Every finding on record at Harris Hill Center, Genesis HealthCare

Based on observation, interview, and record review, the facility failed to ensure that a resident that self-administered medications was assessed as clinically appropriate for 1 of 2 residents reviewed for choices in a final sample of 20 residents. (Resident identifier is #31.)Findings include: Observation on 4/13/26 at approximately 10:40 a.m. in Resident #31's room revealed that Resident #31 had a medicine cup with pills and was self-administering the pills with no staff present. Review on 4/13/26 of Resident #31's self-administration of medication assessment, dated 1/8/26, revealed that Resident #31 required assistance to administer oral medications and was not approved for self-administration of medications. Review on 4/13/26 of Resident #31's April 2026 Medication Administration Record revealed the following medications documented as administered on 4/13/26 (scheduled 8:00 a.m., 9:00 a.m., and 10:00 a.m.): Ascorbic Acid 500 mg (milligram) one tablet, Blood-Builder-Supplement one tablet, Calcium Citrate two tablet, Cholecalciferol (Vitamin D) 1000 unit one tablet, Choline-Inositol 250-250 mg one capsule, Vitamin A 5000 unit, Vitamin B Complex 2 capsules, and Lactobacillus two capsules. Review on 4/13/26 of Resident #31's active physician orders revealed the no orders to self-administer medications. Interview on 4/14/26 at approximately 12:45 p.m. with Staff G (Licensed Practical Nurse) revealed that he/she was the nurse for Resident #31 on 4/13/26 day shift (7:00 a.m. to 3:00 p.m.) and gave the above medications to Resident #31 to self-administer. Staff G confirmed the above findings that Resident #31 did not have an order to self-administer. Review on 4/14/26 of the facility policy titled, Medications: Self-Administration, review date of 10/15/24, revealed, .Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: A physician/advanced practice provider (APP) order is required, self-administration and medication self-storage must be care planned .

Based on record review and interview, the facility failed to send a copy of the notice of transfer to the Long-Term Care (LTC) Ombudsman for 2 of 3 closed records reviewed and 1 of 2 hospitalizations reviewed in a final sample of 20 residents (Resident Identifiers are #77, #1, and #79).Findings include:Resident #77 Review on 4/14/26 of Resident #77's progress notes revealed that Resident #77 was transferred to the hospital on 3/7/26. There was no documentation that the LTC Ombudsman was sent a copy of Resident #77's notice of transfer. Interview on 4/15/26 at approximately 2:00 p.m. with Staff A (Administrator) confirmed the above finding. Staff A was unable to provide documentation that the LTC Ombudsman was sent a copy of the notice of transfer to the hospital for Resident #77. Resident #79 Review on 4/14/26 of Resident #79's progress notes revealed that Resident #79 was discharge home on 2/11/26. There was no documentation that the LTC Ombudsman was sent a copy of Resident #79's notice of discharge. Interview on 4/15/26 at approximately 2:00 p.m. with Staff A confirmed the above finding. Staff A revealed that Resident #79 discharged Against Medical Advice. Staff A was unable to provide documentation that the Long-Term Care Ombudsman was sent a copy of the notice of discharge for Resident #79. Resident #1 Review on 4/13/26 of Resident #1's medical record revealed a hospitalizations on 1/30/26. Review on 4/15/26 of Resident #1's record revealed no completed notice of transfer/discharge available and no evidence the notice was sent to the LTC Ombudsman for the above hospitalizations. Interview on 4/15/26 at approximately 12:30 p.m. with Staff A confirmed the above findings. Review on 4/15/26 of facility policy titled COR412 Discharge Record Processing revised 1/15/26 revealed .PROCESS.2. discharge documentation must include:.2.4 Notice of Transfer or Discharge.

Based on observation, interview, and policy review, the facility failed to permit only authorized personnel to have access to medication room keys for 2 of 2 medication rooms observed. Findings include:Interview on 4/15/26 at approximately 10:27 a.m. with Staff J (Maintenance Director) revealed that he/she has keys to access the second floor and third floor medication rooms because oxygen tanks are stored there. Staff J also revealed that he/she accessed the medication rooms to perform maintenance on the HVAC (Heating, Ventilation, and Air Conditioning) systems located inside those rooms.Observation on 4/15/26 at approximately 10:27 a.m. on the third floor unit with Staff J revealed that Staff J accessed the medication room using keys that he/she keeps. The third floor medication room had oxygen tanks, medication bingo cards on the counter, over the counter medications on the shelves, and an unlocked medication refrigerator with medications in it. There were no nurses or medication nursing assistants supervising while the medication room was accessed by Staff J. Observation on 4/15/26 at approximately 10:35 a.m. on the second floor unit with Staff J revealed that Staff J accessed the medication room using keys that he/she keeps. The second floor medication room had oxygen tanks, intravenous medications on the counter, over the counter medications on the shelves, and an unlocked medication refrigerator with medications in it. There were no nurses or medication nursing assistants supervising while the medication room was accessed by Staff J. Review on 4/15/26 of the facility policy titled, Storage of Medication, dated 1/26, revealed, .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access .

Based on interview and record review, the facility failed to ensure that a staff was offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine for 1 of 1 staff reviewed for COVID-19 vaccination. (Staff identifier is H.)Findings include: Review on 4/14/26 of Staff H (Licensed Practical Nurse) COVID-19 vaccine record revealed Staff H received COVID 19 vaccines on 12/30/20, 1/20/21, and 12/31/21. There was no documentation of COVID-19 vaccination after 12/31/21, and no documentation that Staff H was offered the COVID-19 vaccine or given information on obtaining COVID-19 vaccine. Interview on 4/14/26 at approximately 11:00 a.m. with Staff K (Infection Preventionist) confirmed the above mentioned Staff H's COVID-19 vaccination record. Staff K revealed that he/she did not offer Staff H the COVID-19 vaccine or provide information on obtaining a COVID-19 vaccine. Staff K also revealed that they don't offer the COVID-19 vaccine or provide information on obtaining the COVID-19 vaccine to agency (e.g. contracted) staff. Interview on 4/14/26 at approximately 11:06 a.m. with Staff H revealed that he/she was not offered the COVID-19 vaccine or provided with information on obtaining a COVID-19 vaccine since working at the facility. Review on 4/14/26 of the facility policy titled, COVID-19 Vaccination, review date of 3/20/26, revealed, . 'Staff' means this individuals who work in the facility on a regular (that is, at least once a week) basis .This also includes visiting healthcare personnel/individuals under contract or arrangement .A licensed nurse or authorized health care provider will administer COVID-19 vaccinations: .In adherence with current recommendations of the Advisory Committee on Immunization Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC) Employees are encouraged to obtain COVID-19 vaccination from their personal health provider, health department, or community health partners. Employees who consent to COVID-19 vaccinations through their personal health provider, health department, or community health partners should consult with their supervisor regarding alternate potential sources to obtain the COVID-19 vaccination .Obtain consent .Employee COVID-19 Informed Consent in the approved automated system .Document refusal .If an employee refuses COVID-19 vaccination, document the declination on the COVID-19 Vaccine Informed Declination in the approved automated system .

Based on observation, interview, and record review, the facility failed to maintain two equipment per manufacturer's instruction for 1 of 1 resident reviewed for respiratory care and 1 of 1 portable air conditioner observed. Findings include: Resident #28Observation on 4/13/26 at approximately 10:17 a.m. in Resident #28's room revealed a non-invasive mechanical ventilator machine (i.e. equipment) on top of Resident #28's bedside cabinet drawer. Interview on 4/13/26 at approximately 10:17 a.m. with Resident #28 revealed that he/she had not used the above mentioned machine for 2-3 months due to a warning indicator showing it required service from the contracted rental company. Resident #28 also revealed that the staff was aware, called the contracted rental company, and they had not come in to service the equipment.Review on 4/14/26 of Resident #28's care plan revealed that Resident #28 has sleep apnea and utilize a Continuous Positive Airway Pressure (CPAP) machine.Observation on 4/14/26 at approximately 12:46 p.m. with Resident #28 and Staff G (Licensed Practical Nurse (LPN)) revealed that Resident #28's CPAP machine turned on and initially did not display a warning sign indicator. A few minutes later after pressing buttons on the CPAP machine, it displayed a message that indicated motor life exceeded call the provider.Interview on 4/14/26 at approximately 12:46 p.m. with Staff G confirmed the above finding. Staff G was the unit manager on the third floor unit and was unaware of any issues with Resident #28's CPAP machine. Interview on 4/14/26 at approximately 12:46 p.m. with Resident #28 revealed that the CPAP machine's air filter needed to be change. Resident #28 could not recall when it was last replaced and there was no new air filter to replace it.Review on 4/14/26 of the CPAP machine manufacturer's instruction revealed, Caring for your device .Check the air filter and replace it at least every six months. replace it more often if there are any holes or blockages by dirt or dust .Design life Device, power supply unit: 5 years .Review on 4/14/26 of Resident #28's April 2026 Treatment Administration Record revealed treatment for CPAP to apply at bedtime and remove in the morning with a start date of 5/12/22. Further review revealed orders to clean the CPAP filter, reservoir, mask, and tubing weekly; and clean CPAP mask daily. Review also revealed that the CPAP machine was signed off as administered from 4/1/26 to 4/7/26 and 4/9/26 to 4/13/26.There were no orders to replace the CPAP machine's air filter every six months. Interview on 4/14/26 at approximately 1:46 p.m. with Staff G confirmed that there was no order to replace the air filter of Resident #28's CPAP machine. Staff G revealed that the nursing staff does not replace the air filter of the CPAP machine. Interview on 4/14/26 at approximately 3:15 p.m. with Staff J (Maintenance Director) revealed that they do not replace the air filter of any CPAP machine in the facility. Interview on 4/15/26 at approximately 12:38 p.m. with Staff M (Registered Nurse) revealed that he/she regularly works the night shift (11:00 p.m. to 7:00 a.m.) on the third floor unit and does not replace the air filter of Resident #28's CPAP machine. Review on 4/15/26 of the facility's contracted respiratory healthcare company form for Resident #28's CPAP machine revealed that one CPAP machine was delivered on 8/23/18. Interview on 4/15/26 at approximately 9:00 a.m. with Staff J confirmed the above finding. Staff J revealed that Resident #28's CPAP machine needed to be replaced. Staff J was unable to provide documentation of communication to the respiratory healthcare company about Resident #28's CPAP machine displaying a message motor life exceeded call the provider prior to survey.Review on 4/14/26 of the facility's policy titled, Bi-Level Positive Airway Pressure (BIPAP)/Continuous Positive Airway Pressure (CPAP) procedure, revision date of 10/15/24, revealed, Cleaning the system: .Change the intake filter per manufacturer's instructions .Replace equipment immediately when it is broken or malfunctions .replace equipment routinely in accordance with manufacturer's recommendations . Portable Air ConditionerObservation on 4/13/26 at approximately 8:35 a.m. with Staff L (LPN) in the second floor medication room revealed a portable air conditioner. Staff L also revealed that the maintenance department maintains the portable air conditioner. Observation on 4/15/26 at approximately 10:27 a.m. with Staff J in the second floor medication revealed a portable air conditioner with both an upper and lower air filter. The upper air filter appeared dark with small amount of dust accumulation, and the lower air filter was heavily covered with dark dust buildup on both the front and back surfaces.Interview on 4/15/26 at approximately 10:27 a.m. with Staff J confirmed the above observation. Staff J revealed that he/she last cleaned the air filters on 4/15/26. Staff J was unable to provide documentation of verification of air filter cleaning. Review on 4/15/26 of the portable air conditioner manufacturer's instruction revealed, .Air Filter Cleaning .Maintenance Tips Be sure to clean the air filter every 2 weeks for optimal performance .

Based on interview and record review, the facility failed to administer drugs and biologicals to 1 of 1 resident reviewed for new admissions in a final sample of 20 residents (Resident Identifier is #82).Findings include:Interview on 4/13/26 at approximately 9:30 a.m. of Resident #82 revealed that he/she did not receive all of his/her medications when they were admitted . Further interview revealed he/she came into the facility on 4/10/26.Review on 4/13/26 of Resident #82's April 2026 Medication Administration Record revealed on 4/10/26 the following 8pm and 9pm medications: Bupropion XL 300mg, Celexa 20mg, Insulin Lispro 100unit/ml, Metformin 1000mg, Metoprolol Tartrate 25mg, Topiramate 25mg, Vancomycin 125mg were all documented as not given with NN [Nurses Note].Review on 4/14/26 of Resident #82's progress notes confirmed Resident #82 was admitted [DATE]. Further review revealed no nurse notes for 4/10/26 missed medications. Nurses notes dated 4/11/26 state the following medications were not available from the pharmacy: Metformin, Insulin Glargine 100 unit/ml, Metoprolol Tartrate, Vancomycin, Topiramate, Celexa, and Bupropion. There was no documentation of provider notification.Interview on 4/15/26 at approximately 9:00 a.m. with Staff E (Regional Clinical Lead) confirmed above findings. Review on 4/15/26 of facilities medications 'Inventory on Hand' list for their general and emergency use medications available in the medication room revealed the following medications were in the facility: Celexa, Metformin, Metoprolol Tartrate, and Vancomycin (5 out of 7 medications of his/her missed medications).

Based on observation, interview, and record review, the facility failed to follow professional standards for 1 out of 5 residents observed for medication administration and for 2 of 2 wound care observations in a final sample of 20 residents (Resident Identifiers are #16, #51, and #7).Findings include:Standard: [NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier. Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. Resident #16 Review on 4/13/26 of Resident #16's April 2026 Treatment Administration Record revealed an order dated 4/10/26 for Wound Care: wash lower legs with wound cleanser, pat dry, apply collagen to left lateral and right medial lower legs wounds. Cover with collagen AG sheet. Apply Xeroform to any other open or weeping areas. Cover with ABDs, secure with conform rolled gauze. Ace bandage from base of toes to just below bend of knee. Every evening shift on Mon, Fri for wound care. Further review revealed it signed as completed on 4/10/26 and 4/13/26. Observation on 4/13/26 at approximately 12:00 p.m. of Resident #16's bilateral lower legs revealed ace wraps on each leg, that were intact with a date of 4/8/26 on both legs. Interview on 4/13/26 at approximately 12:00 p.m. of Resident #16 revealed that dressings were not done all the days they are scheduled, and some were skipped. Observation on 4/15/26 at approximately 9:45 a.m. of Resident #16's wound care being performed revealed both leg dressings that were removed were dated 4/8/26. Interview on 4/15/26 at approximately 9:45 a.m. with Staff B (Physician's Assistant) and Staff C (Wound Nurse) confirmed the findings above and concluded the dressings had not been changed when ordered. Resident #51 Review on 4/15/26 of Resident #51's April 2026 Treatment Administration Record revealed an order for Wound Care: left heel pressure injury: cleanse with wound cleanser, pat dry, skin prep to intact skin, Pluogel to slough, cover with bordered Optifoam HEEL dressing Heelzup in bed to offload heels. Everyday Mon, Weds, Fri for wound care. Further review revealed it signed as completed 4/13/26. Observation on 4/15/2026 at approximately 10:45 a.m. of Resident #51's wound care being performed revealed the left heel dressing removed was dated 4/11/26. Interview on 4/15/26 at approximately 10:45 a.m. with Staff B (Physician's Assistant) and Staff C (Wound Nurse) confirmed the findings above and concluded the dressing had not been changed when ordered. Interview on 4/15/26 at approximately 11:15 a.m. with Staff D (Registered Nurse) revealed that the dressing on resident #51's left heel was documented as completed on 4/13/26, but the treatment was not done. Review on 4/15/26 of facility policy titled NSG236 Skin Integrity and Wound Management revised 9/15/25 revealed, .PRACTICE STANDARDS.6.13 Implement special wound care treatments/techniques, as indicated and ordered. Resident #7 Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Observation on 4/14/26 at approximately 8:14 a.m. with Staff H (Licensed Practical Nurse) revealed that Staff H popped 1 capsule of Gabapentin 100 mg (milligram) from a medication bingo card and administered it to Resident #7. Interview on 4/14/26 at approximately 8:14 a.m. with Staff H confirmed the above findings. Staff H revealed that he/she gave 1 capsule (100 mg) because the Gabapentin 100 mg bingo card instruction indicated to give 100 mg by mouth twice daily. Review on 4/14/26 during Resident #7's medication administration observation with Staff H revealed that the electronic medication administration record revealed an order for Gabapentin capsule give 100 mg by mouth twice a day for nerve pain, and give two capsules (order date of 12/16/25). The Gabapentin 100 mg bingo card indicated to give 100 mg by mouth twice a day for nerve pain. Review on 4/14/26 of Resident #7's provider note dated 12/16/25 revealed that Gabapentin 200 mg once daily was increase to 200 mg twice daily for sciatica pain. Interview on 4/14/26 at approximately 2:44 p.m. with Staff I (Advanced Practice Registered Nurse) confirmed that the order for Gabapentin was for 200 mg twice daily. Review on 4/15/26 of the facility policy titled, Medication Administration, dated 1/26, revealed, .Medications are administered in accordance with written orders of the prescriber .Verify medication is correct three (3) times before administering the medication. 1. when pulling medication package from med cart b. when dose is prepared c. before dose is administered .

Based on observation and interview, it was determined that the facility failed to ensure that medications were appropriately labeled and expired medications removed from use for 1 of 2 medication carts observed. Finding include: Observation on 3/19/25 at approximately 9:10 a.m. of the second floor low medication cart with Staff B (Licensed Practical Nurse) revealed an Albuterol Sulfate inhaler that contained no resident identifier and the medication was not in the pharmacy dispensed container. Further observation revealed a manufacturer's expiration date of 2/23. Interview on 3/19/25 at approximately 9:12 a.m. with Staff B confirmed the above findings. Review on 3/21/25 of the Facilities Policy Titled Medication Storage: Storage of Medications, Reviewed on 1/25, revealed .7. Medications for oral inhalation are stores in the dispensed containers following manufacturer guidelines . 14. Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock .

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications were appropriate for 1 of 2 residents reviewed for choices in a final sample of 18 residents (Resident identifier is #25). Findings include: Observation on 3/19/25 at approximately 10:02 a.m. of Resident #25's room revealed a small container of a whitish cream on Resident #25's night stand. Interview on 3/19/25 at approximately 10:05 a.m. with Resident #25 revealed that the container of whitish cream was Voltaren and they self apply the cream as needed for pain. Resident #25 stated that the nurse will refill the container as needed. Review on 3/19/25 of Resident #25's medical record revealed a physician's order for Diclofenac Sodium External Gel (Voltaren) 1 % (percent) Apply to back and legs topically two times a day for osteoarthritis pain, with a start date of 11/11/2024. Further review of Resident 25's medical record revealed that there was no assessment for self-administration of Voltaren. Observation on 3/21/25 at approximately 8:23 a.m. revealed that the container with the whitish cream (Voltaren) remained at Resident #25's beside. Interview on 3/21/25 at approximately 8:23 a.m. with Staff F (Medication Nursing Assistant) confirmed that there was a container of whitish cream (Voltaren) at Resident #25's bedside. Staff F stated that Resident #25 does not have an order to self-administer the Voltaren Cream. Review on 3/21/25 of Resident #25's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/22/25 revealed a BIMS (Brief Interview of Mental Status) score of 15/15, indicating little to no impairment. Interview on 3/21/25 at approximately 10:42 a.m. with Staff C (Clinical Corporate Nurse) confirmed that Resident #25 did not have an assessment to self-administer medications. Review on 3/21/25 of the facility's policy titled NSG: Medications: Self-Administration, reviewed on 10/15/24, revealed . Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self administer: A physician/advanced practice provider (APP) order is required .Patient must be instructed in self-administration Evaluation of capability must be performed initially, quarterly, and with any significant change in condition .

Based on record review and interview, it was determined that the facility failed to refer residents with an evident or possible serious mental disorder for a Level II Pre-Admission Screening and Resident Review (PASARR) for 1 of 1 resident reviewed for PASARR in a final sample of 18 residents (Resident identifier is #16). Findings include: Review on 3/21/25 of Resident #16's medical record revealed that Resident #16 admitted to the facility in August 2024 with a known diagnosis of schizoaffective disorder, bipolar type, anxiety disorder, and panic disorder. Further review revealed a PASARR Level 1 completed 8/18/2024 and signed by a medical professional indicating a temporary admission for a convalescent stay with a maximum length of stay for 90 days, determined no Level II PASARR was needed at the time. Review on 3/21/25 of Resident #16's Level I PASARR form (completed on 10/1/24 and signed by a medical professional) revealed: Section 2A: Suspected Diagnosis: Bipolar, Schizophrenia/schizoaffective, and Severe Anxiety/panic and Psychiatric Inpatient, Associated with a mental health agency, Medication management, and At-home supportive services were checked yes. Section 2B: Interpersonal Function: Easily upset/anxious and Fearful of strangers were checked yes. Section 2D: Adaptation to Changes: Mental health intervention due to increased symptoms were checked yes. Section 8: Level I Screening Summary: Required PASARR involvement - Level II face to face and Length of stay requesting for Level II: Long Term Care were checked. Interview on 3/21/25 at 1:20 p.m. with Staff G (Social Service Director) revealed that Resident #16 never had a Level II PASARR as required from their PASARR Level I screening. Review on 3/21/25 of facility policy titled, Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients, dated 2/16/24, revealed: . 1.1 It is learned after admission that the Pre-Admission Screening and Resident Review was not completed or is incorrect, or .2.1 Refer to the appropriate state designated authority when a patient is identified as having an evident or possible MD, ID or related condition .

Based on interview and record review, it was determined that the facility failed to implement the plan of care for 1 of 1 resident reviewed for change of condition (Resident identifier is #32) and 1 of 1 resident reviewed for insulin (Resident identifier is #58) in a final sample of 18 residents. Findings include: Resident #32 Review on 3/20/25 of Resident #32's current care plan revealed the care plan intervention, initiated 2/14/25, for Congested Heart Failure: weigh daily, notify physician of weight gain greater than 2 pounds per day. Review on 3/20/25 of Resident #32's weights and vitals summary, dated 3/16/24, revealed a weight of 329.8 pounds on 3/16/25 and a weight of 333 pounds on 3/17/25 (an increase of 3.2 pounds). Review on 3/20/25 of Resident #32's medical record revealed that there was no documentation of notification to a provider on 3/17/25 when Resident #32 had an increase of greater than 2 pounds in one day. Interview on 3/20/25 at 9:30 am with Staff D (Medical Director) confirmed that he/she was not notified of the above mentioned increase in weight on 3/17/25 and there was no documentation of a provider notification in the medical record. Resident #58 Review on 3/19/25 of Resident #58's medical record revealed a progress note, dated 3/16/25, that stated [Resident #58 name omitted] was in the dayroom for super [sic], ate all [pronoun omitted] supper; but when [pronoun omitted] CBG [capillary blood glucose] was checked by 1930 [7:30 p.m.], it was 106. About 2100 [9:00 p.m.] it read 60. Glucose adm. [administered] and went up to 70 in about 20 minutes. Night nurse updated and will continue to check resident and appropriate interventions until res. [resident] CBG is stable. Further review of Resident #58's medical record revealed no documented physician notification regarding receiving Glucose for low blood sugar. Review on 3/21/25 of Resident #58's physician orders revealed an order for Insta-Glucose Gel 77.4% (percent), start date 2/21/24, Give 1 dose by mouth as needed for BG (Blood Glucose) less than 70, pt (patient) arousable, conscious and able to swallow. Hold all diabetic medications until provider authorizes resumption. Remain with pt., keep pt in bed/chair for safety. Repeat blood glucose in 15 min. (minutes). Review on 3/21/25 of Resident #58's current care plan revealed the following care plan intervention, initiated 2/23/24, for insulin dependant diabetes: Access and record blood glucose levels as ordered. Call MD [Medical Doctor] if CBG is < [less than] 70 or >[greater than] 250. Interview on 3/21/25 at approximately 9:55 a.m. with Staff D (Medical Director) confirmed that there was no documentation of physician notification for Resident #58's low blood sugar episode requiring glucose administration. Staff D stated that a provider needed to be notified in accordance with the physician order.

Based on observation, interview and record review, it was determined that the facility failed to ensure that insulin was administered per manufacturer's instructions and per facility policy and procedure for 1 of 4 residents observed for medication administration. (Resident identifier is #77.) Findings include: Review on 3/19/25 of Resident # 77's physician orders revealed an order for Novolog Flex Pen subcutaneous solution pen-injector 100 unit/ml (milliliter) Inject 4 units subcutaneously before meals for DM II (Diabetes Mellitus). Observation on 3/19/25 at approximately 12:00 p.m. of Resident #77's insulin administration with Staff A (Registered Nurse) revealed that Staff A primed the Insulin Pen with only 1 unit of insulin prior to administration of scheduled 4 unit dose and when injecting the insulin into Resident #77 he/she held the Insulin Pen in place for 3 seconds. Interview on 3/19/25 at approximately 12:00 p.m. with Staff A confirmed that he/she had primed the insulin pen with only 1 unit of insulin and had held the pen in place for 3 seconds after injecting the scheduled dose of Insulin. Review on 3/20/25 of manufacturers instructions for Novolog Flex Pen revealed: Giving the airshot before each injection E. Turn the dose selector to select 2 units . G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. Giving the Injection . Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in . Review on 3/20/25 of facility policy titled Medication Administration Subcutaneous Insulin, dated 01/23 revealed: Always perform the safety test before each injection . A. Select the dose of units by turning the dosage selector (diagram indicates 2 units) . D. Hold the pen with the needle pointing upwards . F. Press the injection button all the way in . A. Insert the needle into the skin at a 90 degree angle. B. Deliver the dose by pressing the injection button in all the way . C. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures the full dose will be delivered.

Based on interview and record review, it was determined that the facility failed to ensure that 1 of 4 residents reviewed for insulin was free from exposure to bloodborne and bacterial pathogen transmission when staff administered the resident insulin from another resident's used insulin pen (Resident Identifier #1). Findings include: Interview on 6/4/24 at 9:30 a.m. with Staff C (Registered Nurse) revealed that he/she was Resident #1's evening nurse on 5/28/24 and that he/she was not able to locate Resident #1's Humalog 75/25 insulin or any back-up/emergency stock in the medication room for the 6:00 p.m. ordered dose. Staff C confirmed that he/she went to another medication cart to use another resident's (Resident #2) Humalog 75/25 insulin pen. Staff C revealed that he/she drew up 10 units of the insulin with a syringe and administered it to Resident #1. Staff C confirmed that the insulin pen was opened and had already been used for Resident #2. Interview on 6/03/24 at 9:30 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed that Staff C used Resident #2's Humalog 75/25 insulin pen to draw up the 10 units of insulin for Resident #1 on 5/28/24. Staff A revealed that the insulin pen had already been used for Resident #2. Interview on 6/4/24 at 10:25 a.m. with Staff B (Director of Nursing) confirmed that it was not the facility's policy to borrow medication from another resident. Review on 6/4/24 of Resident #1's May Medication Administration Record (MAR) revealed a physician's order for Humalog Mix 75/25 for 10 units subcutaneously before dinner for diabetes mellitus. Review on 6/4/24 of the Humalog Mix 75/25 KwikPen insert, provided by the facility, revealed, .Do Not share your Humalog Mix75/25 KwikPen or needles with anyone else. You may give an infection to them or get an infection from them . Review on 6/4/24 of the facility's pharmacy policy titled Appropriate Use of Prefilled Insulin Pen Devices, provided by the facility revealed, .Insulin pens include a number of manufacturer-unique administrative devices designed for accurate and simple insulin administration. These benefits are only realized if prefilled pen devices are used appropriately .Never access the rubber seal of the cartridge containing insulin with a syringe and needle. Never use the same pen for more than one resident . Review on 6/4/24 of the facility's policy Medication Shortages/Unavailable Medications revealed, .If a medication is unavailable during normal Pharmacy hours . A Facility nurse should call Pharmacy to determine the status of the order . If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery, if medically necessary . If a medication is unavailable is discovered after normal Pharmacy hours . If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to mange the plan of action. Action may include . Emergency delivery; or . Use of an emergency (back-up) Third Party Pharmacy . If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . Review on 6/4/24 of the Centers for Disease Control and Prevention (CDC) handout retrieved 6/4/24 from https://www.cdc.gov/injection-safety/media/pdfs/Insulin-Pen-Safety-Handout-P.pdf revealed, .Injection equipment (e.g., insulin pens, needles and syringes) should never be used for more than one person . It is critical to remember that insulin pens are meant for only one person . Although invisible to the eye, back flow of blood into the insulin pen can happen during an injection. This creates a risk of bloodborne and bacterial pathogen transmission to patients if the pen is used for more than one person, even when the needle is changed . Interview on 6/4/24 at 2:00 p.m. with Staff B revealed that on 5/29/24 she had worked late to audit and in-service staff working the 3:00 p.m. to 11:00 p.m. and the 11:00 p.m. to 7:00 a.m. shift regarding administration of insulin pens and not using another residents' insulin. Staff B stated that on 5/30/24 audits had been conducted for all residents to be sure that there was no additional missing insulin with no additional concerns found. Review on 6/4/24 of the facility's in-service training record for insulin pen administration, medications not available, abuse/misappropriation revealed it was started on 5/29/24. Review on 6/4/24 of the facility's competencies for medication not being available, abuse, insulin pens, following physician's orders and insulin replacement revealed it was started on 5/29/24 and all staff had been trained prior to working their first shift. Review on 6/4/24 of the facility's Ad Hoc Quality Assurance and Performance Improvement meeting held on 5/30/24 at 10:00 a.m. revealed the facility had reviewed the above incident which included a root cause analysis, review of audits and plan for auditing. Review on 6/4/24 of the facility's Public Health Communication Timeline revealed that the facility had notified New Hampshire Public Health on 5/30/24 regarding the above incident and had followed up on 5/31/24. 45419

Based on observation and interview, it was determined that the facility failed to serve food in accordance with professional standards in 1 of 2 dining rooms observed. Findings Include: Observation on 2/27/2024 at 12:40 pm of the third floor lunch meal service revealed that Staff F (Licensed Nursing Assistant) served a hamburger to a resident by placing the top bun onto the burger with bare hands and handing the hamburger to the resident. Interview on 2/27/2024 at 12:45 with Staff F confirmed the above findings. Review on 3/4/24 of the Food Code, U.S. Public Health Service, U.S. Food and Drug Administration, 2017 retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands . (B) FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.

Based on observation, record review, and interview, it was determined that the facility failed to maintain an environment free of accident hazards for 1 of 2 residents reviewed for smoking in a final sample of 27 residents (Resident Identifier #20). Findings include: Observation on 2/27/24 at approximately 8:00 a.m. revealed Resident #20 outside smoking in the designated smoking area alone. Review on 2/28/24 of Resident #20's Smoking Evaluation dated 12/9/23, revealed Section E. Evaluation 1. Smoking Decision 1) Independent smoking is allowed .3. Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. Review on 2/28/24 of facility policy titled OPS137 Smoking review and revision date 8/7/23, revealed on page 3 of 3 section 2.6 Smoking supplies .maintained by staff .kept at the nursing station. Interview on 2/29/24 at approximately 9:30 a.m. with Staff E (License Nursing Assistant) revealed Resident #20 keeps his/her smoking supplies on his/her person. Interview on 2/29/24 at approximately 10:30 a.m. with Staff D (Licensed Practical Nurse) revealed Resident #20 is supposed to turn in [pronoun omitted] smoking supplies, but [pronoun omitted] does not.

1) Based on observation, record review, and interview it was determined that the facility failed to follow physicians' orders to provide compression stockings for 1 of 1 resident reviewed for edema in a final sample of 27 (Resident Identifier #14). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians Orders The physician is responsible for directing medical treatment. Nurses follow physicians's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 2/27/24 at approximately 10:00 a.m. of Resident #14 revealed edema to bilateral feet and ankles. Resident #14 was dressed and in bed with no compression stockings on. Observation on 2/28/24 at approximately 10:00 a.m. revealed Resident #14 up, dressed, and walking to the Resident Council meeting. Resident #14 was wearing black socks but no compression stockings. Interview on 2/27/24 at approximately 10:10 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings. Review on 2/29/24 of Resident #14's active physician orders revealed an order for [name omitted] compression stockings to bilateral lower extremities. Apply in the morning and remove at bedtime with a start date of 8/25/23. Review on 2/29/24 of Resident #14's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no order for compression stockings to bilateral lower extremities. Interview on 2/29/24 at approximately 12:13 p.m. with Staff B confirmed the above findings. Interview on 2/29/24 at approximately 12:20 p.m. with Resident #14 revealed he/she has not had compression stockings In a long time. 40522 2) Based on observation, interview, and record review, it was determined that the facility failed to ensure that professional standards were followed for administering medication in a Peripherally Inserted Central Catheter (PICC) line for 1 of 1 PICC line medication administration observed (Resident Identifier #182). Findings include: Standards: Wolters Kluwer. [NAME] Nursing Procedures. 8th edition. Philadelphia, PA: Wolters Kluwer, 2019. Page 599-600- Administering drugs using a PICC .Perform a vigorous mechanical scrub of the needless connector for at least an antiseptic pad. Allow it to dry completely. While maintaining the sterility of the syringe tip . Observation on 2/28/24 at approximately 1:37 p.m. with Staff G (Licensed Practical Nurse) revealed that Staff G scrubbed Resident #182's PICC line the purple needleless connector and then the red needleless connector with an alcohol swab. Staff G released the purple needleless connector and it touched Resident #182's clothing and his/her wheelchair. Staff G proceeded to flush the red needleless connector with 10 milliliter (ml) of normal saline flush with resistance then flushed the purple needleless connector without disinfecting the purple needleless connector with an alcohol swab. Interview on 2/28/24 at approximately 1:40 p.m. with Staff G confirmed the above findings. Review on 2/28/24 of the facility's policy titled Administration of an intermitted infusion revision date of 6/1/21, revealed .Licensed nurses caring for patients receiving infusion therapies must adhere to Aseptic Non Touch Technique (ANTT) for all infusion-related procedures as a critical aspect of infection prevention .Adhere to Standard-ANTT when connecting, changing, and accessing administration set injection ports .Equipment: .alcohol pads .Procedure: .Perform a vigorous mechanical scrub to manually disinfect the needless connector. Allow to aid dry.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medication are stored in accordance with professional standards for vaccines, inhalers, and expired medications for 1 of 2 medication rooms and 2 out of 2 medication carts observed. Findings include: Standard: Review on 1/19/23 of the Centers for Disease Control and Prevention (CDC) website titled, Vaccine Storage and Handling Toolkit, dated January 2023, retrieved from:https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, revealed .Handle With Care: Protect Your Vaccines Protect Your Patients .Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min/max temperatures at start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday) . Second floor medication room Observation 1/19/23 at 10:08 a.m. with Staff A (License Practical Nurse (LPN)) revealed the following medications in the second floor medication room refrigerator: 1 used Tuberculin Aplisol 0.1 milliliter (ml) that had a discard after 30 days when opened pharmacy sticker with no open date. Manufacturer's instruction with the Tuberculin vial stated vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency Resident #24's used C-NH-Diphenhydramine/Lidocaine/Nystatin 1:1:1 with expiration date of 12/17/22 9 Acetaminophen 650 milligram (mg) suppository with expiration date of December 2022 Further observation revealed that Influenza vaccines and Pneumococcal vaccines were stored in the second floor medication room refrigerator. Observation also revealed that the thermometer recorded a temperature which was 5.5 degrees Celsius, with no minimum or maximum temperature. Review on 1/19/23 of the second floor medication room refrigerator log for January 2023 revealed that temperatures were recorded once a day on 1/3/23 to 1/11/23 and 1/13/23 to 1/18/23. Further review of the second floor medication room refrigerator log revealed that there were no temperatures recorded for 1/12/23. Interview on 1/19/23 at approximately 10:10 a.m. with Staff A confirmed the above findings in the second floor medication room. Third floor low side medication cart Observation on 1/19/23 at approximately 10:30 a.m. with Staff H (LPN) revealed the following medication in the third floor low side medication cart: Resident #16's used Incruse Ellipta 62.5 microgram (mcg) inhaler with no open date on inhaler or the inhaler container. Manufacturer's instruction with inhaler stated to discard in 6 weeks after opening the foil tray. Resident #16's used Incruse Ellipta 62.5 mcg inhaler with open date of 11/21/22, which is more than 6 weeks of the manufacturer's instruction of 6 weeks when opened. Resident #43's used Incruse Ellipta 62.5 mcg inhaler with no open date. Interview on 1/19/23 at approximately 10:40 a.m. with Staff H confirmed the above findings in the third floor low side medication cart. Review on 1/20/23 of Resident #16's active physician's order revealed that Resident #16 had an order for Incruse Ellipta 62.5 mcg inhaler once a day with a start date of 5/18/22. Review on 1/20/23 of Resident #43's active physician's order revealed that Resident #43 had an order for Incruse Ellipta 62.5 mcg inhaler once a day with a start date of 8/14/19. Second floor medication cart Observation on 1/19/23 at 11:05 a.m. with Staff K (Registered Nurse) revealed that Resident #8 Wixela (Fluticasone-Salmeterol) 100-50 mcg inhaler had a dispense date of 11/7/22 and no open date on the inhaler or the inhaler container. Manufacturer's instruction with the inhaler stated to discard after 30 days when open. Interview on 1/19/23 at 11:05 a.m. with Staff K confirmed the above findings in the second floor medication cart. Review on 1/20/23 of Resident #8's active physician's order revealed that Resident #8 had an order for Advair Diskus (Fluticasone-Salmeterol)100-50 mcg inhaler (the same medication as Wixela) with a start date of 10/15/22. Review on 1/20/23 of the facility's policy titled, Storage and Expiration Dating of Medications, Biological, dated 7/21/22, revealed .Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened .Facility Staff should monitor the temperature of vaccines twice a day .Facility should monitor cold storage containing vaccines twice a day per CDC guidelines .

Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient staff to meet the needs of the residents on the third floor Dementia Unit on days and evenings for 16 out of 30 days of nursing schedule reviewed (Resident identifiers are #23, #33, #41, and #69). Findings include: Review on 1/18/23 at approximately 11:00 a.m. of the facility assessment Section II. Staffing, Training, Service & Personnel revealed the following: .A.1. Function- Sufficiency Analysis Summary 1. Staffing and scheduling systems - Daily discussions regarding staffing on each of the units. The Unit Managers provide updates on resident needs. The scheduler will make staffing adjustments based on census and acuity. Scheduler and Clinical Team meet weekly for labor meeting to evaluate staffing needs, hires, terminations and all activities/report that link directly to the adequate staffing in the center .Caregivers collaborate via their Unit Manager/Supervisor, huddles, staff meetings and 1:1 [one to one] to determine changes to work loads, and assignments. All senior leaders with lic [license] support Direct Care Staff and partner to ensure adequate numbers for safety and quality . Interview on 1/18/23 at approximately 12:00 p.m. with Staff U (Administrative assistant) revealed that the Licensed Nursing Assistant (LNA) staffing minimum for the center on the third floor Dementia Unit is three LNAs on days and three LNAs on evenings. Resident #23 Interview on 1/18/23 at approximately 10:22 a.m. with Resident #23 revealed that they routinely are not able to take their weekly shower as they are told they do not have enough staff. Resident #23 stated they only get about one shower a month. Review on 1/20/23 at approximately 11:15 a.m. of Resident #23's LNA task documentation for bathing revealed they are scheduled to receive a shower every Friday on day shift. Further review of Resident #23's LNA task documentation from 12/22/22 through 1/20/23 for bathing revealed the only shower marked as completed was done on 1/6/23. Interview on 1/20/23 at approximately 11:45 a.m. with Staff I (Interim Director of Nursing) confirmed that Resident #23 is scheduled to receive weekly showers. Review on 1/23/23 at approximately 8:30 a.m. of Resident # 23's Activities of Daily Living (ADL) care plan, revised on 12/12/22, revealed that Resident #23 requires total assist of two for transfers and requires total assist of one for bathing. Resident #69 Interview on 1/18/23 at approximately 9:02 a.m. with Resident #69 revealed that they routinely are not given their weekly shower. Resident #69 stated that when he/she ask about it, he/she were told they do not have enough staff. Review on 1/20/23 at approximately 11:15 a.m. of Resident #69's LNA task documentation for bathing revealed they are scheduled to receive a shower every Saturday on the evening shift. Further review of the LNA task documentation 12/22/22 through 1/20/23 for bathing revealed the only shower marked as completed was done on 1/4/23. Interview on 1/20/23 at approximately 11:45 a.m. with Staff I confirmed that Resident #69 was to receive weekly showers. Review on 1/23/23 at approximately 8:30 a.m. of Resident #69's ADL care plan, revised on 1/20/23, revealed that Resident #69 requires extensive assist of one for transfers and total assist of one for bathing. Resident #33 Interview on 1/19/23 at approximately 10:15 a.m. at Resident Council Resident #33 stated that they have not had a shower in a month. Review on 1/19/23 at approximately 11:30 a.m. of Resident #33's LNA task documentation revealed that from 12/22/22 to 1/20/23 Resident #33 had not received a shower. Interview on 1/20/23 at approximately 9:30 a.m. with Staff M (Unit 3 Nurse Manager) confirmed that Resident #33 is supposed to have weekly showers Interview on 1/20/23 at approximately 9:05 a.m. with Staff S (Licensed Practical Nurse (LPN)) revealed that staffing with three LNAs on the third floor Dementia Unit happens most days and it is difficult for the staff to complete tasks due to the heaviness of the residents and the number of two assists on the unit. Interview on 1/20/23 at approximately 9:20 a.m. with Staff V (LNA) revealed that it was very hard to get tasks done on the third floor Dementia Unit with only three LNAs. Staff V stated that there were days that scheduled showers were not able to be completed due to this. Interview on 1/20/23 at approximately 9:30 a.m. with Staff M revealed that there were times when scheduled showers cannot be completed. Resident #41 Observation on 1/18/23 of the lunch meal service for third floor Dementia Unit revealed Resident #41's meal tray was delivered at 12:25 p.m., which remained covered at bedside. At approximately 12:50 p.m. a staff member returned and began to assist Resident #41 with their meal (Total weight time of 25 minutes). Interview on 1/18/23 at approximately 1:00 p.m. with Staff S revealed that Resident #41 requires total assist from staff to consume meals. Observation on 1/19/23 of the lunch meal service for the third floor Dementia Unit revealed Resident #41 was given their meal at 12:15 p.m., which remained covered at bed side. At 12:50 p.m. a staff member returned and began to assist Resident #41 with eating their meal (Total wait time of 35 minutes). Interview on 1/20/23 at approximately 9:20 a.m. with Staff V revealed that due to the number of people that require assistance with eating it sometimes takes up to 45 minutes from when the meals come to the floor and when you can sit down to assist them. Interview on 1/20/23 at approximately 12:35 p.m. with Staff Y (Scheduler) revealed that staffing levels are pre-established and they staff to a minimum of three LNAs on each unit across days and evenings shifts. Staff Y denies having heard anyone communicate concerns with staffing being too low or that staff are unable to get their work done with only three LNAs particularly on the third floor Dementia Unit. Interview on 1/20/23 at approximately 12:40 p.m. with Staff X (Human Resources) revealed that there has been no increase in overtime and Staff X also denied having heard anyone communicate concerns with staffing being too low or that staff are unable to get their work done with only three LNAs particularly on the third floor Dementia Unit. Interview on 1/20/23 at approximately 1:00 p.m. with Staff I revealed they were unaware of any concerns with staff not having enough help on the third floor Dementia Unit to complete tasks. Staff I stated they were unaware of any residents' concerns related to staffing. Review on 1/20/23 at approximately 2:30 p.m. of the resident listing, provided on 1/18/23, revealed a total of 44 residents on the third floor Dementia Unit. Review on 1/20/23 at approximately 2:30 p.m. of the facility nursing schedule revealed the following staffing on the third floor Dementia Unit from 12/20/22 through 1/20/23: Day Shift: 12/24/22 1 LPN, 1 MNA (Medication Nursing Assistant), 2.5 LNAs (1 LNA scheduled 8:30 a.m. to 12:00p.m.); 12/31/22 1 LPN, 1 MNA, 3 LNA's; 1/2/23 2 LPN's, 3 LNA's; 1/8/23 1 LPN, 1 MNA, 3 LNA's; 1/9/23 2 LPN's, 3 LNA's; 1/20/23 2 LPN's, 3 LNA's. Evening Shift 12/22/22 1 LPN, 1 MNA, 3 LNA's; 12/23/22 1 RN, 1 LPN, 3 LNA's; 12/28/22 1 LPN, 1 MNA, 3 LNA's; 12/29/22 1 RN, 1 MNA, 3 LNA's; 1/2/23 2 LPN's, 3 LNA's; 1/7/23 2 LPN's, 3 LNA's; 1/8/23 1 RN, 1 LPN, 3 LNA's; 1/17/23 1 LPN, 1 MNA, 3 LNA's Review on 1/20/23 at approximately 2:00 p.m. of the Centers for Medicare & Medicaid Services (CMS) form 672 for the third floor Dementia Unit revealed the following information regarding ADL assistance for the residents on the third floor unit: Bathing: 5 are independent, 16 require 1-2 staff assistance, and 23 are dependent on staff; Eating: 31 are in independent, 4 require 1-2 staff assistance, and 9 are dependent on staff.

Based on interview, observation, and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 2 of 2 residents reviewed for position and mobility (Resident identifiers are #4 and #50), and for 2 of 5 residents reviewed for unnecessary mediations in a final sample of 33 residents (Resident identifiers are #23 and #50). Findings include: Resident #4 Observation on 1/18/23 at approximately 8:49 a.m. of Resident #4 revealed a left hand orthotic on side table. Further observation of Resident #4 revealed left had to be contracted. Review on 1/19/23 at approximately 3:42 p.m. of Resident # 4's medical record revealed the following Occupational Therapy entries: 11/26/22 that stated: Pt [patient] with moderate to severe flexion contracture of all digits of L [left] hand; middle fingers most involved; resistive to care. At risk for further contracture and altered palmar skin integrity and hygiene . 1/16/23 that stated .PROM [Passive Range of Motion] to left hand/fingers to increase ROM [Range of Motion] and ability to wear an orthotic and to protect skin integrity . Further review of Resident #4's medical record revealed no care plan for contracture or increased risk for further contracture of left hand and no care plan for Occupational Therapy services. Interview on 1/23/23 at approximately 11:37 a.m. with Staff I (Interim Director of Nursing) confirmed the above findings. Resident #23 Review on 1/19/23 at approximately 2:30 p.m. of Resident #23's medical record revealed the following active physician's orders: Buspirone (anxiolytic) 10 milligrams (mg) four times a day for anxiety, with a start date of 12/9/22; Fluoxetine (antidepressant) 30 mg once a day for mood, with a start date of 12/10/22; Risperidone (antipsychotic) 3 mg twice a day for mood, with a start date of 12/10/22. Further review of Resident #23's medical record revealed the following active diagnosis: Bipolar disorder, paranoid schizophrenia, schizoaffective disorder, and dementia with other behavioral disturbances. Review on 1/19/23 at approximately 2:30 p.m. of Resident #23's care plan revealed no care plan for anxiety, mood and behaviors, schizophrenia, or bipolar disorder. Interview on 1/23/23 at approximately 11:37 a.m. with Staff I confirmed the above information. Resident #50 Review on 1/19/23 at approximately 8:44 a.m. of Resident #50's medical record revealed an active diagnosis of Post-Traumatic Stress Disorder (PTSD); Further review of Resident #50's medical record revealed an active physician orders: Risperdal (antipsychotic) 1 mg once a day for behavior changes, with a start date of 8/11/22. Review on 1/19/23 at approximately 1:41 p.m. of Resident #50's active care plan revealed no care plan for PTSD, or any target behaviors related care plan for Risperdal use. Review on 1/19/23 at approximately 1:41 p.m. of Resident #50's most recent MediTelecare [psychiatric service[]note dated 9/7/22 revealed identification of PTSD as a diagnosis and identifies Resident #50 is stable. Further review of MediTelecare note reveals no identification of PTSD triggers or behaviors associated with PTSD. Review on 1/23/23 at approximately 8:40 a.m. of Resident #50's behavior monitoring on the January 2023 Medication Administration Record for Risperdal use revealed no identification of target behaviors being monitored. The daily documentation buy nursing indicated N [no] for observed behaviors. Interview on 1/23/23 at approximately 8:45 a.m. with Staff M (Third floor Nurse Manager) revealed they were unaware of the target behaviors for Risperdal and what if any triggers for PTSD for Resident #50. Interview on 1/23/23 at approximately 9:13 a.m. with Staff F (Special Services Specialist) confirmed that Resident #50 has an active diagnosis of PTSD and no care plan identifying PTSD and triggers and behavior management of PTSD. Staff F confirmed that Resident #50 is taking scheduled Risperdal for behavior changes but there is no care plan identifying the target behaviors. 47129 Resident #50 Review on 1/23/23 at approximately 8:45 a.m. of Resident #50's current care plan revealed the following focus, goal and interventions: .Focus: Restorative Range of Motion . [name omitted] demonstrates loss of range of motion in left hand created 10/5/22 .Goal . [name omitted] will tolerate ROM [Range of Motion] daily and allow adaptive carrot to be put on daily .Interventions .Please do ROM . Wash hand . Put splint on . [name omitted] will likely remove if [pronoun omitted] does - put back on . Please document and report compliance with this . .Focus: Restorative Splint C Grip [orthotics device] . [name omitted] cannot apply or remove created 3/23/22 .Goal .Prevent contractures and maintain skin integrity .Interventions . C-grip to left hand . Put splint on once up . Leave on for 6-7 hours . Splint application . See RNP [Restorative Nurse Program] book for instruction . Observation of Resident #50 on 1/18/23 at approximately 8:30 a.m. revealed Resident #50 sitting in a chair, left hand contracted and nothing in hand for skin protection. Further observation revealed Resident #50's C-grip splint on his/her side table. Interview on 1/18/23 at approximately 8:30 a.m. with Resident #50 revealed Resident #50 is working with Occupational Therapy for his/her left hand. Observation on 1/18/23 at approximately 8:30 a.m. revealed Resident #50 was not in his/her room and Resident #50's C-grip splint was on his/her side table. Observation on 1/19/23 at approximately 12:15 a.m. revealed Resident #50 eating lunch in his/her room and Resident #50's C-grip splint was on his/her side table. Observation on 1/23/23 at approximately 8:50 a.m. of Resident #50 revealed Resident #50 was not wearing a C-grip splint on his/her left hand. Review on 1/23/23 of Resident #50's active diagnosis list revealed a diagnosis of Contracture, left hand. Review on 1/23/23 of Resident #50's active physician orders revealed Resident #50 is to wear a C-grip splint on his/her left hand daily. Interview on 1/23/23 at approximately 9:40 a.m. with Staff M confirmed the care plan was not being followed.

Based on record review and interview, it was determined that the facility failed to document advanced directives for 1 out of 33 residents reviewed for advanced directives in a final sample of 33 residents (Resident identifier is #69). Findings include: Review on [DATE] at approximately 8:18 a.m. of Resident #69's electronic medical record revealed Resident #69 readmitted to the facility on [DATE]. Review on [DATE] at approximately 8:18 a.m. of Resident #69's medical record revealed no current physician orders for code status. Further review of Resident #69's medical record revealed no indication of what Resident #69's code status wishes were. Interview on [DATE] at approximately 8:30 a.m. with Staff H (Licensed Practical Nurse) confirmed the above findings. Staff H stated that if they were to find Resident #69 unresponsive and could not verify code status they would initiate CPR [Cardio Pulmonary Resuscitation] and call 911. Review on [DATE] at approximately 8:10 a.m. of Resident #69's medical record revealed an order dated [DATE] for Do Not Resuscitate. Interview on [DATE] at approximately 8:30 a.m. with Staff I (Interim Director of Nursing) confirmed that Resident #69 was a Do Not Resuscitate. Staff I stated that when Resident #69 re-entered facility on [DATE] the code status was not entered in to the system. Review on [DATE] of facility policy titled Code Status Orders, effective date [DATE], revealed .1. Upon admission / re-admission, a code status order is required as soon as possible as part of the patient's admission order set. 1.4 Orders for code status include Fill Code or DNR [Do Not Resuscitate] .2. Staff should verify the patient's wishes with regard to code status (Full Code vs. DNR) upon admission .3. If a patient experienced cardiopulmonary arrest prior to receiving a code status order or verbal declination by the [NAME] or, if applicable, the resident representative, the Center will perform CPR .

Based on record review and interview it was determined that the facility failed to provide proper pain management and care after a fall with fracture for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #1). Findings include: During record review of the nurses notes dated 2/6/13 it revealed that Resident #1 sustained a fall at 2:30 p.m. Immediately after the fall the pain was described as "sharp" and rated "10/10". Nurses note dated 2/6/13 states "...PRN (as needed) Oxy ([MEDICATION NAME]) 5 mg administered at 345, at this time pt (patient) only c/o (complaining of) 10/10 pain in right leg. Pt (patient) reported slight to no relief. PRN Tylenol 650 mg administered along with scheduled [MEDICATION NAME] at 5 p.m. Family in to see pt. Pt continued to be in pain...new orders to increase oxy ([MEDICATION NAME]) and ice. PRN oxy ([MEDICATION NAME]) 5 mg administered at 615 and right knee/leg iced. Reported some relief but continued to have pain." On review of the physicians order dated 2/6/13 it states "Administer one-two tabs [MEDICATION NAME] 5 mg PO (by mouth) PRN pain..." On review of the MAR (Medication administration record) for 2/6/13 only one tab was given with a negative effect. Interview on 2/19/13 with Staff C (Registered Nurse) at time of record review confirmed that the proper pain management was not provided and that the order states "Administer [MEDICATION NAME] 5mg one tab po q 6h Prn Rated 1-5. [MEDICATION NAME] 5mg two tabs Po q 6h Prn pain 6-10..." On the history and physical examination History of Present Illness...severe 10 out of 10 pain in (Resident #1's) right leg....(Resident #1) pain was severe and so they called for an ambulance and (Resident #1) was brought to the emergency department for evaluation. Prior to going to the emergency department (Resident #1) had oral [MEDICATION NAME] at home which are part of her home medications. These did not help; 4 mg of IV [MEDICATION NAME] in the emergency department helped quite a bit. The patient had evaluation by this examiner, (Resident #1) is comfortable at rest but exquisitely painful with any movement of the right leg." Record Review on 2/19/13 revealed the following: Nurses notes dated 2/6/13 state "...X-ray orders obtained...pt (patient) only c/o (complaining of) 10/10 pain in right leg... X-ray completed at 18:32 (6:32 p.m.) showing "Mid-shaft [MEDICAL CONDITION] femoral shaft with overlapping fragments as described". Findings "...displaced angulated [MEDICAL CONDITION]-shaft of the right femur. Overlapping fragments are demonstrated...Shafts are overlapping. The distal fragment is positioned lateral to the proximal fragment and displaced greater than 1 full shaft width, with overlapping fragments..." At 21:32 (9:32 p.m.) on 2/6/13 a nurse's note is written that states "Pt (patient) obtained fall at 230 PM. C/O (complaining of) 10/10 pain in BLE (Bilateral Lower Extremities) ...Pt (patient) transferred via 911 per family request)".