Every finding on record at Kimwell Nursing and Rehabilitation

Based on observations and interviews, the facility failed to ensure residents had a homelike environment on three of three units. Specifically, the facility failed to: 1. Repair water damaged ceiling tiles on the K3 unit; 2. Ensure Resident #18 had a bedroom with walls, blinds, and durable medical condition in good repair; and 3. Ensure residents' bedrooms were homelike and free from holes and damaged window treatments on the K1 and K2 units.Findings include:Review of the facility's policy titled Homelike Environment, dated 2001, indicated but was not limited to the following:-the facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These include a clean, sanitary, and orderly environment.-the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.During an interview on 3/11/26 at 11:00 A.M., the Ombudsman Program Director said she observed ceiling tiles that were drooping from water damage, and one of them had a hole which she reported to staff on the unit last week.Throughout the survey, the surveyor observed the ceiling tiles drooping from water damage on the K3 unit at the following times:-3/10/26 at 10:06 A.M., two staff members were standing under the damaged tiles looking up at them.-3/11/26 at 8:39 A.M., one resident was sitting under the damaged tiles.-3/12/26 at 7:30 A.M., four residents were sitting under the damaged tiles.-3/12/26 at 1:00 P.M., two residents were sitting under the damaged tiles.Review of the TELS (a comprehensive building management platform that streamlines work order creation, preventive maintenance, and asset management for facilities, particularly in senior living communities) work order log failed to indicate the damaged ceiling tiles on the K3 unit were reported.During an observation with an interview on 3/11/26 at 1:40 P.M., Nurse #4 was passing medications near the damaged tiles and said if there is anything on the unit that is broken or damaged, she would report it in TELS. She said the maintenance department monitors the system and will repair the reported concern. She said she reported a concern related to a deflating air mattress today.During an interview on 3/12/26 at 11:19 A.M., the Maintenance Director said he starts his day by reviewing the work orders reported in TELS and if he sees something he will write it down on a scrap piece of paper to remind him to complete later. He said he was not aware the tiles were damaged. He said it was likely from the excessive snow and melting from a recent storm on 2/22/26.During an interview with an observation on 3/12/26 at12:14 P.M., the Administrator said he expects concerns like damaged ceiling tiles to be reported immediately and fixed quickly. He said all staff have access to the system and should be reporting any damaged part of the building they observe. 2. Resident #18 was admitted to the facility in February 2026 with a history of falls. Review of the Minimum Data Set assessment, dated 2/21/26, indicated Resident #18 scored 14 out of 15 on the Brief Interview for Mental Status indicating he/she is cognitively intact.During an interview on 3/10/26 at 11:40 A.M., Resident #18 said the wheelchair and his/her room have been in disrepair since he/she was admitted to the facility in February. The Resident said the wheelchair, provided to him/her by the facility, had a ripped armrest with the foam exposed. Resident #18 said he/she has had a lot of interactions with various staff members daily, but it has not been identified by staff as needing repair despite its ripped appearance and foam exposure. In addition, the Resident said there are holes and scratches in the walls. The Resident said he/she would hope that as staff come into the room they would let someone know, especially since the staff providing care have better vision than him/her, they would report it to maintenance. The Resident also said the blinds have had a large rip in them since the day he/she moved into their room.During an interview on 3/12/26 at 11:19 A.M., the Maintenance Director said he doesn't have time to work on preventative maintenance projects because most of his day is filled with working on items in TELS and he depends on staff to inform him if something is in disrepair. He said he was unaware of the Resident's equipment or condition of the room. He expects the residents would have a clean and homelike environment.During an interview on 3/12/26 at 12:14 P.M., the Administrator said he expects resident rooms to be clean and in good repair prior to a resident admitting to the facility. He said there should be a process for ensuring the room is homelike for the resident. 3. During a tour of the K1 unit on 3/11/26 at 1:25 P.M., the surveyor observed the following:-The dining room had 8-inch scratches on the wall, paint chipped, and an air conditioner in the wall covered with a bed sheet. Four residents were in the room with two staff members.-room [ROOM NUMBER] had blinds that were ripped.-room [ROOM NUMBER] had blinds that were ripped and the curtain bracket was coming out of the wall. The blind was being held up by face masks tied together. There was a round hole in the sheetrock.-room [ROOM NUMBER] had broken curtain brackets and holes in the window wall approximately 5 inches in height. The wall had an approximate 6-inch gauge with areas in disrepair. The molding was detached off the wall and large areas of paint was removed from wall located next to the heating vent. There was a large gaping hole located on the right-hand side of window and with rotted wood around window.During a tour of the K2 unit on 3/11/26 at 1:55 P.M., the surveyor observed the following:-The dining area/living room area on the second floor had blinds with multiple rips in them.-room [ROOM NUMBER] had a broken cabinet on the nightstand.-room [ROOM NUMBER] had a windowsill in disrepair, appearing from water damage.-rooms [ROOM NUMBER] had blinds that were ripped.-room [ROOM NUMBER] had the curtain bracket detached from the wall.-In the hallway, there were two areas of approximately one foot each of handrails that were not securely affixed to the wall and were loose to the touch.Review of the TELS log failed to indicate these areas observed by the surveyor were reported or identified by staff or the maintenance director.During an interview on 3/12/26 at 11:19 A.M., the Maintenance Director said he relies on staff to identify areas that need maintenance and report them in TELS.During an interview on 3/12/26 at 12:26 P.M., the Ombudsman said the environment takes a long time to get noticed and fixed. He said once he brings it to the facility's attention it will get fixed but sometimes there is a delay. He said he does not believe there is any preventative maintenance being done. During an observation with interview on 3/12/26 at 12:14 P.M., the Administrator said he expects the residents to have a homelike environment which is not what is reflected in some areas after touring the three units. He said he expects the issues to be addressed, and that staff are identifying and reporting these environmental issues every day.

Based on interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified. Specifically, the facility failed to ensure timely and accurate surveillance data for all infection types to identify a pattern of E-Coli Urinary Tract Infections (UTI) (bacterial infection, caused by E-Coli bacteria, typically originating from the gut, entering the urinary tract, and causing inflammation, often due to improper wiping/perineal care) and implement interventions to decrease the risk of residents developing E-Coli UTIs. Findings include:Review of the facility's policy titled Surveillance for Infections, dated as last revised September 2017, indicated but was not limited to the following:-The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions (TBP) and other preventative interventions.-The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections.-Infections that will be included in routine surveillance include those with clinically significant morbidity or mortality associated with the infection (pneumonia, urinary tract infection (UTI), and C. difficile).-Nursing staff will monitor residents for signs and symptoms that may suggest infection and will document, and report suspected infections to the charge nurse.-Gathering Surveillance Data: If laboratory reports are used to identify relevant information, the following findings merit further evaluation: positive urine cultures (bacteriuria) with corresponding signs and symptoms that suggest infection.-In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted.-Data Collection and Recording: For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: Date of onset of infection, list symptoms, diagnostic test result, infection site, pathogens, pertinent remarks of symptoms, and treatment measures and precautions.-For targeted surveillance: Collect information, summarize monthly data by unit, site, and pathogen, identify predominant pathogens or sites of infections and observe for trends, and compare infection rates.-Interpreting Surveillance Data: Analyze the data to identify trends and consider how increases or decreases might relate to recent process changes, events, or activities in the facility (changes in handwashing preparations, increased turnover in personnel or residents). Review of the facility's Infections Line Listing reports from October 2025 through March 2026 indicated but were not limited to the following:OCTOBER 2025:-23 of the 31 entries had missing and/or incomplete data.-9 UTIs; 4 had the organism documented; 1 with no culture; 2 E-Coli.NOVEMBER 2025:-26 of the 42 entries had missing and/or incomplete data.-17 UTIs; 12 had the organism documented; 3 with no culture; 4 E-Coli.DECEMBER 2025:-11 of the 25 entries had missing and/or incomplete data.-7 UTIs; 5 had the organism documented; 1 E-Coli.JANUARY 2026:-17 of the 33 entries had missing and/or incomplete data.-13 UTIs; 10 had the organism documented; 1 with no culture; 4 E-Coli.FEBRUARY 2026:-33 of the 41 entries had missing and/or incomplete data.-8 UTIs; 3 had the organism documented; 2 with no culture; 3 E-Coli.MARCH 2026:-6 of the 11 entries had missing and/or incomplete data.-3 UTIs; 3 E-Coli. During an interview on 3/13/26 at 2:52 P.M., Unit Manager #2 said she runs an antibiotic report at the end of the month to complete the line list. She said they discuss things in morning meeting, but she fills out the Line List at the end of the month. During an interview on 3/13/26 at 3:34 P.M., the Infection Preventionist (IP) said if someone goes on an antibiotic then they are added to the Line List, the McGeer and Antibiotic Time-Out are done. She said the Line List is done on the units by the Unit Managers and then turned in. She said she does not always review the Line List for accuracy or review the notes/McGeer. The surveyor reviewed the Line List with the IP, and the IP said there was missing data and missing entries. She said she had seen a trend in UTIs a while ago but had not currently identified a trend with the E-Coli UTIs. She said overall the Line List is not very good because it doesn't show all the details for analysis since there is data missing. She said with the E-Coli pattern, that should have led to more education and training with the direct care staff, because they are usually from not washing well. She said we did that a while ago but not recently. During an interview on 3/13/26 at 4:31 P.M., the Director of Nurses said the Line List should be complete and accurate to be able to analyze the data. She said the progress notes should tell the story related to the infection and symptoms and they do not. She said she doesn't review the Line List monthly, the IP reviews it for trends, but the symptoms, type of organism, treatment, and follow up should all be documented and they are not. She said the E-Coli pattern indicates we should be doing more in-servicing around peri care. Refer to F881

Based on interview and document review, the facility failed to implement an antibiotic stewardship program which included a system to monitor antibiotic use, including prophylactic antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance. Specifically, the facility failed:1. For Resident #56, to document the rationale for antibiotic treatment of an infection not meeting the criteria of an infection;2. For Resident #2, to ensure he/she was prescribed an antibiotic susceptible to the organism growth and to document rationale for antibiotic treatment of an infection not meeting the criteria of an infection;3. For Resident #35, to ensure he/she was prescribed an antibiotic susceptible to the organism growth and not treated with a prophylactic antibiotic concurrently and to document rationale for antibiotic treatment of an infection not meeting the criteria of an infection;4. For Resident #21, to document the rationale for antibiotic treatment from a Hospice recommendation of an infection not meeting the criteria of an infection and to document follow up with provider after a repeat culture was recommended; and5. For Resident #16, to document the rationale for antibiotic treatment of an infection not meeting the criteria of an infection and to document follow up with provider after the culture resulted. Findings include:Review of the facility's policy titled Antibiotic Stewardship, dated as last revised December 2016, indicated but was not limited to the following:-The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.-When a nurse calls a physician/prescriber to communicate a suspected infection, he/she will have the following information available: Signs and symptoms, when they started, hydration status, infection type, and time of the last antibiotic dose.-When antibiotics are prescribed over the phone, the primary care practitioner will access the resident within 72 hours of the telephone order. Review of the facility's policy titled Antibiotic Stewardship-Orders for Antibiotics, dated as last revised December 2016, indicated but was not limited to the following:-Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).-Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record. Review of the facility's policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated as last revised December 2016, indicated but was not limited to the following:-The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship.-All clinical infections treated with antibiotics will undergo review by the IP.-All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered will include date that symptoms appeared, name of antibiotic, start/stop date of antibiotic, date of culture, pathogen identified, and outcome. 1. Resident #56 was admitted to the facility in October 2025 with diagnoses which included Urinary Tract Infection (UTI), diabetes, and paranoid psychotic disorder. Review of the medical record including nursing notes, physician progress notes, McGeer Assessments (tool utilized to see if an illness meets the criteria for an infection), orders, Medication Administration Records (MAR), and lab results indicated but were not limited to the following: NOVEMBER 2025-11/1/25 through 11/25/25 no signs/symptoms of a UTI documented.-11/5/25 seen by the Nurse Practitioner (NP) and complained of dysuria (discomfort urinating) with new order for labs and a urine (UA C&S).-11/10/25 seen by the Physician (MD), no sign/symptoms of a UTI reported, and started on Bactrim twice daily for three days.-Urine culture report not provided by the facility to the surveyor.-He/she completed the course of antibiotics.-A McGeer Assessment was completed indicating additional symptoms not documented in the medical record had been present and the UTI met criteria.-The UTI was coded on the monthly Line List of Infections as a HealthCare Associated Infection (HAI) that met criteria for an infection (although it did not meet criteria per documentation).-11/25/25 noted with confusion, new order from NP for labs, chest X-Ray, and urine.-11/26/25 he/she had no documented signs/symptoms of a UTI, was started on Rocephin Igram (g) intramuscularly (IM) daily for five days, culture still pending.-11/28/25 the culture resulted positive for Klebsiella Pneumoniae greater than 100,000colonies /milliliter (c/ml) and to continue antibiotic as ordered.-He/she completed the course of antibiotics.-A McGeer Assessment was completed indicating additional symptoms not documented in the medical record had been present and the UTI met criteria.-The UTI was coded on the monthly Line List of Infections as a HAI that met criteria for an infection (although it did not meet criteria per documentation). DECEMBER 2025-12/20/25 started Clindamycin for cellulitis (skin infection)-12/23/25 Clindamycin discontinued due to loose stools.-12/28/25 he/she was behavioral and hallucinating and was transferred to the hospital.-12/31/25 returned to the facility with a UTI (diagnosed on [DATE]), to complete a course of Cefuroxime 500mg twice daily for a week.-A McGeer Assessment was not completed for cellulitis or the UTI.-The cellulitis was coded on the monthly Line List of Infections as a HAI that met criteria for an infection.-The UTI was not coded on the monthly Line List of Infections. JANUARY 2026-He/she completed the course of antibiotics for UTI on 1/8/26.-1/1/26 through 1/31/26 he/she had no signs/symptoms of UTI documented.-1/21/26 he/she was hallucinating and NP ordered labs, a urine, and for psych to see him/her.-1/21/26 urinalysis resulted negative.-A McGeer Assessment was not completed for the UTI diagnosed at the hospital.-The UTI was coded on the monthly Line List of Infections as a Community Acquired Infection (CAI) that met criteria for an infection (although it did not meet criteria per documentation) and should have been coded as a HAI as culture date was the date of transfer. 2. Resident #2 was admitted to the facility in October 2025 with diagnoses which included obstructive reflux uropathy (urine flow is blocked or flows backwards), UTI, and urogenital implants (medical device to treat incontinence). Review of the medical record including nursing notes, physician progress notes, McGeer Assessments, Hospital paperwork, orders, MARs and lab results indicated but were not limited to the following: NOVEMBER 2025-11/1/25 and 11/2/25 he/she had no signs/symptoms of a UTI documented.-11/2/25 he/she was transferred to the emergency room for chest pain and returned the same day after being treated for muscular chest pain, chest congestion, and viral respiratory illness.-11/3/25 verbal orders for labs, a UA C&S, and Prednisone (steroid) taper were given. No signs/symptoms of a UTI were documented.-11/7/25 he/she continued to have no signs/symptoms of a UTI, had congestion, cough, and wheezing noted. New order obtained for a chest X-ray.-11/7/25 UA C&S resulted positive for Klebsiella Pneumoniae and Enterococcus Faecalis both greater than 100,000 c/ml. Resident remained asymptomatic and was started on Ertapenem 1g IM for five days. Neither organism was susceptible to Ertapenem per the culture report.-A McGeer Assessment was not completed.-Nurse Practitioner (NP) note indicated the culture was reviewed and antibiotics started and failed to indicate any symptoms of a UTI had been present.-He/she completed the course of IM antibiotics for a positive urine culture with no clinical symptoms.-The UTI was coded on the monthly Line List of Infections as a HAI that met criteria for an infection (although it did not meet criteria per documentation). FEBRUARY 2026-2/1/26 through 2/10/26 he/she had no signs/symptoms of a UTI.-2/9/26 a UA C&S was obtained and pending results. The progress notes failed to indicate why a UA C&S was obtained.-2/10/26 he/she was transferred to the hospital with uncontrolled shaking and diagnosed with a UTI. He/she returned to the facility seven days later after completing a course of antibiotics at the hospital.- A McGeer Assessment was not completed.-The infection was not tracked on the monthly Line List of Infections. 3. Resident #35 was admitted to the facility in June 2025 with diagnoses which included Benign Prostatic Hyperplasia (BPH-enlarged prostate) with lower urinary tract symptoms, neuromuscular dysfunction of the bladder (nerve damage to bladder), cerebral infarct (CVA-stroke), and resistance to Vancomycin (potent antibiotic to treat serious resistant bacterial infections). Review of the medical record including nursing notes, physician progress notes, McGeer Assessments, orders, MARs, and lab results indicated but were not limited to the following: JANUARY 2026-Methenamine Hippurate (Hiprex-antibiotic to reduce/prevent UTIs) 1g twice a day indefinitely. (6/25/25)-1/5/26 seen by NP, lethargic and confused, insulin dose increased, and labs ordered.-1/6/26 lab work indicated high white blood cell count 11.9 (WBC-high levels often indicate inflammation or infection, normal range is 5-10).-1/6/26 through 1/10/26 he/she had no documented signs/symptoms of a UTI.-1/10/26 UA C&S resulted positive for Escherichia Coli (E-Coli) greater than 100,000c/ml. Resident remained asymptomatic and was started on Vantin 200mg twice daily for seven days. The culture and sensitivity report did not list Vantin as an antibiotic the organism was susceptible to or resistant to.-A McGeer Assessment was completed indicating an additional symptom not documented in the medical record had been present and the infection met criteria.-He/she completed the course of antibiotics for a positive urine culture with no clinical symptoms other than confusion and lethargy four days prior to the urine resulting and received the Hiprex daily.-The UTI was coded on the monthly Line List of Infections as a HAI that met criteria for an infection (although it did not meet criteria per documentation). FEBRUARY 2026-Methenamine Hippurate (Hiprex) 1g twice a day indefinitely. (6/25/25)-2/1/26 through 2/15/26 he/she had no signs/symptoms of a UTI.-2/15/26 he/she was confused, agitated, and attempted to walk (despite being unable to ambulate). Labs, urine, and Trazodone (medication to treat agitation) were ordered.-2/17/26 he/she was coughing, chest X-Ray showed air disease, and he/she was started on Levaquin 500mg for seven days. UA C&S remained pending with no documented signs/symptoms of a UTI.-2/18/26 Urinalysis resulted positive, culture was still pending. NP changed antibiotics from Levaquin to Bactrim twice a day for seven days, review culture when complete.-A McGeer Assessment was done for respiratory illness meeting criteria of an infection however the McGeer failed to address the UTI.-2/21/26 UA C&S resulted positive for E-Coli/Extended-spectrum beta-lactamase (ESBL-bacteria resistant to many antibiotics) 50,000-100,000c/ml. The organism was resistant to both Levaquin and Bactrim. NP ordered Macrobid 100mg twice a day for seven days.-Resident continued to present with no signs/symptoms of a UTI and completed the course of antibiotics and received the Hiprex daily until 2/26 when the pharmacist recommended it be held while on the Macrobid.-The Pneumonia and UTI were coded on the monthly Line List of Infections as a HAI that met criteria for an infection (although the UTI did not meet criteria per documentation). 4. Resident #21 was admitted to the facility in November 2023 with diagnoses which included hemorrhoids, chronic constipation, flaccid neuropathic bladder, and palliative care. Review of the medical record including nursing notes, physician progress notes, McGeer Assessments, orders, MARs, and lab results indicated but were not limited to the following: JANUARY 2026-1/1/26 through 1/13/26 he/she had no signs/symptoms of a UTI.-He/she had a Foley catheter in place.-1/13/26 he/she presented with hematuria (blood in the urine) in the catheter bag.-1/13/26 he/she was seen by the Hospice Nurse, and a recommendation was made for Keflex 250mg twice a day for five days for a suspected UTI. The only symptom noted was hematuria.-A urine was not ordered.-He/she completed the course of antibiotics. Hematuria continued off and on.-1/20/26 Foley catheter irrigation ordered.-1/21/26 Hospice advised staff to contact them with increased hematuria/clots.-A McGeer Assessment was completed indicating an additional symptom not documented in the medical record had been present and the infection met criteria.-The UTI was coded on the monthly Line List of Infections as a HAI that met criteria for an infection (although it did not meet criteria per documentation). FEBRUARY 2026-2/1/26 through 2/3/26 he/she had no signs/symptoms of a UTI documented.-2/3/26 he/she had hematuria and Hospice recommend obtaining a urine. No other signs/symptoms of a UTI were documented, and the Foley catheter remained in place.-2/6/26 he/she presented with respiratory symptoms, urine culture resulted positive for greater than 100,000c/ml mixed gram-negative organisms and recommended a repeat culture if clinically indicated.-2/7/26 he/she was seen by Hospice who recommended Doxycycline 100mg twice a day for upper respiratory infection (URI).-The notes failed to indicate the provider was made aware of the recommendation for a repeat culture.-He/she completed the course of antibiotics.-A McGeer Assessment was completed indicating an additional symptom not documented in the medical record had been present and the UTI met criteria however the McGeer failed to address the URI.-The URI was coded on the monthly Line List of Infections as a HAI that met criteria for an infection. 5. Resident #16 was admitted to the facility in July 2025 with diagnoses which include BPH without lower urinary tract symptoms, urinary retention, and diabetes. Review of the Medial Record including nursing notes, physician progress notes, McGeer Assessments, orders, MARs, and lab results indicated but were not limited to the following: FEBRUARY 2026-2/1/26 through 2/18/26 no documented signs/symptoms of a UTI documented.-2/18/26 he/she was sent to the hospital for hip pain. He/she returned the same day with diagnoses of hip pain and urinary retention. Labs at the hospital indicate a WBC of 15.1 and urine culture was pending. Nursing to follow up on the culture with the hospital. Additional labs ordered.-2/19/26 call placed to hospital requesting culture. Repeat urine ordered due to glucosuria (glucose in the urine).-2/21/26 at 6:55 A.M., NP returned 12:00 A.M., phone call regarding the urinalysis and hematuria, covering NP ordered Cipro 500mg twice daily for seven days for UTI and to encourage fluids (the culture was still pending at this time).-2/21/26 at 8:29 A.M., the culture resulted with less than 10,000c/ml mixed gram positive and negative. The progress notes failed to indicate this culture result was reported to the NP/MD.-2/21/26 through 2/28/26 he/she continued with off and on hematuria, but no other signs/symptoms of a UTI had been documented.-He/she completed the course of antibiotics.-A McGeer Assessment was completed indicating an additional symptom not documented in the medical record had been present and the UTI did not meet criteria.-The URI was coded on the monthly Line List of Infections as a possible UTI on prophylactic treatment. During an interview on 3/13/26 at 2:52 P.M., Unit Manager (UM) #2 said the nurses on the unit do the McGeer Assessment and she doesn't check them for accuracy. She said the Antibiotic time out is done by the nurse too and they do not write good notes, so she is unable to speak of what information may have been discussed and why these residents continued antibiotic treatment. UM #2 said she runs a report at the end of the month of all residents on antibiotics and those are the residents she puts on the Line List of Infections. She said she has two residents on prophylactic antibiotics but those are not tracked. She said the Infection Preventionist (IP) reviews it all. During an interview on 3/13/26 at 3:34 P.M., the IP said if a test resulted positive, they would go on the Line List to track the infection and anyone on an antibiotic. She said the UM's complete the Line List but she doesn't review it for accuracy. She said the line list is not great because it doesn't show all of the data accurately as it should. She said they do not have a tracking system for prophylactic antibiotics; she said they defer to the specialists and did not know what residents were on prophylactic treatment or if their medical record had an indication for use and follow up from the providers. She said every infection/illness should have an accurate McGeer assessment completed and the symptoms should be documented in the notes. She said the McGeer assessments are not all accurate. She said the antibiotic 48-hour review with the MD is a check box and the system doesn't prompt the nurses to write a note, but they should. Additionally, if the culture isn't back when the 48-hour alert populates there is not an additional one. She said if the infection does not meet criteria the provider should be notified, detailed notes written, and an additional note written about why the treatment is going to continue. The IP said the Hospice recommendations need to be reviewed with the provider and a note detailing why treatment is occurring if the infection doesn't meet criteria should be done and there is nothing in the record. These issues do not follow our Antibiotic Stewardship program to ensure residents are not on antibiotics they may not need. During an interview on 3/13/26 at 4:31 P.M., the Director of Nurses (DON) said the McGeer assessments and the Line List should be complete and accurate to ensure proper use of the antibiotics and tracking of infections. She said the signs/symptoms should be documented in the medical record to match the McGeer assessment and many do not match. Additionally, all applicable sections of McGeer assessments should be complete and they are not. She said for infections not meeting criteria there should be additional notes indicating why they are being treated and there are not. She said they need to do a better job to ensure residents are not being treated with antibiotics they may not need or are incorrect.

Based on observations, record review, and interviews, the facility failed to ensure activities of daily living (ADL) care was provided to maintain good personal hygiene for one Resident (#35), in a total sample of 21 residents. Specifically, the facility failed to ensure showers were offered and provided per his/her shower schedule. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL) Support, dated as last revised March 2018, indicated but was not limited to the following:-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.-Refusal of care and information are documented in the resident's clinical record.-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including support and assistance with hygiene (bathing, dressing, grooming, and oral care). Resident #35 was admitted to the facility in June 2025 with diagnoses which included abnormal gait and mobility, cerebral infarct (stroke), osteoarthritis, and left hip pain. Review of the Minimum Data Set (MDS) Assessment, dated 3/11/26, indicated Resident #35 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, and was dependent on staff for ADLs, bathing, and showering, and had not refused care. Review of the Nursing Assignment roster indicated Resident #35 was scheduled for showers twice weekly, Tuesday 7-3 shift and Wednesday 3-11 shift. Review of the Certified Nursing Assistant (CNA) Assignment sheet indicated Resident #35 was scheduled for showers twice weekly, Tuesday 7-3 shift and Wednesday 3-11 shift. Review of the Comprehensive Care Plan indicated but was not limited to the following:FOCUS:-The Resident has an ADL self-care performance deficit related to deconditioning and fatigue.INTERVENTION:-Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated.-Maximum assistance with bathing.-May use Hoyer (mechanical lift) as needed (PRN). Review of the CNA Care Card/Kardex indicated but was not limited to the following:-Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated.-Maximum assistance with bathing.-May use Hoyer PRN. During an interview on 3/10/26 at 9:15 A.M., Resident #35 said he/she had not been showered in at least three weeks. The Resident said he/she would like a shower, but the staff don't do it because they must Hoyer me to the shower bed and it is a pain. The Resident said he/she cannot sit safely in the regular shower chair which is why they need to use the shower bed. Additionally, he/she said their nails are long and dirty, they have not been cut, and he/she has never had nail care done. The Resident said he/she was going to ask for them to be cut again today because he/she had an appointment. The surveyor made the following observations:-3/10/26 at 9:15 A.M., Resident lying in bed, hair long, greasy, nails long and dirty with dark substance under the nail bed.-3/11/26 at 12:18 P.M., Resident sitting in reclining Broda chair (positioning chair), disheveled with hair long, greasy, and uncombed. Nails were trimmed at his/her request. During an interview on 3/11/26 at 12:18 P.M., Resident #35 said he/she was not showered last night or this morning. He/she said the CNAs are afraid to use the chair because he/she might fall out of it and they must use the big shower bed. He/she said they used it a couple of weeks ago, but there are not always enough staff to use it. Review of the CNA shower documentation from 2/1/26 through 3/12/26 indicated Resident #35 was not showered 6 out of 12 scheduled days and one out of the 12 scheduled days it was documented the Resident refused. Review of the nursing progress notes from 2/1/26 through 3/12/26 failed to indicate he/she was offered and refused a shower. Further review of the one refusal indicated it occurred on 3/11/26 on the 3-11 shift. During an interview on 3/12/26 at 12:05 P.M., Resident #35 said he/she did not get a shower yesterday, but this morning staff washed him/her up in bed. He/she said it's fine, but they would prefer a shower. During an interview on 3/12/26 at 2:15 P.M., CNA #1 said showers are given weekly, the schedule for every resident is on the assignment sheet. She said they have a shower chair and a shower bed for those residents that are Hoyer lifts. She said they document if they got the shower or not in the computer. During an interview on 3/12/26 at 2:20 P.M., Nurse #1 said showers are scheduled twice a week, one on day shift and one on evening shift. She said the CNAs document if they got it or not, but any refusal should be reported to the nurse and then documented int the progress notes. During an interview on 3/12/26 at 2:29 P.M., Unit Manager #2 said showers are to be given per the schedule on the assignment sheet. She said it is on both the nurses and CNAs' assignment sheet. She said one is during the day and one in the evening and she would expect the nurses to check with the aides to ensure it was done. Additionally, she said if someone refuses, the nurse should talk to them and then document in the progress note that they refused. She said the CNAs have been educated to let the nurse know if someone refuses so they can follow up. She said the CNAs document on the computer whether the resident got the shower or not, but the nurse does not have a check off on the treatment sheets. She said Resident #35 got a good bed bath today, hair was washed, combed, and trimmed. During an interview on 3/12/26 at 3:10 P.M., the Director of Nurses (DON) said showers should be given twice a week and if a resident refuses the nurse should be notified. Then the nurse should check with the resident and if they still refuse it should be documented in the progress notes. During an interview on 3/13/26 at 4:41 P.M., the DON said she would expect the shower to be given on each scheduled day, and it was not per the documentation. She said the CNAs should not be documenting not applicable (N/A) in the scheduled shower days, it should state the residents transfer status for the shower or refused if they refused the shower. Additionally, she said if he/she had refused for some reason there should be a progress note and there are not any.

Based on record review and interview, the facility failed to ensure a resident at with an alteration in skin integrity related to a wound, specifically chronic venous ulcers, received necessary treatment and services to promote healing for one Resident (#74), out of a total sample of 21 residents. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary for seven days. Findings include: Review of the facility's policy titled Medication Orders, dated as last revised November 2014, indicated but was not limited to the following:-A current list of orders must be maintained in the clinical record of each resident.-Treatment Orders: When recording treatment orders, specify the treatment, frequency, and duration of the treatment. Review of the facility's policy titled Charting and Documentation, dated as last revised July 2017, indicated but was not limited to the following:-All services provided to the resident, progress toward the care planned goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the Interdisciplinary Team (IDT) regarding the resident's condition and response to care.-The following information is to be documented in the resident medical record: Treatments or services provided.-Documentation in the medical record will be objective, complete, and accurate. Resident #74 was admitted to the facility in January 2026 with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA) infection, localized edema, chronic venous hypertension with ulcer of bilateral lower extremities, peripheral vascular angioplasty with implants and grafts, non-pressure chronic ulcer of part of the left lower leg, and chronic venous insufficiency. Review of the Minimum Data Set (MDS) Assessment, dated 3/5/26, indicated Resident #74 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, was a risk for pressure ulcers, and had medication/ointments applied. Review of the medical record indicated he/she was transferred to the hospital and re-admitted to the facility after a 10-day stay at an acute care hospital for sepsis, pneumonia, and wound management. Review of the Comprehensive Care Plan indicated but was not limited to the following:FOCUS: The resident has potential/actual impairment to skin integrity related to fragile skin. Actual: LLE vascular Ulcers.INTERVENTIONS:-Follow facility protocol for treatment of injuries.-Monitor/Document location, size, and treatment of skin injury. Review of the Discharge summary, dated [DATE], indicated but was not limited to the following:-discharge date : [DATE]-Follow up issues for provider: Continue Wound Care.-Assessment and Plan: Left lower extremity (LLE) stasis ulcer: Antibiotic course for wound infection completed. Continue with local wound care: LLE: Cleanse with warm water and mild soap, dry, apply A&D ointment to intact skin, Aquacel AG to wound bed, cover with ABD pads, secure with kling. Change dressing every Monday-Wednesday-Friday. 2/5/26 wound culture +MRSA and Carbapenem resistant pseudomonas. Contact Precautions. Review of the admission orders on 2/24/26 failed to indicate a treatment was ordered for the LLE ulcer until 3/3/26. Review of the Treatment Administration Record (TAR) for February and March 2026 indicated but was not limited to the following:-A treatment was in place for the LLE ulcer prior to the hospitalization. (Cleanse LLE with wound cleanser, pat dry, apply xeroform, followed by 4x4 gauze, wrap with kling and change twice daily. 1/29/26)-No treatment was in place for LLE ulcer from 2/24/26 through 3/3/26.-A treatment was ordered for LLE ulcer on 3/3/26. (Cleanse LLE with wound cleanser and pat dry. Apply xeroform to open areas, apply Abd pad followed by kerlix wrap one time day. 3/3/26). Review of the Nursing Progress note, dated 2/24/26, indicated Resident #74 was readmitted and the LLE treatment remained in place. Review of the Nursing and Physician progress notes from February and March failed to indicate the physician declined to order the treatment per the Discharge Summary to the LLE upon return from the hospital. During an interview on 3/13/26 at 2:44 P.M., Nurse #6 said she did the admission and the LLE treatment was not entered into the computer. She said it was the first one she had done, had some help, but the order was missed. She said orders from the Discharge Summary should have been entered into the computer when Resident #74 returned from the hospital. She said she was off for a few days and when she returned to work, she realized there was not a treatment order in place for the LLE ulcer and obtained an order for one on 3/3/26. She said when they do an admission a second nurse checks the medications, but she was unsure if anyone checks the treatments to ensure nothing was missed. During an interview on 3/12/26 at 2:52 P.M., Unit Manager (UM) #2 said all medication and treatment orders from the Discharge Summary should have been reviewed with the provider and entered into the computer. She said she follows up for appointments, labs, etc. Additionally, she said a second nurse checks the medications and then the UM completes an audit tool, but she could not recall if the audit was done for this readmission and was unsure why the orders were not implemented for a week. During an interview on 3/13/26 at 4:30 P.M., the Director of Nurses (DON) said the nurse confirms the meds and treatments with the provider and enters them into the computer. She said the audit tool should be done by leadership and then given to her, but in this case the order was missed, and the audit was not done due to the snowstorm.

Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Properly monitor medication refrigeration temperatures in one of three medication storage rooms reviewed to ensure the safety and integrity of vaccines stored; and2. Provide a permanently affixed compartment and separate from all other medications for the storage of schedule IV (low potential for misuse and dependence) controlled substance in two of three medication room refrigerators reviewed. Findings include:Review of the facility's policy titled Medication Storage in the Facility, dated November 2021, indicated but was not limited to the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.-Controlled substances that require refrigeration are stored within a locked box within the refrigerator.-This box must be attached to the inside of the refrigerator.-The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC (Centers for Disease Control and Prevention) guidelines. Review of CDC guidance titled Epidemiology and Prevention of Vaccine-Preventable Diseases: Chapter 5: Vaccine Storage and Handling, dated 4/3/24, indicated but was not limited to the following:Monitoring Vaccine Temperatures:-To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD (temperature monitoring device) that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). 1. On 3/11/26 at 10:34 A.M., the surveyor reviewed the facility's medication storage room on the K1 Unit with Nurse #3 and observed the following inside the medication refrigerator:-One dose of Afluria Quadrivalent (inactivated influenza vaccine).-One dose of Prevnar 20 (vaccine used to prevent pneumococcal pneumonia and invasive disease). During an interview on 3/5/26 at 11:39 A.M., Nurse #3 said vaccines are stored in this refrigerator for the residents on the unit. She said the temperature is monitored only once a day on the 11:00 P.M.-7:00 A.M. shift. Review of the medication refrigerator Temperature Logs dated September 2025 through March 2026 indicated temperatures were being monitored and recorded only once daily. 2. On 3/11/26 at 11:04 A.M., the surveyor reviewed the facility's medication storage room on the K2 Unit with Nurse #5 and observed the following inside the medication refrigerator:-A locked box glued to a removable glass shelf. Nurse #5 opened the lock box and inside was the following medications:-Two bottles of liquid Lorazepam 0.5 milligrams (mg) (a schedule IV narcotic used to treat anxiety)Nurse #5 said the locked box is not secure inside the refrigerator and can be easily removed. Nurse #5 said it is supposed to be secured. On 3/11/26 at 11:12 A.M., the surveyor reviewed the facility's medication storage room on the K3 Unit with Nurse #2 and observed the following inside the medication refrigerator:-A locked box glued to a removable glass shelf. Nurse #2 opened the lock box and inside was the following medication:-One bottle of liquid Lorazepam 0.5 mgNurse #2 said the locked box is supposed to be secured to the refrigerator and not removable. She said it is not secure as it should be. During an interview on 3/16/26 at 11:51 A.M., the Director of Nursing (DON) said her expectation is for refrigerator temperatures to be monitored twice a day for all vaccine storage to maintain the efficacy of the vaccines. The DON said all narcotics must be stored with a double locking method. She said the lock boxes must be affixed to the refrigerator and not a shelf that can be removed.

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for two Residents (#74 and #35), out of a total sample of 21 residents. Specifically, the facility failed to ensure:1. For Resident #74, the Medical Orders for Life Saving Treatment (MOLST) in the Electronic Medical Record (EMR) matched the active Do Not Resuscitate, Intubate, or Ventilate physician's order; and2. For Resident #35, with a diagnosis of dysphagia (difficulty swallowing), he/she did not have conflicting therapeutic diet orders of Regular texture versus Mechanical Soft/Ground texture in the active medical record. Findings include: 1. Review of the facility's policy titled Electronic Medical Record (EMR), dated 12/19/22, indicated but was not limited to the following:-The EMR's quality and integrity shall be maintained by adhering to identified standards in entering complete, concise, accurate and updated information that produces clear and useful medical record.-Staff making entry into the EMR are responsible for checking for contradictory information and ensuring the accuracy of the medical necessity of any information that is imported. Review of the facility's policy titled Do Not Resuscitate (DNR) Order, dated as last revised March 2024, indicated but was not limited to the following:-DNR orders must be signed by the resident's attending physician on the physician's order sheet and maintained in the resident's medical record. Resident #74 was admitted to the facility in January 2026 with diagnoses which included myocardial infarction (MI/heart attack), malignant neoplasm of the skin, heart failure, and heart block. Review of the active Physician's Orders in the EMR indicated but was not limited to the following:-Honor most recent MOLST-DNR, Do Not Intubate and Ventilate (DNI), Do Not use CPAP, Transfer to the Hospital, May use Dialysis, No Artificial Nutrition, Use Artificial Hydration. (2/26/26). Review of the EMR indicated but was not limited to the following:-The scanned documents section had one MOLST, dated 1/6/26, indicating Resident #74 was a Full Code and wanted to be resuscitated, intubated, and ventilated. Review of the paper chart/medical record indicated but was not limited to the following:-A pink MOLST, dated 2/26/26, indicated Resident #74 was a DNR, DNI. During an interview on 3/12/26 at 2:20 P.M., Nurse #1 said when a MOLST is updated, the original is put in the paper chart, and a copy is placed into the bin to be scanned. She said Medical Records scans them in, usually within a week. She looked in the bin and there were not any documents for Resident #74. She said she always checks the paper chart, but the most recent and accurate MOLST should be scanned into the EMR. During an interview on 3/12/26 at 2:29 P.M., Unit Manager #2 said when a MOLST is changed the original goes in the paper record and a copy goes in the bin to be scanned. She said everything should be scanned within a week. She said we have had some issues with things not being scanned in timely. During an interview on 3/12/26 at 3:10 P.M., the Director of Nurses (DON) said when a MOLST is updated the original goes in the paper chart and a copy is made and placed in the bin for Medical Records to scan. She said they scan documents a couple times a week but would expect it to be scanned within a week. She said the nurses have been educated to check the paper charts for the MOLST and to go by that one, but she could see how there is potential for someone to get the wrong information. 2. Review of the facility's policy titled Therapeutic Diets, undated, indicated but was not limited to the following:-Diet will be determined in accordance with treatment goals and wishes.-Therapeutic diet must be prescribed by the attending physician.-A Therapeutic diet is considered a diet ordered to modify specific nutrients or to alter the texture of a diet, for example: diabetic/calorie controlled or altered consistency diet.-If a mechanically altered diet is ordered, the provider will specify the texture modification.-The dietician, nursing staff, and attending physician will regularly review the need for and acceptance of his/her therapeutic diet.-Snacks will be compatible with the therapeutic diet. Resident #35 was admitted to the facility in June 2025 with diagnoses which included diabetes mellitus, heart disease, and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) Assessment, dated 3/11/26, indicated Resident #35 scored 10 out of 15 in the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, was on a therapeutic diet, and not on a mechanically altered diet. During an interview on 3/10/26 at 9:15 A.M., Resident #35 said he/she didn't think the facility was managing his/her diet very well. Review of the active Physician's Orders indicated the following:-CCHO/Diabetic Diet: Mechanical Soft (ground meat) texture, thin consistency. (3/2/26)-CCHO/Diabetic Diet: Regular texture, thin consistency, diabetic diet, DOUBLE PROTEIN, half portion of starch, sugar free ice cream with lunch and dinner. (8/29/25) Review of the ST evaluation and notes indicated but were not limited to the following:-3/3/26 Evaluation: Diagnosis: Dysphagia (difficulty swallowing). Patient was referred by nursing for a swallowing evaluation due to difficulty masticating (chewing) solids/meats. Assessment Summary: Patient requires ST for dysphagia management, compensatory strategies, and education. Diet Considerations: Thin liquids and Mechanical soft/chopped textures.-3/3/26 through 3/12/26 visit notes indicate functional status as a result of skilled interventions: Thin liquids and Mechanical soft/chopped textures During an interview on 3/12/26 at 12:10 P.M., Unit Manager (UM) #2 said the nurse on Team One checks the lunch trays for correct texture and for thickened liquids if needed. After reviewing the meal ticket for Resident #35, UM #2 said she thought the word Regular referred to the liquids because it also says Mechanical Soft/Ground but was not sure. She said no one should have two active diet orders because they could get the wrong one. Additionally, she said she wasn't sure where the CNAs got diet information from if it was outside of mealtime. During an interview on 3/12/26 at 12:13 P.M., the Infection Preventionist (IP) said the CNAs and other staff get diet information from a daily printed diet report. During an interview on 3/12/26 at 12:14 P.M., the Activities Director said there is a report that gets printed daily with everyone's diet order. He printed the report and provided it to the surveyor. Review of the Diet Type Report indicated but was not limited to the following:-Resident #35: Diet Type: CCHO/Diabetic; Diet Texture: Mechanical Soft (ground meat); Fluid Consistency: Thin-Resident #35: Diet Type: CCHO/Diabetic; Diet Texture: Regular; Fluid Consistency: Thin; Additional Directions: diabetic diet, DOUBLE PROTEIN, half portion of starch, sugar free ice cream with lunch and dinner During an interview on 3/12/26 at 12:16 P.M., the Activities Director said Resident #35 had two diet orders listed and that is an issue because it is not clear which one is correct. During an interview on 3/12/26 at 12:16 P.M., the Assistant Director of Nurses said the aides should be asking the nurse about a diet if they have questions. She said the accurate diet for Resident #35 is a regular diet. She said there are two different orders in the computer and there shouldn't be. She said when a new diet order is written the previous one should be discontinued. During an interview on 3/12/26 at 12:19 P.M., UM #2 said she reviewed the orders and speech downgraded the diet to ground meat on 3/2/26 and the nurse that reviewed and signed the order must have forgotten to discontinue the other diet and that is why there are two different orders. She said the kitchen is sending ground meat, but orders need to be fixed. During an interview on 3/12/26 at 3:10 P.M., the Director of Nurses (DON) said the nurse checks the tray at meals to ensure the correct texture. She said the CNAs or Activity staff have questions; they should ask the nurse. She said the meal ticket does show both the Ground and Regular texture, the orders in the computer show both as active orders, and the Diet report has Resident #35 listed twice with two different diet orders. She said the CNAs and Activities staff use the daily report to reference diets and this is not clear what Resident #35 should in fact be getting. She said the nurse should have questioned why there were two orders and clarified to ensure they only get the correct diet. She said when the nurse took the diet downgrade order on 3/2/26 they did not discontinue the previous order. She said the computer program used for meal tickets communicates with the physician orders and that is why both diets are listed. She said there should be only one active order.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who became unsteady during a transfer and was lowered to the floor by staff, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 08/30/25, after Resident #1 was lowered to the floor, two Certified Nurse Aides (CNAs) transferred him/her up off the floor without informing and having the nurse assess him/her first for the potential for physical injury, Resident #1 exhibited a sudden change in his/her condition, with signs and symptoms of severe pain, was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fracture of his/her left hip.Findings include:Review of the Facility's Policy, titled Falls and Fall Risk, Managing, dated as revised March 2018 indicated the following:-a fall is defined as: unintentionally coming to rest on the ground, floor or other lower level; an episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall.-a fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Review of the Facility's Certified Nursing Assistant (CNA) Job Description, dated as revised October 2020, indicated the following:-the primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as directed by supervisors. -report all changes in the resident's condition to the Charge Nurse/ Nurse Supervisor as soon as practical.-perform all assigned tasks in accordance with established facility policies and procedures, and as instructed by your supervisors.Resident #1 was admitted to the Facility in November 2023, diagnoses included Dementia, cognitive communication deficit, disorders of bone density and structure (affects strength and composition of bones), rheumatoid arthritis, and hypertensive heart disease (high blood pressure).Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/04/25, indicated that he/she was severely cognitively impaired.Review of Resident #1's Fall Risk Assessment, dated 08/21/25, indicated that he/she was at moderate risk for falls.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/05/25, indicated on 08/30/25 at approximately 11:30 A.M., CNA #1 was transferring Resident #1 to the toilet, he/she became unsteady, and CNA #1 lowered him/her to the floor. The Report indicated that CNA #1 called for assistance (from another CNA), both CNA #1 and CNA #2 stood Resident #1 up and pivoted him/her onto the toilet, he/she then had a sudden change in his/her (facial) color, was diaphoretic (sweating) and the CNAs called out for the nurse. The Report further indicated that Resident #1 complained of pain 10/10 (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain), but the origin of pain could not be identified, he/she was sent to the hospital for evaluation, a Computed Tomography (CT) scan (imaging test that uses X-rays) of his/her abdomen revealed a left hip fracture, and he/she was admitted .Review of Resident #1's Nurse Progress Note, dated 08/30/25 (written by Nurse #1), indicated that Nurse #1 was called to Resident #1's bathroom related to a change in his/her condition and when Nurse #1 entered the room Resident #1 was sitting on the toilet. The Note indicated that Resident #1 looked ashy in color and when asked if he/she was having pain, Resident #1 answered yes but he/she was unable to identify the location of his/her pain.The Note indicated that Resident #1's vital signs, range of motion and neurological signs were assessed, he/she continued to yell out in pain, clenching his/her body with facial grimacing and was noted to be crying. The Note further indicated that the Nurse Practitioner was notified immediately, and an order was given to send Resident #1 to the hospital for evaluation and treatment.Review of Resident #1's Pain Assessment, dated 08/30/25, indicated that Resident #1 was unable to verbally answer but exhibited non-verbal/non-cognitive signs of pain that included crying/whimpering, frowning/scowling, grimacing, groaning, guarding, moaning and perspiration, according to the faces on the pain Scale, his/her pain was noted as hurts worst. The Assessment indicated that his/her pain intensity was a 10 out 10 and the location of his/her pain was unable to be identified.During an interview on 10/07/25 at 12:54 P.M., (which included review of her written statement dated 08/30/25) CNA #1 said on 8/30/25 around 11:30 A.M. she went to toilet Resident #1, assisted him/her to a standing position and his/her whole body started shaking. CNA #1 said she lowered Resident #1 to the floor because he/she was unsteady and she did not want him/her to fall. CNA #1 said she yelled out to CNA #2 for help and said they stood Resident #1 up, then transferred him/her onto the toilet. CNA #1 said Resident #1 started to look pale, his/her face was sweating, and she called for the nurse. CNA #1 said she should have called for the nurse before transferring Resident #1 from the floor onto the toilet but said she did not think when she lowered Resident #1 to the floor that it was considered a fall. During an interview on 10/07/25 at 1:54 P.M., (which included review of her written statement dated 08/30/25) CNA #2 said CNA #1 came out of Resident #1's room and asked her for help. CNA #2 said she went to Resident #1's room, saw him/her sitting on the floor outside the bathroom doorway, and said asked CNA #1 if Resident #1 had fallen. CNA #2 said CNA #1 told her that Resident #1 was wobbly, unsteady and she (CNA #1) had lowered him/her to the floor.CNA #2 said she and CNA #1 stood Resident #1 up and transferred him/her onto the toilet. CNA #2 said Resident #1 looked sweaty and pale, he/she did not respond when they asked him/her if he/she was okay and said CNA #1 went to get the nurse.CNA #2 said she did not call for the nurse when Resident #1 was on the floor because CNA #1 told her she lowered Resident #1 to the floor and said she (CNA #2) did not think it was considered a fall.During an interview on 10/08/25 at 12:57 P.M., Nurse #1 said on 08/30/25, CNA #1 and CNA #2 called her to Resident #1's bathroom. Nurse #1 said when she entered Resident #1's bathroom, he/she was sitting on the toilet, looked ashy in color and had facial grimacing. Nurse #1 said she asked Resident #1 if he/she had pain, he/she stated yeah and when asked where his/her pain was, he/she did not respond.Nurse #1 said she asked the CNAs exactly what happened, and that's when CNA #1 told her when she went to toilet Resident #1, he/she could not stay standing up and that she (CNA #1) had lowered Resident #1 to the floor. Nurse #1 said she then asked the CNAs how Resident #1 got onto the toilet and said CNA #1 told her that she (CNA #1) had asked CNA #2 to help get Resident #1 up and they (CNAs) transferred him/her onto the toilet.Nurse #1 said if a resident is lowered to the floor, it is considered a fall. Nurse #1 said she was not informed when Resident #1 was lowered to the floor and said that the CNAs should have informed her before moving Resident #1 so she could have assessed him/her at that time for any potential injuries.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED with nonspecific pain and he/she was noticed to have some tenderness overlying his/her left hip. The Summary indicated Resident #1's CT scan showed an acute comminuted left femoral intertrochanteric fracture (hip fracture) and he/she was admitted .During an interview on 10/07/25 at 3:08 P.M., the Director of Nursing (DON) said she was notified on 08/30/25 by Nurse #1 that Resident #1 was being sent to the hospital for evaluation due to a change in his/her condition. The DON said she interviewed staff and determined that Resident #1 had been lowered to the floor because he/she became shaky and CNA #1 and CNA #2 transferred him/her up off the floor onto the toilet (prior to notifying Nurse #1).The DON said anytime a resident is lowered to the floor or there's a change in plane, it is considered a fall. The DON said her expectation was that both CNA #1 and CNA #2 should have called for the nurse prior to getting Resident #1 up off the floor and transferring Resident #1 onto the toilet.

Based on observations, interviews, and maintenance record review, the facility failed to ensure the environment was free from accident hazards for two out of three units in the facility. Specifically, the facility failed to ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms and shower rooms. Findings include: Review of the facility's policy titled Water Temperatures, Safety of, dated 2001, included but was not limited to the following: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. -Policy Interpretation and Implementation: 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 115 degrees Fahrenheit, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (such as hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. 5. Direct care staff shall be informed of the risk factors for scalding/burns that are more common in the elderly, such as: a. decreased skin thickness; b. decreased skin sensitivity; c. peripheral neuropathy; d. reduced reaction time; e. decreased cognition; f. decreased mobility; and g. decreased communication. 6. The length of exposure to warm or hot water, the amount of skin exposed, and the resident's current condition affect whether or not exposure to certain temperatures will cause scalding or burns. Therefore, ongoing resident observation and assessment during prolonged exposure to warm or hot water will help to determine the safety of the situation. Review of the Department of Public Health 105 CMR 150.470 Standards for Long Term Care Facilities indicated hot water supplied to fixtures accessible to residents shall be controlled to maintain a temperature between 110 and 120 degrees Fahrenheit (F). On 12/11/24 at 3:43 P.M., during an environmental tour of the facility, the surveyors tested the temperature of the hot water in resident bathroom sinks and shower rooms with the following results: -room [ROOM NUMBER]: 133F at 3:43 P.M. -room [ROOM NUMBER]: 133.2F at 3:50 P.M. -room [ROOM NUMBER]: 124.7F at 3:55 P.M. -Shower room [ROOM NUMBER] (on Unit 2): 138.5F at 4:13 P.M. -Shower room [ROOM NUMBER] (on Unit 2): 133.7F at 4:16 P.M. -Shower room [ROOM NUMBER] (on Unit 3): 135.5F at 4:23 P.M. -Shower room [ROOM NUMBER] (on Unit 3): 138.5F at 4:28 P.M. During an interview on 12/11/24 at 4:02 P.M., Resident #84 said the water temperature in the shower room could get too hot and was unsafe. Resident #84 said when he/she is in the shower room, he/she is offered to feel the water temperature by the Certified Nursing Assistant (CNA) prior to being showered. Resident #84 said there had been instances when the water was way too hot and he/she could have been scalded had he/she not tested the water temperature. The Resident said residents are at the mercy of the staff and expressed concern that staff could harm residents with the hot water. During an interview on 12/11/24 at 5:04 P.M., the Director of Maintenance (DOM) said he checks water temperatures every week but hadn't in the past two weeks. The DOM said each week he sampled faucet water in ten resident rooms by running the water for three minutes to get it as hot as possible. The DOM said the water in resident and shower rooms should not exceed 110F and anything above 110F could be too hot and unsafe. The DOM said if any resident room or shower room water temperatures exceed 110F, he would then lower the water temperature at the main boiler (a closed vessel in which fluid is heated) and adjust the house mixing valve (a device, also known as a temperature control valve, that controls the mix of hot and cold water in order to deliver water at a consistent, safe temperature) that delivers water to the units, including resident and shower rooms. The DOM said he keeps the boiler temperature at 135-140F, and there have been no water temperature issues since he came to the facility in July 2024. On 12/11/24 at 5:15 P.M., the DOM and surveyors tested the water temperatures for rooms #203, #204, and Shower room [ROOM NUMBER] (on Unit 2) with the following results: -#203: 140F -#204: 158F -Shower room [ROOM NUMBER]: 120F The DOM said these water temperatures were too high and he was surprised by the readings. Review of the Weekly Water Temperature Logs indicated water temperatures had not been monitored for the past 13 days and were last monitored on 11/29/24. The Weekly Water Temperature Logs indicated but were not limited to the following: November 2024 -11/6/24, House mixing valve: 120F -11/8/24, House mixing valve: 140F -11/13/24, House mixing valve: 120F -11/15/24, House mixing valve: 120F -11/22/24, House mixing valve: 120F -11/29/24, House mixing valve: 120F -Water temperature ranges for resident rooms and shower rooms sampled this month: 107-112F October 2024 -House mixing valve: 140F during four of four days monitored in October -Water temperature ranges for resident rooms and shower rooms sampled this month: 110-112F September 2024 -House mixing valve: 140F during six of six days monitored in September -Water temperature ranges for resident rooms and shower rooms sampled this month: 109-112F The Weekly Water Temperature Logs indicated but were not limited to the following: Please make sure the water in the resident's bath sink, shower room, common area lavatories doesn't exceed 115 or below 110 at the plumbing fixtures. Mixing valve 120. Please report any discrepancies to Director of Maintenance. During an interview on 12/11/24 at 5:30 P.M., the Administrator said the boiler temperature was 135F and he had just lowered the boiler temperature to 120F in recent minutes due to the surveyors' expressed concern over water temperatures. During an interview on 12/12/24 at 7:43 A.M., Certified Nursing Assistant (CNA) #1, who normally works on the first floor, said the water temperatures in resident bathroom sinks can vary and would get too hot in rooms [ROOM NUMBERS]. She said this was not a new issue and she thought management knew. During an interview on 12/12/24 at 7:48 A.M., CNA #2, who normally works on the first floor, said the sink water can run too hot sometimes and she tries to fill basins right when she turns the water on before it gets too hot. During an interview on 12/12/24 at 2:25 P.M., the DOM and surveyor observed the boiler and the house mixing valve. The pipe extending from the house mixing valve had a dial thermometer around the piping. The DOM said the thermometer measured the temperature of the water delivered to the units and it was this thermometer that he used to measure the temperature for the house mixing valve on the Weekly Water Temperature Logs. The DOM and surveyor reviewed the Weekly Water Temperature Logs, specifically the values for the house mixing valve where the value was 140F. The DOM said he adjusted the temperature of the house mixing valve based on the water temperature values obtained from resident rooms and shower rooms during weekly water temperature monitoring. The DOM said if the house mixing valve thermometer read 140F, it was possible for 140F water to travel from the mixing valve to the units, and the temperature of water traveling from the mixing valve to the units should not exceed 115-120F per facility policy and regulation. 49428

Based on interview and record review, the facility failed to provide the Pneumococcal and Influenza immunizations as requested/consented for three Residents (#94, #90 and #11), out of a total sample of five residents. Findings include: Review of the facility's policy titled Influenza Vaccine, dated as revised in September 2024, indicated the following: -between as early as August 1st through March 31st of the following year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated, or the resident has already been immunized -residents admitted between August 1st (or when the vaccine is available) and March 31st of the following year shall be offered the vaccine within five (5) working days of the resident's admission to the facility Review of the facility's policy titled Pneumococcal Vaccine, dated as revised in March 2023, indicated the following: -all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections -prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated/available, are offered the vaccine series within the facility unless medically contraindicated, awaiting shipments of vaccines, or the resident has already been vaccinated -assessments of pneumococcal vaccination status are conducted within thirty (30) days of the resident's admission if not conducted prior to admission -administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination During an interview on 12/12/24 at 12:15 P.M., the Infection Control Preventionist said when a resident admits to the facility the admitting nurse will review the vaccine options and obtain either consent or declination for the vaccines. She said she will then review the risks and benefits with the Resident, check the Massachusetts Immunization Information System (MIIS) for a history of immunizations, and then administer immunizations as indicated and document in the medical record. Review of the medical record for Resident #94 indicated the Resident was admitted to the facility in October 2024. Review of the Immunization Consent form indicated the Resident consented to the Pneumococcal vaccine and had declined the influenza vaccine and any COVID-19 boosters. Review of the electronic medical record indicated Resident #94 declined the Pneumococcal vaccine and the influenza vaccine. Record review failed to indicate the Resident had been administered the Pneumococcal vaccine. During an interview on 12/12/24 at 12:15 P.M., the Infection Control Preventionist said she thinks she might have gone to offer Resident #94 the Pneumococcal vaccine, but she couldn't be sure. She said she reviewed the medical record and was unable to find any documentation to indicate if she had and she would have to meet with the Resident again to administer the vaccine. Review of the medical record for Resident #90 indicated the Resident was admitted to the facility in October 2024. Review of the Immunization Consent form indicated the Resident consented to the Influenza vaccine and the Pneumococcal vaccine. Review of the electronic medical record indicated Resident #90 declined the Influenza and the Pneumococcal vaccines. Record review failed to indicate the Resident had been administered either vaccine. During an interview on 12/12/24 at 12:15 P.M., the Infection Control Preventionist said the consent form had been missed and she had not gone to offer either of the vaccines to Resident #90 and should have. Review of the medical record for Resident #11 indicated the Resident was admitted to the facility in November 2024. Review of the Immunization Consent form indicated the Resident's representative consented to the Influenza, the Pneumococcal and the COVID-19 booster vaccines. Review of the electronic medical record indicated Resident #1 was administered the Influenza vaccine at the facility on 11/21/24. The electronic medical record indicated the Resident had received the PCV (Pneumococcal conjugate vaccines)-13 vaccine on 2/3/23. The medical record failed to indicate if the Resident had been assessed eligibility for additional Pneumococcal vaccines. Further review of the paper medical record for Resident #11 indicated the previous facility had sent an immunization history for the Resident indicating the Resident had received their 2024-2025 flu season Influenza vaccine on 9/27/24. During an interview on 12/12/24 at 12:15 P.M., the Infection Control Preventionist said she had not assessed the eligibility guidelines for additional Pneumococcal vaccines for Resident #11. She said in reviewing the guidelines, Resident #11 was eligible to receive the PCV 20 vaccine and had not been administered the vaccine. She said she would have to review the medical record and the MIIS to determine how the Resident was administered the Influenza vaccine in September 2024 and November 2024. During an interview on 12/12/24 at 1:25 P.M., the Infection Control Preventionist said Resident #11 had been administered the Influenza vaccine at the previous facility and at the current facility. She said she had not reviewed the discharge paperwork sent from the previous facility to note the administration of the Influenza vaccine and had relied on the MIIS being up to date.

Based on record review and interview, the facility failed to ensure the Court Order of Appointment of Guardian for an Incapacitated Person was followed for one Resident (#77), in a sample of 20 residents. Specifically, the facility failed to ensure for Resident #77 that the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, which was signed by the previous Health Care Proxy (HCP), was voided with the appointment of a court designated guardian (a professional guardian who is unrelated to the incapacitated adult) who revoked the previous HCP and did not have authority to make advanced directive treatment decisions. Findings include: Review of the facility's policy titled Resident Representative, dated as last revised February 2021, indicated the following: -If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed to act on the resident's behalf. -The court-appointed resident representative will exercise the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with state law. Resident #77 was admitted to the facility in June 2023 with a diagnosis of dementia. Review of the medical record indicated the previous facility in which Resident #77 resided petitioned the court for guardianship in November 2022. In March 2023, the previous facility submitted a Motion to Amend Petition (which was granted) to remove the request for authorization to consent to advanced directives. The Motion indicated Resident #77 had two estranged children, that advanced directives were not recommended by the treating clinicians and were not necessary at that time. Review of the medical record indicated the court designated an attorney as a temporary legal guardian in March 2023 and then ordered the attorney to be the permanent legal guardian in May 2023. Review of both court orders indicated the legal guardian had authority to admit the Resident to a nursing home and to revoke the previous Health Care Proxy. The Order did not indicate the guardian had authority to make decisions regarding advanced directives. Review of the medical record failed to indicate who the previous designated HCP was. Further review of the medical record included a MOLST form and physician's orders indicating Resident #77 was not to be resuscitated, not to be intubated and not to be transferred to the hospital. The MOLST form was signed by the sister of Resident #77 on 7/30/22, prior to the appointment of the professional guardian. During an interview on 12/12/24 at 9:38 A.M., Resident #77's sister said the previous facility had petitioned for a professional guardian related to discrepancies between herself and the Resident's spouse on the goals of care. She said she was not clear on the role of the professional guardian and her own role and if she maintained any rights as the previous HCP. During an interview on 12/12/24 at 10:17 A.M., the Social Worker said the Director of Social Services usually handles the guardianships for residents but was currently on leave. The Social Worker said she was unfamiliar with the rules for guardianship so could not say if the MOLST form signed by the Resident's sister was valid if there was a court appointed guardian. She said she was not sure if the Resident's sister was previously the HCP and was unable to locate the information in the medical record. She said she did not know why there was a court appointed guardian if there had previously been a HCP and was not sure if there had been any concerns with the previous HCP. She said she would have to bring the information to the Unit Manager to review if the MOLST was valid. During an interview on 12/12/24 at 11:17 A.M., the Director of Nurses (DON) said Resident #77 admitted to the facility as a direct admission from another facility. She said she was able to access the medical records from the previous facility and was able to locate a copy of the HCP, which indicated the Resident had previously designated his/her sister as the HCP. She said when the Resident was admitted to the facility, he/she had a permanent legal guardian. The DON said, because the previous HCP had signed the MOLST form, she assumed it was still valid. She said she had not seen the Motion to Amend Petition which indicated the removal of authority for advanced directives from the guardianship authority. She said she did not know why the previous HCP was revoked. During an interview on 12/12/24 at 3:15 P.M., the DON said she had attempted to contact the guardian to determine if the MOLST was valid, but with no response. During an interview on 12/16/24 at 7:32 A.M., the DON said they had contacted the facility legal counsel regarding Resident #77. She said the legal office advised that when the permanent guardianship became effective the MOLST was no longer effective and should have been voided. During the survey process, the surveyors and the facility attempted to contact the professional guardian with no response.

Based on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#2) with a diagnosed mental condition, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated but was not limited to the following: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. a. All residents will receive a Level 1 PASARR screen prior to admission. Resident #2 was admitted to the facility in November 2024 with diagnoses including: bipolar disorder, anxiety, depression, and schizophrenia. Review of the Hospital Discharge Summary, dated 11/15/24, indicated the Resident's past medical history included schizoaffective disorder, schizophrenia, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #2, dated 11/22/24, indicated under Section I (Active Diagnoses) the Resident had anxiety disorder, depression, bipolar disorder, and schizophrenia coded as active diagnoses. Review of the physician's progress note for Resident #2, dated 11/19/24, indicated the Resident's past medical history included paranoid schizophrenia and anxiety. Further review of the physician's progress note indicated the Resident was hospitalized at a psychiatric facility in May 2022 and from October 2022 through March 2023. Review of the medical record failed to indicate a Level 1 PASARR was completed for Resident #2. During an interview on 12/11/24 at 12:20 P.M., the Director of Nurses (DON) said the facility did not have a completed Level 1 PASARR in the medical record for Resident #2. During an interview on 12/11/24 at 2:22 P.M., Social Worker #1 said she had been responsible for completing the PASARR forms since November 2024. She said she looked in the record for a completed Level 1 PASARR for Resident #2 but was unable to find it and probably never completed it.

Based on observations, interview, and record review, the facility failed to follow professional standards of practice to administer oxygen therapy as ordered for one Resident (#68), in a total sample of 20 residents. Specifically, the facility administered Oxygen at 5 liters (L) per minute for Resident #68 with an order for Oxygen at 2L. Findings include: Resident #68 was admitted to the facility in May 2024 with a diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and makes it difficult to breathe) and had an active diagnosis of pneumonia during the survey period. Review of the Physician's Orders included an order to administer Oxygen at 2L via nasal cannula effective 11/10/24. Review of the Nurse Practitioner (NP) Progress Note, dated 11/11/24, indicated Resident #68 had COPD and to continue Oxygen at 2 to 3L. Review of the NP Progress Note, dated 11/14/24, indicated Resident #68 had COPD and to continue Oxygen at 2 to 3L. Review of the nursing progress notes indicated the following: -12/6/24: Resident's oxygen saturation increased from 83% to 98% with raising the head of the bed, Resident on 2L of Oxygen -12/6/24: Resident's oxygen saturation at 80% with head of bed low (10%), head of bed raised and nebulizer treatment provided and oxygen saturation increased to 98% on 2L of Oxygen -12/9/24: Resident's oxygen saturation at 89% with head of bed at 30% and Resident refusing to increase the head of bed elevation, nebulizer treatment administered -12/9/24: vital signs stable with oxygen saturation at 92% on 2L of Oxygen -12/10/24: Resident's oxygen saturation at 85% and head of bed almost all the way down, head of bed was raised, oxygen saturation increased to 91% on 2L of Oxygen -12/10/24: Resident stable with oxygen saturation at 90-93% on 2L of Oxygen On 12/11/24 at 10:13 A.M., the surveyor observed Resident #68 in bed, wearing a nasal cannula. The oxygen concentrator was observed set to 5L. On 12/11/24 at 2:47 P.M., the surveyor observed Resident #68 in bed, wearing a nasal cannula. The oxygen concentrator was observed set to 5L. On 12/12/24 at 8:05 A.M., the surveyor observed Resident #68 in bed, wearing a nasal cannula. The oxygen concentrator was observed set to 5L. During an interview on 12/12/24 at 8:24 A.M., Nurse #3 said she was caring for Resident #68 on this day and had been in to the room to administer a nebulizer breathing treatment to the Resident. She said the Resident has an order for the Oxygen to be administered at 2 liters per minute and she thinks she confirmed the administration on the concentrator this morning. During an interview with observation on 12/12/24 at 8:26 A.M., Nurse #3 observed the Oxygen concentrator for Resident #68 set at 5L. She said the Oxygen concentrator should not be set at 5L and should be set at 2L. She reviewed the medical record and confirmed the physician orders were to administer the Oxygen at 2L. She said she was not sure how the setting was changed to 5L and she should have noticed this morning when administering the nebulizer treatment. During an interview on 12/12/24 at 3:13 P.M., the Director of Nurses (DON) said the physician's orders for administering Oxygen should be followed and the physician should be contacted for any changes.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on four days for the period of 7/1/24 to 9/30/24. Findings include: 1. Review of the Payroll Based Journal (PBJ) Staffing Data Report, dated Quarter 4: 2024 (July 1 - September 30), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1 -No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours Review of the as worked nursing schedule provided by the facility failed to indicate that a RN worked for eight hours in the facility on the following days: -8/3/24 -8/4/24 -8/25/24 -9/21/24 During the Entrance Conference Interview on 12/10/24 at 8:58 A.M., the Administrator and the Director of Nurses (DON) said the facility did not have any nurse waivers in place. During an interview on 12/16/24 at 9:17 A.M., Human Resource Manager #1 said the facility was aware of the PBJ report triggering for four or more days within the quarter with no RN during Quarter 4. She said she submits the information for the PBJ report. She said she confirmed before submitting the data that there was no RN coverage for those days. During an interview on 12/16/24 at 12:00 P.M., the Administrator said he is aware of the need to have RN coverage for a consecutive eight hours a day for seven days a week in the building, but there is on call coverage available from the nurse management team for clinical needs. We identified we did not have the coverage we are required to have.

Based on record review and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#77), in a total sample of 20 residents. Specifically, the facility failed to obtain a social history for Resident #77 which included complicated family relations, possible lack of care in the community from a family member, and a history of substance use disorder. Findings include: Review of the facility's policy titled Social Services, dated as revised in September 2021, indicated but was not limited to the following: -the facility staff are able to identify and address factors that have potentially negative effect on psychosocial functioning of a resident; examples include: situations that impede the resident's dignity and sense of control, lack of family/community support system, substance abuse; -the social worker/social service staff are responsible for: identifying and seeking ways to support residents needs through the assessment and care planning process Review of the facility's policy titled Social Assessment, dated as revised in July 2014, indicated but was not limited to the following: -a social assessment will be done to help identify the resident's personal and social situation, needs, and problems; -social service staff will obtain information during the initial interview of the family and upon the resident's admission; -the purpose is to identify information to help staff develop a personalized plan of care that will utilize the individual's existing strengths, try to compensate for physical and functional deficits, optimize function and quality of life, and meet the individual's needs and preferences -Components of the Social Assessment include: personal and family history, employment and professional history, hobbies and interests, personal preferences, and wishes about medical treatment and care, including advanced directives Resident #77 was admitted to the facility in June 2023 with a diagnosis of dementia and had a court Order of Appointment of Guardian for an Incapacitated Person. Review of the Minimum Data Set (MDS) assessment, dated 9/20/24, indicated Resident #77 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident had a severe cognitive impairment. Review of the medical record indicated a petition for guardianship was filed in November 2022, prior to admission. In March 2023 the previous facility submitted a Motion to Amend Petition (which was granted) to remove the request for authorization to consent to advanced directives. The Motion indicated Resident #77 had two estranged children, that advanced directives were not recommended by the treating clinicians and were not necessary at that time. Further review of the medical record included a MOLST form and physician's orders indicating Resident #77 was not to be resuscitated, not to be intubated and not to be transferred to the hospital. The MOLST form was signed by the sister of Resident #77 on 7/30/22, prior to the appointment of the professional guardian. Review of the medical record indicated the first Social Service Assessment was completed on 9/27/23, three months after the Resident was admitted to the facility. The Social Service Assessment indicated the following: -highest level of education: unknown -occupation: unknown -advanced care planning: Health Care Proxy (guardianship was not indicated) -code status reviewed: yes -marital status: widowed -number and names of children: see face sheet -identified support system: family -drug/alcohol abuse: no -source of information: Resident Review of the medical record included Social Service Assessments from the following dates: 1/9/24, 4/3/24, 6/26/24, 9/19/24 all indicated the following: -highest level of education: unknown -occupation: unknown -advanced care planning: Health Care Proxy (guardianship was not indicated) -code status reviewed: yes -marital status: widowed -number and names of children: see face sheet -identified support system: family -drug/alcohol abuse: no -source of information: Resident During an interview on 12/12/24 at 9:38 A.M., Resident #77's sister said Resident #77 previously lived at home with his/her spouse, was losing weight and had bed sores which he/she has been gauging with his/her fingers. She said the Resident was admitted to the hospital and then sent to a nursing home. She said the spouse of Resident #77 and herself did not get along and she had been threatened by the spouse. She said the spouse of Resident #77 had been visiting the Resident at the facility up until six months ago. She said the Resident had two children, both who had not been to visit in over a year. The Resident's sister said she was previously the designated HCP, but there was now a professional guardian, and she was not clear on if she was still able to make any medical decisions. During an interview on 12/12/24 at 10:17 A.M., the Social Worker said she had been at the facility since October 2023 and was the Social Worker for Resident #77. She reviewed the medical record and said she was unable to find any social service documentation prior to September 2023. She said Social Service Assessments were completed upon admission and every quarter for each resident. She said she had completed the last four Social Service Assessments for Resident #77. She said the process was to copy the answers from the previous assessments and she had not reached out to any family members for Resident #77 to obtain a social history. She said she did not think the Resident was married or had any children. The Social Worker then reviewed the Resident's contacts and said, Oh, he/she is married. During the continued interview, the Social Worker said the Director of Social Services usually handles the guardianships for residents but was currently on leave. The Social Worker said she was unfamiliar with the rules for guardianship and could not say if the MOLST form signed by the Resident's sister was valid if there was a court appointed guardian. She said she was not sure if the Resident's sister was previously the HCP and was unable to locate the information in the medical record. She said she did not know why there was a court appointed guardian if there had previously been a HCP and was not sure if there had been any concerns with the previous HCP. She said she had indicated on the Social Service Assessment that she had reviewed the advanced directives but would have to check with a nurse to see if the MOLST was valid. During an interview on 12/12/24 at 11:17 A.M., the Director of Nurses (DON) said Resident #77 was admitted to the facility as a direct admission from another facility and was admitted to be closer to a family member, but not a spouse and that the Resident was not married. She said she was able to access the medical records from the previous facility and was able to locate a copy of the HCP, which indicated the Resident had previously designated his/her sister as the HCP. She said when the Resident was admitted to the facility, he/she had a permanent legal guardian. The DON said because the previous HCP had signed the MOLST form she assumed it was still valid. She said she had not seen the Motion to Amend Petition which indicated the removal of authority for advanced directives from the guardianship authority. She said she did not know why the previous HCP was revoked. During an interview on 12/12/24 at 1:33 P.M., the Social Worker said she had called the sister of Resident #77 to obtain a social history and found out the Resident was still married and had two children who were estranged. She said the sister identified that the Resident also had a history of alcohol abuse. She said the facility was unaware of this information prior.

Based on the Beneficiary Protection Notification Review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) to two of three sampled Residents (#207 and #208) and failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two of three sampled Residents (#208 and #86). Findings include: The NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. The SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of the Beneficiary Protection Notification Review indicated Resident #208 was receiving Medicare Part A services from 8/2/24 with a last covered day of 8/15/24 and then remained at the facility and was not provided the NOMNC or the SNF ABN. Review of the Beneficiary Protection Notification Review indicated Resident #207 was receiving Medicare Part A services from 9/6/24 until he/she discharged to the community on 9/16/24 and was not provided the NOMNC. Review of the Beneficiary Protection Notification Review indicated Resident #86 was receiving Medicare Part A services from 11/16/24 with a last covered day of 11/27/24 and then remained at the facility and was not provided the SNF ABN. During an interview on 12/12/24 at 2:51 P.M., the Administrator said the facility was unable to locate notices for two of the three residents. He said the Social Worker provides the notices to the residents but was unable to provide evidence the notices were issued. During an interview on 12/12/24 at 3:00 P.M., the Social Worker said she had provided the representative for Resident #86 with the NOMNC, but had not provided them with the information for the SNF ABN and she had forgotten to provide the additional notice. She said herself and the Business Office manager were unable to locate any notices for Resident #207 or Resident #208.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when on 09/05/24, Resident #1 was found sitting on the floor against the bed after an unwitnessed fall. Findings include: Review of the Facility's Policy, titled Change in a Resident's Condition or Status, dated as revised February 2022, indicated the following: -our facility promptly notifies the resident's attending physician, the resident representative of change in the resident's medical/mental condition and/or status; -a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of unknown source; -the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Facility Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised July 2022, indicated that all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the administrator. The Policy further indicated that the charge nurse shall promptly initiate and document investigation of the accident or incident. Resident #1 was admitted to the Facility in July 2024, diagnoses included fracture of right pubis, osteoarthritis, type 2 diabetes mellitus, dysphagia, anxiety, depressive disorder, muscle weakness, muscle wasting, chronic kidney disease stage 3 and cerebral infarction. Review of Resident #1's Medical Record indicated Resident #1's Health Care Proxy was invoked on August 23, 2024. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 09/12/24, indicated that on 09/05/24 at approximately 5:00 A.M., Resident #1 sustained a fall out of bed and did not sustain any injuries. Review of an Accident/Incident Report, dated 09/05/24, indicated that at 5:05 A.M., Resident #1 was found siting on the floor against the bed after an unwitnessed fall. The Report indicated that Resident #1's HCA was not notified. During an interview on 10/30/24 at 8:16 A.M., Nurse #3 said that she worked the 11:00 P.M. to 7:00 A.M. shift on 09/04/24 into 09/05/24. Nurse #3 said that on 09/05/24 at approximately 5:00 A.M., Resident #1 was found lying on the floor in his/her room next to his/her bed. Nurse #3 said that she could not recall if she notified Resident #1's HCA of the fall, but should have. Nurse #3 said that if she did not document that she notified Resident #1's HCA of the fall, then she probably did not notify him/her. Review of Resident #1's Medical Record indicated that there was no documentation from Nurse #3 related to Resident #1's unwitnessed fall or any documentation to support Nurse #3 notified Resident #1's HCA of his/her unwitnessed fall on 09/05/24. Review of a written and signed statement by Resident #1's HCA, dated 09/09/24, the HCA said they were not notified of Resident #1's unwitnessed fall on 09/05/24. This was not consistent with the Facility's Change in a Resident's Condition or Status and Accidents and Incidents - Investigating and Reporting Policies. The Surveyor was unable to interview Resident #1's HCA, as he/she did not respond to the Department of Public Health's telephone requests for an interview. During an interview on 10/29/24 at 3:35 P.M., the Director of Nurses (DON) said that Resident #1 had sustained an unwitnessed fall on 09/05/24 and said she could not find any documentation in Resident #1's Medical Record regarding his/her unwitnessed fall on 09/05/24. The DON said it was her expectation that Nurse #3 should have documented in a progress note about Resident #1's unwitnessed fall and immediately notified Resident #1's HCA of his/her unwitnessed fall, but had not. The DON said that Nurse #3 did not follow the Facility's policies.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was found sitting on the floor against his/her bed after an unwitnessed fall, the Facility failed to ensure they maintained complete and accurate medical/clinical records, when there was no nursing documentation in the Medical Record related to Resident #1's unwitnessed fall. Finding Include: Review of the Facility Policy titled, Charting and Documentation, dated as revised July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record. The Policy further indicated that the following information is to be documented in the resident medical record: -objective observations; -treatments or services performed; -changes in the resident's condition; -events, incidents or accidents involving the resident; Review of the Facility Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised July 2022, indicated that all accidents and incidents involving residents occurring on our premises shall be investigated and reported to the administrator. The Policy further indicated that the charge nurse shall promptly initiate and document investigation of the accident or incident. Resident #1 was admitted to the Facility in July 2024, diagnoses included fracture of right pubis, osteoarthritis, type 2 diabetes mellitus, dysphagia, anxiety, depressive disorder, muscle weakness, muscle wasting, chronic kidney disease stage 3 and cerebral infarction. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 09/12/24, indicated that on 09/05/24 at approximately 5:00 A.M., Resident #1 sustained a fall out of bed and did not sustain any injuries. Review of an Accident/Incident Report, dated 09/05/24, indicated that at 5:05 A.M., Resident #1 was found siting on the floor against the bed after an unwitnessed fall. The Report indicated that Resident #1's HCA was not notified. During an interview on 10/30/24 at 8:16 A.M., Nurse #3 said that she worked the 11:00 P.M. to 7:00 A.M. shift on 09/04/24 into 09/05/24. Nurse #3 said that on 09/05/24 at approximately 5:00 A.M., Resident #1 was found lying on the floor in his/her room next to his/her bed. Nurse #3 said that she thought she documented the incident (fall) in Resident #1's medical record, and said she could not explain why there was no documentation in Resident #1's medical record regarding his/her unwitnessed fall on 09/05/24. Review of Resident #1's Medical Record indicated that there was no documentation from Nurse #3 related to Resident #1's unwitnessed fall. This was not consistent with the Facility's Charting and Documentation and Accidents and Incidents - Investigating and Reporting Policies. During an interview on 10/29/24 at 3:35 P.M., the Director of Nurses (DON) said that Resident #1 had sustained an unwitnessed fall on 09/05/24 and said she could not find any documentation in Resident #1's Medical Record regarding his/her unwitnessed fall. The DON said it was her expectation that Nurse #3 should have documented in a progress note about Resident #1's unwitnessed fall, but had not. The DON said that Nurse #3 did not follow the Facility's policies.

Based on observation and staff interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) met the needs of each resident. Specifically, the facility failed to: a. Ensure medication kits were replaced by the pharmacy after being opened with medications removed, and not accounted for; b. Ensure proper handling of extra unused medications; and c. Ensure prescriptions for controlled substances were logged into the narcotic register. Findings include: On 8/17/23 at 1:52 P.M., the surveyor, with Nurse #6 present, inspected the K-1 medication storage room, and identified the following issue: a. An emergency Super Kit of medications was lying directly on the floor in the K-1 medication storage room. The 2nd and 3rd drawers of the emergency kit were opened indicating medications had been removed for resident use. During an interview at this time, Nurse #6 said that whenever the emergency kit is opened, the nurse must fill out a form that indicates what the medication was that was removed from the kit, the resident's name, the date and time it was removed, and the name of the nurse who removed the medication. The form must then be faxed to the pharmacy so a replacement kit can be delivered to the facility. Nurse #6 said that once the form is faxed to the pharmacy, the replacement kit is typically delivered to the facility by the pharmacy later that same day. Nurse #6 said that the emergency kit on the K-1 unit is the only emergency drug kit in the facility, and that it contains medication not available on other units at the facility. Nurse #6 also said that there was no evidence that the form was faxed to the pharmacy by the nurse who opened it. During an interview on 8/17/23 at 1:55 P.M., Nurse #6 said she didn't know when the emergency kit was opened, who it was opened for, what medication was removed, or who the nurse was that opened it. b. A plastic bag containing multiple vials of the antibiotics Ertapenem and Cefepime were observed in a drawer to the right of, and below the shelf of over the counter (OTC) medications. Neither the bag, nor the vials of antibiotic powder, were labeled with a resident name, the medication, or any other information typically contained on medication dispensed from the pharmacy. During an interview on 8/17/23 at 1:55 P.M., Nurse #6 said that the nurses keep the extra antibiotics that go unused by residents and use them while they wait for the pharmacy to deliver a newly ordered antibiotic for a resident. c. On 8/17/23 at 2:00 P.M., the surveyor inspected the Team 1 medication cart on the K-1 unit and observed two prescriptions for two residents for controlled substances in the top drawer of the medication cart. The prescriptions were for: -Tramadol 100 mg, dated 8/2/23 -Ativan 0.5 mg, dated 8/8/23 Review of the Narcotic Register indicated that neither of the prescriptions had been logged into the unit narcotic register as required. During an interview on 8/17/23 at 2:00 P.M., Nurse #10 said that the prescriptions for controlled substances should have been logged into the narcotic register and accounted for during the change of shift narcotic count.

Based on observation and staff interview, the facility failed to ensure that all medications and biologicals were labeled in accordance with currently accepted principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, the facility failed to label medication stored in the medication storage room. Findings include: On 8/17/23 at 1:52 P.M., the surveyor inspected the K-1 medication room and observed the following: A plastic bag containing multiple glass vials of the antibiotics Ertapenem and Cefepime (powder requiring reconstitution) were in a drawer to the right of, and below, the shelf of over the counter (OTC) medications. Neither the plastic bag, nor the vials of antibiotic powder, were labeled with a resident name, the medication, or any other information typically contained on medication dispensed to the facility from the pharmacy. During an interview on 8/17/23 at 1:55 P.M., Nurse #6 said that the nurses keep the extra antibiotics that go unused by residents and use them while they wait for the pharmacy to deliver a newly ordered antibiotic for a resident. She acknowledged that the practice of stockpiling discontinued medications is prohibited.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) the Facility failed to ensure Resident #1's dignity was maintained and that he/she was treated with respect, when after he/she refused a bed bath, and insisted on taking a shower, Certified Nurse Aide (CNA) #1 took him/her in for the shower and then sprayed water in his/her face, said words to the effect of, there, there is your shower. Resident #1 was upset by the incident and reported it to the social worker. Findings include. Resident #1's most recent Minimum Data Set (MDS) Assessment Form, completed 8/14/20, indicated that his/her cognitive patterns were intact and he/she was dependent on the assistance of staff members with bathing. During an interview at 10:00 A.M. on 10/20/20, Resident #1 said that on 10/4/20, he/she was scheduled for a shower. Resident #1 said that when he/she asked CNA #1 for the shower, CNA #1 tried to convince him/her to take a bed bath instead. Resident #1 said although CNA #1 tried repeatedly to convince him/her, he/she insisted on the shower. Resident #1 said that once in the shower, CNA #1 sprayed the water in his/her face and stated words to the effect of there, there is your shower. Resident #1 said she reported the alleged incident to Social Worker #1. Resident #1 said he/she was upset after the alleged incident and felt nervous before taking his/her next shower. During an interview at 12:15 P.M. on 10/20/20, Social Worker #1 said that on 10/6/20 Resident #1 reported to her that an incident that had occurred on 10/04/20 when CNA #1 assisted him/her with a shower. Social Worker #1 said that Resident #1 told her that although CNA#1 tried to convince him/her to have a bed bath, Resident #1 insisted on having a shower. Social Worker #1 said that Resident #1 told her that during the shower, CNA #1 told Resident #1 that he/she was too much trouble, squirted water in his/her face and stated words to the effect of, there, there's your shower. During an interview at 11:00 A.M. on 10/20/20, the Director of Nurses said that on 10/6/20, Social Worker #1 reported Resident #1's allegation that CNA #1 sprayed him/her in the face during a shower. The Director of Nurses said that she interviewed CNA #1 about the incident. The Director of Nurses said although CNA #1 said she did not spray Resident #1 with water, CNA #1's statements about the incident were inconsistent, conflicting and difficult to follow. The Director of Nurses said that although CNA #1 told her that the alleged incident could not have occurred because CNA #2 was present for Resident #1's shower, CNA #2 told the Director of Nurses that she left the shower room before the shower was complete. Social Worker #1 and the Director of Nurses said that Resident #1 was alert, oriented and was a reliable historian. On 10/20/20, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) The Facility suspended CNA #1 on 10/6/20 when the allegation was reported and terminated her after the investigation concluded on 10/8/20. B) Resident #1 was offered supportive visits by the Social Worker on 10/6/20 and 10/9/20, the Psychiatric Nurse Practitioner on 10/6/20 and the Psychotherapist on 10/7/20. C) On 10/6/20, the Social Worker interviewed other residents on CNA #'s assignment for 10/4/20 and two additional alert and oriented residents from Resident #1's unit without identifying additional concerns with the care provided by CNA #1. D) The Assistant Director of Nurses initiated Abuse Prevention Training with Facility nursing staff on 10/06/20 and education continued through 10/19/20, to ensure majority of nursing staff were re-educated. E) On 10/5/20, 10/12/20 and 10/13/20, the Social Worker conducted interviews of four residents to assess the effectiveness of staff training and the residents' experience of interactions with staff members during personal care. The Director of Nursing said these interviews would continue weekly until 10/27/20 and monthly though December 2020. F) The Director of Nurses said the Quality Assurance Committee would review the results of the investigation and the correction plan at a 10/27/20 meeting. G) The Director of Nurses and his/her designee is responsible for overall compliance.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure that Nurse #1 followed acceptable standards of practice for administering medications and reporting medication errors. Resident #1 was an insulin dependent diabetic. On 7/11/15, at approximately 5:00 P.M., Nurse #1 administered [MEDICATION NAME] R U-500 Concentrated (5 times more concentrated than [MEDICATION NAME] R U-100) insulin to Resident #1, which she had drawn up earlier for another resident and left on top of the medication cart. - Nurse #1 did not report the medication error to any supervisory staff, did not call the physician to report the error and obtain instructions and new orders to immediately counteract the effects of the error; and Nurse #1 did not complete a medication incident report. - Nurse #1 administered [MEDICATION NAME] (antihypoglycemic) to Resident #1 without a physician's orders [REDACTED].#1's scheduled insulin, [MEDICATION NAME] U-100 two hours after the error, without consulting a physician. After Nurse #1's shift ended, Resident #1 was found presenting with symptoms of possible low blood glucose level; and was transferred emergently to the Hospital and was admitted for low blood glucose levels. - After Resident #1 was transferred emergently to the Hospital, it was determined in response to the error, Nurse #1 provided Resident #1 with extra snacks, added sugar to Resident #1's coffee and juice, rechecked Resident #1's capillary blood glucose (CBG) several times, but did not document having performed these tasks. Findings include: The Facility's Policy related to Medication and Insulin Administration, dated 11/30/14, indicated, obtain and verify physician's orders [REDACTED]. The Facility's Policy related to Medication Discrepancy, dated 11/10/14, indicated medication discrepancy refers to an omitted, incorrect, or inappropriate medication that is prescribed, dispensed and/or given to a resident. The Medication Discrepancy Policy indicated, the licensed nurse will; report error to nursing supervisor/manager, notify the attending physician, notify family/responsible party, implement physician's orders [REDACTED]. The Food and Drug Administration (FDA), prescribing information, indicated [MEDICATION NAME] Regular (R) U-500 (concentrated) insulin contains 500 units of insulin in each milliliter (five times more concentrated than [MEDICATION NAME] R U-100). The FDA, prescribing information indicated medication errors associated with [MEDICATION NAME] U-500 resulted in Residents experiencing severe [DIAGNOSES REDACTED], unconsciousness, convulsions, temporary or permanent impairment of brain function or death. Resident #1's MAR, dated 7/01/15 through 7/11/15, indicated he/she received [MEDICATION NAME] U-100 unit/ml subcutaneous (sc) solution, inject 22 units at 8:00 P.M. Resident #1's MAR indicated [REDACTED].M., 11:30 A.M., and 4:30 P.M., and Resident #1 received [MEDICATION NAME] U-100 unit/ml subcutaneous solution, three times per day based on blood glucose levels. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR, dated 7/11/15, indicated his/her CBGs were documented as follows; 7:30 A.M., 104 mg/dl. 11:30 A.M., 141 mg/dl, 4:30 P.M., 178 mg/dl, with no other CBGs documented as being obtained. Resident #1's MAR indicated [REDACTED].M., by Nurse #1. The Medication Error Report, dated 7/13/15 indicated, on 7/11/15 at approximately 5:00 P.M., Nurse #1 mistakenly administered [MEDICATION NAME] R U-500 (a five times more concentrated dose than U-100) 15 units to Resident #1. Resident #1 had a hypoglycemic reaction, and was sent to the Hospital. Nurse #1's written statement, dated 7/14/15, indicated she admitted to administering the incorrect insulin to Resident #1 on 7/11/15, that she immediately realized the mistake, and failed to report it to the physician, nursing supervisor, or family/responsible party. Nurse #1's written statement indicated she gave Resident #1 a snack and orange juice, rechecked Resident #1's CBG, added extra sugar to Resident #1's coffee at dinner time, rechecked Resident #1's CBG again, administered [MEDICATION NAME] to Resident #1 at 6:30 P.M., and that Resident #1 was alert and responsive at 7:00 P.M., for change of shift report. Nurse #1's written statement indicated she did not notify the physician or the family at the time of the medication error because Resident #1's condition was stable. Nurse #1 did not obtain an order for [REDACTED].>The Surveyor interviewed Nurse #1 at 9:15 A.M., on 10/21/15 via telephone. Nurse #1 said on 7/11/15 at approximately 5:00 P.M., she prepared another residents medications, which included [MEDICATION NAME] R U-500, 15 units. Upon entering the room, the resident was not available, so she left the room, did not secure or label it, but just placed the un-dispensed [MEDICATION NAME] R U-500 insulin on top of the medication cart. Nurse #1 said she responded to a bed alarm, then moved onto Resident #1's room to resume her medication pass. Nurse #1 said she picked up the insulin syringe with the [MEDICATION NAME] R U-500 she left on the medication cart earlier, along with Resident #1's other scheduled medications, administered it to Resident #1, and immediately realized her mistake. Nurse #1 said she did not know the difference between [MEDICATION NAME] R U-500 and [MEDICATION NAME] U-100, only that the [MEDICATION NAME] was a stronger insulin, and did not think to look up the medication for adverse reactions. Nurse #1 said she did not call the physician, on-call Nursing Supervisor (Unit Manager #2), or the guardian to report the medication error. Nurse #1 said instead of notifying anyone, she gave Resident #1 a snack with orange juice, put extra sugar in Resident #1's coffee at dinner time, rechecked Resident #1's CBGs several times after the error occurred, but had not documented it in Resident #1's record. Nurse #1 said she rechecked Resident #1's CBG at 6:00 P.M., it was 81 mg/dl, and administered Resident #1 [MEDICATION NAME]. Nurse #1 said she did not document the additional CBGs she obtained while monitoring Resident #1 for [DIAGNOSES REDACTED], but was able to recall every one of them from memory. Nurse #1 said she knew Resident #1 did not have a physician's orders [REDACTED].#1 said she knew [MEDICATION NAME] was administered only after a CBG of less the 60 mg/dl was noted, and said she gave Resident #1 [MEDICATION NAME] to keep his/her CBG from dropping any lower. Nurse #1 said she sent the on-call Supervisor (Unit Manager #2) a text message informing him she used the emergency kit [MEDICATION NAME], but did not tell him why, or that Resident #1 was administered a highly concentrated dose of [MEDICATION NAME] R U-500 in error. Nurse #1 said she told Nurse #4 during change of shift report that she administered the wrong insulin to Resident #1 earlier, but did not provide Nurse #4 with exact details, and she told Nurse #4 that Resident #1 was fine. Nurse #1 said she told Nurse #4 to call Resident #1's physician and guardian to report the medication error. Nurse #1 said that on 7/11/15, she did not administer Resident #1's [MEDICATION NAME] U-100 at bedtime and could not explain why she documented it was administered. The Surveyor interviewed Nurse #4 at 7:42 A.M., on 10/20/15 via telephone. Nurse #4 said on 7/11/15, at approximately 7:00 P.M., while she was in the process of administering medications, Nurse #1 approached her to with end of shift report. Nurse #4 said Nurse #1 informed her that Resident #1 had received the wrong insulin earlier that day, did not provide any other details, but informed her Resident #1 was fine. Nurse #4 said after Nurse #1 left the Facility, Resident #1 complained of not feeling well, was dizzy, diaphoretic (sweating), and she checked Resident #1's CBG it was low. Nurse #4 said she could not find a nurse's note, medication error report, or any documentation from Nurse #1 regarding the insulin error. Nurse #4 said she called the Physician, administered [MEDICATION NAME] as ordered, was unable to keep Resident #1's blood sugar level up, and the Physician ordered Resident #1 transferred to the Hospital for evaluation. Nurse #4 said she called the on-call Supervisor (Unit Manager #2) to report Resident #1's change in condition, and Hospital transfer. The Hospital Discharge Summary, dated 7/12/15, indicated Resident #1 was transferred to the emergency department related to altered mental status and unresponsiveness due to [DIAGNOSES REDACTED], and was admitted to the Hospital for intravenous (IV) administration of D5W ([MEDICATION NAME] 5% in water),frequent blood glucose checks, and to allow the insulin to dissipate or wear off.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to ensure medications were administered as ordered by the physician. On 7/11/15, at approximately 5:00 P.M., Nurse #1 administered [MEDICATION NAME] R U-500 Concentrated (5 times more concentrated than [MEDICATION NAME] R U-100) insulin, 15 units via subcutaneous (sc) injection, to Resident #1, who did not have a physician's orders [REDACTED]. Resident #1 was an insulin dependent diabetic, but was not scheduled to receive his/her insulin, [MEDICATION NAME] U-100, 22 units via sc injection until, 8:00 P.M., at bed time. Resident #1 was admitted to the Hospital as a result of the error. -After the error, Nurse #1 did not report the error to a physician or a supervisor and instead, gave Resident #1 [MEDICATION NAME] (medication used to treat low blood glucose levels), without a physician's orders [REDACTED]. Findings include: Resident #1's Medication Administration Record [REDACTED].M., at bedtime. Resident #1's MAR indicated [REDACTED].M., 11:30 A.M., and 4:30 P.M., and Resident #1 received [MEDICATION NAME] U-100 unit/ml subcutaneous solution, inject by sc route three times per day using Sliding Scale Protocol. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR, dated 7/11/15, indicated his/her CBGs were documented as follows; 7:30 A.M., 104 mg/dl. 11:30 A.M., 141 mg/dl, 4:30 P.M., 178 mg/dl, with no other CBGs documented as being obtained by day or evening shift nursing staff. The Facility's Policy related to Medication and Insulin Administration, dated 11/30/14, indicated, obtain and verify physician's orders [REDACTED].>The Facility's medication Administration Program Policy Manual, revised 9/10/10, indicated medication must never be prepared at any time except immediately prior to the administration of that medication. The Medication Error Report, dated 7/13/15 indicated, on 7/11/15 at approximately 5:00 P.M., Nurse #1 mistakenly administered to Resident #1 [MEDICATION NAME] R U-500, 15 units via sc injection, that Resident #1's physician's orders [REDACTED].#1 had a hypoglycemic reaction, and was sent to the Hospital. Nurse #1's written statement, dated 7/14/15, indicated she admitted to administering the incorrect insulin to Resident #1 on 7/11/15, that she immediately realized the mistake, and failed to report it to the physician, nursing supervisor, or family/responsible party. Nurse #1's written statement indicated she gave Resident #1 a snack and orange juice and added extra sugar to Resident #1's coffee at dinner time, Nurse #1's written statement indicated that at 6:30 P.M., she administered [MEDICATION NAME] to Resident #1. Nurse #1's written statement indicated she did not call the physician because Resident #1 was stable. The Surveyor interviewed Nurse #1 at 9:15 A.M., on 10/21/15 via telephone. Nurse #1 said on 7/11/15 at approximately 5:00 P.M., she prepared another residents medications, which included [MEDICATION NAME] R U-500, 15 units, the resident was not available, so she left the room, did not secure or label it, but just placed the undispensed [MEDICATION NAME] R U-500 insulin syringe on top of the medication cart. Nurse #1 said she responded to a bed alarm, then moved onto Resident #1's room to resume her medication pass. Nurse #1 said she picked up the insulin syringe with the [MEDICATION NAME] R U-500 she left on the medication cart earlier, along with Resident #1's other scheduled medications, administered it to Resident #1, and immediately realized her mistake. Nurse #1 said she did not know the difference between [MEDICATION NAME] R U-500 and [MEDICATION NAME] U-100, only that the [MEDICATION NAME] was a stronger insulin, and did not think to look up the medication for adverse reactions and did not call the physician for instructions. Nurse #1 said she did notify the on-call Supervisor (Unit Manager #2), or the guardian to report the medication error. Nurse #1 said instead of notifying anyone, she gave Resident #1 a snack with orange juice, put extra sugar in Resident #1's coffee at dinner time, rechecked Resident #1's CBGs several times after the error occurred, but did not document the additional CBGs in Resident #1's record. Nurse #1 said she rechecked Resident #1's CBG at 6:00 P.M., it was 81 mg/dl, and administered Resident #1 [MEDICATION NAME]. Nurse #1 said she even though she did not document the additional CBGs she obtained while monitoring Resident #1 for [DIAGNOSES REDACTED], she was able to recall every one of them from memory. Nurse #1 said she knew Resident #1 did not have a physician's orders [REDACTED].#1 [MEDICATION NAME] to keep his/her CBG from dropping any lower. Nurse #1 said she sent the on-call Supervisor (Unit Manager #2) a text message informing him she used the emergency kit [MEDICATION NAME], but did not tell him why, or that Resident #1 was administered a highly concentrated dose of [MEDICATION NAME] R U-500 in error. Nurse #1 said she told Nurse #4 during change of shift report that she administered the wrong insulin to Resident #1 earlier, did not provide Nurse #4 with exact details, and she told Nurse #4 that Resident #1 was fine. The Surveyor interviewed Nurse #4 at 7:42 A.M., on 10/20/15 via telephone. Nurse #4 said on 7/11/15, at approximately 7:00 P.M., while she was in the process of administering medications, Nurse #1 approached her to with end of shift report. Nurse #4 said Nurse #1 informed her that Resident #1 had received the wrong insulin earlier that day, but did not provide any other details, but informed her Resident #1 was fine. Nurse #4 said after Nurse #1 left the Facility, Resident #1 complained of not feeling well, was dizzy, diaphoretic (sweating - which are symptoms indicative of possible low blood glucose levels), and she checked Resident #1's CBG which was low. Nurse #4 said she could not find a nurse's note, medication error report, or any documentation from Nurse #1 regarding the insulin error. Nurse #4 said she called the Physician, administered [MEDICATION NAME] as ordered, was unable to keep Resident #1's blood sugar level up, and the Physician ordered Resident #1 transferred to the Hospital for evaluation. Nurse #4 said she called the on-call Supervisor (Unit Manager #2) to report Resident #1's change in condition, and Hospital transfer. The Hospital Discharge Summary, dated 7/12/15, indicated Resident #1 was transferred to the emergency department related to altered mental status and unresponsiveness due to [DIAGNOSES REDACTED], and was admitted to the Hospital for intravenous (IV) administration of D5W ([MEDICATION NAME] 5% in water),frequent blood glucose checks, and to allow the insulin to dissipate or wear off.

Based on record review, interview with the resident and interview with staff, the facility failed to provide the necessary services and adequate assistance to maintain good oral hygiene and prevent a decline in oral health, for one resident (#21) in a total sample of 24 residents. Findings include: For Resident #21, who was unable to effectively brush his/her own teeth due to severe tremors, the facility failed to provide the resident with the physical assistance the resident required to maintain good oral hygiene. The resident's dentist documented the deterioration of the resident's oral health, documented the resident's inability to brush his/her own teeth and the need for staff to brush the resident's teeth twice a day, and documented that without good oral hygiene, the resident's oral health would decline further. The necessary care was not provided and the resident's oral health status declined. Despite the resident's ongoing request for dental hygienist services, these services were not provided. Resident #21 was a long term care resident admitted in February, 2009 and had [DIAGNOSES REDACTED]. Review of the current nurse aide care worksheet dated 6/6/11 for Resident #21 indicated the resident was to receive total care for mouth care two times daily. During review of the resident's record on 3/19/12, documentation from two examination visits by the dentist was noted. The first dental report on 8/1/11, indicated the clinical findings of very poor oral hygiene. The [MEDICATION NAME] mucosa, i.e. the lining of the cheeks and the back of the lips inside the mouth where they touch the teeth, was noted to be enlarged along the bite line on the right side. The findings also revealed that the resident suffered from moderate to severe gingivitis, i.e. an inflammation of the gums surrounding the teeth. The dentist wrote that there was advanced periodontal disease with mobility of the teeth, three teeth that were of concern and might need extraction, and six teeth needed restorative work. The dentist noted that a full mouth scaling was done for generalized heavy plaque and calculus, with large sub-gingival deposits causing heavy bleeding during removal, and a [MEDICATION NAME] varnish was applied to all surfaces. The dentist wrote that the resident was motivated to improve oral hygiene and was very eager to have the cleaning that day. The dentist wrote that the resident said he/she was unable to brush own teeth and noted the resident needed assistance brushing two times every day. The dentist also recommended that the resident be put on a three month dental schedule to combat periodontal disease. The dentist reexamined the resident on 9/7/11, and identified two teeth that needed extraction and nine teeth that needed restorative work and x-rays were taken. The dentist identified multiple deep carious root [MEDICAL CONDITION], and one tooth was identified as having a large deep root caries extending to the root of the adjacent tooth and serious enough to require extraction of at least the compromised tooth and possibly the adjacent tooth as well. The dentist wrote that the resident was a poor candidate for restorative dentistry as the resident had hunched-over posture in a small wheelchair and also wrote that the resident was a poor candidate for restorative work unless the oral hygiene improved. The dentist's recommendations to the facility were for 6 month exam/cleaning, staff to be notified to assist with tooth brushing. The dentist also requested to see the resident every 3 months. Review of the resident's record revealed that the facility did not arrange either a 3 month dental follow-up or a 6 month exam and cleaning. None of these recommendations were followed by the facility. Review of the annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/27/11, indicated the resident had no identified oral or dental problems. The MDS indicated the resident required extensive assistance of a staff person for personal hygiene needs. Review of the resident's record on 3/19/12 indicated the facility staff nurses completed an oral assessment on 2/17/12. The assessment documented the resident's natural teeth were intact; there was no information related to the condition of the teeth or gums or to the resident's oral hygiene status. The last quarterly MDS assessment dated [DATE] also indicated the resident required staff assistance for personal hygiene needs. A review of the Nurse Practitioner's progress note dated 2/22/12, indicated the resident had tremors related to his/her [MEDICAL CONDITION], and the resident's annual physical examination dated 3/5/12 documented the resident's ongoing tremors. A review of the care plan conference summary, dated 3/1/12, indicated the resident required extensive assistance with all activities of daily living (ADLs). The care plan problem identified as alteration in ADLs and functional mobility, and noted the resident had a decreased ability to initiate or follow through with tasks due to [MEDICAL CONDITION]. During the group interview with residents on 3/13/12 at 3:30 P.M., Resident #21 said to the surveyor that a dental hygienist had not been to the facility to provide any dental cleaning for the resident. The resident said that dental cleaning and proper care was important personally, and that although the resident had requested the hygienist, the facility did not arrange the service. Review of the nurse aides' ADL flow sheets for grooming, completed every shift for care provided to residents, indicated for February and March 2012, the resident was independent on the day shift and required extensive physical assistance on the evening shift. The nurse aide flow sheets for the day shift did not indicate the staff assisted the resident with oral hygiene as outlined on the nurse aide care worksheet that the resident was to receive total care for mouth care two times daily. On 3/19/12 at 11:20 A.M., the resident was interviewed. The resident reported that maintaining and cleaning his teeth has always been important and repeated the desire to see a dental hygienist for regular oral cleanings as he/she voiced during the group interview. The resident was observed during survey to be hunched forward in a low seated wheelchair and had tremors of the upper extremities. The resident said he/she usually brushed his/her own teeth, and staff only brought the toothbrush and other items for him/her to do the task. He reported that staff rarely asked if the resident needed or wanted assistance but would allow assistance since the resident knew that he/she wasn't doing a good job. The resident pointed out to the surveyor that the tooth-brushing implements were on top of the bedside table at that time. Observation revealed a small emesis basin with what appeared to be a standard toothbrush and a small tube of toothpaste. The resident said he/she wanted a dental hygienist to clean his/her teeth because the resident did not believe that his/her teeth and mouth were taken care of well enough on a routine basis. On 3/19/12 at 12:25 P.M., Certified Nurse Aide (CNA) #2 was interviewed and she said that she often cared for Resident #21. CNA #2 said that the resident brushed his/her own teeth. CNA #2 said the resident always wanted to do it on his/her own. CNA #2 said she set him up with the basics, water and toothpaste, and then the resident did the tooth brushing. On 3/20/12 at 8:05 A.M., Unit Manager #2 was interviewed and reviewed the dental reports and recommendations. Unit Manager #2 said she was unaware of these recommendations as the examinations took place prior to her assuming responsibility for the unit. Unit Manager #2 said that Resident #21 had an electric toothbrush and brushed his/her own teeth. The care plan and care worksheet were reviewed with Unit Manager #2 including the references to staff providing oral hygiene care to the resident. She said that she could not explain the discrepancies. Unit Manager #2 said she would try to find out why the resident had never been put on a 3 month dental schedule and would speak with the CNA staff about providing assistance to the resident. Unit Manager #2 said the dentist was due to come back to the facility the next day and would follow up after Resident #21's examination. On 3/20/12 at 8:50 A.M., the Medical Records person approached the surveyor with Unit Manager #2 and said that when the dentist last saw the resident in September 2011, she had talked with the resident about the recommendation for extractions, but the resident refused and said that he/she just wanted a hygienist to clean the teeth. Unit Manager #2 said that she would follow-up with Resident #21 that morning to discuss assistance needed for oral hygiene. (Please refer to F 412)