Every finding on record at Jesmond Skilled Nursing & Rehabilitation Center

Based on observations, interviews and records reviewed, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#10) out of sample of 15 residents. Specifically, for Resident #10, the facility failed to assess the Resident's respiratory status and response to therapy.Findings include: Review of facility policy, titled Oxygen Administration and Storage, undated, indicated the following:-Review Physician Order for instructions regarding flow rate (liters/minute), means of administration (mask or cannula), and whether oxygen is to be administered on a continuous or PRN (as needed) basis. If ordered, PRN, indications for use must be included in the order.Review of the facility policy, titled Respiratory Care Policy, dated as last reviewed 7/25/24, indicated the following:To provide safe, effective, and consistent respiratory care to residents requiring respiratory support in the facility.-Respiratory services shall be provided in accordance with physician orders, resident needs, and evidence-based guidelines. -Respiratory Care: Services that include oxygen therapy, nebulizer treatments, suctioning, tracheostomy care, ventilator support (if applicable), and respiratory assessments.-Responsibilities- Nursing Staff: Monitor and document resident response to treatments. -Physician/NP: Order and review respiratory treatments. Evaluate resident response and modify care as needed. -Oxygen Therapy: Monitor for oxygen saturation, skin breakdown, and signs of hypoxia or toxicity.Nebulizer Treatments: Observe and document resident's response, including respiratory rate, breath sounds, and any adverse effects. -Documentation: Record all respiratory interventions, resident response, and any complications. Document oxygen saturation levels, respiratory assessments, and treatment times. Resident #10 was admitted to the facility in April 2025 with diagnoses that included chronic obstructive pulmonary disease, saddle embolus of pulmonary artery, anemia and hypertension.Review of Resident #10's most recent Minimum Data Set (MDS) Assessment, dated 7/10/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS indicated the use of oxygen therapy.Review of Resident #10's current physician's orders indicated the following:- Budesonide Powder (Budesonide (Bulk) Give 2 inhalation by mouth two times a day for COPD. Budesonide formoterol fumarate inhalation Aerosol 160-4.5 MCG/ACT (budesonide-formoterol fumarate dihydrate) 2 inhalation orally two times a day for COPD. Administration time 9:00A.M., and 6:00 P.M.- HOB (head of bed) elevated 30-45 degrees for SOB every shift related to Chronic Obstructive Pulmonary Disease (COPD).-O2 (oxygen) @ 2L (2 Liters) via NC (nasal cannula) for O2 SAT (saturation) <90 as needed related to other Chronic Obstructive Pulmonary Disease (COPD).Review of Resident #10's Medication Administrant Record (MAR) and Treatment Administration Record (TAR) dated August 2025 indicated the following: - Budesonide Powder (Budesonide (Bulk) Give 2 inhalation by mouth two times a day for COPD. Documented as administered as ordered. - HOB (head of bed) elevated 30-45 degrees for SOB. Documented as administered as ordered-O2 (oxygen) @ 2L (2 Liters) via NC (nasal cannula) for O2 SAT (saturation) <90 as needed. Contained no documentation of administration. Review of Resident #10s active COPD care plan indicated the following:-Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. - Head of bed elevated at 30-45 degree angle at all times d/t becomes short of breath when lying flat- Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance.- Monitor for s/sx (signs/symptoms) of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB (shortness of breath) at rest, Cyanosis, Somnolence.Review of Resident #10's medical record indicated the following oxygen saturation summary:-7/25/25 93% room air.Review of Resident #10's progress notes indicated the last documented oxygen saturation level was 93% on room air was on 7/30/25. Further review of the medical record failed to indicate an ongoing assessment of the Resident's respiratory status and response to therapy. On 8/5/25 at 10:54 A.M., Resident #10 was observed lying in bed and was unable to be interviewed by the surveyor or speak to his/her oxygen use.During an interview on 8/5/25 at 1:57 P.M., Nurse #2 said she does not check the resident's oxygenation status unless he/she shows signs of shortness of breath and said he/she has an oxygen order if it is needed. During an interview on 8/6/25 at 11:14 A.M., Nurse #1 said we used to document the respiratory status in the medical record before and after a medication was given but we no longer do and said he is not sure why. Nurse #1 said there are no other respiratory assessments on order for him/her and said staff will document or check the oxygenation status when we want to. Nurse #1 said he checked Resident #10's oxygenation level today and it was 96% on room air. Nurse #1 said Resident #10 should have a respiratory assessment completed because he/she has a history of shortness of breath and is on inhalers. During an interview on 8/6/25 at 12:33 P.M., Corporate Nurse #1 said Resident #10 should have an order to assess his/her respiratory status and response to medications at least once per shift to determine if the Resident requires oxygen therapy or not. During an interview on 8/6/25 at 1:06 P.M., the Director of Nurses said Resident #10 should have respiratory assessments completed and documented in the medical record.

Based on observation, record review and interview the facility failed to ensure for one Resident (#5), out of total of 15 residents that the Health Care Proxy (a document executed in advance which designates a Health Care Agent, to make informed medical decisions, when a person is determined by a medical provider to lack the capacity to make health care decisions) was activated in accordance to standards of practice. Findings include: Review of the document titled 'GENERAL LAWS OF MASSACHUSETTS CHAPTER 201D. HEALTH CARE PROXIES.' Included but not limited to the following: Chapter 201D: Section 6. Incapacity of patient; regained capacity Section 6. The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall contain the attending physician's opinion regarding the cause and nature of the principal's incapacity as well as its extent and probable duration. This written determination shall be entered into the principal's permanent medical record. If the attending physician determines that a patient lacks capacity because of mental illness or developmental disability, the attending physician who makes the determination must have, or must consult with a health care professional who has, specialized training or experience in diagnosing or treating mental illness or developmental disabilities of the same or similar nature in making such determination. A physician who has been appointed as a patient's agent shall not make the determination of the patient's capacity to make health care decisions. Notice of a determination that a principal lacks capacity to make health care decisions shall promptly be given orally and in writing: (i) to the principal, where there is any indication of the principal's ability to comprehend such notice; (ii) to the agent; and (iii) if the patient is in or is transferred from a mental health facility, to the facility director. A determination made pursuant to this section that a principal lacks capacity to make health care decisions is solely for the purpose of empowering an agent to make health care decisions pursuant to a health care proxy. Notwithstanding a determination pursuant to this section that the principal lacks capacity to make health care decisions, where a principal objects to a health care decision made by an agent pursuant to a health care proxy the principal's decisions shall prevail unless the principal is determined to lack capacity to make health care decisions by court order. In the event the attending physician determines that the principal has regained capacity: (i) the authority of the agent shall cease but shall recommence if the principal subsequently loses capacity; and (ii) the principal's consent for treatment shall be required.Review of the Facility's policy titled Advanced Directives, not dated, indicated the following: Prior to admission, each individual will be asked if they have an advance directive by the Social Worker. He/she will be provided with information regarding the Massachusetts Health Care Proxy, Living Will and Durable Power of Attorney. At admission, the Social Worker will ask if the resident has an advance directive, if they do not have an advance directive and have not received information regarding advanced directives, they will be provided with this information as they request it. Whether or not an individual has executed an advanced directive will be documented in the individual's clinical record. Resident #5 was admitted to the facility in June 2025 and has diagnoses that include but are not limited to cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, adult failure to thrive, chronic obstructive pulmonary disease, and age-related cognitive decline. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating he/she as having moderately impaired cognition. Further, the MDS indicated Resident #5 has an existing Health Care Proxy and it is not invoked. Review of Resident #5's clinical record indicated a MOLST (medical orders for life sustaining treatment) was signed by Resident #5's Health Care Proxy Agent. Review of the Document in Resident #5's clinical record titled 'Resident Incapacity Pursuant to Massachusetts Health Care Proxy ACT M.G. L. C201D' was blank, therefore the HCP agent was not invoked. Review of the physician's active orders failed to indicate an order for the invocation of the Health Care Agent. During an interview on 8/05/2025 4:22 P.M., the Social Worker said the Nurse Practitioner did not want to invoke the Health Care Proxy Agent on admission and that Resident #5 requested his/her Health Care Agent to sign all his/her admission documents including the MOLST.Further review of Resident #5's clinical record indicated the following: -A Hospice Provider Team Care Plan dated 6/27/25 Directives: Health Care Proxy designated. Health Care Proxy activated (invoked), MOLST completed. -A Nurse Practitioner note dated 6/17/25 and 7/29/25, expected cognitive decline, cognitive impairment, BIMS 11, Activate HCP.-A Nurse Practitioner progress note dated 8/5/25 Plan Cognitive impairment, vascular, age related, BIMS 11, HCP activated per pt's request. During an interview on 8/6/25 at 8:24 A.M., the Social Worker said she was not aware that the Nurse Practitioner documented in her progress notes to activate the Health Care Proxy and that the activation form should have been completed. During an interview on 8/06/2025 at 8:38 A.M., Administrator #2 said she would expect an order to be written to activate the proxy and that the HCP activation form be completed.

Based on observation, interview, and records reviewed, the facility failed to provide a dignified experience for one Resident (#11) out of a total sample of 15 residents. Specifically: for Resident #11 the facility failed to ensure the Resident was provided dignity during activities of daily living (ADL) care. Findings include: Review of the facility policy titled Dignity and Respect dated revised 8/1/24, indicated that the facility will ensure that all residents are treated with dignity and respect. Further review indicated that the intent of the policy includes maintaining resident privacy of body. Resident #11 was admitted to the facility in February 2025 with diagnoses including severe dementia with psychotic disturbance, stroke and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #11 is severely cognitively impaired, scoring a 4 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #11 requires assistance with ADL care including bathing and dressing.On 8/05/2025 at 7:22 A.M. the surveyor observed Resident #11 in the bathroom receiving ADL care, in full view of the roommate. Resident #11 did not have clothes on and was exposed to his/her roommate. Review of the care plan dated 8/2/25, indicated that Resident #11 requires assistance with ADLs. During an interview on 8/05/2025 at 7:23 A.M., Certified Nurse's Aide (CNA) #1 said that Resident #11 doesn't like to have the bathroom door closed when he/she is receiving care.CNA #1 said she should have pulled the privacy curtain or asked staff for help. During an interview on 8/06/2025 at 8:34 A.M., Corporate Nurse said that the CNA should have pulled the privacy curtain to prevent the Resident from being exposed to his/her roommate or pulled the call light for another staff member to come and help.

Based on observations, record review, and interviews, the facility failed to notify the physician of a change in nutritional status resulting in a hospitalization for dehydration and hypernatremia for one Resident (#24), out of a total sample of 20 residents. Findings include: Resident #24 was admitted to the facility in August 2022 with diagnoses including Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #24 was dependent on staff for all daily care tasks. Review of Resident #24's care plans indicated a hydration care plan last revised 7/9/24, with the following intervention: -Monitor/document/report to MD PRN s/sx (signs/symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. On 8/13/24 at 7:39 A.M., Resident #24 was observed lying in bed with a significant amount of thick, greenish/brown mucous build-up on his/her lips, sealing his/her lips approximately 75% closed. Unit Manager #1 entered the room with surveyor and observed the Resident's mouth. Unit Manager #1said mouth care had been provided the evening prior and said the Resident has been declining recently and the facility had discussed placing the Resident on hospice services but is not currently receiving hospice services. Resident #24 was sent to the hospital on 8/13/24. Review of the admitting hospital paperwork dated 8/13/24 indicated the following diagnoses and testing results: -Found to have severe hypernatremia and dehydration -Throat: oral cavity very dry, lips dry -Labs: Sodium 158 (sodium levels above 145 indicate hypernatremia) -Labs: BUN (blood urea nitrogen test) of 42 (A BUN level above 20 milligrams per deciliter (mg/dL) is generally considered abnormal and could indicate dehydration.) -Dehydration with hypernatremia: due to free water deficit (lack of water), worsened by Alzheimer's Dementia. -Hypercalcemia: likely related to severe dehydration. Review of the percent of meals taken section on the Medication Administration Record indicated the following: -Resident #24 did not have any intake of meals for 7 out of 8 meals from the evening of 8/10/24 to the morning of 8/13/24. The only meal consumed was the morning of 8/12/24 with only 30% of the meal consumed. Review of the clinical record failed to indicate that the nurse practitioner, physician, or dietitian were notified of Resident #24's meal or fluid intake. During an interview on 8/15/24 at 10:45, Nurse #1 said she worked on 8/11/24 and during this day, Resident #24 had not eaten during any meals and was not accepting any fluid. Nurse #1 said this was a change of status for the Resident and she gave this information in report and asked the oncoming nurse for the night shift to pass this on to the Unit Manager on 8/12/24 and ask for the Nurse Practitioner to be called. Nurse #1 said she did not work on 8/12/24 but when she returned to work on 8/13/24 she realized this information was not passed on to the Unit Manager and the Nurse Practitioner was never called. Nurse #1 said that as soon as a Resident has a significant change in amount of intake with food and fluid the Nurse Practitioner should be notified. During an interview on 8/15/24 at 9:04 A.M., the Dietitian said she is at the facility at least once if not twice a week. The Dietitian said that when at the facility she looks at the intake records for all residents to assess who is not having adequate intake of food and fluids. The Dietitian said she would expect a call from nursing if she is not at the building and a resident has a change in intake status. The Dietitian said that although Resident #24 at times has a poor appetite, she was not made aware of Resident #24's change in status and lack of intake of food and fluids. The Dietitian said she would have expected to be notified for this change. During an interview on 8/15/24 at 11:26 A.M., Unit Manager #1 said she has constant communication with the Dietitian as needed and will call if there are any concerns. Unit Manager #1 said she returned from vacation on 8/12/24 and observed Resident #24 had a change in status and had an alteration in his/her appetite over the weekend and asked the nursing assistant to encourage fluids and the Resident did poorly with intake throughout the day. Unit Manager #1 said she was unaware Nurse #1 had reported a change in condition and thought the Nurse Practitioner should be notified. Unit Manager #1 said she watched the Resident on 8/12/24 and the Nurse Practitioner was expected in the building on 8/13/24 so she would speak with her regarding Resident #24 then. Unit Manager #1 said when she observed the Resident's condition with the surveyor on 8/13/24 she did not like the color of the Resident's mucous build up and felt at that point his/her condition was critical and she contacted the Nurse Practitioner. During an interview on 8/15/24 at 8:13 A.M., the Nurse Practitioner said she had not been notified of the change in Resident #24's status and poor intake until 8/13/24. The Nurse Practitioner said she would have wanted a phone call with that clinical information as she would have put interventions in place sooner. Ref F692

Based on observation, record review and interview, the facility failed to address the nutrition and hydration status of two Residents (#24, #32) out of a total sample of 20 residents. Specifically, the facility failed to: 1) provide one Resident (#24) with nutritional intervention leading to a diagnosis of severe dehydration. 2) Ensure Resident #32's documented significant weight losses and weight gains were addressed by the Registered Dietitian and develop a resident focused care plan for nutrition care. Findings include: 1) Review of the policy titled, Resident Hydration and Prevention of Dehydration, undated, indicated the following: -If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be informed. -Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. Resident #24 was admitted to the facility in August 2022 with diagnoses including Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #24 was dependent on staff for all daily care tasks. Review of the MOLST form dated 4/5/22 indicated the following: -Resident #24's spouse signed the form as the Resident's guardian and patient's representative. -Resident #24's spouse indicated Resident #24's goals of care were -Use artificial nutrition, but short term only -Use artificial hydration, but short term only Review of Resident #24's care plans indicated the following hydration care plan last revised 7/9/24: -Focus: (The Resident) a has Potential dehydration or potential fluid deficit r/t malnutrition, impaired cognition and communication r/t dementia and alzheimers. -Goal: (The Resident) will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor by next review. -Interventions: -Monitor/document/report to MD PRN s/sx (signs/symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Review of a dental visit note dated 7/22/24 indicated at the time of the visit Resident #24's lips were dry and cracked and the oral mucosa was dry. On 8/13/24 at 7:39 A.M., Resident #24 was observed lying in bed with a significant amount of thick, greenish/brown mucous build-up on his/her lips, sealing his/her lips approximately 75% closed. Unit Manager #1 entered the room with surveyor and observed the Resident's mouth. Unit Manager #1 said mouth care had been provided the evening prior and said the Resident has been declining recently and the facility had discussed placing the Resident on hospice services but is not currently receiving hospice services. Resident #24 was sent to the hospital on 8/13/24. Review of the admitting hospital paperwork dated 8/13/24 indicated the following diagnoses and testing results: -Found to have severe hypernatremia and dehydration -Throat: oral cavity very dry, lips dry -Labs: Sodium 158 (sodium levels above 145 indicate hypernatremia) -Labs: BUN (blood urea nitrogen test) of 42 (A BUN level above 20 milligrams per deciliter (mg/dL) is generally considered abnormal and could indicate dehydration.) -Dehydration with hypernatremia: due to free water deficit (lack of water), worsened by Alzheimer's Dementia. -Hypercalcemia: likely related to severe dehydration. Review of the percent of meals taken section on the Medication Administration Record indicated the following: -Resident #24 did not have any intake of meals for 7 out of 8 meals from the evening of 8/10/24 to the morning of 8/13/24. The only meal consumed was the morning of 8/12/24 with only 30% of the meal consumed. Review of the clinical record failed to indicate that the nurse practitioner, physician, or dietitian were notified of Resident #24's meal or fluid intake. During an interview on 8/15/24 at 10:45, Nurse #1 said she worked on 8/11/24 and during this day, Resident #24 had not eaten during any meals and was not accepting any fluid. Nurse #1 said this was a change of status for the Resident and she gave this information in report and asked the oncoming nurse for the night shift to pass this on to the Unit Manager on 8/12/24 and ask for the Nurse Practitioner to be called. Nurse #1 said she did not work on 8/12/24 but when she returned to work on 8/13/24 she realized this information was not passed on to the Unit Manager and the Nurse Practitioner was never called. Nurse #1 said that as soon as a Resident has a significant change in amount of intake with food and fluid the Nurse Practitioner should be notified. Nurse #1 said the fact Resident #24 was not taking in fluid was a concern for dehydration. During an interview on 8/15/24 at 9:04 A.M., the Dietitian said she is at the facility at least once if not twice a week. The Dietitian said that when at the facility she looks at the intake records for all residents to assess who is not having adequate intake of food and fluids. The Dietitian said she would expect a call from nursing if she is not at the building and a resident has a change in intake status. The Dietitian said that although Resident #24 at times has a poor appetite, she was not made aware of Resident #24's change in status and lack of intake of food and fluids. The Dietitian said she would have expected to be notified for this change. During an interview on 8/15/24 at 11:26 A.M., Unit Manager #1 said she has constant communication with the Dietitian as needed and will call if there are any concerns. Unit Manager #1 said she returned from vacation on 8/12/24 and observed Resident #24 had a change in status and had an alteration in his/her appetite over the weekend and asked the nursing assistant to encourage fluids and the Resident did poorly with intake throughout the day. Unit Manager #1 said she was unaware Nurse #1 had reported a change in condition and thought the Nurse Practitioner should be notified. Unit Manager #1 said she watched the Resident on 8/12/24 and the Nurse Practitioner was expected in the building on 8/13/24 so she would speak with her regarding Resident #24 then. Unit Manager #1 said when she observed the Resident's condition with the surveyor on 8/13/24 she did not like the color of the Resident's mucous build up and felt at that point his/her condition was critical and she contacted the Nurse Practitioner. During an interview on 8/15/24 at 8:13 A.M., the Nurse Practitioner said she had not been notified of the change in Resident #24's status and poor intake until 8/13/24. The Nurse Practitioner said she would have wanted a phone call with that clinical information as she would have put interventions in place sooner. 45984 2) Review of the facility policy titled Weight Policy and Weight Loss Protocol, revised and dated 9/6/22, indicated the following: - The facility will monitor resident's weight to ensure their optimal weight is maintained unless a loss/gain is avoidable. - A weight variance is defined as any unplanned gain/loss as followed: - +/- 3 lbs. (pounds) in 1 week - +/- 5% in 1 month - +/- 7.5% in 3 months - +/- 10% in 6 months - For any weight variance the following should occur: - MD documentation of plan of care with persistent weight loss - Nursing documentation of change to plan of care, notifications, resident condition - RD documentation and care plan revisions as needed - Resident progress and potential for occurrence of significant change will be discussed at the weekly clinical meeting Resident #32 was admitted to the facility in November 2023 with diagnoses including congestive heart failure, moderate protein-calorie malnutrition, adult failure to thrive and type 2 diabetes mellitus. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #32 has had a loss of 5% or more in the last month or loss of 10% of more in the last 6 months and is not on a prescribed weight-loss program. Review of Resident #32's weight log summary indicated the following: - Dated 1/10/24: 168 lbs. - Dated 1/17/24: 168.5 lbs. - Dated 1/25/24: 163.5 lbs. - Dated 2/1/24: 167.5 lbs. - Dated 2/7/24: 166 lbs. - Dated 2/14/24: 165 lbs. - Dated 2/22/24: 165.8 lbs. - Dated 2/28/24: 169.4 lbs. - Dated 3/7/24: 171 lbs. - Dated 3/13/24: 168.5 lbs. - Dated 3/20/24: 171 lbs. - Dated 3/28/24: 175.5 lbs. - Dated 4/3/24: 172.5 lbs. - Dated 4/11/24: 168.5 lbs. - Dated 4/17/24: 170 lbs. - Dated 4/25/24: 165.5 lbs. - Dated 5/2/24: 177.2 lbs. - Dated 5/8/24: 170.5 lbs. - Dated 5/16/24: 171 lbs. - Dated 5/23/24: 166.5 lbs. - Dated 5/29/24: 162.5 lbs. - Dated 6/5/24: 161.8 lbs. - Dated 6/12/24: 162.6 lbs. - Dated 6/19/24: 148.6 lbs. - Dated 7/3/24: 155.5 lbs. - Dated 7/10/24: 153 lbs. - Dated 7/18/24: 161.8 lbs. - Dated 7/24/24: 159.8 lbs. - Dated 7/31/24: 160 lbs. - Dated 8/7/24: 160 lbs. - Dated 8/14/24: 176.5 lbs. Resident #32 has had the following documented significant weight changes: - From 1/25/24 to 3/28/24, Resident #32 had a 7.34% weight gain - From 3/28/24 to 4/25/24, Resident #32 had a 5.7% weight loss - From 4/25/24 to 5/2/24, Resident #32 had a 7.07% weight gain - From 5/2/24 to 6/5/24, Resident #32 had a 8.69% weight loss - From 3/20/24 to 6/19/24, Resident #32 had a 13.10% weight loss - From 8/7/24 to 8/14/24, Resident #32 had a 10.31% weight gain Review of Resident #32's most recent Nutritional assessment dated [DATE] indicated the following: -Nutritional summary/goals: Resident presents with high risk for nutrition issues due to BMI (body mass index), # meds (medications) daily, dx(disease)/condition, physical needs and potential skin breakdown. Follow and change plan PRN (as needed). - Care plan interventions: Monitor wt (weight) and PO (by mouth) intake. Review of Resident #32's medical record failed to indicate that the Resident has been assessed by the Registered Dietitian (RD) since the 1/10/24 assessment. Review of Resident #32's electronic medical record failed to indicate that any nutrition progress notes or weight change progress notes were developed since 8/13/23. Review of Resident #32's nutrition progress notes and weight change progress notes failed to indicate that the RD has documented any interventions or notes regarding Resident #32's significant weight changes. The surveyor requested Resident #32's active care plans from the facility staff, the care plans failed to indicate that a care plan related to nutritional care was implemented for Resident #32. Review of Resident #32's physician's progress notes dated 7/30/24, 6/11/24, 6/4/24, 4/30/24, 4/16/24 indicated the following: - Sign (significant) wgt (weight) gain desired 2/2 (secondary to) malnutrition on admission no s/s (signs/symptoms) overload. Weight gain desired 2/2 severe malnutrition on admission. Resident #32's physician's progress notes failed to indicate what the parameters of the desired weight gain were and how much weight gain was desired for the Resident. The physician's progress notes also failed to indicate the documented significant weight loss Resident #32 has had. During a telephone interview on 8/15/24 at 9:03 A.M., the Registered Dietitian (RD) said she is in the facility one or two times each week for a total of 5-6 hours. The RD said if a resident has a significant weight change, she will look at the resident's diet, meal sheets and and try supplements. The RD said if she is notified of a significant weight change she will request the resident to be reweighed and she will put in a weight change progress note into the electronic medical record. She continued to say she will complete nutrition assessments every three months and annually. When asked about Resident #32, the RD said his/her weights are wonky due to the Hoyer lift needing to be adjusted. When asked about Resident #32's documented significant weight changes, the RD said she does not document or intervene for significant weight gains because she would prefer Resident #32 to gain weight and not lose it. When asked even if she does not document weight gains with Residents who have Congestive Heart Failure (CHF) such as Resident #32 she said she does not and she does not do nutrition assessments for every significant weight loss or gain, only progress notes. When asked if the RD provides ay education to Resident #32 regarding weight changes and CHF she said she does not. The RD said she reviews the meal consumption logs and speaks to nursing about interventions and weights, and she would expect nursing to document those conversations. The RD said she was not sure why there were no progress notes or a nutritional care plan in place for Resident #32. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said the RD will come speak with nursing if any nutrition changes need to be made for a resident and the RD will document those changes in the medical record to all staff are aware. Nurse #2 said a significant weight gain would be concerning for Resident #32 due to him/her having CHF. Nurse #2 continued to say he does not recall speaking to the RD about Resident #32's significant weight changes. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said if a significant weight loss or gain is identified then the RD would assess the resident for complete a weight change progress note with interventions. The DON and Unit Manager #1 said Resident #32's weights have been fluctuating a lot and with him/her having CHF, any significant weight changes should be followed. The DON and Unit Manager #1 then said they are not sure why there was no documentation regarding Resident #32's significant weight changes or the presence of a nutrition care plan.

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for five dependent Residents (#1, #2, #38, #19, #12) out of a total sample of 20 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #1. 2) Provide supervision while eating for three Residents (#2, #38, #19). 3) Provide showers as ordered for Resident #12. Findings include: Review of the facility's policy titled Activities of Daily Living, effective date 01/01/2015 indicated the following: A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Educations is provided to resident and family. Process: 1. Hygiene/Grooming: 2. Dressing: 3. Feeding: 4. Elimination: 5. Ambulation: 1) Review of the facility's policy titled Bladder Incontinence Management, with a revision date of 10/1/05 indicated: Fundamental Information: Based on Bladder Incontinence Assessment, the interdisciplinary team will determine the most appropriate course of action to assist the resident to either: re-establish continence, or: Manage incontinence in a dignified, healthy manner. Documentation: The resident care plan will reflect the current management plan. Resident #1 was admitted to the facility in February 2011 and has diagnoses that include unspecified dementia with agitation, schizophrenia and epilepsy and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the staff assessment for mental status indicated Resident #1 as severely cognitively impaired, is dependent on staff for bathing, dressing, toileting, personal hygiene and eating. Further the MDS indicated Resident #1 as always incontinent of bladder and bowel, is not on a urinary or bowel toileting program, and at risk for developing pressure ulcers. Review of Resident #1's care plan indicated the following: -Resident has functional bowel and bladder incontinence r/t (related to) confusion, Dementia, Impaired Mobility, Inability to communicate needs, Medication Side Effects, Combative and resistive to care dated as reviewed 6/18/24 with a target date of 9/6/2024. Interventions not dated included: Incontinent care, check as needed for incontinence. Wash rinse and dry perineum. Incontinent care with dependent x 2 every 2 hours and prn for toilet hygiene dated as created 4/17/23. -Resident has potential for skin breakdown r/t (related to) decreased mobility, COPD (chronic obstructive pulmonary disease), CHF, incontinent of urine and bowel, anemia and PVD (peripheral vascular disease), dated as reviewed 6/18/2024 with a target date of 9/6/2024 and interventions that include: Bed mobility and positioning every 2 hours and prn (as needed) with dependent x 2 rolling left to right and right to left, [NAME] (sic) to sit and sit to [NAME] (sic) with mechanical lift. On 8/13/24 at 7:45 A.M., Resident 31 was not in his/her room. The Unit Manger said Resident #1 gets up early and is in the sitting (dining) room waiting for breakfast. On 8/13/24 at 8:29 A.M., Resident #1 was observed in a Broda chair (a specialized chair that can recline) in the dining room alone. Resident #1 had his/her eyes closed and was leaning on his/her left side and his/her clothes were bunched up. On 8/13/24 the following observations were made: -At 8:41 A.M., Resident #1 was in the dining room in a Broda chair leaning on his/her left side. His/her eyes were closed. Staff were distributing the breakfast meals. -At 8:51 A.M., Resident #1 was in the dining room, sitting in a Broda chair leaning on his/her left side. -At 9:02 A.M., Resident #1 had his/her hand on his/her chin and other hand in his/her lap. -At 8:59 A.M., Resident #1 was alone in the dining room sitting in the Broda Chair. -At 9:05 A.M., A Certified Nursing Assistant (CNA) approached Resident #1 with a clothing cover and said softly 'wake up' and placed the clothing cover on the Resident. -At 9:07 A.M. a nurse and CNA assisted Resident #1 to be sitting upright in the chair. -At 9:12 A.M., Resident #1 was fed his/her breakfast by a CNA. -At 9:34 A.M., Resident #1 remained sitting in the dining room. -At 10:00 A.M., Resident #1 was sitting in his/her chair which was slightly reclined and holding a baby doll. Resident #1's eyes were closed. -At 10:19 A.M., Resident #1 was in the dining room sitting in his/her Broda chair. At no time during the observation did staff check for or provide incontinence care. During the observation on 8/13/24 which began at 12:07 P.M., and concluded at 2:50 P.M., the following was observed: -At 12:07 P.M., Resident #1 was sitting in the dining room in a Broda Chair. Staff was feeding Resident #1. -At 12:50 P.M., 1:12 P.M., 1:33 P.M., 2: 02 P.M., Resident #1 was seated in his/her Broda chair in the same location in the dining room. -At 2:19 P.M., music was on in the room. Resident #1 was in his/her Broda chair leaning on his/her left arm. His/her eyes were opened, and a doll was on his/her lap. -At 2:24 P.M., Resident #1 was sitting in his/her Broda chair. -At 2:50 P.M., Resident #1 remained in the dining room in his/her Broda chair. At no time is the two hours and 50 minutes was Resident #1 checked for or provided incontinence care. On 8/14/24 at 7:32 A.M., Resident #1 was observed in his/her room with a Hoyer (a pad used with a mechanical lift) pad underneath him/her. During observation on 8/14/24 from 7:46 A.M., through 11:30 P.M., the following was observed: -At 7:46 A.M., Resident #1 was sitting in his/her Broda chair in the dining room. -At 7:59 A.M., 8:17 A.M., Resident #1 was sitting in his/her Broda chair leaning toward his/her left side. in dining room in broda chair. -At 9:01 A.M., 9:18 A.M., Resident #1 was sitting in his/her Broda chair in the dining room. -At 9:20 A.M., Resident #1 was looking around, his/her eyes were wide open, he/she reached out a hand and his/her other hand was picking at His/her shirt. -At 10:07 A.M., Resident #1 was in the dining room with music playing and activity staff present. -At 10:11 A.M., 10:55 A.M., Resident #1 remained in the dining room during a sing a-long activity, holding a baby doll. -At 11:02 A.M., Resident #1 was in the dining room and shortly after the Activities Assistant moved Resident #1 to his/her room. During an interview on 8/14/24 at 11:36 A.M., Certified Nursing Assistant #2 said if a resident is incontinent, they check to see if a change is needed by taking the resident into their room and checking the brief and will change if needed. CNA #2 said incontinent care is provided in the morning and then residents are checked. CNA #2 said she is taking care of Resident #1 today and that Resident #1 requires a two person assist. CNA #2 said she got Resident #1 up before breakfast and has not provided incontinence care to Resident #1 since then. On 8/14/24 at approximately 11:50 A.M., Resident #1 was brought to his/her room for incontinence care. Resident #1's incontinence brief was observed to be wet with urine requiring a change. Resident #1 was not provided incontinence care for over three hours, and it was not until the surveyor brought it to the attention of staff was then Resident #1 brought back to his/her room and provided care. On 8/14/24 at 11:45 A.M., Nurse #1 said every person with incontinence has a care plan with a toileting schedule. Nurse #1 said Resident #1 needs to be checked or changed every two to three hours. Nurse #1 said Resident #1 is at risk for skin breakdown due to incontinence. During an interview on 8/14/24 at 12:26 P.M., the Unit Manger said she would expect the incontinence care plan to be followed for Resident #1. On 8/14/24 at 1:36 P.M., the Director of Nurses (DON) said residents who are incontinent should be checked for odor, changed as needed, and changed after lunch. The DON said staff should be aware of the plan of care and provide the care as required. The DON said Resident #1 should be provided incontinence care timely. 45984 2a) Resident #2 was admitted the facility in November 2023 with diagnoses including dysphagia, unspecified dementia and type 2 diabetes mellitus. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 3 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated that Resident #2 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/13/24 at 8:44 A.M., Resident #2 was laying in his/her bed eating breakfast with no staff members in the room providing supervision. Resident #2 was eating pancakes with his/her hands and was observed pulling pieces of pancakes out of his/her mouth. At 8:54 A.M., Resident #2 was heard coughing by the surveyor while in the hallway. No staff members checked in on Resident #2. - On 8/14/24 at 8:50 A.M., Resident #2 was laying in his/her bed eating breakfast with no staff members in the room providing supervision with the door shut. Resident #2 could not be seen from the hallway. Review of Resident #2's Kardex (a form describing the type of care a resident needs) indicated the following under the Eating section: Continual Supervision (1:8). Review of Resident #2's ADL Self Care Performance Deficit care plan, revised and dated 7/23/24 indicated the following intervention: Eat with supervision. Review of a nursing progress note dated 8/1/24 indicated the following: - Resident is alert and confused as per baseline. Continues to feel weaker than usual. Lack of appetite, difficulty to swallow. Will continue to monitor. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's Kardex form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's Kardex form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the Kardex and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the Kardex is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moments notice. 2b) Resident #32 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, failure to thrive and type 2 diabetes mellitus. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #32 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/14/24 at 8:58 A.M., Resident #32 was observed laying in his bed eating breakfast with no staff supervision in the room. Resident #32's door to his/her room was shut and the Resident could not be seen from the hallway. - On 8/15/24 at 8:53 A.M., a Certified Nursing Assistant (CNA) was observed setting up Resident #32's breakfast tray while he/she was laying in bed. The CNA then left Resident #32's room and he/she was observed eating without continuous supervision. Review of Resident #32's Kardex (a form describing the type of care a resident needs) indicated the following under the Eating section: Continual Supervision (1:8). Review of Resident #32's ADL Self Care Performance Deficit care plan, revised and dated 6/24/24 indicated the following intervention: Eat with supervision. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's Kardex form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's Kardex form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the Kardex and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the Kardex is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. The DON said staff would not be able to see a Resident from the hallway if his/her door was closed. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moment's notice. 2c) Resident #19 was admitted to the facility in October 2015 with diagnoses including unspecified dementia, anxiety disorder and unspecified protein calorie malnutrition. Review of Resident #19's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review of the MDS indicated that Resident #19 requires supervision or touching assistance with eating and is dependent on staff for all other activities of daily living. The surveyor made the following observations: - On 8/13/24 at 12:30 P.M., a Certified Nursing Assistant (CNA) set up Resident #19's lunch tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her lunch. The surveyor observed Resident #19 not receive any supervision with his/her meal until 12:49 P.M. - On 8/14/24 at 9:01 A.M., a CNA set up Resident #19's breakfast tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her breakfast. - On 8/15/24 at 8:37 A.M., a CNA set up Resident #19's breakfast tray while he/she was sitting on his/her bed. The CNA then left the room and left Resident #19 unsupervised with his/her breakfast. Review of Resident #19's Kardex (a form describing the type of care a resident needs) indicated the following under the Eating section: Totally Dependent Review of Resident #19's ADL Self Care Performance Deficit care plan, revised and dated 6/24/24 indicated the following intervention: Eat with supervision. During an interview on 8/15/24 at 10:42 A.M., Certified Nursing Assistant (CNA) #4 said she uses the Resident's Kardex form to know the type of care each resident needs. CNA #4 said continuous supervision means residents need to be watched at all times while they are eating until they are finished. During an interview on 8/15/24 at 11:01 A.M., CNA #5 and CNA #6 said they use the Resident's Kardex form to know the type of care they need. CNA #5 and CNA #6 continued to say continuous supervision for meals means residents need to be watched at all times while they are eating. During an interview on 8/15/24 at 11:11 A.M., Nurse #2 said continuous supervision means a staff member should always be watching a resident while they are eating. Nurse #2 said a resident might be on continuous supervision if they have trouble chewing food or swallowing or if they need encouragement. Nurse #2 said anyone could choke or have trouble swallowing in a moment's notice. The surveyor and Nurse #2 reviewed the Kardex and Nurse #2 said Continuous supervision (1:8) means someone can check on the resident and come back, the surveyor asked Nurse #2 how someone could be continuously watching the resident if they left the resident, and he said the Kardex is up to interpretation. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said continuous supervision means you can watch a resident eat and leave and come back and check on them. When asked if they thought that was continuous and always watching a resident eat the DON and Unit Manager #1 said that's how they interpret it. When asked if a resident had trouble with swallowing could they choke in a moment's notice and the DON said there is no time limit for choking and it could happen in a moment's notice. 46339 3. Resident #12 was admitted to the facility in January 2017 with diagnoses including respiratory failure and heart failure. Review of resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status of 14 out of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #12 required substantial assistance from staff for bathing tasks. During an interview on 8/13/24 at 7:42 A.M., Resident #12 was observed to have a brown stain in his/her face surrounding his/her mouth. Resident #12 said he/she had not been given a shower in 3-4 weeks and would like to be assisted with a shower. Review of the weekly shower schedule indicated Resident #12 was scheduled to have showers on Mondays and Thursdays on the 3-11 shift. During an interview on 8/15/24 at 9:38 A.M., Certified Nursing Assistant (CNA #3) said he did not give Resident #12 a shower on Monday 3-11. He said the Resident refused as the Resident has a preference of not receiving showers from male care givers. When asked if CNA #3 reported to the nurse of the refusal he said he did not. During an interview on 8/15/24 at 9:39 A.M., Nurse #1 said she was unaware Resident #12 had not been provided his/her weekly shower and staff should be reporting any refusals of care to the nurse.

Based on observation, record review and interview the facility failed to ensure advanced directives were followed, resulting in one Resident (#24) being transferred to the hospital, out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Advanced Care Planning, dated [DATE], indicated the following: -Individuals will have the opportunity to discuss preferences for care and treatment upon admission and to establish written directives, preferences, and choices for care and treatment in the event that the individual becomes unable to continue to express his or her wishes at a later time. -Known as an Advanced Care Plan, these preferences, directives, and choices will guide care and treatment for individuals who can no longer express their goals for care or make treatment choices. -Advanced Care Planning is a process enabling a patient to express wishes about his or her future health care in consultation with health care providers, family members and other important people in their lives. Based on the ethical principle of patient autonomy and the legal doctrine of patient consent, advanced care planning helps to ensure that the concept of consent is respected if the patient becomes incapable of participating in treatment decisions. -Health Care Proxy (HCP) sometimes called the durable power of attorney or power of attorney for health care, the health care proxy is a type of advanced directive appointing a decision maker to make medical decisions if an individual is no longer able to make those decisions. The HCP is only activated if the individual is incapable to make medical decisions and must be activated by the physician. The HCP deals with all medical decisions not just end of life. The Proxy must make decisions based on the resident's wishes not on the Proxy's opinion the DHCP is legal in 48 states. -New or revised documents and orders may be needed to implement revised or new treatment choices. Updating should be done within a time frame that is relevant to changes in an individual's prognosis, condition, and wishes. Resident #24 was admitted to the facility in [DATE] with diagnoses including Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #24 was dependent on staff for all daily care tasks. Review of Resident #24's admission paperwork indicated the Resident was originally admitted to the facility for respite care and the hospital had an electronic copy of the Health Care Proxy available. The medical record failed to include a copy of the health care proxy form and there were no notes to indicate the facility attempted to obtain a copy of the form. The hospital discharge instructions listed the following under the advanced directives section: -Intubation (a tube used to support breathing) : no - Intravenous Fluid and Support : yes -CPR (cardio pulmonary resuscitation): no -Life Support : no -MOLST(Medical Orders for Life Sustaining Treatment) form: yes -Health Care Proxy (a person assigned to make medical decisions for a patient who is unable): yes Review of Resident #24's medical record indicated the following: -The Resident's spouse was listed as his/her health care proxy on his/her face sheet (a form listing pertinent information regarding a resident's identifying information, payer information, care providers and contact information). -The admission social service note listed the Resident's spouse as his/her health care proxy. -Resident #24's spouse was listed as his/her guardian (an individual assigned by the court to make decisions on behalf of the resident) as of [DATE]. -Upon admission, the Nurse Practitioner invoked Resident #24's health care proxy which indicated the Resident was unable to make his/her own decisions. -Upon admission, the physician initiated an order for the Resident to be DNR (Do not Resuscitate)/DNI (Do not Intubate and Ventilate)/DNH (Do not Hospitalize). Further review of the medical record failed to indicate the Resident's Massachusetts Health Care Proxy Form. When asked to provide a copy of the health care proxy form, the facility was unable to do so. Review of the MOLST form dated [DATE] indicated the following: -Resident #24's spouse signed the form as the Resident's guardian and patient's representative. -Resident #24's spouse indicated Resident #24's goals of care were -Do not Resuscitate -Do not Intubate and Ventilate -Use Non-Invasive Ventilation -Do not Transfer to Hospital (unless needed for comfort) -No Dialysis -Use artificial nutrition, but short term only -Use artificial hydration, but short term only Review of Resident #24's active advanced directives care plan indicated the following: Focus: Advance Directives as follows: HX (history) Guardianship MOLST: DNR/DNI, Use non- invasive Ventilation, DNH, No dialysis, Use artificial nutrition but short term and Use artificial hydration but short term only. On [DATE] at 7:39 A.M., Resident #24 was observed lying in bed with a significant amount of thick, greenish/brown mucous build-up on his/her lips, sealing his/her lips approximately 75% closed. Unit Manager #1 entered the room with surveyor and observed the Resident's mouth. Unit Manager #1 said mouth care had been provided the evening prior and said the Resident has been declining recently and the facility had discussed placing the Resident on hospice services. Review of the social service note dated [DATE] indicated Resident #24's spouse passed away in [DATE]. All further social service notes indicated the facility referred the Resident for alternate guardianship after his/her spouse passed away. The notes failed, however, to indicate the facility sought guidance regarding the Resident's advanced directives and continued to maintain the physician order of DNR/DNI/DNH. Review of the social service note dated [DATE] indicated the following: -MOLST DNR/DNI/DNH Review of the Physician note dated [DATE] indicated Resident #24 was at the end of life and referred to his/her spouse as the health care proxy. Review of Resident #24's comprehensive Minimum Data Set assessment dated [DATE] at Section S, indicated Resident #24 was coded as having a guardian, coded as a Do Not Resuscitate, Do Not Hospitalize, Do Not Intubate, Feeding Restrictions, Other treatment Restrictions. Review of the Nurse Practitioner note dated [DATE], two months after the Resident's spouse passed away, indicated the following: -I confirm today that the patient's Advance Care Plan is documented in the medical record either by discussing and documenting the patient's Advance Care Plan, confirming that the patient surrogate decision maker is documented in the medical record, or confirming that the patient's Advanced Care Plan is presently documented. -advanced directives: DNR/DNI (noninvasive intubation OK), no HD (hemodialysis), short term art (artificial) nutrition and IVF (intravenous fluids) OK. Resident #24 was sent out to the hospital on [DATE]. Review of the physician orders indicated Resident #24's orders changed from DNR/DNI/DNH to Full Code on [DATE] just prior to the Resident being sent to the hospital on [DATE]. During an interview on [DATE] at 1:59 P.M., the Social Worker (SW) said all residents' advance directives are determined upon admission and if needed, the medical team will activate the heath care proxy of a resident if they are not able to make their own decisions. The SW said that if a MOLST is in place, there is never a circumstance when the MOLST is not followed, and the facility should always follow the orders for a resident's advanced directives. The SW said that Resident #24's spouse had been making all medical decisions up until he/she passed away and the facility had never questioned his/her decisions and felt he/she was making them in the best interest of the Resident. The SW said the facility made a referral to a law office to obtain a new guardian for Resident #24 when his/her spouse passed away and the facility is waiting for a court date. The SW said she consulted the attorney being used by the facility to obtain a new guardian for the Resident and this attorney told the facility to make the Resident a full code now that the spouse has passed away. The SW said the conversation regarding changing the Resident's code status occurred on [DATE] when the facility wanted to send Resident #24 out to the hospital. During an interview on [DATE] at 3:12 P.M., Attorney #1 said the authority of Resident #24's spouse to make advance directive decisions became invalid once he/she passed away. When asked how Resident #24's advanced directives will be determined, the Attorney said the firm will apply for new guardianship, one piece of evidence that will be used will be the MOLST form previously filled out by the spouse. During an interview on [DATE] at 10:45 A.M., Nurse #1 said Resident #24 had always been a DNR since admission. Nurse #1 said Resident #24 had been declining and as soon as Unit Manager #1 saw the Resident on [DATE], she had made the decision that Resident #24 needed to be sent to the hospital. During an interview on [DATE] at 11:26 A.M., Unit Manager #1 said once she saw Resident #24 with the surveyor on the morning of [DATE], she realized the Resident's condition was critical and had the NP order labs, a chest x-ray and oxygen. Unit Manager #1 said the facility then made the decision to send the Resident to the hospital. Unit Manager #1 said the facility had not looked into the Resident's advanced directives prior to [DATE] because there was no clinical need to. During an interview on [DATE] at 8:13 A.M., the Nurse Practitioner (NP) said Resident #24 was admitted to the facility with advanced dementia and the Resident's spouse had been making the Resident's healthcare decisions for him/her. The NP said she received a call from the facility stating that a lawyer told the facility the Resident needed to be made a full code and that superseded what she thought clinically, and the Resident was sent out to the hospital. The NP said she is very frustrated by this decision as Resident #24's health has been declining. The NP said she felt this decision was not right and that the Resident's wishes were not being followed. The NP said she feels the MOLST form should be 100% valid because it was the decision made when the spouse was alive. The NP said the Resident should be comfort care only and that this creates suffering at end of life. The NP said there is no reason to put Resident #24 through this ordeal due to his/her recent decline and now when he/she actually needs the comfort care he/she is not able to get it. The NP said this is not dying with dignity and because the code changed the Resident will most likely be sent back and forth to the hospital until the hospital does the right thing and admits him/her to hospice care. The NP said people should not have to suffer at the end of life. During a follow-up interview on [DATE] at 9:52 A.M., the SW said although the law firm had been contacted to obtain a new guardian for the Resident, there had been no discussion about changing his/her advanced directives until she had contacted the law firm on [DATE]. The SW said she contacted the attorney about changing the residents code status on [DATE] because she wanted to let them know she was being sent to the hospital and did not want the Resident to be alone in the hospital. The SW could not confirm whether she made the call before or after the facility made the choice to send the Resident to the hospital.

Based on observation, record review and interview the facility failed to implement the use of a hand splint in accordance with the rehabilitation plan of care for one Resident (#38), out of a total sample of 20 residents. Findings include: Review of the facility policy titled Therapy Screen Policy, dated January 2017, indicted the following: - Therapy will screen residents for appropriateness of therapy intervention. This will include quarterly, annual or as needed screens or referrals from other clinical team members. Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on staff for Activities of Daily Living and has a right hand contracture. The surveyor made the following observations: - On 8/13/24 at 7:40 A.M., Resident #38's was laying in his/her bed. Resident #38 said he/she had just woken up and was not dressed or bathed for the day yet. Resident #38's fingers on his/her right hand were observed to be slightly curled into a fist position. Resident #38 had to use his/her left hand to extend the fingers on the right hand. Resident #38 was not wearing a hand splint on his/her right hand. No hand splint was visible in Resident #38's room. - On 8/14/24 at 7:05 A.M., Resident #38's was laying in his/her bed. Resident #38 said he/she had just woken up and was not dressed or bathed for the day yet. Resident #38 was observed not wearing a hand splint on his/her right hand. No hand splint was visible in Resident #38's room. The surveyor observed the second floor's Activities of Daily Living book on 8/14/24 at 7:31 A.M., Resident #38 was not documented as receiving AM care yet. Review of Resident #38's physician's order dated 12/6/23 indicated the following order: - Right resting hand splint: apply after PM (nighttime) care and remove before AM (morning) care. Check skin integrity when donning and doffing. Every day and evening shift for support. Review of Resident #38's ADL self-care performance deficit related to right hemiparesis and right hand contracture care plan, revised and dated 7/28/24 indicated the following interventions: - PT/OT/SP (physical therapy/occupational therapy/speech pathology) evaluation and treatment as per MD (medical doctor) orders - Right resting hand splint: Right resting hand splint: apply after PM care and remove before AM care. Check skin integrity when donning and doffing. Review of Resident #38's document titled Occupational Therapy Certification dated from 11/14/23 through 12/11/23 indicted the following: - Range of motion: R (right) digits impaired Review of Resident #38's document titled Occupational Therapy Discharge Summary dated from 11/14/23 through 12/11/23 indicted the following: - Pt (patient) was issued a right resting hand splint to wear overnight in order to reduce risk of further contracture development and skin breakdown. Staff have vocalized 100% carryover with no questions/concerns regarding splint use/wear/donning techniques. The Occupational Therapy Discharge Summary failed to document the current range of motion values for Resident #38's right hand. During an interview on 8/14/24 at 10:11 A.M., the Certified Occupational Therapy Assistant (COTA) said if staff sees something relating to a resident's range of motion they can send a referral slip to therapy. The COTA said Resident #38 does not wear devices for his/her hands and she does not remember if he/she had a hand splint ordered. The COTA continued to say a Resident would wear a hand splint for contracture management so the contracture would not get worse and she would expect all physician's orders to be followed. The COTA said if no measurements were documented we cannot monitor if the contracture has gotten worse. The COTA said she would have the facilities Occupational Therapist evaluate Resident #38. During an interview on 8/14/24 at 2:32 P.M., the Occupational Therapist (OT) said Resident #38's should be wearing his/her hand splint at night time if that is what the current physician's order says. The OT continued to say that the device is for contracture management so the hand contracture does not get worse. Review of Resident #38's document titled Occupational Therapy Certification, dated 8/14/24 through 9/10/24 indicated the following: - Patient/Caregiver Goal: Pt was educated on purpose of OT evaluation to assess current right UE (upper extremity) and ROM (range of motion), function and need for orthotic. - Goals: Right hand resting splint and schedule is still appropriate for pt. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) said all physician's orders should be followed and Resident #38 should be wearing a hand splint at bed time.

Based on observations, record review, and interviews, the facility failed to implement the infection prevention and control program. Specifically: the facility failed to ensure nursing implemented infection control standards for blood glucose meter cleaning. Review of the facility policy, infection control, undated indicated the following but not limited to: -Equipment if disinfecting is not possible, clean and disinfect equipment using the same guidelines as for environmental cleaning, after contact with the resident and prior to using the equipment on another resident. -All equipment must be cleaned with PDI sani-cloth germicidal disposable cloth. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 gather supplies to obtain a Resident's blood sugar. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 obtain Resident #2's blood sugar. Nurse #2 exited the room with the contaminated glucometer and placed it in the carrier case where there were more lancets (devices used to obtain blood for testing blood sugar levels) test strips and alcohol wipes. Nurse #2 did not disinfect the blood glucose meter. During an interview on 8/13/24 at 2:20 P.M., Nurse #2 said the blood glucose meter should be sanitized after each use. Nurse #2 said they use the sani-cloth wipe to disinfect the glucose meter.

Based on observations, record review and interview, the facility failed to maintain an accurate medical record for one Resident (#25) out of a total sample of 20 residents. Findings include: Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift, every shift for positioning. On 8/13/24 at 7:35 A.M., 8:41 A.M., 11:19 A.M., and 1:26 A.M., Resident #25's bed was observed with a facility pressure relieving mattress, not an air mattress. Review of the Medication Treatment Record indicated the Nursing staff had documented the presence of the air mattress on 8/13/24. During an interview on 8/13/24 at 1:24 P.M., Unit Manager #1 said Resident #25 has not had an air mattress for at least two weeks. Unit Manager #1 said Nurses should not check off an order as complete if not actually completed.

Based on observation, interview and record review, the facility failed to ensure that the correct diet texture was implemented for one Resident (#38) out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 received a minced textured diet as ordered by the physician. Findings include: Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on staff for Activities of Daily Living. The surveyor made the following observations: - On 8/13/24 at 12:27 P.M., Resident #38 was observed eating lunch in the second-floor dining room. On Resident #38's lunch plate was a whole cutlet of chicken roughly five inches in length. The chicken was not cut up in any way. - On 8/13/24 at 12:30 P.M., Resident #38's meal card that was on his/her lunch tray indicated that the Resident is on a regular diet. The meal card failed to indicate that he/she was on a minced texture diet as well. - On 8/14/24 at 8:38 A.M., Resident #38 was observed eating breakfast in the second-floor dining room. On Resident #38's breakfast plate was a whole sausage with a casing on it that was not cut up in any way. Review of Resident #38's physician's order dated 8/9/24 indicated the following: - Regular diet, minced texture, mechanically altered, easy to chew During an interview on 8/14/24 at 1:00 P.M., Nurse #2 said a minced diet means the food should be cut up into small pieces. Nurse #2 said there has been some confusion among the nurses with what minced means. The surveyor showed Nurse #2 photos of Resident #38's meals and he said the sausage and chicken should have been cut up into small pieces. During an interview on 8/14/24 at 1:23 P.M., the Food Service Director (SD) said she gets diet slips from nursing that state the type of diet and texture each resident needs and the kitchen staff will make meal cards from that information. The FSD said she received a diet slip from nursing on 8/8/24 that said Resident #38 was on a regular diet and regular texture. The FSD said the Registered Dietitian has a binder that states which foods need to be altered depending on what textured diet a resident in on. The FSD continued to say when a resident is on a minced texture the kitchen staff will alter the food texture in the kitchen. The FSD said if the nursing slip said Resident #38 was on a minced diet she would have made sure the sausage and chicken were cut up. The surveyor showed the FSD photos of the sausage and chicken that Resident #38 received, and she said it was not minced. Review of the document titled Diet Orders that was hanging on the wall in the kitchen indicated that Resident #38 was on a minced, textured diet. Review of the Diet Binder in the kitchen indicated that a Resident who is on a minced diet texture should have sausages that are ground and chicken that is ground. During a telephone interview on 8/15/24 at 9:03 A.M., the Registered Dietitian (RD) said staff must have missed that Resident #38 was on a minced textured diet and it should have been on his/her meal card. During an interview on 8/15/24 at 11:42 A.M., the Director of Nursing (DON) and Unit Manager #1 said there was miscommunication among staff for Resident #38's diet texture and his/her meal card should have said he/she was on a minced diet texture. The DON and Unit Manager #1 said all physician's orders should be followed.

Based on observations, policy review and interviews, the facility failed to ensure medications with short expirations dates were dated when opened, expired medications were removed from supply, medications were securely stored and medication carts were locked when unattended. Findings include: Review of the facility policy titled 'Medication Storage In The Facility', dated 2017, indicated the following but not limited to: -Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. During an inspection of the first-floor medication cart on 8/14/24 at 6:52 A.M., the following medications were available for administration: -Ocuflox eye drops open and undated. -Earwax removal solution expired 7/2024 -Artificial tears with an expiration date of 3/2024 During an interview on 8/14/24 at 7:00 A.M., Nurse # 3 said the nurses are responsible to ensure medications are dated when opened and expired items are removed and destroyed. 2. During a medication pass observation on 8/13/24 at 10:54 A.M., Nurse #2 prepared medications to administer. Nurse #2 then walked away from his medication cart in the hallway and into the dining room. On the medication cart were multiple bottles of over the counter medications that were left unsecured. There was a resident who was walking in the hallway. During an interview on 8/13/24 at 10:56 A.M., Nurse #2 said medications should be secured in the medication cart. During an interview on 8/14/24 at 1:36 P.M., the Director of Nursing said medications with short expiration dates should be dated when opened and that the nurses and the pharmacist are responsible of ensuring expired medications are removed and discarded. 45984 3. During an observation on 8/13/24 at 12:20 P.M., the medication cart was left open and unattended on the second-floor unit. The surveyor was able to pull the drawer open. No nursing staff was visible in the hallway where the cart was located. A resident walked by the cart while it was open. During an interview on 8/13/24 at 12:24 P.M., Nurse #2 said the cart should have been locked when he was not with it. During an observation on 8/14/24 at 9:01 A.M., the medication cart was left open and unattended on the second-floor unit. The surveyor was able to pull the drawer open, multiple Certified Nursing Assistant walked by the open medication cart. During an interview on 8/14/24 at 9:09 A.M., the surveyor asked Nurse #2 if the medication cart should be left open while unattended, Nurse #2 said it should be locked at all times when he is not with it. During an interview on 8/14/24 at 1:34 P.M., the Director of Nursing said medications carts should be locked when not in use or when they are out of sight of the nurse.

Based on observations, record review, policy review and interviews, the facility failed to complete an investigation of a fall for one Resident (#12) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Accident and Incident Reports, undated, indicated the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Resident #12 was admitted to the facility in January 2017 with diagnoses including respiratory failure and heart failure. Review of resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status of 14 out of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #12 required substantial assistance from staff for mobility tasks. During an interview on 8/13/24 at 7:42 A.M., Resident #12 said he/she sustained a fall within the last year and he/she has felt weaker since this fall. Review of the form titled, Referral for Rehabilitation Services dated 9/15/24 indicated the following: -Reason for therapy referral: Fall -Resident #12 rolled out of bed approx. (approximately) 2 p.m. - as reported. -The form was signed by the Director of Rehabilitation (DOR) Rehabilitation screen dated 9/19/23 Pt (patient) had an unwitnessed fall 9/15 and was found next to (his/her) bed. Nursing evaluated pt and implemented a HR (handrail) on the bed. Pt currently on PT (Physical Therapy) services, plan to continue and to focus on safety awareness and balance. Review of the nursing notes for 9/15/22 to 9/19/23 failed to indicate any nursing notes regarding Resident #12's fall. The facility was unable to provide an incident report with investigation of Resident #12's self-reported fall. During an interview on 8/14/24 at 11:13 A.M., the DOR said she had made the referral to therapy after Resident #12 had reported to her that he/she had fallen. The DOR said it would be the expectation of the facility to report the fall to the nursing staff, however, she could not remember if she had. The DOR said nursing would have to complete an investigation of the fall. The DOR reviewed the therapy screen and said the screen confirmed the report of the Resident's fall. During an interview on 8/14/24 at 12:06 P.M., the Corporate Nurse said the therapy staff should have reported the fall to the nursing staff. The Corporate Nurse said Resident #12 sometimes says things have occurred that haven't, but regardless, the facility would still need to complete a fall investigation to conclude whether the fall occurred. The Corporate Nurse said she would expect an investigation with this incident and there is not one.

Based on observation, record review and interview the facility failed to ensure one Resident (#1) was free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to implement an established care plan for incontinence care resulting in incontinence care not being provided in a timely manner. Findings include: Review of the facility's policy titled Resident Abuse/Mistreatment/Neglect/Exploitation Misappropriation of Property Policy, not dated indicated the following: It is the policy of the facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property. Further, each resident at the facility will be treated with respect and dignity at all times. Definitions Neglect: failure to provide goods and services necessary to avoid physical harm mental anguish or mental illness. In determining whether or not neglect has occurred the following standards shall apply: 1 A resident has been mistreated a) an individual has failed to provide appropriate care, treatment, or service to the resident and b The individual's failure to provide the treatment, care or service to the resident is either intentional or the result of carelessness. Resident #1 was admitted to the facility in February 2011 and has diagnoses that include unspecified dementia with agitation, schizophrenia and epilepsy and chronic systolic heart failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the staff assessment for mental status indicated Resident #1 as severely cognitively impaired, is dependent on staff for bathing, dressing, toileting, personal hygiene and eating. Further the MDS indicated Resident #1 as always incontinent of bladder and bowel, at risk for developing pressure ulcers and had dulsions and behaviors verbal and other behaviors. On 8/13/24 Resident #1 was out of bed and in his/her Broda chair at 7:45 A.M. From 8:29 A.M. through 10:19 A.M., Resident #1 was observed sitting in a Broda chair (a specialized chair that can recline) in the dining room. At no time during the observation did staff check on Resident #1 to assess if incontinence had occurred or provide incontinence care. Resident #1 was not provided incontinence care after the breakfast meal. On 8/13/24 from 12:07 P.M. through 2:50 P.M., the following was observed sitting in his/her Broda chair in the dining room. At no time did staff check to see on Resident #1 to see if incontinence occurred or remove from the room to provide incontinence care. Resident #1 was not provided incontinence care after the lunch meal. On 8/14/24 from 7:32 A.M. through approximately 11:50 P.M., Resident #1 was observed sitting in his/her Broda chair in the dining room. At no time during the observation did staff check on Resident #1 to assess for the need for incontinence care or remove from the room to provide incontinence care. Resident #1 was not provided incontinence care after the breakfast meal. Review of Resident #1's care plans indicated the following: -Resident has functional bowel and bladder incontinence r/t (related to) confusion, Dementia, Impaired Mobility, Inability to communicate needs, Medication Side Effects, Combative and resistive to care dated as reviewed 6/18/24 with a target date of 9/6/2024. Interventions not dated included: Incontinent care, check as needed for incontinence. Wash rinse and dry perineum. Incontinent care with dependent x 2 every 2 hours and prn for toilet hygiene dated as created 4/17/23 observe skin after each incontinent episode and notify the nurse if skin breakdown. -Resident has potential for skin breakdown r/t (related to) decreased mobility, COPD (chronic obstructive pulmonary disease), CHF, incontinent of urine and bowel, anemia and PVD (peripheral vascular disease), dated as reviewed 6/18/2024 with a target date of 9/6/2024 and interventions that include: Bed mobility and positioning every 2 hours and prn (as needed) with dependent x 2 rolling left to right and right to left, [NAME] (sic) to sit and sit to [NAME] (sic) with mechanical lift. Review of the Kardex (a document that summarizes a resident's care requirements) indicated the following: Ambulation: did not occur, Toileting Total dependence of 2/Hoyer (a mechanical lift used to transfer a resident from bed to chair). Bladder: incontinent Bowel: incontinent. During an interview on 8/14/24 at 11:29 A.M., Certified Nursing Assistant (CNA) #3 said he is trained on abuse prevention at least once a year. CNA #3 said neglect is when a resident needs something that they do not get. CNA # 3 said with incontinence care you have to keep checking a resident to see if they need to be changed. If a resident cannot tell you then you have to check. CNA #3 said Resident #1 gets his/her morning care before breakfast and then will do incontinent care after lunch. During an interview on 8/14/24 at 11:36 A.M., Certified Nursing Assistant #2 said if a resident is incontinent, they check to see if a change is needed by taking the resident into their room and checking the brief and will change if needed. CNA #2 said incontinent care is provided in the morning and then residents are checked. CNA #2 said she is taking care of Resident #1 today and that Resident #1 requires a two person assist and requires a Hoyer lift. CNA #2 said she got Resident #1 up before breakfast and has not provided incontinence care to Resident #1 since then. On 8/14/24 at approximately 11:50 A.M., after the surveyor brought it to the attention of staff that Resident #1 was brought to his/her room for incontinence care. Resident #1's incontinence brief was observed to be wet with urine requiring a change. During an interview on 8/14/24 at 11:45 A.M., Nurse #1 said every person with incontinence has a care plan with a toileting schedule. Nurse #1 said Resident #1 needs to be checked or changed every two to three hours. Nurse #1 said Resident #1 is at risk for skin breakdown due to incontinence. Nurse #1 said neglect can be not providing the care a person requires. Nurse #1 said Resident #1 should be checked or changed at least every three hours. Nurse #1 said she noted that residents were not being changed timely yesterday. During an interview on 8/14/24 at 12:26 P.M., the Unit Manger said she would expect the incontinence care plan to be followed for Resident #1. On 8/14/24 at 1:36 P.M., the Director of Nurses (DON) said residents who are incontinent should be checked for odor, changed as needed, and changed after lunch. The DON said staff should be aware of the plan of care and provide the care as required and if it is not provided that would be a neglect concern. Ref. F677

Based on observations, interviews and record review, the facility failed to complete a restraint assessment for one Resident (#36) out of a total sample of 20 residents. Specifically, the facility failed to complete a bed safety assessment prior to adding a bolster pillow in the Resident's bed. Findings include: A review of the facility policy titled 'Restraints' with no revision date indicated the following: -Definitions-Physical restraint-any manual or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Goal-To provide a systematic method of evaluating and monitoring restraint use to assure utilization of the least restrictive method and medical necessity. -It is the facility policy that the resident has the right to be free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptom. When it is determined a restraint is necessary based on an interdisciplinary evaluation, the least restrictive method will be utilized. -A written physician's order is necessary when utilizing a restraint. The physician's order must be specific to the type of restraint, the time it will be used and the medical necessity for use. Resident #36 was admitted to the facility in June 2023 with diagnoses including Dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating moderate cognitive impairment. On 8/13/24 at 7:43 A.M., the surveyor observed Resident #36 sleeping in a low positioned bed. The Resident's bed had a bolster pillow tucked in under the bedsheets on the edge of the Resident's bed. The bolster pillow appeared as a raised border on the edge of the Resident's bed. On 8/14/24 at 7:11 A.M., the surveyor observed Resident #36 sleeping in a bed placed in a low position. The Resident's bed had a bolster pillow tucked in under the bed sheets on the edge of the Resident's bed. The bolster pillow appeared as a raised border on the edge of the Resident's bed. A review of Resident #36's August physician's orders failed to indicate the necessity of a bolster pillow in the Resident's bed. A review of Resident #36's care plan with a revision date of 3/11/24 indicated the following: -Bed mobility with positioning with dependent x 2-rolling left to right and right to left, sit to [NAME] and [NAME] to sit with dependent x 2 with mechanical lift. [sic] A review of the bed safety assessments dated 3/4/24 and 5/23/24 indicated the following: -Cognitive-unaware of safety needs. -Fall history-history of rolling out of bed. -Safety device needed-low bed, fall mat on left side. -Safety device listed above recommended at this time. Further review of the bed safety assessments failed to indicate a bolster pillow as a safety device. During an observation and interview on 8/14/24 at 7:34 A.M., Certified Nurse's Assistant (CNA) #1 and the surveyor observed the Resident in bed. There was a bolster pillow tucked in the bed sheets on the edge of the Resident's bed. CNA #1 said she was not sure why there was a bolster pillow in the Resident's bed. She said the physician's orders would indicate if the bolster pillow should be in the Resident's bed, if it did not, then the bolster pillow should not be in the Resident's bed. During an interview on 8/14/24 at 7:37 A.M., Resident #36 said he/she did not know why he/she has a bolster pillow in his/her bed. He/she said he/she felt that the bolster pillow on the edge of his/her bed has a blocking effect on him/her while he/she is in bed. During an observation and interview on 8/14/24 at 7:44 A.M., Nurse #2 and the surveyor observed the Resident in bed. There was a bolster pillow tucked in the bed sheets on the edge of the Resident's bed. Nurse #2 said any equipment added in the Resident's bed should be assessed before being placed in the Resident's bed. Nurse #2 said if there is no bed safety assessment that includes the bolster pillow, one wasn't done and should have been done before the bolster pillow was added to the Resident's bed. During an interview on 8/14/24 at 7:51 A.M., the Clinical Corporate Nurse said she expects the staff to complete a bed safety assessment before placing any equipment in the Resident's bed even if the Resident or the responsible party prefers the equipment in the bed. She said a bed safety assessment should have been completed before adding a bolster pillow in the Resident's bed.

Based on observations, record review and interview, the facility failed to follow the plan of care for three Residents (#25, #26 and #41) out of a total sample of 20 residents. Specifically, the facility 1) Failed to follow a physician's order to provide an air mattress for Resident #25. 2) Failed to offload Resident #26's heels as written in his/her care plan. 3) Failed to offload Resident #41's right heel as ordered by the physician. Findings include: 1. Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift for positioning. On 8/13/24 at 7:35 A.M., 8:41 A.M., 11:19 A.M., and 1:26 A.M., Resident #25's bed was observed with a facility pressure relieving mattress, not an air mattress. During an interview on 8/13/24 at 1:24 P.M., Unit Manager #1 reviewed Resident #25's physician orders and confirmed the order for the air mattress was an active order. Unit Manager #1 said all physician orders should be followed as ordered. 2. Resident #26 was admitted to the facility in September 2023 with diagnoses including stroke, left hemiplegia and muscle weakness. Review of Resident #26's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #26 is dependent on staff for bed mobility tasks. Review of Resident #26's skin integrity care plan, last revised on 7/1/24, indicated the following intervention: -Off load heels when in bed. On 8/13/24 at 7:54 A.M. and 10:30 A.M., Resident #26 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. On 8/14/24 at 7:20 A.M., and 8:39 A.M., Resident #26 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. Review of Resident #26's medical record failed to indicate Resident #26 refused to offload his/her heels. During an interview on 8/14/24 at 9:00 A.M., Certified Nursing Assistant (CNA) #2 said the CNAs should ask the nursing staff if residents require any special care or equipment. CNA #2 said Resident #26 did not have any orders or care plan to have any special equipment while lying in bed. During an interview on 8/14/24 at 9:06 A.M., Nurse #1 said Resident #26 should have his/her heels offloaded while in bed. Nurse #1 was unaware Resident #26's heels were not offloaded while lying in bed. During an interview on 8/14/24 at 8/14/24 9:42 A.M., Unit Manager #1 said she would expect all care plans and orders to be followed as written. 3. Resident #41 was admitted to the facility in July 2024 with diagnoses including stroke, right side hemiplegia and muscle weakness. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident was unable to complete the Brief interview for Mental Status (BIMS) assessment and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #41 is dependent on staff for bed mobility tasks. Review of Resident #41's physician orders indicated the following order initiates on 7/10/24: - elevate right heel off of bed for pressure relief, every shift for pressure relief, On 8/13/24 at 9:22 A.M., Resident #41 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. On 8/14/24 at 7:17 A.M., Resident #41 was observed lying in bed with both heels directly on the bed. No pillows were observed in the bed by his/her feet or on the floor near the bed. During an interview on 8/14/24 at 7:26 A.M., Certified Nursing Assistant (CNA) #2 said she was unaware if Resident #41 had any skin concerns or if he/she had any special equipment when lying in bed. Review of Resident #41's nursing notes failed to indicate Resident #41 refused to elevate his/her right heel on 8/13/24 or 8/14/24. During an interview on 8/14/24 at 7:39 A.M., Nurse #1 said Resident #41's heels should be offloaded when in bed. Nurse #1 said Resident #41 may refuse to offload his/her heels, but if he/she does refuse, nursing would have to write a note indicating the Resident refused. At this time, Nurse #1 entered Resident #41's room and observed his/her heels directly on the bed. Nurse #1 spoke to the Resident in his/her native language and the Resident told Nurse #1 that staff did not offload his/her heels on the prior night. During an interview on 8/14/24 at 9:42 A.M., Unit Manager #1 said all physician orders should be followed as ordered.

Based on observation, record reviews and interviews, the facility failed to ensure a physician's order was implemented as ordered for one Resident (#25) out of a total sample of 20 residents. Specifically, the facility failed to obtain blood pressure parameters as ordered. Findings include: Resident #25 was admitted to the facility in April 2028 with diagnoses including cardiomyopathy. Review of Resident #25's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During a medication observation pass on 8/13/24 at 9:15 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #25 including metoprolol 12.5 mg (milligram). Review of Resident #25's physician orders for the month of August 2024 indicated the following order: -Metoprolol succinate tab 25 mg (milligram) extended release. Give 12.5 mg orally one time a day related to cardiomyopathy. Hold for systolic blood pressure less than 110 and heart rate less than 60. Review of the Medication Administration Record (MAR) for the month of August 2024 failed to indicate that blood pressure parameters were obtained and documented. During an interview on 8/13/24 at 2:00 P.M., Nurse #1 said the blood pressure was done by the night shift nurse. When asked where it was documented, Nurse #1 said it should be documented in the MAR. During an interview on 8/14/24 at 1:36 P.M., the Director of Nursing said physician orders should be followed as ordered and the nurses should document parameters in the medical records.

Based on observations, record review and interview, the facility failed to implement the medical plan of care for two Residents (#28, #32) who are assessed as high risk for developing pressure ulcers, out of a total sample of 20 residents. Specifically, the weekly skin assessments for both residents were not completed in accordance with the physician's orders. Findings include: 1) Resident #28 was admitted to the facility in 9/2023 with diagnoses that include but are not limited to unspecified dementia, Parkinson's disease, congested heart failure, and anemia. Review of Resident #28's Minimum Data Set assessment dated [DATE] indicated Resident #28 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderate cognition, is dependent on staff for bathing, toileting, dressing and is at risk for developing pressure ulcers. Review of Resident #28's medical record indicated the following: -The Norton Scale for Predicating Risk of Developing Pressure Ulcers dated 12/2/23 with a score of 6, 2/22/24 with a score of 7, and 5/25/24 with a score of 5, (a score of 10 or less is high risk) assessed Resident #28 as high risk for developing pressure ulcers. Review of Resident #28's physicians orders indicated the following: -Weekly skin assessment on Mon (Monday) 7-3 shift in the morning every Mon for skin checks. Order date 1/17/24. .Record review indicated the following: -A documented weekly skin check dated 6/27/24. The medical record failed to have any further documented skin checks for the next four weeks until 7/29/24. During an interview on 8/14/24 at 9:45 A.M., Unit Manger #1 said all residents have weekly skin checks. UM#1 said she was not sure of Resident #28's Norton Scale Score and therefore could not say if Resident #28 was at risk for developing pressure ulcers and would need to review it. UM #1 reviewed the medical record with the surveyor which revealed the weekly skin checks were not completed for four weeks between 6/27/24 and 7/29/24. 45984 2) Resident #32 was admitted to the facility in November 2023 with diagnoses including congestive heart failure, cerebral infarction, failure to thrive and type 2 diabetes mellitus. Review of Resident #32's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #32 is at risk of developing pressure ulcers. Review of Resident #32's physician's order dated 2/7/23 indicated the following: - Weekly Skin Assessment on Tuesday 7-3 every day shift every Tue (Tuesday) Review of Resident #32's Norton Scale for Predicting Risk of Pressure Ulcer dated 6/14/24, indicated that Resident #32 was a high risk for pressure ulcer development. Review of Resident #32's Potential for Skin Breakdown Care Plan revised and dated 6/24/24 indicated the following interventions: - Norton Plus Assessment every 90 days - Skin protocol per house policy Review of Resident #32's weekly skin checks indicated the skin checks ordered for 7/30/24 and 8/13/24 were not completed. During an interview on 8/15/24 at 8:51 A.M., Nurse #2 said skin checks are done weekly by nursing and are documented only in the electronic medical record. Nurse #2 said a resident with congestive heart failure and at risk for pressure ulcers has potential for skin issues. Nurse #2 said Resident #32 should have weekly skin checks and the nurse must have forgotten to complete them on 7/30/24 and 8/13/24. During an interview on 8/15/24 at 11:15 A.M., the Director of Nursing (DON) and Unit Manager #1 said skin checks should be done weekly, and all physician's orders should be followed. Unit Manager #1 said the skin checks must have been missed.

Based on observations, policy review, record review and interviews, the facility failed to provide assistance for meals for 4 Residents (#31, #23, #5, and #6) out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 1/1/2015, indicated the following: *A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Education is provided to resident and family. *Feeding: Meals are planned considering needs and desires of residents. 1. Resident #31 was admitted to the facility in May 2018 with diagnoses including stroke and left sided hemiplegia (paralysis). Review of Resident #31's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #31 requires supervision for self-feeding tasks. On 6/20/23 at 9:16 A.M., Resident #31 was observed eating breakfast while lying in bed without staff present to supervise or assist if needed. The Resident was unable to be seen from the hallway. On 6/20/23 at 12:36 P.M., Resident #31 was observed eating lunch in his/her room while sitting in the wheelchair. There were no staff present to supervise or assist if needed. The Resident had his/her back to the door and could not be viewed from the hallway. On 6/21/23 at 8:30 A.M., Resident #31 was observed eating breakfast while lying in bed without staff present to supervise or assist if needed. The Resident was unable to be seen from the hallway. Review of Resident #31's activity of daily living care plan last revised 5/19/23, indicated the following intervention: *Eating with continual supervision with 1:8 ratio. Review of Resident #31's Care Card (a form indicating the level of assist each resident needs) indicated the Resident requires continual supervision with meals. During an interview on 6/21/23 at 8:41 A.M. Certified Nursing Assistant (CNA) #1 said the Care Card explains the level of assistance a resident requires with activities of daily living. CNA #1 said Resident #31 requires supervision with meals. During an interview on 6/21/23 at 9:25 A.M., the Administrator and Director of Nursing said they expect staff to look at the Care Cards and provide the level of care written. The Director of Nursing said continuous supervision means supervision throughout the meal and if a resident was alone in their room for any portion of the meal, they were not receiving continuous supervision. 2. Resident #23 was admitted to the facility in December of 2018 with diagnosis including dysphagia, dehydration, and osteoarthritis. Review of Resident #23 most recent Minimum Data Set (MDS) dated , 3/29/23, indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicates Resident #23 requires supervision with self-feeding tasks. On 6/20/23 at 10:24 A.M., Resident #23 was observed eating breakfast in bed, alone in his/her room. The Resident was not visible from the hallway and there were not staff present to provide assistance or supervision if needed. On 6/21/23 at 8:28 A.M., Resident #23 was observed eating breakfast in bed, alone in his/her room. The Resident was not visible from the hallway and there were not staff present to provide assistance or supervision if needed. Review of Resident #23's activity of daily living care plan last revised 1/18/23, indicates Resident requires eating with continuous supervision 1:8 ratio. Review of Resident #23's care card (form indicating level of assistance each Resident needs) indicates the Resident requires continual supervision 1:8 while eating. During an interview on 6/21/23 at 8:42 A.M., Certified Nursing Assistant (CNA) #1 said staff are to follow the care card form for providing care to all Residents. CNA #1 said Resident #1 requires supervision during meals. During an interview on 6/21/23 at 8:36 A.M., Unit Manager #1 said staff should provide the level of care listed on the care card and care plan. 36876 3. Resident #5 was admitted to the facility in March 2020 with diagnoses including dementia and chronic pulmonary disease. Review of Resident #5's Minimum Data Set assessment dated [DATE] indicated he/she scored 7 out of a possible 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. On 6/20/23 at 12:34 P.M. and 12:44 P.M. the surveyor observed Resident #5 in his/her room with with his/her lunch meal untouched in front of him/her. There were no staff present providing supervision, assistance, or encouragement. Resident #5 presented as thin and confused. Resident #5 said I'm not hungry but I'll eat it but made no attempts to feed himself/herself. On 6/20/23 at 1:01 P.M. the surveyor observed Resident #5's lunch tray on the food truck. The tray had 100% of his/her meal remaining. Review of Resident #5's Activities of Daily Living (ADL) care plan dated 2/16/23, indicated the following intervention: Eating with continual supervision with 1:8 ratio. Ask Resident what time he/she prefers to get up. Review of Resident #5's care card, undated, indicated Resident #5 requires continual supervision 1:8 with eating. Review of Resident #5's Nutrition care plan indicated Resident #5 had a significant weight loss of 11% of his/her total body weight in February 2023 and 14.5% in April 2023. Interventions implemented effective 2/22/23 included: Assist at meals, allow adequate time to eat, offer alternative meals. Review of Resident #5's clinical record included notes from the Dietitian dated 2/22/23 and 4/29/23 indicating staff will continue to provide encouragement and assistance with Resident #5 during meals. On 6/21/23 at 9:04 A.M., the surveyor observed Physical Therapy Aide (PTA) #1 preparing Resident #5's tray for breakfast. PTA said he was not sure what kind of assistance Resident #5 requires with eating and was helping the Resident with breakfast because he was asked to. During an interview with Certified Nurses Aide (CNA) #3 on 6/21/23 9:26 A.M., she said that Resident #5 eats alone in his/her room and does not need any assistance. On 6/21/23 at 12:34 P.M. the surveyor observed a CNA deliver Resident #5's lunch meal and leave the room. Resident #5 was observed eating alone in his/her room without supervision, assistance, or staff encouragement per the plan of care. During an interview on 6/21/23 at 9:25 A.M., the Director of Nursing said continuous supervision means supervision throughout the meal and if a resident was alone in their room for any portion of the meal, they were not receiving continuous supervision. During an interview with Unit Manager #1 on 6/21/23 at 2:08 P.M., she said that for Resident's with care plans indicating they need supervision or assistance with meals, staff should be following the plan of care. Unit Manager #1 said that Resident #5 would refuse physical assistance with meals, but said she understood that Resident #5's care plan indicated he/she required encouragement with meals and continuous supervision. Unit Manager #1 said that CNA #3 may have reported the information to the surveyor incorrectly due to a language barrier. CNA #3 then joined the interview and said that Resident #5 does not need supervision or encouragement during meals. 45763 3. Resident #6 was admitted to the facility in May 2016 with diagnoses including abnormal weight loss, dementia, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. Further review of the MDS indicated Resident #6 is totally dependent on staff to assist with eating. On 6/20/23 at 8:44 A.M., the Surveyor observed Resident #6 eating scrambled eggs using his/her hands alone in his/her room. On 6/21/23 at 8:37 A.M., the Surveyor observed Resident #6 eating in common area without the assistance of staff. On 6/21/23 at 12:33 P.M., the Surveyor observed Resident #6 eating in common area without the assistance of staff. The Resident was spilling drinks on to himself/herself, and attempting, unsuccessfully, to use his/her fork to pick up food that had fallen on to the table. Resident #6 was then observed attempting to, unsuccessfully, open his/her closed Magic Cup (a high calorie, nutrient fortified ice-cream prescribed to prevent weight loss). Review of Resident #6's Activities of Daily Living (ADL) care plan indicated the following intervention: *Dependent x1 for eating, updated 6/19/23 Review of Resident #6's care card, undated, indicated Resident #6 is totally dependent for eating Review of the Activities of Daily Living Functional Coding guidelines reference page indicated the following: *Totally Dependent - the resident is fed by nursing staff During an interview on 6/21/23 at 12:51 P.M., the Director of Rehab Services said the expectation would be for staff to assist Resident #6 if they see the Resident struggling with her meal. During an interview on 6/21/23 at 1:56 P.M. Certified Nursing Assistant (CNA) #4 said residents should be provided the level of care outlined on their care cards. CAN #4 said Resident #6 requires assistance with eating, and that a staff member should be sitting and assisting the Resident throughout the entirety of the meal. During an interview on 6/21/23 at 2:08 P.M., the Unit Manager #1 said that for Resident's with care plans indicating they need supervision or assistance with meals, staff should be following the plan of and care. 48671

Based on observations, policy review and interviews, the facility failed to provide a dignified dining experience to the residents on the first floor. Findings include: Review of the facility policy titled, Dignity and Respect, dated 8/1/22, indicated the following: *Promoting independence & dignity and dining: facility and staff should avoid: staff standing over residents while assisting them to eat and staff interacting/conversing only with each other rather than with residents while assisting residents. The following was observed in the first floor dining room during the breakfast meal on 6/20/23 at 8:33 A.M.: * Two Certified Nursing Assistants (CNAs) were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other in Spanish, however, never conversed with the residents. The following was observed in the first floor dining room during the lunch meal on 6/20/23 at 12:35 P.M.: * Two CNAs were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other in Spanish, however, never conversed with the residents. The following was observed in the first floor dining room during the breakfast meal on 6/21/23 at 8:10 A.M.: * An Activities Assistance was observed feeding a resident while standing, not at the eye level of the resident. * Two CNAs were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other, however, never conversed with the residents. During an interview on 6/21/23 at 8:31 A.M., Unit Manager #1 said staff should be conversing with residents as they are assisting them with their meals. Unit Manger #1 said staff should be speaking in the language of the residents and not to each other in a foreign language and that is something that has been an issue in the building. Unit Manager #1 said if staff are assisting residents with their meals, they should be sitting, not standing over them.

Based on observation, record review, and interviews, the facility failed for 2 sampled residents (#4 and #10) of 3 applicable residents with pressure sores out of a total sample of 12 residents, to keep the residents from developing pressure sores. The facility also failed to ensure that necessary treatment and services were provided to promote healing. Findings include: 1. For Resident #4, the facility failed to follow their skin care protocols and care plan, they did not provide a pressure relieving cushion to prevent pressure ulcer development. The facility also failed to provide timely treatment to prevent worsening of a pressure ulcer. The resident developed a pressure ulcer to his/her coccyx which was first documented as a "red" area and progressed to an unable to stage area requiring treatment with a topical [MEDICATION NAME] agent (removes non-viable tissue). Review of the resident's clinical record, on 01/08/14, indicated that the resident was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set Assessment (MDS), dated [DATE], indicated that the resident required extensive assistance for bed mobility and transfers. He/she required limited assistance once walking. The MDS coded the resident as having two unstageable pressure areas, one on each foot. The MDS also indicated that the resident was utilizing a chair cushion for pressure reduction. Review of the facility's "Skin Care Protocol for All Residents", not dated, included the following: * Norton Plus Skin Assessment Scale will be done on admission and quarterly. * The Charge Nurse will be notified of any redness or open areas. This may warrant another Norton Plus Assessment. * Complete description and measurement of all wounds will be documented on admission or at onset and at weekly intervals to assist in tracking the effectiveness of treatment. * Prevention Protocol: Pressure Relief in Chair: Verbally direct patient to shift weight in chair every hour when possible. * Utilize appropriate pressure relief devices in chairs, never use foam donuts, and reposition every 2 hours or put resident back to bed according to schedule. Review of the resident's most recent Norton Plus Pressure Ulcer Scale, dated 11/26/13, indicated that the resident scored a 12, which indicates that the resident is at moderate risk for skin breakdown. Despite an area of redness identified on 12/28/13, a subsequent Norton Plus assessment was not completed despite the facility skin care policy indicating that another assessment be completed. A care plan, dated 11/26/13, was developed for "At risk for development of pressure ulcers related to severe dementia and diabetes type 2", with a goal that the "resident will not develop pressure ulcers in the next 90 days. Interventions included the following: * Pressure relief mattress * Pressure relief cushion * Heel protectors * Turning schedule as appropriate * Norton Plus assessment weekly for 3 weeks after admission. then quarterly, annually and with significant change * CNA observation of skin during care with report * Weekly skin check by Licensed Nurse * Lotion to skin with AM/PM care * Head of bed maintained in lowest comfortable position * Monitor dietary intakes, weights and hydration for adequacy * Resident/caregiver ed-pressure relief and nutrition * Skin prep to areas on bottom of bilateral feet every shift * Obtain diabetic shoes * Non skid socks when in bed Review of the December 2013 Treatment Administration Record (TAR), indicated an entry by a Licensed Nurse as follows: * 12/28/13- Cream applied to coccyx, buttock very red Review of the January 2014 TAR, indicated entries by Licensed Nurses as follows: * 1/1/14 -Buttock area slightly red, treatment applied. * 1/2/14 -Buttock area red, intact, open, treatment applied. * 1/6/14-Coccyx area 2.5 centimeter (cm) by 1.5 cm by 0.3 cm. There was no TAR documentation in regard to the progress of the coccyx pressure area on 01/03/14, 01/04/14, 01/05/14. Review of the Monthly skin check tools indicated the following: December 2013: * 12/26/13- Right and left feet-small black unstageable areas. Stoma intact. There were no entries in regard to the resident's coccyx. January 2014: * 01/02/13 (although on the January 2014 monthly form)- coccyx area red, small open area noted measuring 0.75 cm by 0.5 cm. Bilateral legs dry, intact. (There were no corresponding nurses' notes or new physician orders [REDACTED]. * 01/09/14- Small open area on coccyx. Two small unstagable areas on bottom of bilateral feet. Review of interim physician telephone orders indicated the following: * 12/28/13-Apply clear moisture barrier cream secondary to redness twice a day * 12/31/13- Discontinue clear moisture barrier cream to coccyx and change to Triad paste to coccyx twice a day (there are no corresponding nurses notes that explain the need for change in treatment) * 01/07/14- [MEDICATION NAME] AG, to coccyx change every 3 days or as needed, wash area with normal saline and pat dry, skin prep to perimeter before dressing application (5 days after nursing first documented on the skin check tool that the resident's coccyx was open) * 01/09/14- Wash area with normal saline, pat dry, skin prep surrounding skin. Apply a small amount of Santyl (a topical [MEDICATION NAME] agent) cover with a [MEDICATION NAME] border, change daily and as needed. There was no evidence that the physician was notified or that a treatment plan was revised once the pressure ulcer open on 01/02/14. Treatment observation on 01/09/14 at 11:30 A.M., revealed an open area to the resident's coccyx. The area was approximately 1.5 cm by 1.5 cm by 0.2 cm, a small area of slough was identified. This was also observed by Nurse Practitioner #1 who said that the wound now needed [MEDICATION NAME]. Review of Nurse Practitioner #1's progress note, dated 01/09/14, indicated that the area to the resident's coccyx was now an unable to stage area, and if no better, would refer the resident to the wound clinic next week. During interview on 01/10/14 at 10:30 A.M., Nurse Manager #1 said that she was not aware that there was documentation on 1/02/14 identifying that the area on the resident's coccyx was open. She said she wasn't aware until 01/06/14. She said that there was no change in the treatment plan until 01/07/14. Observation on 1/8/14 at 10:30 A.M., revealed the resident sitting in a specialized wheelchair with a pressure relieving cushion. During interview on 01/08/14 at 10:40 A.M., Physical Therapy Assistant #1 (PTA #1) said that he was trying new seating for Resident #4 because she/he was having difficulty with positioning and had a new open area. He continued to say that this was the first cushion issued to this resident. When asked why the resident didn't have a cushion in place prior to 01/08/14, PTA #1 said because she could ambulate around. During interview on 01/08/14 at 11:00 A.M., Nurse Manager #1 (NM #1) said that Resident #4 does not ambulate independently and would not get up from a seated position without staff intervention. She continued to say that a new routine was implemented to keep the resident off of his/her coccyx, because she/he has a pressure ulcer on the coccyx. This schedule was not in place prior to the development of the pressure ulcer. Review of the resident's Certified Nurses Aide Assignment, dated 12/30/13, indicated that the resident required assistance with mobility and transfer. There was no indication that a chair cushion was utilized. 2. For Resident #10, the facility failed to develop and ensure that the resident received effective, preventive interventions that would relieve pressure to the resident's heel, in order to prevent the development of a pressure area as well as aid in healing of the pressure ulcer. The resident developed a stage two pressure ulcer (2 centimeter (cm) by 2.5 cm blister) to his/her left heel. Review of the facility "Skin Care Protocol for All Residents", not dated, included the following: * Norton Plus Skin Assessment Scale will be done on admission and quarterly. * The Charge Nurse will be notified of any redness or open areas. This may warrant another Norton Plus Assessment. * Complete description and measurement of all wounds will be documented on admission or at onset and at weekly intervals to assist in tracking the effectiveness of treatment. * Prevention Protocol: Pressure Relief in Chair: Verbally direct patient to shift weight in chair every hour when possible. * Utilize appropriate pressure relief devices in chairs, never use foam donuts, and reposition every 2 hours or put resident back to bed according to schedule. Review of the resident's medical record on 10/09/14 at 3:00 P.M., indicated that the resident was admitted to the facility in 11/2013, with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 12/02/13, indicated that the resident scored a 15 on the BIMS (Brief Interview for Mental Status) interview, indicating that the resident was cognitively intact, and the resident required extensive assist for transfers, dressing, bathing and grooming. The resident coded "0" for the presence of pressure sores. Review of the "risk for impaired skin integrity related to diabetes" care plan, initiated 11/26/13, indicated the following: * Initial /weekly skin checks * Diabetic foot care daily * Ensure proper footwear and socks(white) * Regular podiatry visits The care plan did not address keeping the resident's left foot off the bed to prevent pressure ulcer development (per the facility skin care protocols). Review of the "Alteration in skin integrity, resident has stage 2 pressure ulcer" care plan, initiated 12/17/13, after the pressure ulcer developed, indicated the following: * Pressure relief mattress * Pressure relief cushion * Multi podus boot (free floats the resident's heel), must be worn in bed daily * Skin prep to left heel twice daily Review of the resident's 01/2014 treatment record indicated the following treatments: * Multipodus Boot to left heel, must be worn in bed daily * Weekly skin assessment on Monday 7-3 shift * Monitor left heel every shift for intactness Review of a weekly pressure ulcer progress report,dated 12/17/13, indicated the resident developed a blister on his/her left heel. The blister measured 2 cm by 2 cm. On 01/10/14 at 11:00 A.M., observation of the resident's left heel revealed a flat discolored blister approximately 4 cm by 3 cm in diameter. Review of the CNA (certified nurse aide) assignment, dated 12/13/13 indicated the following preventative measures: *[MEDICATION NAME] cream ( although it did not say to which body parts) * Wheelchair cushion Review of the CNA flow sheet, dated December 2013, indicated the resident received Baza cream to heels and coccyx twice daily. The CNA flow sheet did not address the need for keeping the resident's left heel off the bed to decrease prevention of pressure ulcer development, per the facility skin care protocols. On 01/10/14 at 8:15 A.M., observation of the resident revealed him/her lying in bed with his/her left foot lying on the bed. He/she had a slipper sock on. Further observation revealed a blue heel protector boot stored on top of the resident's closet. This was out of the resident's reach. During interview on 01/10/14 at 9:45 A.M., Resident #10 said that he/she is supposed to wear the blue boot when he/she is in bed. He/she said it hasn't been on for awhile. The surveyor asked if it had been off since he/she went to bed the previous evening. He/she said yes, as I said, it hasn't been on for awhile. During interview on 01/10/14 at 11:30 A.M, Nurse Manager #2 said she saw it wasn't on and had since put it on the resident's left foot.

Based on observation, record review and interviews, the facility failed to notify the physician of a change in condition with a pressure ulcer for 1 Resident (#4) in a total sample of 12 residents. Findings include: Review of the resident's clinical record, on 01/08/14, indicated that the resident was admitted to the facility in 11/2013 with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set Assessment (MDS), dated [DATE], indicated that the resident required extensive assistance for bed mobility and transfers. He/she required limited assistance once walking. The MDS coded the resident as having two unstageable pressure areas, one on each foot. The MDS also indicated that the resident was utilizing a chair cushion for pressure reduction. Review of the December 2013 Treatment Administration Record (TAR), indicated an entry by a Licensed Nurse as follows: * 12/28/13- Cream applied to coccyx, buttock very red. Review of the January 2014 TAR, indicated entries by Licensed Nurses as follows: * 1/1/14 -Buttock area slightly red, treatment applied. * 1/2/14 -Buttock area red, intact, open, treatment applied. * 1/6/14-Coccyx area 2.5 centimeters (cm) by 1.5 cm by 0.3 cm. There was no TAR documentation in regard to the progress of the coccyx pressure area on 01/03/14, 01/04/14, 01/05/14. Review of the Monthly skin check tools indicated the following: December 2013: * 12/26/13- Right and left feet-small black unstageable areas. Stoma intact.- There were no entries in regard to the resident's coccyx. January 2014: * 01/02/13 (although on the January 2014 monthly form)- coccyx area red, small open area noted measuring 0.75 cm by 0.5 cm. Bilateral legs dry, intact. (There were no corresponding nurses' notes or new physician orders [REDACTED]. * 01/09/14- Small open area on coccyx. Two small unstagable areas on bottom of bilateral feet. Review of interim physician telephone orders indicated the following: * 12/28/13-Apply clear moisture barrier cream secondary to redness twice a day * 12/31/13- Discontinue clear moisture barrier cream to coccyx and change to Triad paste to coccyx twice a day (there are no corresponding nurses notes that explain the need for change in treatment) * 01/07/14- [MEDICATION NAME] AG, to coccyx change every 3 days or as needed, wash area with normal saline and pat dry, skin prep to parameter before dressing application (5 days after nursing first documented on the skin check tool that the resident's coccyx was open) * 01/09/14- Wash area with normal saline, pat dry, skin prep surrounding skin. apply a small amount of Santyl (a topical [MEDICATION NAME] agent) cover with a [MEDICATION NAME] border, change daily and as needed There was no evidence that the physician was notified or that a treatment plan was revised once the pressure ulcer opened on 01/02/14. During interview on 01/10/14 at 10:30 A.M., Nurse Manager #1 said that she was not aware that there was documentation on 1/02/14 identifying that the area on the resident's coccyx was open. She said she wasn't aware until 01/06/14. She said that there was no change in the treatment plan until 01/07/14. She continued to say that the physician was not notified of a change in the pressure ulcer until 01/07/14. The facility failed to ensure the resident's physician was notified timely with a change of condition of a pressure ulcer. Please refer to F314

Based on observation, record review and interviews, for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure that 1) Resident #1's bed sensor alarm pad functioned properly and sounded when Resident #1 fell from the bed on 2/20/12 at 4:45 A.M. and sustained a fracture of the right distal ulna. 2) In addition, the bed sensor alarms used for 3 of 3 sampled residents at risk for falls (Resident #2, Resident #3, and Resident #4) were not always used per manufacturer's instructions and, therefore, the bed sensor alarm pads were potentially ineffective interventions to prevent falls. Findings include: 1) The Admission Record indicated that Resident #1 was admitted to the Facility January, 2012. The Accummulative [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 1/9/12, indicated that Resident #1's cognitive ability was moderately impaired and Resident #1 ambulated with a 1 person assist and a rolling walker Certified Nurse Aide (CNA) #1 was interviewed on 3/16/12 at 1:20 P.M. CNA #1 said that Resident #1's bed sensor alarm pad was checked at approximately 11 P.M. on 2/19/12, and it was operational. Charge Nurse #1 was interviewed on 3/16/12 at 11:15 A.M. Charge Nurse #1 said the CNAs checked the bed sensor alarms at the start of the shift. Charge Nurse #1 said that a call for help was heard at approximately 4:45 A.M. on 2/20/12, and Charge Nurse #1 found Resident #1 lying by the bed on the floor on Resident #1's right side. Charge Nurse #1 said the bed sensor alarm was not sounding. Charge Nurse #1 said Resident #1 complained of pain to the right arm or wrist. Charge Nurse #1 said after Resident #1's assessment, Resident #1 was put back to bed. Review of Resident #1's Radiology Report, dated 2/20/12, indicated that the right forearm demonstrated a subtle fracture of the distal ulna. Charge Nurse #1 said Resident #1 was sent to the Hospital. Charge Nurse #1 said she checked the bed sensor alarm unit and the bed sensor alarm pad. Charge Nurse #1 said the bed sensor alarm pad was connected by a wire to the bed sensor alarm unit. Charge Nurse #1 said the battery cover was on the bed sensor alarm unit, and there was no indication the batteries needed replacement. Charge Nurse #1 said Resident #1's bed sensor alarm unit was restarted and the bed sensor alarm pad was found to be fully operational. Charge Nurse #1 said it was not known why Resident #1's bed sensor alarm did not sound when Resident #1 fell off the bed. On 3/16/12 at 1:45 P.M. the Surveyor observed Resident #1 in bed. The Director of Nurses (DON) removed Resident #1's bed sensor alarm pad for the Surveyor to review. Resident #1's bed sensor alarm pad was observed to have been underneath an air mattress which was located on top of the mattress. Resident #1's bed sensor alarm pad instructions noted that for optimal performance of the thin bed sensor pad, to adhere to the following guidelines. The sensor pad noted the following as "Important!" The thin Bed Sensor Pad (6 month guarantee) do not use with patients under 100 pounds, do not use under mattress and replace after 6 months of use. Resident #1's bed sensor alarm pad noted which side was to be facing up, and set up instructions included to record the initial use on the pad. 2) The Director of Nurses (DON) was interviewed on 3/16/12 at approximately 2:40 P.M. The DON said she had not known that the bed sensor alarm pad's initial use needed to be dated on the pad and that residents had to weigh over 100 pounds. The DON said the Facility did not know how long the bed sensor alarm pads for each resident had been in use. The DON said the Facility did not have information specifying that staff received training on the proper use of the bed sensor pads. Per Interdisciplinary Care Plan Approaches, (dated 7/12/11 for Resident #2 and dated 10/26/11 for Resident #3) Resident #2 and Resident #3 used a bed sensor alarm. A review was conducted of residents' current weights as of 3/12/12 and 3/15/12 to a list of residents using bed sensor alarms. Resident #2 and Resident #3 were found to weigh less than 100 pounds. On 3/12/12 Resident #3 weighed 95.8 pounds and on 3/15/12 Resident #2 weighed 85 pounds. On 3/16/12 at 2:44 P.M., the Surveyor observed Resident #2's bed sensor pad was on top of the mattress placed upside down. The date of 9/1/11 was noted on the bed sensor pad. The bed sensor pad noted the following as "Important!" The thin Bed Sensor Pad (6 month guarantee). On 3/16/12 at 2:43 P.M. the Surveyor observed Resident #3 lying in bed with the bed sensor alarm pad in place on top of the mattress with no date of its initial use recorded. On 3/16/12 at 2:45 P.M. the Surveyor observed, in the presence of the DON, that Resident #4's bed sensor alarm was manufactured by a different company than the other residents's bed sensor alarms. The DON stated that the DON did not know that a different manufacturer's sensor alarm system existed in use in the Facility. The DON said the DON did not have an owners manual or any information on the system. During the Surveyor's investigation on 3/16/12 at 9:23 A.M. Resident #4 was observed seated in a wheelchair in the hallway on a chair sensor alarm pad. The Surveyor observed that Resident #4's chair sensor alarm unit (attached to the pad by a wire) was missing the cover of the battery compartment. The Surveyor observed that two out of the four batteries were partially dislodged. The chair sensor alarm did not sound when Resident #4 was assisted off the wheelchair. Resident #4's chair sensor unit's batteries were pushed into position, but the unit still continued to not function. Resident #4's chair sensor unit only functioned properly after the battery cover was located and secured over the batteries. The DON said the Facility did not routinely replace batteries on the bed sensor alarm unit or the chair sensor alarm units unless a distinct noise was heard to sound to indicate the batteries were weak. CNA #1 said sometimes at the start of the 11 P.M. shift, residents' bed sensor alarms were found by CNA #1 not to be operational because the batteries were dead or the batteries made a distinct sound to indicate they were weak.

Based on observation, record review and interview with staff, the facility failed to ensure that 1 resident (#3) in a sample of 16 residents received the necessary care and services to address the resident's change in medical condition. The findings include: For resident #3, the facility failed to provide the resident with the necessary care and services when the resident was observed with a change in mental status, garbled speech, drool from the right side of the mouth and left hand weakness. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/2011 at 12:00 P.M., the resident was observed eating lunch in his/her bedroom. A certified nurses aide was observed verbally encouraging the resident to finish eating the lunch meal. Review of the resident's clinical record on 6/7/2011 at 11:30 A.M., revealed a significant change Minimum Data Set ((MDS) dated [DATE] which indicated the resident had a legal guardian, was moderately impaired with daily decision making, required extensive assistance with activities of daily living,was independent with eating and was continent of bladder and bowel. The most recent quarterly MDS dated [DATE] which indicated the resident was moderately impaired with daily decision making, required extensive assistance with activities of daily living, was independent with eating and was frequently incontinent of bladder and bowel. Review of the clinical record on 6/7/2011 at 11:45 A.M., revealed a nursing note dated 11/11/2010 at 2:15 P.M. which read, "Resident change in mental status, garbled speech, drool from right side of mouth, left hand weakness, unable to follow simple commands, 160/70. To send to hospital ER for eval. Guardian aware of transfer. " Review of the physician's orders [REDACTED].M., revealed the resident had a physician's orders [REDACTED]. Further record review on 6/7/2011 at 12:00 P.M., revealed a nursing note dated 11/12/2010 late entry for 11/11/2010, 7 - 3 shift. The nursing note indicated that at 2:15 P.M., nursing responded to the sound of an alarm and found the resident sitting on the edge of the bed. The nurse asked the resident if he/she could help the resident and the resident responded, "I need to go to the bathroom". The nursing note indicated the resident ambulated to the bathroom without any difficultly and then a certified nursing aide assisted the resident with toileting. The resident was brought to the dining room when another staff person asked "what is wrong with the resident ?". According to the nurse, "the resident was not speaking, but would smile when asked if he/she was okay". The resident's blood pressure was documented to be 160/78, pulse 68 and respirations 24. The resident's grasp had a slight weakness in the left hand, left pupil was smaller and less reactive to light. The resident was able to follow commands such as lifting his/her legs, but was not able to hold a cup with the left hand. The nurse noted that the resident responded to questions in a low garbled manner. There was no futher information at that time that indicated the nurse identified the resident's change in medical condition required urgent medical intervention.. On 6/7/2011 at 12:09 P.M., further review of the nursing noted dated 11/12/2010, indicated there was an emergency with another resident which the nurse responded to. The nurse did not request urgent medical care regarding resident #3's change in condition before he/she attended to the other emergency. The nurse returned approximately 10 minutes later and observed the resident to be alert and attempting to stand. However, according to the nurse, the resident did not respond verbally. At this time, the nurse notified the Nurse Practitioner (NP) who requested that the resident's guardian be notified to find out if the guardian wanted the resident be transferred to the hospital. The guardian was contacted and wanted the resident to be transferred to the hospital. The NP was contacted again, and approximately 10 to 15 minutes later, an order was obtained from the NP to transfer the resident to the hospital. The facility requested an ambulance and the resident left the facility at approximately 3:30 P.M. This was a delay of approximately one hour from the time the resident had a change in medical condition. On 6/8/2011 at 9:05 A.M., review of the ambulance report dated 11/11/2010 indicated "stable per caller, left sided weakness, caller specifically stated that an emergency response was not required ". According to the ambulance report, the ambulance was contacted by the facility at 3:01 P.M., dispatched at 3:04 P.M., and arrived at the facility at 3:32 P.M. The ambulance's travel time was 28 minutes to the facility, as this ambulance request was not considered an emergency by the facility. The ambulance arrived at the hospital at 4:02 P.M, resulting in an one and one half hour delay since the resident was first observed with a change in medical condition. On 6/8/2011 at 9:15 A.., review of the hospital emergency report dated 11/11/2010 indicated the resident had [MEDICAL CONDITION], but was able to follow commands. The resident presented to the emergency room with weakness of the right side of the face. The emergency report also stated,"Spoke with doctor---- from Neuro who reviewed Cat scan and there is already evidence of an [MEDICAL CONDITION] suggesting time course over 3 hours". Further review of the hospital emergency room report indicated the Neuro physician "spoke with the NH and the pt. awoke from nap with symptoms and as such the exact onset is over three hours and pt. is not lytic candidate". The resident was admitted to the hospital with a preliminary [DIAGNOSES REDACTED]. On 6/8/2011 at 9:20 A.M., review of the hospital neurological consultation dated 11/12/2010 indicated a left frontal stroke, but the age could not be determined. The consultation further stated because of the lack of timeline, t-PA (Tissue Plasminogen Activator, a clot busting medication which needs to be given within 3 hours after the start of stroke symptoms) was not given. On 6/8/2011 at 9:25 A.M., review of the hospital discharge summary dated 11/12/2010 indicated the resident had a CAT scan of the head while in the emergency room which showed cerebral atrophy with diffuse small vessel ischemic change. The resident's discharge [DIAGNOSES REDACTED]. 1. Probable left hemisphere stroke. 2. [MEDICAL CONDITION] secondary to #1. 3. [MEDICAL CONDITION]. 4. History of sick sinus syndrome status [REDACTED]. 5. History of falls. According to the hospital discharge summary, the resident's condition had slightly improved and the resident was being discharged back to the facility. The resident was readmitted back to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/8/2011 at 9:30 A.M., the Director of Nurses (DON) stated that he/she had contacted the nurse (no longer employed at the facility) who cared for the resident on 11/11/10, approximately 7 months ago. Review of the statement dated 6/7/2011 by the nurse indicated the resident was more talkative and was getting up from a chair before the NP was notified. This statement was not consistent with the nurse's note written by the nurse dated 11/12/2010 that indicated the resident was not verbally responsive before the NP was notified. On 6/8/2011 at 9:35 A.M., the DON stated that according to the facility's clinical protocol, if a nurse assesses a resident who has signs and symptoms that could indicate a stroke, the resident's physician is contacted. The physician will evaluate whether a hospital transfer is indicated for additional evaluation and treatment. Review of the 10/2010 facility's Stroke/[MEDICAL CONDITION] (TIA) -Clinical Protocol on 6/8/2011 at 9:40 A.M. confirmed what the DON had stated regarding the facility's protocol for a stroke. After surveyor inquiry, the facility revised the clinical protocol. On 6/8/2011 at 9:50 A.M., the DON stated the facility's new clinical protocol will be if a new stroke is suspected, the nurse will immediately dial 911 and state that an emergency response is required. On 6/8/2011 at 10:15 A.M. and 10:50 A.M., the resident was observed seated in a chair in the second floor activity/dining room. At 10:55 A.M., the surveyor spoke to the resident and the resident responded with a "Hello" and smiled. The facility failed to immediately notify the ambulance company that an emergency response was needed after the nurse assessed and determined the resident had a change in medical condition. As a result, the ambulance arrived at the hospital at 4:02 P.M., one and one half hours after the resident had a change in medical condition. The delay in treatment prevented the resident from receiving the t-PA clot buster medication.