the Renal Diet menu and realized there were other options that could have been served. During an interview on 10/3/24 at 3:30 P.M., Dietary Aide #1 said she completes a menu selection process (choosing the main meal or the alternate meal) with nine residents (out of a total census of 121) at the facility. She said two out of the nine residents were on a Renal Diet. She said there were not a lot of residents on the list who were on a Renal Diet because they had more restrictions and not a lot of options. She said the menu for the Renal Diet had a lot of fish.

Based on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#23), out of a total sample of 24 residents, hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to ensure collaboration between the facility, Hospice, and the family, regarding the Hospice Aide schedule and the decrease in services for the weekly Hospice Aide to ensure the continuity of care for the Resident. Findings include: Review of the facility's policy titled Care and Treatment, End of Life, Hospice Program, dated September 2022, indicated but was not limited to the following: -In general, it is the responsibility of the Hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: a. Determining the appropriate Hospice plan of care; b. Changing the level of services provided when it is deemed appropriate. -Our facility has designated social service department to coordinate care provided to the resident by our facility staff and the Hospice staff. (Note: this individual is a member of the interdisciplinary team (IDT) with clinical and assessment skills who is operating within the scope of practice act). He or she is responsible for the following: a. Collaborating with Hospice representatives and coordinating facility staff participation in the Hospice care planning process for residents receiving these services; b. Communicating with Hospice representative and other health care providers participating in the provision of care for the terminal illness, related conditions, in other conditions, to ensure quality of care for the resident and family; c. Obtaining the following information from Hospice: a. The most recent Hospice plan of care specific to each resident; -Coordinated care plans for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility in order to maintain the resident's highest practical physical, mental, and psychological well-being. -The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status. Review of the Hospice Care Services Agreement between the facility and the contracted Hospice Provider, dated 5/23/19, indicated but was not limited to the following: Plan of care: -Hospice shall designate a registered nurse to coordinate the implementation of the plan of care. -Hospice shall communicate with facility to ensure coordination of patient care services. Resident #23 was admitted to the facility in October 2023 with diagnoses which included cerebrovascular disease (stroke) with right hemiplegia (weakness or paralysis) and dementia. Review of the Minimum Data Set (MDS) assessment, dated 7/24/24, indicated Resident #23 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. During a telephonic interview on 10/02/24 at 4:53 P.M., Family Member (FM) #1 said he/she did question if Hospice services were worth having because there is no communication, and they never returned his/her phone calls until he/she was questioning stopping the Hospice services. FM #1 said after talking to a Hospice representative he/she decided to continue with Hospice because it was explained as an extra layer of care. FM #1 said he/she was not aware the weekly Hospice Aide visits were decreased from 3-4 per week down to 1-3 times a week. Review of Resident #23's care plan indicated but was not limited to the following: -Resident #23's healthcare proxy/family member elected Hospice services. -Care for Resident #23 will be provided through both interdisciplinary team in collaboration with Hospice team through the contracted vendor throughout the review. -Care will be collaborated with the team from the contracted vendor. -Social services will work with Hospice social worker in an effort to provide support to Resident #23 and his/her family. On 10/1/24, review of Resident #23's Hospice Binder indicated the most recent Hospice Plan of Care with certification period of 7/18/24 to 9/15/24, which indicated but was not limited to the following: -Discipline orders: Aide; 3-4 times a week for 9 weeks; beginning during week of 7/18/24- Ending on 9/14/24. There was no Hospice Care plan or progress notes after 9/16/24 in the Hospice binder. On 10/2/24, the surveyor reviewed an updated Hospice Plan of Care with a certification period of 9/16/24 to 11/14/24, which indicated but was not limited to the following: -Discipline orders: Aide; 1-3 times a week for 9 weeks; beginning during week of 9/16/24- Ending on 11/14/2024. The new Care plan reflected a decrease in Hospice Aide services. Review of a Social Service's note, dated 9/12/24, FM #1 inquired on the process of disenrolling from Hospice as the family does not feel the patient is benefiting from the program. Notified the contracted Hospice representative of the same who will reach out to the family to discuss concerns and discuss disenrollment process; team made aware of potential change in status. Review of a Social Service's note, dated 9/13/24, indicated FM #1 had a discussion with the Hospice team and decided to keep Resident #23 on Hospice services. Social Worker (SW) #1 met with Hospice Nurse and Chaplain today in regard to the same. Plan to continue with Hospice services at request of FM #1. Further review of the medical record and social service notes did not indicate any collaborative documentation reflecting the facility or family were aware of the decreased weekly Hospice Aide serves effective 9/16/24. During an interview on 10/02/24 at 1:54 P.M., the Director of Nurses (DON) said the facility Hospice coordinator was SW #1. During an interview on 10/02/24 at 3:07 P.M., SW #1 said she was not aware or involved in the discussion to decrease the weekly Hospice Aide services. SW #1 said FM #1 was thinking of disenrolling in Hospice services and FM #1 spoke directly to Hospice about disenrolling. SW #1 said maybe that was when they decreased the weekly Aide services. During an interview on 10/02/24 at 4:45 P.M., the DON said she was not aware Resident #23's weekly Hospice Aide was decreased from 3-4 times per week to 1-3 times a week. During an interview on 10/02/24 at 2:06 P.M., Nurse #2 said she does not know when the Hospice Nurse or Aide are coming, she usually just sees them, and they sign out with her. During an interview on 10/02/24 at 2:50 P.M., Hospice Staff #2 said she usually works with Resident #23. She gets her assignment the night before and her assignment depends on the Hospice Staff availability. She said the facility does not know when she is coming, but she does sign the sign-in sheet in the hospice book and sign out with the nurse. Review of the Skilled Nursing Facility Hospice Visit Log sign-in sheet indicated the following frequency visits from 8/11/24 through 9/16/24 which were Care planned for three to four times per week: Week 8/11/24 through 8/17/24 indicated Aide visited two times. Week 8/18/24 through 8/24/24 indicated Aide visited two times. Week 8/25/24 through 8/31/24 indicated Aide visited three times. Week 9/1/24 through 9/7/24 indicated Aide visited two times. Week 9/8/24 through 9/14/24 indicated Aide visited one time. During a telephonic interview on 10/04/24 at 11:54 A.M. and 12:59 P.M., Hospice Staff #1 said the Hospice team collaborates with the facility with the sign-in process, communication notes in the hospice binder, and the weekly progress notes that are in the binder. The surveyor reviewed with Hospice Staff #1 there were no weekly notes, no current care plan indicating the aides' visits were reduced to 1-2 times a week and no documentation in the electronic medical record. In addition, the surveyor informed her that FM #1, the DON, and the SS #1 were not aware the aides' visits had been decreased on 9/16/24. Hospice Staff #1 said there should be collaboration and it should be documented.

Based on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for one Resident (#74), out of a total sample of 24 residents, to ensure Albuterol Inhalation Aerosol Solution (a bronchodilator used to relax airway muscles) was not left unsecured and unattended in the Resident's room. Findings include: Review of the facility's policy titled 11-Self-Administration of Medications, dated September 2023, indicated but was not limited to the following: -The interdisciplinary team must also determine whether the resident or the nursing staff will be responsible for the storage and documentation of the administration of the drugs, and whether the drugs will be in the resident's room or at the nurse's station. -Lock boxes must be available for residents to maintain medications at the bedside. -Document on the resident's care plan. Resident #74 was admitted to the facility in January 2024 with diagnoses including acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 9/25/24, indicated Resident #74 scored 14 out of 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of Resident #74's care plans and assessments failed to indicate the Resident was able to self-administer medication. During an observation with an interview on 10/1/24 at 7:54 A.M., Resident #74 said he/she kept the Albuterol in his/her room because he/she did not want to have to wait for staff to bring it in when he/she needs it. The Resident said he/she self-administers it whenever he/she feels as though he/she needs it. The Resident said he/she usually keeps it next to him/her on the bedside table. On 10/2/24 at 8:07 A.M., the surveyor observed the inhaler on the Resident's tray table unsecured and undated. During an interview on 10/2/24 at 12:30 P.M., Unit Manager #1 said Resident #74 could keep the inhaler in his/her room if the medication was secured and locked. She said the resident's ability to self-administer medication is assessed quarterly. During an observation with an interview on 10/3/24 at 9:31 A.M., the surveyor observed the Resident's inhaler on the tray table. Resident #74 said he/she liked to keep it in case he/she suddenly felt anxious, agitated, or short of breath. Resident #74 said he/she did not have a key for any of his/her drawers or a lock box in the room. On 10/4/24 at 11:50 A.M., the surveyor observed the Resident with the inhaler in their lap while sitting in the wheelchair and he/she said if he/she leaves his/her room, he/she likes to always keep it with him/her. During an interview on 10/4/24 at 12:15 P.M., the Director of Nurses read the policy to the surveyor and said the policy was not being followed. She said the Resident should not have the medication in their room unsecured or undated. She said if the Resident was not supposed to be self-administering medication, then the inhaler should be secured in the nurse's medication cart.

Based on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#47 and #32), out of 24 sampled residents. Specifically, the facility failed: 1. For Resident #47, to notify the physician and obtain orders post-left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) revision and document the Resident's condition on return to the facility post-surgery; and 2. For Resident #32, to remove the pressure dressing applied by the dialysis center to the fistula in the left arm, as ordered by the physician, as recommended by the dialysis center and to provide proper monitoring of the site. Findings include: Review of the facility's policy titled Dialysis Guideline, dated Revised 2019, indicated but was not limited to the following: -Care interventions required when a resident is on hemodialysis may exceed the usual identified problems and interventions provided to residents in long-term care setting. The following information will provide additional directions in assessment, planning and provision of care to our residents. -Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for continuity of care. -Communication between outpatient dialysis provider and facility should include: Written communication form with review of daily weights, any changes in condition or mood. -Pre-Dialysis Protocol: -Be cognizant of medications ordered and timing of administration. -Observe for lethargy, chest pain, headache, unsteady gait or nausea. -Communicate symptoms to outpatient dialysis center and physician. -Post Dialysis Protocol: -Review Communication Binder for any pertinent information. -Remove fistula/graft-dressing evening of dialysis treatment. -Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula). This must be done daily, best after dressing is removed. -If bleeding occurs any time after dialysis, apply pressure with clean gauze for 5-10 minutes. Repeat until bleeding stops or call dialysis unit (if open) or MD for further instructions. -Blood pressure as needed/daily or as the physician orders (do not take B/P on arm that fistula is in). Normal activity as tolerated. Review of the facility's policy titled Change in Resident Condition, dated 11/17, indicated but was not limited to the following: -The facility shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical/mental condition and/or status. -The nurse will notify the resident's Attending Physician or physician on call when there has been: -Significant change in the resident's physical/emotional/mental condition. -Need to alter the resident's medical treatment significantly. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. 1. Resident #47 was admitted to the facility in August 2024 with diagnoses including end stage renal disease, dependent on renal dialysis, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 9/3/24, indicated Resident #47's cognition was intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and was receiving dialysis services. Review of the Physician's Orders indicated but were not limited to the following: -Check bruit/thrill every shift to Left arm fistula. (8/28/24) -Dialysis days are every M/W/F. (8/28/24) -Left AV Fistula Revision 10/1/24. (9/24/24) Review of the After Visit Summary, dated 10/1/24, indicated but was not limited to the following: -Change nystatin powder to apply topically two times a day as needed (red, moist patches limited to intertriginous skin folds). -Follow up with MD in clinic in 1-2 weeks. -Keep left upper extremity elevated for 24 hours after your surgery; do not lift greater than 10 pounds with your left upper extremity until your follow-up appointment. -The ACE wrap may be removed 1 day after surgery; the remaining surgical dressings may be removed 2 days after the surgery; under the dressing are sutures and staples that will be removed at your follow-up appointment. -You may shower and get the incision wet in 48 hours; let water and soap run down the incision and pat the incision dry; do not scrub. -You can apply ice to the area to assist with pain and swelling (15 minutes indirectly laid over your surgery site, then 15 minutes off). -Return to the emergency room if you exhibit any of the following: dizziness, increased pain, vomiting, shortness of breath, redness or swelling, chest pain or discomfort, bleeding, fever, or any new or worsening symptoms. Review of the nursing progress notes failed to indicate Resident #47 had returned to the facility post left AV shunt revision and an assessment had been completed. Further review of the Physician's Orders failed to indicate any additional orders for the care of the AV fistula post revision on 10/1/24 were obtained. During an interview and observation on 10/2/24 at 8:45 A.M., Resident #47 said he/she returned after having surgery on his/her left arm last night. Resident #47 said his/her shunt was not working. Resident #47's left upper extremity was noted to have an ACE bandage (a brand of elastic bandage or compression bandage that provides support and compression to help with recovery and return to activity) around operative site. Resident #47 said the ACE bandage should come off today. Resident #47 said he/she was not having pain. During an interview and observation on 10/2/24 at 2:47 P.M., the surveyor observed Resident #47 lying in bed with his/her left arm resting on the bed. Resident #47's left upper extremity had an ACE bandage around the operative site. Resident #47 said the nurse had not looked at his/her dressing yet. During an interview and observation on 10/3/24 at 10:50 A.M., the surveyor observed Resident #47 lying in bed with his/her left arm resting on the bed. Resident #47's left upper extremity had an ACE bandage around the operative site. Resident #47 said the nurse peeked at his/her dressing but had not touched it. Resident #47 said no one had told him/her to keep his/her left arm elevated. During an interview and observation on 10/4/24 at 8:33 A.M., the surveyor observed Resident #47 lying in bed with his/her left arm resting on the bed. Resident #47's left upper extremity had the ACE bandage around the operative site removed. Resident #47 said the nurse took the ACE bandage off last night. There were three dressings in place secured with surgical tape over the left AV fistula. Resident #47 said the nurse looked at the dressings but had not changed them. Resident #47 said the dressings were the original dressings from his/her surgery. Review of the Comprehensive Care Plan failed to indicate a care plan for the care and treatment of an AV fistula shunt revision had been developed. On 10/4/24 at 8:00 A.M., the surveyor placed a call to Nurse #3 with no return call. During an interview on 10/4/24 at 8:29 A.M., Unit Manager (UM) #2 reviewed Resident #47's discharge information and medical record. UM #2 could not locate a progress note that Resident #47 was assessed post AV shunt revision or that the physician was notified of any changes. UM #2 said the receiving nurse should have reviewed the discharge information and contacted the physician for new orders. During an interview on 10/4/24 at 8:42 A.M., the Director of Nursing (DON) reviewed Resident #47's return from an AV shunt fistula revision that occurred on 10/1/24. The DON reviewed the discharge summary instructions and said the expectation was for the receiving nurse to review the discharge summary, obtain new orders and write a progress note. The DON said the nurse failed to do that. 36542 2. Resident #32 was admitted to the facility in August 2024 with a diagnosis of End Stage Renal Disease and was actively receiving dialysis treatments. Review of the MDS assessment, dated 9/25/24, indicated Resident #32 scored 15 out of 15 on the BIMS, indicating he/she was cognitively intact. The MDS indicated Resident #32 was receiving hemodialysis before and during their stay at the facility. Review of the Physician's Orders included an order written to remove the left upper extremity dressing every evening after dialysis on Mondays, Wednesdays, and Fridays and an additional order to monitor the dialysis access site every shift, every day. Review of the medical record indicated Resident #32 attended dialysis the previous evening (9/30/24) and the Treatment Administration Record (TAR) indicated the dressing to the left upper extremity had been removed. On 10/1/24 at 9:30 A.M., the surveyor observed Resident #32 in bed with a bandage on their left upper extremity and had not been removed as indicated on the TAR. Review of the Dialysis Communication Book indicated on every day of dialysis the Dialysis Center had indicated to remove the fistula (a surgically created connection between an artery and a vein that allows patients to receive dialysis) dressing after four hours. Further review indicated the following notes: 8/14/24- Please take off pressure dressing no later than morning after Hemodialysis, patient arrived with pressure dressing on fistula Review of the medical record indicated Resident #32 had a lengthy hospitalization from the end of August 2024 through the middle of September 2024, with no dialysis communication needed during this time. Further review of the Dialysis Communication book for Resident #32 indicated the following handwritten notes in the Dialysis Access Notes (only if applicable) section, in addition to the regularly circled directions of removing the dressing after four hours: 9/27/24- remove dressing after four hours 9/30/24- remove dressing after four hours 10/2/24- remove dressing after four hours; and with an asterisk (*) please remove dressing after four hours On 10/2/24 at 10:37 A.M., the surveyor observed Resident #32 return from dialysis. On 10/2/24 at 4:30 P.M., the surveyor observed Resident #32 sleeping in bed with a dressing on the left upper extremity over the fistula. During an interview with observation on 10/3/24 at 8:51 A.M., the surveyor observed that Resident #32 had a dressing on the left upper extremity. The Resident said the nurses at the Dialysis Center want the nurses at the facility to remove the dressings the night of dialysis, but sometimes they forget. He/she said no one removed the dressing the previous night (10/2/24) after he/she returned from dialysis. During an interview on 10/3/24 at 9:10 A.M., Nurse #2 said the dressing was in place over the fistula used for dialysis. She said she was not sure when the dressing was supposed to be removed and would need to check. She said the Resident attended dialysis on 10/2/24. During an interview on 10/3/24 at 11:10 A.M., Nurse #2 said she had reviewed the orders and the dressing to the left upper extremity should have been removed the night prior. During an interview on 10/3/24 at 4:10 P.M., Unit Manager #3 said the dressing should be removed during the 3:00 P.M. to 11:00 P.M. shift the night of dialysis. He said the process was for the 7:00 A.M. to 3:00 P.M. nurse to review the dialysis communication book when the Resident returned from dialysis and the nurse should have been communicating with the 3:00 P.M. to 11:00 P.M. shift about notes regarding removing the dressing.

Based on observation, record review, interview, and policy review, the facility failed to ensure the proper care and treatment of a peripherally inserted intravenous (IV) line device (a thin flexible tube that allows for the administration of fluids, medications, and blood product directly into a vein) and to ensure proper care and treatment of an internal jugular (IJ) venous access site after IJ line removal was provided in accordance with professional standards of practice for one Resident (#102), out of a total sample of 24 residents. Specifically, the facility failed to ensure: a. for the peripheral IV site: the dressing was changed, the line was replaced/site rotated after 96 hours, an order was obtained for an extended dwell time (greater than 96 hours but a seven-day maximum), and the line was not used after the maximum dwell time of seven days; b. for the IJ site: treatment orders were obtained to remove/change/apply a dressing and to monitor the insertion site for signs/symptoms of infection/bleeding post removal of the line. Findings include: Review of the Massachusetts 244 CMR Board of Registration in Nursing, Section 3, dated 6/11/21, indicated but was not limited to the following: -A registered nurse shall bear full and ultimate responsibility for the quality of nursing care he or she provides to individuals or groups. Included in such responsibility is health maintenance, teaching, counseling, collaborative planning and restoration of optimal functioning and comfort. -A registered nurse shall systematically assess health status, plan, and implement nursing intervention, evaluate outcomes and initiate change when appropriate, collaborate, communicate and cooperate as appropriate with other health care providers. -A licensed practical nurse bears full responsibility for the quality of health care she or he provides to patients or health care consumers. -A licensed practical nurse shall assess an individual's basic health status, evaluate outcomes of basic nursing intervention, and initiate or encourage change in plans of care, and collaborate, cooperate, and communicate with other health care professionals. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling #9324, titled Accepting, Verifying, Transcribing and Implementing Orders, dated as last revised 4/11/2018, indicated but was not limited to the following: -It is the responsibility of the licensed nurse to ensure there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication or activity that requires which order in accordance with accepted standard of practice and in compliance with the Boards regulations. -Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. -The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurses knowledge of that particular patient's care. It is the responsibility and obligation of the nurse to question a patient care order that is deemed inappropriate by a nurse according to his/her educational preparation and clinical experience. Review of the facility's policy titled Short Peripheral Catheter Insertion, dated January 2022, indicated but was not limited to the following: -The short peripheral intravenous catheter (PIVC) site is rotated every 96 hours and for any IV related complications. If resident has limited access, and there are no signs and symptoms or IV related complications, consult the prescriber and request an extension up to a total of 7 days maximum. -For residents with limited access, the prescriber may order to extend dwell time beyond 96 hours. The licensed nurse will perform a thorough site assessment prior to obtaining an order to extend dwell time and the licensed nurse will document, in the medical record, that there are no signs or symptoms of any IV related complications. Maximum duration of dwell time should not exceed 7 days. -Short PIVC site assessment should be performed at the following intervals: at least once per shift, when not in use. Review of the facility's policy titled Physician Orders, dated as last reviewed 9/2023, indicated but was not limited to the following: -If there is any question concerning interpretation of the physician's orders, the nurse will contact the physician for verification of the order. Resident #102 was readmitted to the facility in September 2024 with diagnoses which included bacteremia (infection in the blood), End-Stage Renal Disease (ESRD) on hemodialysis, diabetes mellitus, and pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 8/5/24, indicated Resident #102 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. He/she had ESRD and was on dialysis, had pneumonia, a pressure ulcer, and a diabetic ulcer. The surveyor observed the following: -10/1/24 at 3:13 P.M., Resident was lying in bed with a peripheral IV in his/her right forearm/wrist area with a tegaderm dressing (transparent adhesive dressing) covering the insertion site, the dressing was dated 9/21/24. Additionally, he/she had a large tegaderm dressing on the right side of his/her neck. The dressing was loose and falling off on the top corner. The dressing was dated 9/25/24 and said REMOVE 9/26/24. An IV pole was next to the bed with an empty bag of Cefazolin (antibiotic) with tubing attached hanging from the IV pole. -10/2/24 at 10:45 A.M, Resident was lying in bed with peripheral IV in his/her right forearm/wrist area with a tegaderm dressing covering the insertion site, the dressing was dated 9/21/24. Additionally, he/she had a white border gauze dressing on the right side of his/her neck dated 10/1/24. During an interview on 10/1/24 at 3:13 P.M., Resident #102 said they only administered the antibiotic in the IV once on this floor. He/she said they usually do it at dialysis and the nurses up here just flush it sometimes. He/she said no one had changed the dressing and that dressing and IV had been there since the hospital. Additionally, Resident #102 said the dressing on his/her neck had been there since the hospital as well and wasn't sure when it was supposed to be changed or if it was still needed. He/she said it was covering the insertion site from a different IV catheter they had used at the hospital. During an interview on 10/2/24 at 10:45 A.M., Resident #102 said he/she asked the nurse last night to change the bandage on his/her neck because it was falling off and you (the surveyor) had asked about it. He/she said the nurse put a new dressing on but wasn't sure if it was still needed. Resident #102 said he/she was going to ask the nurse to change the dressing on his/her forearm/wrist today when she came back in the room. Additionally, he/she said the pharmacy sent the wrong antibiotic dose, so they couldn't give it after dialysis today, so they were going to administer the dose when it arrived from the pharmacy. Review of the medical record indicated Resident #102 was hospitalized in September 2024. Review of the re-admission assessment failed to indicate the IV sites were assessed. Review of the re-admission nurse's note, dated 9/26/24, indicated Resident #102 was on IV antibiotics via right arm peripheral line for six weeks. Review of the Comprehensive Care Plan indicated a care plan was not developed until 10/2/24 for the IV antibiotic use. Review of the nursing progress notes failed to indicate staff had discussed the care and management of the IV sites with the provider. Review of the hospital discharge paperwork indicated but was not limited to the following: -A Peripheral IV was placed in right forearm on 9/21/24 at 17:33. Dressing change was due on 9/28/24. -A temporary right IJ was placed and subsequently removed on 9/23/24. -He/she was discharged back to the facility on [DATE]. Review of the Physician's Orders indicated the following: -Flush peripheral line with 10 milliliters (ml) normal saline before medication and 10 ml following medication every Monday, Wednesday, and Friday. (9/28/24) -Flush peripheral line with 10 ml normal saline daily for patency every Tuesday, Thursday, Saturday, and Sunday. (9/28/24) -Change peripheral catheter site dressing when compromised, with each site rotation, at least every 96 hours and as needed. (if extended dwell is indicated, obtain MD order. Maximum dwell should not exceed 7 days.) (9/28/24) -Observe peripheral site every shift with intermittent therapy or when not in use. (9/28/24) -Cefazolin 1 grams (gm) -use 2 gm IV one time a day every Monday and Wednesday for sepsis until 11/1/24. (9/30/24-clarified stop date on 10/2/24-order re-written) -Cefazolin 1 gm - use 3 gm IV one time a day every Friday for sepsis until 11/1/24. (9/30/24-clarified stop date on 10/2/24-order re-written) -Cefazolin 2 gm IV one time a day every Monday and Wednesday for sepsis with dialysis until 11/13/24. (10/2/24) -Cefazolin use 3 gm IV one time a day every Friday for sepsis with dialysis until 11/13/24. (10/2/24) Further review of the Physician's Orders failed to indicate an order for extended dwell time of the peripheral line and failed to indicate any orders related to the IJ site. During an interview on 10/2/24 at 11:28 A.M., Nurse #1 said they put a call out to the IV team for a new peripheral IV because the one in his/her arm was old and they need to administer antibiotics today. On 10/2/24 at approximately 11:30 A.M., the peripheral line was removed from the right forearm/wrist of Resident #102. During an interview on 10/2/24 at 1:28 P.M., Resident #102 said they were waiting for the IV Team to come and put a new IV in. He/she said they just took the one from the hospital out and said they wanted to put a new one in. During an interview on 10/2/24 at 1:30 P.M., Nurse #1 said she was not sure why they took the other line out, she said there must have been something wrong with it and they were waiting for the IV Team to come put a new one in to administer the antibiotics. She said the pharmacy had sent the wrong dose so they could not administer after dialysis and were going to give it once the new IV was in place and she did not know anything about the dressing on his/her neck. During an interview on 10/2/24 at 1:42 P.M., Unit Manager #2 said the Nurse Practitioner wanted a new line inserted it because that one was more than 7 days old. She said they only used it for the antibiotics once when he/she first came back. She said dialysis had been giving the medication after treatment and they had been flushing the IV to keep it patent. Review of the September 2024 Treatment Administration Record (TAR) indicated the following: -IV Cephazolin was administered via the peripheral line on 9/28/24. -The treatment sheets failed to indicate an order to flush the line pre/post medication on 9/28/24. -The peripheral line had been flushed on 9/29/24. -The peripheral line site had been monitored every shift since 9/28/24 starting with the 3-11 shift. -Change peripheral catheter site dressing when compromised, with each site rotation, at least every 96 hours and as needed. 9/28/24 treatment marked refused. -No additional attempts to change dressing and/or rotate site were documented. Review of the October 2024 TAR indicated: -The peripheral line had been flushed on 10/1/24 during day shift and 10/2/24 at 9:00 A.M. -The peripheral line site had been monitored every shift. -Change peripheral catheter site dressing when compromised, with each site rotation, at least every 96 hours and as needed. 10/2/24 at 12:07 A.M., treatment signed off as administered. In Summary: -The peripheral IV was greater than 96 hours old, with no order for extended dwell time (up to 7 days) -The peripheral IV was accessed and used to administer normal saline and Cefazolin until 10/2. -The peripheral IV line and dressing were not changed until the line was 11 days old (after the surveyor inquired). During an interview on 10/4/24 at 9:52 A.M., the Director of Nurses (DON) said the IV was placed on 9/21/24 at the hospital and should not have still been in use on 10/2/24. She said the nurses were flushing the line per the orders, but the line should have already been replaced. She said the dwell time is four days and a maximum of seven days with a physician's order. The DON said she did not see an order for extended dwell time so this line should have been removed/replaced after four days. She said the nurses should have called the provider to let them know the line had been in for over four days and obtained an order for extended dwell time, to replace or remove the line. Additionally, she said the orders should have been written on 9/26/24 upon re-admission and they were not written until 9/28/24. The DON said there were no orders related to the IJ site and there should have been an order written to remove the dressing on 9/26/24 and to monitor the site for signs and symptoms of infection, and if the physician wanted a new dressing applied, then an order should have been written for that treatment. The DON was not sure why the orders were not implemented correctly.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a physician's order dated 9/27/23, for nursing to obtain a urine sample for a suspected urinary tract infection (UTI), the Facility failed to ensure he/she received care and services consistent with professional standards of practice, when his/her urine sample was not obtained by nursing until 10/05/23 (more than a week later), which resulted in a delay in treatment of Resident #1's UTI. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in July 2023, diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance, caused by illness), dementia, depression, and a urinary tract infection. Review of Resident # 1's Physician's Progress Note, dated 9/27/23, indicated he/she had recently been treated for a urinary tract infection with persistent hematuria and that a repeat urinalysis was to be obtained by nursing staff. Review of Resident #1's Physician's Order, dated 9/27/23, indicated to obtain a urine sample for a urinalysis with culture and sensitivity (UA/CS, testing to confirm an infection). Review of Resident #1's Nurse Progress Note (written by the Assistant Director of Nurses), dated 9/27/23, indicated that a new order was obtained to collect a urine specimen to perform an UA/CS. Review of Resident #1's Medication Administration Record (MAR) documentation, dated 9/27/23 through 10/04/23, indicated that during this eight day time period a urine specimen was not collected. The MAR indicated that nursing documented the following comments as to why the urine sample was not obtained; unable to be obtained due to incontinence, unable to obtain, or he/she refused. Review of Resident #1's Medical Record from 9/27/23 through 10/03/23 indicated there was no documentation to support nursing staff notified his/her physician that the original urine specimen ordered on 9/27/23 had not been collected. Review of Resident #1's Physician's Order, dated 10/04/23, indicated to obtain a urine specimen for a UA/CS. Review of Resident #1's Physician's Order, dated 10/05/23, indicated to straight catheterize (a sterile tube inserted into the bladder to drain urine) him/her to obtain a urine sample. Review of Resident #1's Nurse Progress Note, dated 10/05/23, indicated nursing obtained his/her urine via straight catheterization (which was eight days after the original physician's order was obtained). Review of Resident #1's Physician's Order, dated 10/06/23, indicated to administer Bactrim (antibiotic used to treat bacterial infections) Double Strength (DS) oral tablet 800-160 milligrams (mg), give one tablet by mouth two times a day until 10/14/23 for a urinary tract infection. Review of Resident #1's Situation, Background, Assessment, Recommendation (SBAR) Form, dated 10/06/23, indicated he/she was experiencing an altered level of consciousness with signs of delirium, decreased mobility, swallowing difficulties, increased confusion, and was transferred to the Hospital Emergency Department for evaluation. During a telephone interview on 10/31/23 at 12:29 P.M., Nurse #3 said he was aware that there was an order to obtain a urine specimen from Resident #1, but he said he/she could be very agitated and uncooperative. Nurse #3 said he did not think to call the Physician to obtain an order to straight catheterize Resident #1. Nurse #3 said he usually works the 11:00 P.M. to 7:00 A.M. shift and would only call the physician or family member for a critical reason. During an interview on 10/26/23 at 3:40 P.M., Nurse #2 said she was aware of the order in place to obtain a urine specimen from Resident #1 and said there was a delay in collecting the urine because he/she could be resistant to care. Nurse #2 said she knows she should have called the physician to inform him of not being able to obtain the urine and she said she should have requested an order to straight catheterize him/her. During an interview on 10/26/23 at 12:57 P.M., the Nurse Manager said she was aware that there was a physician's order in place to obtain a urine from Resident #1 on 9/27/23 and said she was not aware until a few days later that the urine for Resident #1 was never obtained. The Nurse Manager said it was the Facility's expectation that if the nurses are unable to obtain a urine specimen after a few attempts, that nursing is to notify the physician and get an order to straight catheterize the resident. During an interview on 10/26/23 at 1:19 P.M., the Assistant Director of Nurses (ADON) said on 9/27/23 she wrote the order to obtain a urine spec from Resident #1 and said she knew he/she could be resistive to care at times. The ADON said it was the Facility's expectation that if nursing us unable to collect a urine specimen after 48 hours, nursing is to call the physician and request an order to straight catheterize the resident. During an interview on 10/26/23 at 4:04 P.M., the Director of Nurses (DON) said she was unaware that Resident #1's urine specimen, ordered on 9/27/23, had not been obtained by nursing staff. The DON said it was the Facility's expectation that once a physician order is obtained to collect a resident's urine, nursing will initiate a SBAR Form to enhance communication between shifts and track important information required to report to the physician. The DON said residents that are incontinent may be unlikely to provide a urine easily and said when a nurse gets a physician's order to obtain a urine specimen, nursing will ask the physician how the urine specimen should be obtained. The DON said nursing staff is to promptly notify the physician if they are unable to complete the order given. On 10/19/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidence by; A) On 10/06/23, Resident #1 was transferred to the Hospital Emergency Department for evaluation and treatment. B) On 10/13/23 through 10/19/23, Staff Development Coordinator (SDC) re-educated all nursing staff to complete an SBAR with any change in condition including weight loss, hematuria, and refusal of care. C) On 10/18/23, the SDC began a audit on all specimens collect, urine and/or stool for date ordered, SBAR in place, date specimen obtained, physician notification, results, and family/HCP notified. D) The results of the audit will be brought to Quality Assurance Performance Improvement (QAPI) by the SDC and/or designee times three months or until compliance has been met. E) On 10/19/23, the SDC re-educated nursing staff of when obtaining a physician's order for urinalysis, to include how to obtain the urine, notify the physician and the family with any changes in condition, if unable to carry out a physician's order, resident refusal , and with all lab results. F) On 10/19/23, an Ad-Hoc QAPI meeting was held for the above issues. G) The Director of Nurses and/or designee is responsible for the overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a physician's order dated 9/27/23, for nursing to obtain a urine sample for a suspected urinary tract infection (UTI), the Facility failed to ensure nursing staff promptly notified his/her physician when they were unable to obtain his/her urine sample in a timely manner. Resident #1's urine sample was not obtained by nursing until 10/05/23 (more than a week later), which resulted in a delay in treatment. Findings include: Review of the Facility Policy titled Change in Resident's Condition, dated as last revised 9/2023, indicated that the facility will promptly notify the resident, his/her attending physician, and family representative of changes in the residents medical/mental condition and/or status. Review of the Facility Education Documents, dated 10/19/23, indicated that is the responsibility of all licensed nursing staff to carry out a physician's order and for any reason they are unable to do so, nursing must notify the residents physician in a timely manner and ask for additional guidance. Resident #1 was admitted to the Facility in July 2023, diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance, caused by illness), dementia, depression, and a urinary tract infection. Review of Resident # 1's Physician's Progress Note, dated 9/27/23, indicated he/she had recently been treated for a urinary tract infection with persistent hematuria and that a repeat urinalysis was to be obtained by nursing staff. Review of Resident #1's Physician's Order, dated 9/27/23, indicated to obtain a urine sample for a urinalysis with culture and sensitivity (UA/CS, testing to confirm an infection). Review of Resident #1's Nurse Progress Note (written by the Assistant Director of Nurses), dated 9/27/23, indicated that a new order was obtained to collect a urine specimen to perform an UA/CS. Review of Resident #1's Medication Administration Record (MAR) documentation, dated 9/27/23 through 10/04/23, indicated that during this eight-day time period a urine specimen was not collected. The MAR indicated that nursing documented the following comments as to why the urine sample was not obtained; unable to be obtained due to incontinence, unable to obtain, or he/she refused. Further review of Resident #1's Medical Record from 9/27/23 through 10/03/23, indicated there was no documentation to support nursing notified his/her physician that the urine specimen ordered on 9/27/23 had not been collected. Review of Resident #1's Physician's Order, dated 10/05/23, indicated to straight catheterize (a sterile tube inserted into the bladder to drain urine) him/her to obtain a urine sample. During an interview on 10/26/23 at 3:40 P.M., Nurse #2 said she was aware of the order in place to obtain a urine specimen from Resident #1 and said there was a delay in collecting the urine because he/she could be resistant to care. Nurse #2 said she knows she should have called the physician to inform him of not being able to obtain the urine, but had not. During a telephone interview on 10/31/23 at 12:29 P.M., Nurse #3 said he was aware that there was an order to obtain a urine specimen from Resident #1, but he said he/she could be very agitated and uncooperative. Nurse #3 said he did not think to call the Physician to obtain an order to straight catheterize Resident #1. During an interview on 10/26/23 at 12:57 P.M., the Nurse Manager said she was aware that there was a physician's order in place to obtain a urine from Resident #1 on 9/27/23 and said she was not aware until a few days later that the urine specimen for Resident #1 had not been obtained. The Nurse Manager said it was the Facility's expectation that if the nurses are unable to obtain a urine specimen after a few attempts, that nursing is to notify the physician and get an order to straight catheterize the resident. During an interview on 10/26/23 at 1:19 P.M., the Assistant Director of Nurses (ADON) said on 9/27/23 she wrote the order to obtain a urine specimen from Resident #1 and said she knew he/she could be resistive to care at times. The ADON said it was the Facility's expectation that if nursing was unable to collect a urine specimen after 48 hours, nursing is to call the physician and request an order to straight catheterize the resident. During an interview on 10/26/23 at 4:04 P.M., the Director of Nurses (DON) said she was unaware that Resident #1's urine specimen, ordered on 9/27/23, had not been obtained by nursing staff. The DON said it was the Facility's expectation that once a physician order is obtained to collect a resident's urine, nursing will initiate a SBAR Form to enhance communication between shifts and track important information required to report to the physician. The DON said residents that are incontinent may be unlikely to provide a urine easily and said when a nurse gets a physician's order to obtain a urine specimen, nursing will ask the physician how the urine specimen should be obtained. The DON said nursing staff is to promptly notify the physician if they are unable to complete the order given. On 10/19/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidence by; A) On 10/06/23, Resident #1 was transferred to the Hospital Emergency Department for evaluation and treatment. B) On 10/13/23 through 10/19/23, Staff Development Coordinator (SDC) re-educated all nursing staff to complete an SBAR with any change in condition including weight loss, hematuria, and refusal of care. C) On 10/18/23, the SDC began an audit on all specimens collected, urine and/or stool for date ordered, SBAR in place, date specimen obtained, physician notification, results, and family/HCP notified. D) The results of the audit will be brought to Quality Assurance Performance Improvement (QAPI) by the SDC and/or designee times three months or until compliance has been met. E) On 10/19/23, the SDC re-educated nursing staff of when obtaining a physician's order for urinalysis, to include how to obtain the urine, promptly notify the physician and the family with any changes in condition, if unable to carry out a physician's order, resident refusal , and with all lab results. F) On 10/19/23, an Ad-Hoc QAPI meeting was held for the above issues. G) The Director of Nurses and/or designee is responsible for the overall compliance.

Based on observation, record review, and interview, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#16), out of a total sample of 27 residents. Findings include: Resident #16 was admitted to the facility in February 2019 and has diagnoses that included but were not limited to age-related osteoporosis, nutritional anemia, dementia, abnormalities of gait and mobility, insomnia, and unspecified protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 6/6/23, indicated Resident #15 scored a 3 out of 15 on the Brief Interview for Mental Status exam indicating a severe cognitive impairment and is dependent on staff for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. Review of the MDS assessments, dated 3/15/23 and 6/6/23, indicated Resident #16's functional limitation in Range of Motion for both of his/her lower extremity (hip, knee, ankle, foot) had no impairment. Review of Resident #16's medical record indicated the following in a nursing progress note dated 5/17/23: Resident alert with increased anxiety, yelling out verbally abusive C/O (complained of) pain, Left leg and left knee flexed; difficulty to extend leg due to severe pain, reported to RNP (Nurse Practitioner) and NO (new order). Give Tramadol 25 mg tab, every six hours as needed. During an interview on 7/12/23 at 10:56 A.M., Certified Nursing Assistant (CNA) #2 said Resident #16 requires two staff for care. CNA #2 said Resident #16 recently went on hospice and the hospice aide provides care 2 times week. CNA #2 said Resident #16 can be behavioral during care which could be from pain, and he reports this to the nurse. He said Resident #16 has declined, used to be able to move him/herself in the wheelchair using his/her feet and arms to get around the unit. CNA #2 said Resident #16 always keeps his/her left leg bent and he never sees him/her extend it. CNA #2 said it has been that way for about the last three months. Further review of Resident #16's medical record indicated the following: -A care plan, date initiated 3/15/19, indicated Resident has chronic pain related to osteoarthritis with an intervention, observe and report changes in usual routine, sleep patterns, decrease functional abilities, decrease ROM, withdrawal or resistance to care, date initiated 3/15/23. -A care plan date initiated 2/2019, indicated Resident has an ADL (activities of daily living) performance deficit related to weakness. Goal: Resident will maintain current level in ADLs through the review date, target date 10/20/23. Intervention dated 2/12/2019 PT/OT evaluation and treatment as per medical doctor orders. The care plans did not indicate any interventions to prevent the development of decrease range of motion or contractures. -A Medical note, dated 5/30/23, indicated pain in left lower limb, Nursing reporting the patient has been declining. Continues to complain of left leg pain, often screaming out when he/she is transferred in and out of his/her wheelchair. Musculoskeletal: no soft tissue swelling or joint swelling and myalgia (muscle aches and pain) and limited motion. (The note failed to specify the location of the limited motion.) -A Medical note, dated 6/14/23, patient seen for follow up dementia. Failure to thrive. Lower leg pains in left knee. Musculoskeletal: myalgia and limited motion. (The note failed to specify the location of the limited motion.) On 7/13/23 at 8:46 A.M., the surveyor observed Resident #16 sitting in his/her wheelchair in his/her room. Resident #16's right leg was at a 90 degree angle and his/her foot was on the floor. Resident #16's left leg was bent at the knee less than 90 degrees and was under the wheelchair. Hospice Aide #1 was present and had just provided care to Resident #16. During an interview at this time, Hospice Aide #1 said she had been caring for the Resident just for a few weeks and that Resident #16 cannot always extend his/her left leg and that she reports behaviors and pain to the nurse. On 7/13/23 at 1:21 P.M., the surveyor observed Resident #16 in the dining room sitting in his/her wheelchair with his/her left knee bent back less than 90 degrees. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 3/3/23, provided by the Director of Rehabilitation (DOR) on 7/12/23, indicated the following: Resident #16; Weight bearing: LE (lower extremity) weight bearing status=Weight bearing as tolerated. Musculoskeletal System Assessment: Right Lower Extremity (RLE) ROM (range of motion)= WFL (Within Functional Limits), Left Lower Extremity ROM= WFL. Contracture Function limitations Present due to contracture= No On 7/13/23 at 9:15 A.M., Unit Manager #1 said Resident #16 used to be able to push him/herself around in a wheelchair using his/her legs. Unit Manager #1 said the Resident had increased left leg/knee pain that the NP and doctor were addressing. Unit Manager #1 said he did not believe the Resident could extend his/her left leg. On 7/13/23 at 10:01 A.M., the Director of Rehabilitation said Resident #16 was last seen in March 2023 by physical therapy after having COVID. The DOR said that physical or occupational therapy have not screened Resident #16 since then. The DOR said the rehabilitation staff get referrals to screen residents from nursing, the Nurse Practitioner/Doctor, when there is a change of condition or a functional decline, or concerns including positioning or pain. On 7/13/23 at 10:01 A.M., the surveyors, the DOR, Unit Manager #1, and CNA #2 observed Resident #16 in his/her wheelchair in his/her room. Resident #16's left leg was bent under the seat of the chair less than 90 degrees. Resident #16 was asked and was amenable to CNA #2 and the DOR to touch his/her lower extremity. Resident #16 was unable to extend his/her left leg on command and was unable to have the DOR passively extend his/her left leg. The DOR stopped when Resident #16 reacted as though he/she was in pain. The DOR asked the Resident was he/she having pain and where the pain was. Resident #16 did not clearly answer. At this time, CNA #2 said Resident #16 keeps his/her left leg bent at the knee on top of his/her right leg when in bed and it has been this way for about four to five months. The DOR said Resident #16's hamstring was tight on both the right and left leg and the left leg had impairment in range of motion and was limited by pain. The DOR said she would need to get an order to screen Resident #16 fully from the hospice provider. Unit Manager #1 said hospice residents can be seen by rehabilitation services. Review of the Physical Therapy PT Evaluation and Plan of Treatment, dated 7/13/23, indicated the following: Reason referral, Patient is a long-term care resident referred for Left knee ROM assessment by nurse unit manager. Patient presents with reduced knee ROM Left greater than the right and adaptive positioning in supine. Contracture functional limitations present due to contracture=Yes. Will Physical Therapy address contracture management? =yes. Review of the document indicated that Resident #16 developed a new contracture to his/her lower extremity. During an interview on 7/13/23 at 2:15 P.M., the Assistant Director of Nursing said Resident #16 had declined and was followed for pain in his/her left leg but not his/her range of motion. The Assistant Director of Nursing said that a rehabilitation referral was not done to assess Resident #16's decline in ROM and function.

Based on observation, record review, and interview, the facility failed to implement treatment interventions for a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin), for one Resident (#58), out of a total of 27 sampled residents. Subsequently, the wound deteriorated. Findings include: Review of the facility's Skin Integrity Guidelines, dated 2019, indicated: *The interdisciplinary team will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Resident #58 was admitted to the facility in June 2022 with diagnoses including cancer and epilepsy. Review of Minimum Data Set (MDS) assessment, dated 6/28/23, indicated he/she scored 13 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. The MDS also indicated he/she requires physical assistance with bed mobility and transfers. On 7/11/23 at 10:42 A.M., the surveyor observed Resident #58 resting in bed on an air mattress (a mattress utilized to redistribute air to promote circulation and reduce pressure). Review of Resident #58's clinical record indicated he/she developed a DTI on his/her left heel in February 2023. Review of the Wound Physician's notes indicated the following: -4/20/23: Unstageable DTI with intact skin. Etiology: Pressure Size: 2 centimeters (CM) X 4 CM. Exudate (fluid from wound): None. Treatment plan: Skin prep, apply once daily. -4/27/23: Unstageable DTI with intact skin. Etiology: Pressure Size: 2 CM X 4 CM. Exudate: Moderate serosanguinous fluid. Treatment plan: Alginate calcium apply once daily for 30 days. Gauze island with border apply once daily. Review of Resident #58's Treatment Administration Records (TAR), dated April 2023 and May 2023, indicated that the treatment recommended by the Wound Physician was not implemented until 5/4/23; 8 days after the recommendation. Review of the Wound Physician's notes indicated the following: -5/4/23: Unstageable wound. Etiology: Pressure. Size: 2 CM X 4 CM X .3 CM. Exudate: Moderate serosanguinous. Slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy): 30% Debridement Procedure (a surgical procedure to remove dead tissue). Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade pick ups were used to surgically excise 1.6 CM of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues. Resident #58's left heel wound had deteriorated evidenced by the presence of slough and subsequent debridement. During an interview on 7/13/23 at 10:27 A.M., the Wound Physician reviewed his notes and said during his visit on 4/27/23, there had been drainage from Resident #58's wound leading to his new treatment recommendation. The Wound Physician said that if a treatment is not implemented to a wound, it can lead to further drainage, maceration, infection and deterioration. The Wound Physician said that he rounds the building once a week and makes recommendations for treatments. The Wound Physician said that he rounds with a nurse who then inputs the recommendations as orders in the electronic clinical record. The Wound Physician said that he has not had an attending physician decline the recommended treatment. During an interview on 7/13/23 at 10:52 A.M., the Assistant Director of Nursing (ADON) said that there had been a nurse responsible to round with the Wound Physician and input his recommendations as orders into the electronic clinical record, but she is no longer employed at the facility. The ADON said that the expectation is for the Resident's attending to review and approve of the orders within 24 hours and that an attending has not declined to implement treatment recommendations made by the Wound Physician. The ADON said that she was not aware that Resident #58 had no treatments implemented between 4/27/23 and 5/4/23 to his/her left heel.

Based on observation, record review, policy review, and interview, the facility failed to ensure dignity was maintained for residents on the Four East Unit, out of a total of six nursing care units. Findings include: Review of the facility's policy titled Quality of Life-Dignity, dated 9/2022, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. -Residents shall be treated with dignity and respect at all times. -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. During meal service on the Four East Unit, the surveyor made the following observations: On 7/11/23 at 9:18 A.M., Resident #92 was served his/her breakfast tray. The tray was placed in front of him/her, and the plate cover removed. Resident #92 was awake and looking at his/her meal. No staff were present to assist Resident #92 to eat and he/she did not try to eat the meal and continued to look at the meal. Staff were observed passing trays and walking by Resident #92's room. On 7/11/23 at 9:33 A.M., a Certified Nursing Assistant (CNA) entered the room, after 16 minutes of the Resident staring at his/her breakfast and began to assist him/her to eat. During an interview on 7/13/23 at 1:44 P.M., Nurse #3 said a meal tray for a resident who needs assistance should not be delivered and left with the resident until the staff who is going to provide the assistance is present. The tray should be left on the food cart to keep the food temperature hot and so the resident is not staring at the meal. On 7/12/23 at 9:33 A.M., CNA #2 was feeding a Resident breakfast, which was a pureed consistency. CNA #2 was scooping food into the Resident's mouth while looking down at something. The surveyor observed CNA #2 looking at his cell phone which was resting on his leg. CNA #2 continued to spoon food into the Resident's mouth without engaging with the Resident or giving the Resident their full attention. CNA #2 stopped assisting the Resident when the roommate's chair alarm sounded. Without speaking to or explaining to the Resident what was happening he left the Resident to assist the roommate and brought the roommate to the bathroom. During an interview on 7/12/23 at 4:26 P.M., CNA #3 said cell phones are not to be used on the unit and should only be used during a break. During an interview on 7/12/23 at 4:26 P.M., the Administrator said staff should not be using their cell phone while feeding a resident.

Based on observations, records reviewed, and interviews, the facility failed to ensure that timely interventions were identified and provided for one Resident (#54), based on the comprehensive assessment from a total sample of 24 residents. Specifically, the facility 1.) Failed to implement timely nutritional interventions to prevent further weight loss; 2.) Failed to provide necessary eating assistance; and 3.) Failed to monitor meal intakes. Findings include: 1. Resident #54 was admitted to the facility in December 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record indicated Resident #54 had a recent unplanned weight loss without timely nutrition intervention which was then followed by significant weight loss (one that is greater than 5% in 30 days and 10 % in 6 months). Review of the facility's policy titled Determining and Addressing Significant Weight Changes, dated 9/17 and reviewed 8/20, indicated, but is not limited to: - The nutritional and hydration status of residents will be maximized with appropriate and timely intervention. - A resident experiencing weight loss or gain per Omnibus Budget Reconciliation Act (OBRA) /Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines: include 5% in one month and 10% in six months should be referred to the dietitian for further monitoring. Review of Resident #54's Minimum Data Set (MDS) assessment, dated 6/16/21, indicated he/she required set-up assistance to eat and was dependent upon staff for other activities of daily living, was non-ambulatory, weighed 164 pounds and was 68 inches tall. This assessment indicated the Resident received a therapeutic diet (no added salt restricted). Review of a Dietary progress note, dated 6/23/21, indicated Resident #54's meal intake was variable depending on day or mood and weighed 163.7 pounds. The nutritional recommendation included to try an Ensure Plus supplement once a day for additional protein and calorie intake and monitor acceptance. Review of the medical record, physician orders, and medication administration records indicated the Dietitian's 6/23/21 recommendation to address the resident's variable meal intake and to add a nutritional (Ensure Plus) supplement was not implemented. During an interview on 8/17/21 at 11:45 A.M., the Dietitian had no explanation why the recommendation was not implemented. Review of Weight records (6/25/21 to 7/2/21) indicated Resident #54's weight status showed an 8.2 pound weight loss over a one week period, with a significant loss of 6.6 % (10.8 pounds) in one month (on 6/2/21 weighing 164.8 to 154 pounds on 7/2/21). Further review of Weight records indicated Resident #54 continued to lose weight each week. On 7/9/21, the resident weighed 150 pounds, and on 7/16/21, he/she weighed 144 pounds, representing another significant 12% weight loss (19.7 pounds) in one month. There were no additional nutritional interventions added during these two weeks the Resident had weight loss. Although the nutrition intervention to add a nutrition supplement (Ensure Plus) was recommended on 6/23/21, it was not implemented until 7/19/21, after a significant weight loss of 19.7 pounds (163 to 144 pounds) occurred. Review of a Nursing progress note, dated 7/19/21, indicated Resident #54's weight loss was verified and that he/she requires encouragement and assistance with meals due to fatigue/refusal of meals at times. The Dietitian and Nurse Practitioner were notified. Review of a Dietary progress note, dated 7/19/21, indicated Resident #54 had a significant 12% weight loss with increased behaviors and decreased appetite affecting meal intakes. At that time, the nutritional recommendation included to remove the no added salt diet restriction and to add an Ensure Plus supplement twice a day. Additionally, review of the Nutritional Plan of Care, dated 7/19/21, failed to indicate that the care plan was updated to reflect the Resident's decline in function and the need for assistance at meals. On 7/23/21, the Resident weighed 143.2 pounds, and at that time the nutritional plan for variable intake and weight loss was revised to add a soft sandwich on the lunch tray. 2. During the noon meal service on 8/10/21 at 1:10 P.M., the surveyor observed Resident #54 lying in his/her bed with the head of bed not positioned upright, as it was less than 30 degrees, the meal tray was left on the overbed table, and there was no staff assisting him/her to eat. At 1:13 P.M., the surveyor observed Resident #54 reaching for items on the meal tray, but was unable to eat. During an interview on 8/10/21 at 1:23 P.M., the surveyor asked the Director of Nurses (DON) who was on the unit to observe the Resident's positioning and assist the Resident with the meal tray. The DON said that the Resident needs to be repositioned and called Nurse #3 to assist with repositioning and assistance to eat. During an interview on 8/13/21 at 9:02 A.M., the surveyor observed Nurse Aide #4 leaving Resident #54's room and asked her if the Resident ate breakfast. Nurse Aide #4 said, I tried and he/she will not eat. At that time the surveyor went into the room and CNA #4 followed. Resident #54 was observed with eyes closed and meal tray uneaten. With the surveyor present, CNA #4 proceeded to offer food and fed the resident spoonfuls of cereal. At 9:15 A.M., the Resident had eaten one bowl of corn flakes and milk, a cut up banana, and two ounces of juice. The Resident did not eat the second bowl of cereal or muffin and said he/she was done. On 8/13/21 at 12:38 P.M., the Resident was served a meal tray of crab cake, sweet potato fries, zucchini and yellow squash, a sandwich, milk, and an ice cream. The Resident was observed in the room without encouragement to eat. Only upon picking up the meal tray at 1:25 P.M., did staff engage in conversation and ask whether the Resident was finished. The Resident only ate the ice cream and milk. During an interview on 8/17/21 at 9:00 A.M., the Director of Nurses said during COVID-19 restrictions all residents ate meals in their rooms. Now they have the main dining room open at the noon meal, and at this time there were no other supervised dining areas. During an interview on 8/17/21 at 11:45 A.M., the Dietitian said in the past, Resident #54 used to eat the noon meal out of the room but that has not been the recent practice. 3. Review of the Nutritional care plan, initiated 12/20, indicated to document meal acceptance. Review of Resident #54's July 2021 meal intake records indicated the percentage of the meals eaten was not documented and left blank for 15 of 31 days. For these 15 days, the Resident's food intake was not recorded at one to three meals: for example on 7/13/21, 7/14/21 and 7/27/21, there were no percentages recorded of meals eaten for all three meals. During an interview on 8/17/21 at 11:45 A.M., the Dietitian said she provided in-service education to nursing regarding the need to provide Resident #54 with assistance at meals. The Dietitian said the Resident was recently admitted to hospice, completed a significant change assessment on 8/11/21, and increased the Ensure Plus supplement to three times a day on 8/11/21.

Based on observation, interviews and medical record review, the Facility failed to ensure that one Resident (Resident #245), was provided pain management in a timely manner after admission from the hospital and according to the physician's orders [REDACTED]. Findings include: Resident #245 was admitted to the Facility in 2/2018 with chronic back pain and a surgical history of a cervical laminectomy (1/2018 or 1 month prior to admission), [MEDICAL CONDITION] arthritis and a recent [MEDICAL CONDITION] infection of the right lower extremity (RLE) with teno[DIAGNOSES REDACTED] (inflammation for the tendon sheath where muscle connects to bone, which includes pain, swelling and difficulty in moving the affected joint) of right foot and severe pain. Review of the Facility's Pain Management Guidelines (effective date 10/17) indicates the following: * Each Resident will be assessed for pain and develop an appropriate pain management program with the physician, resident and/or family as part of the interdisciplinary care process. * Each resident will have a comprehensive pain assessment completed within 8 hours after admission or re-entry into the building or with a significant change in condition. * Severe pain is 7-10 on a numeric scale of 0-10. * Residents shall be asked to classify their pain level using a numeric or verbal scale. Each resident experiencing pain should have a defined goal for pain relief noted in their care plan (the Resident's acceptable level of pain was not indicated on the Care Plan for Pain) * Methods of pain control may include non-pharmacological interventions (repositioning, massage, application of heat/cold, relaxation, distraction or imagery (according to the interview with Resident #245, the Facility did not incorporate adjuvant non-pharmacological interventions and the Care Plan did not indicate their use). * Residents shall receive education on the various types of pain control available. Review of the Resident's initial Comprehensive Minimum Data Set (3/2/18) indicated the following pertinent information: Brief Interview for Mental Status=15 or cognitively intact. Section J0100 for Pain Management indicated the following: Pain presence in last 5 days= yes, Pain frequency= frequently, Pain effect on function= yes, Over past 5 days, has pain made it difficult for you to sleep at night?= yes, Over past 5 days, have you limited your day-to-day activities because of pain=yes and Pain Intensity (over last 5 days on a scale from 0-10) = 09. The verbal description scale was left blank. Review of the Care Plan for acute pain (initiated 2/27/18) indicates the following interventions: * administer [MEDICATION NAME] as ordered * anticipate the resident's need for pain relief and respond immediately to any complaint of pain. * evaluate the effectiveness of pain interventions- review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and cognition. The Care Plan for acute pain did not include a defined goal for a pain threshold, education on various types of pain or non-pharmacological interventions, according to the Facility's Pain Management Guidelines. On 2/27/18 at 5:00 P.M. the Surveyor observed Nurse #6 pass medications to Resident #245. Following the medication observation, Resident #245 asked to speak with the Surveyor in private. The Surveyor interviewed the Resident who said that he/she was a new admission from the hospital and had not received pain medication until the morning of his/her second day in the facility. The Resident said that his/her pain was horrible (10/10) and that it was a long ambulance ride from the hospital to the Facility which exacerbated the pain and he/she was up crying, and tossed and turned for 2 nights in bed. The Resident also said that he/she had complained to the evening nurse and the supervisor and thought that one of the staff said that an incident report would be completed in response to the Resident's complaint. The Resident said that he/she had inquired about pain medication several times during the evening and night shift on the first day of admission, but that the nurses were very rushed because it was a weekend. The Resident also said that she asked about getting pain medication and the evening nurse stormed out of his/her room and said it's not up from pharmacy yet and there's nothing I can do about it. Review of the physician's orders [REDACTED].>*[MEDICATION NAME](indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.) 1 tab TID for chronic pains (6:00 A.M.-2:00 P.M.-10:00 P.M.). * Tylenol Extra Strength 500 mg. (give 2 caps) TID for pain (6:00 A.M.-2:00 P.M.-10:0 P.M.) * [MEDICATION NAME] caps 4mg- give 2 caps TID for muscle spasms. * [MEDICATION NAME] HCl tab 10 mg. -give 1 tab by mouth every 6 hours as needed for breakthrough pain. Review of the Omnicell item list indicates the following medications were available for nursing staff to administer to the Resident, but did not utilize: [MEDICATION NAME] HCl 5 mg. tablet (8) available [MEDICATION NAME] 10 mg./20 mg./ml. vials (2 of each available) Review of the Nursing Admission Note of 2/23/18 indicates that the Resident's orders were not verified until 22:54 (or 6 minutes before 11:00 P.M.), although the Resident was admitted at 3:50 P.M. (therefore, 7 hours after admission). Further review indicates that the Resident received only his/her scheduled Tylenol at 9:00 P.M. for pain, with no description of pain rating or its effectiveness in the nursing progress notes or Medication Administration Record. Review of the Medical Attending Note dated 2/26/18 (2 days after admission) indicates: chronic pain longstanding involving back and joints and pain has improved after lumbar surgery 1/2018, but now has excruciating pain in his/her right foot-continue current regimen with [MEDICATION NAME] 30 mg. extended-release, 1 tab 3x/day (TID) and [MEDICATION NAME] 10 mg.- 2 tabs every 4 hours as needed for break-through pain. Review of the Medication Administration Record [REDACTED] 2/23/18 or date of admission: [MEDICATION NAME] mg. ([MEDICATION NAME] ER) 1 tab TID for chronic pains due @ 6:00 A.M., 2:00 P.M. and 10:00 P.M. not received at 10:00 P.M. with a charting code of 9 indicating other. The pain level for the scheduled 10:00 P.M. medication was left blank and the corresponding nursing not does not indicate the reason for other and not being administered as scheduled. 2/24/17 [MEDICATION NAME] (first dose received) at 06:30 A.M. or 14 hours after admission from hospital Corresponding Nursing Note of 2/24/18 @ 5:56 A.M. indicates: complains of back pain (no further description, no numeric value and no alternate intervention offered) Administered [MEDICATION NAME] some effect, awaiting [MEDICATION NAME] and [MEDICATION NAME] from pharmacy. Review of the Pain levels indicated on the MAR from 2/23-2/28/18 indicates the following levels from a scale of 0-10 (mild pain=1-3, moderate pain=4-6 and severe pain=7-10): * 2/23/18 no level documented and medication not available * 2/24/18= 9 8 and 7 * 2/25/18= 3, 8 9 and 7 * 2/26/18= 8, no pain level, but with administration of MS Contin, 9, 3, 8 and 8 * 2/27/18= 8, 6 and 7 * 2/28/18= no level documented, 8, 7, 10, 8, 8 and 8 Review of the Narcotics Sheet for [MEDICATION NAME] HCl 10 mg. (2 tabs by mouth every 6 hours as needed) indicates the first delivery on 2/24/18 at 6:30 A.M. from pharmacy or 14 hours following admission to the Facility. On 3/7/18 at 11:54 A.M. the Surveyor interviewed Nurse #1 by telephone, who admitted the Resident. Nurse #1 said that she did not recall the Resident being in pain upon admission, but thought that the Resident could have experienced an increase in his/her pain as the shift went on, but could not recall details. Nurse #1 said that she was aware of the medication being available in the Omnicell. The Surveyor asked about the administration of scheduled Extrastrength Tylenol and her corresponding note indicating Tylenol at 9:00 P.M. for pain and why there was no description or numeric value assigned to the Resident's level of pain. Nurse #1 said that she could not recall because of the high turnover of residents on that unit. Nurse #1 did not recall getting upset with the Resident's request for pain medication, according to the Surveyor's interview with Resident #245 on 2/27/18 at 5:00 P.M. The Surveyor attempted to interview the evening supervisor two times on 3/9/18 and left two messages. The evening supervisor did not return the Surveyor's telephone calls. The Surveyor interviewed the Director of Nursing Services (DNS) throughout the survey. The DNS was asked about the admission process and availability of medications for pain management. The DNS said that as soon as orders are verified, prescriptions should be faxed to the pharmacy and at a minimum, delivered within 4 hours. The DNS said that the Omnicell was used as a back up while medications were unavailable. The DNS did not recall the development of an incident report for the Resident's complaint of pain. The DNS did not provide any further documentation to support adequate pain relief for Resident #245 prior to exit.

Based on record review and interview, for one of three sampled residents (Resident #1), the facility failed to ensure medications were administered as ordered by the physician. On 8/22/14, the Physician reduced Resident #1's [MEDICATION NAME] (anticoagulant) to 1 mg daily, but the previous order for [MEDICATION NAME] 2.5 mg daily was not removed from the Medication Administration Record [REDACTED]. On 8/31/14, Resident #1 experienced a change in condition, was transferred to the Hospital emergency department for evaluation, admitted with a [DIAGNOSES REDACTED]. Findings include: Resident #1 was admitted to the Facility in May, 2014, for short term rehabilitation, and medical [DIAGNOSES REDACTED]. Resident #1's Plan of Care, dated 5/29/14, included use of the anticoagulant [MEDICATION NAME], with dosing based on Resident #1's INR levels. The Surveyor interviewed Nurse #1 at 10:20 A.M., on 9/22/14. Nurse #1 said on 8/22/14, she reported Resident #1's INR to the Physician, obtained new orders for Resident #1's [MEDICATION NAME], and when the next INR blood level should be obtained. Nurse #1 said, per the physician's orders [REDACTED].M., was to be discontinued, Resident #1 was to be administered [MEDICATION NAME] 1 mg, daily at 5:00 P.M., and staff recheck Resident #1's INR on 8/25/14. The Physician Orders, dated 8/22/14, indicated to discontinue Resident #1's [MEDICATION NAME] 2.5 mg, and start [MEDICATION NAME] 1.0 mg tablet once daily, recheck Resident #1's INR on 8/25/14, and report results to the Physician. The MAR, dated 8/22/14, indicated [MEDICATION NAME] 2.5 mg at 5:00 P.M., remained on hold on the MAR, and the nurse documented Resident #1 received [MEDICATION NAME] 1 mg at 5:00 P.M., per Physicians orders. The MAR, dated 8/23/14 and 8/24/14, indicated the nurses documented they administered to Resident #1 [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 1 mg at 5:00 P.M.,which was not consistent with the 8/22/14 physician's orders [REDACTED]. The physician's orders [REDACTED].#1 [MEDICATION NAME] 1 mg, at 5:00 P.M., recheck Resident #1's INR on 9/01/14, and report results to the Physician. The MAR, dated 8/25/14 through 8/30/14, indicated the nurses documented Resident #1 received [MEDICATION NAME] 2.5 mg, and [MEDICATION NAME] 1 mg, for a total of 3.5 mg daily. On 8/31/14, at approximately 3:30 A.M., Resident #1 complained of an upset stomach, dry heaves, was noted to be weak, diaphoretic (very sweaty), and per physician's orders [REDACTED]. Resident #1 was admitted to the hospital with [REDACTED].#1's INR was 8.8 (critically high). The Surveyor interviewed the Director of Nurses (DON) at 10:30 A.M., on 9/18/14. The DON said Resident #1's order for [MEDICATION NAME] 2.5 mg daily at 5:00 P.M.,was not removed from the active MAR indicated [REDACTED].

Complaint #14-0894 Based on record review and interview,one of three sampled residents (Resident #1), the Facility failed to ensure medications prescribed by the Physician were correctly transcribed onto Resident #1's Medication Administration Record [REDACTED].M.. On 8/22/14, Nurse #1 entered Resident #1's new [MEDICATION NAME] 1.0 mg orders into the computer, but did not discontinue the previous [MEDICATION NAME] 2.5 mg order, and from 8/23/14, through 8/30/14, indicated Resident #1 received [MEDICATION NAME] 3.5 mg. Resident #1 was admitted to the hospital with [REDACTED]. Findings include: Resident #1 was admitted to the Facility in May, 2014, for short term rehabilitation, and medical [DIAGNOSES REDACTED]. Resident #1's Plan of Care indicated the use of the anticoagulant [MEDICATION NAME], which was dosed according to the INR, (international normalized ratio). The Physician Orders, dated 8/22/14, indicated to discontinue Resident #1's order for [MEDICATION NAME] 2.5 mg daily at 5:00 P.M., and administer [MEDICATION NAME] 1.0 mg tablet, daily at 5:00 P.M., recheck Resident #1's INR on 8/25/14, and report results to the Physician. The MAR, dated 8/23/14 and 8/24/14, indicated Resident #1 received [MEDICATION NAME] 2.5 mg, and [MEDICATION NAME] 1 mg at 5:00 P.M., for a total of 3.5 mg daily. The MAR, dated from 8/25/14 through 8/30/14, indicated Resident #1 continued to receive [MEDICATION NAME] 2.5 mg daily (discontinued by the Physician on 8/22/14), as well as [MEDICATION NAME] 1 mg daily, for a total of 3.5 mg daily. On 8/31/14, at approximately 3:30 A.M., Resident #1 complained of an upset stomach, dry heaves, was noted to be weak, diaphoretic (very sweaty), and per physician's orders [REDACTED]. Resident #1 was admitted to the hospital with [REDACTED].#1 had an INR of 8.8 (critically high). The Surveyor interviewed Nurse #1 at 10:20 A.M., on 9/22/14. Nurse #1 said on 8/22/14, she reported Resident #1's INR to the Physician, obtained new orders for Resident #1's [MEDICATION NAME] and when the next INR blood level should be obtained. Nurse #1 said, per the physician's orders [REDACTED].M., was to be discontinued, Resident #1 was to be administered [MEDICATION NAME] 1 mg, daily at 5:00 P.M., and recheck Resident #1's INR on 8/25/15, with results to the Physician. The Surveyor interviewed the Director of Nurses (DON) at 10:30 A.M., on 9/18/14. The DON said Resident #1's order for [MEDICATION NAME] 2.5 mg, daily at 5:00 P.M., was not removed from the active MAR indicated [REDACTED]. The DON said Nurse #1 forgot to remove Resident #1's previous order for [MEDICATION NAME] 2.5 mg, when she obtained and entered Resident #1's new order for [MEDICATION NAME] 1 mg daily onto the MAR.