Every finding on record at Hillcrest Commons Nursing & Rehabilitation Center

Based on interviews and record review, the facility failed to offer and/or administer updated Pneumococcal immunizations, according to Centers for Disease Control (CDC) recommendations to 14 Residents (#83, #18, #55, #148, #158, #207, #78, #191, #114, #108, #143, #186, #79, and #134) of 25 applicable residents for vaccinations, out of a total sample of 35 residents, placing the residents at risk for to develop pneumococcal infections. Specifically, the facility failed to: 1. Administer an updated Pneumococcal Vaccine to Residents #83, #18, #55, #148, #158, #207, #78, #191, #114, #108, and #143, when the Residents were eligible for the vaccine and consented to receive an updated Pneumococcal Vaccine. 2. Offer an updated Pneumococcal Vaccine to Residents #186, #79, and #134, when the Residents were eligible to receive an updated Pneumococcal Vaccine. Findings include: Review of the facility's Resident Pneumococcal Immunization Policy, dated September 2011 and revised 9/1/23, indicated the following: -Residents will be offered immunization to protect them from pneumococcal disease unless the vaccine is medically contraindicated, or the resident has already been immunized. -Pneumococcal immunizations will be provided as recommended by the CDC Advisory Committee for Immunization Practices (ACIP) recommendations. Review of the CDC Pneumococcal Vaccine Timing for Adults,aged [AGE] years and older Complete Pneumococcal Vaccine Schedules Guidance, revised March 2025, indicated the following: -Make sure your patients are up to date with pneumococcal vaccination. -Adults previously vaccinated with PCV13 at any age and PPSV23 five years or more prior, offer a PCV20 or PCV21 vaccine. -Shared clinical decision-making for adults aged 65 years and older who already completed the series with PCV13 and PPSV23: >Together, with the patient, vaccine Providers may choose to administer PCV20 or PCV21 to adults [AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. 1a. Resident #83 was admitted to the facility in January 2012 with diagnoses including Hypertension. Review of Resident #83's clinical record indicated the Resident: -Received the PCV13 vaccine on 10/1/15. -Received the PPSV23 vaccine on 11/21/19 at age greater than 65 years. -Consented to receive the PCV20 vaccine on 6/11/23, according to current and future vaccination guidelines. Further review of Resident #83's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident became eligible and consented to receive the vaccine. 1b. Resident #18 was admitted to the facility in November 2014 with diagnoses including Hypertension and Diabetes. Review of Resident #18's clinical record indicated the Resident: -Received the PCV13 vaccine on 11/27/19. -Received the PPSV23 vaccine on 4/6/21 at age greater than 65 years. -Consented to receive the PCV20 vaccine on 6/22/23, according to current and future vaccination guidelines. Further review of Resident #18's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident became eligible and consented to receive the vaccine. 1c. Resident #55 was admitted to the facility in May 2019 with diagnoses including Hyperlipidemia and Hypothyroidism. Review of Resident #55's clinical record indicated the Resident: -Received the PCV13 vaccine on 11/21/19. -Received the PPSV23 vaccine on 4/9/21 at age less than 65 years. -Consented to receive the PCV20 vaccine on 6/11/23, according to current and future vaccination guidelines. Further review of Resident #55's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine when the Resident became eligible and consented to receive the vaccine. 1d. Resident #148 was admitted to the facility in September 2019 with diagnoses including Diabetes. Review of Resident #148's clinical record indicated the Resident: -Received the PCV13 vaccine on 11/21/19. -Received the PPSV23 vaccine on 4/9/21 at age greater than 65 years. -Consented to receive the PCV20 vaccine on 6/19/23, according to current and future vaccination guidelines. Further review of Resident #148's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine when the Resident became eligible and consented to receive the vaccine. 1e. Resident #158 was admitted to the facility in March 2021 with diagnoses including Hyperlipidemia and Hypertension. Review of Resident #158's clinical record indicated the Resident: -Received the PCV13 vaccine on 3/10/16. -Received the PPSV23 vaccine on 4/19/21 at age [AGE] years or greater. -Consented to receive the PCV20 vaccine on 6/14/23, according to current and future vaccination guidelines. Further review of Resident #158's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident became eligible and consented to receive the vaccine. 1f. Resident #207 was admitted to the facility in January 2024 with diagnoses including Diabetes. Review of Resident #207's clinical record indicated the Resident: -Received the PCV13 vaccine on 2/25/16. -Received the PPSV23 vaccine on 3/29/18 at age less than 65 years. -Consented to receive the Pneumococcal Vaccine on 11/17/24, according to current and future vaccination guidelines. Further review of Resident #207's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident was eligible and consented to receive the vaccine. 1g. Resident #78 was admitted to the facility in April 2024 with diagnoses including Hypotension and Asthma. Review of Resident #78's clinical record indicated the Resident: -Received the PCV13 vaccine on 4/16/15. -Received the PPSV23 vaccine on 4/6/17 at age less than 65 years. -Consented to receive the Pneumococcal Vaccine on 10/3/24, according to current and future vaccination guidelines. Further review of Resident #78's clinical record failed to include evidence that the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident was eligible and consented to receive the vaccine. 1h. Resident #191 was admitted to the facility in May 2024 with diagnoses including Diabetes and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #191's clinical record indicated the Resident: -Received the PCV13 vaccine on 6/2/13. -Received the PPSV23 vaccine on 4/24/20 at age less than 65 years. -Consented to receive the PCV20 vaccine on 5/14/24, according to current and future vaccination guidelines. Further review of Resident #191's clinical record failed to include evidence the facility administered the PCV20 or PCV21 vaccine to the Resident when the Resident became eligible and consented to receive the vaccine. 1i. Resident #114 was admitted to the facility in September 2025 with diagnoses including Acute Kidney Failure and acute embolism and thrombosis of lower extremity deep veins. Review of Resident #114's clinical record indicated the Resident: -Received the PCV13 on 8/1/14. -Received the PPSV23 vaccine on 10/19/20 (when the Resident was aged less than 65 years). -Consented to receive the pneumococcal vaccine on 9/16/25, according to current and future vaccination guidelines. Further review of Resident #114's clinical record failed to include evidence the facility administered an updated Pneumococcal Vaccine according to vaccination guidelines when the Resident became eligible and consented to receive the vaccine. 1j. Resident #108 was admitted to the facility in January 2026 with diagnoses including Shortness of Breath. Review of Resident #108's clinical record indicated the Resident: -Received the PCV13 vaccine on 11/15/18. -Received the PPSV23 vaccine on 3/20/19 at age less than 65 years. -Consented to receive the Pneumococcal Vaccine on 1/9/26, according to current and future vaccination guidelines. Further review of Resident #108's clinical record failed to include evidence the facility administered an updated Pneumococcal Vaccine according to vaccination guidelines when the Resident was eligible and consented to receive the vaccine. 1k. Resident #143 was admitted to the facility in April 2026 with diagnoses including Hypertension and Diabetes. Review of Resident #143's clinical record indicated the Resident: -Received the PPSV23 vaccine on 11/2/07 at age [AGE] years or greater. -Received the PCV13 vaccine on 6/8/15. -Consented to receive the pneumococcal vaccine on 6/26/25, according to current and future vaccination guidelines.Further review of Resident #143's clinical record failed to include evidence the facility administered an updated Pneumococcal Vaccine according to vaccination guidelines when the Resident was eligible and had consented to receive the vaccine. 2a. Resident #186 was admitted to the facility in March 2014 with diagnoses including Adult Failure to Thrive and COPD. Review of Resident #186's clinical record indicated the Resident: -Received the PCV13 vaccine on 9/1/15. -Received the PPSV23 vaccine on 11/21/19 at age [AGE] years or greater. Further review of Resident #186's clinical record failed to include evidence that the facility offered the PCV20 or PCV21 vaccine to the Resident. 2b. Resident #79 was admitted to the facility in August 2015 with diagnoses including Hypertension, Atrial Fibrillation (AFib), and Chronic Kidney Disease (CKD). Review of Resident #79's clinical record indicated the Resident: -Received the PCV13 vaccine on 11/21/19. -Received the PPSV23 vaccine on 4/9/21 at age less than 65 years. Further review of Resident #79's clinical record failed to include evidence the Resident was offered the PCV20 or PCV21 vaccine when the Resident became eligible to receive the PCV20 or PCV21 vaccine. 2c. Resident #134 was admitted to the facility in October 2016 with diagnoses including Dementia. Review of Resident #134's clinical record indicated the Resident: -Received the PCV13 vaccine on 7/12/16. -Received the PPSV23 vaccine on 11/21/19 at age [AGE] years or greater. Further review of Resident #134's clinical record failed to include evidence the facility offered the Resident the PCV20 or PCV21 vaccine when the Resident became eligible to receive the vaccine. During an interview on 6/24/26 at 11:04 A.M., with the Infection Preventionist (IP) and the Director of Infection Prevention, the IP said residents who had already received both the PCV13 and PPSV23 vaccines are considered up to date and the facility does not offer those residents an updated Pneumococcal Vaccine. The Director of Infection Prevention said the facility offers and administers Pneumococcal Vaccines to residents according to CDC recommendations. The Director of Infection Prevention said the facility is required to offer the PCV21 vaccine to all eligible residents and that the facility no longer offers the PCV20 vaccine. The Director of Infection Prevention said he uses the CDC Pneumococcal Vaccine Recommendations calculator to determine whether residents are eligible to receive the PCV21 vaccine. The Director of Infection Prevention said all residents who are eligible to receive the PCV21 vaccine should be offered the vaccine and that the PCV21 vaccine should be administered to all eligible residents who consent to receive the vaccine. The Director of Infection Prevention said the PCV21 vaccine should be ordered and administered to all eligible residents who consent to receive the vaccine within a week or so of consent. During an interview on 6/25/26 at 12:45 P.M., the Director of Infection Control indicated: -Resident #143 was eligible to receive an updated Pneumococcal Vaccine in June 2020. -Resident #78 was eligible to receive an updated Pneumococcal Vaccine in April 2022. -Resident #207 was eligible to receive an updated Pneumococcal Vaccine in March 2023. -Resident #108 was eligible to receive an updated Pneumococcal Vaccine in March 2024. -Residents #83, #186, and #134 were eligible to receive updated Pneumococcal Vaccines in November 2024. -Resident #191 was eligible to receive an updated Pneumococcal Vaccine in April 2025. -Resident #114 was eligible to receive an updated Pneumococcal Vaccine in October 2025. -Residents #18, #79, #55, #148, and #158 were eligible to receive an updated Pneumococcal Vaccine in April 2026. The Director of Infection Prevention further said the facility should have offered updated pneumococcal immunizations, according to CDC guidance and shared clinical decision-making with the Residents/Representatives, for each of the Residents discussed during the interview. The Director of Infection Prevention said updated PCV21 vaccines should have been ordered and administered to each eligible Resident upon obtaining consent for administration of the vaccine. The Director of Infection Prevention said it is important to offer and administer updated Pneumococcal Vaccines to Residents to protect the Residents from pneumococcal disease.

Based on observation, interviews, and record review, the facility failed to notify the Physician/Nurse Practitioner (NP) of consistent refusal of a weekly prescribed medication for one Resident (#11) out of a total sample of 35 residents.Specifically, for Resident #11, the facility failed to notify the Physician/NP of the Resident's refusal of his/her weekly medication order for Methotrexate (anti-inflammatory, pain-reducing medication used to treat certain cancers, severe psoriasis, and autoimmune diseases), placing the Resident at risk of disease progression and discomfort. Findings include: Review of the facility's policy titled Physician Notification, dated 11/11/09, revised September 2011, indicated:-Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated.-Purpose is to communicate a change in residents' condition to physicians and initiate interventions as needed/ordered.-The protocols for physician notification may be used to determine additional physician and historical data to be collected for report to physician.-If clinical findings indicate routine notification, notify the physician as soon as possible during normal business hours.-Document physician notification and response.Review of the facility's policy titled Documentation, revised 12/29/25 indicated:-If a scheduled medication is withheld or not given as ordered, the Nurse documents this and lists the reason for the resident not receiving the medication and what was done to attempt to administer the medication. Resident #11 was admitted to the facility in November 2023 with diagnoses including chronic pain syndrome, disease of the spinal cord, cervical disc disorder with myelopathy, arthropathic psoriasis and psoriatic arthritis mutilans.During an interview of 6/23/26 at 11:35 A.M., Resident #11 said he/she was in pain all the time and that his/her pain level was at eight on a scale of zero to 10 numerical scale.Review of the Minimum Data Set (MDS) Assessment, dated 6/11/26, indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. Review of Resident #11's Care Plan, initiated 12/16/25, indicated:-Resident has potential for alteration in comfort/pain related to arthritis, muscle spasms, due to paraplegia, cervical myelopathy, multiple joint deformities, psoriatic arthritis.-Administer analgesia as per orders.-Medicate per physician's orders (see MAR - Medication Administration Record).-Notify Physicians if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Review of the Palliative Care Note dated 5/13/26, indicated Resident #11:-was receiving Methotrexate Sodium 25 milligram/milliliter (mg/ml) injection solution 7.5 mg weekly, start 11/6/23.Review of Resident #11's June 2026 Physician's orders indicated:-Methotrexate 25 mg/ml vial, inject 0.3 ml subcutaneously one time a day, every Thursday related to psoriatic arthritis mutilans, order date 4/2/25, start date 12/3/25. Review of Resident #11's February 2026 through 6/23/26 MARs indicated that the Resident refused the Methotrexate medication on the following dates:-February: 2/12/26, 2/26/26-March: 3/5/26, 3/19/26, 3/26/26-April: 4/2/26, 4/9/26, 4/16/26, 4/23/26, 4/30/26-May: 5/7/26, 5/14/26, 5/21/26, 5/28/26-June: 6/4/26, 6/11/26, 6/18/26, 6/25/26 Review of Resident #11's Clinical Record did not show evidence that the Physician/NP had been notified of the Resident's refusal of the Methotrexate medication on the dates listed from February 2026 through 6/23/26.During an interview on 6/25/26 at 10:15 A.M., the surveyor and the Corporate Regional Nurse (CRN) reviewed Resident #11's MAR and the CRN said there was no evidence that a Physician/NP were notified of the Resident's refusal of the Methotrexate medication. During an interview of 6/25/26 at 1:16 P.M., Nurse #2 said she worked on Resident #11's unit on the days the Resident was scheduled for Methotrexate medication. Nurse #2 said the Resident would refuse his/her Methotrexate medication but had not notified the Physician/NP. Nurse #2 said she should have notified the Physician/NP, but she had not.During an interview on 6/25/26 at 1:29 P.M., NP #1 said she had not been made aware that Resident #11 had been refusing his/her Methotrexate medication. During an interview on 6/25/26 at 2:02 P.M., NP #2 said the Methotrexate medication was prescribed to assist in slowing down the progression of Resident #11's psoriatic arthritic disease, help the Resident to maintain physical abilities and relieve the Resident's pain. NP #2 further said the facility staff should have notified the Physician/NP of the Resident's medication refusals, but they had not.

Based on observation, record review, and interview, the facility failed to provide appropriate accommodation of needs for one Resident (#6), out of a total sample of 35 residents. Specifically, for Resident #6, the facility failed to provide a wheelchair that accommodated the Resident's physical needs for use while he/she was out of bed, and the Resident's preference was to get out of bed and his/her bedroom, placing the Resident at risk for decreased mobility and psychosocial wellbeing. Findings include: Review of the facility policy titled Residents' Rights Policy indicated: -A resident has the right to a dignified existence, self-determination, and communication with and access to people inside and outside the facility. -A resident has the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of other residents. Resident #6 was admitted to the facility in October 2025 with diagnoses including Morbid Obesity, and dependence on renal dialysis. Review of the Minimum Data Set (MDS) Assessment, dated 2/19/26, indicated Resident#6:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15-was dependent for transfers out of bed-has range of motion impairments of both lower extremities During an interview on 6/25/26 at 8:57 A.M., the surveyor observed Resident #6 seated upright in bed with a craft project on the over the bed table directly in front of him/her. Resident #6 said that the facility took his/her wheelchair months ago to use for another resident and now they won't let him/her get out of bed. Resident #6 said that he/she attends hemodialysis four days a week and would like to be able to get out of bed and out of his/her room on non-hemodialysis days. Resident #6 also said that he/she gets tired of looking at the same walls all the time. The surveyor did not observe a wheelchair in the Resident's room at the time. During an interview on 6/25/26 at 9:27 A.M., Unit Manager (UM) #2 said that up until about six months ago Resident #6 was getting out of bed into a facility wheelchair on non-hemodialysis days one or twice per week. UM #2 said about three and a half weeks ago, Resident #6 requested to get out of bed, but the large wheelchair which was used to accommodate Resident #6's size had disappeared. UM #2 said she contacted the therapy department so that they could locate the wheelchair but had not heard anything about whether the chair had been located or was being used for another resident. UM #2 said she should have followed up on obtaining the necessary wheelchair for Resident #6 sooner, and that three and a half weeks was too long for Resident #6 to wait to get out of bed to a wheelchair. During an interview on 6/25/26 at 9:47 A.M., Rehabilitation (Rehab) Staff #1 said that Resident #6 used to have a large wheelchair to use to get out of bed, and when Resident #6 stopped requesting to get out of bed, the chair was then used for a different resident. Rehab Staff #1 said the Rehab Department had not been made aware at any time that Resident #6 had requested to get out of bed or needed a wheelchair. Rehab staff #1 said that if facility staff couldn't locate an appropriate wheelchair in the facility, then the facility would have to purchase one to accommodate the Resident.

Based on observation and interview, the facility failed to ensure that resident rights were honored for one Resident (#182) out of a total sample of 35 residents, when the Resident had a specific request relative to medication administration.Specifically, for Resident #182, the facility staff failed to honor the Resident's request to take his/her morning medications with a meal when the Resident notified the Nurse that he/she was experiencing stomach discomfort and expressed a preference to take his/her morning medications with the breakfast meal. Findings include:Review of the facility policy titled Resident's Rights, initiated June 1996 and revised 10/4/23, indicated:-A resident has the right to a dignified existence, self-determination, and communication with and have access to people inside and outside the facility.-A facility must treat each resident with respect and dignity and care in a manner and environment, that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality.-The resident has the right to be informed of, and participate in, his or her treatment.-The Resident has a right to be treated with respect and dignity.-The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice.-The resident has the right to make choices about aspects of his/her life in the facility that is significant to the resident. Resident #182 was admitted to the facility in August 2023 with diagnoses including cirrhosis of liver, gastric varices, gastrointestinal hemorrhage and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #182 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an interview on 6/23/26 at 8:20 A.M., Resident #182 said he/she had stomach discomfort which started three days prior. Resident #182 said Nurse #1 gave him/her the morning medications around 7:40 A.M., and the Resident told Nurse #1 that he/she had stomach discomfort and asked if Nurse #1 could return with his/her morning medication when the breakfast meal arrived. Resident #182 said Nurse #1 said that she would throw away the medications if the Resident refused to take his/her medications. Resident #182 said Nurse #1 left his/her room and Unit Manager (UM #1) came to tell him/her that if he/she did not take the medications, the medications would be thrown away. Resident #182 said he/she also told UM #1 that he/she would like to take his/her morning medications with a meal due to his/her stomach discomfort and UM #1 insisted that the Resident take his/her medications. Resident #182 said he/she took the medications despite having stomach discomfort. During an interview on 6/23/26 at 2:15 P.M., Nurse #1 said Resident #182 had expressed that he/she did not want to take his/her medications. Nurse #1 said she knew Resident #182 preferred to take all his/her morning medications early and did not want to delay the process. Nurse #1 said the Resident said he/she would have preferred to take his/her morning medications with his/her breakfast meal due to the Resident experiencing stomach discomfort. Nurse #1 said she informed UM #1 about Resident #182. During an interview on 6/23/26 at 2:30 P.M., UM #1 said Nurse #1 informed her of Resident #182's refusal of his/her morning medications. UM #1 said she spoke to the Resident, and the Resident took his/her medications. UM #1 said she did not assess the Resident when the Resident expressed stomach discomfort. UM #1 said she explained to Resident #182 that if he/she did not accept his/her morning medications, it would be discarded and would take a while for Nurse #1 to administer the medications. UM #1 said Nurse #1 should have assessed Resident #182 when he/she expressed stomach discomfort, should have offered the Resident a snack or she should have waited to administer the medications with his/her breakfast meal, but she did not. During an interview on 6/23/26 at 2:35 P.M., Nurse #1 said should have assessed Resident #182 when he/she expressed stomach discomfort, should have offered the Resident a snack or should have waited to administer the medications with the Resident's breakfast meal, but she did not. During an interview on 6/24/26 at 8:50 A.M., the Director of Nursing (DON) said Nurse #1 and UM #1 should have respected the rights of Resident #182, offered the Resident a snack and waited for his/her breakfast to arrive before Nurse #1 administered the morning medications. During an interview on 6/24/26 at 9:16 A.M., the Corporate Clinical Nurse (CCN) said the Nurses should have respected the rights of Resident #182, and they had not.

Based on observations, interviews, and record reviews, the facility failed to ensure nutritional interventions were implemented per the Registered Dietitian (RD) recommendation to address unanticipated, unplanned weight loss for one Resident (#9), of seven applicable residents reviewed for nutrition care and services, out of a total sample of 35 residents.Specifically, for Resident #9, the facility failed to ensure fortified ice cream (Magic Cup) was added to the Resident's lunch tray per the RD's recommendation when the Resident experienced ongoing significant weight loss (weight loss greater than or equal to 5 percent (%) over one month, 7.5% over three months, 10 % over 6-month period) and was determined to be at increased nutritional risk. Findings include: Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated the following:-Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition.-Resident will receive a therapeutic diet when indicated.-Nutritional assessment and care planning will be completed by the Interdisciplinary team.-Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed.-Avoidable means that the resident did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following:>Define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice;>Monitor and evaluate the impact of the interventions.-Review RD recommendations. Obtain orders per recommendations. If Medical Doctor does not want to follow recommendations, document explanation in a nursing note.-Review RD's progress notes to identify ongoing progress and recommendations.-Review resident's care plan as needed.-Document:>Percentage of food intake,>Resident response to nutritional interventions in nursing notes and in care plan evaluation. Resident #9 was admitted to the facility in August 2025 with diagnoses including schizoaffective disorder. Review of the Minimum Data Set (MDS) Assessment, dated 4/30/26, indicated Resident #9:-Has moderate cognitive impairment as evidenced by a Brief Interview for Mental (BIMS) score of ten out of 15 points,-Required supervision or touch assist with meals,-Had unplanned weight loss of 5% in one month or more than 10% in six months and was not on a prescribed weight loss regimen. Review of the Nutrition Note, dated 5/11/26, indicated Resident #9 had a significant weight loss of 5 pounds (lbs.) (5%) in one month and had lost 11 lbs. (10%) in a six-month period.>The RD indicated the Resident's weights were as follows:-106 lbs. on 11/4/25-100 lbs. on 4/1/26-95.2 lbs. on 5/6/26>The RD plan indicated that a Magic Cup ice cream would be added to the Resident's lunch meal daily and to continue to monitor and document the Resident's intake and weights. Review of Resident #9's Comprehensive Care Plans indicated:>Increased nutritional risk related to inadequate energy intake, varied intake and unintended significant weight loss, initiated 2/11/26 and revised 5/11/26, and included the following intervention:-Provide diet/supplement. Review of the clinical record indicated Resident #9 was 94.8 lbs. on 6/3/26. Review of Resident #9's June 2026 Physician's orders included the following:-House diet, Regular texture, initiated 11/24/25-Offer a snack appropriate for the Resident's diet every day at bedtime, initiated 12/6/25-Weight monthly by the 7th of the month. Reweigh for a 3% or greater weight variance. Complete the re-weigh by the 14th of the month, initiated 1/19/26-House supplement, one time daily. Please give supplement separate from meals and document time, initiated 4/15/26 On 6/25/26 at 8:53 A.M., the surveyor observed Resident #9 lying in bed during breakfast mealtime. The Resident's breakfast tray was observed on the over the bed table positioned next to the Resident and contained a covered bowl of hot cereal, a covered small bowl of canned fruit, a covered cup of coffee and a plate containing two triangles of toast and a partially eaten egg and cheese bake. Certified Nurse Aide (CNA) #1 was observed to enter the Resident's room and encourage Resident #9 to eat his/her breakfast. During an interview on 6/25/26 at 8:55 A.M., CNA #1 said she was very familiar with Resident #9 and that the Resident preferred to eat in his/her room. CNA #1 said Resident #9 needed encouragement to eat and that the Resident's intake with meals varied daily. CNA #1 said she not aware of any special nutritional interventions in place to help with the Resident's weight, but that snacks are provided to all of the residents daily. CNA #1 said Resident #9 ate about half of his/her egg bake and drank some juice for breakfast this morning but did not eat the hot cereal, toast or fruit. On 6/25/26 at 12:26 P.M., the surveyor observed Resident #9 had a plate containing a slice of turkey meatloaf, mashed turnip and mixed vegetables, a glass of apple juice, a glass of water, a mug of coffee and a slice of apple pie during the lunch meal. The surveyor did not observe any Magic Cup ice cream on the Resident's meal ticket or on the Resident's meal tray. The Resident was observed to have consumed all of the apple pie, a small amount of the turkey meatloaf, most of his/her juice and approximately half of the water. During an interview on 6/25/26 at 12:26 P.M., CNA #1 said Resident #9's weight fluctuates up and down. CNA #1 said the Resident does not receive any special nutritional items on his/her meal trays. CNA#1 said the facility has Magic Cup ice cream, but this specific food item was not given to residents unless the Dietary department orders it. During an interview on 6/25/26 at 12:35 P.M., Nurse #3 said Resident #9 has a house supplement (Boost High Calorie) that is ordered to be administered at 2:00 P.M., but she was not aware of a recommendation for Magic Cup ice cream to be given to the Resident during lunch. During an interview on 6/25/26 at 12:47 P.M., Unit Manager (UM) #3 said Resident #9 was being monitored for weight loss. UM #3 said Resident #9 has experienced weight loss since admission, had gained some weight at the end of February 2026 but has been trending down in his/her weight again. UM #3 said the RD makes nutrition recommendations on paper or via email, and that these recommendations would be reviewed with the Provider and addressed by the facility staff. UM #3 reviewed the Nutrition Note dated 5/11/26 and said she reviewed her emails and did not receive communication from the RD about the recommendation to add Magic Cup ice cream daily to Resident #9's lunch tray. UM #3 said had she been aware of the RD recommendation to add the Magic Cup ice cream, she would have reviewed it with the Resident's Provider and added it to the Resident's diet order. UM #3 said the information would also be included on the Resident's lunch meal tickets. During an interview on 6/25/26 at 2:21 P.M., the RD said she had been contracted to work at the facility since April 2026 or May 2026. The RD said she notifies the Food Service Director (FSD) when there are nutrition recommendations for residents. During an interview on 6/25/26 at 2:52 P.M., the FSD said the contracted RD will email her with any nutrition recommendations or changes to resident diets. During an interview on 6/25/26 at 3:11 P.M., the FSD said she reviewed her emails since 5/11/26 and did not receive any recommendations from the RD about adding the Magic Cup ice cream to Resident #9's lunch trays. During an interview on 6/26/26 at 10:14 A.M., the RD said she recommended adding the Magic cup ice cream to Resident #9's lunch tray on 5/11/26 so that the Resident's weight would stabilize with a goal for his/her weight to increase. The RD said Resident #9 has had significant weight loss, and the Magic Cup ice cream has 300 calories, 20 grams of protein, and that many residents would accept it as a sweet treat. The RD said she either writes down her nutrition recommendations on paper or emails the recommendations to the FSD and other support staff. The RD said she thinks she may have written down the nutrition recommendation to add the Magic Cup ice cream to Resident #9's lunch meals on 5/11/26 and handed it to someone in the kitchen but she could not recall who. The RD said she was unable to find evidence that she had sent an email about the nutrition recommendation for Resident #9 on 5/11/26. The RD said she keeps a written tracker of nutrition recommendations made and would periodically follow up to ensure that these recommendations have been followed up on. The RD said she had not been aware that the recommendation to add the Magic Cup ice cream to the Resident's meal trays had not been implemented. The RD said the recommendation from 5/11/26 should have been reviewed prior to 6/26/26 to ensure that the recommendation was implemented.

Based on observation, interview, and record review, the facility failed to ensure that the facility main kitchen was maintained in a clean and sanitary manner to prevent contamination and the spread of foodborne illnesses. Specifically, the facility staff failed to ensure: -food for resident consumption was stored appropriately and were labeled and dated. -equipment used for meal preparation were clean and free of debris when not in use. -fans utilized in the kitchen remained dust free preventing potential physical contamination. -an issue with the facility dish machine was identified when the minimum wash temperatures were not obtained, as required. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions, revised 9/21/22, indicated that the facility will follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The policy also included the following: -safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues through the facility's food handling process -Types of food contamination include physical contamination -Factors implicated in foodborne illness include contaminated equipment >improper equipment sanitation procedures -Food Receiving and Storage >when food is purchased by the nursing home, inspection for safe transport and quality upon receipt and proper storage helps ensure its safety >Keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer is indicated. >practices to maintain safe refrigerator storage include: labeling, use by dating and monitoring refrigerated foods, including but not limited to leftovers, so it is used by it's used by date, frozen (if applicable) or discarded. -Equipment and Utensil Cleaning and Sanitization >potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of contaminated equipment. >protecting equipment fro contamination via splash, dust, grease, etc. is indicated >Dishwashing machines, operated according to manufacturers specifications, wash, rinse and sanitize dishes and utensils using either heat or chemical sanitization. >High Temperature Dish machine (heat sanitization) -wash 150- 165 degrees Fahrenheit wash, and -final rinse- 180 degrees Fahrenheit final rinse . -When cleaning fixed equipment (mixers, slicers and other equipment that cannot be readily immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air dried and sprayed with sanitizing solution (at the effective concentration). On 3/18/25 at 7:20 A.M., the surveyor conducted an initial tour of the facility main kitchen and the following was observed: -walk-in refrigerator had a sheet pan of raw hamburger and clear packages of thawed cut up chicken that were not labeled or dated -the window behind the steam table was open and had no screen -the industrial can opener had built up black thick debris on the blade -the slicer had light colored debris on the blade and surrounding parts of the machine -an unlabeled and undated large bin containing flour. The outside top of the bin was tacky to the touch and was visibly dirty on the outside and on the sliding cover During an interview at the time, Dietary Staff #3, who was the [NAME] said the sheet pan of hamburger and the chicken were pulled yesterday from the freezer to be thawed. Dietary Staff #3 said there should be labels and dates on both items. On 3/25/25 at 10:16 A.M., the surveyor conducted a follow-up walk through of the facility main kitchen with the Food Service Director (FSD) and the following was observed: -the bin containing flour remained dirty on the outside -the slicer had light colored debris on the blade and on the surrounding parts of the machine. During an interview at the time, Dietary Staff #3 said the slicer had not been used since the previous day when slicing turkey and was cleaned after its use. -two fans that were in use (on) and were attached to the walls in the dish room were dust laden. One fan was located where clean dishware was stored. -the dish machine was in use and the wash temperature was 140 degrees Fahrenheit [F] (after running several racks of dishes through the machine) and the final rinse temperature was ranging from 180- 190 degrees F. During an interview with the FSD immediately following the observations, the FSD said: -the inside of the flour bin was cleaned out weekly, but the outside of the bin needed to be cleaned -the slicer was not thoroughly cleaned and needed to be cleaned again -the kitchen windows should not be open if there were no screens because it could allow pests (mice/bugs) to enter the kitchen -both of the fans that were in use in the dish room needed to be cleaned because they were covered in dust -the minimum dish machine wash temperature should be 160 degrees F. The FSD further said he had checked the temperature that morning and it was within range. The FSD said that the dish machine should not be used and he would contact their vendor for further instructions. During an interview on 3/25/25 at 10:46 A.M., Dietary Staff #3 said she keeps instructing staff to keep the window in the kitchen closed because there was no screen. Dietary Staff #3 said she has also been educating the dietary staff about ensuring kitchen equipment, like the can opener and surfaces were cleaned after every use because they could be a cause of potential cross contamination. During a follow-up interview on 3/25/25 at 11:08 A.M., the FSD said he spoke with the vendor relative to the facility dish machine and was instructed to connect the chemical sanitizer and the dish machine would be safe to use until they were able to provide an on-site visit to remedy the wash temperature issue. The FSD said the temperatures were taken in the beginning when the dish machine was used and the wash temperature was 167 degrees F. The FSD said the machine had been running for a while when he and the surveyor observed the wash temperatures of 140 F, and that the staff using the dish machine should be monitoring the temperatures to ensure they are within the acceptable ranges.

Based on interview, and record review, the facility failed to implement corrective and preventive actions and re-evaluate a performance improvement plan (PIP) when the identified interventions were no longer making progress toward the identified goal for reducing the amount of food allergens that were sent to residents on meal trays. Specifically, the facility failed to ensure that an effective system was maintained for implementing changes and monitoring performance putting residents in the facility at risk for significant harm relative to ingesting a food allergen. Findings include: Review of the facility Quality Assurance and Performance Improvement (QAPI) Plan, undated, indicated the following: -Purpose and Goals -Take a proactive approach to continually improve the way we care for and engage with our residents/clients, caregivers, and other partners . -Guiding Principles: -Uses QAPI to make decisions and guide our day to day operations. -Makes decisions based on data . -Collects and monitors data related to the outcomes of subpopulations .and uses the data to determine QAPI initiatives. -Sets goals for performance using internal and external benchmarks and measures progress towards those goals. -Feedback, Data Systems and Monitoring: -The QAPI Team will meet monthly to review the analysis, trends, and action items from the data compiled within appropriate time frame as indicated. The QAPI team will evaluate and gather data on the system processes to evaluate their effectiveness. -Systemic Analysis and Systemic Action : -Will focus on making changes to systems and processes rather than focusing on addressing individual behaviors to minimize the risk of problem reoccurring. -Root Cause Analysis (RCA) underpins all the performance improvement activities of this organization. The Change team may use any of the following methods: -Barrier exercise-mind, system, information, leader barriers -Swiss cheese model-management, organization, programmatic, or individual barriers -5 Why's-asking why until cause determined -Fishbone diagram During the survey period of 3/18/25 through 3/21/25, and 3/24/25 through 3/25/25, the following occurred: -During the initial screening process on 3/18/25 one Resident reported he/she had concerns as he/she had been served meals that contained food items that he/she had listed as an allergen. -On 3/19/25 at 12:44 P.M., the surveyor observed Resident #163 was actively being assisted with his/her lunch meal and a round bowl containing a pureed chocolate dessert on the Resident's tray. The surveyor requested Unit Manager (UM) #2 intervene and remove the chocolate dessert from the Resident's tray as Resident #163 had a documented allergy on his/her meal ticket of chocolate flavoring, chocolate, and cocoa. -On 3/24/25 at 2:09 P.M., Resident #215 told a surveyor that he/she had received a dessert at lunch that contained coconut, an ingredient that he/she had a listed allergen. Following the incident Nurse #7 said Resident #215 was allergic to coconut, that Nurse #7 had assessed Resident #215 and offered the Resident Benadryl (an antihistamine). -27 Residents who resided in the facility have been identified by the facility as having a food allergy. During an interview on 3/19/25 at 2:00 P.M., the Food Services Supervisor said the facility was currently doing a PIP for QAPI regarding allergens being served on meal trays. The Food Services Supervisor said allergens being served on meal trays had been an ongoing issue within the facility. Review of the PIP documentation indicated the following: September 2024 -the first QAPI meeting the PIP information was provided to the committee about accuracy of meal trays relative to allergies. -Accuracy of allergy trays sent to the units was 95.5% accurate. -The Goal was 100% accuracy. -Plan of correction was to continue with tray audits. -No target date for achieving the 100% accuracy goal was identified in notes that were provided. -No audit tools were provided to correspond with how the facility reached the 95.5% accuracy for the tray audits. October 2024 -Accuracy of allergy trays sent to the units was 91.7% accurate. -The Goal was 100% accuracy. -Plan of correction was to continue with tray audits, and to highlight allergies in different colors on meal tickets. -No target date for achieving the 100% accuracy goal was identified in notes that were provided. -No audit tools were provided to correspond with how the facility reached the 91.7% accuracy for tray audits. -No in-servicing documentation was provided to show what staff members had been in-serviced. November 2024 -Accuracy of allergy trays sent to the units was 90% accurate. -The Goal was 100% accuracy. -Plan of correction was to continue to audit trays, highlighting allergies in different colors, new cart order system to be implemented which was allergy trays to be the first trays placed in carts, and specific food service employees were to be trained for ensuring tray line accuracy. -No target date for achieving the 100% accuracy goal was identified in the notes that were provided. -No audit tools were provided to correspond with how the facility reached the 90% accuracy for tray audits. -No in-servicing documentation was provided to show what staff members had been in-serviced December 2024 -Accuracy of allergy trays sent to the units was 94.7% accurate. -The Goal was 100% accuracy. -Plan of correction was to continue with tray audits, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be the first trays placed in the carts, and specific food service employees were to be trained for ensuring tray line accuracy. -No new interventions were implemented at this time. -No target date for achieving the 100% accuracy goal was identified in the notes that were provided. -No audit tools were provided to correspond with how the facility reached the 94.7% accuracy for tray audits. -No in-servicing documentation was provided. January 2025 -Accuracy of allergy trays sent to the units was 96.3% accurate. -The Goal was 100% accuracy -Plan of correction was to continue to with tray audits,, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be the first trays placed in carts, and specific food service employees were to be trained for ensuring tray line accuracy. -No new interventions were implemented this month. -No target date for achieving the 100% accuracy goal was identified in the notes that were provided. -No audit tools were provided to correspond with how the facility reached the 96.3% accuracy for tray audits. -No in-servicing documentation was provided. February 2025 -Accuracy of allergy trays sent to the units was 93.6% accurate. -The Goal was 100% accuracy. -Plan of correction was to continue with tray audits, highlighting allergies in different colors, a new cart order system to be implemented with allergy trays to be first trays placed in carts, and specific food service employees were to be trained for checking tray line accuracy. -No new interventions were implemented this month. -No target date for achieving the 100% accuracy goal was identified in the notes that were provided. -No audit tools were provided to correspond with how the facility reached the 93.6% accuracy for tray audits. -No in-servicing documentation was provided. The facility provided documentation to the survey team for one in-service titled Accurate Tray Card Reading and Allergies, that completed with the dietary staff from 3/4/25 through 3/8/25. During an interview on 3/24/25 at 2:29 P.M., the Food Services Supervisor said the dietary department had been doing a PIP since August 2024, relative to ensuring residents received the correct diets on their meal trays, and were not provided with food that contained an allergen. The Food Service Supervisor said she was unable to locate the audit tools used monthly for the PIP and was also unable to locate any in-servicing that had been done as part of the PIP. During a follow-up interview with the Food Service Director (FSD) and the Food Service Supervisor on 3/25/25 at 9:22 A.M., the FSD said the current auditing process was to check ten meal trays randomly during each meal to ensure meal accuracy and ensure allergens were not going to be served to a resident with an allergy. The Food Services Supervisor said staff not only monitored accuracy of trays during the tray line, a senior staff member double checked the trays at the completion of the tray line, and the trays were to be checked by the Nursing Unit Manager once the trays arrived on the units. The Food Services Supervisor said that even with the multi-check system, allergens were still being served on meal trays. The surveyor asked the FSD and the Food Service Supervisor what the concern would be if only checking ten trays randomly when there was a known problem of allergens being served. Both the FSD and Food Services Supervisor said they risked missing a tray of a resident who did have allergies, and they should have been monitoring all allergy trays prior to them leaving the kitchen. The FSD said the PIP was not effective and due to the severity of the concern being addressed in the PIP he would have expected the goal for the project to only have been one month and the fact that it has gone on for many months without resolve was concerning and put residents at risk for having an allergic reaction. During an interview on 3/25/25 at 11:36 P.M., the Administrator said the current PIP relative to food allergens had not been effective and the team needed to take a deeper look into the problem.

Based on observation, interview, and record review, the facility failed to implement infection control practices in accordance with professional standards of practice to prevent the potential spread of infection for one Resident (#209), out of a total sample of 36 residents, and on four units (Unit 1, Unit 2, Unit 3 and Unit 4) out of five units. Specifically, the facility failed to: -ensure the appropriate precautions were initiated timely when Resident #209 was identified with gastrointestinal symptoms (nausea and vomiting) increasing the risk for the spread of infection to other residents and staff. -initiate norovirus outbreak monitoring timely resulting in the spread of infection to Unit's 1, 2, 3, and 4. Findings include: Review of CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, revised March 21, 2024, retrieved from, https://www.cdc.gov/infection-control/hcp/norovirus-guidelines/summary-recommendations.html indicated: -Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis. -When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. Dependent upon facility characteristics, approaches for cohorting patients during outbreaks may include placing patients in multi-occupancy rooms, or designating patient care areas or contiguous sections within a facility for patient cohorts. -During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. -Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks. -Consider restricting symptomatic and recovering patients from leaving the patient-care area unless it is for essential care or treatment to reduce the likelihood of environmental contamination and transmission of norovirus in unaffected clinical areas. -Consider suspending group activities (e.g., dining events) for the duration of a norovirus outbreak. -If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material. -Use a surgical or procedure mask and eye protection or a full-face shield if there is an anticipated risk of splashes to the face during the care of patients, particularly among those who are vomiting. -For those affected areas where it is necessary to have continued visitor privileges during outbreaks, screen and exclude visitors with symptoms consistent with norovirus infection and ensure that they comply with hand hygiene and Contact Precautions. -Provide education to staff, patients, and visitors, including recognition of norovirus symptoms, preventing infection, and modes of transmission upon the recognition and throughout the duration of a norovirus gastroenteritis outbreak. -Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility. Use a specified case definition and implement line lists to track both exposed and symptomatic patients and staff. Collect relevant epidemiological, clinical, and demographic data as well as information on patient location and outcomes. Review of the facility policy titled Outbreak Investigation, initiated September 2011, indicated: -It is the policy of facility that outbreak measures will be instituted whenever there is an incidence of infection above what would normally be expected. -The Infection Preventionist (IP) will have the authority to implement control measures as appropriate, in coordination with facility administration and medical staff. Purpose: a) To establish that an outbreak exists. b) To provide timely, appropriate monitoring of ill residents. c) To prevent the transmission of infection from one resident to others. d) To provide facility employees, medical and administrative staff, and state/local agencies to accurate, organized, and objective information. e) To prevent future outbreaks of similar illness. -The importance of handwashing, compliance with isolation precautions and the benefit to prevent outbreaks. -Get the facts yourself! Confirm that symptoms really exist by chart review, and ask the following questions: -If gastrointestinal illness is reported: a) How many loose stools in a 24-hour period? b) Have any resident experienced loose stools, document the information on a line list. c) Are there other symptoms, example, nausea, vomiting or diarrhea? -Look for new cases. -Keep records of how events transpired. -Educate staff, residents and visitors. 1. Resident #209 was admitted to the facility in October 2024 with diagnoses including Cerebrovascular Accident (CVA), Diabetes, and Hypertension. Review of Resident #209's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of total possible 15. Review of Resident #209's Nursing Progress Note dated 3/19/25 at 8:18 P.M. indicated the Resident had nausea, vomited, refused dinner, and dinnertime Insulin medication. The Nursing Progress Note further indicated ginger ale was offered to the Resident, but he/she was afraid to consume due to nausea and vomiting. On 3/20/25 at 7:59 A.M., the surveyor observed Resident #209 was lying in bed asleep. The surveyor also observed there was no precaution sign (s) posted at Resident #209's room. During an interview on 3/20/25 at 11:12 A.M., the IP said there were no active infections other than residents that had been placed on Enhanced Barrier Precautions (EBP - targeted infection prevention strategy, focusing on gown and glove use during high-contact resident care activities, to reduce the transmission of multi-drug-resistant organisms [MDROs] in the facility). The IP further said Resident #209 would not be discharged home as planned due to the Resident not feeling well. On 3/20/25 at 2:37 P.M., the surveyor observed Contact Precaution signage was posted on Resident #209's door, that indicated staff should wear gown and gloves before entering the Resident's room. During an interview on 3/20/25 at 3:02 P.M., Unit Secretary #2 said Resident #209 was in the activity room playing bingo. During an interview on 3/20/25 at 3:06 P.M., Nurse #9 said Resident #209's discharge was on hold due to the Resident being sick with nausea and vomiting that began in the evening on 3/19/25. Nurse #9 said the Resident had refused breakfast and lunch on 3/20/25. Nurse #9 said Resident #209 would be in his/her room and if the Resident came out of the room, the Resident would be wearing a mask. On 3/20/25 at 3:12 P.M., the surveyor observed Resident #209 seated in a wheelchair in the activity room with eight other residents playing bingo. The surveyor did not observe Resident #209 wearing a mask. During an interview on 3/20/25 at 3:16 P.M., the Corporate Infection Preventionist (CIP) said it was just brought to his/her attention that three Residents had diarrhea, and that the facility was reviewing these reports. During an interview on 3/20/25 at 3:18 P.M., the IP said she was aware Resident #209 had vomiting and diarrhea in the morning and had placed a Contact Precaution sign at the Resident's door. The IP further said she had been made aware that two other Residents had started with nausea and vomiting on the same unit as Resident #209. During an interview on 3/20/25 at 3:27 P.M., Activity Assistant (AA#1) said she was not aware that any residents had nausea and vomiting at the facility. During an interview on 3/21/25 at 11:14 A.M., the IP provided a line listing that indicated that four Residents including Resident #209 had nausea and vomiting with symptom onset as of 3/20/25. The IP said Resident #209 should not have attended the bingo activity without a mask and proper hand hygiene. The surveyor and the IP reviewed the line listing, and the IP said she was not aware that the GI symptom onset was 3/19/25 and had not reviewed Resident #209's progress notes. The surveyor, IP, and CIP, reviewed Resident #209's progress note dated 3/19/25 at 8:18 P.M., indicating the Resident was experiencing nausea and vomiting. The IP said Resident #209 should have been placed on Contact Precaution as soon as his/her symptoms were identified on 3/19/25 to avoid the spread of the virus but he/she was not placed on precautions. The IP further said Resident #209 should not have attended the bingo activity with other residents. During an interview on 3/25/25 at 10:18 A.M., the IP and CIP provided a line listing that indicated fifteen other residents had developed nausea and vomiting and one resident was hospitalized . The IP further said six out of the total 16 residents on the line listing for the outbreak were on Unit 2, the same unit as Resident #209, seven of the residents resided on Unit 4, one resident resided on Unit 3, and one resident resided on Unit 1.

Based on interview, and record review, the facility failed to provide therapeutic diets as ordered by the health care Provider for nutrition and hydration management for four Residents (#163, #89, #125, and #40) out of a total sample of 36 residents. Specifically, 1. For Resident #163, the facility failed to ensure a nutritional supplement was administered as ordered by the Physician after the Resident had a significant weight loss potentially resulting in a further weight decline. 2. For Resident #89, the facility staff failed to establish an accurate fluid plan as ordered by the Physician and inconsistently recorded the total daily fluid intake, placing the Resident at risk for fluid volume overload and related complications when more than the fluid restricted limit was consumed. 3. For Resident #125, the facility failed to review the Physician's order and accurately monitor the Resident's fluid intake for the Resident who was on dialysis. 4. For Resident #40, the facility failed to accurately assess 24-hour fluid amounts when a fluid restriction was ordered by the Physician for the Resident who was on dialysis. Findings include: 1. Review of the facility policy titled Nutrition Management, revised 9/30/24, indicated the following: >Policy: --Residents will receive care and services to ensure acceptable parameters of nutrition status are maintained to the extent possible as indicated by the resident's clinical condition. -Residents will receive a therapeutic diet when indicated. -Nutritional assessment and care planning will be completed by the Interdisciplinary team. -Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. >Purpose: . --To recognize, evaluate, and address the nutritional needs of every resident, including, but not limited to, the resident at risk or currently experiencing impaired nutrition. -To provide a therapeutic diet that takes into account he resident's clinical condition and preferences, when there is a nutritional indication. >Procedure: - .Review dietician's recommendations. -Obtain orders per recommendations. -If Medical Doctor (MD) does not want to follow recommendations, document explanation in nursing note. Resident#163 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease. Review of the recent comprehensive Minimum Data Set (MDS) Assessment, dated 2/14/25, indicated Resident #163: -required substantial to max assist to eat his/her meals. -had severely impaired long term memory and short term memory. -was coded as having a significant weight loss of 5% or more in the last month or of 10% or more in the last six months. Review of the Vital Parameters Report dated 3/24/25, indicated the following weights for Resident #163: -8/2/24: 117.2 pounds (lbs) -9/10/24: 115.6 lbs -10/8/24: 111.8 lbs -11/5/24: 108.9 lbs -12/3/24: 108.2 lbs -1/3/25: 105.6 lbs -1/10/25: 92 lbs -2/1/25: 103 lbs (12.12% weight loss in six months from 8/2/24 to 2/1/25) -3/3/25: 84 lbs -3/4/25: 83 lbs (19.42% weight loss in one month from 2/1/25 to 3/4/25) Review of the Dietary Progress Note dated 1/31/25, indicated Resident #163: -had a significant weight loss of 14.9% in one month and a 17.71% weight loss in three months. -had a Dietician recommendation to provide Boost Very High Calorie (VHC-a nutritional drink) after each meal if intake was less than 50%. Review of the Dietary Progress Note dated 2/12/25, indicated Resident #163: -had significant weight loss. -oral (PO) intake. -continue with current recommendations as ordered. Review of Resident #163's March 2025 Physician's orders indicated: -Supplement: Boost VHC Vanilla 8 ounces (oz) box/can, one box/can as needed (PRN). Provide Boost VHC (vanilla only) after each meal if intake is less than 50%. Start date 2/1/25. Review of Resident #163's Meal Intake Report indicated: -February 2025: the Resident ate less than 50% for 69 out of 84 meals. -March 2025: from 3/1/25 through 3/19/25, the Resident ate less than 50% for 17 out of 27 meals. Review of Resident #163's February 2025 and March 2025 Medication Administration Records (MARs) failed to indicate documentation that Resident #163 was administered Boost VHC after meals when he/she had consumed 50% of less of the meal. Review of the Dietary Progress Note dated 3/13/25, indicated Resident #163: -triggered for significant weight loss (loss of 23% in one month), -was prescribed 4 oz. Boost Breeze (juice based nutritional supplement) twice daily and house supplement 237 milliliters (equivalent to 8 oz) as needed (PRN) for poor PO intake -consumption for this supplement is unknown. During an interview on 3/20/25 at 11:35 A.M., the surveyor and Nurse #2 reviewed Resident #163 Physician's orders and Nurse #2 said Resident #163 had an order for Boost VHC vanilla after meals if the Resident's intake was less than 50% at each meal. Nurse #2 said if there was no documentation on the MAR indicating a Boost VHC vanilla was administered then the Boost VHC vanilla had not been offered. Nurse #2 further said Resident #163 did not like the Boost VHC vanilla and preferred the Boost Breeze. During an interview on 3/20/25 at 11:59 A.M., the Director of Nursing (DON) said if Resident #163 had an order in place for Boost VHC vanilla after meals if he/she did not consume 50% or more of the meal, nursing staff should have been offering the supplement to the Resident as ordered. During an interview on 3/20/25 at 12:21 P.M., Nurse #2 said she had not offered Resident #163 any Boost VHC vanilla when she worked on the unit and was unaware of the order until she reviewed the Resident's chart with the surveyor. Nurse #2 said the process for new dietary orders was that the Dietician would let the Unit Manager (UM) know, the UM would then get the order and update the staff regarding the new dietary order. Nurse #2 said the staff member who assisted Resident #163 during meals, would then provide the Nurse with a meal intake percentage after each meal. Nurse #2 said nursing should have administered the Boost VHC vanilla as ordered, and it did not appear to have been administered as ordered. Nurse #2 said Resident #163 had recently lost weight. During an interview on 3/20/25 at 1:49 P.M., the Dietician said she recommended Resident #163 to be administered Boost VHC as he/she had been losing weight and was comfort care with the goal of trying to stabilize or slow the weight loss. The Dietician said an order was put into place on 2/1/25 for the Resident to receive Boost VHC vanilla after meals if he/she ate less than 50% of the meal. The Dietician said nursing staff should have been administering Boost VHC vanilla as ordered and then document the percentage of the nutritional supplement the Resident consumed but there was no documentation in February 2025 or March 2025 to indicate the Resident had been offered the Boost VHC vanilla. The Dietician said she was unsure if she had followed up regarding why there was no documentation on the days Resident #163 should have been administered the Boost VHC vanilla. During an interview 3/20/25 at 2:13 P.M., the Dietician provided the surveyor with an email from UM #2 indicating Resident #163 did not like the Boost VHC vanilla. The Dietician said nursing staff at that time should have changed the order to provide Resident #163 with Boost Breeze which the Resident preferred and this was not done. During an interview on 3/24/25 at 10:49 A.M., UM #2 said all Nurses working on the unit should review as needed (PRN) orders every shift. UM #2 said the order for Boost VHC vanilla was a PRN order for when Resident #163 ate less than 50% of his/her meal. UM #2 said she was unsure why the order for the Boost VHC vanilla was never implemented as ordered. UM #2 also said staff were aware Resident #163 preferred Boost Breeze over Boost VHC vanilla and nursing staff should have had the order changed to Boost Breeze and this was not done. 50138 2. Resident #89 was admitted to the facility in October 2024 with diagnoses including End Stage Renal Disease (ESRD), Diastolic Congestive Heart Failure and Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of Resident #89's March 2025 Physician's orders indicated: -Fluid restriction 1200 ml (milliliter) a day, effective 10/22/24. -May not omit diet restriction on special occasions, effective 10/18/24. -Hemodialysis via shunt Tuesdays, Thursdays and Saturdays. Review of Resident #89's Comprehensive Person-Centered Care Plans indicated: <Hydration, effective 10/31/24: Problem = Resident #89 had a potential alteration in hydration status related to fluid restriction, kidney disease and diuretic use with interventions that included - Establish fluid plan including meals, med pass and nourishments. <End Stage Renal Disease, effective 10/21/24: Problem: Resident #89 has required Hemodialysis with interventions including a fluid restriction as ordered with intake monitoring. Review of Resident #89's Medication Administration Records (MAR) from January 2025, February 2025 and March 2025 indicated the following; Fluid Restriction 1200 ml/day: -Day shift (7:00 A.M.-3:00 P.M.) Dietary: Breakfast 240 ml, Lunch 240 ml. Nursing: Day = 600 ml, effective 10/22/24. -Evening Shift (3:00 P.M.-11:00 P.M.) Dietary: Dinner 120 ml. Nursing Evening = 480 ml, effective 10/22/24. -Night Shift (11:00 P.M.-7:00 A.M.) Nursing NOC (night) =120 ml, effective 10/22/24. On 3/20/25 at 11:40 A.M., the surveyor and UM #3 reviewed Resident #89's MAR's which indicated: -January 2025 MAR: total documented daily intake exceeded the 1200 ml limit for 29 out of 31 days, and was not totaled accurately. -February 2025 MAR: total documented daily intake exceeded the 1200 ml limit for 26 out of 28 days, total was inaccurate. -March 2025 MAR: total documented daily intake exceeded the 1200 ml for 16 out of 19 days, total was inaccurate. During an interview at the time, UM #3 said that Resident #89's fluid intake was not totaled accurately during January 2025, February 2025, and March 2025, but should have been because too much fluid could be dangerous to a hemodialysis resident. UM #3 said that Resident #89's fluid restriction breakdowns by shift on the Resident's MAR was entered incorrectly to equal 1800 ml and should have been 1200 ml. During an interview on 3/20/25 at 8:07 A.M., the Director of Nursing (DON) said that Resident #89 was ordered for a 1200 ml fluid restriction by the Physician. The DON said that the shift-to-shift breakdown on the Resident's MAR for fluids allowed under the current fluid restriction order exceeded the 1200 ml fluid restriction and totaled 1800 ml. The DON said that the Registered Dietitian (RD) made the recommendation for fluid restriction breakdown via email to the DON for dietary and nursing to share. The DON said that the Unit Manager (UM) is then responsible to transcribe the fluid restriction breakdown recommendation to the Resident's MAR so that each shift would know how much fluid should be provided per shift. The DON said that the fluid restriction recommendations were transcribed incorrectly by the UM and the Resident was therefore allotted for 1800 ml of fluids a day, not the ordered 1200 ml/daily. The DON said that daily intakes should be totaled by the night shift (11:00 P.M.-7:00 A.M.) Nurse but they were not. The DON said that accurate totaling of fluid intake was important for Resident #89 so that a fluid imbalance could be identified. The DON said when a Residents' fluid balance was over the prescribed fluid restriction the UM should notify the Residents' Provider because having too much fluid intake could result in fluid volume overload and cause cardiopulmonary distress. During an interview on 3/24/25 at 11:55 A.M., the RD said that she first identified that fluid intake documentation for Resident #89 was a concern last week during survey when questions were raised by the survey team. The RD said that fluid restrictions were a part of a therapeutic diet order and should be followed. The RD said that the fluid intake for Resident #89 was a concern because the fluid restriction had been exceeded and not totaled every day. The RD said that if a Resident exceeds the daily fluid restriction it would be a concern because excess fluids could be more taxing on the resident's system and affect the level of dialysis required as an outpatient. The RD said that if a Resident was regularly going over the fluid restriction the facility nurses should provide notification to the RD and Physician. The RD said she had not been notified by the nursing staff relative to Resident #89 exceeding the fluid restriction regularly but should have been. 47901 3. Resident #125 was admitted to the facility in January 2025 with diagnoses including End Stage Renal Disease (ESRD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Hypertension (HTN), and Respiratory Failure with Hypoxia. Review of Resident #125's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total possible 15. Review of Resident #125's March 2025 Physician orders, dated 1/28/25, indicated: -Fluid Restriction 1200 milliliters (ml) per day >Dietary Day Shift Breakfast - 240 ml >Lunch - 240 ml >Nursing Day - 600 ml -Add meal intake to total shift Review of Resident #125's Dietician Progress Note dated 1/30/25, indicated: -Resident back from stay in hospital due to CHF and SOB (Shortness of Breath). -Before Dialysis weight in hospital was reported as 186.5 pounds. -After dialysis weight was reported as 166.5 pounds. -Indicates the Resident was retaining more fluids -Current diet order HCC/renal/mech soft/thin -1200 ml fluid restriction. -Continue fluid restriction 1200 ml due to recent hospitalization . On 3/20/25 at 8:43 A.M., the surveyor and Unit Manager (UM) #5 reviewed Resident #125's Physician order and Intake and Output (I&O) documentation and the following were identified: -Physician order for fluid intake did not include supper, evening shift, and night shift. -I&O for January 2025 was not documented for nursing on the MAR. -I&O's for February 2025 were over the 1200 ml every day -I&O's for 3/1/25 - 3/19/25, were over the 1200 ml fluid restriction limit. During an interview at the time, UM #5 said Resident #125's fluid restrictions had not been reviewed by facility staff, and they should have been reviewed. UM #5 further said the Physician's order was inaccurate. During an interview on 3/20/25 at 10:16 A.M., Clinical Nurse Support (CNS) #3 said the Physician order was inaccurate, the facility staff had not reviewed the I&O, and they should have. 37400 4. Resident #40 was admitted to the facility in August 2020 with diagnoses including End Stage Renal Disease (ESRD) and Pulmonary Edema. Review of the MDS Assessment, dated 12/25/24, indicated Resident #40: -was cognitively intact as evidenced by a BIMS score of 15 out of 15 -received a therapeutically altered diet -was on dialysis Review of the Renal Dialysis Care Plan, initiated 10/20/20 and revised 1/25/25, indicated Resident #40 had a need for hemodialysis and included the following interventions also initiated 10/20/20: -monitor for signs and symptoms of fluid overload (shortness of breath, increased fatigue, significant weight gain, edema). -Notify Medical Doctor/Nurse Practitioner of significant changes as needed. -fluid restriction as ordered with intake monitoring (see nutritional care plan) Review of the Nutritional Care Plan, initiated 8/19/20 and revised 3/18/25, indicated Resident #40 presented at nutritional risk related to kidney and endocrine dysfunction and end stage renal disease requiring hemodialysis and poor diet compliance, and included the following interventions: -fluid restriction as ordered, dated 3/18/25 -document intake regarding percent (%) of solids and fluids consumed, dated 3/18/25 -educate resident and family on dietary restrictions, dated 3/18/25 Review of the Certified Nurses Aide (CNA) Care Card indicated Resident #40 was on a 1500 ml Fluid Restriction. Review of the March 2025 Physician's Orders included the following orders, initiated 1/23/25: -Day Fluid Restriction 1500 ml, Day shift (7:00 A.M. to 3:00 P.M.): >Dietary: breakfast =240 ml >Dietary: lunch = 240 ml >Nursing Day = 300 ml >add meal intake to total shift intake -Eve [sic] Fluid Restriction 1500 ml, Evening shift (3:00 P.M. to 11:00 P.M.): >Dietary: dinner = 240 ml >Nursing: Eve = 300 ml >add meal intake to total shift intake -Noc [sic] Fluid Restriction 1500 ml, Noc shift (11:00 P.M. to 7:00 A.M.) >Nursing Noc = 180 ml Review of the January 2025 to March 2025 Medication Administration Records (MARs) indicated the total fluid intake amounts recorded on each shift and the total 24- hour total amounts recorded with the following results: January 2025 -24-hour total = 0 mls was documented twice 1/23/25, 1/31/25 -1500 ml restriction was exceeded on 1/23/25, 1/25/25 -24-hour total documented that was different from intake totals on 1/24/25, 1/25/25,1/26/25,1/27/25, 1/29/25, 1/31/25 February 2025 -24-hour total = 0 mls was documented 2/2/25, 2/5/25, 2/7/25, 2/8/25, 2/14/25, 2/17/25, 2/19/25, 2/26/25 -24-hour total documented that was different from intake totals on 2/1/25 - 2/28/25 March 2025 -24-hour total = 0 mls was documented four times on 3/2/25, 3/15/25, 3/21/25, 3/22/25 -1500 ml restriction was exceeded on 3/4/25 -24-hour total documented that was different from intake totals on 3/1/25 - 3/22/25 Review of the CNA Meal Intake by Day Report from January through March 2025 indicated Resident #40 consumed more than the allotted 240 mls with each meal on the following: January 2025 -Breakfast: 1/25/25 - 1/30/25 -Lunch: 1/24/25 -Dinner: 1/23/25, 1/31/25 -No intake documentation for breakfast and lunch - 1/23/25, 1/31/25 February 2025 -Breakfast: 2/1/25, 2/3/25 - 2/6/25, 2/8/25 - 2/11/25, 2/14/25 - 2/16/25, 2/18/25, 2/20/25 - 2/21/25, 2/23/25 - 2/25/25, 2/27/25 - 2/28/25 -Lunch: 2/2/25, 2/17/25 -Dinner: 2/7/25, 2/12/25 March 2025 -Breakfast: 3/1/25 - 3/10/25, 3/13/25 - 3/15/25 - 3/20/25, 3/22/25 - 3/23/25 -Lunch: 3/1/25 - 3/5/25, 3/8/25 - 3/10/25, 3/13/25, 3/15/25, 3/17/25 - 3/18/25, 3/20/25 -3/23/25 -Dinner: 3/1/25, 3/3/25, 3/5/25, 3/8/25 - 3/10/25, 3/11/25, 3/15/25 - 3/23/25 On 3/20/25 at 3:50 P.M., the surveyor observed Resident #40 seated upright in bed and multiple closed individual cups containing apple juice were observed on the Resident's over bed table along with a large reusable covered cup with a straw which were within the Resident's reach. Two open containers of ice cream were observed on the Resident's bed and the surveyor observed him/her eating one. During an interview at the time, Resident #40 said he/she was on a fluid restriction, was unsure how much the fluid restriction was for, but was allowed to have the fluid contained in the large reusable cup daily. Resident #40 said he/she kept the cups of apple juice on his/her overbed table to use when he/she needed to take a medication to lower his/her potassium level because he/she liked to mix the medication in the apple juice. Resident #40 said he/she did not usually consume all of the drinks provided on his/her meal trays but usually consumed the coffee. During an interview on 3/24/25 at 10:13 A.M., CNA # 1 said Resident #40 was on a fluid restriction but he was not sure how much he/she was allowed to have with meals. CNA #1 said Resident #40 usually received an eight ounce (oz) carton of milk and a container of juice (4 oz) with meals. CNA #1 said that he documents the amount the Resident consumes of the food and fluids in the CNA documentation and would report to the Nurse if the Resident didn't eat/drink because that would be a change for him/her. On 3/24/25 at 12:01 P.M., the surveyor requested copies of the Resident #40's meal tickets from the Food Service Supervisor. The meal tickets included the following: -Fluid Rest: (sic) 1500 ml D: 720, which was located on each meal ticket. During an interview at the time, the Food Service Supervisor said Resident #40 was on 1500 ml Fluid Restriction. When the surveyor asked about the 720 indicated on each meal ticket, the Food Service Supervisor said she was not sure, but thought it may be the fluid amount allowed for that meal. The Food Service Supervisor said when she was notified that a Resident was on a fluid restriction, nursing would notify the kitchen of the amounts allowed from meals and then she or the Dietitian would meet with the Resident to review what fluids were requested with meals. On 3/24/25 at 12:13 P.M., the surveyor and the Dietitian reviewed Resident #40's meal tickets. During an interview at the time, the Dietitian said the D: 720 indicated the total amount of fluids allowed from dietary for the day, not for the meal. The Dietitian said there was a breakdown of fluid amounts that were to be provided with each meal from dietary. The Dietitian said that if the Resident was routinely going over his/her fluid restriction amount, she would expect the facility staff to notify her so she could follow-up with the Resident. The Dietitian said if extra fluids were provided to the Resident, it could be taxing on him/her because he/she goes to dialysis, and it would be more fluid that would need to be removed during the dialysis process. The Dietitian said she did not routinely review the 24-hour fluid intakes documented by nursing and after reviewing the 24-hour fluid amounts for Resident #40, she further said that there needed to be more education with the nursing staff about fluid restrictions. The Dietitian reviewed the printout of Resident #40's meal tickets and said some of the information on the Resident's tickets were not accurate. During an interview on 3/24/25 at 3:10 P.M., Nurse #5, who regularly worked the 11:00 P.M. to 7:00 A.M. shift, said fluid restriction amounts for residents were broken up by the three nursing shifts. Nurse #5 said she would document the amount she provided to the resident on her shift and would then total the amounts provided on the other shifts and document total fluid amount on the 24-hour totals. Nurse #5 said sometimes the fluid amounts were not documented on previous shifts, so she would mark not applicable and notify the UM. Nurse #5 said there were some residents who were not good about following their fluid restrictions, and if they went over their fluid amounts allotted for the day, she would provide education to them and document this in the resident's clincal record. Nurse #5 said she also communicated with the CNAs about how much fluid they provided to the resident and this would be documented on the fluid amounts for that shift. During an interview on 3/24/25 at 4:27 P.M., UM #1 said for residents on fluid restriction, the Nurses should be documenting the total fluid intake amounts consumed during their shift which included fluids taken during meals, snacks and what nursing provided. UM #1 said the 11:00 P.M. to 7:00 A.M. shift should total these shift amounts and complete the 24-hour fluid intake totals. UM #1 said the resident's fluid intake amounts should be reviewed every couple of days for trends, and if the resident was over the fluid restriction amount, the Physician and the Dietitian would be notified. UM #1 said the CNAs should know when a resident was on a fluid restriction and there should be communication between the CNAs and the Nurses relative to the fluid amounts the resident consumed during that shift. During an interview on 3/25/25 at 10:46 A.M., Dietary Staff #3 said items like coffee, tea, juices, ice cream, sauces, gravies and soup count as fluids. Dietary Staff #3 said when a resident is on a fluid restriction, the dietary staff would follow what was listed on the resident's meal tickets which indicate what should be put on the meal trays. During a follow-up interview on 3/25/25 at 10:48 A.M., the Food Service Supervisor said she was working with the Dietitian to review the resident meal tickets relative to fluid restrictions. The Food Service Supervisor said any liquid drinks, soups, ice cream and Jello would count as liquids. The Food Service Supervisor said she didn't count sauces, gravies and creamers as fluids but she probably should. The Food Service Supervisor said she reviewed what the D: 720 meant on Resident #40's meal tickets and was told that it was total fluid amount allowed from dietary for the day, not for each meal.

Based on record review, and interview, the facility failed to maintain accurate documentation of controlled substance (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) for two units (Unit 2, side one and Unit 2, side two) out of five units reviewed. Specifically, the facility failed to maintain accurate documentation in the controlled substance register (Narcotic Book Documentation). Findings include: Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/22, indicated: -It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy. Purpose: -To provide for proper ordering, storage, disposal and security of controlled substances. -To minimize the opportunity for abuse or diversion of controlled substances. -To promote occupational and patient safety. -Medication information is logged into the Controlled Substances Register as follows: >One controlled substance per patient page. >Each new patient page shall include: >Patient's name. >Prescriber's name. >Drug name and strength. >Directions for use. >Prescription number and date. On 3/25/25 at 9:20 A.M., the surveyor and Unit Manager (UM) #5 reviewed the controlled substance register on Unit 2, side one. The surveyor observed that the controlled substance register did not include documentation of prescription numbers for the controlled substance medications and no dates indicating receipt of the controlled substance medications. During an interview at the time, UM #5 said the prescription numbers of the controlled substances should have been documented in the controlled substance register but there were not. On 3/25/25 at 9:35 A.M., the surveyor reviewed the controlled substance register on the Unit 2, side two medication cart. The surveyor observed that the controlled substance register had no prescription numbers documented and no dates of the receipt of the controlled substance medications. On 3/25/25 at 9:57 A.M., the surveyor and Nurse #6 reviewed the controlled substance register on Unit 1, side two. Nurse #6 said 48 pages of the controlled substance register did not have documentation for prescription numbers and dates the controlled substances were received from the pharmacy. On 3/25/24 at 10:06 A.M., the surveyor and Nurse #10 reviewed the controlled substance register on Unit 1, side one. Nurse #10 said 175 pages of the controlled substance register did not have the prescription numbers of the controlled substance medications documented and the dates the controlled substances were received from the pharmacy. During an interview on 3/25/24 at 10:37 A.M., the Director of Nursing (DON) said the prescription numbers for the controlled substance medications and the dates the controlled substances were received should be documented in the controlled substance register, but they were not documented. The DON further said it was important to accurately document the prescription numbers and dates the medications were received to minimize the opportunity for abuse or diversion of controlled substances.

Based on interview, and record review, the facility failed to ensure that appropriate competencies related to medication administration was completed for one Licensed Nurse (Nurse #9) out of 5 staff records reviewed. Specifically, the facility failed to provide documentation that Nurse #9 had completed the appropriate nursing competencies for medication administration and controlled substances (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) documentation. Findings include: Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/2022, indicated: -It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy. Purpose: -To provide for proper ordering, storage, disposal, and security of controlled substances. -To minimize the opportunity for abuse or diversion of controlled substances. -To promote occupational and patient safety. -Medication information is logged into the Controlled Substances Register as follows: >One controlled substance per patient page. >Each new patient page shall include: >Patient's name. >Prescriber's name. >Drug name and strength. >Directions for use. >Prescription number and date. Review of the Facility Assessment, revised on 7/26/24, indicated: -It is the policy of the facility to assure all staff are provided education and competency training based on the needs of the resident population that is consistent within their expected role. -Mandatory education and training is required that outlines clinical capabilities and based on resident population. On 3/25/25 at 9:35 A.M., the surveyor reviewed the controlled substance register on the Unit Two, side two medication cart. The surveyor observed that the controlled substance register had no prescription numbers documented and no date of receipt of the controlled substances. Further review of the controlled substance register indicated Nurse #9 had signed as the Nurse on duty, and had received count of the controlled substances that were in her possession. During an interview on 3/25/25 at 9:40 A.M., Nurse #9 said there was no need to document the prescription numbers in the controlled substance register. Nurse #9 also said there was no need to document the date the controlled substances had been received from the pharmacy. During an interview on 3/25/25 at 11:02 A.M., the Staff Development Coordination (SDC) said Nurse #9 was new to the facility and was hired on 3/2/25. The SDC said Nurse #9 was in training and did not complete the competency for medication administration and/or competency for the documentation of controlled substances. During a follow-up interview on 3/25/25 at 1:15 P.M., the SDC said Nurse #9 should not have been in receipt of the controlled substances. The SDC further said Nurse #9 should not have been on the medication cart by herself until the nursing competency for medication administration and the competency for controlled substances had been completed.

Based on observation, interview, and record review, the facility failed to provide appropriate medical care and supervision for one Resident (#224) out of a total sample of 36 Residents. Specifically, for Resident #224, the facility failed to ensure that the Provider was aware of the Resident's weight loss and oversaw his/her nutritional status. Findings include: Resident #224 was admitted to the facility in February 2025 with diagnoses including Anoxic Brain Damage, posterior reversible Encephalopathy, Aphasia and Gastrostomy Status. Review of Resident #224's Minimum Data Set (MDS) assessment dated [DATE]. indicated: -based on staff assessment the Resident had some difficulty with daily decision making in new situations only. -the Resident received 25 - 50% of his/her caloric intake from Tube Feeding. Review of Resident #224's weights indicated the following: -2/21/25: 196.6 pounds (lbs) -3/4/25: 189 lbs. -3/5/25: 186.6 lbs. (a 5% loss in less than 30 days) Review of Resident #224's medical record failed to indicate any evidence the Provider was aware of the Resident's weight loss and was supervising immediate care for nutritional needs. During an interview on 3/25/25 at 9:52 A.M., the surveyor and Unit Manager (UM) #1 reviewed Resident #224's weights. UM #1 said that the Provider should be made aware of the weight loss and would review the record. During a follow-up interview on 3/25/25 at 10:24 A.M., UM #1 said that 3/5/25 was a re-weight and that was not accepted. UM #1 further said a second re-weight was completed again on 3/13/25, but waiting eight days to complete a re-weight was not an acceptable timeframe as the weight would have the potential to have changed in that time. UM#1 said that if there is a significant weight loss of 5% or more, the Provider should have been notified to oversee the Resident's care but she could find no evidence in the medical record that the Provider was notified.

Based on interview, and record review, the facility failed to ensure that triggers relative to a past trauma were identified to create an individualized trauma care plan for one Resident (#199) out of a total sample of 36 residents. Specifically, for Resident #199, the facility failed to ensure that an individualized care plan addressed Resident #199's triggers so they could be reduced in his/her environment. Findings include: Review of the facility policy titled Trauma Informed Care, revised 6/17/24, indicated the following: -Social service department will develop a person-centered trauma-informed care plan that addresses the assessed emotional and psychosocial needs of the resident. -Interdisciplinary team (IDT) to provide ongoing assessment, evaluation, and revision of care plan. Resident #199 was admitted to the facility in June 2024 with diagnoses including Cerebral Infarction (stroke) with left sided hemiplegia and hemiparesis and Major Depressive Disorder. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/4/24 indicated Resident #199: -had clear speech -was usually able to make his/herself understood -usually able to understand others During an interview on 3/18/25 at 4:50 P.M., Resident #199 said he/she was having a difficult time adjusting to his/her room since his/her most recent room change. Resident #199 said he/she had a history of trauma and doors slamming, loud noises he/she could not see the source of, dark spaces, and inability to lock his/her door were things that increased his/her anxiety. Resident #199 said pulling the curtain closed between him/her and the roommates' side of the room, having the television or radio playing at night, keeping the door closed (when in the community he/she closed and locked all doors at night) were coping mechanisms to help with periods of increased anxiety. Resident #199 said it was very difficult at night because he/she was not able to close the door to his/her room because of his/her roommate and was unable to have the television on at night to help reduce the sound of loud noises from the hallway. Review of Resident #199's Trauma Informed Care assessment dated [DATE], indicated: -Have you ever had an experience so upsetting that you think it changed you emotionally, spiritually, physically or behaviorally? -Yes -Do you think any of these things bother you now? -Yes -Sexual Assault? -Experienced -Avoided Activities or situation because they reminded you? -Most of the time Further review of the Trauma Informed Care Assessment failed to indicate documentation on what interventions where beneficial for the Resident or what coping skills the Resident utilized relative to his/her past history of trauma. Review of the Resident #199's Trauma Care Plan, dated 7/3/24, indicated the following: -Identify triggers for anxiety, psychosocial decline. Further review of the Trauma Care Plan failed to indicate Resident #199's: -trauma triggers -coping mechanisms During an interview on 3/20/25 at 8:33 A.M., Social Worker (SW) #1 said she was aware Resident #199 had a history of trauma because it was identified on the Trauma Informed Care Assessment completed on 6/20/24 and because the Resident's Guardian had expressed that Resident #199 often became more anxious when he/she heard other people crying out. SW #1 said she had not spoken with Resident #199 about specific triggers or coping strategies he/she used during periods of increased anxiety. SW #1 said a person-centered care plan should be created for any resident with a history of trauma. SW #1 further said the staff should identify what a resident's trauma triggers were and the best interventions/coping mechanisms that the resident could use, or that the staff could use to help the resident through any changes in their psychosocial well-being. The surveyor and SW #1 reviewed Resident #199's Trauma Care Plan and SW #1 said Resident #199's Care Plan was not individualized. SW #1 said there were no specific triggers for staff to watch out for and no specific coping mechanisms that the Resident utilized to reduce his/her anxiety included in the Care Plan. SW #1 said the Resident's Trauma Care Plan should have been updated to include triggers and person-centered interventions.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#40) received dialysis care in accordance with professional standards of practice for three applicable residents receiving dialysis, out of a total sample of 36 residents. Specifically, the facility failed to ensure nursing assessments, including assessment of the dialysis access site, vital signs and blood sugar levels, were performed when Resident #40 returned from dialysis. Findings include: Review of the facility policy titled Coordination of Care of Dialysis Residents, revised 11/19/18, indicated the nursing facility was responsible for the overall quality of care and services the resident receives and provides the services, consistent with professional standard of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care. The policy also included the following: -a comprehensive person-centered plan of care is developed and implemented based on comprehensive assessment in collaboration with the Dialysis Center, in accordance with professional standards of practice. -the plan of care will be evaluated an revised as indicated based on resident's response to interventions. -care plan will include: >monitoring of vital signs . Resident #40 was admitted to the facility in August 2020 with diagnoses including End Stage Renal Disease (ESRD) and Diabetes. Review of the Renal Dialysis Care Plan initiated 10/20/20, indicated Resident #40 received hemodialysis on Mondays, Wednesdays and Fridays for End Stage Renal Disease. The plan of care included the following interventions: -monitor for complications of dialysis, hypotension, anemia, muscle cramps, and blood loss as indicated. Review of the Minimum Data Set (MDS) Assessment, dated 12/25/24, indicated Resident #40: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -was on dialysis Review of the March 2025 Physician's orders included the following: -Dialysis: Mondays, Wednesdays and Fridays, initiated 2/6/25 Review of the Dialysis Communication Record form, utilized by the facility, indicated three sections labeled as follows: *Section A: to be completed by the facility, which included the following information to be obtained prior to transfer to the dialysis clinic: -location, type and assessment of the dialysis access site, -vitals time, -temperature, -heart rate, -respiratory rate, -oxygen saturation level, -blood pressure, -blood glucose level. *Section B: to be completed by the dialysis center . *Section C: to be completed by the facility on Resident return to facility, which included the following information: -assessment of the dialysis access site -vitals time, -temperature, -heart rate, -respiratory rate, -oxygen saturation level, -blood pressure, -blood glucose level Review of the Dialysis Communication Forms, dated 1/1/25 through 3/24/25, failed to indicate documented evidence that a nursing assessment was completed which included an assessment of the Resident's access site and vitals and blood sugar levels upon return from dialysis treatments, for 26 out of 34 treatments. During an interview on 3/20/25 at 10:04 A.M., Resident #40 said he/she received dialysis yesterday (Wednesday 3/19/25) and was tired today. Resident #40 said he/she has been on dialysis for about five years and it takes a lot out of him/her. Resident #40 said he/she leaves the facility early in the morning and returns to the facility around lunch time. During a follow-up interview on 3/24/25 at 3:44 P.M., Resident #40 said he/she had dialysis treatment today and was very tired. Resident #40 said he/she has a dialysis communication book that was given to the Nurses when he/she returned to the facility from dialysis treatments. Resident #40 said he/she has a fistula and has had no issues with it. Resident #40 said he/she has been having increased episodes of nausea and that he/she took a medication for relief. During an inteview on 3/24/25 at 4:19 P.M., Nurse #11, who worked Per Diem at the facility, said she obtained the Resident's vitals today upon his/her return from dialysis. Nurse #11 said she documented the Resident's vitals in the dialysis communication book and they were stable. Nurse #11 further said the Resident requested medication which was administered for nausea and pain upon return from dialysis. During an interview on 3/24/25 at 4:27 P.M., Unit Manager (UM) #1 said the expectation was for nursing to assess Resident #40 when he/she returned from dialysis and part of that assessment would include obtaining vitals signs upon return. UM #1 said it was important to check the Resident's dialysis site for bleeding and check his/her vitals to assess tolerance to treatment. UM #1 said she reviewed the Resident's clinical record and the Dialysis Communication Forms and noticed that the required information had not been consistently obtained by the nursing staff.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment to prevent further decrease in range of motion (ROM) for one Resident (#123) with limited ROM, out of a total sample of 36 residents. Specifically, the facility failed to implement a passive ROM (PROM) program to Resident #123's lower extremities when the Resident had bilateral lower extremity contractures and was unable to perform his/her own lower extremity ROM, which increased the Resident's risk for progression of lower extremity contractures and pain. Findings include: Review of the American Stroke Association guidance titled Spasticity, https://www.stroke.org/en/about-stroke/effects-of-stroke/physical-effects/spasticity last reviewed 5/30/23, indicated the following: -Spasticity is a common post-stroke condition that causes stiff or rigid muscles. -When a muscle cannot complete its full ROM, the surrounding tendons and soft tissue can become tight. -This makes stretching the muscle much more difficult. -If left untreated, spasticity can also lead to joints in the arm and leg to be stuck or frozen in an abnormal and possibly painful position. This is called contracture. -Treatment may include: >Physical exercise and stretching: Stretching helps maintain full range of motion and prevents permanent muscle shortening. Resident #123 was admitted to the facility in March 2023 with diagnoses including Cerebrovascular Accident (CVA) with hemiparesis and Contracture of Multiple Sites. Review of Resident #123's Activities of Daily Living Care Plan, dated 3/6/23, indicated: -Alteration in ability to provide self-care . due to Arthritis, Degenerative Joint Disease (DJD), CVA with Left Paralysis, . decreased mobility, and generalized weakness. -Encourage movement of extremities during ADL care if tolerated and applicable as needed. -The Resident was unable to walk. -The Resident required a mechanical lift for transfers. Review of Resident #123's Pressure Ulcer (PU) Risk Care Plan, dated 3/6/23, indicated: -at risk for PU development related to . mobility. -Encourage activity and mobility. -Rehab (Rehabilitation) evaluation as needed. -Use devices the eliminate pressure on the heels: pillows as needed. Review of Resident #123's Cognitive Care Plan, dated 5/29/23, indicated: -compromised insight into his/her physical limitations and care needs. Review of Resident #123's Splint Care Plan, dated 11/19/24, indicated: -ROM with care as appropriate. -Use positioning devices. -PT . evaluation as ordered. Review of Resident #123's Physical Therapy (PT) Evaluation, dated 12/9/24, indicated: -referred to PT for positioning and contracture management. -Presented with: -decreased ROM to bilateral lower extremities. -joint mobility/integrity deficits. -limitations in ROM. -muscle disuse/atrophy. -paralysis/paresis. -inability to stand. -The Resident sat almost criss cross in his/her wheelchair due to lower extremity contractures of the hips and knees. -The Resident's rehabilitation potential was fair due to . supportive caregivers/staff. -The focus of treatment was adaptation. -The Resident was not fully aware of the extent of his/her diagnosis and prognosis due to cognitive deficit and language barrier. Review of Resident #123's PT Progress Note, dated 12/9/24, indicated: -The Resident showed heavy amounts of contracture into hip flexion, knee flexion, hip abduction, and ankle plantar flexion. -PT would attempt to work on lower extremity contracture management and positioning. Review of Resident #123's Minimum Data Set (MDS) Assessment, dated 1/7/25, indicated: -Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points indicating the Resident was cognitively intact. -Bilateral lower extremity ROM limitation that interfered with daily function were present. -was dependent for ADLs and was unable to walk. -had received PT services over the previous seven days. Review of Resident #123's PT Note, dated 2/5/25, indicated: -Discontinuation of PT services due to insurance coverage ending, was discussed with the Resident. -Goals met and not met were discussed with the Resident. -Physical Therapist educated Resident #123 to have staff position the Resident better to decrease contractures from forming. Review of Resident #123's PT Discharge Summary, dated 2/5/25, indicated: -lower extremity ROM improved. -to reside long-term in the facility. -was referred for RNP (Restorative Nursing Program)/FMP (Functional Maintenance Program). Further review of Resident #123's PT Discharge Summary indicated: concerned with staff carryover as they have never shown ability to properly position [Resident] even with education and they have no desire to work on contracture management program as there is no carryover. Resident will constantly be a pickup and d/c (discharge) with [Resident] progressively getting more contracted due to no carryover. D/C (Discharge) due to insurance cut and will attempt to pick back up at later date for contracture management program again. On 3/18/25 at 9:05 A.M., the surveyor observed Resident #123 seated in the Unit One Dining Area, reclined position, in a geri chair (chair equipped with a reclining backrest and elevating leg rests), and his/her lower body covered with a sheet. The Resident's legs were both observed to be flexed at the knees and both of the Resident's knees were directed outward toward the armrests of the wheelchair. The surveyor further observed there was one pillow positioned between the Resident's outer knees and the armrests of the wheelchair. On 3/20/25 at 8:29 A.M., the surveyor observed Resident #123 seated, reclined in a geri chair in the Unit One Dining Area. Both of the Resident's lower extremities were observed to be flexed at the knees and hips and rotated out toward the armrests of the chair. The outer aspect of the Resident's right foot was observed positioned on the seat of the geri chair and the Resident's right heel was approximately three inches from his/her buttocks. The outer aspect of the Resident's left foot was observed also positioned on the seat of the geri chair. On 3/20/25 at 9:52 A.M., the surveyor observed that Resident #123 remained in the same position as the previous observation made at 8:29 A.M. During an interview at the time, Resident #123 said that he/she could move his/her left foot a little bit. Resident #123 lifted his/her left foot off of the seat of the geri chair and moved his/her foot slightly with his/her knee and hip still flexed. The Resident was unable to demonstrate movement of his/her right lower extremity when the surveyor asked if he/she was able to move the right leg. During an interview on 3/20/25 at 10:02 A.M., CNA #3 said that PT worked with Resident #123 recently and had instructed him relative to the Resident's positioning in the geri chair and performing some lower extremity ROM. CNA #3 said that when he cared for the Resident, he provided PROM for the resident's lower extremities and that the Resident sometimes reported pain with PROM. CNA #3 said he did not know whether other staff members provided Resident #123 with lower extremity PROM. During an interview on 3/20/25 at 3:55 P.M., the Physical Therapist said that he provided PT services to Resident #123 recently and that the Resident's PT services were discontinued on 2/5/25. The Physical Therapist said that the focus of the PT intervention was on lower extremity ROM and positioning, and that the Resident's contractures were significant. The PT said that he talked with CNA #3 relative to positioning the Resident in the geri chair and also relative to performing PROM to the Resident's lower extremities. The PT said that he discussed this with CNA #3 because he knew CNA #3 would follow through on the interventions for the Resident. The PT said he did not develop a formal or written PROM for Resident #123 for other staff to implement for Resident #123 when the Resident was discharged from PT services on 2/5/25. On 3/21/25 at 8:15 A.M., the surveyor observed the following in Resident #123's room: -Resident #123 was lying in bed, his/her head slightly elevated, with a mechanical lift sling under his/her body. -Resident 123's knees and hips were flexed and rotated outward so that his/her outer legs were flat against the mattress. -Resident 123's right heel was positioned just below his/her buttocks. -Certified Nurses Aides (CNAs) #4 and #5 used the mechanical lift to transfer the Resident from the bed. -While in the air, during transfer, the Resident's right leg was observed fully flexed and was rotated outward with his/her foot positioned up against his/her buttocks inside of the mechanical lift sling. -CNAs #4 and #5 assisted Resident #123 into the geri chair, then removed the mechanical lift device. -CNA #4 then placed a pillow on each side of the Resident's lower extremities, between the Resident's outer knees and armrests of the chair, and one pillow behind the Resident's left heel and under his/her right foot. -CNA #5 then removed Resident #123 from the room and transported the Resident to the Unit One Dining Area. During an interview on 3/21/25 at 8:30 A.M., CNA #5 said that Resident #123's lower extremities were contracted and staff would attempt to position the Resident in the geri chair with pillows to reduce the Resident's risk for developing pressure ulcers. CNA #5 said that (Rehabilitation) therapy usually worked with Resident #123 for lower extremity PROM and that she was not sure if therapy was still working with the Resident. CNA #5 said staff would complete PROM program with Resident #123 if a program had been set up by the Physical Therapist. CNA #5 said there was no PROM program in place for staff to complete with the Resident. CNA #5 further said that if there was a PROM program that staff needed to complete with the Resident, therapy would develop the program and complete an in-service with the staff. CNA #5 said no in-service had been provided to staff relative to lower extremity PROM for Resident #123. During an interview on 3/21/25 at 8:33 A.M., CNA #4 said that she was not aware of any specified lower extremity PROM program in place for staff to complete with Resident #123. CNA #4 said that she did not provide the Resident with lower extremity PROM. On 3/25/25 at 10:44 A.M., the surveyor requested to speak to the Rehabilitation Director, but the Rehabilitation Director was unavailable for interview. During an interview on 3/25/25 at 11:04 A.M., the Director of Nursing (DON) said if a resident could not perform their own ROM, staff would be required to complete PROM with the resident. The DON said that ROM programs carried out for residents by nursing staff would be based on recommendations from Rehab staff. The DON said Rehab staff would use an instruction sheet to educate the staff members responsible for the resident's care, and once education was completed, the instruction sheet would be provided to the Unit Manager (UM). The DON said the UM would then update the resident's Kardex (document containing information for how to care for each resident) with the specified instructions for the resident to ensure staff caring for the resident had the information needed to effectively carry out the recommendations. The DON said Resident #123's condition warranted individualized instruction for PROM due to the degree of the Resident's contractures. Review of Resident #123's active Kardex failed to indicate any instructions relative to the Resident's lower extremity contractures or ROM. During a follow-up interview on 3/25/25 at 11:14 A.M., the PT said when he provided PROM to Resident #123, he instructed the Resident on the level of discomfort that may be expected as well as what symptoms would indicate when to stop applying stretch to the Resident's lower extremity contractures. The PTsaid that it was important to know when to stop applying passive stretch to the contractures to avoid causing muscle damage and an inflammatory response. The PT said that some CNAs could be expected to perform PROM properly and some CNAs may need more instruction if they do not know how much stretch to apply to a contracted joint. The PT said that no formal education relative to lower extremity PROM was provided to staff responsible to care for Resident #123. The PT further said that concerns with PROM not being provided by staff included further progression of contractures and pain.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#215) out of a total sample of 36 Residents received quality of care in accordance with professional standards of practice. Specifically, for Resident #215, the facility failed to: -apply ACE bandages on the day shift as ordered to the Resident's bilateral legs to manage swelling and treatment of bilateral leg edema. -provide care and services that reflected the Resident's preference for application of the ACE bandages when the Treatment Administration Record (TAR) indicated the ACE bandages were applied to the Resident's lower extremites and the Resident was observed without the ACE bandages in place. Findings include: Resident #215 was admitted to the facility in December 2024 with diagnoses including Hypertension, Hypothyroidism and lower extremity (leg) edema. Review of the facility policy titled Documentation -Clinical, revised on 10/31/23, indicated the following: -Medication and Treatment: >the Licensed Nurse notes the time and date of all medications and treatments administered on medication administration record or treatment record. >The Nurse who administers the medication and/or treatment must document it on the residence record. >If a scheduled medication is withheld or not given as ordered, the Nurse documents this and lists the reason for the resident not receiving the medication and what was done to attempt to administer the medication. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #215 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #215's March 2025 Physician orders indicated: -Ace (type of bandage used to control swelling) wraps to bilateral LE (lower extremity) from knee to ankle on day shift. Order date 2/13/25. -Ace wraps to bilateral LE: remove at bedtime. Order date 2/13/25. During an interview on 3/18/25 at 11:53 A.M., Resident #215 said that both of his/her legs are supposed to be wrapped with ACE bandages daily in the morning and then taken off at night, due to leg edema. The surveyor observed Resident #215's legs was not wrapped in ACE bandages at the time. Resident #215 said if the surveyor were to ask the Nurse why the wraps were not on the Resident's legs, the surveyor would be told it was because the Resident went out to an appointment this morning at 9:15 A.M. Resident #215 said that the Nurse did not offer to wrap his/her legs before leaving for the appointment or when he/she returned from the appointment. Resident #215 further said that he/she could not recall the last time his/her legs had been wrapped. During an interview on 3/20/25 at 10:45 A.M., Resident #215 said that his/her leg wraps had not been completed at this point in the morning. The surveyor observed that Resident #215 did not have his/her legs wrapped in ACE bandages at the time. During an interview on 3/24/25 at 2:35 P.M., Nurse #7 said Resident #215 was to have bilateral leg wraps applied daily. Nurse #7 said it was the overnight (11:00 P.M. to 7:00 A.M.) shift's responsibility to put on the leg wraps per the Physician's order. Nurse #7 said the Resident often refused to have the leg wraps put on. Nurse #7 said the Resident did not have the leg wraps on today and she did not know why the leg wraps had not been applied, as she did not receive that information during the shift change over. Review of Resident #215's March 2025 Treatment Administration Record (TAR) indicated the Resident refused the ACE wraps as indicated by an H with a corresponding note stating, held due to Resident refused on the following dates: 3/4/25, 3/7/25, 3/11/25, 3/17/25, and 3/19/25. Further review of Resident #215's March 2025 TAR indicated the ACE wraps had been applied to bilateral LE, as evidenced by a Nurse's signature indicating the order had been followed and completed on the following dates: -3/18/25 (no leg wraps in place - surveyor observation) -3/20/25 (no leg wraps in place - surveyor observation) -3/24/25 (Nurse #7 provided the surveyor notification that the leg wraps were not applied to the Resident's lower extremities) During an interview on 3/24/25 at 2:36 P.M., the surveyor and Unit Manager (UM) #4 reviewed the current Physician orders and the TAR administration history for March 2025. UM #4 said the Physician orders indicated the leg wraps were supposed to be put on the Resident during the day (7:00 A.M.-3:00 P.M.) shift, not the overnight (11:00 P.M.-7:00 A.M.) shift. UM #4 said she purposely did not put a time on the order, only which shift it should be completed on, to allow some leeway as well as to work with Resident #215 when he/she is available. UM #4 said that the wraps should then be removed before bed. UM #4 said the TAR for today was signed off by Nurse #7, indicating that Nurse #7 had put the leg wraps on Resident #215 this morning (3/24/25). UM #4 said that based on the order and the administration history she would have expected to see the leg wraps on the Resident today, but she did not. UM #4 said if the TAR is signed off with a Nurses' initials and no other notation, it was assumed that the order had been completed and that the leg wraps had been applied. UM #4 further said if the Resident refused or was not available, the Nurse should document H (Held) and document a note with a reason as to why the leg wraps were held. On 3/25/25 at 9:38 A.M., the surveyor observed that Resident #215 had bilateral leg wraps on. During an interview at the time, Resident #215 said the leg wraps were only applied this morning because the state was at the facility. Resident #215 further said that he/she was afraid that the leg wraps would not be done daily after the state left the facility.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care in accordance with assessed needs, goals for care, preferences, and recognized standards of practice for one Resident (#155) out of a total sample of 36 residents. Specifically, for Resident #155, the facility failed to: -provide consistent ADL assistance relative to dressing, nail and hand hygiene care when the Resident had bilateral hand contractures and was dependent on staff for bathing, dressing and personal hygiene increasing the risk for skin breakdown and resulting in development of a fungal infection in his/her left hand that required medical treatment. Findings include: Review of the facility policy titled ADLs: basic skills needed in regular daily life including ambulating, dressing, bathing, eating), dated 11/14/16, indicated: -Each Resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, consistent with the Resident's comprehensive assessment and plan of care. >The care and services for ADL will be based on Resident's ability as identified in the Minimum Data Set (MDS) Assessment, rehab (rehabilitation) evaluation, nursing assessment, and person-centered care plan. >Assistive Devices and adaptive equipment are provided as needed. >Resident's abilities, personal choices and self-image are accounted for during ADLs. Review of the facility policy titled Care of Foot and Nails, dated 2/27/17, indicated but was not limited to the following: -Resident's need special care to prevent infection, odors, and injury to soft tissue. > .To provide nail care to promote optimum health, safety and comfort of the Resident, reduce health risk secondary to existing medical condition, and prevent infection. >Licensed Nurse can delegate to Nursing Assistants the trimming of nails of non-diabetic residents or residents without circulatory impairments. Licensed Nurse can trim the nails of residents with diabetes and circulatory impairments only. Review of the facility policy titled Skin Integrity Management, revised 5/21/21, indicated: -Based on the comprehensive assessment of a resident, the facility must ensure that the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not develop pressure ulcer or injury unless the individual's clinical condition demonstrates that they were unavoidable, consistent with CMS requirement and guidance. >maintain the integrity of our resident's skin, the largest organ in the body which plays a significant factor in their overall health. >minimize the risks and prevent the occurrence of skin breakdown through initial comprehensive and regular skin assessments. >develop and implement a comprehensive, person-centered plan of care aimed at maintaining skin integrity, prompt identification, intervention and management of any skin breakdown on accepted clinical standards of practice. Resident # 155 was admitted to the facility in September 2022, with diagnoses including Anoxic Brain Damage and Cardiac Arrest. Review of the Minimum Data Set (MDS) Assessment, dated 1/7/25, indicated Resident #155: -has severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of a total possible score of 15. -has no range of motion (ROM) deficits. -was dependent on the assistance of staff with toileting, personal hygiene, bathing, dressing, turning, repositioning and transfers. -has diagnoses including Anoxic Brain injury, wound infection, and malnutrition. -was at risk for pressure ulcers and had one Stage 4 Pressure injury (full thickness tissue loss resulting from pressure) [of the coccyx]. Review of Resident #155's Activities of Daily Living (ADL) Care Plan initiated 9/20/22, effective 1/6/25, indicated: -alteration in the ability to provide self-care/ perform ADLs, with an anoxic brain injury, bedbound and was dependent on staff. The ADL Care Plan included the following interventions: -Provide movement of the extremities during ADL care as tolerated, effective 9/20/22. -Be alert to non-verbal cues of discomfort: grimace, restless, etc. (et cetera) Review of Resident 155's At Risk for Skin Breakdown Care Plan, initiated 9/20/22, effective 1/6/25, indicated: >was at risk for pressure ulcer development related to bedbound status, impaired mobility, incontinence, dependent on staff, and had a Stage 4 wound on the coccyx upon admission to the facility. The At Risk for Skin Breakdown Care Plan included the following interventions: -Observation of skin condition during care - report pink, red or open areas to the Nurse, initiated 9/20/22. -Update Physician of new skin conditions and obtain orders, initiated 9/20/22. -Avoid/limit skin to skin contact. Use pillows/foam wedges to keep body prominences from direct contact with each other, initiated 9/20/22 On 3/18/25 at 9:12 A.M., the surveyor observed Resident #155 was lying in bed wearing a hospital gown. The surveyor observed the Resident's right hand was contracted into a fist position, with long, chipped and misshapen fingernails and brown material under the fingernails. The surveyor further observed Resident #155's fingernails on the left hand were long, jagged, with brown material under the fingernails. Resident #155 was unable to open either his/her right or left hand at the surveyor's request. On 3/19/25 at 2:43 P.M., the surveyor observed that Resident #155 was lying in bed wearing a hospital gown and had a facecloth tucked into the closed fists of both his/her left and right hand. On 3/20/25 at 8:44 A.M., the surveyor observed that Resident #155 was lying in bed wearing a hospital gown with his/her right and left hands contracted into fists. The Resident was unable to open his/her right or left hand at the surveyors request. On 3/20/25 at 9:35 A.M., the surveyor observed CNA #6 and Nurse #12 as they attempted to open Resident #155's left hand. During an interview at the time, Nurse #12 said Resident #155's left hand fingernails were thick, very long, and dirty and that she had a hard time viewing the condition of the Resident's skin because of the hand contracture. Nurse #12 said there was a foul odor when the Resident's left palm was exposed. CNA #6 said he could smell something foul when the Resident's left hand was opened. The surveyor was standing at the foot of the Resident's bed at the time and observed a foul odor when Resident #155's left hand was opened. Resident #155 was observed to allow a facecloth to be placed in his/her left hand but not his/her right hand. During an interview on 3/20/25 at 11:50 A.M., Nurse #12 said the CNA's will often ask a Nurse to help when providing care to the Resident so that a facecloth can be placed into the left and right hands and the Nurse can assess the Resident's skin integrity of both hands. Nurse #12 said that she is not always able to clearly visualize the Resident's palms or between the fingers because of his/her contractures. Nurse #12 said that Resident #155 has had a yeasty odor for a few weeks. During an interview on 3/20/25 at 11:55 A.M., CNA #6 said he has trimmed Resident #155's fingernails in the past but was unable to recall when fingernail trimming was last done. CNA #6 further said that too much time had passed since the Resident's fingernails had been trimmed. During an interview on 3/20/25 at 11:56 A.M., Unit Manager (UM) #4 said the CNAs are responsible for trimming fingernails unless directed otherwise by the Nurses. UM #4 said she observed Resident #155's fingernails today and the Resident's fingernails were very long and dirty and it was evident that Resident #155's fingernails had not been trimmed for a long time. Review of Resident #155's Nurse Practitioner (NP) Progress Note, dated 3/20/25, indicated: -Bilateral hand contractures were present, along with mild swelling and tenderness on left hand. -fungal rash was also observed. Review of Resident #155's Physician orders, dated 3/20/25, indicated: -Lotrimin Antifungal Cream 1% to left hand twice a day for 14 days for alteration in skin integrity. During a follow-up interview with UM #4 on 3/20/25 at 2:32 P.M., UM #4 said Resident #155 was evaluated by the Provider, who ordered an antifungal cream for the Resident's left hand due to a fungal infection. During an interview on 3/21/25 at 7:58 A.M., UM #4 said that CNAs are responsible to perform fingernail care weekly and as needed, but fingernail care had not occurred for Resident #155. UM #4 said that CNAs inform the Nurses if fingernail care was unable to be performed for any reason. On 3/21/25 at 8:04 A.M., the surveyor observed Resident #155 lying in bed wearing a hospital gown with a rolled facecloth tucked in both the right and left hands.

Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for ten Residents (#132, #171, #53, #158, #229, #10, #155, #123, #226 and #47), out of a total sample of 36 residents. Specifically: 1) For Resident #132, the facility failed to accurately code the Resident as having a feeding tube in use. 2) For Resident #171, the facility failed to accurately code medication administration relative to the Resident receiving Insulin medication when the Resident was prescribed and administered a Diabetes medication that was non- Insulin. 3) For Resident #53, the facility failed to ensure that the most recent comprehensive MDS Assessments was coded accurately relative to upper extremity limited range of motion (ROM). 4) For Resident #158, the facility failed to ensure the most recent comprehensive MDS Assessment was coded accurately relative to a vision related diagnosis. 5) For Resident #229, the facility failed to ensure the discharge MDS Assessment was coded accurately relative to discharge destination. 6) For Resident #10, the facility failed to accurately code a MDS Assessment relative to access of a pressure redistribution cushion for the Resident's wheelchair. 7) For Resident #155, the facility failed to accurately code one MDS Assessment to reflect the Resident's limitation in upper extremity range of motion (ROM) when the Resident had bilateral upper extremity contractures. 8) For Resident #123, the facility failed to accurately code one MDS Assessment to reflect the Resident's limitation in upper extremity ROM when the Resident had bilateral upper extremity contractures. 9) For Resident #226, the facility failed to accurately code the Resident's ability to be understood when the MDS was coded as rarely/never understood. 10) For Resident #47, the facility failed to accurately code the MDS Assessment to reflect that the Resident had broken natural teeth and was not absent of natural teeth. Findings include: 1) Resident #132 was admitted to the facility in December 2024 with diagnoses including Amyotrophic Lateral Sclerosis (ALS) and Dysphagia. Review of Resident #132's MDS assessment dated [DATE] failed to indicate that the Resident had a feeding tube as the box for feeding tube was not checked. Review of Resident #132's March 2025 Physician orders indicated: -Peg-Jejunostomy Enteral Tube 12 french (Fr: measurement used to size the tube) to LLQ initiated 12/12/24. -Isosource 1.5 calorie 1000 ml bag via kangaroo pump at 80 milliliters (ML) per hour, please give 100 ML flush pre and post feeding, up at 6:00 P.M., down at 2:00 P.M., total formula volume 1600 ML, total calories 2025 kCal (a type of measurement of calories), total protein 92 grams, free water hourly bolus 50 ML per hour for 20 hours. During an interview on 3/25/25 at 10:03 A.M., MDS Nurse #1 said she had reviewed documentation for Resident #132 and that the Resident had a Feeding Tube in use at the time of the 3/5/25 MDS Assessment period. MDS Nurse #1 further said that the 3/5/25 MDS should have been coded to indicate that the Resident had a Feeding Tube in use but it was not. 2) Resident #171 was admitted to the facility in May 2024 with diagnoses including Type 2 Diabetes. Review of Resident #171's MDS assessment dated [DATE], indicated the Resident had received one day of Insulin medication during the assessment period. Review of Resident #171's February 2025 Physician orders indicated: -Mounjaro (a GLP-1 medication: a non-insulin injectable medication used to treat diabetes) 7.5 mg/0.5 ml injection subcutaneously once a week initiated on 2/3/25 and discontinued 2/14/25. -no Physician orders for Insulin medication. Review of Resident #171's Medication Administration Record (MAR) indicated: -the Resident received the Mounjaro medication as ordered during the assessment period on 2/7/25. -no evidence that the Resident was administered Insulin medication. During an interview on 3/25/25 at 1:34 P.M., MDS Nurse #1 said that the Resident was coded on the 2/12/25 MDS as having received Insulin for 1 day during the assessment period. MDS Nurse #1 further said that she reviewed the Resident's medical record and the Resident had not received any Insulin during the assessment period. MDS Nurse #1 said this was an error in coding. 42741 3) Resident #53 was admitted to the facility in April 2021 with diagnoses including Alzheimer's Disease. Review of Resident #53's Nursing Progress Note dated 10/1/24, indicated Resident #53 had been diagnosed with a left-hand contracture. The surveyor observed Resident #53 seated in the unit dining room, his/her left hand was visibly contracted, and Resident #53 only had use of his/her left thumb while the remaining fingers remained tightly pressed against his/her palm on the following observations: -3/19/25 at 8:05 A.M. -3/20/25 at 10:02 A.M. During an interview on 3/20/25 at 10:03 A.M., Nurse #2 said Resident #53 had a left-hand contracture and utilized a palm guard daily. Review of the most recent comprehensive MDS assessment dated [DATE], indicated Resident #53 had no limited ROM in his/her upper extremities. During an interview on 3/24/25 at 11:37 A.M., MDS Nurse #1 said the MDS assessment dated [DATE] was coded inaccurately. MDS Nurse #1 said Resident #53 had a limited range of motion in his/her left upper extremity, the MDS should have accurately reflected Resident #53 had a functional limitation on one side of his/her upper extremities, and the MDS Assessment needed to be corrected. 4) Resident #158 was admitted to the facility in September 2022 with diagnoses including Glaucoma. Review of the most recent comprehensive MDS assessment dated [DATE], indicated Resident #158 had no active vision diagnoses. During an interview on 3/24/25 at 11:22 A.M., MDS Nurse #1 said Resident #158 was admitted with a diagnosis of Glaucoma and the MDS assessment dated [DATE] was coded inaccurately. 5) Resident #229 was admitted to the facility in June 2024 with diagnoses including cellulitis. Review of the Nursing Progress Note dated 1/3/25, indicated Resident #229 was discharged from the facility back to the community. Review of the discharge MDS assessment dated [DATE], indicated Resident #229 was discharged from the facility to a short-term general hospital. During an interview on 3/24/25 at 11:21 A.M., MDS Nurse #1 said Resident #229 was discharged back to the community and the MDS assessment dated [DATE], was coded inaccurately and needed to be corrected to reflect that Resident #229 was discharged to the community. 42690 6) Resident #10 was admitted to the facility in April 2013 with diagnoses including Protein-Calorie Malnutrition and End Sage Renal Disease (ESRD). Review of Resident #10's Skin Breakdown Care Plan, initiated on 5/28/21, and updated 3/24/25, indicated the following interventions: -Pressure redistribution cushion in chair/wheelchair. Review of the most recent MDS assessment dated [DATE], failed to indicate a pressure reducing cushion was in place for the Resident's wheelchair, as the pressure reducing cushion box was not selected. On 3/20/25 at 9:38 A.M., Resident #10 was observed in the day room, seated in a wheelchair with a pressure redistribution cushion in place. On 3/25/25 at 8:41 A.M., the surveyor and MDS Nurse #3 observed Resident #10 in the day room, seated in a wheelchair with a pressure redistribution cushion in place. MDS Nurse #3 reviewed Resident #10's Care Plan, the previous MDS dated [DATE], and the most current MDS dated [DATE]. During an interview at the time, MDS Nurse #3 said the Care Plan indicated a pressure reducing device for the chair/wheelchair should be in place as an intervention, the MDS dated [DATE] indicated a pressure reducing device was in place for the wheelchair, and that the MDS completed on 1/2/25 did not indicate that a pressure reducing device for the wheelchair was in place. MDS Nurse #3 said that it was a coding error because the Resident has always had the pressure reducing device for the wheelchair in place and should be coded to reflect that a pressure reducing device was in use. 51466 7) Resident #155 was admitted to the facility in September 2022 with diagnoses including Anoxic Brain Damage and Cardiac Arrest. Review of the Occupational Therapy (OT) Evaluation dated 3/19/24, indicated Resident #155 had bilateral hand contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #155 had no range of motion (ROM) deficits. During an interview on 3/21/25 at 1:27 P.M., MDS Nurse #1 said that the MDS assessment dated [DATE], was coded inaccurately and should have reflected that Resident #155 had bilateral upper extremity ROM impairments. 42761 8) Resident #123 was admitted to the facility in March 2023 with diagnoses including Cerebrovascular Accident (CVA) with hemiparesis and Contracture of Multiple Sites. Review of Resident #123's Activities of Daily Living (ADL) Care Plan dated 3/6/23, indicated the Resident had altered ability to provide self-care due to . left paralysis . Review of the Splint Care Plan dated 11/19/24, indicated Resident #123: -had joint contractures. -required the use of bilateral hand orthotics. Review of Resident #123's MDS assessment dated [DATE], indicated the Resident: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -was dependent on staff for ADLs. -had progressive neurological conditions. -had no upper extremity limitations in ROM that interfered with daily functions . On 3/18/25 at 9:05 A.M., the surveyor observed the following in the Unit One Dining Area: -Resident #123 was seated in a reclining wheelchair. -Resident #123 wore orthotic devices on both hands and his/her fingers were flexed around the orthotic devices. During an interview at the time, Resident #123 said that he/she could not open his/her hands. The surveyor observed Resident #123 lift his/her arms up in the air slightly with his/her fingers remaining flexed around the orthotic devices. During an interview on 3/20/25 at 10:02 A.M., Certified Nurses Aide (CNA) #3 said that Resident #123 was dependent on facility staff for ADLs. CNA #3 said that Resident #123 had limitations in ROM of the upper extremities which impacted the Resident's abilities to perform self-care. CNA #3 said that the Resident required staff to provide passive ROM (PROM) to the Resident's upper extremities and orthotics for the Resident's hands in attempt to prevent the contractures from getting worse. During an interview on 3/21/25 at 1:34 P.M., the MDS Nurse said that Resident #123 did have limitations in bilateral upper extremity ROM that were present at the time of the Resident's MDS Assessment, dated 1/7/25. The MDS Nurse said that the MDS assessment dated [DATE] was inaccurate and should have been coded to indicate the Resident had bilateral upper extremity ROM limitations. 47901 9) Resident #226 was admitted in March 2025 with diagnoses including unspecified fracture, repeated falls, systolic Congestive Heart Failure (CHF) and Depression. Review of Resident #226's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of total possible 15. -was rarely/never understood. During an interview on 3/21/25 at 1:25 P.M., MDS Nurse #1 said Resident #226 was coded as rarely/never understood in error. 50138 10) Resident #47 was admitted to the facility in March 2023 with diagnoses including Dysphagia and Dementia. During an interview on 3/18/25 at 10:47 A.M., Resident #47 said this tooth was supposed to come out. The surveyor observed that the Resident pointed at a tooth on the front of the lower oral cavity. The surveyor further observed the Resident's teeth was decayed with broken teeth along the front lower gum line. Review of Resident #47's Dental Group Consult Form dated 7/1/24, indicated the Resident: -had Root Remnants (RR-visible or felt root fragments) on teeth #23, #24 and #25. -had a fractured (broken) tooth #27. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #47: -had no natural teeth or tooth fragment(s). -was edentulous (without teeth). Review of the Resident #47's March 2025 Physician orders indicated: -Prevident 5000 Booster 1/1% Paste (Sodium Fluoride), a pea sized amount, Day shift 7:00 A.M. - 3:00 P.M. for sensitive teeth, effective 1/31/25. On 3/24/25 at 3:41 P.M., the surveyor and MDS Nurse #1 observed Resident #47's teeth and MDS Nurse #1 said that Resident #47 had tooth fragments and a broken tooth. MDS Nurse #1 said that the Resident's MDS dated [DATE], had not been coded correctly. MDS Nurse #1 said that the MDS should have been coded for broken natural teeth because the Resident presented with broken tooth fragments. MDS Nurse #1 said that accurate coding is important for the MDS so that a Residents' assessments accurately reflected current condition for care planning and delivery of care/services. Please Refer to F688.

Based on interview, and record review, the facility failed to ensure written notification was provided for two Residents (#40 and #199) out of a total of 36 residents, who experienced room and/or roommates changes. Specifically, 1. For Resident #40, the facility failed to provide written notification when the Resident had several roommate changes after his/her roommate/ significant other (SO) passed away. 2. For Resident #199, the facility failed to notify and provide written notification to the Resident when two separate room changes occurred within a timeframe of less than one week. Findings include: Review of the facility policy titled Residents' Rights Policy, revised 10/4/23, indicated residents/resident representatives have rights and protections under federal law ensuring fair care and services are rendered without reprisals. The policy also included the following: -a facility must treat each resident with respect and dignity and care in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality. -the facility must protect and promote the rights of the resident, -the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility changed, -the right to refuse to transfer to another room within the facility if it is to another distinct part of the facility or for staff convenience, -the resident shall have the right to appeal to the facilities or institution's medical director a decision to move the resident to a different living quarter or to a different room within the facility or institution. 1. Resident #40 was admitted to the facility in August 2020 with diagnoses including end stage renal disease (ESRD). Review of the Minimum Data Set (MDS) Assessment, dated 12/25/24 indicated Resident #40: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 -was dependent on transfers and mobility -utilized a wheel chair -has bilateral lower extremity range of motion deficits -received dialysis during the reference period Review of the clinical record indicated the following: -2/7/25: Social Service Note indicating that the Resident was notified of his/her roommate's (significant other - SO) passing when he/she returned from dialysis. -2/13/25: Social Service Note, indicating the Social Worker (SW) followed up with Resident #40 on 2/10/25 and the Resident was reported to be upset about returning from dialysis (on 2/10/25) to find his/her SO's belongings removed from the room .the Resident was notified that he/she would be receiving a roommate the next day (2/11/25) and that the facility tried to give him/her as much time as possible Further review of the clinical record failed to indicate documented evidence that written notification was provided to Resident #40 when he/she had two separate roommates. During an interview on 3/20/25 at 3:50 P.M., Resident #40 said he/she resided with their SO, and that he/she passed away on Friday 2/7/25. Resident #40 said that he/she had requested to have a week to clean out his/her SO's items from their room, and when he/she returned from dialysis the following Monday (three days later on 2/10/25), his/her SO's items had been removed from their room and he/she was very upset about this. Resident #40 said he/she received a roommate the next day (2/11/25) and did not know until the roommate was moving in. Resident #40 said that particular roommate had issues with the room and items in the room, and was moved to another room shortly after and another person who was actively passing was put into the room. Resident #40 said he/she was not notified that he/she was going to be receiving a change in roommate, and the second roommate passed away shortly after, which affected him/her because he/she was already grieving the loss of his/her significant other. Resident #40 said it felt like the facility staff did not think about how these room changes would have affected him/her after the death of his/her SO. During an interview on 3/24/25 at 1:34 P.M., Social Worker (SW) #1, who had worked in the facility for about a year, said she had never been instructed to and had not been providing written notification to residents when they were receiving a roommate. SW #1 said she was aware of the situation that transpired with Resident #40 and did not agree with how this situation was handled. SW #1 said she did advocate on the Resident's behalf but was not aware of the details on how bed management occurred relative to room changes or roommate changes. SW #1 said she could recall that Resident #40 had a roommate that was actively passing after the death of his/her SO and that this passing resident was put into Resident #40's room after there was an issue with the resident's previous roommate, and that this was not an ideal situation. During an interview on 3/24/25 at 4:27 P.M., Unit Manager (UM) #1 said Resident #40 and his/her SO had been rooming together for over two years. UM #1 said when Resident #40's SO passed away, the Resident was given a couple of days to remove the SO's items out of the room. UM #1 said Resident #40 was out at dialysis when the SO's items were removed from their room by facility staff, and the items were removed because the Resident was to receive a new roommate. During a follow-up interview on 3/25/25 at 11:45 A.M., UM #1 said resident room changes were discussed daily during morning meeting and that the admissions staff drive this process. UM #1 said she was unsure if residents receive notification of new roommates prior to receiving them, and that room changes can be challenging given the complexities on her unit. 42741 2. Resident #199 was admitted to the facility in June 2024 with diagnoses including cerebral infarction (stroke) with left hemiplegia and hemiparesis. Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/4/24, indicated Resident #199: -had clear speech -was usually able to make his/herself understood -usually able to understand others During an interview on 3/18/25 at 4:49 P.M., Resident #199 said he/she had to have his/her room changed multiple times while at the facility. Resident #199 said he/she was very pleased with his/her room previously, but the facility told his/her Guardian that he/she needed to change rooms. Resident#199 said he/she had moved rooms two times recently and it was very frustrating. Review of the Clinical/Charting Snapshot dated 3/20/25, indicated Resident #199 had his/her room changed on 3/12/25 and 3/15/25. Review of the Social Services Progress Note dated 3/4/25, indicated Social Services had let the Resident's Guardian know that Resident #199 was being moved. Further review of the Resident's medical record failed to indicate written documentation that Resident #199 had been updated about the room changes prior to the room changes on 3/12/25 and 3/15/25. During an interview on 3/20/25 at 8:26 A.M., SW #1 said Resident #199 was moved to another unit because he/she no longer needed ventilator care. SW #1 said she had spoken with Resident #199's Guardian prior to the Resident's room changes but she had not spoken with Resident #199 prior to the room changes or provided him/her with any written documentation about the room changes. SW #1 further said she was unaware of any written forms or documentation that was to be used and provided to a Resident prior to a room change.

Based on record review, observation, and interview, the facility failed to assess self-administration of medication for one Resident (#135), out of a total sample of 36 residents. Specifically, for Resident #135, the facility failed to: -ensure an IDT (Interdisciplinary Team) assessment was completed for the Resident to self-administer Albuterol Sulfate Inhaler (bronchodilator medication) and Trelegy Ellipta Inhaler (combination beta-agonist/anticholinergic/ corticosteroid medication) medications prior to allowing the Resident to have the inhalers in his/her possession. -ensure that the medication was safely and appropriately stored when the Resident was observed to store an inhaler in their clothing, on his/her bedside table, and in an unlocked bedside drawer. Findings include: Review of the facility's policy titled Self Administration of Medications, revised June 2021, indicated the following: -The Resident will be assessed for cognitive, physical and visual ability to self-administer medications upon admission, quarterly and as needed with significant change in status. -If the Resident wishes to self-administer, the IDT will determine the Resident's ability to safely self-administer. -Ensure Medical Doctor orders are in place. -Provide safe, locked storage if keeping medications at bedside. -Medication nurse will monitor Resident's compliance and record on MAR (Medication Administration Record). Resident #135 was admitted to the facility in May 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment, dated 2/20/25, indicated Resident #135: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 -was able to make his/her needs known -understand others -utilized oxygen therapy Review of Resident #135's Comprehensive Person-centered Care Plan, indicated: -alteration in ability to provide self-care/perform ADLs (Activities of Daily Living) related to poor follow through of personal hygiene tasks and occasional weakness related to COPD and depression, initiated 6/15/22. -diagnosis of mild cognitive impairment, initiated 6/1/22, effective 4/29/23. -alteration in respiratory function related to COPD with history of respiratory failure. Shortness of Breath with exertion and when lying flat, initiated 6/23/22, effective date 10/24/23. Care Plan interventions included: >Administer medications as ordered and assess for effectiveness and adverse side effects. Review of Resident #135's March 2025 active Physician orders, indicated: -Albuterol Sulfate 0.09 milligram (mg)/1 Actuation Aerosol Powder, 4 puffs inhalation every 4 hours as needed (PRN) for shortness of breath (SOB), wheezing, initiated 9/29/23. -Trelegy Ellipta 5-25 micrograms (mcg) powder, one puff inhalation daily for COPD, initiated 1/13/25. Review of Resident #135's March 2025 Medication Administration Record (MAR), indicated: -Albuterol 0.09 mg/1 actuation Aerosol Powder Inhaler, 4 puffs inhalation every four hours as needed for shortness of breath/ wheezing - was not administered from 3/1/25 through 3/25/25. -Trelegy Ellipta 5-25 mcg powder, one puff inhalation daily for COPD - documented as administered daily from 3/1/25 - 3/25/25. Review of Resident #135's clinical record failed to indicate any documented evidence that Resident #135 was assessed by the IDT to self-administer medications. On 3/18/25 at 11:42 A.M., Resident #135 showed the surveyor an Albuterol inhaler that was in his/her pants pocket. During an interview at the time, Resident #135 said he/she takes the Albuterol inhaler four to five times per day, usually one or two puffs at a time. Resident #135 said the staff gave him/her the Albuterol inhaler to hold onto. On 3/19/25 at 2:39 P.M., Resident #135 was observed lying in bed and asleep. The surveyor observed the Albuterol inhaler was on the Resident's bedside table. On 3/20/25 at 8:09 A.M., Resident #135 was observed lying in bed and the Albuterol inhaler was on the bedside table within reach of the Resident. On 3/21/25 at 8:10 A.M., Resident #135 was observed with the Albuterol inhaler on the over bed table at his/her bedside. At the time, Resident #135 opened the top drawer of his/her bedside table and showed the surveyor a Trelegy inhaler that was stored in the bedside table drawer. During an interview on 3/21/25 at 10:15 A.M., Nurse #12 said that she often takes care of Resident #135 and when the Resident had SOB, he/she would ask for his/her Albuterol inhaler. Nurse #12 said that she was not aware that Resident #135 had inhalers at the bedside. Nurse #12 said the inhalers should be kept in a locked medication cart. During an interview on 3/21/25 at 10:20 A.M., Unit Manager (UM) #4 said Resident #135 had been keeping the Albuterol Inhaler and Trelegy Inhaler at the bedside for quite some time prior to a Self-Administration Assessment being completed on 3/19/25. UM #4 said the facility completed the Self- Administration Assessment on 3/19/25 because the state surveyors were in the building. UM #4 was unable to provide evidence of any that a Medication Self Administration Assessment was completed for Resident #135 prior to 3/19/25.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and had difficulty making his/her needs known, the Facility failed to ensure he/she was free from abuse by a staff member, when on 08/03/23 Nurse Aide (NA) #1, found Resident #1 in another resident's bed and attempted to remove him/her from that bed, during which NA #1 engaged in an altercation that progressively became physically abusive and only increased Resident #1's agitation. Nurse Aide #1 was witnessed by another staff member as he pulled at, struck out and hit Resident #1, and as NA #1 continued to struggle with Resident #1, they both ended up falling to the floor. Several days after the incident, Resident #1 seemed apprehensive when another staff member approached him/her to assist him/her with care and said words to the effect of you're not going to hit me, are you? Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation and Reporting, dated as revised 02/17/17, indicated it is the policy of the Facility and the responsibility of all staff to ensure an environment free from abuse, neglect, mistreatment, misappropriation or resident property, and exploitation. The Policy indicated physical abuse includes hitting, slapping, pinching, kicking or attempting to control behavior through corporal punishment, and non-accidental use of physical force that results in bodily injury, pain or impairment (including but not limited to bruising, skin tears or fractures). Resident #1 was admitted to the facility in October 2018, diagnoses included Wernicke's encephalopathy (a degenerative brain disorder), anxiety disorder, dementia with behavioral disturbances and a history of Traumatic Brain Injury (TBI). Review of Resident #1's Medical Record indicated his/her Health Care Proxy (HCP) was activated on 09/18/20. Resident #1's Minimum Data Set (MDS) Assessment, dated 06/29/23, indicated Resident #1 was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #1's Communication Care Plan, dated as reviewed 06/29/23, indicated he/she had compromised verbal skills and understanding due to severe cognitive limitations. Interventions identified for Resident #1 included explaining all procedures clearly. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as reviewed 06/29/23, indicated he/she required continual supervision when ambulating on the unit and required assistance at times when fatigued and for longer distances. Review of Resident #1's Behavior Care Plan, dated as reviewed 6/29/23, indicated he/she was resistant to care as evidenced by becoming verbally and physically aggressive (yelling, cursing, screaming, hitting, swatting, or making threatening gestures). The Care Plan also indicated Resident #1 was intrusive at times. Interventions identified for Resident #1 included the following: -Use a calm, slow approach, greet by name, introduce yourself, smile, explain care step by step. -Redirect the resident in a non-harmful manner. Set realistic limits. -Talk with the resident in a calm manner during the behavior. Review of Resident #1's Psychiatric Evaluation, dated 07/31/23, indicated he/she was unable to fully participate in the visit, given the extent of his/her neurocognitive disorder (NCD). Review of the Evaluation indicated the areas labeled Psychosis and Violent/Angry thoughts were documented as unable to assess. Further review of the Evaluation indicated Resident #1 had abnormal memory, impaired insight, and impaired judgement with everyday activities and social situations. Review of the Facility's Internal Investigation Summary, undated, indicated that on the afternoon of 08/03/23 at approximately 2:30 P.M., Activity Aide #1 witnessed a physical altercation between Nurse Aide (NA) #1 and Resident #1. The Report indicated that NA #1 entered Resident #1's room and found him/her lying on his/her roommate's bed. The Report indicated that when NA #1 tried to move Resident #1 off his/her roommate's bed, he/she struck NA #1 in the chest. The Report indicated that while NA #1 held on to Resident #1 and continued to try to lead him/her to the other side of the room, NA #1 stumbled and fell , pulling Resident #1 down on top of him. The Summary also indicated Resident #1 suffered a 2.5 centimeter (cm) superficial scratch to his/her right inner upper arm. The Summary indicated that Activity Aide #1 alleged NA #1 grabbed Resident #1 without explaining to him/her what was going to happen when he (NA #1) stood him/her (Resident #1) up from the bed. The Summary indicated that during an interview with the Human Resource Manager, Administrator, and Director of Nurses, NA #1 said he pulled Resident #1 up from the bed without asking him/her to get up. During an interview on 08/23/23 at 2:03 P.M., Activity Aide # 1 (which also included a review of her written witness statement dated 08/03/23) said she was going room to room, passing out drinks to residents when she witnessed a physical altercation between NA #1 and Resident #1. Activity Aide #1 said that she witnessed the incident from the hall and said the door to the room and the privacy curtain were both open. Activity Aide #1 said she saw Resident #1 lying in his/her roommate's bed. Activity Aide #1 said she heard NA #1 tell Resident #1 that he/she was in the wrong bed, and then saw as NA #1 forcefully grabbed him/her by both arms and pulled him/her out of the bed, without first explaining to Resident #1 what he was going to do. Activity Aide #1 said that once Resident #1 was up off the bed, she saw both NA #1 and Resident #1 holding on to one another in sort of a struggle. Activity Aide #1 said it appeared as though NA #1 was trying to steer Resident #1 over to his/her own side of the room, while he/she resisted. Activity Aide #1 said that NA #1 appeared frustrated, and he struggled with Resident #1 instead of stepping away and then re-approaching him/her. Activity Aide #1 said she witnessed Resident #1 hit NA #1 in the chest, and NA #1 responded by hitting him/her back, once around the face and head area, and that she heard NA #1 say to Resident #1 Don't you hit me! Activity Aide #1 said she heard a loud slapping sound when NA #1 struck Resident #1 and that Resident #1's facial expression looked like he/she was startled, and that he/she appeared confused and afraid. Activity Aide #1 said she immediately ran to get Nurse #1. Based on the reasonable person concept, it would be more than likely that Resident #1 would have experienced psychosocial harm, recurrent fear, anxiety or anger as a result of the physical abuse since there is an expectation that he/she would not pulled at or struck by a caregiver. Review of Resident #1's Nurse Practitioner Visit Note, dated 08/03/23 indicated Resident #1 had been hit on the left side of his/her head by a caregiver. The Note indicated Resident #1 was not in visible distress and had no visible trauma and he/she was unable to participate in interview due to advanced dementia. The Note indicated when the Nurse Practitioner asked Resident #1 if he/she had any pain or any other bothersome symptoms, he/she replied with nonsensical, unrelated words. Review of Resident #1's Psychiatric Evaluation, dated 08/09/23, indicated a psychiatric evaluation was requested as Resident #1 was struck by a staff member after becoming combative with care. Further review of the Evaluation indicated Resident #1 was asleep in his/her room and was unable to participate in the visit. Review of Nurse Aide (NA) #1's Written Witness Statement, dated 08/03/23, indicated that on that afternoon, he was assigned to provide Resident 1's roommate with one-to-one supervision. The Statement indicated that he (NA #1) entered Resident #1's room and found him/her lying in his/her roommate's bed. The Statement indicated that he (NA #1) struggled to remove [Resident #1] from his/her roommate's bed, while sustaining attacks from him/her. The Statement indicated he (NA) #1 managed to get [Resident #1] up and lead him/her out of the way, when Resident #1 punched him (NA #1) in the center of his chest. The Statement indicated that he (NA) #1 instinctively struck Resident #1 back. The Statement indicated NA #1 had tried to lead Resident #1 to the other side of the room, by holding his/her hands, when he tripped and fell , and Resident #1 landed on top of him. The Surveyor was unable to interview Nurse Aide #1 as he did not respond to the Department of Public Health's request for an interview. During an interview on 08/02/23 at 1:33 P.M., Nurse #1 (which also included a review of her written witness statement dated 08/04/23) said that Activity Aide #1 came to her on 08/03/23 sometime after 2:00 P.M. and told her that she had just witnessed NA #1 being aggressive with a resident down the hall. Nurse #1 said she responded immediately and found Resident #1 on the floor of his/her room and that NA #1 was standing on the opposite side of the room. Nurse #1 said Resident #1 was trying to get up off floor, so she assisted him/her up and over to his/her bed. Nurse #1 said that when she asked NA #1 what had happened, he told her that Resident #1 had fallen when he got him/her out of his/her roommate's bed. Nurse #1 said she directed NA #1 to go downstairs (to a non-resident area) and she reported the incident to the Director of Nurses. Review of the Director of Nurses (DON) Written Summary of Activity Aide #1's re-enactment of the altercation she witnessed, on 08/03/23, between Nurse Aide #1 and Resident #1, dated 08/04/23, indicated that Activity Aide #1 was in the doorway to Resident #1's room when she heard NA #1 tell Resident #1 to get up out of that bed. The Summary indicated that when Resident #1 had not responded to NA #1's command, Activity Aide #1 saw NA #1 place his hands on both of his/her (Resident #1's) forearms and pull him/her very fast, up out of bed. The Summary indicated that Activity Aide #1 witnessed a struggle between NA #1 and Resident #1 at the bedside, and saw him/her (Resident #1) hit NA#1 in the chest. The Summary indicated Activity Aide #1 saw NA #1's arm move, followed by a loud slapping sound, and heard NA #1 say, don't you do that to me. Review of the Assistant Administrator and Director of Nurses Written Summary of their interview with Nurse Aide #1, dated 08/03/23, indicated that Nurse Aide #1 told them that when Resident #1 hit him (NA #1) in the chest, he instinctively swung his own arm up and hit him/her. The Summary indicated that when NA #1 was asked where he hit Resident #1, he said he hit Resident #1 with an open hand and then gestured toward his own face, to demonstrate how he struck Resident #1 in the neck and jaw area. The Summary indicated the Nurse Aide #1 reported that the struggle continued and he pulled Resident #1 away from the bed while he/she tried to sit back down on the bed and that during the struggle, he (NA #1) tumbled backwards, landed on the floor and Resident #1 fell on top of him. The Summary indicated NA #1 said he rolled out from under Resident #1 and stood up, just prior to Nurse #1's arrival to the room. During an interview on 08/22/23 at 2:10 P.M., Certified Nurse Aide (CNA) #2 said that Resident #1 tended to be resistant during care and had a history of being combative with staff. CNA #2 said that if Resident #1 resisted care the protocol was to reapproach and notify the nurse if he/she got combative. CNA #2 said that she worked 7:00 A.M. to 11:00 P.M. on 08/03/23, the day of the altercation between NA #1 and Resident #1. CNA #2 said after the altercation Resident #1 stayed in his/her room that evening. CNA #2 said that when she worked the evening shift on 08/04/23, the day after the altercation, Resident #1 appeared nervous and jumpy when she initially approached him/her. During an interview on 08/22/23 at 1:50 P.M., Certified Nurse Aide (CNA) #3 said that approximately one week after the incident that occurred on 08/03/23, when she approached Resident #1 to provide care, he/she seemed very apprehensive and he/she said words to the effect of, you are not going to hit me, are you? During an interview on 08/22/23 at 3:30 P.M., the Director of Nurses (DON) said that Nurse Aide (NA) #1 had completed his training for certification and had not yet taken the exam to become a Certified Nurse Aide. The DON said NA #1 was immediately removed from the nursing unit following the incident. The DON said the incident was immediately reported to the police, and NA #1 was arrested on the Facility grounds. The DON said Resident #1 could not recall the incident, shortly after it occurred and said he was not aware if Resident #1 demonstrated any signs of distress. During an interview on 08/22/23 at 4:00 P.M., the Administrator said the facility substantiated the allegation of abuse as a result of their internal investigation. The Administrator said that NA #1 was very matter of fact when describing the incident and admitted to hitting Resident #1. The Administrator said NA #1 had not walked back any statements during the interviews and said that although NA #1 stated he had no intention of harming Resident #1, said he was not apologetic either. The Administrator said that Nurse Aide (NA) #1 should have reapproached Resident #1 rather than insist he/she get out of his/her roommate's bed. The Administrator said that NA #1 removed Resident #1 from the bed in a manner that he was not taught at this facility. On 08/22/23, The Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, The Plan of Correction is as follows: A) The Facility immediately suspended Nurse Aide #1 on 08/03/23 during the investigation and terminated him on 08/18/23. B) On 08/03/23, nursing immediately assessed Resident #1 for the potential for any injuries sustained during the incident and nursing staff continued to monitor him/her for any changes in behavior or head/neck injuries, for 72 hours after the incident. Resident #1 was seen by the Nurse Practitioner on the day of the incident. C) The Facility implemented a plan for on-going monitoring of Resident #1's mood following the incident and he/she was seen by social services on 08/04/23 and 08/09/23 and behavioral health services on 08/09/23. D) During the Facility internal investigation, the Social Worker interviewed 10 residents that had received care from Nurse Aide #1 and no additional care or abuse concerns were reported. E) On 08/04/23, the Staff Development Coordinator initiated education for all staff on abuse, neglect and mistreatment, and provided the staff on the dementia unit with education on how to care for difficult and/or aggressive residents. The Facility demonstrated sufficient evidence to support substantial compliance effective 08/19/23. F) Starting on 08/04/23 each Resident or their representative were interviewed by members of the leadership team to determine if there were any concerns. G) Members of the leadership team will randomly audit 10 residents weekly for four weeks, then monthly for three months to screen for any concerns not brought forward to the facility by any resident. This is overseen by the Assistant Administrator. H) Results of the audits will be reviewed and evaluated for any issues identified or actions required to ensure there are no abuse, neglect, or mistreatment concerns at the facility. All issues will be addressed in real time by Administration and Reviewed at Quality Assessment and Performance Improvement (QAPI) meetings, monthly for three months, starting on 08/24/23. I) The Administrator and /or his/her designee are responsible for overall compliance.

Based on records reviewed and interviews, for two of three sampled Residents (Resident #1 and Resident #2), the Facility failed to ensure the resident's environment was free from environmental hazards and failed to provide adequate supervision to ensure resident safety. - On 1/11/22 at approximately 10:15 A.M., Resident #1, who resided on the secured unit, ingested approximately 800 milliliters (ml) of an alcohol hand sanitizer (active ingredient [MEDICATION(S)] alcohol 70%). Resident #1 was found intoxicated stumbling into the wall in the hallway outside his/her room, with slurred and garbled speech and minutes later he/she became unresponsive. - On 1/16/22, Resident #2 who had impaired judgement for everyday activities and social situations, successfully eloped from the Facility twice that day. The 2nd elopement occurred while Resident #2 was suppose to be under 1:1 supervision (staff observing a resident continuously and within arm's reach of the resident) by a staff member. Findings include: According to the Facility's standard of practice resource, Clinical Nursing Skills and Techniques, Perry and Potter, 8th Edition, indicated that: Safety was defined as freedom from psychological and physical injury. Health care provided in a safe manner and a safe environment is essential for a resident's survival and well-being. The Nurse is responsible for incorporating critical thinking skills when using the nursing process, assessing each resident and his or her environment for hazards that threaten safety and planning and intervening appropriately to maintain a safe environment. The Facility's Policy, Behavior Rounds Protocol, dated 8/01/18, indicated that the weekly behavioral rounds are completed by the interdisciplinary team. The behavior rounds will consist of discussed targeted behaviors and behavioral trends since the previous review and current interventions, care discussions and recommendation for interventions. A. Resident #1 was admitted to the Facility in 2/2020, diagnoses included, Wernicke's [CONDITION(S)], alcohol dependence with withdrawal, history of seeking alcohol in any form and traumatic brain injury. Review of Resident #1's Nursing Progress Note, dated 8/26/21, indicated Resident #1 was observed drinking hand sanitizer from the wall mounted dispenser. Review of Resident #1's Nursing Progress Note, dated 8/31/21, indicated that Resident #1 took a bottle of alcohol hand sanitizer from the medication cart, this Nurse followed him/her immediately to his/her room where Resident #1 was pumping hand sanitizer into his/her mouth. Resident #1 was monitored and there was no adverse reaction noted related to his/her ingestion of the hand sanitizer. The Behavioral Director and Nurse Practitioner were notified of the incident. Review of Resident #1's Nursing Progress Note, dated 10/31/21, indicated that Resident #1 was found on two separated occasions chewing on alcohol sanitizing wipes. Review of Resident #1's Nursing Progress Note, dated 11/29/21, indicated that Resident #1 was witnessed chewing something and he/she refused to spit it out for staff. The Note indicated Resident #1 said that his/her roommate had given him/her an alcohol hand sanitizer wipe and he/she eventually spit out the hand wipe. Review of Resident #1's most recent Minimum Data Set, dated dated [DATE], indicated he/she was cognitively intact, had both verbal behaviors directed toward others and behavioral symptoms not directed toward others, had rejection of care and wandering behaviors, and behavioral symptoms that became worse since the last review. Review of Resident #1's Care Plan Meeting, dated 12/23/21, indicated Resident #1 resided on a secured Behavioral Unit and he/she continued to look for things to ingest that contained alcohol. Review of the Facility's Behavioral Rounds, dated 1/03/22 (approximately one week prior to Resident #1's ingestion of approximately 800 ml of alcohol hand gel), indicated an environmental assessment for large unsecured volumes of hand gel was not thoroughly addressed (in order to prevent Resident #1's alcohol poisoning on 1/11/22). Review of the Facility's Internal Investigation, dated 1/11/22, indicated that Resident #1 was found in his/her room on the secured Behavioral Unit, he/she had consumed a bag of hand sanitizer, (one of the refill inserts for the wall mount units), he/she was unable to answer questions or sit up and had slurred speech and that the Nurse Practitioner was immediately notified. The Investigation findings indicated that it was unclear how or when Resident #1 obtained the refill bag of alcohol hand sanitizer from the wall mount unit. Interventions included that all wall mount hand sanitizer units had been removed from the Behavioral Unit and the staff will have bottles of hand sanitizer on their person. During an interview on 1/27/22, at 8:43 A.M., Certified Nurse Aide (CNA) #2 said at approximately 9:00 A.M., he witnessed Nurse #4 coming out of Resident #1's room with a large empty bag of the alcohol hand sanitizer, then Resident #1 walked out of his/her room into the hall, Resident #1 was unsteady on his/her feet and banged into the hallway wall. CNA #2 said he held him/her up and called for assistance and then asked Resident #1's roommate to get a wheelchair. CNA #2 said Resident #1 kept saying, words to the effect, I want alcohol. CNA #2 said Resident #1 would say that every day. CNA #2 said Resident #1 was assisted back to bed, and said he stayed with him/her and provided 1:1 supervision until Emergency Medical Services (EMS) arrived. CNA #2 said he/she did not know where Resident #1 found the large bag of hand sanitizer. Review of Resident #1's Nursing Progress Note, dated 1/11/22, indicated that when Nurse #4 entered Resident #1's room to administer his/her medications, Resident #1 was found with a cup of hand sanitizer on his/her bedside table which he/she drank. The Note indicated Resident #1 was also found with a 1000 ml bag of hand sanitizer nearly empty on the floor. The Note indicated Nurse #4 assigned CNA #2 to sit with Resident #1 while she reported the incident to the Director of the Behavioral Unit and to the Nurse Practitioner, who arrived on the unit, assessed Resident #1 and advised the Nurse to send him/her to the Hospital. Resident #1 was transferred to the Hospital. During an interview on 1/27/22, at 1:40 P.M., Nurse #4 said that Resident #1 had a history of chewing on the alcohol hand wipes that came from the Kitchen on the meal trays for washing your hands before meals. Nurse #4 said he/she chewed on the wipes for their alcohol content, and these wipes were removed from the meal trays. Nurse #4 said prior to his/her ingestion of the hand sanitizer on 1/11/22, Resident #1 would drink the hand sanitizer from the wall mounted pumps. Nurse #4 said on 1/11/22 sometime between 9:45 A.M. and 10:00 A.M., as soon as she opened the door to Resident #1's room, there was a strong alcohol smell, there was a cup half full of the alcohol hand sanitizer gel, with about another 100 ml all over the tray table, and an empty bag of the hand sanitizer gel beside Resident #1 on the floor. Nurse #4 said Resident #1 was unresponsive, his/her speech was slurred, and she could not understand what he/she was saying. Nurse #4 said she called the Nurse Practitioner, who arrived immediately. Review Resident #1's Nurse Practitioner's Note, dated 1/11/22, indicated Resident #1 was found unresponsive with an empty 1,000 ml bag of alcohol hand sanitizer. The Surveyor conducted Environmental Observations on two secured units, findings were as follows: On 1/27/22 at 8:30 A.M., on the secured Dementia Unit, the Surveyor observed Housekeeper #1 demonstrate how the unsecured wall mounted hand sanitizer stations could be quickly opened and then the 1,000 ml bag of hand sanitizer could be easily removed and opened within five seconds. After observing Housekeeper #1 open the hand sanitizer station, the Surveyor was also able to open the unsecured hand sanitizer station, with one push of the button on the bottom of the dispenser and remove the 1,000 ml bag within 5 seconds. On 1/27/22 at 8:40 A.M. and 9:15 A.M., on the secured Behavioral Unit (Resident #1's Unit), with Housekeeper #1 and Housekeeper #2, both Housekeepers said that prior to Resident #1's ingestion of the hand sanitizer on 1/11/22, they were still replacing the 1,000 ml bags of the wall mounted hand sanitizers (contains [MEDICATION(S)] Alcohol 70%), in the room entrances of the Woman's side of the Corridor. The location of the hand sanitizer stations on the Woman's Corridor were within 4 feet of entering each resident's room, when the resident's room door was open, these stations could be observed in each room from the hallway. Four of the ten hand sanitizer stations had a lock to the prevent resident access. However, six of the ten hand sanitizer stations in the entrance of the Women's Rooms were unsecured (a lock was not needed to access them) prior to Resident #1's ingestion on 1/11/22. Review of Resident #1's Ambulance Run Report, dated 1/11/22, indicated EMS was dispatched urgently to the Facility for Resident #1 who had ingested hand sanitizer. Resident #1 had a prior history of ingesting hand sanitizer. Resident #1 was unresponsive, his/her oxygen saturation level was 90% to 92% low (amount of oxygen in the blood stream, normal 95% or greater) on room air, treated with supplemental oxygen, with an increase of oxygen saturation level to 95%, an intravenous line was inserted and intravenous therapy was started, he/she was transported to the Hospital. Resident #1's Hospital Physician's Note, dated 1/11/22, indicated Resident #1 was diagnosed with acute alcohol poisoning, with a critical blood alcohol level of 384 elevated (normal is less than 50, intoxicated is greater than 50, critical is greater than 300), had an abnormal respiratory effort, was intubated, ventilated, and admitted to Critical Care. The Note indicated Resident #1 recovered and was discharged on [DATE] to a Nursing Home. During an interview on 1/27/22 at 11:15 A.M. the Director of Nurses (DON) said the Facility investigation did not find where Resident #1 obtained the hand sanitizer on the secure unit. The DON said he was not sure if there were any sources of the bag hand sanitizers on the Behavioral Unit when Resident #1 ingested approximately one bag (800 ml) of the alcohol hand sanitizer. B. The Facility's Policy, Elopement Prevention and Response, dated 6/25/18, indicated that: - Elopement is when a resident leaves the premises (or a safe area) without the Facility's knowledge. - To provide mechanisms for monitoring and managing residents at risk for elopement in order to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. - To ensure that the resident environment remains secure and free from accidental hazards and that each resident receives adequate supervision to prevent accidents. - Assessment of risk factors for Elopement include: a. Medical conditions b. Psychological triggers (new environment, change of routine) c. Cognitive status (purposeful exit seeking, impulsiveness, memory loss) d. Behavior patterns e. Lifestyle history (activities and career) Resident #2's Hospital Psychiatric Note, dated 10/20/21, (prior to his/her admission to the Facility), indicated that due to Resident #2's chronic alcohol use and chronic [CONDITION(S)], his/her judgement was impaired for everyday activities and social situations. The Note indicated, although Resident #2 is oriented to person, place and time, he/she was unable to understand the severity of his/her current medical condition and lacked the capacity to make medical decisions for him/herself and the Physician recommended invoking his/her Healthcare Proxy. The Note indicated Resident #2 was a current tobacco user and smoked 40 cigarettes a day, he/she did not want to go to a Nursing Home, although if Resident #2 could smoke then he/she might be okay with it. Resident #2 was admitted to the Facility in 11/2021 diagnoses included, Wernicke's [CONDITION(S)], alcohol dependency, and delusional disorder. Review of Resident #2's Wandering and Elopement Risk Assessment, dated 11/20/21, indicated that Resident #2 stated his/her intent to leave the Facility, displayed behavior or body language indicating elopement behavior. The Assessment indicated that the plan will be to implement a high-risk elopement care plan, and to place a wander detection device on Resident #2. Review of Resident #2's Elopement Care Plan, dated 11/20/21, indicated Resident #2 was at risk for elopement due to cognitive impairment with poor decision-making skills, interventions included to attempt to identify triggers for his/her behaviors of wandering and elopement and to monitor resident is he/she displays behaviors or language indicating that elopement an attempt is reasonably possible. The Care Plan indicated to monitor response to events or activity in surroundings at time of elopement attempt. Review Resident #2's Social Service Note, dated 11/21/21, indicated that prior to admission, Resident #2 was living in a tent, name and location (greater than 20 miles away), he/she was unable to make reasonable decisions for him/herself, and Facility was working on finding an Agent for a Health Care Proxy for him/her. Review Resident #2's Acknowledgement of the Resident Smoking Policy, dated 11/22/21, indicated Resident #2 needed to be supervised by staff when smoking, that he/she was looking for cigarette butts on the ground, and asking staff and residents for beer. Review of Resident #2's Admission Minimum Data Set, dated dated [DATE], indicated Resident #2 was cognitively intact, had behavioral symptoms not directed toward others, had rejection of care, and wandering behaviors. Review of Resident #2's Nursing Progress Note, dated 1/14/22, at 3:03 P.M., indicated that Resident #2 tested positive for COVID-19, he/she was being transferred from the 2nd floor unit to the COVID Quarantine and Recovery Unit (an unsecured unit on the ground floor). Review of Resident #2's Nursing Progress Note, dated 1/15/22, at 9:32 A.M., indicated that Resident #2 was confused and disoriented, was reoriented to reality but with poor results. Review of Nurse #2's Nursing Progress Note, dated 1/16/22, at 8:27 A.M., indicated that when Nurse #2 attempted to administer Resident #2's morning medications, he/she refused to take these medications because he/she was not allowed to go out to smoke. The Note indicated Nurse #2 educated Resident #2 that due to the weather outside, the whole Facility was not going out to smoke. Review of Nurse #2's Nursing Progress Note, dated 1/16/22 written at 10:04 A.M., indicated Resident #2 had asked several times if he/she could go out to smoke, prior to his/her elopement. The Note indicated the Housekeeper asked Nurse #2, if Resident #2 was supposed to be outdoors by him/herself and when Nurse #2 checked if Resident #2 was in his/her room and he/she was not there. The Note indicated a staff member (Nurse #3) drove her car down the street, found Resident #2 walking away from the Facility, he/she was brought back to the Facility and taken out to smoke. The Note indicated that Resident #2 told her that he/she walked out the front door when he/she eloped. The Note indicated that upon arrival back to the Facility a (new) wander guard was placed on Resident #2's right wrist and he/she was placed on 1:1 supervision. Review of Nurse #3's Written Witness Statement, dated 1/16/22, indicated that Staff reported that a Housekeeper had seen Resident #2 by the dumpster in back of the building and that a Code Green (an Emergency Protocol for an elopement) was called for Resident #2's elopement. The Statement indicated Nurse #3 left the Facility drove down the street, saw Resident #2 walking by the side of the road, she was able to get him/her into her car, and Resident #2 was returned to the Facility. During an interview on 1/27/22 at 7:55 A.M., Nurse #3 said it was cold outdoors the day Resident #2 eloped, she found him/her approximately 0.4 miles from the Facility and he/she was wearing blue jeans and a jacket. Review of the Facility's Internal Investigation, dated 1/16/22 at 9:20 A.M., written by Nurse #2, indicated Resident #2 was confused before his/her elopement, that he/she went out the front door of the Facility, and that he/she was found down the street. The Investigation indicated that after the elopement, Resident #2 was place on 1:1 supervision and a wander guard was placed on him/her. The Investigation Findings for this elopement indicated on 1/17/22, video footage was reviewed of the front access door and rear access door, and Resident #2 was not seen leaving the facility through these doors. Review of Nurse #2's Nursing Progress Note, dated 1/16/22, at 2:39 P.M., indicated that prior to Resident #2's second elopement, he/she was on 1:1 supervision, with CNA #1 sitting right outside Resident #2's room in the hallway, with Resident #2's door closed due to him/her testing positive for COVID-19. The Note indicated Nurse #2 was notified that Resident #2 had left the Facility for the second time and was seen on a road (0.4 miles) away from the Facility, that Nurse #2 along with other staff members drove their cars in search of Resident #2, and he/she was found and brought back to the Facility. The Note indicated that after Resident #2's second elopement, his/her room window was checked, and it was found to be open. During an interview on 1/26/22 at 2:45 P.M. and on 1/27/22 at 7:00 A.M., CNA #1 said that he was assigned to provide 1:1 supervision to Resident #2 after his/her first elopement. CNA #1 said prior to Resident #2's second elopement, he/she was agitated and upset that he/she could not go outside to smoke. CNA #2 said Resident #2 told him, he/she was going to leave the Facility, if he/she could not smoke. CNA #1 said he immediately told the Nurse of Resident #2's intentions to leave the Facility, if he/she could not smoke. CNA #1 said the Nurse told him Resident #2 could not go out to smoke. Review of the Facility's Internal Investigation, dated 1/16/22 at 2:10 P.M., indicated Resident #2, had a second elopement (approximately 5 hours after the first elopement), when he/she climbed out of his/her bedroom window, staff found Resident #2 and returned him/her to the Facility. The Investigation indicated that Resident #2 was in a ground floor room (prior to 1/14/22, he/she was on the 2nd floor) and a room inspection revealed the window was open, with the screw bracket (which allowed the window to open only four inches) was removed. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 1/16/22, indicated that he (CNA #1) was outside Resident #2's (closed) room door, to make sure he/she did not elope and that Resident #2 kept coming out of his/her room every 5 to 10 minutes asking to smoke. The Statement indicated approximately at 2:25 P.M., a supervisor came to the Unit and said Resident #2 had eloped from the Facility through his/her bedroom window. During an interview on 1/27/22 at 8:15 A.M., the Director of Nurses said the Facility did not have a policy or protocol for defining resident supervision, such as 1:1 supervision, or a defined process for providing 1:1 supervision for a resident who was an elopement risk on the Quarantine Recovery COVID-19 Unit. Review of Resident #2's Wandering and Elopement Risk Assessment, dated 1/16/22, indicated that Resident #2 was non-compliant with leaving the building, he/she questioned the need to be here, and was cognitively impaired with poor decision skills. Resident #2 made statements about the Facility or seeking people or things, and had a history of elopement. During an interview on 1/26/22 at 2:10 P.M., Nurse #2 said her assignment included Resident #2 on 1/16/22 during the 7:00 A.M. to 3:00 P.M. shift, when Resident #2 eloped twice from the Facility, five hours apart from the same room. Nurse #2 said Resident #2 had behaviors of perseveration about smoking. Nurse #2 said she wrote the report for the investigation of the two elopements. Nurse #2 said she wrote for the first investigation that Resident #2 eloped through the front door because Resident #2 told her that he/she left the Facility through the front door, although there were no witnesses, including the receptionist who was stationed by the front door. Nurse #2 said after the first elopement, an environmental assessment was not performed of Resident #2's room to evaluate if there was an unsecured mode of egress. Nurse #2 said she had implemented 1:1 supervision for Resident #2 right after his/her first elopement. Review of the Administrative Assistant's Written Witness Statement, dated 1/16/22 at 2:09 P.M., indicated that she was informed that Resident #2 was seen outdoors talking to the mailman down the street from the Facility. The Statement indicated that she wanted to validate this with CNA #1 (who was providing 1:1 supervision), so she went to where CNA #1 was sitting outside Resident #2's closed door in the hallway and CNA #1 said, Of course, yes (he/she) is in the room and when they walked into Resident #2's room, he/she was not there, and his/her window was wide open. The Statement indicated that Resident #2 was located approximately 0.4 miles from the Facility and brought back to the Facility. During an interview on 1/27/22 at 10:30 A.M., the Administrative Assistant said that when she and staff, entered Resident #2's room, they could not find Resident #2 in his/her room, they then opened the curtain, and the sliding window was opened approximately 18 inches, and a Code Green was called. The Administrative Assistant said Resident #2 was approximately 0.4 miles away from the Facility, and said when she asked Resident #2 where he/she was going, Resident #2 told her that he/she wanted a cigarette, and he/she was walking home (greater than 20 miles away). The Administrative Assistant said she brought Resident #2 back to the Facility, to his/her Unit, and he/she was taken out side and given a cigarette. The Facility's findings from their investigation indicated Resident #2's anxiety and agitation was focused around smoking times, any disruption in his/her smoking schedule causes agitation and that staff will continue to monitor the need for smoking and set agreed upon times. During an interview on 1/27/22 at 12:30 P.M., Resident #2 said that he/she did not leave the Facility on 1/16/22 through the front door, but instead he/she left twice through the window in his/her room. Resident #2 said it was easy to open the window the first time, that he/she worked as a mechanic, so opening the window was easy. Resident #2 said after the first time he/she left the Facility through the window, no one had checked that it was unlocked, and so he/she left through the same window again for the second time. During an interview on 1/26/22 at 2:45 P.M. and on 1/27/22 at 7:00 A.M., Certified Nurse Aide (CNA) #1 said after Resident #2's first elopement, he/she was assigned to provide 1:1 supervision. CNA #1 said that 1:1 supervision was having eyes on the resident continuously and being within an arm's reach of the resident, but instead, he was told since Resident #2 was positive for COVID-19, to sit in a chair in the hall outside his/her room with the door closed (the door to Resident #2's room was a solid door with no window or way to observe Resident #2). CNA #1 said he intermittently provided supervision by opening Resident #2's room door every 10 to 15 minutes to observe him/her. CNA #1 said at approximately 2:20 P.M., the Administrative Assistant came to where he was sitting in the hallway by Resident #2's room door and asked me if Resident #2 was in his/her room. CNA #1 said that he was sure Resident #2 was in his/her room and when he opened the door, he/she was not in the room. CNA #1 said he looked behind the window curtain and the window was opened. During an interview on 1/26/22 at 2:10 P.M., Nurse #2 said Resident #2's triggers for his/her elopement included his/her new environment, he/she was moved to a new unit on the ground floor, and his/her history of tobacco dependency. Nurse #2 said Resident #2's psychological and physical triggers to smoke were exacerbated on 1/16/22, when outdoor smoking was canceled due to the cold weather. Nurse #2 said that his/her increased agitation and verbalization that that he/she would leave the Facility occurred when Resident #2 was unable to smoke.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure his/her environment was free of hazards, and that his/her safety was maintained to prevent injury. On [DATE], during the night shift, Resident #1 displayed extreme self-injurious behavior by banging his/her head on a dining table in the day room. Resident #1, who was in a wheelchair, was left seated in front of the table and between 1:00 A.M. to 5:00 A.M., continued to forcefully and repeatedly bang his/her head on the table. Approximately nine hours later, Resident #1 was found seated in the day room, was unresponsive, and was emergently transported to the Hospital Emergency Department, for further evaluation. Findings include: The Facility's Policy, Fall Management, dated [DATE], indicated that all residents experiencing a fall (a type of trauma) will receive appropriate care and investigation of the cause. To address any injury, provide care for recovery. Document the condition of the resident after the incident and perform neurological checks if the fall (trauma) was unwitnessed or if the resident hit his/her head. The Lippincott Manual of Nursing Practice, 10th edition, indicated that head injuries commonly occur with falls (trauma), which included intracranial hemorrhage; defined as significant bleeding into a space or a potential space between the skull and the brain, which is a serious complication of a head injury and the potential for brain herniation; intracranial pressure is a life-threatening medical emergency that requires immediate recognition and prompt intervention. Resident #1 was admitted to the Facility in ,d+[DATE] diagnoses included dementia, a prior [CONDITION(S)] and cardiovascular disease treated with Aspirin (an anti-platelet medication to prevent clotting) and a history of multiple falls. Review of Resident #1's Behavioral Care Plan, dated [DATE], indicated he/she had poor safety awareness due to depression and non-compliance, interventions included to notify the Physician of behaviors, medical issues or safety issues. Review of Nurse #1's Nursing Progress Note, dated [DATE] at 5:53 A.M., indicated Resident #1 required constant supervision to prevent him/her from falling, he/she would not stay in bed, kept taking off his/her clothes and blankets, and he/she was a severe fall risk all night long. Review of the Facility's Internal Investigation, dated [DATE], which per the Administrator was dated [DATE], to show incident occurred during the [DATE] - [DATE] night shift, signed by Nurse #1, indicated that Resident #1 was extremely agitated the entire 11:00 P.M. to 7:00 A.M. shift. Resident #1 needed to be monitored by a staff members within arm's reach for the entire shift. Pillows and blankets were used in the wheelchair to ensure safety. Resident #1 was repeatedly banging his/her head on the table. Review of Certified Nurse Aide #2's witness statement, dated [DATE], indicated the following: Resident #1 had been agitated on [DATE] during the 3:00 P.M. to 11:00 P.M. shift and during the 11:00 P.M. to 7:00 A.M. shift. During the 11:00 P.M. to 7:00 A.M. shift., Resident #1 stayed in his/her wheelchair all night due to increased restlessness and agitation. Resident #1 was sitting at a (Dining Room) table (in the Day Room) purposely hitting his/her head on the table. Resident #1 was banging his/her head so hard that you could hear his/her head striking the table. Attempts were made to protect his/her head by putting a pillow and blankets on the table, but he/she kept throwing them on the floor. Review of Nurse #1's written witness statement, dated [DATE], indicated the following: On [DATE], Resident #1 was agitated right from the start of the 11:00 P.M. to 7:00 A.M. shift, and was purposely banging his/her head on the (Dining Room) table, secondary to agitation. Nurse #1 wrote that conservatively he/she (directly) banged his/her head on the table six or eight times. Pillows were put on the table and many times his/her head hit the pillow but his/her head also hit the table. Resident #1 struck his/her head significantly hard. Other than the agitation, there was no change in his/her neurological status. The statement indicated he (Nurse #1) and CNA #2 took turns staying with him/her. Review of Resident #1's medical record indicated there was no documentation in Nurse #1's written statement or progress notes to support that he performed or completed neurological checks on Resident #1 after the episode of injurious behavior. There was also no documentation to support that Nurse #1 or another nursing staff member attempted to redirect Resident #1 by moving him/her away from the table, in an effort to stop the behavior. During an interview on [DATE] at 2:35 P.M., Nurse #1 said that Resident #1 had been agitated, and he/she had sun-downing behaviors. Nurse #1 said that on [DATE], from 1:00 A.M. until 5:00 A.M., Resident #1 intermittently banged his/her head against the dining room table. Nurse #1 said Resident #1's head made contact directly with the table six to eight times, and said this was a change in his/her behavior, but said he did not notify the physician of this self-injurious behavior. Nurse #1 said he tried to put blankets and pillows on the table where Resident #1 was sitting but said this intervention did not consistently work, because Resident #1 removed them and would bang his/her head on the table. Nurse #1 said that he did not report Resident #1's head banging to the Nurse at 7:00 A.M., during shift change report. Nurse #1 said he told the Nurse that she would probably have to send Resident #1 to the Hospital due to his/her change in condition with his/her restlessness. Nurse #1 said he did not report the incident of Resident #1's head banging to Nursing Management or a Nursing Supervisor. Staff members interviewed, did not offer an explanation as to why, Resident #1 who was seated in a wheelchair, was not moved away from the table, as a potential intervention to stop him/her from repeatedly banging his/her head on the table. Review of Unit Manager #1's Nursing Progress Note, dated [DATE] at 10:58 A.M., indicated Resident #1 became unresponsive, with a pulse rate of 55 (normal 60 to 100), blood pressure ,d+[DATE] (normal ,d+[DATE]), and oxygen saturation of 97% (normal greater than 95%). Review of Resident #1's Situation Background Appearance and Review (SBAR Form), dated [DATE], indicated that Resident #1 had a change in condition, was unresponsive, and had weakness. Review of the Facility's Internal Investigation, dated [DATE], which per the Administrator was dated [DATE], to show incident occurred during the [DATE] - [DATE] night shift, indicated (that on [DATE] during the day) Resident #1 had decreased responsiveness, while sitting in the Day Room. Resident #1 was transferred to the Hospital Emergency Department due to a change in his/her condition, the Nurses Notes indicated he/she had episodic agitation, and interviews with the Nursing Staff indicated that Resident #1 had self-inflicted harm. The Investigation indicated that Resident #1 repeatedly struck his/her head against a table despite the staff being with the resident. Review of Resident #1's Ambulance Run Report, dated [DATE] at 10:15 A.M., indicated the Emergency Medical Services (EMS) was dispatched emergently, after a 911 call for an unresponsive resident with low blood pressure. The Nurse said the Resident was in this condition for 30 minutes and had been previously complaining of weakness. On EMS arrival, Resident #1 was unresponsive, sitting in a wheelchair slumped, breathing normally with an oxygen saturation of 95%, he/she was started on 4 liters of oxygen via a nasal cannula, and an intravenous line was started. Resident #1 did not return to the Facility and died while at the Hospital.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls and required the assistance of two staff members for bed mobility and transfers, the Facility failed to ensure staff maintained safety measures to prevent incidents with injury. On 07/29/21 Certified Nurse Aide (CNA) #1 provided care to Resident #1 without another staff member present, Resident #1 fell out of bed onto the floor, sustained a laceration to his/her forehead, was transferred to the Hospital Emergency Department for evaluation, and required sutures to close the laceration. Findings include: The Facility's Policy titled, Falls Risk Reduction, dated 11/28/18, indicated that, those residents who have been assessed for falls risk factors and determined to have risk factors for falls, will receive individualized interventions based on the risk factors in other to reduce risk for falls and minimize the actual occurrence of falls. Resident #1 was admitted to the Facility in July 2020, diagnoses included persistent vegetative state, dependent on respirator, and [CONDITION(S)]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on staff with activities of daily living, bed mobility and transfers. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL), dated 07/07/21, indicated Resident #1 was dependent on two staff persons for assistance with the following; bathing, grooming, dressing, transfers, toileting, bed mobility and positioning. Review of Resident #1's Plan of Care related to Falls Prevention, dated 06/18/21, indicated that Resident #1 was at risk for falls due to complete dependence on staff for positioning and safety in the environment. The Plan of Care indicated nursing should monitor his/her position in bed and proximity to edges of bed to prevent falls. Review of the Facility's Investigation Report, dated 07/29/21, indicated that while CNA #1 was providing incontinent care to Resident #1, CNA #1 turned him/her onto his/her left side, that Resident #1's legs drifted off the side of the bed, CNA #1 lost grip of him/her, and Resident #1 fell out of bed to the floor. The Report indicated that Resident #1 was bleeding from his/her forehead and was transferred to the Hospital Emergency Department for further evaluation. Review of Facility's Corrective Action Notice, dated 07/29/21, indicated that CNA #1 did not follow Resident #1's plan of care as it related to the level of assist he/she required, and that this resulted in resident injury. During an interview on 08/26/21 at 12:40 P.M., CNA #1 said on 07/29/21 she was assigned to care for Resident #1 on the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said she was alone providing incontinent care to Resident #1 when he/she fell off the bed onto the floor. CNA #1 said she turned Resident #1 onto his/her left side away from her (CNA #1), that he/she started jerking in bed, and that she lost grip of Resident #1. CNA #1 said Resident #1 was at the edge of the bed when she lost grip of him/her before Resident #1 fell . CNA #1 said she knew that Resident #1 required two staff persons to assist with grooming, bed mobility and transfers. CNA #1 said she did not ask for assistance from a second staff person because she wanted to quickly get Resident #1 up and ready for family visitation that day. Review of Resident #1's Interdisciplinary Progress Notes, dated 07/29/21, indicated Resident #1 fell out of bed when CNA #1 was providing care. The Note indicated that Nurse #1 assessed Resident #1 to have a 3.8 centimeter (cm) laceration above his/her left eye, and that he/she was transferred to the Hospital Emergency Department for further evaluation. During an interview on 08/26/21 at 1:16 P.M., Nurse #1 said at 1:45 P.M., she was at the Nurses station when she heard CNA #1 yelling for help with Resident #1, who had fallen. Nurse #1 said when she got to Resident #1's room, he/she was lying on his/her back on the floor, and that CNA #1, CNA #2 and the Respiratory Therapist (RT) were already in the room. Nurse #1 said Resident #1 was bleeding from his/her forehead area. Nurse #1 said she instructed staff to activate 911 while she assessed and initiated first aid measures. During an interview on 8/26/21 at 2:30 P.M., the Unit Manager said she was in her office when CNA #1 came and got her and said that Resident #1 was on the floor. The Unit Manager said blood was oozing from Resident #1's right upper forehead area. The Unit Manager said she assessed a three centimeters (3 cm) long laceration, and said that she applied steri strips to the wound site before Resident #1 was transferred to the hospital. During an interview on 08/31/21 at 12:11 P.M., the Respiratory Therapist (RT) said he was alerted by the ventilator alarm in the hallway and that he responded by going into Resident #1's room. The RT said Resident #1 was on the floor faced-down. During an interview on 08/31/21 at 12:20 P.M., CNA #2 said CNA #1 did not ask her to assist with Resident #1's care that day. During an interview on 08/26/21 at 2:40 P.M., the Director of Nurses (DON) said she investigated the fall incident involving Resident #1 on 07/29/21 and found that Resident #1 fell during care performed by one staff person (CNA #1) instead of two persons. The DON said CNA #1 did not follow Resident #1's plan of care. Review of Resident #1's Hospital Discharge Record, dated 07/29/21, indicated Resident #1 was evaluated and treated for forehead laceration (head injury), and sutures were applied to his/her forehead. On 08/26/21, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) Resident #1 was transferred to the Hospital on 07/29/21 for further evaluation and treatment. B) On 08/09/21, the Director of Nurses re-educated CNA #1 on following plan of care related to level of assistance for resident(s). C) On 08/11/21, DON completed Personal Care Competency with the CNAs, where CNAs verbalized the process to locate residents Plans of Care and demonstrate where in the resident chart the level of assistance was located. The DON reviewed the CNA Job Description with the CNAs. D) On 08/11/21, the DON initiated a Facility wide audit of residents' chart to ensure all residents were receiving care with the appropriate level of assistance. E) Results of the audits will be discussed in the quality Assurance Performance Improvement (QAPI) meeting which is also attended by the Medical Director. The next QAPI meeting is 09/02/21. F) The Director of Nurses (DON) and/or designee will be responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was at risk for falls and required the assistance of two persons for bed mobility and transfers, the Facility failed to ensure staff implemented interventions from his/her plan of care, when on 07/29/21 Certified Nurse Aide (CNA) #1 turned and repositioned Resident #1 in his/her bed, without the assistance of another staff member, Resident #1 fell out of bed onto the floor, sustained a laceration to his/her forehead, required transfer to the Hospital Emergency Department for evaluation and required sutures to close the laceration. Findings include: The Facility's Policy titled, Falls Risk Reduction, dated 11/28/18, indicated that, those residents who have been assessed for falls risk factors and determined to have risk factors for falls, will receive individualized interventions based on the risk factors in other to reduce risk for falls and minimize the actual occurrence of falls. Resident #1 was admitted to the Facility in July 2020, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on staff with all activities of daily living, bed mobility and transfers. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL), dated 07/07/21, indicated Resident #1 was dependent on two staff persons for assistance with the following; bathing, grooming, dressing, transfers, toileting, bed mobility and positioning. Review of Resident #1's Plan of Care related to Falls Prevention, dated 06/18/21, indicated that Resident #1 was at risk for falls due to complete dependence on staff for positioning and safety in the environment. The Plan of Care indicated nursing staff should monitor his/her position in bed and proximity to edges of bed to prevent falls. Review of the Facility's Investigation Report, dated 07/29/21, indicated that while CNA #1 was providing incontinent care to Resident #1, CNA #1 turned Resident #1 onto his/her left side, that Resident #1's legs drifted off the side of the bed, CNA #1 lost grip of him/her, and Resident #1 fell out of bed onto the floor. The Report indicated that Resident #1 was bleeding from his/her forehead and was transferred to the Hospital Emergency Department for further evaluation. Review of Facility's Corrective Action Notice, dated 07/29/21, indicated that CNA #1 did not follow Resident #1's plan of care as it related to his/her required level of assist, and that this resulted in resident injury. During an interview on 08/26/21 at 12:40 P.M., CNA #1 said on 07/29/21 she was assigned to care for Resident #1 on the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said she was alone providing incontinent care to Resident #1 when he/she fell off the bed onto the floor. CNA #1 said she turned Resident #1 onto his/her left side away from her (CNA #1), that he/she started jerking in bed, and that she lost grip of Resident #1. CNA #1 said Resident #1 was at the edge of the bed when she lost grip of him/her before Resident #1 fell . CNA #1 said she knew that Resident #1 required a two person assist with grooming, bed mobility and transfers. CNA #1 said she did not ask for assistance from a second staff person because she wanted to quickly get Resident #1 up and ready for family visitation that day. Review of Resident #1's Interdisciplinary Progress Notes, dated 07/29/21, indicated Resident #1 fell out of bed when CNA #1 was providing care. The Note indicated that Nurse #1 assessed Resident #1 to have a 3.8 centimeter (cm) laceration above his/her left eye, and that he/she was transferred to the Hospital Emergency Department for further evaluation. During an interview on 08/26/21 at 1:16 P.M., Nurse #1 said at 1:45 P.M., she was at the Nurses station when she heard CNA #1 yelling for help with Resident #1, who had fallen. Nurse #1 said when she got to Resident #1's room, he/she was lying on his/her back on the floor, and that CNA #1, CNA #2 and the Respiratory Therapist (RT) were already in the room. Nurse #1 said Resident #1 was bleeding from his/her forehead area. Nurse #1 said she instructed staff to activate 911 while she assessed and initiated first aid measures. During an interview on 08/31/21 at 12:20 P.M., CNA #2 said CNA #1 did not ask her to assist with Resident #1's care that day. Review of Resident #1's Hospital Discharge Record, dated 07/29/21, indicated Resident #1 was evaluated and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/26/21 at 2:40 P.M., the Director of Nurses (DON) said she investigated the fall incident involving Resident #1 on 07/29/21 and found that Resident #1 fell during care performed by one staff person (CNA #1) instead of two persons. The DON said CNA #1 did not follow Resident #1's plan of care. On 08/26/21, the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: A) Resident #1 was transferred to the Hospital on 07/29/21 for evaluation and treatment, and returned to the facility. B) On 08/09/21, the Director of Nurses re-educated CNA #1 on following plans of care related to level of assistance for resident(s). C) On 08/11/21, DON completed Personal Care Competency with the CNAs, where CNAs verbalized the process to locate residents Plans of Care and demonstrate where in the resident chart the level of assistance was located. The DON reviewed the CNA Job Description with the CNAs. D) On 08/11/21, the DON initiated a Facility wide audit of residents' charts to ensure all residents were receiving care with the appropriate level of assistance. E) Results of the audits will be discussed in the Quality Assurance Performance Improvement (QAPI) meeting which is also attended by the Medical Director. The next QAPI meeting is 09/02/21. F) The Director of Nurses (DON) and/or designee will be responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from significant medication errors, when he/she was administered six medications in error daily, for more than a month while in the Facility and the transcription error was not identified by the Facility until after Resident #1 was discharged from the Facility and readmitted to the Hospital. - On 01/05/21, upon Resident #1's admission to the Facility, along with a list of his/her discharge medications, there was a page containing another patients' hospital discharge medication list, with the other patients name clearly identified on the top of that page, the medications on that list were transcribed in error onto Resident #1's physician medications orders and onto his/her medication administration record. Along with the medications that were ordered for Resident #1 by his/her physician, the medications transcribed in error, were also ordered and administered to Resident #1 daily, while in the Facility. The medications administered in error included the following; - [MEDICATION(S)] (anti-psychotic) 1 milligram (mg) by mouth daily - [MEDICATION(S)] 3 mg by mouth at bedtime - [MEDICATION(S)] (anti-depressant) 200 mg by mouth at bedtime - [MEDICATION(S)] (anti-depressant) 200 by mouth daily - [MEDICATION(S)] 0.4 mg ( [CONDITION(S)] medication) by mouth at bedtime - [MEDICATION(S)] (statin, cholesterol medication) 20 mg by mouth every day - [MEDICATION(S)] (medication for asthma or chronic obstructive pulmonary disease) 18 micrograms (mcg) daily via a hand-held inhaler - Resident #1 was administered the above medications while in the Facility from 01/05/21 through 02/12/21, he/she experienced a significant decline in condition with episodes of lethargy, confusion, [CONDITION(S)], refusing meals and was unable to participate in rehabilitation therapy. Prior to his/her admission, Resident #1 lived in his/her own home in the community with minimal assistance require. Resident #1's Health Care Agent was so concerned with Resident #1's significant decline in physical condition and mental status, that he had Resident #1 discharged against medical advice, however as a result of the medication error not being identified while Resident #1 was in the Facility, he/she was subsequently discharged home on the medications and continued to receive them in error. Findings include: The Facility Policy titled, Admission & Discharge Drug Regimen Review & Medication Reconciliation Policy, dated 10/17/18, indicated that during the admission process, the Nurse will obtain a medication history from the following sources: the discharge summary, physician discharge orders, any other medication information provided by the referring agency and from a resident interview or the family or resident representative if the resident can't be interviewed. The Nurse will review the collected information and identify any discrepancies during the review between the medication history and current medication order and report to the attending physician for clarification and reconciliation. The Admitting Nurse will review with the transferring Nurse the clinical record to ensure current orders and medication administration records have been transferred with the resident. Lexicom, an e-pharmacology reference, dated 2021, indicated that: - [MEDICATION(S)] (anti-psychotic medication) can cause significant sedation, orthostatic [CONDITION(S)] (low blood pressure), anticholinergic effects of confusion and [CONDITION(S)]. Geriatric considerations: the elderly have an increased risk of adverse (unwanted) effects, cognitive impairment, [CONDITION(S)] and falls. The initial oral dose, in the elderly of 0.5 mg is the usual starting dose. - [MEDICATION(S)] (anti-depressant medication, type an SSRI - selective serotonin reuptake inhibitor) can cause orthostatic [CONDITION(S)], fatigue, loss of strength and energy. [MEDICATION(S)] may cause anticholinergic effects of confusion and [CONDITION(S)]. This medication can cause depression like thoughts of suicide, agitation, irritability, behavioral changes or confusion. [MEDICATION(S)] may cause cardiac arrhythmias (abnormal heart conduction or heart rate), may increase the risk of QT prolongation (a measurement of slow heart conduction) including [CONDITION(S)] (a fast ineffective heart rate). Geriatric considerations: very sedating. The initial oral dose is 25 mg to 50 mg, with a gradual increase to a usual dose of 75 mg to 150 mg a day. - [MEDICATION(S)] (anti-depressant medication, type an SSRI) can cause orthostatic [CONDITION(S)], fatigue, loss of energy, loss of appetite, emotional instability, agitation, irritability, behavioral changes or confusion, with a boxed warning that it may cause suicidality (suicidal thoughts about taking one's life). A warning related to adverse effects with QT prolongation and torsade de pointes (a life-threatening heart rhythm disturbance). The initial oral dose, in the elderly of 25 mg a day is the usual starting dose. - [MEDICATION(S)] (a medication for obstructive [CONDITION(S)], or [CONDITION(S)]) a significant adverse reaction is orthostatic [CONDITION(S)]. It can cause dizziness and drowsiness. Geriatric considerations: metabolism may be slower and older residents may be more sensitive to the orthostatic [CONDITION(S)] caused by this medication. Drug interactions when [MEDICATION(S)] is combined with antipsychotic agents, or blood pressure lowering agents, may enhance their hypotensive effects. - [MEDICATION(S)] (an anti-cholinergic medication for asthma or chronic obstructive pulmonary disease) use with caution it may worsen symptoms of narrow angle [CONDITION(S)] or symptoms of bladder neck obstruction ([CONDITION(S)]). [MEDICATION(S)] may cause trouble urinating a dry mouth, and nausea. - [MEDICATION(S)] (a medication to lower cholesterol levels) use with caution with residents with advanced age, because they are predisposed to [CONDITION(S)] (a disease that affects the muscle fibers causing muscle cramps, stiffness and spasms). Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/23/21, indicated the following: - Resident #1 was given the wrong medications starting on 01/05/21 through to his/her discharge on 02/12/21. - The Hospital discharge medication list included a page with medications for another patient. - On admission to the Facility, six medications were transcribed in error on to Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - The Admission Nurse entered some of Resident #1's medication orders into the electronic medical record - Nurse #4 entered the remaining medication orders - Resident #1's Healthcare Agent called the Facility on 02/11/21, concerned that Resident #1 had a decline in his/her condition since he/she was admitted to the Facility - The Healthcare Agent decided to have Resident #1 discharged against medical advice on 02/12/21 - Resident #1 was readmitted to the Hospital 02/15/21 - Medication errors were not detected until 02/16/21, three days after Resident #1 was discharged A Medication Variance Report, dated 02/23/21, indicated that on 01/05/21, a medication list of another patient was included in Resident #1's hospital discharge packet and during the Facility admission process, the medication reconciliation process was not followed. The Report indicated the variances identified were: - The wrong medication - The wrong resident - A transcription error - The Facility policy not being followed Review of Resident #1's Hospital Discharge Medication List, date 01/05/21, indicated he/she was to continue the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (antacid) 1250 mg daily - [MEDICATION(S)] (beta blocker) 50 mg twice a day - [MEDICATION(S)] (vitamin for eyes) 2 capsules twice a day - [MEDICATION(S)] (opthalmic beta blocker) 0.5% solution, instill 1 drop each eye daily in the morning - Travoposte 0.004% solution (prostaglandin analog) instill 1 drop each eye at bedtime - [MEDICATION(S)] (anticoagulant) 5 mg daily - [MEDICATION(S)] (Remeron, anti-depressant) 15 mg at bed time - [MEDICATION(S)] ([MEDICATION(S)], anti-anxiolytic) 0.25 mg twice a day and 0.25 mg twice daily as needed Review of Resident #1's Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. by Nurse #4 and signed by the Physician on 01/07/21 at 11:54 A.M., which indicated to administer: - [MEDICATION(S)] 1 mg by mouth at 9:00 A.M. daily for an unspecified anxiety disorder - [MEDICATION(S)] 3 mg by mouth at 9:00 P.M., for an unspecified anxiety disorder However, Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 200 mg by mouth at 9:00 P.M. for [CONDITION(S)] (inability to sleep) However Resident #1 did not have an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 200 mg by mouth daily for depression However Resident #1 did not have an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 0.4 mg by mouth (a medication for obstructive [CONDITION(S)], or [CONDITION(S)]) at bedtime for prevention. However, there was no documentation in Resident #1's medical record or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] (an anti-cholinergic medication for asthma or chronic obstructive pulmonary disease) 18 mcg via a hand-held inhaler, for prevention. However, there was no documentation in Resident #1's medical record or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] (a medication to lower cholesterol levels) 20 mg by mouth every day for prevention. However, there was no documentation in Resident #1's medical record or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/27/21 at 10:15 A.M., the Admission Nurse said on 01/05/21, she started entering Resident #1's medications into the electronic medical record on the evening shift (3:00 P.M. to 11:00 P.M.). The Admission Nurse said she used Resident #1's Discharge Instruction Visit Report, dated 01/05/21, to obtain his/her discharge medication list. The Admission Nurse said she did not have the Hospital Discharge Summary to review for Resident #1's Facility admission and said it was required to reconcile his/her medications and diagnoses. The Admission Nurse said at the end of her shift, she left Resident #1's admission packet at the nursing station and asked Nurse #4 to complete the admission. During an interview on 04/27/21 at 4:45 P.M. and on 05/11/21 at 6:50 A.M., Nurse #4 said the Admission Nurse completed part of Resident #1's admission during the evening shift on 01/05/21, and left Resident #1's admission packet for her at the Nurses Station, so she could complete the rest of the admission during the overnight shift (11:00 P.M. to 7:00 A.M.). Nurse #4 said the Hospital sent four pages of a medication discharge list for Resident #1 that needed to be ordered and transcribed, and put into the electronic record (e-record). Nurse #4 said she did not read the name on the top each page of the medication lists to ensure that the medications were for the same resident (Resident #1). Nurse #4 said Resident #1's Hospital Discharge Summary was not available at the time of his/her admission to the Facility, and said the medication list she used to transcribe Resident #1's medications did not include active diagnoses. Nurse #4 said when she entered Resident #1's admission medications orders in the electronic e-record on 01/06/21, (which include the six medications transcribed in error), said because Resident #1 did not have current or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Resident #1 did not have current psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Resident #1 did not have a current or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Resident #1 did not have current or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #4 said Resident #1 did not have a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 1 mg by mouth daily, (21 doses administered in error) - [MEDICATION(S)] 3 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 200 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 200 mg by mouth daily, (22 doses administered in error) - [MEDICATION(S)] 0.4 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 20 mg by mouth every day, (22 doses administered in error) - [MEDICATION(S)] 18 micrograms daily via a hand-held inhaler, (21 days administered in error) Review of Resident #1 MAR, dated 02/01/21 through 02/12/21, indicated Resident #1 was administered, the following medications in error: - [MEDICATION(S)] 1 mg by mouth daily, (12 doses administered in error) - [MEDICATION(S)] 3 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 200 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 200 mg by mouth daily, (12 doses administered in error) - [MEDICATION(S)] 0.4 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 20 mg by mouth every day, (10 doses administered in error) - [MEDICATION(S)] 18 mcg daily via a hand-held inhaler, (12 days administered in error) Review of the Nurse Progress Note, dated 01/26/21 (three weeks after admission), indicated at 7:30 A.M., Resident #1 was lethargic, his/her blood pressure was low at 88/50 (normal 120/80). The Note indicated Resident #1's blood pressure was rechecked at 7:45 A.M. and was 90/50 (low). Review of the Nurse Practitioner's (NP) Note, dated 01/26/21, indicated that she was asked to examine Resident #1 for lethargy and [CONDITION(S)]. The NP's Note indicated Resident #1's blood pressure was 116/79 (normal 120/80). The NP's Note indicated Resident #1 was alert and oriented to person, place and time. Review of the Nurse Practitioner's (NP) Note, dated 01/28/21, indicated that she was asked to examine Resident #1 for lethargy and [CONDITION(S)]. The NP's Note indicated Resident #1 was alert but drowsy and that his/her blood pressure was 90/50 (low). The NP's Note indicated upon assessment, Resident #1 had consistently low blood pressure in the morning, and was prescribed multiple medications that can cause drowsiness and lethargy in the morning. The NP Note indicated Resident #1 was being treated with [MEDICATION(S)] and [MEDICATION(S)] at night. The NP Note indicated Resident #1 was also being treated with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. The NP Note indicated to decreased Resident #1's [MEDICATION(S)] (beta blocker, treats high blood pressure) from 50 mg daily to 25 mg daily and to change the administration time of [MEDICATION(S)] 200 mg from at bedtime to the morning. During an interview on 04/27/21 at 2:10 P.M., the Nurse Practitioner said that the [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] medications could cause the decrease in Resident #1's blood pressure and lethargy, but said at the time of her evaluation she was not aware that Resident #1 was on these medications in error and said his/her medication orders were continued. The Nurse Practitioner said if she knew that the antipsychotic and antidepressant medications caused his/her low blood pressure and decline in mental status, she would have discontinued those medications. Review of the Psychiatric Mental Health Consultation, dated 01/07/21, indicated Resident #1 was on very high doses of psychiatric medications for someone his/her age. The Consult indicated Resident #1's psychiatric history was unremarkable (no active psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Consult indicated the writer was unaware of any past history psychiatrically, but that Resident #1's medications are significantly high doses, even for a much younger person. The Consult indicated to monitor for any presence of [CONDITION(S)], [CONDITION(S)], depression or anxiety, will continue to monitor for any possible reduction in doses availability. The Consult indicated question of a possible dose reduction and follow up in two to three weeks (approximate revisit dates 01/21/21 through 02/02/21). During an interview on 05/11/21 at 10:44 A.M., the Physician said that he had assumed that the admission medications had been confirmed and he did not review them, and said he just signed off on the orders. The Physician said when starting [MEDICATION(S)] or [MEDICATION(S)], he would have ordered a baseline EKG (an electrocardiogram - to measure the electrical activity of the heart) for the QT prolongation, but said he was not aware that these were new medications ordered for Resident #1. There was no documentation to support when the Physician signed Resident #1's orders on 01/07/21, that the physician questioned if Resident #1 needed to be administered five different [CONDITION(S)] medications, which included [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. There was also no documentation to support the Physician questioned why Resident #1 was being administered [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)], for which there were no current or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation to support when the Nurse Practitioner evaluated Resident #1 for reports of increased lethargy and low blood pressure, that she questioned if Resident #1 needed to be administered five different [CONDITION(S)] medications, which included [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. There was also no documentation to support that the NP questioned why Resident #1 was being administered [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)], for which there were no current or active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation to support that the Physician or the Nurse Practitioner reviewed or were made aware of results from Resident #1's Psychiatric Mental Health Consultation conducted on 01/07/21, that questioned the number of [CONDITION(S)] medications being administered to Resident #1, the high dose amounts and the lack of supporting active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's Discharge Medications List, dated 02/12/21, indicated that along with his/her actual physician ordered medications, Resident #1 was to continue on the six admission medications that had been started on 01/05/21 in error, which included: - [MEDICATION(S)] 1 mg by mouth daily - [MEDICATION(S)] 3 mg by mouth at bedtime - [MEDICATION(S)] 200 mg by mouth at bedtime - [MEDICATION(S)] 200 by mouth every day - [MEDICATION(S)] 0.4 mg by mouth at bedtime - [MEDICATION(S)] 20 mg by mouth every day - [MEDICATION(S)] 18 mcg daily via a hand-held inhaler During an interview on 04/07/21 at 12:20 P.M. and at 5:23 P.M., Resident #1's Health Care Agent (HCA) said that Resident #1 experienced a horrible physical and mental decline while at the Facility, that he/she was admitted for short term rehabilitation to recover his/her strength and then was to be discharged back home. The HCA said when Resident #1 went into the Facility, he/she was walking, talking and able to shower him/herself. The HCA said after being at the Facility for just over five weeks, he/she was just a shell of a human being, he/she was completely broken down, had lost weight, could not stand, was dead weight with transfers, needed to be cued with eating, and said he/she wouldn't even open his/her mouth. The Health Care Agent said when he saw Resident #1 on 02/11/21, he/she was looking down, not maintaining eye contact, wasn't talking, was confused and had no strength. The HCA said this was a dramatic change in Resident #1. The HCA said he told Facility Administration that he was taking Resident #1 home on 02/12/21. The HCA said Resident #1's personality and sense of usefulness had deteriorated. The Health Care Agent said when he brought Resident #1 home, he/she was lethargic and exhausted, and said three days later, Resident #1 felt lousy, was miserable and wanted to die. The HCA said Resident #1 was readmitted to the Hospital on 02/15/21, with [CONDITION(S)] (life threatening complication of an infection) due to an infection in his/her sacral pressure injury, that he/she developed while in the Facility.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure Resident #1 was free from the administration of unnecessary [CONDITION(S)] medications (medications that affect brain activity associated with mental processes and behavior). Upon admission to the Facility in January 2021, in addition to Resident #1 physician ordered medications, which include two [CONDITION(S)] medications, another patients hospital discharge medication list was included in Resident #1's Hospital discharge packet and as a result, three additional [CONDITION(S)] medications were ordered and administered, in error, to Resident #1 during his/her admission to the Facility, (for greater than 30 days). - Resident #1 received the medications [MEDICATION(S)] (anti-psychotic), [MEDICATION(S)] (anti-depressant), and [MEDICATION(S)] (anti-depressant), in error, while in the Facility, and as a result, he/she experienced a significant decline in medical and cognitive status that included increased lethargy, low blood pressures, poor appetite, and the development of pressure injuries. Also, as a result of the medication error not being identified while Resident #1 was in the Facility, he/she was subsequently discharged home on these medications. Resident #1 was readmitted to the Hospital 02/15/21 with [CONDITION(S)] (low blood pressure), tachycardia (a fast heart rate) and was diagnosed with septic shock (a blood infection) secondary to a large infected sacral pressure injury. Findings include: The Facility Policy, titled [CONDITION(S)] Medications, dated 10/17/18, indicated that in caring for residents with [CONDITION(S)] and behavioral health conditions, properly ordered [CONDITION(S)] medications may be used. [CONDITION(S)] medications are drugs that impact mood and behavior, included anti-psychotic drugs, anti-depressant drugs, and anti-anxiety drugs. Ensure that the residents receive appropriate care for [CONDITION(S)] and behavioral health conditions when appropriate. Residents receiving [CONDITION(S)] medications shall be monitored for effectiveness of the medication and for adverse reaction, with the results of such monitoring documented in the resident's record. Review of the Hospital Physician's Emergency Note, dated 01/04/21, indicated Resident #1 had a chief complaint of weakness with two falls at home, he/she called 911, traumatic imaging was negative, that Resident #1 appeared well and was in no apparent distress. The Note included a review of systems for a psychiatric history that indicated Resident #1 denied having anxiety or depression, found that Resident #1 was alert and oriented, and he/she had a normal affect (the emotional tone, a flat or blunted affect would be a common feature of a psychiatric disorder). Review of Resident #1's Hospital Emergency Department Nursing Assessment, dated 01/04/21, indicated he/she was oriented and cognitively intact with appropriate behaviors. The Hospital's Admitting Physician's Note, dated 01/05/21, indicated Resident #1 was a fairly good historian, and he/she reported decreased oral intake, malaise, fatigue, and weakness. The Note indicated Resident #1's active problem list did not include any psychiatric illnesses, and that he/she had a past medical history of depression. The Hospital Discharge Summary, dated 01/05/21, indicated Resident #1 would be discharged to a Nursing Home for rehabilitation services and would continue home medications without changes. Resident #1 was admitted to the Facility in January 2021, psychiatric diagnoses included anxiety. Review of Resident #1's Hospital Discharge Medication List, date 01/05/21, indicated he/she was to continue the following [CONDITION(S)] medications: - [MEDICATION(S)] (Remeron, anti-depressant), 15 milligrams (mg) at bedtime - [MEDICATION(S)] ([MEDICATION(S)], anti-anxiety), 0.25 mg twice a day and 0.25 mg twice a day as needed Review of Resident #1's Physician's Admission Orders, indicated that three additional [CONDITION(S)] medications were transcribed in error and entered into his/her electronic medical record on 01/06/21 at 4:54 A.M. by Nurse #4 and signed by the Physician on 01/07/21 at 11:54 A.M., which indicated to administer: - [MEDICATION(S)] 1 mg by mouth at 9:00 A.M. daily for an unspecified anxiety disorder - [MEDICATION(S)] 3 mg by mouth at 9:00 P.M. for an unspecified anxiety disorder - [MEDICATION(S)] 200 mg by mouth at 9:00 P.M. for [CONDITION(S)] (inability to sleep) - [MEDICATION(S)] 200 mg by mouth daily for depression Lexicom, an e-pharmacology reference, dated 2021, indicated that: - [MEDICATION(S)] (anti-psychotic medication) can cause significant sedation, orthostatic [CONDITION(S)] (low blood pressure), anticholinergic effects of confusion and [CONDITION(S)]. Geriatric considerations: the elderly have an increased risk of adverse (unwanted) effects, cognitive impairment, [CONDITION(S)] and falls. The initial oral dose, in the elderly of 0.5 mg is the usual starting dose. - [MEDICATION(S)] (anti-depressant medication, type an SSRI - selective serotonin reuptake inhibitor) can cause orthostatic [CONDITION(S)], fatigue, loss of strength and energy. [MEDICATION(S)] may cause anticholinergic effects of confusion and [CONDITION(S)]. This medication may cause depression like thoughts of suicide, agitation, irritability, behavioral changes or confusion. May cause cardiac arrhythmias (abnormal heart conduction or heart rate), may increase the risk of QT prolongation (a measurement of slow heart conduction) including ventricular tachycardia (a fast ineffective heart rate). Geriatric considerations: very sedating. The initial oral dose is 25 mg to 50 mg, with a gradual increase to a usual dose of 75 mg to 150 mg a day. - [MEDICATION(S)] (anti-depressant medication, type an SSRI) can cause orthostatic [CONDITION(S)], fatigue, loss of energy, emotional instability, agitation, irritability, behavioral changes or confusion, with a boxed warning that it may cause suicidality (suicidal thoughts about taking one's life). A warning related to adverse effects with QT prolongation and torsade de pointes (a life-threatening heart rhythm disturbance). The initial oral dose, in the elderly of 25 mg a day is the usual starting dose. During an interview on 04/27/21 at 10:15 A.M., the Admission Nurse said only the medication discharge list arrived from the Hospital with Resident #1. The Admission Nurse said she read the discharge medication list to the Nurse Practitioner over the telephone on 01/05/21 at approximately 7:00 P.M. and said the Nurse Practitioner approved the orders. The Admission Nurse said she did not check the resident name, date of birth, or hospital medical record number on each page to verify that all of the pages were Resident #1's medication list, before requesting the Nurse Practitioner to verbally approve Resident #1's medication orders. Review of the Admission Nurse's Written Witness Statement, dated 02/17/21, indicated that on 01/05/21, Resident #1 was admitted at night time (during the 3:00 P.M. to 11:00 P.M. shift) and she tried to have Resident #1 sign consent forms. The Statement indicated Resident #1 would not sign the admission consent forms at first, so she had a family member (the Health Care Agent) talk with Resident #1 on the phone to get him/her to sign the consents. The Statement indicated the Admission Nurse obtained signed consents for the [CONDITION(S)] medications on Resident #1's discharge medication list. Review of Resident #1's Informed Consent for [CONDITION(S)] Administration Form(s), signed and dated 01/05/21 at 11:00 P.M., indicated the Admission Nurse had Resident #1 sign consent forms for five different [CONDITION(S)] medications. Resident #1 signed consent forms for Facility staff to administer [MEDICATION(S)], [MEDICATION(S)], which were ordered by his/her physician. However, Resident #1 also signed consents for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], the three [CONDITION(S)] medications that were ordered for him/her as a result of a transcription error. During an interview on 04/30/21 at 11:23 A.M., Resident #1's Health Care Agent said he was called by the staff on 01/06/21 to speak with Resident #1 to convince him/her to take the medications he/she was refusing. The Health Care Agent said, at that time, he was not aware that the medications Resident #1 was refusing to take, were not his/her previous medications, and later learned they had been ordered for Resident #1 in error. Review of the Nurses Progress Note, written by the Admission Nurse, dated 01/06/21, indicated that Resident #1 continued to refuse medications and assessments. The Note indicated the Health Care Proxy was invoked, and the Social Worker will notify the Family Member (Health Care Agent). Review of Resident #1's Physician's orders, dated 01/06/21 at 11:54 A.M., indicated the Admission Nurse obtained an order to have Resident #1's Health Care Proxy invoked (which was 12 hours after he/she signed informed consents for five [CONDITION(S)] medications, three of which were ordered in error). During an interview on 04/27/21 at 4:45 P.M. and on 05/11/21 at 6:50 A.M., Nurse #4 said the Admission Nurse completed part of Resident #1's admission during the evening shift on 01/05/21, and left Resident #1's admission packet for her at the Nurses Station, so she could complete the rest of the admission during the overnight shift (11:00 P.M. to 7:00 A.M.). Nurse #4 said the Hospital sent four pages of a medication discharge list for Resident #1 that needed to be ordered and transcribed and put into the electronic record (e-record). Nurse #4 said she did not read the name on the top of each page of the medication lists to ensure that the medications were for the same resident (Resident #1). Nurse #4 said the medication list she used to transcribe Resident #1's medications did not include active diagnoses. Nurse #4 said when she entered Resident #1's admission medications orders in the electronic e-record on 01/06/21, (which include the three [CONDITION(S)] medications transcribed in error) Resident #1 did not have current or active diagnosis for some of the medications, so she searched and selected an appropriate diagnosis from the drop-down menu for each medication. Nurse #4 said Resident #1 did not have a current psychiatric diagnosis for the administration of [MEDICATION(S)], but said he/she had a past history of an unspecified anxiety disorder on his/her problem list, so she entered an unspecified anxiety disorder as the diagnosis for the use of [MEDICATION(S)]. Nurse #4 said Resident #1 did not have a current or active diagnosis for the administration of [MEDICATION(S)], but said he/she had a past history of [CONDITION(S)], so she entered [CONDITION(S)] as the diagnosis for the use of [MEDICATION(S)]. Nurse #4 said Resident #1 did not have current or active diagnosis for the administration of [MEDICATION(S)], but said he/she had a past history of depression, so she entered depression as the diagnosis for the use of [MEDICATION(S)]. Review of the Psychiatric Mental Health Consultation, dated 01/07/21, indicated Resident #1 was on very high doses of psychiatric medications for someone his/her age. The Consult indicated Resident #1's psychiatric history was unremarkable (no active psychiatric diagnoses to support the treatment with [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]). The Consult indicated the writer was unaware of any past history psychiatrically, but that Resident #1's medications are significantly high doses, even for a much younger person. The Consult indicated to monitor for any presence of [CONDITION(S)], [CONDITION(S)], depression or anxiety, will continue to monitor for any possible reduction in doses availability. The Consult indicated question of a possible dose reduction and follow up in two to three weeks (approximate revisit dates 01/21/21 through 02/02/21). Review of Resident #1's medical record indicated there were no specific medication recommendations made by the Psychiatric Consultant and there was no follow up psychiatric visit conducted, as indicated. During an interview on 05/11/21 at 8:00 A.M., the Administrator said that a follow up Psychiatric evaluation was not performed, although that would have been the expectation. During an interview on 05/11/21 at 10:44 A.M., the Physician said that he had assumed that the admission medications had been confirmed, said he did not review them, and said that he just signed off on the orders. The Physician said when starting [MEDICATION(S)] or [MEDICATION(S)], he would have ordered a baseline EKG (an electrocardiogram, to measure the electrical activity of the heart) for the QT prolongation, but said he was not aware these were new medications ordered for Resident #1 in error. Review of Interdisciplinary Progress Notes for Resident #1, dated 01/05/21 through 02/12/21, indicated that Resident #1 was sleepy or lethargic. Review of the Nurse Progress Note, dated 01/06/21 at 7:32 P.M., indicated that Resident #1 slept throughout the shift. Review of the Nurse Progress Note, dated 01/06/21 at 10:22 P.M., indicated Resident #1 was in bed most of the shift, and was unable to stay awake. The Note indicated Resident #1 refused supper, did not consumer the solid foods, but drank all the fluids. Review of the Nurse Progress Note, dated 01/11/21 at 5:51 A.M., indicated Resident #1 slept most of the 3:00 P.M. to 11:00 P.M. shift and also during the 11:00 P.M. to 7:00 A.M. shift. Review of the Nurse Progress Note, dated 01/14/21 at 10:41 P.M., indicated Resident #1 was unable to stay awake most of the 3:00 P.M. to 11:00 P.M. shift and all medications were held for sedation. The Note indicated Resident #1 did not eat his/her supper or snack. Review of the Physician Note, dated 01/14/21, indicated he was requested to see Resident #1 for lethargy, he/she was found to be lethargic, laboratory work ordered (no laboratory work abnormality was noted). Review of the Vital Signs Parameters, dated 01/18/21, indicated Resident #1 weighed 111.5 lbs, with his/her baseline weight on 01/05/21 noted as 117.7 lbs. at time of discharged from the Hospital. This indicated a weight loss of 5% in 13 days, after being admitted to the Facility. Review of the Nurse Progress Note, dated 01/25/21 at 9:05 P.M., indicated Resident #1 slept most of the 3:00 P.M. to 11:00 P.M. shift and was medication compliant. Review of the Nurse Progress Note, dated 01/26/21 at 2:38 P.M., indicated that Resident #1 was lethargic with decreased blood pressures of 88/50 and 90/50 (120/80 normal), changes in status were reported to the Nurse Practitioner. Review of the Nurse Practitioner's (NP) Note, dated 01/26/21 at 9:54 P.M., indicated that she was asked to evaluate Resident #1 for lethargy and [CONDITION(S)]. The NP Note indicated, Resident #1 was found to be more alert and awake than reported and blood pressure was 116/79. Review of the Nurse Practitioner's (NP) Note, dated 01/28/21, indicated that she was asked to examine Resident #1 for lethargy and [CONDITION(S)]. The NP's Note indicated Resident #1 was alert but drowsy and that his/her blood pressure was 90/50 (low). The NP's Note indicated upon assessment, Resident #1 had consistently low blood pressure in the morning, and was prescribed multiple medications that can cause drowsiness and lethargy in the morning. The NP Note indicated Resident #1 was being treated with [MEDICATION(S)] and [MEDICATION(S)] at night. The NP Note indicated Resident #1 was also being treated with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. The NP Note indicated to decreased Resident #1's [MEDICATION(S)] (beta blocker, treats high blood pressure) from 50 mg daily to 25 mg daily and to change the administration time of [MEDICATION(S)] 200 mg from at bedtime to the morning. Review of Resident #1's Medication Administration Record (MAR), dated 01/05/21 through 01/31/21, indicated while in the Facility, Resident #1 was administered the following medications in error: - [MEDICATION(S)] 1 mg by mouth daily - [MEDICATION(S)] 3 mg by mouth daily at bedtime - [MEDICATION(S)] 200 mg by mouth daily at bedtime - [MEDICATION(S)] 200 mg by mouth daily Review of Resident #1's MAR, dated 02/01/21 through 02/12/21, indicated while in the Facility, Resident #1 was administered the following medications in error: - [MEDICATION(S)] 1 mg by mouth daily - [MEDICATION(S)] 3 mg by mouth at daily bedtime - [MEDICATION(S)] 200 mg by mouth daily at bedtime - [MEDICATION(S)] 200 mg by mouth daily Review of Resident #1's Physical Therapy, Discharge Summary, dated 02/12/21, indicated that Resident #1's progress and response to treatment demonstrated a medical decline, that the plan of care and goals had been adjusted. The Summary indicated Resident #1's Health Care Agent (Family Member) was educated regarding Resident #1's status, with the Health Care Agent deciding to take him/her home due to the noted decline. During an interview on 04/07/21 at 12:20 P.M. and at 5:23 P.M., Resident #1's Health Care Agent (HCA) said that Resident #1 experienced a horrible decline at the Facility, that he/she had been admitted to the Facility for rehabilitation to recover his/her strength and then was to be discharged home. The HCA said that when Resident #1 went into the Facility, he/she was walking, talking and able to shower him/herself. The HCA said after being at the Facility for just over five weeks, he/she was just a shell of a human being, he/she was completely broken down, he/she had lost weight, was emaciated, could not stand, was dead weight with transfers, needed to be cued with eating, and said Resident #1 would not even open his/her mouth. The Health Care Agent said when he saw Resident #1 on 02/11/21, he/she was looking down, not maintaining eye contact, wasn't talking, was confused and had no strength. The HCA said this was a dramatic change in Resident #1. The HCA said he told the Facility Administration that he was taking Resident #1 home on 02/12/21. The HCA said Resident #1's personality and sense of usefulness had deteriorated. The HCA said Resident #1 should not have been on all of those [CONDITION(S)] medications, that he learned later that some of them were not his/her medications, and that when he/she was discharged , Resident #1 was still on all of those medications. The HCA said Resident #1 was subsequently lethargic and exhausted, and said three days after Resident #1 was discharged from the Facility, he/she felt lousy, was miserable and wanted to die.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure care and treatments provided to Resident #1 were conducted in accordance with professional standards of practice. As a result of a transcription error, Resident #1 was administered medications, from another patients hospital discharge medication list, that were not listed on his/her Hospital Discharge Summary, daily in error during his/her entire length of stay at the Facility, which contributed to his/her change in his/her mental status, and his/her significant decline in condition. - From 01/05/21 through 02/12/21, Resident #1 was administered five different [CONDITION(S)] medications, three of which were not on his/her Hospital Discharge Medication List, Resident #1 became increasingly lethargic, was unable to reposition him/herself, remained in bed, slept most of time across several shifts, had decreased nutritional intake, and developed two preventable pressure injuries, a right heel pressure injury, stage 2 (a partial-thickness injury which may be a blister, it is damage to the skin from remaining in one position for an extended period of time) and a sacral (low back) pressure injury, unstageable (a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (dead tissue). - On 02/03/21, Resident #1 had an elevated INR (International Normalized Ratio used to standardize prothrombin times, or how long it takes for blood to clot) of 14.6, (normal 2.0 to 3.0 range for [CONDITION(S)] fibrillation), and he/she required vitamin K injections (a reversal agent for [MEDICATION(S)]) to be administered. Two of the medications Resident #1 was administered in error, were SSRI (selective serotonin reuptake inhibitors) which can enhance the bleeding potential of [MEDICATION(S)] (anticoagulant medication), and therefore causing the significant increase in his/her INR, which also placed Resident #1 at risk for increased or uncontrolled bleeding with an injury. Findings include: According to the Facility's standard of practice resource, Clinical Nursing Skills and Techniques, Perry and Potter, 8th Edition, Safe Medication Preparation, indicated standards are actions that help ensure safe nursing practice. To prevent medication errors follow the six rights of medication administration. Many medication errors are linked to some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Medication errors often occur because one patient gets a drug intended for another patient. Therefore a key step in administering medications safely is being sure to give the right medication to the right patient. Acceptable patient identifiers include the patient's name, an identification number or date of birth assigned by the health care agency. Once identifiers are assigned to a patient a nurse uses them to match the patient with the patient name on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Lexicom, an e-pharmacology reference, dated 2021, indicated that: - [MEDICATION(S)] (anti-depressant medication, type an SSRI - selective serotonin reupdate inhibitor) can cause [CONDITION(S)], fatigue, loss of strength and energy, weight loss or weight gain and confusion. [MEDICATION(S)] increases the risk of bleeding if used with [MEDICATION(S)] or other anticoagulants (decreases blood clotting). Geriatric considerations: very sedating. - [MEDICATION(S)] (anti-depressant medication, type an SSRI) can cause [CONDITION(S)], fatigue, loss of energy, loss of appetite, emotional instability, agitation, irritability, behavioral changes or confusion. A significant adverse reaction is the increased bleeding risk. - [MEDICATION(S)] (anti-psychotic medication) can cause significant sedation, confusion, [CONDITION(S)] (low blood pressure), cognitive impairment and [CONDITION(S)]. - [MEDICATION(S)] (a medication for [CONDITION(S)], or urinary retention) a significant adverse reaction is [CONDITION(S)]. It can cause dizziness and drowsiness. Drug interactions when [MEDICATION(S)] is combined with antipsychotic agents, or blood pressure lowering agents, may enhance their hypotensive effects. Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Related to medication error and decline in condition: Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/23/21, indicated the following: - Resident #1 was given the wrong medications starting on 01/05/21 through to his/her discharge on 02/12/21. - The Hospital discharge medication list included a page with medications for another patient. - On admission to the Facility, six medications were transcribed in error on to Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - The Admission Nurse entered some of Resident #1's medication orders into the electronic medical record. - Nurse #4 then entered the remaining medication orders. - Resident #1's Healthcare Agent called the Facility on 02/11/21, concerned that Resident #1 had a decline in his/her condition since he/she was admitted to the Facility. - The Healthcare Agent decided to have Resident #1 discharged against medical advice on 02/12/21. - Resident #1 was readmitted to the Hospital 02/15/21. - Medication errors were not detected until 02/16/21, three days after Resident #1 was discharged . A Medication Variance Report, dated 02/23/21, indicated that on 01/05/21, a medication list of another patient was included in Resident #1's hospital discharge packet and during the Facility admission process, the medication reconciliation process was not followed. The Report indicated the variances identified were: - The wrong medication - The wrong resident - A transcription error - The Facility policy not being followed Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 1 milligram (mg) by mouth daily, (21 doses administered in error) - [MEDICATION(S)] 3 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 200 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 200 mg by mouth daily, (22 doses administered in error) - [MEDICATION(S)] 0.4 mg by mouth at bedtime, (22 doses administered in error) - [MEDICATION(S)] 20 mg by mouth every day, (22 doses administered in error) - [MEDICATION(S)] 18 micrograms daily via a hand-held inhaler, (21 days administered in error) Review of Resident #1 MAR, dated 02/01/21 through 02/12/21, indicated Resident #1 was administered, the following medications in error: - [MEDICATION(S)] 1 mg by mouth daily, (12 doses administered in error) - [MEDICATION(S)] 3 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 200 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 200 mg by mouth daily, (12 doses administered in error) - [MEDICATION(S)] 0.4 mg by mouth at bedtime, (10 doses administered in error) - [MEDICATION(S)] 20 mg by mouth every day, (10 doses administered in error) - [MEDICATION(S)] 18 mcg daily via a hand-held inhaler, (12 days administered in error) Review of the Nurse Progress Note, dated 01/26/21 (three weeks after admission), indicated at 7:30 A.M., Resident #1 was lethargic, his/her blood pressure was low at 88/50 (normal 120/80). The Note indicated Resident #1's blood pressure was rechecked at 7:45 A.M. and was 90/50 (low). Review of the Nurse Practitioner's (NP) Note, dated 01/28/21, indicated that she was asked to examine Resident #1 for lethargy and [CONDITION(S)]. The NP's Note indicated Resident #1 was alert but drowsy and that his/her blood pressure was 90/50 (low). The NP's Note indicated upon assessment, Resident #1 had consistently low blood pressure in the morning and was prescribed multiple medications that can cause drowsiness and lethargy in the morning. The NP Note indicated Resident #1 was also being treated with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. The NP Note indicated to decreased Resident #1's [MEDICATION(S)] (beta blocker, treats high blood pressure) from 50 mg daily to 25 mg daily and to change the administration time of [MEDICATION(S)] 200 mg from at bedtime to the morning. During an interview on 04/27/21 at 2:10 P.M., the Nurse Practitioner said that the [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] medications could cause the decrease in Resident #1's blood pressure and lethargy, but at the time of her evaluation, she was not aware that Resident #1 was on these medications in error, and said that his/her medication orders were continued. The Nurse Practitioner said if she knew that the antipsychotic and antidepressant medications caused his/her low blood pressure and decline in mental status, she would have discontinued those medications. Review of the Social Service Note, dated 01/07/21, indicated that Resident #1 lived in a first-floor apartment in town by him/herself and had home health services. The Note indicated the goal for Resident #1 was to return to his/her previous living arrangement, once clinical and rehabilitation goal had been met. Resident #1's Physical Therapy Discharge Summary, dated 02/12/21, indicated that since Resident #1's progress and response to treatment demonstrated a medical decline in the plan of care, goals had been adjusted. Educated Resident #1's Family Member (Health Care Agent, HCA) regarding Resident #1's status, with HCA deciding to take him/her home due to the noted decline. 2. Related to adverse effects of medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (anti-depressant medication, type an SSRI - selective serotonin reupdate inhibitor) can cause [CONDITION(S)], fatigue, loss of strength and energy, weight loss or weight gain and confusion. [MEDICATION(S)] increases the risk of Bleeding if used with [MEDICATION(S)] or other anticoagulants (decreases blood clotting). Geriatric considerations: very sedating. Review of the Interdisciplinary Progress Notes for Resident #1 from 01/05/21 through 02/12/21, indicated Resident #1 was prescribed [MEDICATION(S)] (an anti-coagulant, bleeding is the major adverse effect & SSRI medications enhance [MEDICATION(S)]), he/she had increased INRs laboratory values as follows: Review of the Nurse Progress Note dated, 01/25/21, indicated Resident #1 had an elevated INR of 3.6, [MEDICATION(S)] was held for one night. Review of the Nurse Progress Note dated, 02/03/21, indicated Resident #1 had an elevated INR of 14.6, a new order was obtained for a vitamin K injection (a reversal agent for [MEDICATION(S)]). The NP Note indicated Resident #1 was also being treated with [MEDICATION(S)] and [MEDICATION(S)] (anti-depressant medications, and both are SSRI - selective serotonin reupdate inhibitor). Both [MEDICATION(S)] and [MEDICATION(S)], increases the risk of bleeding if used with [MEDICATION(S)] or other anticoagulants (decreases blood clotting). However, there was no documentation to support that the Physician or the Nurse Practitioner considered that Resident #1's elevated INR could be attributed to the [MEDICATION(S)] and [MEDICATION(S)], both of which he/she was being administered in error. 3. Related to pressure injuries: Review of the Nursing Admission Assessment, dated 01/05/21, indicated Resident #1 had no pressure injuries on admission, and no skin issues were noted. The Norton Score (Skin Risk Assessment), dated 01/06/21, indicated Resident #1 triggered as high risk for skin breakdown and for the development of a pressure injury. Review of the Admission Minimum Data Set, dated dated [DATE], indicated that Resident #1, was severely cognitively impaired, required an extensive assist of one staff person for bed mobility, transfers and ambulation, and was frequently incontinent of urine. The MDS indicated Resident #1 had no unhealed pressure injuries or other wounds or skin problems, and indicated he/she was at increased risk for the development of pressure injuries. Review of the MDS, Care Area Assessment, dated 01/16/21, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Review of Resident #1's care plans, dated 01/05/21 through 02/12/21, indicated there was no documentation to support that the Facility developed or implemented a care plan related to his/her potential for altered skin integrity or increased risk for the development of a pressure injury. Review of the Skin Condition Record for Resident #1, dated 02/01/21, indicated he/she had developed a sacral pressure injury measuring 3.5 centimeters (cm) in length by 4.5 cm in width and 0 depth, with 100% slough in the wound bed with the surrounding tissue dark red to purple in color. Review of the Nurse Progress Note, dated 02/03/21 at 3:51 P.M., indicated Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin Condition Record for Resident #1, dated 02/03/21, indicated he/she had a Stage II, pressure injury to the right heel, measuring 3.5 cm in length by 6 cm in width and 0 depth, with a purplish intact blister. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her right heel pressure injury measured 5 cm in length by 7 cm in width and 0 depth, with an intact blood blister. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her sacral pressure injury measured 4.5 cm in length by 7.5 cm in width and 0 depth, with a dark red and black wound bed with the surrounding tissue dark red to purple in color. During an interview on 05/11/21 at 2:45 P.M., Unit Manager #1 said there was no evidence that the air mattress for healing the coccyx and heel pressure injury was actually ordered and applied to his/her bed. Review of Resident #1's medical record indicated there was no documentation to support and the Facility was unable to provide documentation to support that a care plan was developed or implemented related to his/her pressure areas and ongoing treatments. During an interview on 04/27/21 at 2:45 P.M., the Quality Assurance (QA) Coordinator said Resident #1 had no care plan for preventing pressure injury, or for promoting healing of a pressure injury. The QA Coordinator said there were no turning and positioning sheets. 4. Related to weight loss and loss of appetite: Review of the Interdisciplinary Progress Notes for Resident #1 from 01/05/2021 through 02/12/2021, indicated that Resident #1 refused food or left food untouched: Review of the Nurse Progress Note, dated 01/05/21 at 2:23 P.M., indicated Resident #1 refused nourishment. Review of the Nurse Progress Note, dated 01/06/21 at 10:22 P.M., indicated Resident #1 refused supper the solid food but drank all the fluids. Review of the Nurse Progress Note, dated 01/14/21 at 10:41 P.M., indicated Resident #1 did not eat his/her supper or snack. Review of the Nurse Progress Note, dated 01/25/21 at 9:05 P.M., indicated Resident #1 barely touched dinner, was not hungry. Review of the Nurse Progress Note, dated 01/29/21 at 4:07 P.M., indicated Resident #1 had a poor food intake during this shift. Review of Resident #1's Certified Nurse Aide (CNA) meal intake (percent consumed) flow sheets, dated 01/06/21 through 01/31/21, indicated that: - Approximately 49% of the meals were not documented, 37 meals out of 75 meals, flow sheet was left blank - Approximately 42% of the snacks were not documented, 21 snacks out of 50 snacks, flow sheet was left blank Review of Resident #1's CNA meal intake flow sheets, dated 02/01/21 through 02/12/21, indicated that: - Approximately 36% of the meals were not documented,13 meals out of 36 meals, flow sheet was left blank - Approximately 33% of the snacks were not documented, 8 snacks out of 24 snacks, flow sheet was left blank Review of the limited documentation of meal and snack intake for Resident #1, for January and February 2021, indicated he/she consumer 50% or less. During an interview on 05/11/21 at 8:55 A.M., the Dietician said that Resident #1's documented meal percent intake during his/her admission to the Facility was sub-optimal. The Dietician said a great deal of meal intake data was missing, (flow sheets were blank) which made it difficult for her to adequately monitor Resident #1 nutritional status or report a persistent decline in intake. Review of the Vital Signs Report, dated 01/05/21 through 02/12/21, indicated the weight recorded for Resident #1 on 01/19/21 was 158.2 lbs. The Dietician said staff did not obtain a weight for Resident #1 upon admission to the Facility as required per their policy, and said the weight of 158 lbs was not an accurate weight. The Dietician said that Resident #1's weight on 01/18/21 was 111.5 lbs (13 days after admission), and said that this was the only accurate weight performed during his/her stay in the Facility. The Dietician said that Resident #1 significant weight loss was not detected during his/her admission, because there was no baseline weight on admission (not until 12 days after admission, on 01/18/21) for comparison. The Dietician said she was not aware of Resident #1's low serum [MEDICATION(S)] levels of 2.2 gm/dl and 2.1 g/dl, because no one reported these [MEDICATION(S)] levels to her. During an interview on 04/07/21 at 12:20 P.M. and at 5:23 P.M., the Health Care Agent (HCA) said that Resident #1 was admitted to the Facility for short term rehabilitation to recover his/her strength and then was to be discharged back home. The HCA said Resident #1 went into the Facility walking, talking and able to shower him/herself, and said after being at the Facility for approximately five and a half week weeks, he/she was a just a shell of a human being. The HCA said Resident #1 experienced a horrible decline while at the Facility, that he/she was completely broken down, had lost weight, could not stand, was dead weight with transfers, needed to be cued with eating, and said he/she wouldn't even open his/her mouth. The HCA said when he saw Resident #1 on 02/11/21, he/she was not maintaining eye contact, was looking down, wasn't talking, was more confused and had no strength, that it was a dramatic change in him/her. The HCA said he told Facility Administration he was taking Resident #1 home on 02/12/21. The HCA said Resident #1 was neglected at the Facility, his/her whole personality and sense of usefulness had deteriorated. The HCA said two days after Resident #1 was discharge from the Facility, he/she felt lousy, was miserable and wanted to die. Review of the Hospice Physician's Home Care Note, dated 02/19/21, indicated that Resident #1 was eligible for hospice services due to his/her dramatic and precipitous change in condition. The Hospice Note indicated six weeks ago, he/she was living at home but fell (without injury) and went into a skilled nursing facility after a brief hospital stay. The Hospice Note indicated compared to six weeks ago, he/she has gone from walking with a walker to being bed-bound, from requiring only minimal assistance with dressing and bathing to being total assistance, from feeding him/herself to refusing food and only sipping liquids, and requiring feeding if he/she is amenable to eating.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission to the Facility in January 2021, was documented by nursing to have intact skin, and was assessed as being at increased risk for skin breakdown, the Facility failed to ensure he/she was provided with adequate treatment and services to prevent the development of pressure injuries, failed to ensure preventative devices were put in place and failed to ensure preventative measures were consistently implemented by staff to help prevent and promote wound healing. - On 02/01/21, Resident #1 was assessed by nursing to have a pressure injury on his/her sacral area measuring 3.5 centimeters (cm) in length by 4.5 cm in width and 0 depth, with 100% slough in the wound bed with the surrounding tissue dark red to purple in color. - On 02/03/21, Resident #1 was assessed by nursing to have a Stage II (a partial-thickness injury which may be a blister, it is damage to the skin from remaining in one position for an extended period of time) right heel pressure injury, measuring 3.5 cm in length by 6 cm in width and 0 depth, with a purplish intact blister. Findings include: The Facility Policy titled, Skin Integrity Management, dated 12/22/16, indicated that a comprehensive assessment is completed on every resident and the resident receives care, consistent with professional standards of practice to prevent pressure injuries and does not develop pressure injuries unless the resident's clinical condition demonstrates that they were unavoidable. Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Assessment, dated 01/05/21, indicated Resident #1 had no pressure injuries on admission, and no skin issues were noted. The Norton Score (Skin Risk Assessment), dated 01/06/21, indicated Resident #1 triggered as high risk for the development of a pressure injury. Review of the Admission Minimum Data Set, dated dated [DATE], indicated that Resident #1, was severely cognitively impaired, was an extensive assist of one staff person for bed mobility, transfers and ambulation, was frequently incontinent of urine, had no unhealed pressure injuries, other wounds or skin problems and was at increased risk for development of pressure injuries. Review of the MDS, Care Area Assessment, dated 01/16/21, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. During an interview on 05/11/21 at 8:15 A.M., the MDS Nurse said Resident #1 was at risk for developing a pressure injury, which was triggered by the Care Area Assessment. The MDS Nurse said that a pressure injury care plan was not developed or implemented for Resident #1, and said a care plan for pressure injury prevention should have been in place. Review of Resident #1's care plans, dated 01/05/21 through 02/12/21, indicated there was no documentation to support that the Facility developed or implemented a plan of care related his/her potential for altered skin integrity or increased risk for development of a pressure injury. Review of the Skin Condition Record for Resident #1, dated 02/01/21, indicated he/she had developed a sacral pressure injury measuring 3.5 cm in length by 4.5 cm in width and 0 depth, with 100% slough in the wound bed with the surrounding tissue dark red to purple in color. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Progress Note, dated 02/03/21 at 3:51 P.M., indicated Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin Condition Record for Resident #1, dated 02/03/21, indicated he/she had a Stage II, pressure injury to the right heel, measuring 3.5 cm in length by 6 cm in width and 0 depth, with a purplish intact blister. Review of Resident #1's Physician Orders, dated 02/03/21, indicated treatment to right heel pressure injury, nursing to apply skin prep, cover with foam, change weekly and as needed. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her right heel pressure injury measured 5 cm in length by 7 cm in width and 0 depth, with an intact blood blister. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her sacral pressure injury measured 4.5 cm in length by 7.5 cm in width and 0 depth, with a dark red and black wound bed with the surrounding tissue dark red to purple in color. During an interview on 05/11/21 at 2:45 P.M., Unit Manager #1 said that an air mattress would be used when there is a decline in the resident's function or when the resident is frail. Unit Manager #1 said when a resident is identified as requiring an air mattress the maintenance department is notified and they obtain and install the air mattress on the residents' bed Unit Manager #1 said the Head of Maintenance was notified that Resident #1 required an air mattress, but said nursing never followed through to ensure an air mattress was put in place. Unit Manager #1 said Resident #1 would have benefited from an air mattress to help promote healing of his/her sacral and right heel pressure injury areas. During the interview the Surveyor and Unit Manager #1 reviewed Resident #1's pressure injury documentation. Unit Manager #1 said Resident #1's sacral pressure injury wound bed had been covered with 100% slough, and was unstageable. Unit Manager #1 said Resident #1's sacral pressure injury, had not improved, had definitely become worse, and said the wound area had gotten larger from one week to the next week. Unit Manager #1 said Resident #1's the right heel pressure injury had also not shown signs of improvement, and said the right heel pressure injury had worsened and was larger. During an interview on 04/27/21 at 2:45 P.M., the Quality Assurance (QA) Coordinator said there were no care plan developed for Resident #1 for the prevention of developing a pressure injury, or for promoting healing of a pressure injury. The QA Coordinator said there were no turning and positioning sheets for Resident #1, to support he/she was repositioned by staff, to help prevent the development of pressure injuries. Review of the Resident #1's Pressure Ulcer Prevention Flow Sheets (completed by Certified Nurse Aides, CNA), for January 2021, indicated the following treatments were to be completed twice a day (once during the 7:00 A.M. to 3:00 P.M./day shift and once during either the 3:00 P.M. to 11:00 P.M./evening or 11:00 P.M. to 7:00 A.M./night shifts). Pressure Prevention for Heels, apply skin barrier cream to both heels twice a day: - documentation, dated 01/05/21 through 01/31/21, indicated the treatment was completed by the Day Shift only four days (01/10/21, 01/27/21, 01/28/21 and 01/29/21) out of a total of 27 days - documentation, dated 01/05/21 through 01/31/21, indicated the treatment was completed by the night and or evening shift one day (01/27/21) out of a total of 27 days Pressure Prevention for the coccyx, application of a skin barrier cream: - documentation, dated 01/05/21 through 01/31/21, indicated the treatment was completed by the Day Shift only six days (01/06/21, 01/08/21, 01/10/21, 01/27/21, 01/28/21 and 01/29/21) out of a total of 27 days - documentation, dated 01/05/21 through 01/31/21, indicated the treatment was completed by the evening shift eight days (01/20/21, 01/21/21, 01/23/21, 01/26/21, 01/27/21, 01/28/21, 01/29/21, and 01/30/21 ) out of a total of 27 days Review of the Resident #1's Pressure Ulcer Prevention Flow Sheets (completed by Certified Nurse Aides, CNA), for February 2021, indicated the following treatments were to be completed twice a day (once during the 7:00 A.M. to 3:00 P.M./day shift and once during either the 3:00 P.M. to 11:00 P.M./evening or 11:00 P.M. to 7:00 A.M./night shifts). Pressure Prevention for Heels, apply skin barrier cream to both heels twice a day: - documentation, dated 02/01/21 through 02/12/21, indicated the treatment was completed by the Day Shift only three days (02/04/21, 02/05/21, and 02/06/21) out of a total of 12 days - documentation, dated 02/01/21 through 02/12/21, indicated the treatment was completed by the evening shift one day (02/04/21) out of a total of 12 days. Pressure Prevention for the coccyx, application of a skin barrier cream: - documentation, dated 02/01/21 through 02/12/21, indicated the treatment was completed by the Day Shift only four days (02/03/21, 02/04/21, 02/05/21, and 02/06/21) out of a total of 12 days - documentation, dated 2/01/21 through 02/12/21, indicated the treatment was completed by the evening shift eight days (02/01/21, 02/02/21, 02/03/21, 02/04/21, 02/07/21, 02/10/21, 02/11/21, and 02/12/21) out of a total of 12 days. The Hospital Emergency Department Physician's Progress Note, dated 02/15/21, indicated Resident #1 presented with a large unstageable sacral pressure injury, which measured 9 cm in length by 5 cm in width and 3 cm in depth, extending to the level of the rectum with associated proctitis (the lining tissue of the inner rectum becomes inflamed). The Noted indicated Resident #1 was admitted to the Critical Care Unit due to septic shock (a severe infection which enters the blood stream), due to an infection in his/her sacral wound and was treated with two intravenous antibiotics.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose medical history included failure to thrive, the Facility failed to ensure Resident #1 nutritional status remained stable during his/her stay in the Facility. Resident #1's initial admission assessment did not include a baseline weight, and based on his/her Hospital discharge weight, he/she experienced an unplanned significant weight loss of 5% of his/her body weight within two weeks of being admitted to the Facility. Resident #1's [MEDICATION(S)] level (a marker that reflects rapid changes in nutritional status) was within normal limits upon transfer from the Hospital at 3.4 grams per deciliter normal (g/dl) (normal is 2.9 to 4.7 g/dl) and on 02/08/21, four days prior to discharge by his/her Health Care Agent, against medical advice, Resident #1's [MEDICATION(S)] level had decreased to 2.1 g/dl, abnormally low. Findings include: The Facility Policy titled, Weighing and Measuring the Resident, dated 10/01/10, indicated that residents will be weighed using a consistent scale on admission and at least monthly thereafter. A repeat weight will be obtained if weight is plus or minus three pounds from previous weight. The Facility Policy titled, Nutrition Management, dated 01/2017, indicated the following: - Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition. -Nutritional assessment and care planning will be completed by the interdisciplinary team. Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. -Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. -Document oral intake routinely, through meal observations. -Document percentage of food intake, administration of oral supplements, notification of status change in nurse's notes. Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Discharge Summary, dated 01/05/21, indicated Resident #1 had an approximate 24-hour admission to the Hospital for a fall at home without injury, general weakness and failure to thrive. The Summary indicated Blood Laboratory work completed on 01/04/21, noted his/her [MEDICATION(S)] level was normal at 3.4 g/dl. Review of the Nursing Admission Assessment, dated 01/05/21, indicated there was no documentation to support that Resident #1 was weighed on admission to the Facility. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she required physical assistance of one person with eating. The MDS indicated Resident #1's admission weight had not been documented. The Initial Nutritional History and Assessment, dated 01/18/21, indicated Resident #1's weight was 111.5 lbs and he/she was at nutritional risk for experiencing or having the potential for weight loss. Review of Resident #1's Certified Nurse Aide (CNA) meal intake (percent consumed) flow sheets, dated 01/06/21 through 01/31/21, indicated that: - Approximately 49% of the meals were not documented, 37 meals out of 75 meals, flow sheet was left blank - Approximately 42% of the snacks were not documented, 21 snacks out of 50 snacks, flow sheet was left blank Review of Resident #1's CNA meal intake flow sheets, dated 02/01/21 through 02/12/21, indicated that: - Approximately 36% of the meals were not documented,13 meals out of 36 meals, flow sheet was left blank - Approximately 33% of the snacks were not documented, 8 snacks out of 24 snacks, flow sheet was left blank Review of the limited CNA documentation of meal and snack intake for Resident #1, for January and February 2021, indicated he/she consumed 50% or less. During an interview on 05/11/21 at 8:55 A.M., the Dietician said that Resident #1's documented meal percent intake during his/her admission to the Facility was sub-optimal. The Dietician said a great deal of meal intake data was missing, (flow sheets were blank) which made it difficult for her to adequately monitor Resident #1 nutritional status or report a persistent decline in intake. Review of the Vital Signs Report, dated 01/05/21 through 02/12/21, indicated the weight recorded for Resident #1 on 01/19/21 was 158.2 lbs. However, this weight greatly differed and conflicted with weight in his/her Hospital Discharge Summary, dated 01/05/21, which indicated Resident #1 weighted 117.7 lbs. The Dietician said staff did not obtain a weight for Resident #1 upon admission to the Facility as required per their policy, and said the weight of 158 lbs was not an accurate weight. The Dietician's Note, dated 01/18/21, indicated Resident #1's intake was 50% to 75% at meals and he/she had an [MEDICATION(S)] level of 3.2 g/dl on 01/18/21, and said she started him/her on a protein supplement three times a day. Resident #1's Laboratory Work, dated 02/02/21 and 02/03/21, indicated he/she had an [MEDICATION(S)] level of 2.2 g/dl (low) and on 02/08/21 Resident #1's [MEDICATION(S)] level was 2.1 g/dl. The Dietician's Note, dated 02/04/21, indicated Resident #1's oral intake was poor at meals and he/she had skin breakdown on his/her heels, and was started on an additional protein supplement with lunch and dinner. The Dietician said that Resident #1's weight on 01/18/21 was 111.5 lbs (13 days after admission), and said that this was the only accurate weight performed during his/her stay in the Facility. The Dietician said that she was not aware that Resident #1's weight on 01/05/21, at the Hospital was 117.7 lbs. The Dietician said Resident #1 had a 6.2 lbs. weight loss, which was a significant weight loss of 5% of his/her body weight over a two week period of time. The Dietician said there were no further weights obtained on Resident #1 after 01/18/21, and that he/she was discharged on [DATE]. The Dietician said that Resident #1 significant weight loss was not detected during his/her admission, because there was no baseline weight on admission for comparison. The Dietician said she was not aware of Resident #1's low serum [MEDICATION(S)] levels of 2.2 gm/dl and 2.1 g/dl, because no one reported these [MEDICATION(S)] levels to her. Review of the Hospital's Critical Care Physician's Note, dated 02/15/21, indicated when Resident #1 was readmitted to the Hospital, Resident #1's weight was 106.7 lbs, which represented an 11 lbs weight loss, since his/her prior hospitalization (117.7 lbs on 1/05/21), and that he/she experienced a severe weight loss of 9%, over a period of approximately 41 days.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure nursing developed a comprehensive person-centered care plan with interventions and treatment goals for all identified areas of concern, and failed to ensure that care plan interventions were consistently implemented by staff, to help meet residents goals. - Upon admission to the Facility, Resident #1 was assessed by nursing to be at high risk for skin breakdown, there was no care plan developed to address this concern area and Resident #1 developed pressure injuries to his/her right heel and sacral area while in the Facility. After Resident #1 was found to have pressure injuries, the Facility failed to ensure a care plan, with interventions and goals, was developed and implemented to prevent further skin breakdown and help promote wound healing. Resident #1 pressure injuries worsened while in the Facility. - Resident #1's medical history included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility failed to ensure staff consistently implemented interventions from Resident #1's Nutrition care plan including monitoring weights and monitoring nutritional intake. Resident #1 had an unplanned significant weight loss of 5% of his/her body weight, while in the Facility. Findings include: 1. The Facility Policy titled, Care Planning, dated 10/09/19, indicated that the Facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Policy indicated the care plan will be developed within seven days after the Minimum Data Set (MDS) which forms the foundation of the comprehensive assessment for all residents in long term care, with the Care Area Assessment (CAA) provides for further assessment of triggered areas by guiding staff to look for causal or confounding factors that may be reversible for certain presenting conditions or issues. Resident #1 was admitted to the Facility in January 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Assessment, dated 01/05/21, indicated Resident #1 had no pressure injuries on admission, and no skin issues were noted. The Norton Score (Skin Risk Assessment), dated 01/06/21, indicated Resident #1 triggered as high risk for skin breakdown and for the development of a pressure injury. Review of the Admission Minimum Data Set, dated dated [DATE], indicated that Resident #1, was severely cognitively impaired, required an extensive assist of one staff person for bed mobility, transfers and ambulation, and was frequently incontinent of urine. The MDS indicated Resident #1 had no unhealed pressure injuries, no other wounds or skin problems, and indicated he/she was at increased risk for the development of pressure injuries. Review of the MDS, Care Area Assessment, dated 01/16/21, indicated pressure injury triggered as an area of concern for Resident #1 and to address the pressure injury risk with a care plan. Review of Resident #1's care plans, dated 01/05/21 through 02/12/21, indicated there was no documentation to support that the Facility developed or implemented a care plan related to his/her potential for altered skin integrity or increased risk for the development of a pressure injury. During an interview on 05/11/21 at 8:15 A.M., the MDS Nurse said Resident #1 was at risk for developing a pressure injury, which was triggered by the Care Area Assessment. The MDS Nurse said that a pressure injury care plan was not developed or implemented for Resident #1, and said a care plan for pressure injury prevention should have been in place. Review of the Skin Condition Record for Resident #1, dated 02/01/21, indicated he/she developed a sacral pressure injury measuring 3.5 centimeters (cm) in length by 4.5 cm in width and 0 depth, with 100% slough in the wound bed with the surrounding tissue dark red to purple in color. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated there was no documentation to support a care plan related to the presence of a new sacral area pressure injury was developed or implemented. Review of the Nurse Progress Note, dated 02/03/21 at 3:51 P.M., indicated Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin Condition Record for Resident #1, dated 02/03/21, indicated he/she had a Stage II (a partial-thickness injury which may be a blister, it is damage to the skin from remaining in one position for an extended period of time) pressure injury to the right heel, measuring 3.5 cm in length by 6 cm in width and 0 depth, with a purplish intact blister. Review of Resident #1's Physician Orders, dated 02/03/21, indicated treatment to right heel pressure injury, nursing to apply skin prep, cover with foam, change weekly and as needed. Review of Resident #1's medical record indicated there was no documentation to support that care plans related to the presence of a new right heel pressure injury or exiting sacral pressure injury, were developed or implemented. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her sacral pressure injury measured 4.5 cm in length by 7.5 cm in width and 0 depth, with a dark red and black wound bed with the surrounding tissue dark red to purple in color. Review of Resident #1's wound documentation, dated 02/08/21, indicated his/her right heel pressure injury measured 5 cm in length by 7 cm in width and 0 depth, with an intact blood blister. Review of Resident #1's medical record indicated there was no documentation to support that even as the condition of Resident #1's sacral and right heel pressure injuries worsened, that a care plan was developed or implemented. During an interview on 05/11/21 at 2:45 P.M. Unit Manager #1 said Resident #1 did not have a care plan related to his/her risk for skin breakdown and said a care plan was not put in place after he/she developed pressure injuries. During an interview on 04/27/21 at 2:45 P.M., the Quality Assurance (QA) Coordinator said Resident #1 did not have a care plan for preventing a pressure injury, or for promoting healing of a pressure injury. 2. The Facility Policy titled, Weighing and Measuring the Resident, dated 10/01/10, indicated that residents will be weighed using a consistent scale on admission and at least monthly thereafter. The Policy indicated a repeat weight will be obtained if weight is plus or minus three pounds from previous weight. The Facility Policy titled, Nutrition Management, dated 01/2017, indicated that Residents will receive care and services to ensure acceptable parameters of nutritional status are maintained to the extent possible as indicated by the resident's clinical condition. The Policy indicated the following: -Nutritional assessment and care planning will be completed by the interdisciplinary team. -Staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. -Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. -Document oral intake routinely, through meal observations. Document percentage of food intake, administration of oral supplements, notification of status change in nurse's notes. Review of the Nursing Admission Assessment, dated 01/05/21, indicated there was no documentation to support that Resident #1 was weighed on admission to the Facility. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated he/she required physical assistance of one person with eating. The MDS indicated Resident #1's admission weight had not been documented. The Nutrition Care Plan, dated 01/18/21, indicated Resident #1 was at risk for an altered nutritional status secondary to cognitive impairment and failure to thrive. The Care Plan indicated nutritional interventions included: - to monitor intake at all meals - alert the dietician and physician of any decline - document the percentage of meal and snack intake - weight per the physician order, if persistent weight loss occurs notify the Physician and the Dietician Review of Resident #1's Certified Nurse Aide (CNA) meal intake (percent consumed) flow sheets, dated 01/06/21 through 01/31/21, indicated that: - Approximately 49% of the meals were not documented, 37 meals out of 75 meals, flow sheet was blank - Approximately 42% of the snacks were not documented, 21 snacks out of 50 snacks, flow sheet was blank Review of Resident #1's CNA meal intake flow sheets, dated 02/01/21 through 02/12/21, indicated that: - Approximately 36% of the meals were not documented,13 meals out of 36 meals, flow sheet was blank - Approximately 33% of the snacks were not documented, 8 snacks out of 24 snacks, flow sheet was blank Review of the limited CNA documentation of meal and snack intake for Resident #1, for January and February 2021, indicated he/she consumed 50% or less at most meals. During an interview on 05/11/21 at 8:55 A.M., the Dietician said that Resident #1's documented meal percent intake during his/her admission to the Facility was sub-optimal. The Dietician said a great deal of meal intake data was missing, (flow sheets were blank) which made it difficult for her to adequately monitor Resident #1 nutritional status or report a decline in intake. Review of the Vital Signs Report, dated 01/05/21 through 02/12/21, indicated the weight recorded for Resident #1 on 01/19/21 was 158.2 pounds (lbs). However, the Initial Nutritional History and Assessment, dated 01/18/21, indicated Resident #1's weight was 111.5 lbs and he/she was at nutritional risk for experiencing or having the potential for weight loss. During an interview on 05/11/21 at 8:55 A.M., the Dietician said that on admission to the Facility, Resident #1 was not weighed, as required per their policy, and said the weight of 158.2 lbs on 01/19/21, was not an accurate weight. The Dietician said that Resident #1's weight on 01/18/21 was 111.5 lbs (13 days after admission), and said that was was the only accurate weight performed during his/her length of stay. The Dietician said there were no further weights obtained for Resident #1 after 01/18/21. The Dietician said that she was not aware that Resident #1's weight on 01/05/21, at the Hospital was 117.7 lbs. The Dietician said Resident #1 had a 6.2 lbs. weight loss, a significant weight loss of 5% of his/her body weight, in a 2 week period (from 01/05/21 to 01/18/21) while at the Facility. Review of the Hospital's Critical Care Physician's Note, dated 02/15/21, indicated when Resident #1 was readmitted to the Hospital (02/15/21), Resident #1's weight was 106.7 lbs, which represented an 11 lbs weight loss (117.7 lbs on 01/05/21) since prior hospitalization , and a severe weight loss of 9% over approximately 41 days.

Based on record review and interview, the facility failed to ensure services provided met professional standards of quality by ensuring physician orders [REDACTED].#71), in a total sample of 35 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Title: Accepting, Verifying, Transcribing and Implementing Prescriber Orders, Advisory Ruling Number: 9324 Authority: The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.[NAME]L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and M.[NAME]L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. In addition, M.[NAME]L. c. 30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board. Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency. The Board's regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice. Date Issued: (MONTH) 22, 1993 Date Revised: (MONTH) 10, 2002; (MONTH) 9, 2009, (MONTH) 8, 2014, (MONTH) 11, (YEAR) Purpose: To guide the practice of Registered Nurses and Licensed Practical Nurses when accepting, verifying, transcribing, and implementing patient care orders from a duly authorized prescriber (i.e., Advanced Practice Registered Nurses with prescriptive authority, Physician Assistants, and Physicians). Indicates in part: All Medication Orders Minimum required elements: The minimum elements required for inclusion in a complete medication order include - Patient/client/resident/student's full name; - Name of the medication; - Dose and route of the medication; - Frequency of the medication administration; - A valid medication order date; - Specific directions for administration; - Signature of the duly authorized prescriber; and - Signature of the individual accepting/verifying the order Resident #71 was admitted to the facility in 4/2017 and had multiple [DIAGNOSES REDACTED]. Record review indicated a physician order, dated 7/2/19, to administer [MEDICATION NAME] (opioid pain medication) 5 milligram (mg) by mouth (PO), every 4 hours as needed (PRN). Further review indicated a physician order, dated 7/4/19, to administer [MEDICATION NAME] (opioid pain medication) 5 mg every 4 hours PO/sublingual (SL-under the tongue) for pain. Review of the 7/2019 Medication Administration Record [REDACTED]. Review of a nurses note dated 7/9/19 00:21 [NAME] M., indicated at the beginning of the shift (7/8/19, 3:00 P.M. - 11:00 P. M.), the resident exhibited signs and symptoms of great pain and discomfort in ribs and was yelling out. PRN [MEDICATION NAME] 5 mg and [MEDICATION NAME] 5 mg were administered at 5:20 P.M. At approximately 8:20 P.M., the resident was noted to have signs and symptoms of shortness of breath and a pulse oxygen saturation (the measurement of oxygen level in the blood) in the upper 70's (pulse oxygen levels under 90 are considered low). The resident was also sluggish in response to verbal stimuli. The nurse practitioner was notified and ordered the resident to be transported to the emergency room (ER) for an evaluation. Review of the hospital emergency progress note, dated 7/8/19, indicated opioid overdose. Additional instructions indicated it would appear the resident was overmedicated resulting in depressed respiratory rate and [MEDICAL CONDITION] (not enough oxygen reaching the tissues) reversed with [MEDICATION NAME] (an opioid reversal agent). Avoid similar opioid medications dosing to prevent overmedication. During an interview and review of physician orders [REDACTED].#5 on 10/17/19 at 8:26 [NAME]M., she said the resident had two different opioid medications, [MEDICATION NAME] and [MEDICATION NAME], and both were scheduled every 4 hrs PRN for pain. UM #5 said the orders did not include which medication should be used for moderate pain or for severe pain. UM #5 said the orders should have included indications for use. During an interview with the Director of Nurses (DON) on 10/17/19 at 2:51 P.M., she said the [MEDICATION NAME] 5 mg and [MEDICATION NAME] 5 mg were ordered for every 4 hrs PRN. The DON said the expectation would be that each order would have clarification/parameters for when to provide which medication, such as pain level moderate or severe, and there were none. The DON said the resident was administered both medications at 5:20 P.M. on 7/8/19 and was transferred to the ER for an evaluation due to a change in condition. The DON said that the expectation would be that after the nurse administered a dose of the pain medication, the nurse should wait a minimum of 30 minutes to assess the effect before administering additional medication. The DON said the nurse in this situation did not do that and should not have administered both opioid/narcotic medications at the same time. Please refer to F760

Based on interview and record review, the facility failed to prevent a significant medication error, when two opioid pain medications were administered at the same time, resulting in an adverse drug reaction that required one Resident (#71), to be transferred to the hospital emergency department for evaluation and required treatment with [MEDICATION NAME] (an opioid reversal agent), in a total sample of 35 residents. Findings include: Resident #71 was admitted to the facility 4/2017 and had multiple [DIAGNOSES REDACTED]. Record review indicated a physician order, dated 7/2/19, to administer [MEDICATION NAME] (opioid pain medication) 5 milligram (mg) by mouth (PO), every 4 hours as needed (PRN). Further review indicated a physician order, dated 7/4/19, to administer [MEDICATION NAME] (opioid pain medication) 5 mg every 4 hours PO/sublingual (SL-under the tongue) for pain. Review of a nurses note dated 7/9/19, 00:21 indicated at the beginning of the shift, the resident exhibited signs and symptoms of great pain and discomfort in ribs and was yelling out. PRN [MEDICATION NAME] 5 mg and [MEDICATION NAME] 5 mg were administered at 5:20 P.M. At approximately 8:20 P.M., the resident was noted to have signs and symptoms of shortness of breath and a pulse oxygen saturation (the measurement of oxygen level in the blood) in the upper 70's (pulse oxygen levels under 90 are considered low). The resident was also sluggish in response to verbal stimuli. The nurse practitioner was notified and ordered the resident to be transported to the emergency room (ER) for an evaluation. Review of the hospital emergency progress note, dated 7/8/19, indicated opioid overdose. Additional instructions indicated it would appear the resident was overmedicated resulting in depressed respiratory rate and [MEDICAL CONDITION] (not enough oxygen reaching the tissues) which was reversed with [MEDICATION NAME] (an opioid reversal agent). Avoid similar opioid medication dosing to prevent overmedication. During an interview with the Director of Nurses (DON) on 10/17/19 at 2:51 P.M., she said the resident was provided both medications at 5:20 P.M. on 7/8/19 and was transferred to the ER for an evaluation. The DON said that the expectation would be that only one opiod medication would be provided at a time and allow time for the medication to take effect. The DON said the nurse should wait a minimum of 30 minutes to assess the effect of the medication and move forward based on that assessment. The DON said the nurse in this situation did not do that and should not have administered both opioid/narcotic medications at the same time.

Based on observations, record reviews and interviews, the facility staff failed to address a decline in one Resident (#387) after a fall,out of a total sample of 37 residents. Findings include: For Resident #387, the facility staff failed to address an increase in pain and decrease in mobility, causing a delay in treatment. Resident #387 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 7/13/18, indicated that the Resident had moderate cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the clinical record indicated the resident sustained [REDACTED]. The Resident had gotten out of bed to throw something in the trash can, became dizzy and fell to the floor. The Resident hit his/her head and was transferred to the hospital for complaints of neck pain. In the emergency room , the Resident received 3 staples to the left side of the neck due to a laceration. Upon return to the facility, the Resident was working with Physical Therapy for transfers, bed mobility and ambulation. Review of the Physical Therapy Note, dated 7/12/18, indicated that the Resident had complaints of pain, especially when putting his/her left foot onto the plate of the wheelchair. The note further indicated that complaints of pain were reported to nursing to further assess knee pain. Review of Nurse's Note, dated 7/12/18, did not address the Resident's complaint of knee pain that occurred during the Physical Therapy session. Review of the Physical Therapy Note, dated 7/19/18, indicated that the Resident had hesitation to bear weight through left lower extremity and had complaints of left hip pain and a request was made to nursing for a hip X-ray. Further review of the Physical Therapy note indicated that the Resident's pain, hesitation to bear weight and the request for an x-ray were reported to the nurse. Review of Nurse's Note, dated 7/19/18, indicated that the note did not address the Resident's complaint of left hip pain or the request for an X-ray. Review of the Physical Therapy Note, dated 7/20/18, indicated that the therapist reported to the Clinical Care Coordinator (CCC) a recommendation for an X-ray of the Resident's left hip, be ordered secondary to pain and the Resident was noted to be offloading while in sitting position. The note further indicated the CCC reported that the Nurse Practitioner (NP) would write an order for [REDACTED].>Review of the Nurse's Note, dated 7/20/18, did not address the therapy recommendation for a hip X-ray. Review of the Physical Therapy Note, dated 7/24/18, indicated that the Resident was off loading on left lower extremity due to increased pain in standing and no X-ray completed to this date. The Physical Therapist spoke with the Resident's Nurse regarding request for a left hip X-ray, as discussed, secondary to increased left hip pain when standing. Review of the Nurse's Note, dated 7/24/18, indicated that the nurse's note did not address the therapy recommendations. Review of the Physical Therapy Note, dated 7/25/18, indicated that the Resident was making slow progress in therapy. This was conveyed to the CCC and the CCC stated that the Resident might be a candidate to be transferred to another unit in the facility. Review of the Physician's Note, dated 7/26/18, indicated that the Resident was gradually improving and there were no other issues for review. Review of the Nurse Note, dated 7/31/18, indicated the Resident had an increase of behaviors by yelling out. The Resident was medicated with [MEDICATION NAME] (an antipsychotic) and continued to yell out until he/she fell asleep. Review of the Physician Note, dated 8/2/18, indicated that on 8/1/18 the Resident complained of left lower extremity pain with weight bearing during therapy session and an X-ray of the left hip was completed. The x-ray indicated that the resident sustained [REDACTED]. The Physician Note further indicated that it was unclear when the trauma occurred and there were no symptoms or signs of left leg trauma leading up to 8/1/18. Review of the facility Physician Notification policy, dated (11/11/09), indicated upon identification of a change in condition, the Protocols for Physician Notification may be used as a reference to help determine urgent or routine identification. Clinician judgment and resident baseline should always be the primary determinate of the timing of physician notification. During an interview on 8/718 at 1:06 P.M., Unit Manager (UM) #5 (who was also the CCC) said she could not recall being asked by Physical Therapy to have a hip X-ray ordered for Resident #387 due to increase in pain and decrease in mobility during therapy sessions. UM #5 could not provide any other information to the Surveyor concerning the reported decline in status for Resident #387.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was at increased risk for injury due to left sided neglect (a neuropsychological condition in which damage to one side of the brain is sustained and there is a deficit in attention and awareness of the one side of the body, inability to perceive stimuli on one side of the body), the Facility failed to provide adequate supervision and monitoring to prevent an accident, with the application and use of a Facility supplied heat pack, which resulted in Resident #1 sustaining a second degree burn (partial thickness loss of skin) which required medical treatment. Findings include: The Facility Policy titled, Use of Heat Pack and Warm Compress, dated 11/1/11, indicated that the purpose of the heat pack application was to promote comfort or softening of tissue. The instructions were to gather supplies, an instant heat pack and an outer covering (i.e. towel); activate the pack, per manufacturer's instructions on the heat pack; wrap the pack in the towel; place on desired area for no greater than 30 minutes; document the date, time and initials on the Treatment Administration Record; document observations and condition of the skin and the Residents response to procedure. The Facility's guidance for nursing practice, Clinical Nursing Skills and Techniques, dated 2014, indicated that one of the adverse outcomes of heat application [MEDICAL CONDITION] increased pain. The Safety Guidelines included; -[MEDICAL CONDITION] hot therapies are preventable events. - Know your resident's risk for injury from heat. Certain residents are more predisposed to injury than others. Never position residents so they cannot move away from the temperature source. - Areas that have decreased fat and underlying tissue are more sensitive than others to temperature extremes. - Do Not leave a patient unattended if he/she is unable to sense temperature changes or move away from the temperature source, you are responsible for the residents' safety. - Check the resident frequently during a heat application. The condition of the skin indicates whether tissue injury is occurring. Manufacturers guidelines for the Heat pack referred to as an Instant Hot Compress, indicated the following; - After rupturing the large pouch, measuring 6 inches by 9 inches (approximately 15 centimeters (cm) by 23 centimeters), wrap the pouch in a soft cloth or towel and apply to the affected site. - Caution: The Peak temperature may reach 160 degrees once activated. - Avoid contact with skin, use cloth or towel for protection. - Do Not use for more than 30 minutes. A Facility report, dated 1/8/18, via the Health Care Facility Reporting System (HCFRS) indicated, the Facility reported that on 1/7/18, Resident #1 sustained a second degree burn to his/her upper back, which was treated with [MEDICATION NAME]. Resident #1 was admitted to the Facility in 12/2017 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment Form, dated 1/5/18, indicated that Resident #1 was moderately cognitively impaired, and required an extensive assist for bed mobility and transfers and was non-ambulatory. The Situation, Background, Assessment, Recommendation (SBAR) Note, dated 1/7/18, indicated Resident #1 was upset with increased shoulder and left rib pain, which started after a fall on 1/6/18. Nurse #1 (who worked the 7:00 A.M. to 3:00 P.M. shift that day) obtained physician orders [REDACTED]. The Physicians Order for Resident #1, dated 1/7/18, indicated may apply a heat pack as needed for pain (to the left upper back, the side which, had weakness and neglect). The Treatment Administration Record for Resident #1, dated 1/7/18, indicated a heat pack was applied on the 7:00 A.M. to 3:00 P.M. shift. The Facility's Internal Investigation, dated 1/7/18, documented by Nurse #1, indicated that on 1/7/18 at approximately12:00 noon, Nurse #1 was called to Resident #1's room by the Certified Occupational Therapist. While the Certified Occupational Therapist (and Physical Therapy Assistant) were washing and dressing Resident #1, there was a large reddened area observed on his/her left upper back. The Social Services Note, dated 1/7/18, indicated Resident #1 complained that the hot pack was too hot and it was removed. The Surveyor interviewed Social Worker #2 at 3:15 P.M. on 4/2/18. Social Worker #2 said that Resident #1 was emaciated (abnormally thin) and on 1/7/18, Resident #1's call bell was on and she answered it. Social Worker #2 said Resident #1 told her the heat pack was too hot and he/she was unable to remove the heat pack from his/her back. Social Worker #2 said Resident #1 was lying in bed on his/her back at an approximate 45 degree angle, with a heat pack between him/her and the bed. Social Worker #2 said she removed the heat pack from Resident #1's back, which was not in a pillow case or any other type of protective covering. Social Worker #2 said she reported Nurse #1, the nurse assigned to Resident #1, of his/her complaint that the heat pack was too hot. Review of Resident #1's medical record indicated there was no Nurse Progress Note written on 1/7/18 from the 7:00 A.M. to 3:00 P.M. shift, by Nurse #1 for the initial placement and/or ongoing monitoring of Resident #1's skin for the use of the heat pack treatment. The Physical Therapy Note, dated 1/7/18, indicated Resident #1 complained of a burning sensation in the left shoulder and there was a reddened area on this/her left shoulder. This new area was reported to Resident #1's nurse (Nurse #1) to assess area. The Note indicated there was a question of a possible burn, on Resident #1's left upper back. The Surveyor interviewed Physical Therapy Assistant #1 at 12:06 P.M. on 3/29/18. Physical Therapy Assistant #1 said that Resident #1 had left sided neglect due to [MEDICAL CONDITION] with surgical resection. Physical Therapist Assistant #1 said Resident #1 told her that a staff employee put something on his/her back that was burning him/her. Although Resident #1 was confused he/she perseverated and was upset about this new burning sensation. Physical Therapy Assistant #1 said she observed on Resident #1's upper scapula (back) a large area of redness which measured approximately 16 cm in width and 12 cm in length. Physical Therapy Assistant #1 said Resident #1 said that he/she was telling the staff to take it off because it was hurting him/her. The Certified Occupational Therapy Note, dated 1/7/18, indicated that Resident #1 reported he/she had a burning sensation in the left shoulder and observed a large reddened area and that nursing was present. The Note indicated that the Nurse (identified as Nurse #1) said she would follow up. The Surveyor interviewed Occupational Therapist Assistant #1 at 12:30 P.M. on 3/29/18. Occupational Therapist Assistant #1 said resident considerations for safe application of a heat pack would be to supervise the resident by staying with him/her during the heat pack treatment, to over layer with protective covering the heat pack to prevent a burn especially if the resident had neglect like Resident #1 did and to monitor the resident's skin for signs and symptoms of a burn every five minutes during the heat treatment. Review of the Internal Investigation, indicated that the body diagram on the investigation report, indicated the area circled for redness was large and the circled area covered the entire left scapula (shoulder blade), although written next to that diagram was, 3 cm - 2 cm (approximately 1 inch x 1 inch), indicating the smaller size of the reddened area. (This is not consistent with account of the staff who witnessed the burn of 1/7/18.) The Investigation Summary, undated, indicated from the incident of 1/7/18, Resident #1 had a pink area with a thin yellow blister from a disposable heat pack. The Summary indicated, Nurse placed the heat pack inside a pillow case and applied it to Resident #1's left upper back. The Summary indicated, the Nurse returned in about 30 minutes to remove the heating pack and the burn was then discovered. (This is not consistent with staff interviews and medical record documentation.) The physician's orders [REDACTED].#1's paralyzed side). The Physician's Note, dated 1/8/18, indicated Resident #1 had a blister on the left scapular area, he/she was using a heat pack and remained on [MEDICATION NAME] (a steroid medication) which can thin and make skin frail and the skin can easily become injured. The physician's orders [REDACTED]. Resident #1 had a new dressing change order to apply to the left shoulder blade, normal saline, pat dry then apply skin prep to any intact blisters and [MEDICATION NAME] 1% cream to open blisters and cover with a dry dressing, change twice a day. Review of Resident #1's Treatment Administration Record for (MONTH) (YEAR) indicated, Resident #1 required treatment to the burn area twice daily from 1/7/18 through 1/11/18. The Surveyor interviewed Nurse #1 at 11:10 on 3/29/18. Nurse #1 said that on 1/7/18 she was Resident #1's Nurse during the 7:00 A.M. to 3:00 P.M. shift. Nurse #1 said that Resident #1 had excruciating back pain from a fall on 1/6/18 at 2:00 A.M. and she obtained a physician's orders [REDACTED]. Nurse #1 said that on 1/7/18 at approximately 9:30 A.M., she went to put the heat pack on Resident #1, she said that the insulating protective cover for the heat pack was not available, so she put the heat pack in a pillow case and applied the heat pack under Resident #1's upper back as he/she laid on the heat pack in bed at a 45-degree angle. Nurse #1 said that she knew Resident #1 was confused on 1/7/18 and she should not have left him/her unsupervised when she applied the heat pack. Nurse #1 said she returned to Resident #1's room at approximately 10:00 A.M., 30 minutes later and Resident #1's skin under the heat pack was slightly pinkish, but since the heat pack was still warm, she did not remove the heat pack from Resident #1's back (which was not consistent with the Facility's policy or manufacturers guidelines for Heat Packs to be removed after 30 minutes). Nurse #1 said she left the room and had not returned to check on Resident #1 again, until she was requested to come to the Resident #1's Room by Certified Occupational Therapy Assistant #1 and Physical Therapy Assistant #1 to assess Resident #1's skin, around approximately 12:00 noon (2 hours later). Nurse #1 said the new area of redness was large, (she held her hands out to demonstrate the size of the red area) without a blister until 1/8/18. The Surveyor measured the position of Nurse #1's hands and stated the width and length was 16 centimeters (cm) in length by 12 centimeters in width (approximately 6 inches by 5 inches). Nurse #1 said once the redness was identified at the site of the heat pack application and Resident #1 complained of tingling, she notified the Physician of the burn and obtained an order for [REDACTED]. Nurse #1 said she did not document initial observations and monitoring of Resident #1's skin or Resident #1's response to procedure, as per the Facility policy when using a heat pack.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice, for assessing, monitoring and implementing interventions to prevent a second-degree burn (a partial thickness destruction of tissue) to the left upper back from a Facility supplied heat pack. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Manufacturers guidelines for the Heat pack referred to as an Instant Hot Compress, indicated that after rupturing the large pouch, measuring 6 inches by 9 inches (approximately 15 centimeters (cm) by 23 centimeters) to do the following; - Wrap the pouch in a soft cloth or towel and apply to the affected site. - Caution: The Peak temperature may reach 160 degrees once activated. Avoid contact with skin, use cloth or towel for protection. -Do Not use for more than 30 minutes. The Facility's guidance for nursing practice, Clinical Nursing Skills and Techniques, dated 2014, indicated that one of the adverse outcomes of heat application [MEDICAL CONDITION] increased pain. The reference indicated, although a resident may initially feel a temperature extreme, once sensory receptors adapt, he/she may become unaware of any temperature variation. Eventually excessive heat causes a burning sensation before pain is sensed. Because of this physiological phenomenon, there is a high risk for tissue injury from heat applications. Certain residents have a greater risk for injury from heat applications, the clinician plays an important role in maintaining resident safety in the application of heat. The reference also indicated the following; - Consider the resident's skin, ability to sense temperature and ability to communicate before applying heat therapy. - Know your resident's risk for injury from heat. Certain residents are more predisposed to injury than others. Never position residents so they cannot move away from the temperature source. -Prevent the heated surface from touching the Resident's skin directly and increasing the risk for injury to the resident's skin. - Never position the resident so he/she is lying directly on the heat pack. This position prevents dissipation of heat and increases the risk for burns. - Monitor the condition of the skin over the site every 5 minutes and ask the resident about the sensation of burning. - Determine if the heat exposure is causing a burn. The Facility Policy titled, Use of Heat Pack and Warm Compress, dated 11/1/11, indicated that the purpose of the heat pack application was to promote comfort or softening of tissue. The instructions were to gather supplies, an instant heat pack and an outer covering (i.e. towel); activate the pack, per manufacturer's instructions on the heat pack; wrap the pack in the towel; place on desired area for no greater than 30 minutes; document the date, time and initials on the Treatment Administration Record; document observations and condition of the skin and the residents response to procedure. Resident #1 was admitted to the Facility in 12/2017 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment Form, dated 1/5/18, indicated that Resident #1 was moderately cognitively impaired, required an extensive assist for bed mobility and transfers and was non-ambulatory. The Situation, Background, Assessment, Recommendation (SBAR) Note, dated 1/7/18, indicated Resident #1 was upset with increased shoulder and left rib pain, which started after a fall on 1/6/18. Nurse #1 (who worked the 7:00 A.M. to 3:00 P.M. shift that day) obtained physician orders [REDACTED]. The Physicians Order, for Resident #1, dated 1/7/18, indicated may apply a heat pack as needed for pain (this was to the left upper back, the side which, had weakness and neglect). The Treatment Administration Record, dated 1/7/18, (for the 7:00 A.M. to 3:00 P.M. shift) indicated a heat pack was applied. The Social Services Note, dated 1/7/18, indicated Resident #1 complained that the heat pack was too hot and it was removed. The Surveyor interviewed Social Worker #2 at 3:15 P.M. on 4/2/18. Social Worker #2 said that Resident #1 was emaciated (abnormally thin) and on 1/7/18, Resident #1 told her (Social Worker #2) that he/she was unable to remove the heat pack from his/her back and that the heat pack was too hot. Social Worker #2 said that Resident #1 was lying in bed on his/her back at an approximate 45-degree angle, with a heat pack between Resident #1 and the bed. Social Worker #2 said she removed the heat pack from Resident #1's back and said the heat pack was not in a pillow case or any kind of protective covering. Social Worker #2 said she reported to Nurse #1, the nurse assigned to Resident #1, of his/her complaint that the heat pack was too hot. The Physical Therapy Note, dated 1/7/18 at 2:50 P.M., indicated Resident #1 complained of a burning sensation on the left shoulder and there was a reddened area on the left shoulder. This new area was reported to Resident #1's Nurse to assess the area, for question of a possible burn. The Surveyor interviewed Physical Therapy Assistant #1 at 12:06 P.M. on 3/29/18. Physical Therapy Assistant #1 said that Resident #1 had left sided neglect (a neuropsychological condition in which damage to one side of the brain is sustained and there is a deficit in attention and awareness of the one side of the body, inability to perceive stimuli on one side of the body), due to [MEDICAL CONDITION] with surgical resection. Physical Therapist Assistant #1 said Resident #1 told her that a staff employee put something on his/her back that was burning him/her. Physical Therapy Assistant #1 said she observed on Resident #1's upper scapula (upper back) a large area of redness which measured approximately 16 centimeters (cm) in width and 12 cm in length. The Occupational Therapy Note, dated 1/7/18, indicated that Resident #1 reported he/she had a burning sensation on the left shoulder and observed a large reddened area, nursing was present, and Nursing would follow up. The Surveyor interviewed Occupational Therapist Assistant #1 at 12:30 P.M. on 3/29/18. Occupational Therapist Assistant #1 said for safe application of a heat pack in a resident with neglect like Resident #1, you would need to monitor the resident's skin for signs and symptoms of a burn every five minutes during the heat treatment. The physician's orders [REDACTED].#1's paralyzed side). Review of Resident #1's medical record indicated there was no Nurse Progress Note written on 1/7/18 from the 7:00 A.M. to 3:00 P.M. shift, by Nurse #1 for the initial placement and ongoing monitoring of Resident #1's skin for the use of the heat pack treatment. The Physician's Note, dated 1/8/18, indicated Resident #1 had a blister on the left scapular area, he/she was using a heat pack and remained on [MEDICATION NAME] (a steroid medication) which can thin and make skin frail and the skin can easily become injured. The physician's orders [REDACTED]. Resident #1 had a new dressing change order to apply to the left shoulder blade, normal saline, pat dry then apply skin prep to any intact blisters and [MEDICATION NAME] 1% cream to open blisters and cover with a dry dressing, change twice a day. The Surveyor interviewed Nurse #1 at 11:10 A.M. on 3/29/18. Nurse #1 said Resident #1 had excruciating left sided back pain due to a fall on 1/6/18, so she obtained an order from the physician for a heat pack. Nurse #1 said that she put the heat pack in a pillow case and applied the heat pack directly under Resident #1's upper back as he/she laid on the heat pack in bed at a 45-degree angle. Nurse #1 said she did not document observations, condition of the skin for monitoring, or Resident #1's response to the treatment, as per the Facility policy for use of a heat pack. Nurse #1 said that after she applied the heat pack to Resident #1's left upper back on 1/7/18 at approximately 9:30 A.M., said she did not monitor Resident #1's skin until 30 minutes later and then again not until 2 hours later when she was called to the Resident's room by Certified Occupational Assistant #1 and Physical Therapy Assistant #1, who reported a large area of redness that was a burn from the heat pack. Nurse #1 said once redness was identified at the site of the heat pack application and Resident #1 complained of tingling, she notified the Physician of the burn and obtained an order for [REDACTED].