Every finding on record at Harbor House Nursing & Rehabilitation Center

Based on observation, record review, and interviews, the facility failed to ensure two Residents (#12 and #77), out of a total sample of 24 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed:1. For Resident #12, to ensure a physician's order for Lidocaine 4% Patch (pain relief patch) was complete and accurately reflected the location the patch was to be applied, ensure the Lidocaine Patch was applied timely per the physician's order, and to ensure the medication was administer by licensed staff; and2. For Resident #77, to ensure the correct dose of Amlodipine (blood pressure medication) was administered per physician's order. Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's 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.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Medication Orders, dated as last reviewed 9/2023, indicated but was not limited to the following:-Medication Orders: When recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered. Review of the facility's policy titled Medication Management-General Policies, dated as last reviewed 9/2024, indicated but was not limited to the following:-When any medication order is incomplete, illegible, or unclear, the licensed nurse must have the order clarified before administering the medication.-Licensed staff who have passed a medication competency test and have been observed passing medications may administer medications in the facility. 1. Resident #12 was admitted to the facility in August 2023 with diagnoses which included bilateral osteoarthritis of knee. Review of the Minimum Data Set (MDS) assessment, dated 8/21/25, indicated Resident #12 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment and was on a scheduled pain regime. On 9/24/25 at 9:45 A.M., the surveyor observed Nurse #2 prepare Resident #12's medication for administration which included but was not limited to the following:-The Medication Administration Record (MAR) display on the Medication Cart computer indicated an order for Lidocaine External Patch 4% apply to knee topically was due at 9:00 A.M.-Nurse #2 failed to remove the Lidocaine 4% Patch from the Medication Cart, she locked the computer screen and proceeded to enter Resident #12's room and administered the other medications.-Upon exiting Resident #12's room at 10:00 A.M., Nurse #2 unlocked the computer screen, clicked the administered icon for the Lidocaine Patch, hit save, and told the surveyor she applied the patches earlier before Resident #12 got out of bed. She then said she was done with Resident #12 and moved to the next resident. Review of the Physician's Orders indicated but were not limited to the following:-Lidocaine External Patch 4% apply to knee topically one time a day for pain and remove per schedule. (start 2/16/25) The order failed to indicate if one patch was to be applied to the right knee, left knee, or both knees. During an interview on 9/24/25 at 11:00 A.M., Resident #12 said the pain patches usually go on both knees in the morning before he/she gets out of bed because it is a pain to pull up the pant legs, but he/she could not recall if the nurse put them on today and was unable to feel them through their sweatpants. During an interview on 9/24/25 at 11:12 A.M., Certified Nursing Assistant (CNA) #1 said Resident #12 gets the patches on both knees every day before getting up. She said she took the old ones from yesterday off when she washed him/her up and the new patches were not on his/her knees when she put the sweatpants on. During an interview on 9/24/25 at 11:30 A.M., Nurse #2 said Resident #12 gets the patches applied to both knees in the morning. She said the order just says knee, but he/she usually gets them on both knees. Nurse #2 said the CNA usually gets the patches from her and puts them on after washing Resident #12, but she didn't today. She said they are on now; they just got put on a few minutes ago. She said they were not on earlier, when she said they were, because she did not put them on and neither did the CNA. She said when giving medications they should be signed off as administered at the time they are administered, but sometimes she does it later when she can. During an interview on 9/24/25 at 2:45 P.M., the Director of Nurses (DON) said the Lidocaine Patch order should be specific with the location the patch is to be applied. She said the order goes back to February and she could not find documentation if the patch was supposed to go on the right knee, the left knee, or on both knees. Additionally, the DON said medications should be signed off as administered at the time they are administered, and the Lidocaine Patch should have been applied during the medication pass by the nurse, and it was not. She said the CNA should not be applying the Lidocaine Patch, only the nurse should be, and she was going to investigate that. During a follow up interview on 9/24/25 at 5:00 P.M., the DON said Nurse #2 was not following the process for medication administration and documentation. The DON said Nurse #2 confirmed with her that she usually has the CNA apply the Lidocaine Patches and that is unacceptable. 2. Resident #77 was admitted to the facility in March 2025 with diagnoses which included hypertensive heart disease (long term heart conditions that develops from chronic high blood pressure) and atherosclerotic heart disease of native coronary artery (build up on the artery walls). Review of the MDS assessment, dated 6/26/25, indicated Resident #77 scored 10 out of 15 on the BIMS indicating he/she had moderate cognitive impairment and had hypertension (high blood pressure-HTN). On 9/24/25 at 9:13 A.M., the surveyor observed Nurse #1 prepare Resident #77's medication for administration which included but was not limited to the following:-One Amlodipine 5 milligram (mg) tablet poured into the medication cup. Review of the MAR indicated but was not limited to the following:-Amlodipine 10mg give one tablet by mouth one time a day for HTN. Due at 9:00 A.M. Review of the Nurse Practitioner's Progress note, dated 9/22/25, indicated they increased the Amlodipine to 10mg due to mildly elevated blood pressure. Review of the Physician's Orders indicated but were not limited [NAME] the following:-Amlodipine 5mg give one tablet by mouth one time a day for HTN. (start 6/17/25 discontinued 9/22/25)-Amlodipine 10mg give one tablet by mouth one time a day for HTN. (start 9/23/25) Review of the Medication Cart with Nurse #1 indicated but was not limited to the following:-The blister pack card of Amlodipine 5mg was in the active medication section for Resident #77.-The blister pack card of Amlodipine 10mg was in the overstock medication section. During an interview on 9/24/25 at 10:45 A.M., Nurse #1 said the order just changed and she gave the wrong dose. She said she should have given two of the 5mg tablets to equal 10mg. She said the new card of 10mg was in the overflow section of the cart because they usually use the rest of the previous card first instead of wasting it. She said she would have to let the provider know and get an order to give the additional 5mg now. During an interview on 9/24/25 at 2:45 P.M., the DON said Nurse #1 already told her about the medication error. She said Nurse #1 did not read the MAR and Medication Card to ensure they matched and gave the wrong dose.

Based on observation, interview, and record review, the facility failed to accommodate the Resident's preference for a Geri chair for comfort to enhance their out of bed tolerance and comfort for improved quality of life for one Resident (#4), out a total sample of 24 residents. Findings include: Resident #4 was admitted to the facility in December 2023 with current diagnoses which included: cerebrovascular accident (CVA) with left sided non-dominant hemiparesis, idiothetic gout (a form of inflammatory arthritis when buildup of uric acid in your body) right and left knee, pain right and left knee, chrondracallanosis (deposits of calcium pyrophosphate crystals in cartilage) left knee, abnormal posture, weakness, and chronic pain. Review of the Minimum Data Set (MDS) assessment, dated 7/7/25, indicated Resident #4 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact.During an interview on 09/18/2025 at 3:16 P.M., Resident #4 said I have a high back wheelchair, but my legs don't bend. Resident #4 said he/she asked for a Geri recliner chair so he/she could get out of bed. During an interview on 9/19/2025 at 11:47 A.M., Resident #4 said he/she has asked for a Geri recliner chair because his/her legs don't bend, and they gave him/her this chair that's not comfortable pointing to the 20-inch-high back chair against the wall. Resident #4 said they offer to get him/her up every day, and he/she asks what they are going to put him/her in, and they say the wheelchair so he/she refuses to get out of bed. Resident #4 said they know he/she can't sit in the wheelchair because his/her legs don't contour to the chair. During a telephonic interview on 9/23/25 at 5:26 P.M., Family Representative (FR) #1 who is power of attorney for Resident #4, visits weekly, and attends Resident #4's care plan meetings, said he and Resident #4 specifically asked the social worker and the nurses for a Geri recliner chair for comfort last spring. FR #1 said the facility has not gotten Resident #4 the chair and he/she won't get out of bed because the wheelchair they gave him/her is not comfortable. Review of Resident #4's Care Plan indicated but was not limited to the following:1. Resident #4 is long-term care. Resident #4 will have all care needs met for 90 days. - Involve Resident #4 in plan of care, invite family to quarterly meetings and communicate as needed. Date initiated 7/16/25.2. Resident #4 has an advanced directive plan.-My wishes will be respected.-Resident #4 would like his/her healthcare proxy FR #1 and. FR #2 involved in all areas of his/her care. Resident consents to them having access to all medical and financial information.3. Resident #4 has an alteration in musculoskeletal status. Osteoarthritis related to pain in left knee. Patient will remain free from pain or at a level of discomfort acceptable to the resident through the review date.-Monitor/Document/ report as needed signs and symptoms or complications related to arthritis; joint pain; Joint stiffness, usually worse on wakening; Swelling; Declined in mobility; Decline in self-care ability; Contracture formation/Joint shape changes: crepitus (Creaking or clicking with joint movement), pain after exercise or weight bearing. Date initiated 4/17/24.4. Resident #4 had a cerebral vascular accident (CVA/stroke) With left hemiparesis (weakness). Resident will be able to communicate needs daily through the review date.-Activity as tolerated. Out of bed and chair. Date initiated 1/17/24.5. Resident has ADL self-care performance deficit related to fatigue, limited mobility, limited range of motion, pain, right thigh, left sided hemiplegia.-Transfer: Resident #4 Requires maximum assist by two staff with mechanical lift and extra-large blue divided leg sling.-Prefers to stay in bed and not transfer out of bed. Date initiated. 12/26/23. Review of a Social Service note, dated 4/16/2025, indicated but was not limited to the following:-Meeting with Resident #4, FR #1, and nursing.-Resident #4 had been on physical therapy early in the month and has a new wheelchair with a high back.-Resident #4 is a mechanical lift transfer.-Resident #4 does get out of bed to chair at times and does need encouragement to do so.-Resident does get concerned if he/she is up for long periods of time (3 hours).-Resident Social Worker who was involved in the care plan meeting no longer works at the facility. Review of a Nursing Note, dated 4/24/25 at 10:17 A.M., indicated as discussed in family meeting last week, they were requesting a Geri Chair, we discussed therapy had assessed and felt that was not appropriate and wheelchair they provided is appropriate chair for Resident #4.During an interview on 9/24/25 at 10:18 A.M., NP #1 said he was reviewing his notes and the physician notes and said they were never notified #4 had requested a Geri chair for comfort. Review of Physical Therapy Evaluation, dated 3/14/2025, indicated but was not limited to the following:-Physical therapy 8 times/period, for a duration of eight weeks, with a certification period of March 14, 2025, through April 12, 2025.-Physical therapy evaluation to determine what is best wheelchair seating system that will accommodate his/her current functional deficits in order for patient to spend more time out of bed with improved posture, positioning, and comfort to improve quality of life within current living. Environment. Patient is currently using an 18-inch-high back recliner manual wheelchair that is too small for him/her. Recommending a 20-inch-high back recliner manual wheelchair to improve comfort, posture and positioning to allow him/her to spend more time out of bed improving his/her quality of life.-Adaptive equipment recommendations: Patient currently using an 18-inch-high back recliner manual wheelchair that is too small for him/her. Recommend a 20-inch-high back reclining manual wheelchair. To improve comfort, posture and positioning. To allow him to spend more time out of bed. Improving his/her quality of life.Short term goal #1: Patient will increase ability to sit on a 20-inch-high back recliner, manual wheelchair supported in wheelchair for three hours using adaptive equipment. Devices to improve comfort, posture and positioning to allow him/her to spend more time out of bed improving his/her quality of life.Long term goal #1: Patient and caregiver will manage wheelchair with independence. For proper positioning to maintain upright sitting to improve comfort, posture to allow him/her to spend more time out of bed, improving his/her quality of life. Review of Physical therapy treatment encounter notes indicated Resident #4 was seen on the following days: 3/14/25, 3/20/25, 3/24/25, 3/27/25, and 4/1/25. Review of Physical Therapy Discharge summary, dated [DATE], indicated but was not limited to the following:-Short term goal #1 Discontinued on 4/1/25: Patient will increase ability to sit on a 20-inch-high back recliner, manual wheelchair supported for three hours. Using adaptive equipment and devices to improve comfort, posture and positioning to allow him/her to spend more time out of bed, improving his quality of life.-Patient unable to sit in wheelchair. Refused to get out of bed with staff often. Required a mechanical Hoyer lift for his/her out of bed transfers.-Long term goal #1 discontinued on 4/1/25: Patient and caregivers will manage wheelchair with independence for proper positioning to maintain upright sitting to improve comfort, posture to allow him/her to spend more time out of bed, improving quality of life.-Wheelchair management. Discontinued at a supervised level. Patient received wheelchair management training, recently issued a 20-inch-high back recliner manual wheelchair to ensure proper joint alignment, posture and positioning. During an interview on 9/24/2025 at 10:24 A.M., Rehab Staff #2 said he evaluated Resident #4 for a new wheelchair because the Resident was not getting out of bed because of his/her current wheelchair. Rehab Staff #2 said Resident #4 had an 18-inch-high back wheelchair and had gained weight from staying in bed, so he ordered Resident #4 a new 20-inch-high back wheelchair due to weight gain. Rehab Staff #2 said prior to discharging Resident #4 from physical therapy services on 4/1/25, he never actually saw Resident #4 in the new wheelchair because the Resident adamantly refused to use the mechanical lift. Rehab Staff #1 said he heard from staff/nurses that Resident #4 has a fear of being in the mechanical lift and that is a barrier to getting out of bed. Rehab Staff #2 could not identify a specific staff member who told him that. Rehab Staff #2 could not recall the exact date the new 20-inch-high back wheelchair was delivered to the facility. Rehab Staff #2 said he was never able to assess Resident #4 in the new chair. He went on how he/she was sitting in the old chair and discharged Resident #4 from physical therapy on 4/1/2025.Review of the invoice dated 3/27/2025, indicated the 20-inch-high back wheelchair was ordered on 3/27/25 and received in the facility on 3/31/2025. During an interview on 9/24/2025 at 11:50 A.M., the Director of Nursing (DON) said she was not sure why the Rehab staff did not evaluate Resident #4 in the new 20-inch-high back wheelchair, she would have to find out.During an interview on 9/24/2025 at 12:09 P.M., FR #1 with Resident #4 present said they have been asking for a Geri reclining chair for a long time. FR #1 said Resident #4 was never the type of person to be lying around in bed, to see him/her in bed all the time is not normal. During an interview with the DON present on 9/24/2025 at 12:51 P.M., FR #1 said we asked for a Geri chair back in March, and Resident #4 is just getting one now in September. FR #1 said he/she doesn't know why they couldn't get Resident #4 one back in March. During an interview on 9/24/2025 at 3:16 P.M., the Rehab Director said Resident #4 looks very good in a Geri chair and we will be picking him/her up for Range of Motion (ROM). During an interview on 9/24/2025 at 2:17 P.M., the DON said there is a progress note indicating Resident #4 did request a Geri chair, but we just don't give out Geri chairs to everyone. Corporate Nurse #1 said they have done everything possible to take care of this Resident. During an interview on 9/24/25 at 3:36 P.M., Corporate Nurse #1 said there is one occupational therapy note which indicated Resident #4 was assessed up in the high back wheelchair. The surveyor reviewed with the Corporate Nurse #1 and the DON, Resident #4 and FR #1 had expressed to the surveyor they requested a Geri chair back in March 2025 for comfort when getting out of bed, Rehab Staff #2 ordered the chair based on old chair and never assessed Resident #4 in the new wheelchair, and was discharged from physical therapy one day after the wheelchair arrived in the facility which was 13 days before the end of the physical therapy certification period of 4/12/25. Refer F688

Based on observation, interview, and record review, the facility failed to prevent loss of range of motion (ROM) in both knees for one Resident (#4), out of 24 residents. Specifically, Resident #4 had ROM within functional limits during last physical therapy session in April 2025 and is now presenting with severely limited right knee flexion (bending the knee) ROM to 12 degrees and left knee flexion to 7 degrees. Findings: Resident #4 was admitted to the facility in December 2023 with current diagnoses which included: Cerebrovascular accident (CVA, stroke) with left sided non-dominant hemiparesis, idiothetic gout (a form of inflammatory arthritis when buildup of uric acid in your body) right and left knee, pain right and left knee, chrondracallanosis (deposits of calcium pyrophosphate crystals in cartilage) left knee, abnormal posture, weakness, and chronic pain. Review of the Minimum Data Set (MDS) assessment, dated 7/7/25, indicated Resident #4 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Further review indicated in section GG Functional Limitations in Range of Motion: GG0115B Resident #4 had lower extremity impairment on one side. Section O indicated to record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily): ROM passive and active- Zero days. During an interview on 09/18/2025 at 3:16 P.M., Resident #4 said, My legs don't bend anymore. During an interview on 9/19/2025 at 11:47 A.M., Resident #4 said the mechanical lift is difficult because his/her legs won't bend. Resident #4 said he/she has been in therapy and if they did not stop therapy, he/she would not be in this condition. Resident #4 said nobody does any ROM with him/her, they just sit there and say he/she must get out of bed. Resident #4 said they know he/she can't sit in the wheelchair because his/her legs don't contour to the chair anymore. Review of Physician Progress Note, dated 3/10/2025, indicated but was not limited to the following:-Chief complaint. pain -No concerning findings on today's exam regarding complaints of generalized weakness, physical therapy and occupational screen placed. Review of Physical Therapy Evaluation, dated 3/14/2025, indicated but was not limited to the following:-Lower extremity range of motion (ROM): Left lower extremity ROM is within functional limits (WFL), right lower extremity ROM is WFL.-Currently non-ambulatory and dependent for all out of bed transfers using a mechanical lift. Resident mostly opts to stay in bed. Dependent for activities of daily living. Review of Physical Therapy Treatment encounter notes indicated but was not limited to the following:-3/14/2025 -Pain: Does pain limit patients' functional activity? Yes. What exacerbates pain? Prolonged activity.-3/20/2025: Patient performed bilateral lower extremity therapeutic exercises, Active assist range of motion (AAROM) with gentle stretching. All joint muscle groups, 2 sets/10 repetitions to increase flexibility and preparation. -3/24/2025: Patient performed bilateral therapeutic exercises AAROM with gentle stretching all joint muscle groups, 1 set/10 repetitions to increase flexibility. -3/27/2025: Patient performed bilateral lower extremity therapeutic active range of motion (AROM) with gentle stretching all joint muscle groups, 1set/10 repetitions to increase. -4/1/2025: Patient performed bilateral lower extremities therapeutic AROM with gentle stretching all joints muscle groups 1 sets/10 repetitions to increase flexibility. Review of Physical Therapy Discharge summary, dated [DATE], indicated but was not limited to the following:-Patient performed bilateral lower extremity therapeutic exercises, AROM with gentle stretching all joints, muscle groups 1 sets/10 reps to increase flexibility. -Restorative programs establish/Trained: Not indicated at this time.-Functional maintenance program established/Trained: Not indicated at this time. Review of Physical Therapy Evaluation dated 3/14/2025, daily notes, and Discharge summary dated [DATE], indicated Resident #4 had bilateral knee range of motion within functional limits, and at the time of discharge. Resident #4 was not placed on a functional maintenance or a restorative program to maintain his/her ROM in bilateral knees. Review of a Physician's note, dated 4/9/2025, indicated but was not limited to the following:-Patient now on therapy services for decline in activities of daily living, function, mobility status post hospitalization.-I was requested by Director of Nurses to evaluate patient due to severe leg pain and history of chronic right arm pain. -In regard to his/her lower extremity pain, he/she reports having chronic, intermittent into alternating right and left lower extremity pain, primarily at the knees. Resident #4 reports having history of reoccurring episodes of gout in both knees. - Left knee positive for edema, no medial or lateral joint line tendons palpation. Patient declined range of motion and further exam of left knee due to pain. -No right knee assessment or refusal of ROM by Resident #4. -Assessment/Plan: -Consider physical therapy for mobility training, equipment as needed, safety for fall prevention, balance, coordination, mobility equipment. Patient with limited functional mobility at baseline.-Bilateral knee pain with gout- Patient noted with chronic history of bilateral knee pain with osteoarthritis and reoccurring episodes of gout. Patient at risk of reoccurring episodes of gout. -Acute exacerbation could inhibit the patients' anticipated progress in therapy period. During an interview on 9/24/25 at 10:25 A.M., Resident #4 said he/she asked Nurse Practitioner (NP) #1 what was going on with his/her legs, they don't move anymore. Resident #4 said his/her pain is well controlled, he/she receives Oxycontin. During an interview on 9/24/25 at 10:18 A.M., NP #1 said he was aware Resident was having knee pain, and he/she saw Resident #4 in August 2025 and increased the oxycontin dosage from 10 mg to 15 mg twice a day with good results. Review of Resident #4's Care Plan indicated but was not limited to the following:-Resident #4 has an alteration in musculoskeletal status. Osteoarthritis related to pain in left knee. Patient will remain free from pain or at a level of discomfort acceptable to the resident through the review date. -Monitor/Document/ report as needed signs and symptoms or complications related to arthritis: joint pain; Joint stiffness, usually worse on wakening; Swelling; Declined in mobility; Decline in self-care ability; Contracture formation/Joint shape changes: crepitus. (Creaking or clicking with joint movement), pain after exercise or weight bearing. Date initiated 4/17/24.Review of Resident #4's nursing progress notes from May 2025 through September 2025 failed to indicate any decline in knee ROM including but not limited to joint stiffness, swelling, decline in mobility, crepitus or contracture formation.Further review of nursing documentation indicated Nursing Weekly Skin Check notes from 3/26/2025 through 9/17/2025 indicated there was no change in ROM, new contracture, or increased spasticity. During an interview 9/24/2025 at 9:45 A.M., the Rehab Director said Resident #4 was not on any functional maintenance or restorative programs because he/she did not have a neurological diagnosis. She said they have a couple of residents on program, but they have a neurological diagnosis like Parkinson's or multiple sclerosis. During an interview on 9/24/2025 at 10:24 A.M., Rehab Staff #2 said Resident #4 has neurological deficits from a previous stroke and his/her range was active assist (AAROM, the patient uses the muscles around a weak joint to complete stretching exercises with the help of a physical therapist). Rehab Staff #2 said when Resident #4 was in physical therapy service in March 2025, Resident #4 had functional ROM (refers to the ability to move within a specific range, which is crucial for performing daily activities and maintaining overall mobility) in both knees and was able to flex them to 90 . Rehab Staff #2 said when Resident #4 was discharged from physical therapy on 4/1/25, he did not recommend Resident #4 be put on a functional maintenance program or a restorative program to maintain ROM in his/her knees. During an observation with interview on 9/24/2025 at 12:58 P.M., the surveyor observed the Rehab Director attempt to flex both of Resident #4's knees (one at a time). The surveyor observed both knees to flex approximately 10 degrees with Resident #4 wincing in pain at the attempts. Resident #4 said, My knees don't bend. Review of a Physical Therapy Evaluation and Plan of Care, dated 9/24/25, indicated but was not limited to the following.-Prior therapy/Outcome: Fair, tolerated bilateral lower extremity range of motion, however, did not want to get out of bed.Pain Assessment: -At rest: 7 out of 10, bilateral, knees left greater than right.-With Movement: 10/10.; Does pain limit participation in therapy? Yes. Does pain limit patients' functional activities? Yes.-Left knee flexion: Impaired, limited to 7 , Patient does have a soft end field and is difficult to obtain accurate range of motion due to pain.-Right knee flexion: Impaired, limited to 12 , Patient does have a soft end field and is difficult to obtain. Accurate range of motion due to pain.-Functional limitations present due to contracture: NoJoint mobility: Patient has limited bilateral knee range of motion; However, it appears to be more from guarding due to pain and would benefit from further assessment and treatment to decrease pain, improved range of motion and overall functional mobility.-Potential for achieving goals: Good Potential if pain can be better managed. During an interview on 9/24/2025 at 3:16 P.M., the Rehab Director said she did a full physical therapy evaluation and Resident #4 had only 7 degrees left knee flexion and 12 degrees right knee flexion at this time. Rehab Director said she confirmed with Rehab Staff #2, he was doing ROM in bed with Resident #4 last April 2025. Rehab Director said they will be picking Resident #4 up for knee ROM. Review of the medical record failed to indicate the decline in ROM in bilateral knee flexion from 90 degrees to right knee flexion to 12 degrees and left knee flexion to 7 degrees, prior to the reevaluation of the Resident's ROM on 9/24/25.

Based on interviews and records reviewed, for one of three sampled residents (Residents #1), who had moderate cognitive impairment, the Facility failed to ensure they developed and implemented an Abuse Prohibition Policy that included written procedures for staff to follow related to the need to immediately report, and to whom, allegations of abuse when, on 11/08/24 at around 1:00 A.M., Resident #1 came to the nurses station with a skin tear and told Nurse #1 that someone named [NAME] stabbed him/her with a box cutter and Nurse #1 did not immediately report the allegation to the Director of Nursing or Administrator, and as a result, they were not made aware of the allegation until about 8 hours later, when the Director of Nursing reviewed Nurse #1's written Incident Report regarding Resident #1's injury. Findings include: Review of the Facility Abuse Policies titled Identification and Reporting Allegations, Prevention of Resident Abuse and Neglect and Investigation Guidelines, last reviewed by the Facility during 9/2023, indicated that all staff members are mandated to report incidents of suspected abuse or neglect to their immediate supervisor, nursing supervisor, Director of Nursing or Administrator. During an interview on 12/02/24 at 1:54 P.M., the Director of Nursing said that the Facility Abuse Policies indicated that staff members should report incidents of suspected abuse to their immediate supervisor, however, the Policies did not indicate that reports of alleged abuse should be made immediately. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/08/24, indicated that around 1:33 A.M. on 11/08/24, staff members observed Resident #1 in the hallway walking toward the nurses station bleeding from the right forearm. The Report indicated that the nurse observed that Resident #1 had a skin tear and when the nurse asked Resident #1 what happened, he/she stated he/she got into a fight with [NAME] and that [NAME] had a box cutter. Resident #1's clinical record indicated he/she was admitted to the Facility during February of 2024 and his/her diagnosis included unspecified dementia, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 8/29/24 indicated that his/her cognitive patterns were moderately impaired. During an interview on 12/02/24 at 10:30 A.M., Nurse #1 said that on 11/08/24 around 1:00 A.M., Resident #1 came to the nurses station with Certified Nurse Aide (CNA) #1 and showed her a skin tear on his/her right forearm. Review of the One Time Skin Check Form, dated 11/08/24, indicated Resident #1 had a 2.5 centimeter (cm) by .25 cm skin tear on his/her right posterior forearm. Nurse #1 said that when she asked Resident #1 what happened, he/she said that he/she got in a fight with [NAME] and [NAME] had a box cutter. Nurse #1 said that there were no residents or staff members on the Unit at the time of Resident #1's report named [NAME] and she did not know to whom Resident #1 was referring. Nurse #1 said that there had been no residents in the hallways before Resident #1 exited his/her room and reported the skin tear and Resident #2 (his/her roommate) was bed bound and unable to get up out of bed on his/her own. During an interview on 12/02/24 at 12:50 P.M., the Director of Nursing said that around 8:00 A.M. on 11/08/24, she made rounds of the Facility and saw that Nurse #1 was completing an Incident Report regarding a skin tear found on Resident #1's forearm during the 11:00 P.M. to 7:00 A.M. shift. The Director of Nursing said that later on during the morning, she reviewed Nurse #1's Incident Report regarding Resident #1's skin tear and said that Nurse #1 should have immediately reported Resident #1's allegation. The Director of Nursing said that when she became aware of the alleged incident more than 8 hours later, she reported it to the Administrator and initiated an investigation.

Based on interviews and records reviewed, for one of three sampled residents (Resident #2), who was severely cognitively impaired and dependent upon staff for care, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when on 8/24/24 around 12:30 A.M., Nurse #1 was made aware of an allegation of abuse of Resident #2, that the door to his/her room was tied so that he/she could not exit if desired, and although Nurse #1 said he reported the allegation to Nurse #2, neither of them reported the allegation to facility Administration and, as a result, they were not aware of the allegation until more than 8 hours later, when Nurse #3 became aware and reported it, as required. Findings include: Review of the Facility Policy titled Prevention of Abuse and Neglect, effective 10/22, indicated that all employees of the Facility are mandated to report incidents of suspected resident abuse, neglect, mistreatment, exploitation or misappropriation to their immediate supervisor, nursing supervisor, Director of Nursing Services or the Executive Director. The Policy defines exploitation to include involuntary seclusion or restraint not required to treat a resident's medical symptoms. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 8/24/24, indicated that at 9:00 A.M., Resident #1 reported to the nurse (later identified as Nurse #3) that during the previous shift, he/she took photographs of a resident's door (Resident #2) with a towel tied to the railing and the door handle, keeping the door closed and the resident from exiting the room. The Report indicated that Resident #1 told the nurse that he/she had reported that the door was tied closed to the nurse (later identified as Nurse #1) during the previous shift. Review of Resident #2's clinical record indicated that he/she was admitted to the Facility during August of 2024 and his/her diagnoses included unspecified dementia. Review of Resident #2's MDS Assessment, dated 8/28/24, indicated that his/her cognitive patterns were severely impaired. Review of Resident #1's clinical record indicated that he/she was admitted to the Facility during June of 2024 and his/her diagnoses included aftercare following shoulder joint prosthesis. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 6/20/24, indicated that his/her cognitive patterns were intact. During a telephone interview on 9/30/24 at 1:50 P.M., Resident #1 said that on 8/24/24 during the overnight shift he/she saw Resident #2's door held closed with a towel tied from the chair rail to the door knob and took photographs of the door. Resident #1 said that he/she reported his/her observation of Resident #2's door to one of the nurse aides and said the nurse aide reported it to the nurse. During telephone interviews on 9/30/24 at 2:15 P.M. with Resident Care Aide #1 and 10/02/24 at 1:45 P.M. with Nurse #1, they said that during the 11:00 P.M. into 7:00 A.M. from 8/23/24 to 8/24/24, Resident #1 alleged that Resident #2's door was tied closed with a towel. Resident Care Aide #1 and Nurse #1 said that Nurse #2, who was the nurse supervisor, heard Resident #1 yelling about the incident and asked them why he/she was yelling. Nurse #1 said that Nurse #2 called him on the phone and asked why Resident #1 was yelling and said he told her that Resident #1 was yelling about a towel being used to tie another resident's door closed. Nurse #1 and Resident Care Aide #1 said Nurse #2 came to Resident #1's Unit and asked who had tied the door closed and they said Nurse #2 told them that tying doors closed could get the Facility in a lot of trouble. During an interview on 9/30/24 at 2:00 P.M. Nurse #2 said that she was nurse supervisor during the 11:00 P.M. to 7:00 A.M. from 8/23/24 into 8/24/24. Nurse #2 said that she was not aware that Resident #1 alleged that a staff member tied Resident #2's door closed. Nurse #2 said that although she had spoken to Nurse #1 about a resident being loud on the Unit and said that she told Nurse #1 to tell the resident (later identified as Resident #1) to quiet down, she said Nurse #1 had not told her that there had been an allegation that Resident #2's door was tied closed. During an interview on 10/02/24 at 2:10 P.M., Nurse #3 said that at 9:00 A.M. on 8/24/24, Resident #1 reported to her that there had been a resident's door tied closed with a towel during the 11:00 P.M. to 7:00 A.M. shift and he/she had taken pictures. Nurse #3 said that she immediately reported Resident #1's allegation to the Director of Nursing and the Administrator. During interviews on 9/30/24 at 9:00 A.M. with the Director of Nursing and on 9/30/24 at 12:30 P.M. with the Administrator, they said that on 8/24/24 around 9:00 A.M., Nurse #3 reported that Resident #1 alleged Resident #2's door was tied closed with a towel during the previous 11:00 P.M. to 7:00 A.M. shift. The Director of Nursing and Administrator said that Nurse #3's report to them was around 8.5 hours after Resident #1 initially reported the allegation to Nurse #1 and Resident Care Aide #1. On 9/30/24 the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A. On 8/24/24, the Facility suspended Resident Care Aide #1 and Nurse #1 pending investigation of the incident. B. On 8/24/24, the Director of Nursing assessed the skin of Resident #2 and all alike residents on his/her Unit. C. Between 8/24/24 and 9/05/24, all Facility employees were trained by the Director of Nurses or designee on the responsibility to report allegations of abuse, neglect, mistreatment, misappropriation and involuntary seclusion to their immediate supervisor, the nursing supervisor, the Director of Nursing or the Administrator. D. On 8/24/24, the Director of Nursing or designee audited all Units for signs of residents being involuntarily secluded. Observations continued on every shift for 7 days, weekly for 4 weeks and monthly for 3 weeks. E. Since 8/24/24, the Director of Nursing continues to review all reportable incidents for the timeliness of staff members reports to their immediate supervisor, the nursing supervisor, the Director of Nursing or the Administrator. F. On 8/24/24, an emergency, ad hoc QAPI meeting was held to review the correction plan. Further ad hoc meetings will be held weekly for 4 weeks and monthly for 3 months. G. The Administrator and/or designee is 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: 1. Ensure facial hair was restrained during food preparation; and 2. Maintain a safe and clean microwave in one out of three kitchenettes; and 3. Maintain a safe and clean ice scoop in one out of three kitchenettes. Findings include: 1. Review of the facility's policy titled Nutrition and Food Service: Employee Practices, dated as revised in September 2023, indicated employees shall use effective hair restraints when working in all food preparation areas to prevent contamination of food or food-contact surfaces. All hair must be restrained and tucked under hairnet. On 8/1/24 at 7:30 A.M., the surveyor observed Dietary Aide #1 at the meal preparation assembly line putting placemats and silverware on the trays. The surveyor observed the Dietary Aide not wearing a hair net on top of their head and not wearing a beard net on their facial hair. On 8/1/24 at 11:30 A.M., the surveyor observed Dietary Aide #1 at the meal preparation assembly line putting placemats and silverware on the trays. The surveyor observed the Dietary Aide wearing a hair net on the top of their head and not wearing a beard net on their facial hair. During an interview on 8/2/24 at 9:40 A.M., the Food Service Director said Dietary Aide #1 should be wearing a beard restraint while in the kitchen. 2. Review of the 2022 Food Code, a model for safeguarding public health and ensuring food is safe for consumption, indicated: 4-201.11 Equipment and Utensils. Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms . Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. On 8/1/24 at 3:10 P.M. the surveyor observed the inside of the microwave in the South Two kitchenette with black markings on the back and top. The inside top contained food splatter and was bubbling and peeling. During an interview on 8/2/24 at 9:55 A.M., the Food Service Director said the top of the microwave was peeling and there were black marks. He said the housekeeping staff were responsible for cleaning he microwaves, and he did not know the inside of the microwave was peeling and he would have it replaced. 3. Review of the facility's policy titled Nutrition and Food Service: Ice Scoop Sanitation, dated as revised in September 2023, indicated ice machine equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. Clean and sanitize the ice scoop and other ice receptacles daily or as needed in the dishwasher and allowed to air dry. Store ice scoop beside or on top of the machine in a clean non-porous container that allows the water to drain off and not pool around the scoop. On 8/1/24 at 3:02 P.M., the surveyor observed the North Two kitchenette ice scoop mounted on the wall in a cylindrical holder. The surveyor observed the bottom of the holder, where the ice scoop rests, with liquid and a brown substance. During an interview with observation on 8/2/24 at 9:50 A.M., the Food Service Director said the ice scoop and the holder should be checked for cleanliness when the dietary staff are checking the kitchenettes. He said the bottom of the scoop should not have pooling liquid and a brown substance.

Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#323), out of a total sample of 24 residents, that the Resident received care and treatment in accordance with the medical care plan. Specifically, the facility failed to perform physician-ordered treatments to the Resident's external fixator pins. Findings include: Review of the facility's policy titled Charting and Documentation, revised in July 2017, indicated but was not limited to the following: -Documentation in the medical record may be electronic, manual or a combination. -The following information is to be documented in the resident medical record: Treatments or services performed -Documentation in the medical record will be objective (not opinionated or speculative) complete, and accurate. Resident #323 was admitted in July 2024 with diagnoses which included bilateral patellar tendon rupture with surgical repair. Review of the Minimum Data Set (MDS) assessment, dated 8/1/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was without cognitive impairment. Review of the Hospital Discharge Summary, dated 7/26/24, indicated that wound care to the internal fixator pins was to be done daily by nursing. Review of the Physician's Orders indicated: -Daily pin care with 1/2 normal saline and 1/2 hydrogen peroxide, apply gently with a Q-Tip to pin sites. Review of the Treatment Administration Record (TAR) indicated that on 7/27/24, 7/28/24,7/29/24, 7/30/24, and 7/31/24, the treatment to the external fixator pins to bilateral lower extremities was performed as ordered. During an interview on 7/31/24 at 1:30 P.M., Resident #323 said that nursing staff had not touched the pins since he/she was admitted . The Resident said the last time the pins were cleaned was in the hospital on 7/26/24. The Resident was not sure how often the pins were supposed to be cleaned by the facility. During an interview with Nurse #4, Resident #323, and Resident #323's Family Member on 7/31/24 at 1:50 P.M., Nurse #4 said she only looked at the bottom fixator pins, and did not see the top pins. She said that she must have signed off cleaning the fixator pins in error because she didn't perform the cleaning/treatment to the pins. The Resident said that no one had unwrapped, or looked at the pins, since the physician did so on Friday morning. The Resident's Family Member said the pins have not been cleaned for five days. During an interview on 7/31/24 at 1:50 P.M., Nurse #1 said she didn't see the order for pin care; she must have missed it. Nurse #1 reviewed the TAR and said that she did not perform the pin care on 7/29/24, but she confirmed that she signed that she had performed the treatment on the TAR. During an interview on 7/31/24 at 2:22 P.M., Nurse #3 said that she looked around the gauze and did not see any redness or drainage. She said she did not see any order for a dressing change. She also said that she did not remove the gauze to look at the pins underneath the gauze. During an interview on 8/1/24 at 12:39 P.M., Nurse #2 said that she worked on Tuesday, 7/30/24. She said that she remembered mixing up the cleaning solution for the pins, she signed off on performing the treatment to the pins, however she said that she didn't get to do the treatment because she got distracted with a new admission. During an interview on 8/6/24 at 11:05 A.M., the Director of Nursing (DON) said that she wasn't sure if Nurse #6 performed the treatment to the fixator pins on 7/27/24 and 7/28/24, although the nurse signed off that she had done the treatments on that date. Additionally, she said that at least 3 of 5 signed treatments to the Resident's fixator pins were not performed as ordered between 7/27/24 and 7/31/24, although they had been signed off by nursing as being done. The DON also said that a nurse should not sign off that a treatment was performed without having performed it.

Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles for one Resident (#322), out of a total sample of 24 residents. Specifically, the facility failed for Resident #322, to ensure the medications were administered under direct supervision and not left at the bedside. Findings include: Review of the facility's policy titled Competency Assessment Administering Oral Medication, revised October 2020, indicated but was not limited to the following: -The purpose of this procedure is to provide guidelines for safe administration of oral medications. -Prepare the correct dose of medication. -Confirm the identity of the resident. -Allow the resident to swallow oral tablets or capsules at his or her comfortable pace. -Remain with the resident until all medications have been taken. -Notify the supervisor if resident refuses the procedure, -Report other information in accordance with facility policy and professional standards of practice. Resident #322 was admitted to the facility in July 2024 with diagnoses which included: Fracture right femur and dementia. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the Resident was cognitively intact. Review of Resident #322's Self-Administration of Medication Assessment, dated 7/25/24, indicated the Resident did not want to have medications at the bedside or did not wish to administer his/her own medications. Review of Resident #322's care plan, dated 7/26/24, indicated but was not limited to the following: -Impaired cognitive function dementia or impaired thought processes. -Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of Resident #322's Medication Administration Record (MAR) for 9:00 A.M. pill administration indicated the following: -Amlodipine Besylate 2.5 milligrams (MG). Give one tablet by mouth for hypertension -Aspirin EC low dose delayed release 81 mg. Give one tablet by mouth for heart health. -Bupropion HCI Extended release (ER) extended release 12-hour 100 mg. Give one tablet by mouth in morning for depression. -Calcium Carbonate tablet chewable. Give 500 mg by mouth in the morning. -Donepezil HCI tablet 5 mg. Give one tablet by mouth for Alzheimer's. -Lamotrigine tablet 150 mg. Give one tablet by mouth in morning for bipolar. -Lexapro tablet 20 mg. Give one tablet by mouth in morning for depression. -Losartan Potassium tablet 100 mg. Give one tablet by mouth in morning for hypertension. -Vitamin D3 tablet 25 micrograms (MCG). Give one tablet by mouth in morning. -Docusate sodium capsule 100 mg. Give one capsule by mouth two times a day for constipation. -Sitagliptin-metformin HCI tablet 50-1000 mg. Give one tablet two times a day for diabetes. -Gabapentin capsule 300 mg. Give one capsule by mouth three times a day for pain. -Tylenol Extra strength tablet 500 mg. Give two tablets by mouth three times a day for pain dose of 1000 mg. On 7/31/24 at 10:40 at A.M., the surveyor observed a pill cup on Resident #322's bedside table containing 12 pills. During an interview on 7/31/24 at 10:40 A.M., Resident #322 said he/she asked the nurse to leave the pills and he/she would take them later. During an interview on 7/31/24 at 10:50 A.M., Nurse #4 said she did not give Resident #322 the medications this morning. Nurse #4 said the student nurse, under the supervision of her instructor, administered the medications. Review of the Nursing Note, dated 7/31/24, indicated this nurse [Nurse #4] observed medications unattended at bedside. During an interview on 7/31/24 at 11:11 A.M., the Director of Nurses (DON) said her expectation is the student nurses train with direct supervision from the instructor and stay with the resident until all the medications are consumed. The DON said Nurse #4 had notified her there were multiple pills left at Resident #322's bedside. She said Nurse #4 reconciled the pills because the Resident #322 told her he/she had already taken some. During an interview on 7/31/24 at 12:00 P.M., Nurse Student Instructor (NSI) said she did go in Resident #322's room with the student nurse and was standing by the end of the bed. She said she did not hear Resident #322 ask to leave the medication and thought Resident #322 had taken all the medication before they left the room. The NSI said she should have made sure Resident #322 took all his/her pills before leaving the room.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had experienced a fall at the Facility on 1/12/24 which resulted in him/her being diagnosed with a subdural hematoma (SDH, pool of blood between the brain and the outermost covering), the Facility failed to ensure nursing staff immediately notified his/her Physician, when on 01/31/24 at approximately 3:00 A.M., Resident #1 had a witnessed fall while being transferred by a Certified Nurse Aide (CNA), Resident #1 struck his/her head during the fall, had visible bruising and an injury to the right side of his/her face/head as a result of the fall, however the Physician was not notified until more than four hours later, at which time an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation and treatment. Findings include: Review of the Facility Policy, titled Change in Resident Condition, dated 09/2022, indicated that the Facility shall promptly notify the resident, his/her Attending Physician, and resident representative of changes in the resident's medical/mental condition and/or status. The Policy further indicated that the Nurse would notify the residents Attending Physician or on call provider when there has been; -accident or incident involving the resident; -discovery of injuries of an unknown origin; -a significant change in the resident's physical/emotional/mental condition; and -need to transfer the resident to the hospital or treatment center. Resident #1 was admitted to the Facility in December 2023, diagnoses included right hip fracture, anemia, chronic kidney disease, and significant dementia. Review of Resident #1's Hospital Discharge Summary, dated 01/13/24, indicated he/she was evaluated in the Emergency Department (ED) after a fall at his/her facility, and was found to have sustained a subdural hematoma (SDH, pool of blood between the brain and the outermost covering) and intraparenchymal (bleeding into the brain) hematoma. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 01/31/24, indicated that Resident #1 had a witnessed fall while transferring with CNA #1. The report indicated CNA #1 slipped backward onto the floor while transferring Resident #1 from his/her wheelchair back to bed and Resident #1 fell face first on top of CNA #1. The Report also indicated that Resident #1 sustained facial bruising to the right side of his/her face and forehead with a skin tear to his/her forehead. The Report indicated Emergency Medical Services (EMS) were called at 8:16 A.M. (which was more than five hours after the fall) to transport Resident #1 to the ED. Review of Resident #1's Nurse Progress Note (written by Nurse #1 at 4:53 A.M.), dated 01/31/24, indicated he/she experienced a witness fall sustaining an injury to his/her right temple and right arm. Although Resident #1 had a history of a SDH after a fall on 1/12/24, review of Resident #1's Medical Record indicated there was no documentation to support that Nurse #1 notified Resident #1's Physician of his/her fall on 1/31/24 with witnessed head strike and noted facial injury. Review of Resident #1's SBAR Nurse Progress Note (written by the Unit Manager and signed as completed at 8:14 A.M.), dated 01/31/24, indicated to send Resident #1 to the Hospital Emergency Department related to new fall, notable injury to his/her right temple, and history of recent SDH. During a telephone interview on 02/26/24 at 1:02 P.M. which included (review of his written witness statement, dated 01/31/24), CNA #1 said that at approximately 2:50 A.M. on 01/31/24 while he was transferring Resident #1 from the wheelchair back to his/her bed after being toileted, Resident #1 fell . CNA #1 said while he was transferring Resident #1, he (CNA #1) lost his footing, fell backwards onto the floor, and Resident #1 fell face forward on top of him. CNA #1 said he heard a banging sound as Resident #1 fell forward but said at that time he could not figure out what he/she (Resident #1) may have hit. CNA #1 said Resident #1 had blood dripping from the right side of his/her face and a skin tear to his/her right elbow area. During a telephone interview on 02/26/24 at 5:29 P.M., which included (review of his written witness statement, dated 01/31/24), CNA #2 said he was working on 01/31/24 during the overnight shift and that he became aware that Resident #1 had fallen around 3:00 A.M., because that was when CNA #1 called out for help. During an interview on 02/21/24 at 5:29 P.M. Nurse #1 said she was the nurse caring for Resident #1 from 11:00 P.M. on 01/30/24 through 7:00 A.M. on 01/31/24, Nurse #1 said that on 01/31/24, Resident #1 fell around 5:00 A.M. Nurse #1 said she was called to Resident #1's room after being notified of his/her fall. Nurse #1 said Resident #1 was sitting on his/her bed when she got to the room, then she went to get the vital signs machine and some treatment supplies for the visible injury to his/her head/face. Nurse #1 said she had not notified Resident #1's Physician after the incident and said she had not notified or asked any other nurses in the building for assistance. Nurse #1 said she just waited until the next shift came in at 7:00 A.M. and she said they took over the investigation and notifications. Nurse #1 said that she was unaware of Resident #1's history of a fall or that he/she had recently been diagnosed with a SDH. Nurse #1 said that this was the first time something like this had happen to her and that she was not sure what to do. Although Nurse #1 said Resident #1's fall on 01/31/24 occurred around 5:00 A.M., this conflicted with statements made by Nurse #1 in her original interview with the Director of Nurse (DON), during which Nurse #1 had reported to the DON that Resident #1's fall had occurred at 3:00 A.M. During an interview on 02/21/24 at 3:46 P.M., Nurse #4 said on 01/31/24, (prior to Resident #1 falling), she had introduced herself to Nurse #1 and told her that if she needed any help with anything to call or page her because she was working that shift, but was on a different unit in the building. Nurse #4 said Nurse #1 never called to inform her of the fall or to ask for any help. During an interview on 02/21/24 at 1:42 P.M., the Unit Manager said she arrived at the Facility on 01/31/24 a little before 7:00 A.M. and went to her office and said she received a phone call from the DON informing her that Resident #1 had a fall. The Unit Manager said she went to speak with Nurse #1, asked her what had happened with Resident #1 and asked Nurse #1 if she had informed the supervisor on that shift, or if she had notified Resident #1's Physician and that Nurse #1 had said no. The Unit Manager said she and the DON went to assess Resident #1 and immediately noted new bruising to his/her face and a dressing in place. The Unit Manager said it is the expectation of the Facility is that if a resident sustains a fall, after first assessing the Resident, the Nurse must notify the Physician and resident representative/HCA as soon as possible and report any injuries and obtain any orders from his/her Physician. During an interview on 02/21/24 at 4:09 P.M., the Director of Nurses (DON) said that she was aware of the fall once she came into the building on 01/312/24, and read the previous shifts nurse progress notes. The DON said she called the Unit Manager to make her aware of the incident and together they went to assess Resident #1. The DON said that the Nurse Practitioner (NP) was in the building, and after reviewing the details of the fall and with Resident #1's history of recent SDH, she went to speak with the NP, and said the NP gave a verbal order to send Resident #1 to the ED. The DON said that it is the expectation of the Facility that nurses immediately notify the Physician, residents responsible party/HCA, and herself of any significant change in condition, including falls. On 02/17/24, 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) 01/31/24, Resident #1 was transferred to the Hospital ED for evaluation and treatment as needed, and returned to the facility the same day. B) 01/31/24, Resident #1 plan of care was reviewed and updated, he/she now requires two-person physical assist for all transfers. C) 01/31/24, The Director of Nurses (DON) reported the incident to Nurse #1's Staffing Agency, and requested that Nurse #1 be placed on the Do Not Return List for Facility. D) 01/31/24, The Director of Nurse (DON) and the Assistant Director of Nurses (ADON) initiated mandatory education for all licensed staff on the following Policies and Procedures (P&P): -Falls and Neurological Checks; -Change in Resident Condition and Notification of Change; -Abuse, Neglect, and Misappropriation; -Resident Rights; -Incident Reporting/Reporting to Supervisor in House; and -Comprehensive Person-Centered Care Plan. E) 01/31/24, Facility Fall Audits were initiated by the DON and ADON ensuring all aspects of a Fall Incident were completed. Fall Audits will be completed every shift for all units for 30 days, then completed weekly for four weeks, and then monthly for three months. Fall Audits will be reviewed at Quality Assurance and Performance Improvement (QAPI) meetings. F) 02/01/24, the DON and ADON initiated daily audits to confirm Agency Staff completed facility required orientation process, which included mandatory education for licensed staff on P&P. G) 02/01/24, Competency testing for licensed nursing staff was instituted related to materials reviewed during In-Servicing to ensure compliance. H) Audits initiated as as result of this incident, will be reviewed daily by the DON and/or designee the following morning for continued compliance. I) 02/01/24, 02/08/24, and 02/14/24, AD HOC QAPI meetings were held with Leadership Team to review the Facility Plan of Correction. J) The DON and/or Designee are responsible for overall compliance.

Based on observations, interviews, and review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was a greater than 14 hours between dinner and breakfast service. Findings include: During the Resident Group meeting held on 5/12/23 1:30 P.M., with 14 residents, the overall concern expressed by the group was evening snacks were not offered or available. Residents in the group specifically said the following: -They never have snacks available. -There are no snacks available at night. -If you want ginger ale or a snack you can have the nurses get them if there are some available. -The dietitian said there are no snacks at nighttime because you guys eat them all during the day. -They used to have a hostess that made sure snacks were always available, now that there is no hostess and we run out of snacks all the time. -They do not offer nighttime snacks and he/she said he/she has become hypoglycemic (low sugar) in the night. -They run out of ice cream at night. -They run out of juice at night. Review of the Food Truck Delivery Times, undated, provided by the Food Service Director indicated there was 14 hours and 50 minutes between dinner and breakfast service. Dinner schedule: SSU (North 1)- 4:40 P.M. North 1 - 4:50 P.M. North 1 - 5:00 P.M. South 2 - 5:10 P.M. South 2 - 5:20 P.M. North 2- 5:30 P.M. North 2- 5:40 P.M. Breakfast schedule: SSU (North 1) 7:30 A.M. North 1- 7:40 A.M. North 1- 7:50 A.M. South 2- 8:00 A.M. South 2- 8:10 A.M. North 2- 8:20 A.M. North 2- 8:30 A.M. Review of the facility provided Hostess Stock List for the kitchenettes included the following foods: -2 Ginger ale -2 Diet Ginger ale -2 Cranberry Juices -1 Diet Cranberry Juice -2 Apple Juices -6 Yogurts -1 Peanut Butter -1 Jelly -3 Apple Sauces cases of the packs -1 Whole Wheat Bread -Bagels / English muffins -1 Country [NAME] Bread -2 Orange Juices -1 Ice cream case (different flavors) and Magic Cups -Unsalted Saltine Crackers -Graham Crackers -Cookies assorted -Condiments: Salt/pepper, ketchup, mustard, etc . -Tea bags On 5/15/23 at 1:15 P.M., the surveyor observed North 1, North 2, and South 2 kitchenettes and they were very sparsely stocked with snacks and food. Specifically, the following observations were made: -No bread, no peanut butter, and jelly in only one kitchenette. -Each kitchenette had one plastic container which was approximately one quarter filled with saltine crackers and 2-3 packages of individually wrapped cookies. -North 1 had one sandwich in the refrigerator supplied by the kitchen. There were no sandwiches available on North 2 and South 2. -South 2 and North 2 had three individual size containers of cereal in the cabinet; North 1 had no cereal available. During an interview on 5/17/23 at 2:15 P.M., the Food Service Director said he was aware through the Resident Council meetings the snack supply was lacking at night. He said the person who stocked the kitchenettes leaves at 2:00 P.M., and they weren't getting the kitchenettes re-stocked for the evenings. He said he would expect the nurses to serve snacks and there should be some protein component to the snacks, especially for the diabetics.

Based on interview, record review, and policy review, the facility failed to implement their Antibiotic Stewardship program and ensure antimicrobial medications were used for an acceptable and prescribed indication and duration of time for two Residents (#15 and #24), in a total sample of 25 residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program, dated September 2022, indicated the mission of the program was to provide the best antibiotic therapy (right dose, drug, and duration) to residents that results in the best outcome with the least amount of toxicity and resistance. In addition, the policy indicated: -The Infection Control Nurse (ICN) will be responsible for infection surveillance and Multidrug Resistant Organism (MDRO) tracking. The ICN and will collect and review the following data: a. Type of antibiotic ordered, route of administration, and cost. b. Whether the order was made by phone, if the order was given by the attending physician or on-call physician/physician extender. c. Whether tests such as cultures were obtained prior to ordering antibiotics. d. Whether the antibiotic was changed during the course of treatment. e. Whether the resident infection report was completed, and resident met the criteria before antibiotic use. f. Feedback will be given to physician/physician extenders by the team on their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated. Review of the facility's policy titled Antibiotic Stewardship Program Orders, dated September 2022, indicated but was not limited to the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program -Prescribers will provide complete antibiotic orders including: drug name, dose, frequency, duration of treatment, start and stop date (or number of days of therapy) and indications for use. -Appropriate indications for use of antibiotics include: criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity. Review of the American Urological Association Recurrent Uncomplicated Urinary Tract Infections Guideline, dated 2022 indicated the following: -Even transient use of antibiotics can affect the carriage of resistant organisms and impact the endemic level of resistance in the population. -The potential harms related to acquiring an antibiotic resistant infection should be factored into the decision for antibiotic prophylaxis for Urinary Tract Infection (UTI) prevention. -In clinical practice, the duration of prophylaxis can be variable, from three to six months to one year, with periodic assessment and monitoring. 1. Resident #15 was admitted to the facility in February 2022 with diagnoses including chronic kidney disease. Review of the medical record indicated Resident #15 had two recurrent UTIs within a month, and the physician ordered Cephalexin Suspension Reconstituted 125 milligrams (mg)/milliliters (ml); give 5 ml by mouth one time a day for UTI prophylaxis (4/7/22). Further review of the medical record indicated Resident #15 developed five UTIs, one episode of community acquired pneumonia and developed a multidrug-resistant infection in his/her stool while being administered prophylactic Cephalexin as follows: -On 9/12/22, the prophylactic Cephalexin was put on hold, and intravenous Meropenem (antibiotic) was administered for 5 days (9/12/22 through 9/17/22) for the treatment of a UTI. The Cephalexin then resumed when the course of Meropenem had been completed. -On 10/24/22, prophylactic Cephalexin was put on hold, and Augmentin (antibiotic) was administered for 7 days (10/24/22 through 10/31/22) for the treatment of a UTI. The Cephalexin then resumed when the course of Augmentin had been completed. -On 2/16/23, prophylactic Cephalexin was put on hold, and Ciprofloxacin (antibiotic) was administered for 5 days (2/16/23 through 2/21/23) for the treatment of a UTI. The Cephalexin then resumed when the course of Ciprofloxacin had been completed. -On 3/6/23, prophylactic Cephalexin was put on hold, and Tetracycline was administered for 7 days (3/6/23 through 3/13/23) for the treatment of a UTI. The Cephalexin then resumed when the course of Tetracycline had been completed. -On 4/10/23, Amoxicillin 875 mg every 12 hours for 5 days and Azithromycin 500 mg one time only and 250 mg daily for 4 days was initiated to treat community acquired pneumonia. Orders for Cephalexin remained in place. Review of a 4/14/23 Medical Note indicated Resident #15 told the physician/physician extender that he/she was experiencing multiple episodes of diarrhea since the previous morning. The clinician ordered a stool culture to rule out c.diff due to antibiotic use (clostridium difficile colitis results from disruption of normal healthy bacteria in the colon, often from antibiotics). Review of 4/21/23 stool culture results indicated Resident #15 did not have c.diff, but had developed enterococcus faecium in his/her stool. According to the Centers for Disease Control, Vancomycin-resistant Enterococci (VRE) in Healthcare Settings (November 13, 2019), is a multidrug resistant organism and those most likely to be infected include people who have been previously treated with antibiotics for long periods of time. The laboratory results indicated the infection was sensitive to Linezolid (antimicrobial drug used to treat VRE) and the physician initiated a 14-day course of Linezolid 600 mg daily. The order for prophylactic Cephalexin remained in place. Review of the American Urological Association Recurrent Uncomplicated Urinary Tract Infections Guideline, dated 2022 indicated the following: -The potential harms related to acquiring an antibiotic resistant infection should be factored into the decision for antibiotic prophylaxis for UTI prevention. -On 5/1/23, prophylactic Cephalexin was put on hold, and Ciprofloxacin was initiated for 5 days to treat a UTI. The Cephalexin was resumed when the completion of the course of Ciprofloxacin was completed. During an interview on 5/16/23 at 1:40 P.M., the Infection Control Nurse said she does not keep a list of residents who are receiving prophylactic antibiotics. She said that the resident information would be added to the line listing when the antibiotic was started, but she does not perform any routine monitoring/documentation/oversight for these residents after the initiation of the prophylactic antibiotic. The Infection Control Nurse said she was not aware that Resident #15 had been on prophylactic Cephalexin for a UTI since April 2022. During an interview on 5/16/23 at 2:40 P.M., the Director of Nurses said the expectation was for the physician (or physician extender) to review the indefinite use of a prophylactic antibiotic. She said if a resident is on long term antibiotics, but still has UTIs, the antibiotic treatment isn't effective and should be reviewed by the physician. During an interview on 5/16/23 at 3:20 P.M., the Nurse Practitioner said the most recent data, approximately six months ago, indicated prophylactic antibiotics for UTIs were not effective for more than three to six months and had been slowly learning about this. She said she and the physician have been reducing long term prophylactic antibiotic use in other buildings, but haven't started at this facility yet. 36542 2. Resident #24 was admitted to the facility in May 2022. Review of the care plans for Resident #24 indicated the Resident had a history of recurrent urinary tract infections (UTI) and received antibiotic therapy prophylactically. Review of the current Physician's Orders indicated Resident #24 had an order for Keflex 250 mg (milligrams) to be given one time per day prophylactically for UTI. The order was initiated on 6/8/22 (11 months prior) and did not include an end date. Review of the manufacture's guidelines for use indicated prolonged use of Keflex may result in the overgrowth of non-susceptible organisms. During an interview on 5/16/23 at 12:05 P.M., the Infection Control Nurse (ICN) said the facility did not really have any long-term care residents on prophylactic antibiotics. She said if a physician ordered a prophylactic antibiotic she did not review this with the physicians as she did not like to tell the physician what to do. During a continued interview at 2:22 P.M., the ICN said she was unaware Resident #24 was on an antibiotic as the Resident was not showing up on the antibiotic report she pulls from the electronic medical record system. She said she had been reviewing antibiotic use at the facility for the previous two months and was unaware of the prophylactic use of antibiotics for Resident #24. The ICN added the facility did not have a policy that addressed the extended use (prophylactic use) of antibiotics. During an interview on 5/16/23 at 2:40 P.M., the Director of Nurses said the expectation was for the physician (or physician extension) to review the indefinite use of a prophylactic and thought the Nurse Practitioner for Resident #24 had reviewed the continued use. During an interview on 5/16/23 at 3:20 P.M., the Nurse Practitioner (NP) said Resident #24 had previously been on prophylactic antibiotics in the community (prior to the admission to the facility in May 2022) and had requested to be placed on the antibiotic again for UTI prevention. The NP said the most recent data, approximately six months ago, indicated prophylactic antibiotics for UTI were not effective for more than three to six months and had been slowly learning about this and had started following this guidance at other facilities. She said she had not received any recommendations from the facility pharmacy consultant on the prophylactic use of antibiotics and found this odd, as she had received recommendations from other facility pharmacy consultants regarding prophylactic antibiotic use. She said she and the physician had not had a chance to re-evaluate the continued use of the antibiotic beyond the recommended time frame for Resident #24.

Based on observation, interview, and policy review, the facility failed to maintain a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: 1. For Resident #66, ensure intravenous tubing connections were disinfected prior to the administration of medication, per facility policy; 2. For Resident #108, a. Ensure staff changed their personal protective equipment in between tasks for the same Resident that could result in the introductions of hazardous germs into the system, b. Ensure staff stored an enteral irrigation syringe in a manner to prevent environmental debris and germs from contaminating it in between uses, and c. Ensure enteral food was labeled and dated per facility policy; and 3. Ensure hand hygiene was performed during medication pass administration. Findings include: 1. Review of the facility's policy titled Intermittent Medication Administration, dated January 2022, indicated but was not limited to the following: - purpose of this policy is to safely administer intermittent intravenous (IV) infusions of medications or solutions to a resident - vigorously scrub needleless connector with an alcohol swab using friction and a twisting motion for 15 seconds, allow to air dry, attach prescribed flush and confirm patency - vigorously scrub needleless connector with alcohol swab, using friction and a twisting motion for 15 seconds, allow to air dry, and connect primed administration set tubing Resident #66 was admitted to the facility in April 2023 with a diagnosis of extradural and subdural abscess (an infection in the epidural and subdural spaces anywhere within the brain and spinal cord). Review of the medical record indicated Resident #66 had a single lumen peripherally inserted central catheter (PICC) in his/her right upper extremity (RUE) for IV antibiotic administration. Review of the current May 2023 Physician's Orders for Resident #66 indicated but was not limited to the following: - Cefazolin 2 grams intravenously every eight hours at midnight, 8:00 A.M., and 4:00 P.M. - Flush procedure for valved catheter: flush with 10 milliliters (ml) normal saline (NS) before medication administration and 10 ml of NS after medication administration. During a medication administration observation on 5/12/23 at 9:23 A.M., the surveyor observed the following: - Nurse #6 performed hand hygiene (HH) using alcohol-based hand rub (ABHR), put on an isolation gown and gloves - Nurse #6 observed the RUE PICC line insertion site for Resident #66 and said it looked to be free of signs and symptoms of infection and verified the dressing was in good condition and dated - Nurse # 6 verified the medication for the Resident and spiked the IV antibiotic with the IV tubing and primed the tubing ensuring no bubbles were in the tubing - Nurse #6 covered the end of the primed tubing and hung the antibiotic on the IV pole, removed her gloves, performed HH with ABHR and put on new gloves - Nurse # 6 removed the cap from the end of Resident #66's PICC line tubing and scrubbed the end (hub) of the tubing for 3-5 seconds with an alcohol wipe - The line was flushed with a syringe of NS; the nurse disconnected the NS syringe and immediately attached the primed IV antibiotic tubing to the hub of the PICC line Nurse #6 was not observed to scrub the hub of the PICC line after flushing the line with NS, nor was she observed to scrub the hub for the necessary time frame to prevent potential germs from entering the blood system (15 seconds). During an interview on 5/12/23 at 1:46 P.M., the Director of Nurses (DON) was made aware of the surveyor's observations of the IV medication administration and said Nurse #6 should have scrubbed the hub of the PICC line for a minimum of 15 seconds before the flush with NS and after, prior to the administration of the medication per the policy and general standard of practice. She said her expectations were not met and good infection control practices were not followed per the policy when Nurse #6 administering IV medications to Resident #66. 2a. Review of the facility's policy titled Transmission-Based Precautions, dated 5/2023, indicated but was not limited to the following: - Enhanced Barrier Precautions (EBP) expand the use of personal protective equipment (PPE) and refers to the use of both gloves and a gown during high contact care activities which provide opportunity for germs to transfer onto staff hands and clothing. - residents with indwelling medical devices or wounds are at high risk for acquiring and becoming colonized with a multi-drug resistant organism - examples of high contact care includes, but is not limited to: providing hygiene, changing linens, assisting with toileting needs, and device care - including a feeding tube. Resident #108 was admitted to the facility in May 2023 with diagnoses including: unspecified intestinal obstruction, malignant neoplasm of the mouth, and a new colostomy. Review of the medical record indicated Resident #108 was on EBP and had a feeding tube in place as well as a new colostomy. On 5/12/23 at 10:00 A.M., the surveyor observed the following: - Nurse #6 performed HH with ABHR and put on a gown and gloves to perform colostomy care for Resident #108 - Nurse #6 used a cloth with warm water to remove feces from the skin and stoma (a surgically created opening in the body) - Nurse #6 assisted the Resident with changing his/her clothing and bedding, which was soiled with feces, and then placed a new ostomy appliance on the Resident - Nurse #6 removed her gloves, performed HH with ABHR, and put on new gloves - Nurse #6 then began the process of administering medications through a feeding tube, without changing her gown During an interview on 5/12/23 at 11:23 A.M., Nurse #6 said she should have changed her gown in between providing colostomy care and administering medications through a feeding tube and it created an infection control concern for germs to potentially enter the tube. b. Review of the facility's policy titled Preventing and identifying enteral feeding complications, dated as reviewed: September 2022, indicated but was not limited to the following: Bacterial contamination may be prevented by: - use proper infection control techniques - all enteral feedings and supplies used, (including irrigation syringe), must be labeled and dated with the nurse's initials Review of the current May 2023 Physician Orders for Resident #108 indicated but was not limited to the following: - Change enteral irrigation syringe daily and date the syringe (3/17/23) On 5/12/23 at 10:29 A.M., the surveyor observed Nurse #6 use an irrigation syringe, that was unlabeled and sitting on the windowsill in the room to administer medications and enteral feedings to Resident #108. During an interview on 5/12/23 at 11:23 A.M., Nurse #6 said the irrigation syringe she used to perform the tasks of medication administration and enteral feeding was unlabeled and on the windowsill of the room and believes it is from the 3:00 P.M. to 11:00 P.M., shift the day prior, as she had worked and said she believes she put it there. She said she brought a new irrigation syringe in with her but did not think it appeared to be compatible and did not want to leave the room again to get supplies and decided to use the old one. She said she should have used a new labeled and dated syringe to provide care to the Resident. During an interview on 5/12/23 at 1:46 P.M., the DON said the nurse should have used a labeled and dated irrigation syringe or a new irrigation syringe to provide care to the Resident and using an unlabeled syringe from the windowsill was an infection control concern for bacteria growth. 41106 c. Review of the facility's policy titled Preventing and Identifying Enteral Feeding Complications, dated September 2022, indicated but was not limited to the following: Bacterial contamination may be prevented by: - Use proper infection control techniques. - All enteral feedings and supplies used, (including irrigation syringe), must be labeled and dated with the nurse's initials. On 5/11/23 at 10:53 A.M., the surveyor observed on Resident #108's dresser a bag of Isosource 1.5 cal (calorie) which was approximately 1/3 full, laying on top of a pull-up under garment, a pair of green hospital socks, and two open light blue under garments. The bag was not labeled, dated with the nurse's initials. The bag of Isosource 1.5 cal bag indicated the following information: -For tube feeding only -Directions for use: Use for a maximum of 48 hours after connection when proper technique is followed. During an interview on 5/11/23 at 10:53 A.M., Resident #108 said they poured his/her food out of the bag of food on his/her dresser. During an interview on 05/15/23 at 5:30 P.M., the Director of Nurses (DON) said she removed the bag of food left on top of the dresser on 5/11/23. She said her expectations would be that the bag is labeled and stored in the medication cart or the medication room. 28450 3a. Resident #122 was admitted to the facility in April 2023 with diagnoses including gastrostomy status, encounter for surgical aftercare following surgery of the digestive system. On 5/16/23 at 8:23 A.M., the surveyor observed Nurse #8 administer medications to the Resident. The surveyor did not observe Nurse #8 perform hand hygiene: before pouring medications, before entering the room, after medications had been administered, and prior to leaving the Resident's room. During an interview on 5/16/23 at 11:55 A.M., Nurse #8 said she forgot to perform hand hygiene during the administration of the Resident's medications. b. Resident #112 was admitted to the facility in March 2022 with diagnoses including anxiety disorder and gastroesophageal reflux disease without esophagitis. On 5/16/23 at 9:20 A.M., the surveyor observed Nurse #3 administer medications to Resident #112. The surveyor did not observe Nurse #3 perform hand hygiene: before pouring medications, before entering the room, after medications had been administered, and prior to leaving the Resident's room. During an interview on 5/16/23 at 12:25 P.M., Nurse #3 said she forgot to perform hand hygiene during the administration of the Resident's medications. During an interview on 5/16/23 at 12:33 P.M., the Assistant Director of Nursing said handwashing should be performed before pouring medications, before entering the room, after medications have been administered, and/or before leaving the Resident's room. During an interview on 5/17/23 at 4:20 P.M., the DON said it was a breech in infection control.

Based on observation, policy review, and interview, the facility failed to ensure 4 of 5 nourishment kitchenettes were maintained in a sanitary manner to prevent potential illness or contamination of food. Specifically, the facility failed to: 1. Ensure foods brought in from the outside were labeled, dated, and discarded timely; and 2. Maintain kitchenette refrigerators, freezers, microwaves, counters, drawers, and cabinets in a clean sanitary manner. Findings include: 1. Review of the facility policy titled: Foods brought in by family/visitor/residents, dated as reviewed 1/2023, indicated but was not limited to the following: - the purpose of this policy is to ensure food safety for residents - food or beverages must be labeled and dated to monitor for food safety - foods must be stored in a clean, covered, container and/or securely wrapped, labeled with resident's name, room number and date food was cooked or stored - foods with manufacturer expiration dates must be labeled with the resident's name and will be thrown away after they have passed the manufacturer date - other foods and beverages will be labeled upon arrival to the facility and thrown away three days of date marked On 5/17/23 at 7:49 A.M., the surveyor observed signs posted in the unit and activity room kitchenettes that indicated the following: -Refrigerator is for resident food only. No staff food. Per regulation all food must be labeled and dated, or it will be thrown out. During an interview on 5/17/23 at 9:25 A.M., the Food Service Director (FSD) said Dietary is responsible for maintaining the kitchenette freezer, refrigerator, ice bins, and stocking of snacks. He said when food is brought in it is to be labeled with a date and resident's name and discarded after three days. During a tour of the kitchenettes with the FSD on 5/17/23, the surveyor made the following observations: 9:25 A.M. South 1 kitchenette: - a clear plastic container of watermelon, in the refrigerator, labeled with the resident's name but no date of expiration or when item was brought in - an open box of Dominos granulated sugar, unlabeled and undated, not in a sealed container or wrapped, that had hardened in the cabinet - a [NAME] Donut's bag wrapped tightly around a donut that was unlabeled and undated - a white paper bag containing food, in the refrigerator, unlabeled and undated - a small brown box of food, labeled with a resident's name and date of 5/12/23 The FSD discarded all items as they were not labeled or dated or outside of their date range and said the small box should have been thrown away on 5/15/23 per the policy. 9:41 A.M. North 2 kitchenette: - a box of Dole peach fruit cups, in the cabinet, labeled with the resident's name and manufacturer's date of 3/27/23 - in the refrigerator, a clear plastic container which held three cupcakes, labeled with a resident's name but no date - a clear plastic container unlabeled, with an illegible expiration date The FSD threw all items in the trash and said they did not meet the policy guidelines for storing resident food. 9:48 A.M. South 2 kitchenette: - a Styrofoam plate of food on the top shelf in the cabinet, unlabeled and undated - an open individual sized applesauce container on the door of the refrigerator, unlabeled and undated - a plastic bag containing food, unlabeled and undated in the refrigerator - a brown paper bag in the refrigerator, containing an empty reusable food container, apple and a knife, unlabeled and undated The FSD threw all items in the trash and said they did not meet the policy guidelines for storing resident food and said the plate of food on the shelf was from an event the day before and should not have been stored in the kitchenette. 2. During an interview on 5/17/23 at 7:55 A.M., Dietary Aide #3 said dietary staff stock all the kitchenettes and check the refrigerator and freezer for temperatures and cleanliness and housekeeping was responsible for cleaning the actual kitchenette to the best of her knowledge unless the process has changed. During an interview on 5/17/23 at 9:25 A.M., the FSD said Dietary is responsible for maintaining the kitchenette freezer, refrigerator, ice bins, and stocking of snacks. He said his belief was that housekeeping cleaned all aspects of the kitchenettes otherwise. During a tour of the kitchenettes with the FSD on 5/17/23, the surveyor made the following observations: 9:25 A.M. South 1 kitchenette: - the microwave had splattered food debris inside, and an approximate 1 1/2-inch area in the top left interior corner of cracked paint that was bubbled up and flaking with dark brown edges - counter in front of the sink with a hard, dry orange substance that had dripped over the counter edge - bins holding plastic utensils that were not individually wrapped with food debris and crumbs in the bin touching the eating surface of the plastic silverware - bin that holds cookies and crackers had loose cookies and the bottom had numerous crumbs in the corners 9:41 A.M. North 2 kitchenette: - drawer that holds condiments/silverware bins with food and crumb debris and dark brown substance in the back corner - front of drawer that holds plastic utensils had a thick, dark brown sticky substance in the crease in between the silverware bin and drawer edge - interior cabinets above sink that stored snacks were dirty with what appears to be yellow stains and spattered food on the shelves and walls of the cabinet - evidence of spills in the refrigerator 9:46 A.M. 2nd Floor Activity Room fridge: - dried, red sticky substance in the bottom of the refrigerator and on all levels of shelves - yellow dried substance in the bottom of the freezer section - two personal ice cube trays including silicone shaped ice cube trays that did not contain ice cubes, but had a dry light-yellow powder like debris in the freezer - two ice cube trays of ice cubes in the freezer that appeared to have an unclear light-yellow substance on top of the ice cubes and on the trays The FSD said the kitchen staff are not involved with cleaning or maintaining the fridge in the activity room at all and the unit needed to be cleaned. He said the kitchen provided house stock beverages and snacks to the activity room. 9:48 A.M. South 2 kitchenette - cabinets where snacks were stored had shelves and walls with evidence of splattered food debris - refrigerator had evidence of yellow substance drippage that had dried on the refrigerator door and numerous crumbs and debris in the bottom of the refrigerator The FSD said that the nourishment kitchenettes do not appear to have been cleaned recently and the microwave on South 1 required replacement. He said the nourishment kitchenettes require more attention for food and supplies to be maintained in a more sanitary way. During an interview on 5/17/23 at 10:07 A.M., the Administrator was made aware of the surveyor's and FSD's observations and said the process needed to be adjusted to maintain things in a better way.

Based on record review and interview, the facility failed to hold the administration of insulin when the capillary blood glucose (CBG) was outside of the physician ordered parameters for one Resident (#86), out of a total sample of 25 residents. Specifically, the facility failed to hold the administration of insulin 26 times out of 228 administration opportunities from 2/25/23 through 5/15/23. Findings include: Resident #86 was admitted to the facility in February 2023 with diagnoses which included type 2 diabetes and dementia. Review of Resident #86's care plan indicated: -The Resident has diabetes mellitus -Administer diabetes medication as ordered by the doctor -Monitor blood sugars as ordered Review of the Medication Administration Record (MAR) for February 2023 indicated: -Humalog (short-acting insulin) Kwik Pen inject 25 units subcutaneously (under the skin) with meals for diabetes effective 2/25/23 through 2/28/23 -Hold for CBG less than 100 -One out of 12 administrations were administered out of parameters on the following dates: -2/26/23 at 5:00 P.M., CBG of 92 Review of the MAR for March 2023 indicated: -Humalog Kwik Pen inject 25 units subcutaneously with meals for diabetes effective 3/1/23 through 3/6/23 -Hold for CBG less than 100 -17 administrations were administered correctly. Review of the MAR for March 2023 indicated: -Humalog Kwik Pen inject 20 units subcutaneously with meals for diabetes effective 3/7/23 through 3/17/23 -Hold for CBG less than 100 -31 administrations were administered correctly. Review of the MAR for March 2023 indicated: -Humalog Kwik Pen inject 15 units subcutaneously with meals for diabetes effective 3/17/23 through 3/20/23 -Hold for CBG less than 140 -Two out of 10 administrations were administered out of parameters on the following dates: -3/17/23 at 12:00 P.M., CBG of 120 -3/18/23 at 5:00 P.M., CBG of 95 Review of the MAR for March 2023 indicated: -Humalog Kwik Pen inject 10 units subcutaneously with meals for diabetes effective 3/20/23 through 3/27/23 -Hold for CBG less than 140 -Four out of 21 administrations were administered out of parameters on the following dates: -3/22/23 at 5:00 P.M., CBG of 134 -3/23/23 at 5:00 P.M., CBG of 139 -3/26/23 at 8:00 A.M., CBG of 133 -3/26/23 at 5:00 P.M., CBG of 132 Review of the MAR for April 2023 indicated: -Humalog Kwik Pen inject 8 units subcutaneously with meals for diabetes effective 3/27/23 through present -Hold for a blood sugar of 140 or less -Fourteen out of 93 administrations were administered out of parameters on the following dates: -4/4/23 at 7:30 A.M., CBG of 96 -4/4/23 at 11:30 A.M., CBG of 102 -4/6/23 at 7:30 A.M., CBG of 100 -4/6/23 at 11:30 A.M., CBG of 118 -4/7/23 at 7:30 A.M., CBG of 128 -4/7/23 at 11:30 A.M., CBG of 81 -4/7/23 at 4:30 P.M., CBG of 135 -4/18/23 at 4:30 P.M., CBG of 112 -4/21/23 at 4:30 P.M., CBG of 123 -4/22/23 at 4:30 P.M., CBG of 118 -4/25/23 at 7:30 A.M., CBG of 139 -4/25/23 at 11:30 A.M., CBG of 127 -4/27/23 at 4:30 P.M., CBG of 130 -4/29/23 at 11:30 A.M., CBG of 119 Review of the MAR for May 2023 indicated: -Humalog Kwik Pen inject 8 units subcutaneously with meals for diabetes effective 3/27/23 through present -Hold for a blood sugar of 140 or less -Five out of 44 administrations were administered out of parameters on the following dates: -5/4/23 at 4:30 P.M., CBG of 115 -5/7/23 at 7:30 A.M., CBG of 111 -5/7/23 at 11:30 A.M., CBG of 121 -5/8/23 at 4:30 P.M., CBG of 126 -5/10/23 at 4:30 P.M., CBG of 102 Further review of the MAR's indicated 13 nurses administered insulin to Resident #68 out of the physician ordered parameters. During an interview on 5/17/23 at 9:45 A.M., Nurse # 11 said if a resident was prescribed short-term acting insulin, the CBG would be checked and the computer indicated how much insulin to administer to the resident. She said Resident #68's insulin would drop to the low range at nighttime, so the physician ordered parameters which indicated not to administer insulin if the CBG was below a certain number. The surveyor and Nurse #11 reviewed Resident #68's MARs for March, April, and May and observed numerous times insulin was administered when the CBG was below 140. Nurse #11 said the MAR indicated the insulin was administered when the nurse checked the box and wrote a note on the delivery route and location. During an interview on 5/17/23 at 10:01 A.M., the Director of Nurses reviewed Resident #86's MARs and said the nurses should not have administered the insulin outside the physician ordered parameters.

Based on observation, record review, and interview, the facility failed to provide a therapeutic diet as ordered by the physician for one Resident (#41), out of a total sample of 25 residents. Findings include: Resident #41 was admitted to the facility in December 2019 with diagnoses including dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Review of the 3/30/23 Minimum Data Set assessment indicated Resident #41's long and short term memory was intact, required supervision with eating, and had dysphagia. Review of the May 2023 Physician's Orders indicated: -House diet, puree texture, moderately thick liquids/honey thick liquids consistency (1/2/20) Review of the most recent Speech Therapy evaluation, dated 1/2/20, indicated Resident #41 had a moderate level of dysphagia with mild risk for aspiration. Review of the Speech Therapy Discharge Summary, dated 1/13/20, indicated Resident #41 was discharged from therapy on International Dysphagia Diet Standardization Initiative (IDDSI) level 3: moderately thick liquids. On 5/11/23 at 1:18 P.M., the surveyor observed Resident #41 in his/her room with a lunch tray on the overbed table. Two cans of soda were on the table and an opened/empty packet of mildly thick/nectar consistency instant food thickener was on the table. Resident #41 said that he/she self thickens fluids using the premeasured packets. Review of a 3/28/23 Dietary note indicated Resident #41 required honey thick consistency liquids for safe swallowing. Review of interdisciplinary care plans included but was not limited to: -Problem: Resident has nutritional problem difficulties chewing/swallowing related to dysphagia as evidenced by swallow studies (12/18/19) -Interventions: Provide, serve diet as ordered: house diet/puree textures/honey thick liquid (12/18/19); Speech Language Pathologist (SLP) to screen and assess resident as needed for diet texture appropriateness (12/18/19) -Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight less than 220 pounds and consuming at least 75% of at least two meals daily through the review date (12/19/19) On 5/16/23 at 12:45 P.M., the surveyor observed Resident #41 sitting in bed. A soda can was on the overbed table and an open packet of mildly thick/nectar consistency instant food thickener was on the table. During an interview on 5/17/23 at 8:30 A.M., Certified Nursing Assistant #2 said Resident #41 is on her assignment and she is very familiar with him/her. She said up until a few months ago, she would assist the Resident with thickening his/her beverages. She said the Resident likes to add thickener to liquids him/herself is provided packets of thickener to keep in his/her room. During an interview in Resident #41's room on 5/17/23 at 8:47 A.M., Nurse #3 said the Resident thickens beverages him/herself and keeps the packets in a bureau drawer. She said the Resident likes to drink soda and always has cans available to drink. Resident #41 gave permission for Nurse #3 to open the drawer where he/she stores the thickening packets. Approximately 20 packets of mildly thick/nectar consistency instant food thickener packets were in a cardboard box. Nurse #3 read the packets and confirmed they were mildly thick/nectar consistency and not honey consistency according to physician's orders. She said she was going to remove them right away and provide the Resident the correct consistency. During an interview on 5/17/23 at 9:40 A.M., the Dietitian said Resident #41 is on a honey thick texture for fluids. She said beverages on meal trays come up from the kitchen already thickened, and any other beverages he/she consumes need to be thickened to a honey consistency. During an interview on 5/17/23 at 11:15 A.M., the Speech Therapist said Resident #41 has not received therapy since January 2020 and was discharged from services on honey consistency liquids. She reviewed the Resident's evaluation and said the Resident is supposed to be on honey thick liquids for all liquids, even soda which she said he/she likes to drink.

Based on interview and record review, the facility failed to ensure a recommendation from the consultant pharmacist was acted upon timely for one Resident #119, out of a total sample of 25 residents. Findings include: Resident #119 was admitted to the facility in September 2022. Review of the medical record indicated Resident #119 had a medication allergy to Atorvastatin (Lipitor). Review of the Consultant Pharmacist's Progress Notes indicated recommendations were made for Resident #119 on 1/20/23. Review of the electronic and paper medical records failed to include the pharmacist's recommendation from 1/20/23. During an interview on 5/16/23 at 4:00 P.M., the Director of Nurses said she believed she kept copies of the recommendations and would follow up. The 1/20/23 Consultant Pharmacist Recommendations to Prescriber form was provided to the surveyor on 5/16/23 at 5:00 P.M. Review of the Consultant Pharmacist Recommendations to Prescriber form, dated 1/20/23, indicated Resident #119 had an allergy to Lipitor but was currently receiving Seroquel, to clarify and if no issues have medical staff override allergy. The Consultant Pharmacist Recommendation to Prescriber was a copy and did not indicate a physician response (agree, disagree, other). Review of the Physician's Orders for Resident #119 failed to include an allergy override of the Lipitor in order to continue to administer the Seroquel. Review of the Physician's Progress Notes dated 1/20/23, 2/1/23, 3/26/23, 4/7/23, and 4/10/23, did not indicate the recommendation from the pharmacy consultant was reviewed. During an interview on 5/17/23 at 8:05 A.M., the Director of Nurses said the monthly Consultant Pharmacist Recommendations to Prescriber were sent directly to the Director of Nurses and the Unit Manager. She said the Unit Manager was responsible for ensuring the recommendations were addressed by the physicians. She said she was unable to locate any information to indicate the 1/20/23 recommendation from the consultant pharmacist was reviewed by the physician.

Based on observation, record review, and policy review, the facility failed to ensure that a licensed nurse had completed the necessary competencies prior to administering medication and enteral feeding through a gastrointestinal tube (tube goes into the stomach) for one Resident (#108). Findings include: Review of the facility's policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, dated 2008, indicated but was not limited to the following: -An orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers. -That's Our orientation program includes, but is not limited to: -In addition to our general orientation, each department will orientate the newly employee/transfer/volunteer to his or her department's policies and procedures, as well as other data will aid him/her in understanding the team concept, attitudes and approaches to resident care. -A written record will be maintained of each employee's/volunteer's individual orientation program. -Orientation records shall include the date reviewed, employee's/volunteer's initials, subject reviewed, and other information deemed necessary or appropriate. -Records of orientation shall be filed in the employee's/volunteer's personnel file upon completion orientation program. -Completed copies of Employee Orientation Checklists are filed in the employee's personnel file. According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. On 5/12/23 at 9:43 A.M., the surveyor observed Nurse #6 prepare and administer medications and an enteral feeding (Isosource) through Resident #108's feeding tube. The surveyor observed Nurse #6 fail to administer the medications per standards of practice and the facility policy and provide the enteral feedings per the physician's order. Specifically, the surveyor did not see Nurse #6 mix the medications with hot water, she did not check for tube placement prior to medication administration, she did not appropriately measure and administer the enteral feeding and flushes as ordered. During an interview on 5/12/23 at 11:23 A.M., Nurse #6 said she did not follow the orders specifically to use hot water to mix the medications in and used the ice water from her medication cart. She said she should have followed the orders specifically. She said she did not flush with 5 ml of water following each medication because she mixed most of the medications together with about 20 ml of cold water and thought that would cover all the required flushes. She said she should have checked for tube placement prior to medication administration and did not. She said she cannot be sure how much water or Isosource was administered to the Resident in total because she did not measure, but that she should have measured all the fluids to ensure the Resident is getting his/her ordered amount of Isosource and flushes. She said she was new to the facility, had only been there for about two weeks and felt nervous about performing medication and enteral feeding administrations. On 5/11/23 at 4:30 P.M., the surveyor reviewed Nurse #6's employee file for nursing competencies. The file did not contain the facility's competency for Medication Administration Through a Feeding Tube, Preparation and Administration of Parenteral Nutrition, or the nursing competencies checklist. During an interview on 5/12/23 at 1:46 P.M., the Director of Nurses (DON) was made aware of the surveyor's observations during medication administration and enteral feeding with Nurse #6. She said Nurse #6 is newer, but not inexperienced and has gone through a full orientation and training program. During an interview on 05/15/23 at 3:14 P.M., the Staff Development Coordinator (SDC) Nurse said she does not have the completed competencies check list for Nurse #6. She said the missing competencies include medication administration and enteral feeding. The SDC Nurse said the new nurses are given their competency checklist during orientation and they are supposed to have the nurse that is working with them, sign off the competencies as they are completed. During an interview on 5/15/23 at 3:24 P.M., Nurse #1 said she did work with Nurse #6 during evening shifts, but she did not sign off on any of her competencies. Nurse #1 said if Nurse #6 had any questions on any residents or procedures she would help, but she was not responsible for training her. During an interview on 5/15/23 at 3:49 P.M., the SDC Nurse said she just found out, in Nurse #6's case, she just went to the scheduler and told her she had completed orientation and was ready to be assigned a regular shift. She said nobody is tracking the new orientees to see if they have completed all their competencies. During an interview on 05/15/23 at 5:30 P.M., Nurse #7 said she does training and signs off new nurse competencies when they are completed. She said she did work with Nurse #6 five to six times but did not sign off on the medication administration or eternal feeding through the g-tube. She said the competencies stay on the unit in a folder until they are completed then they are given to the SDC Nurse. The surveyor and Nurse #7 went to the North 1 nursing station and Nurse #7 was unable to find any folder that contained competencies for new nurses. During an interview on 5/17/23 at 5:05 P.M., the SDC nurse said she is unable to find Nurse #6's completed competencies at this time and Nurse #6 is not returning her phone calls.

Based on observation, policy review, and interview, the facility failed for two Residents (#108 and #117) to maintain professional standards of practice, out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #108, a. Ensure medications that were administered through an enteral feeding tube met professional standards and the facility policy, and b. Provide enteral feedings as ordered by a physician; and 2. Follow the pharmacist recommendation to administer Tegretol (Carbamazepine - used to treat seizures, nerve pain, and bipolar disorder), with food for Resident #117. Findings include: 1. Resident #108 was admitted to the facility in May 2023 with diagnoses including unspecified intestinal obstruction and malignant neoplasm (abnormal growth of tissue) in the mouth. The Resident had a gastrointestinal feeding tube (tube goes into the stomach). a. Review of the facility's policy titled Medication Administration Through a Feeding Tube, dated as reviewed September 2022, indicated but was not limited to the following: - the purpose of this policy is to accurately administer oral medications through an enteral (feeding) tube - location of the feeding tube will be verified by nursing prior to administration of flushes or medications - the tube will be flushed with at least 30 cubic centimeters (cc) of water before and after medications are administered; it is recommended to flush with 5-15 cc of water between each medication administered Procedure: - if liquid medications are not available crush tablets into a fine powder and mix powder with 30-50 cc of water - flush feeding tube with at least 30 cc of warm water between the administration of each medication - administer each medication separately and flush the feeding tube with 5-15 cc of water in between each medication - verify tube placement as drug absorption will be affected by the tubes proper location On 5/12/23 at 9:43 A.M., the surveyor observed Nurse #6 prepare medications for administration to Resident #108 as follows: - Amoxicillin 875 milligrams (mg), crushed and placed in a small plastic medication cup with 20 milliliters (ml) of cold water from the ice water pitcher on the medication cart added to the cup - Azithromycin 250 mg - placed in small pill bag for crushing - Aspirin 81 mg - placed in the same small pill bag for crushing as Azithromycin - Proscar (finasteride) 5 mg - placed in the same small pill bag for crushing as the other pills - Pilocarpine 5 mg - placed in the same small pill bag for crushing as the other pills - Atorvastatin 20 mg - placed in the same small pill bag for crushing as the other pills The five pills were crushed together, placed in a small plastic medication cup, separate from the Amoxicillin, and mixed with 20 ml of cold water from the ice water pitcher on the medication cart. Nurse #6 then removed a large bag of Isosource 1.5 from the bottom drawer of the medication cart that was labeled as belonging to Resident #108 and dated 5/11/23. The surveyor observed Nurse #6 pour the Isosource 1.5 into two 5-ounce plastic cups, filling each cup about three quarters of the way up to the top. She said she does not measure the amount of Isosource, but believes each cup is about 125 ml, and the order is for 250 ml, and she trusts the cup size. Five ounces equals 147.86 ml, the five-ounce cups in use were not observed to be filled to the top and were only observed to be filled approximately three quarters of the way up. Nurse #6 then entered the room for medication administration, but provided other tasks to Resident # 108 prior to administering the medications at 10:29 A.M. (46 minutes after the medications were crushed and placed in cold water). The medications and Isosource 1.5 enteral feeding were placed on a table awaiting administration. At 10:29 A.M., the surveyor made the following observations of medication administration to Resident #108 through an enteral feeding tube: - Nurse #6 used an irrigation syringe from the room to draw up 90 ml of tap water and flush the tube with 90 ml of water - the nurse was not observed to verify placement of Resident #108's enteral tube, prior to flushing the tube or beginning medication administration - attached the irrigation syringe to the end of the enteral tube, without the plunger in place - poured cup of Amoxicillin previously mixed in 20 ml of cold water into the tube - medication residue was observed sticking in the bottom of the cup - poured additional water into the tube; she was not observed measuring the amount and said it was about 20 ml - poured second cup of medications into the syringe connected to the Resident's tube - poured more water into the tube; she was not observed measuring the amount but said it was about 20 ml b. Immediately following the administration of medications Nurse #6 was observed to do the following: - pour water into an empty 5-ounce plastic cup about a third of the way up, the nurse said it was about 30 ml of water, she was not observed to measure the water - the irrigation syringe was then used to draw 60 ml of Isosource 1.5 out of one of the two previously prepared cups and placed in the cup with the 30 ml of water, the cup was observed to be about three quarters of the way full - the irrigation syringe was attached to the Resident's tube, without the plunger - one cup of Isosource 1.5 which was previously poured but not measured, was then poured into the Resident's tube - the nurse said it was about 120 ml of Isosource but confirmed she did not measure it - the cup with 60 ml of Isosource 1.5 and 30 ml of water was then poured into the tube (visually it was the same amount of fluid as the cups of Isosource 1.5) - then the second cup of Isosource 1.5 was poured into the tube - the syringe was disconnected from the Resident and 60 ml of water was drawn into the syringe - the syringe was reattached to the Resident and the 60 ml of water was slowly pushed into the Resident's tube Review of Resident #108's current Physician's Orders for enteral feeding and medications indicated but were not limited to the following: - Aspirin 81 mg one time a day via tube at 9:00 A.M. - Atorvastatin 20 mg one time a day via tube at 9:00 A.M. - Azithromycin 250 mg one time a day via tube at 8:00 A.M. - Finasteride (Proscar) 5 mg one time a day via tube at 9:00 A.M. - Pilocarpine 5 mg one time a day via tube at 9:00 A.M. - Amoxicillin 875 mg two times a day via tube at 8:00 A.M. and 8:00 P.M. - Check placement of tube every shift - Flush feeding tube with 30 ml water before and after each medication pass and flush with 5 ml of water between each medication - Mix medications with hot water prior to administration - Flush feeding tube with 90 ml of water before and after bolus feedings five times a day - Isosource 1.5 bolus, 250 ml five times a day via tube During an interview on 5/12/23 at 11:23 A.M., Nurse #6 said she did not follow the orders specifically to use hot water to mix the medications in and used the ice water from her medication cart. She said she should have followed the orders specifically. She said she did not flush with 5 ml of water following each medication because she mixed most of the medications together with about 20 ml of cold water and thought that would cover all the required flushes. She said she should have checked for tube placement prior to medication administration and did not. She said she cannot be sure how much water or Isosource was administered to the Resident in total because she did not measure, but that she should have measured all the fluids to ensure the Resident is getting his/her ordered amount of Isosource and flushes. She said she was new to the facility, had only been there for about two weeks and felt nervous about performing medication and enteral feeding administrations. During an interview on 5/12/23 at 1:46 P.M., the Director of Nurses was made aware of the surveyor's observations and said Nurse #6 is newer, but not inexperienced and has gone through a full orientation and training program. She said her expectation is that the physician's orders are followed. She said the nurse should have verified placement of the enteral tube prior to administering medications, each medication should have been crushed separately, diluted in water individually, and a flush of water to start, in between each medication, and at the end of the medications. She said her expectations of the orders being followed, tube placement verified and management of the bolus feeding, and medication administration were not met. Refer to F726 28450 2. Resident #117 was admitted to the facility in February 2023 with diagnoses including epilepsy unspecified, not intractable, without status epilepticus. On 05/16/23 at 9:40 A.M., the surveyor observed Nurse #9 administering medications to Resident #117. Nurse #9 poured Tegretol (Carbamazepine) 200 Milligrams (mg) tablets, three tablets to equal 600 MG to administer to the Resident for seizure disorder. Nurse #9 administered the medication with water to the Resident. Review of the Pharmacy medication card, dated May 2023, indicated to administer Carbamazepine to the Resident with food. Review of the electronic Medication Administration Record included no instructions to administer the medication with food. During an interview on 5/16/23 at 11:30 A.M., Unit Manager # 1 said the instructions label from pharmacy take with food was not followed in the Resident's Medication Administration Record. Unit Manager #1 confirmed that the medication was not administered with food as instructed by the Pharmacist. During an interview on 5/16/23 at 11:45 A.M., Nurse #9 said she did not administer the Carbamazepine with food to the Resident. During an interview on 5/17/23 at 9:24 A.M., the Director of Nurses said she would follow-up with the pharmacy for clarification. Review of the order summary clarification from pharmacy, dated 5/17/23, indicated to administer Carbamazepine 200 MG, three tablets (600 MG) by mouth two times a day for seizure disorder, give with food. During an interview on 5/17/23 at 10:40 A.M., the Assistant Director of Nurses said nursing staff failed to follow the instructions on the Resident's Carbamazepine medication card.

Based on record review, interview, and policy review, the facility failed to consistently update and implement a fall care plan with interventions to prevent further falls for one Resident (#117), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Falls Program, dated as reviewed 9/2022, indicated but was not limited to the following: - the purpose of this policy is to prevent actual occurrences of falls and reduce the risk of any injury - develop individualized care plan - review and revise the care plan as needed - residents experiencing a fall will receive appropriate care with investigation of cause and care plan will reflect new interventions initiated Resident #117 was admitted to the facility in February 2023 with the following diagnoses: repeated falls, polyneuropathy (a dysfunction of the nerves that can cause decrease sensation, pain or involuntary movements), and orthostatic hypotension (a drop in blood pressure with a change in position of the body). Review of the Resident Fall Assessments indicated the Resident was a moderate to high risk for falls since admission in February. Review of the current care plans for Resident #117 indicated but was not limited to the following: A. Resident is at risk for falls related to (r/t) unaware of safety needs, impaired mobility, and cognitive deficits. Interventions include: - attempt to anticipate needs (2/6/23) - call light in reach and encourage use (2/6/23) - offer to toilet resident every two hours while awake (2/6/23) - follow facility fall protocol (2/6/23) - ensure proper footwear/slipper socks (2/6/23) - send to emergency room (ER) for evaluation (3/28/23) - bed alarm and chair alarm (3/29/23) B. Resident has had an actual fall 3/27/23 with minor injury to forehead r/t poor balance, actual fall 3/29/23 unassisted toileting, actual fall 3/29/23 bed to wheelchair (wc) transfer, actual fall wc to bed transfer 3/30/23. Interventions include: - continue interventions on the at-risk care plan (3/28/23) - assess for changes in behavior and mental status until 4/4/23 (3/28/23) - patient will resume skilled rehabilitation (3/28/23) - send urinalysis and culture to rule out urinary tract infection (3/29/23) - slipper socks (3/29/23) - surveillance labs to identify any anomaly (3/30/23) - physician review of medications (3/30/23) - orthostatic vital signs for 72 hours (4/7/23) Review of the Fall Incident Reports for Resident #117 indicated but was not limited to the following: A. 3/27/23 unwitnessed fall at 8:30 P.M. - mobility status prior to incident: independent - Resident was in bed prior to fall - small laceration to forehead - intervention added to prevent further fall: blank - resident said he/she was in bed and trying to get up and slid down to the floor - immediate intervention initiated and further recommendations: send to ER for evaluation - follow up summary: (3/28/23) scans done in the ER negative for major injury, small laceration with four staples There was no intervention initiated to prevent further falls upon the Resident's return to the facility. B. 3/29/23 unwitnessed fall at 6:15 A.M. - mobility status prior to incident: assist - resident found sitting on floor in front of the toilet - no apparent injury - intervention added to prevent further fall: urinal at bedside, bed alarm in place - immediate intervention initiated and further recommendations: slipper socks - follow up summary: (3/29/23) blank C. 3/29/23 unwitnessed fall at 3:00 P.M. - mobility status prior to incident: assist - resident found sitting on the floor in front of wheelchair - no apparent injury - intervention added to prevent further fall: leave wheelchair in locked position next to bed - immediate intervention initiated and further recommendations: resident is self-transferring and not using call light, leave wheelchair locked beside bed, resident has a bed alarm - follow up summary: (3/29/23) non-injury fall D. 3/30/23 unwitnessed fall at 12:30 P.M. - mobility status prior to incident: assist - resident found sitting in between the bed and wheelchair (per the drawn picture) - no apparent injury - intervention added to prevent further fall: blank - resident self removed slipper socks - resident had completed skilled rehabilitation and was left in wheelchair in room facing the television - resident said he/she was trying to get to bed from the chair - immediate intervention initiated and further recommendations: surveillance labs and medication list review - follow up summary: (3/30/23) non-injury fall, medical work up, recurrent falls Review of the Physician's Notes indicated Resident #117 was seen by his/her physician on 3/30/23 for increasing falls with unclear etiology. The physician indicated a urinalysis was pending and labs would be obtained as well as a neurological consult. Review of the facility progress notes indicated the following: - 3/31/23: Change in condition, altered mental status, no medication changes in the last week, increase confusion, decrease mobility, increase weakness, urinalysis and labs pending, send to ER for medical work up. - 4/4/23: Resident returned to the facility from the hospital where he/she was diagnosed with urinary tract infection and fractured nose. During an interview on 5/17/23 at 11:07 A.M., Unit Manager #3 reviewed the medical record for Resident #117, including the care plans and said there was no intervention put in place following the Resident's fall on 3/27/23 to prevent further falls, she said the evaluation at the ER was a follow up action and an intervention to prevent falls should have been put in place. She said the Resident had multiple falls and a urine pending to rule out urinary tract infection (UTI), was non-compliant with call light and slipper sock use and had poor safety awareness. She said interventions for falls should be related to the cause of the fall to prevent further incidents and she could not find any evidence of an intervention being implemented that would prevent further falls following the 3/27/23 fall or the 3/30/23 fall. During an interview on 5/17/23 at 11:45 A.M., the Director of Nurses reviewed the medical record and was made aware of the concerns. She said even though the Resident was sent to the hospital following the 3/27/23 fall, an intervention should have been put in place upon his/her return to prevent further incidents and was not. She said the Resident should have had an intervention implemented following the 3/30/23 fall as well, in an attempt to prevent further falls prior to the medical work up being complete. She said the fall policy indicates a new intervention to prevent further falls needs to be implemented and the policy was not followed as it should have been.

Based on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the residents, for two Residents (#339 and #8), out of a total sample of 25 residents. Findings include: Review of the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated August 10, 2013, indicated but was not limited to the following: Instructions: -This form should be signed based on goals of care discussions between the patient (or patient's representative signing below) and the signing clinician. -Sections A through C are valid orders only if sections D and E are complete. If any section is not completed, there is no limitation on the treatment indicated in that section. Section D: Patient or patient's representative signature is required. Section E: Clinician signature required. 1. Resident #339 was admitted to the facility in May 2023 with a diagnosis of a fracture of the proximal right femur (upper leg bone). Review of the Minimum Data Set (MDS) assessment, dated 5/8/23, indicated Resident #339 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated the Resident had mild cognitive impairment. Review of the Physician's Orders indicated Resident #339's Health Care Proxy (HCP) was not invoked. Review of Resident #339's MOLST indicated Section D: Patient or patient's representative signature required had the following handwritten statement, verbal consent obtained from HCP dated 5/4/2023. Resident #339 did not sign the form. 2. Resident #8 was admitted to the facility in August 2022 with diagnoses which included heart attack, heart failure, stroke, and diabetes. Review of the MDS assessment, dated 2/7/23, indicated Resident #8 scored 15 out of 15 on the BIMS exam which indicated the Resident was cognitively intact. Review of the Physician's Orders indicated Resident #8's HCP was not invoked. Review of Resident #8's MOLST indicated Section D: Patient or patient's representative signature required had the following handwritten statement: signed via telephone consent and communicated with HCP (Health Care Proxy) as patient was legally blind on 9/2/2022. Resident #8 did not sign the form. During an interview on 5/16/23 at 5:16 P.M., Nurse #1 said we don't accept verbal orders on the MOLST. She said the Resident has to sign the MOLST if the HCP is not activated. During an interview on 5/16/23 at 5:30 P.M., the Director of Nurses (DON) said if a resident is admitted to the facility with their MOLST signed with a verbal consent or by the wrong person, we have the MOLST corrected upon admission. The DON said her expectation is the resident signs the MOLST, unless the healthcare proxy has been invoked. The DON reviewed the MOLSTs for Residents #339 and #8 and said they were not valid because they were signed with a verbal consent and should have been signed by Resident #339 and #8 respectively.

Based on record review, and interviews for 6 out of 24 residents (#9, #17 and #18) The Facility failed to ensure that residents received adequate supervision and assistive devices to prevent falls. Findings include: Review of the Fall prevention Guidelines, dated 10/08, indicated that all residents have the potential to be at risk for falls, and should have a fall prevention care plan initiated. In an effort to to reduce prevalent risk factors, preventative interventions are listed on the care plan. All residents experiencing a fall should have an intervention put in place at that time. The gait belt policy, dated 10/2015, indicated that gait belts be used for planned transfers or ambulation requiring physical assistance of staff. 1. Resident #18 was admitted to the Facility in 9/2014, and his/her [DIAGNOSES REDACTED]. The care plan, dated 9/29/14, indicated Resident #18 had a potential to fall and care plan interventions included analyze all falls or near falls and Nurse Manager to complete Q.I report for all incidents to review with DON. The annual Minimal Data Set (MDS) assessment, dated 9/2/15, indicated Resident #18 was moderately impaired in decision making, and he/she required supervision with transfers and ambulation. The clinical record indicated Resident #18's had an activated Health Care Proxy due to his/her cognitive deficits. The Surveyor reviewed Resident #18's falls, which occurred on 9/20/15, and 11/9/15 with Unit Manager #1 on 11/24/15. The incident report, dated 9/20/15, indicated that at 8:00 P.M., Resident # 18 yelled out to staff that he/she had tripped and fallen in his/her room and complained of pain in the right ankle. The incident report indicated that Resident #18 had an x-ray of the right ankle. Unit Manager #1 said after Resident #18's fall, which was diagnosed as a sprain, an every two hour toileting schedule was initiated. The care plan, dated 10/30/15, indicated that a bed sensor pad alarm was added to the plan of care. The incident report, dated 11/9/15, indicated that at 8:50 P.M., Resident #18 was found on the floor of his/her room, and he/she was not sure what happened. The incident report indicated that the bed alarm did not sound. The incident report indicated that Resident #18 used words to the effect of I don't know what I was doing trying to shut that off The incident report indicated that Resident #18 complained of severe left leg pain, the Physician was notified and the Physician ordered Resident #18 to the Hospital for evaluation, where it was determined that Resident #18 had a fractured left hip. Review of the Incident analysis form, dated 11/9/15, indicated possible contributing factors to Resident #18's fall was lack of staff supervision and interventions included to anticipate Resident #18's needs. Unit Manager #1 said she spoke with the Certified Nurse Aide (CNA) who provided care to Resident #8 prior to the fall and the CNA said the bed alarm was working and in place. Unit Manager #1 said she was not sure whether Resident #18 was able to shut off the alarm, which was located at the foot of the bed. The Surveyor reviewed the safety device report for 11/9/15, which documented any safety alarms that were in place for Resident #18. The safety device report sheet was left blank for the evening shift (3:00 P.M. to 11:00 P.M.) when Resident #18 fell , so it was not clear from the documentation that Resident #18 had a bed alarm in place and functioning. The Surveyor interviewed CNA #1 on 11/25/15 at 8:15 A.M. CNA #1 said the CNAs check the alarms to make sure they are in place but do not routinely check functioning of the alarms or battery of alarms. CNA #1 said she provided care routinely to Resident #18, and did not think Resident #18 could shut off the safety bed alarm. The Surveyor interviewed the Staff Development Coordinator (SDC) on 11/25/15 at 9:45 A.M. The SDC said there was no policy to routinely check the functioning of safety alarms, or the functioning of the batteries in the alarms. The SDC said when an alarm fails, the central supply staff replace the alarm. There was no indication during the post fall review, that any staff person identified whether Resident #18 had a functioning bed alarm at the time of the fall. The Surveyor interviewed Family Member #1 and Family Member #2 on 11/25/15 at 10:25 A.M. Family member #2 said he/she visited Resident #18 nightly and observed that when Resident #18 activated the bed alarm, it usually took staff several minutes to respond. Family Member #2 said at times it has taken almost 12 minutes to respond to Resident #18's bed alarm. Family Member #1 said that Resident # 18 was unable to shut off the bed alarm due to his/her decreased cognition. 2. For Resident #9 the facility failed to provide adequate supervision and effective interventions to prevent 5 falls which occurred between 2/8/15 and 08/14/15. Resident #9 was admitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. The medical record was reviewed on 11/18/15. The care plan for falls included the following interventions initiated on 3/17/14: keep assistive devices, cane, within reach at all times; analyze all falls/near falls for contributing factors; nurse manager to complete QI report for all incidents and review with DNS and or PT, OT, activities as needed. Review of the most recent Quarterly Minimum Data Set (MDS) and Significant change MDS, with a reference dates of 7/29/15 and 9/17/15 respectively indicated that Resident #9 was cognitively intact, required extensive assistance of 2 staff for transfers and extensive assistance with all activities of daily living and had a history of [REDACTED]. Fall #1 Review of the incident report dated 2/8/15 indicated that Resident #9 had a witnessed fall at 5:45 P.M. in his/her bedroom. The report indicated that a CNA was transferring the Resident from the bed to a chair and he/she fell on to the floor. Further review of the incident report identified that the CNA did not use a gait belt during the transfer as indicated per facility policy. Review of the care plan for falls identified the fall and included a new intervention to work with the Resident on shifting weight more slowly during transfers with no mention of staff utilizing a gait belt for all transfers. Fall #2 Review of the incident report dated 4/7/15 indicated that Resident #9 had a witnessed fall at 5:15 P.M. in his/her bathroom. The report indicated that a CNA was transferring the Resident from the toilet to a wheelchair and he/she lost their balance and was lowered to the floor. Further review of the incident report identified that the CNA did not use a gait belt during the transfer as indicated per facility policy. Review of a physical therapy initial evaluation dated 4/10/15 indicated that Resident #9 requires the assistance of 2 staff for bed mobility and transfers. Fall #3 Review of the incident report dated 5/20/15 indicated that Resident #9 had a witnessed fall at 10:00 P.M. in his/her bathroom. The report indicated that 1 CNA was assisting the Resident with toileting and transferring when the Resident lost his/her balance and fell on to the floor. Further review of the incident report indicated that Resident #9 required the assistance of 2 staff for toileting, but only one staff member had been transferring the Resident. Fall #4 Review of the incident report dated 7/30/15 indicated that Resident #9 had a fall at 11:20 P.M. in his/her bathroom. The report indicated that a CNA was transferring the Resident from the wheelchair to the toilet and he/she lost their balance and fell to the floor. Further review of the incident report indicated that the Resident was transferred by 1 CNA and not 2 CNAs as indicated by the plan of care and the CNA did not use a gait belt during the transfer as indicated per facility policy. Review of the care plan identified the fall and a new intervention to reinforce with the Resident to allow adequate staff assistance with no mention of staff utilizing a gait belt for transfers or performing transfers with the assistance of 2 CNAs. Fall #5 Review of the incident report dated 8/14/15 indicated that Resident #9 had a fall at 10:50 A.M. in the shower room. The report indicated that 1 CNA was attempting to transfer the Resident to a shower chair but had to lower him/her to the floor. Further review of the incident report indicated that the Resident was transferred by 1 CNA and not 2 CNAs as indicated by the plan of care. Review of the care plan identified the fall and a new intervention for the Resident to maintain grasp on the shower rail throughout transfers with no mention of performing transfers with the assistance of 2 CNAs. During interview with Unit Manager #1 on 11/24/15 at 1:00 P.M., the Surveyor reviewed the above referenced Resident Incident Reports and care plan. She was not able to explain why the care plan was not updated following the fall to indicate the assistance of 2 CNAs for all transfers. 3. Resident #17 was admitted to the Facility in 8/2012, and [DIAGNOSES REDACTED]. The care plan, dated 4/16/13, indicated Resident #17 was at risk for falls relating to twitching episodes. Care plan interventions, updated on 6/29/15, indicated Resident #17 was at continued risk for falls related to myoclonic (sudden jerking) tremors and during tremors Resident required assistance of two staff persons. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/28/15, indicated Resident #17 was severely impaired in decision making, he/she required staff assistance with transfers, and ambulation. The Surveyor reviewed Resident #17's falls with Unit Manager #3 on 11/24/15 at 1:15 P.M. The incident report, dated 9/15/15, indicated at 7:15 A.M. a CNA transferred Resident #17 in hallway by holding his/her hand, Resident #17 twitched and was lowered to the floor. The incident report indicated that no gait belt was in place during the fall per facility policy. The incident report, dated 10/18/15, indicated that at 7:05 A.M. a staff nurse ambulated Resident #17 to his/her room when Resident #17 twitched and fell on the floor. The incident report indicated Resident #17 sustained a scrape to the left knee, and staff failed to use a gait belt.