Every finding on record at Lafayette Rehabilitation & Skilled Nursing

Based on observation, policy review and interview the facility failed to provide a dignified dining experience on two out of two units. Findings include: Review of the facility policy titled Dining/Nutrition Guidelines/Protocols, dated as revised 11/2021, failed to indicate that meals are to be provided in a dignified manner. On 8/27/24 at 8:11 A.M., the surveyor observed all meals served in the dining room on the first floor to be left on the trays. On 8/27/24 at 12:15 P.M., the surveyor observed all meals served in the dining room on the first floor to be left on the trays. On 8/27/24 at 8:15 A.M., the surveyor observed all meals served in the dining room on the second floor to be left on the trays. On 8/28/24 at 8:24 A.M., the surveyor observed a Certified Nurses Aide (CNA) serve breakfast to a resident, sitting in the dining room on the second floor, on a tray. The CNA then left the dining room without the tray and the resident continued to eat his/her breakfast from the tray. During an interview on 8/28/24 at 10:20 A.M., Nurse #1 said that all meals served in the dining room should be removed off the trays because this is their home and not an institution. Nurse #1 then said that it is not dignified to serve meals in an institutional manner. During an interview on 8/28/24 at 10:25 A.M., the Director of Nursing said that all meals served in the dining room should be removed off the trays.

Based on the facility's PBJ (Payroll-Based Journal) report, licensed nurse staff schedules, punch cards and interviews, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for nine days for the period of January 1, 2024 to March 31, 2024. Findings include: Review of the PBJ Staffing Data Report, dated Quarter 2 2024 (January 1-March 31), indicated the following: - One star staff rating - Triggered. Review of the facility's payroll-based journal titled Preliminary PBJ Report Quarter 1 2024 (Fiscal Quarter 2) indicated the following: - Please note that if we have any three days without RN coverage, then we automatically receive a one-star rating. However, we may recode [sic] a Director of Nurses (DON) or (Assistant Director of Nurses) ADON's hours to RN, on any days that they worked, and we did not have RN coverage. - Warning: Less than 8 RN hours for Monday 1/1/24. - Warning: Less than 8 RN hours for Saturday 1/27/24. - Warning: Less than 8 RN hours for Sunday 1/28/24. - Warning: Less than 8 RN hours for Saturday 2/3/24. - Warning: Less than 8 RN hours for Sunday 2/4/24. - Warning: No RN hours for Saturday 2/17/24. - Warning: No RN hours for Saturday 3/2/24. - Warning Less than 8 RN hours for Saturday 3/16/24. - Warning: Less than 8 RN hours for Saturday 3/30/24. During an interview on 8/28/24 at 10:07 A.M., the Director of Nursing (DON) said she was aware the facility triggered for one star staffing rating because they did not have RN coverage for eight consecutive hours a day, seven days a week for nine days for the period of January 1, 2024, to March 31, 2024. The DON said that the facility does not have any staffing waivers and she did not provide coverage on the days that had less than 8 RN hours or no RN hours. The DON said the Assistant Director of Nursing (ADON) did not provide any coverage because she is an LPN (Licensed Practical Nurse). The DON said she is aware of the requirement for RN coverage and there should be eight consecutive hours of RN coverage a day and seven days a week.

Based on record review and interview, the facility failed to inform one Resident (#30), out of three records reviewed, of the potential liability for payment for non-covered services, including estimated cost of services. Specifically, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided to Resident #30. Findings include: The SNF ABN notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. Resident #30 was admitted to the facility in July 2024, under a skilled Medicare A level of care, with diagnoses including pneumonia and acute respiratory failure. Review of the facility's census indicated that he/she was discharged from Medicare A skilled services on 8/9/24. Review of the medical record failed to indicate a SNF ABN was given to Resident #30 and/or the Resident's representative. During an interview on 8/27/24 at 2:33 P.M., the Business Office Manager said the facility does not issue SNF ABN forms. During an interview on 8/27/24 at 2:49 P.M., the Social Worker said she was responsible for giving Notice of Medicare Non-coverage (NOMNC) to Resident #30 when he/she discharged from Medicare Part A skilled services. The Social Worker said Resident #30 still had Medicare benefit days remaining when he/she discharged from Medicare A skilled services on 8/9/24. The Social Worker said she was not aware that a SNF ABN was required and does not give it to any residents when they discharge from Medicare Part A skilled services, so she did not issue one to Resident #30. During an interview on 8/27/24 at 7:02 A.M., the Director of Nursing (DON) and Minimum Data Set (MDS) Nurse said they were not aware that SNF ABN forms were required, and they were not being issued as required by Centers for Medicare and Medicaid Services (CMS).

Based on document review and interview the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#24) out of a total sample of 13 residents. Findings include: Resident #24 was admitted to the facility in June 2019 with diagnoses including contracture of the left hand and Alzheimer's dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #24 had upper extremity impairments to one side. Review of the previous MDS's, dated 2/29/24 and 11/30/23, indicated that Resident #24 had upper extremity impairments to one side. Review of the MDS, dated [DATE], indicated that Resident #24 had no range of motion deficits on either of the upper extremities. Review of the current care plan indicated the following intervention: - Has a contracture of Lt. (left) hand. Ensure daily cleansing, open gently and assess skin integrity. During an interview on 8/28/24 at 9:15 A.M., the MDS Nurse said that she had decided that the MDS's criteria for what is an impairment included whether or not the contracture impacted the resident's functional ability. The MDS nurse said that because the Resident is totally dependent for activities of daily living due to his/her level of cognition and not the contracture the MDS should be not coded as having an impairment. The MDS nurse then said that the MDS's prior to the 5/30/24 MDS were coded incorrectly.

Based on observation, records review, policy review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of two nurses observed made two errors out of 27 opportunities resulting in a medication error rate of 7.41%. Those errors impacted two Residents (#18 and #27), out of six residents observed. Findings include: Review of facility policy titled 'Nursing policy and procedure manual',revised 8/4/22, indicated the following but not limited to: Policy: This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than five percent. Definitions: *Daily processes- Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. 1. For Resident #18, Nurse #2 prepared and administered the following medication: -Multivitamin one tablet by mouth. Review of Resident #18's current physician order indicated the following: -1/20/23 Multivitamin men oral tablet ( Multiple vitamin with minerals) give one tablet by mouth in the morning for supplement. During an interview on 8/9/23 at 10:14 A.M., Nurse #2 said she should have administered multivitamin with minerals as per the doctors order. Nurse #2 said she should have not given the regular multivitamin as this is the wrong medication. 2. For Resident #27, Nurse #2 prepared and administered the following medications scheduled for 8:00 A.M. -Celexa 20 mg (milligram) one tablet by mouth -Trazadone 12.5 mg one tablet by mouth -Acetaminophen 500 mg two tablets by mouth -Colace 100 mg one tablet by mouth -Proscar 5 mg one tablet by mouth -MiraLAX powder 17 GM (gram) one scoop mixed in water During Resident #27's medication review the following medication was not administered at 8:00 A.M. -Fludrocortisone Acetate oral tablet 0.1 mg give one tablet by mouth in the morning for orthostatic hypotension. During an interview on 8/9/23 at 10:16 A.M., Nurse #2 said she thought she administered the medication but said she was also confused by the supplemental documentation for pain instead of the blood pressure. Nurse #2 said she should have administered medication as ordered and said that not administering the medication was a medication omission error. During an interview on 8/9/23 at 10:25 A.M., the Director of Nursing said the expectation is that nurses follow a specific procedure during medication administration to avoid errors and should administer medications as ordered by the physician.

Based on observation, record review and interview the facility failed to follow a physician order for prevention of a pressure ulcer for one Resident (#1) out of a total sample of 16 residents. Findings include: Review of facility policy titled 'Air Mattress', date revised March 2023, indicated the following but not limited to: *Residents may require an air mattress for a variety of existing or potential problems. An example of conditions that may require an air mattress are limited bed mobility, pressure sore avoidance or existing skin impairment, resident request, acute illness etc. *The mattress is checked every shift by licensed staff to ensure that it is at the correct setting and if not it is reset and the assistant director of nursing is notified. Resident #47 was admitted to the facility in July 2023, with diagnoses including stage one pressure ulcer to right heel. Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of MDS indicated the Resident had a pressure ulcer. On 8/8/23 at 8:09 A.M.,8/8/23 at 12:01 P.M., 8/9/23 at 6:43 A.M., 8/9/23 at 6:45 A.M., Resident #1 was observed to be lying in his/her bed and his/her air mattress was set to 300 lbs (pounds). On 8/8/23 at 8:09 A.M., Resident #1 said he/she does not alter the setting, he/she further said he/she has a wound on his/her right heel. Review of the physician's orders indicated: -7/18/23 Right heel stage one apply skin prep twice a day, every day and evening shift for wound care. -8/2/23 Alternating air mattress set at 250. Check function every shift. Review of [NAME] assessment, dated 8/1/23, indicated Resident #1's scored an eight which indicated high risk for pressure ulcer development. Review of the weight record dated 8/7/23, indicated Resident #1 weighed 186.2 pounds. Review of the plan of care related to stage 1 pressure ulcer right heel intervention dated 8/1/23 indicated the following: -Specialty Air mattress: air mattress set at 250 During an interview on 8/9/23 at 6:45 A.M., Nurse #1 said air mattresses are checked every shift for proper functioning and setting. Nurse #1 said the air mattress should be at the correct setting of 250 pounds as ordered. During an interview on 8/9/23 at 8:11 A.M., the Director of Nursing (DON) said air mattresses should be checked every shift by staff and said if the air mattress is not working properly maintenance should be made aware. The DON further said doctors orders should be followed accordingly.

Based on record review, interview and observation, the facility failed to obtain a physician order for an air mattress for one Resident (#38) out of a total of 16 sampled residents. Findings Include: Resident #38 was admitted to the facility in July 2023 with diagnoses including adult failure to thrive, sciatica, muscle weakness, fracture of the sacrum. Review of Resident #38's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored 8 out of a possible 15 which indicated Resident #38 had a moderate cognitive impairment. Further review of the MDS indicated Resident #38 was at risk for skin breakdown. On 8/8/23 at 7:59 A.M., the surveyor observed Resident #38 lying in bed on an air mattress. The air mattress was set to max 350 lbs (pounds). On 8/9/23 at 7:30 A.M., the surveyor observed Resident #38 lying in bed on an air mattress. The air mattress was set to max 350 lbs (pounds). Review of Resident #38's weight dated 7/31/23 was 117.2 lbs. Review of Resident #38's [NAME] assessment, dated 8/2/23, indicated he/she scored a 14 which indicated Resident #38 was at moderate risk for skin breakdown. Review of Resident #38's medical record failed to indicate a physician orders or care plan was developed for his/her air mattress. During an interview on 8/9/23 at 10:11 A.M., the Director of Nurses (DON) said that if a resident is on an air mattress then a doctors order should be in place and set to the resident's weight.

Based on observations, record reviews and interviews the facility failed to implement a physician order, specifically, apply derma dot behind resident's ears, for one Resident (#1) out of a total sample of 16 residents. Findings include: Resident #1 was admitted to the facility in July 2023 with diagnoses including rib fracture chronic respiratory failure with hypoxia oxygen dependent. Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. Further review of MDS indicated the Resident is dependent on oxygen. On 8/8/23 at 8:09 A.M., Resident #1 was observed lying in bed, the Resident had oxygen cannula tubing in his/her nose and behind his/her ears, the Resident did not have derma dots behind his/her ears, Resident #1 said he/she has not had anything placed behind his/her ears. On 8/8/23 at 12:01 P.M., Resident #1 was observed lying in his/her bed wearing the oxygen cannula tubing in his/her nose and behind his/her ears. The Resident did not have derma dots behind his/her ears. On 8/9/23 at 6:43 A.M., Resident #1 was observed lying in his/her bed. Resident #1 did not have derma dots on. On 8/9/23 at 6:45 A.M., the surveyor and Nurse #1 observed Resident #1's ears, he/she did not have the derma dots. Review of the current physician order dated August 2023 indicated the following: *Derma dots behind ears. Change weekly on Sunday 7-3 every day shift every Sunday. Review of Treatment Administration Record (TAR) date August 2023 indicated the derma dots were changed on 8/6/2023. During an interview on 8/9/23 at 6:45 A.M., Nurse #1 said the derma dots should be on as ordered. During an interview on 8/9/23 at 8:11 A.M., the Director of Nursing said the protocol for skin integrity when oxygen in use should be carried as ordered.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set Assessment (MDS) for two sampled Residents (#36, #29) out of a total of 16 sampled residents. Findings include: Resident #36 was admitted to the facility in December 2020 with diagnoses including dementia and muscle weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #36 is cognitively impaired and dependent on staff for activities of daily living Additional review on 8/8/23 of MDS Section O indicated; special treatments, procedures and programs on 8/8/23 at 9:00 A.M., indicated that Resident #36 was not receiving hospice services. Review of Resident #36's clinical record indicated a physicians order dated 4/25/23 to admit Resident #36 to hospice and a hospice care plan dated 4/25/23. During an interview on 8/9/23 at 8:15 A.M., the MDS Coordinator said Section O on the MDS dated [DATE] should have indicated Resident #36 was on hospice. 43846 2. Resident #29 was admitted to the facility in August 2019 with diagnoses including Type 2 Diabetes, dysphagia, anxiety and dysphagia. Review of Resident #29 most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of a possible 15 which indicated he/she was cognitively intact. Additional review of the MDS Section O; special treatments, procedures and programs on 8/8/23 at 9:25 A.M., indicated that Resident #29 was not receiving hospice services. Review of Resident #29's physician orders, dated 5/11/23, indicated Hospice Consult. Review of Resident #29's advanced directives care plan, dated 5/15/23, indicated Initiated Hospice 5-15-23. Review of Resident #29's physician note, dated 8/4/23, indicated Pt [sic] is followed by Hospice due to her decline. During an interview on 8/9/23 at 8:15 A.M., the MDS Coordinator said Section O on the MDS dated [DATE] should have indicated Resident #36 was on hospice.

Based on observation, record review, and interview, the facility failed to adhere to practices to prevent cross contamination and prevent foodborne illness in the kitchen and on one of two resident care units. specifically, two dietary staff failed to perform hand hygiene. Findings include: Review of the Facility's policy, titled Proper hand washing and glove wearing guidelines for kitchen staff, dated as revised 8/17/16 indicated at 1) Hands must be washed before and after glove use. Glove wearing guidelines, at 2) Change gloves and wash hands before beginning a different task., 3) After interruption (phone call, dirty dishes, touching contaminated services, after handling meats, after handling any food items. During observation on 7/20/22 at 11:21 A.M., in the main kitchen the following was observed: -Cook #1 used his gloved hands to place small containers of food items on a shelf. He then proceeded to take a cleaning cloth immersed in the sanitizer bucket and wiped down the counter, returned the cloth to the bucket, then used the same gloved hands to move a tray. At no point during the observation did Cook #1 remove his gloves and wash his hands between tasks. -Cook #2 removed her gloves from both hands, and without washing her hands proceeded to grab dry rags, placed them on the food cart and moved the cart to the elevator, and went to the first-floor resident dining room. Hand hygiene was not observed after removing her gloves, potentially contaminating the surfaces she encountered. During an observation of the lunch distribution service on the first-floor Resident dining room on 7/20/22 at 11:55 A.M., the following was observed: -Cook #2 removed her gloves, threw them in the trash, crossed the room into the hall, picked up the telephone to make a call. Cook #2 did not perform hand hygiene after removing her gloves. -Cook #2 completed taking the food temperatures and with her gloved hands, placed the wrappers and used sanitizing wipes into the top of the trash. Wearing the same gloves, Cook #2 then proceeded to start plating food to serve to the Residents. Cook #2 failed to perform hand hygiene between tasks. During an interview on 7/20/22 at 1:51 P.M., Cook #2 said hand washing is required whenever gloves are removed. During an interview with the Food Service Director on 7/20/22 at 2:00 P.M., the observations made by the surveyor were shared with the FSD. The FSD said staff are to wash their hands when gloves are removed and between tasks.

Based on observation, record review and interview the facility failed to adhere to infection control practices to prevent the transmission of infections, including Covid 19 on two of two Resident care units. Specifically, staff failed to wear appropriate PPE (Personal Protective Equipment) in a room with COVID positive Residents and perform hand hygiene appropriately. Findings include: Review of facility policy titled, Protocol for Hand Hygiene, dated 9/17, indicated: - Examples of situations when hand hygiene is indicated: - Before and after direct patient/resident contact - After completing tasks at one patient/resident area before moving to another station - Before procedures - Before and after dressing changes - After contact with items/surfaces at patient/resident areas - After contact with any blood or body fluids - After handling any contaminated items. Review of facility policy titled, Nursing Policy and Procedure Manual, dated 5/15/20 indicated: -Emergency Covid-19 Pandemic Infection Control Policies -During the Covid-19 pandemic, [the facility] will follow the most current, CDC, CMS and the Respective State Department of Health guidance on infection control related to COVID 19 for the care of residents. This includes use of PPE, Cohorting and environmental cleaning to ensure the safety of residents, staff and visitors. Use of Personal Protective equipment (PPE): -Full PPE including N95 respirator or alternative, eye protection, gloves and gown, should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19 1.) During an observation on the 2nd floor unit on 07/20/22 at 08:47 A.M. Certified Nursing Assistant (CNA) #4 was feeding a Covid positive resident, with no eye protection, and a surgical mask only. During an interview on 07/20/22 at 09:26 A.M., CNA #4 said the expectation for PPE for a Covid positive room was gown, gloves, mask and a face shield. CNA #4 acknowledged only wearing personal glasses with no additional eye protection while feeding a Covid positive resident. During an interview on 07/20/22 at 11:26 A.M. the Infection Control Nurse said the expectation for PPE in a Covid positive room was full PPE, N95, eye protection, gloves, and gown. 2.) Multiple observations by the surveyor of no hand hygiene on the 2nd flood Resident Care areas were observed. During an observation on 7/20/22 at 8:23 A.M. Nurse #2 was observed leaving a Resident's room without performing hand hygiene and began preparing medications at the medication cart. Nurse #2 entered a Resident's room and performed hand hygiene, left the room to gather supplies, entered the Resident's room donned gloves and began administering medications via gastronomy tube without hand hygiene. Nurse #2 then removed her gloves, adjusted the Resident in bed with another staff member, and again donned gloves with no hand hygiene. During an interview on 7/20/22 at 8:57 A.M., Nurse #2 said hand hygiene should be performed when entering and exiting a Resident's room and acknowledged hand hygiene should have been performed prior to putting on gloves. During an interview on 07/20/22 at 11:26 A.M., the Infection Control Nurse said the expectation for hand hygiene was to perform hand hygiene on entering and exiting a Resident room. 3. On 7/19/22 at 4:29 P.M., CNA #1 was observed exiting the laundry room, on the first-floor Resident care unit, wearing gloves on both hands. CNA #1 walked past the desk area doffed her gloves and put them in the trash barrel in the hall. CNA #1 then took gloves out of her pocket and while walking down the hall, donned them without performing hand hygiene. CNA #1 then approached a resident who was in the hall seated in a wheelchair. CNA #1 touched the resident's lower backside, then placed her gloved hands on the wheelchair handles and moved the resident into his/her room. 4.) On 7/21/22 at 8:07 A.M. the surveyor observed the following on the first-floor Resident care unit: Nurse #1 approached a medication cart in the hall wearing gloves on both hands. Nurse #1 removed the gloves placed them in the trash, and without hand hygiene, picked up a tissue box, walked to the other medication cart, picked up a box, a medication cup with a spoon, entered room [ROOM NUMBER] and administered medication to a resident. During an interview on 7/21/22 at 8:40 A.M., Nurse #1 said she had opened a capsule at one (medication) cart with gloves, then went to the other cart to pick something up and removed the gloves. Nurse #1 said she should have performed hand hygiene after removing the gloves. During an interview on 7/21/22 at 8:54 A.M., with the Assistance Director of Nurses, the surveyor shared the observations made of CNA #1 and Nurse #1. The ADON acknowledge the infection breaches and said the expectation is for staff to perform hand hygiene after removing gloves.

Based on observation, record review and interview, the facility failed to implement the comprehensive care plans for four sampled Residents, (#7, #6, #19, #37, ) out of a total of 15 sampled residents. Findings include: 1. For Resident #7, the facility failed to provide continuous supervision per his/her care plans resulting in a Resident to Resident altercation. Resident #7 was admitted to the facility in 7/5/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's most recent Minimum Data Set assessment dated [DATE] indicated he/she requires assistance with all activities of daily living and he/she was unable to complete the Brief Interview for Mental Status Exam, indicating significant cognitive impairment. Review of the Resident #7 incident report dated 3/1/22 indicated that on 3/1/22 at 1:15 A.M., staff heard Resident #2 calling out of help and yelling get out. Resident #7 had entered Resident #2's room thinking it was his/her room. Resident #7 believed Resident #1 was in his/her bed and pulled Resident #2 out of bed and he/she landed on the floor. Staff assisted Resident #2 back into bed and Resident #7 returned to his/her room. The staff incident statement indicated Resident #7 was left alone after he/she had been toileting by his/her CNA. In that time, Resident #7 wandered out of the bathroom and into Resident #2's room. The statement indicated that Resident #7 should not be left unattended after using the bathroom and should be assisted back to bed. Review of Resident #7's active care plans at the time of the incident (3/1/22) indicated the following: *Resident #7 is at risk for falls. Interventions: Continue close supervision and avoid any direct contact especially during ambulation unless allowed, 1/2/22. Maintain constant supervision and ensure resident doesn't cross legs while sitting, 1/17/22. *Resident #7 has behavior problems related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: Intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from the situation and take to another location as needed, 7/15/21. Review of Resident #7's Kardex (a form utilized to guide staff on how to care for residents) indicated: 10/26/21: Resident should not be left alone unattended. 12/30/21: Resident going into other people's rooms. 1/2/22: Maintain continuous distant supervision. During an interview with the Director of Nursing on 7/19/22 at 11:47 A.M., she said that Resident #7 should have been supervised per his plan of care. 2. For Resident #37 the facility failed to ensure a wrist brace was implemented in accordance with the medical plan of care. Resident #37 was admitted to the facility in February of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #37 has a severe cognitive impairment, required extensive assistance from staff for transfers, dressing and hygiene and had behaviors of rejecting care in 1-3 days in the last seven day look back period. On 7/19/22 at 8:33 A.M., Resident #37 was observed sitting up in bed, eating his/her breakfast. Resident #37 was not observed wearing any brace on his/her right wrist. Review of Resident #37's medical record on 7/19/22 at 11:25 A.M., indicated the following: -An order, dated 4/6/22, Black wrist support on right wrist at all times except for hygiene and skin checks. Please document patient non-compliance. Further review of the medical record did not indicate the use of the black wrist support on the established care plans or the CNA (certified nursing assistant) care card. Observations made of Resident #37 on 7/19/22 and 7/20/22 indicated the following: -On 7/19/22 at 11:45 A.M., Resident #37 was observed sitting up in his/her wheelchair with his/her right fingers bent towards the palm of his/her hand, no black wrist support observed on the Resident or in the vicinity of the Resident. -On 7/19/22 04:23 P.M., Resident #37 was in a small dining area, sitting with peers listening to music, and was not wearing a black wrist support. - On 7/20/22 at 8:26 A.M., Resident #37 was sitting up in bed, not wearing a black wrist support and had his/her breakfast tray in front of him/her. - On 7/20/22 at 12:49 P.M., Resident # 37 was observed in the dining and was not wearing a black wrist support. Review of the Occupational Therapy Discharge Summary dated 2/28/22 indicated under discharge recommendations; patient to have black wrist support on at all times. Patient frequently removes braces/orthotics but encouraged patient to leave them in place. Nursing to document non-compliance and to offer assistance to put in place. During an interview on 7/20/22 at 1:08 P.M., CNA #2 said Resident #37 had a black wrist brace but refused to wear it and no longer wears it. CNA #2 said she could not recall how long it has been since Resident #37 stopped wearing the wrist support. During an interview on 7/20/22 at 2:06 P.M., Charge Nurse #1 said Resident #37 does not wear a black wrist brace. On 7/20/22 at 2:37 P.M., the Assistant Director of Nurses (ADON) said Resident #37 had a (wrist) brace in the past and often refused to wear it. The ADON reviewed the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a subsequent interview on 7/21/22 at 8:51 A.M., the ADON said the wrist support for Resident #37 was never implemented due to a glitch with the electronic medical record, and the order for the right wrist support was not carried over to the TAR to be donned (put on.) 3. For Resident #6 the facility failed to (a.) implement the care plan for direct supervision with feeding and (b) follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 was admitted to the facility in August 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 4/28/22, indicated inability to complete the Brief Interview for Mental Status (BIMS) exam, due to short and long term memory problem. The MDS further indicated Resident #6 required extensive assistance for eating. a. During an observation on 7/19/22 at 08:46 A.M., Resident #6 was observed feeding his/herself. Staff was in the room but assisting another Resident. During observations on 7/20/22 at 8:47 A.M., 8:52 A.M., and 9:02 A.M. Resident #6 was observed feeding himself/herself breakfast. During a record review on 7/20/22 at 7:41 A.M., a care plan revised 7/15/22 indicated, Resident #6 has swallowing difficulties related to, coughing, and impaired tongue movement. Interventions include using strategies such as cues from trained care givers, allow time between bites to utilize double swallow pattern, alternate sips/bites, allow to complete and clear the oral cavity prior to the next bite and direct supervision. During an interview on 7/20/22 at 9:09 A.M., Unit Manager #4 said Resident #6 received some assistance not direct supervision but, was able to feed him/herself. Unit Manager #4 said the expectation was for the care plan to be followed as initiated. During an interview on 07/21/22 9:20 A.M., the Director of Nursing said the expectation for someone with a care plan indicating direct supervision during feeding would be for staff to be present during the entire feeding. b.) During a medical record review on 7/20/22 at 11:18 A.M., a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Check G-tube placement prior to medication administration every day shift. During an observation on 7/20/22 at 08:36 A.M., Nurse #2 administered multiple medications and water flushes to Resident #6 via g-tube but did not check placement of the g-tube prior to administration. Review of facility policy title, Medication Administration-Enteral Tube, dated May 2015 indicated: -Check the placement of the g- tube in accordance with the facility policy -Place resident in a proper position with head of bed elevated to 45 degrees. -Insert a small amount of air into the tube with a syringe and listen with a stethoscope for placement. During an interview on 7/20/22 at 8:57 A.M., Nurse #2 said she was unsure what the policy was for checking placement of the g-tube prior to medication administration. 4. For Resident #14 the facility failed to follow the care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility policy titled, Weighing Residents updated, 2/2018: *Residents are then weighed monthly unless: -Decline in appetite for 2 or more days - Acute illness with antibiotics ordered - Acute illness without antibiotics at the nurses discretion - NP/MD order Resident #14 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 5/5/22, indicated a score of 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating moderate cognitive impairment. The MDS further indicated Resident #14 required extensive assistance for hygiene tasks. During a record review on 07/20/22 at 07:48 A.M., indicated: -Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Care Plan: At risk for nutrition decline, revision date 6/6/22 obtain weights weekly and record. Review of Resident #14's weights indicated: *6/20/22: 189.4 lbs. (pounds) *7/19/22: 177.8 lbs. The clinical record failed to indicate Resident #14's weights were obtained daily then weekly as ordered. During an interview on 7/20/22 at 10:16 A.M. Unit Manager #4 said upon admission, weights are done daily x 3 days and changed to weekly. Unit Manager #4 was unsure why Resident #14 weights were not completed as ordered, she also checked written weight book with surveyor Unit Manager #4 acknowledged Resident #14 did not have weights completed as ordered.

Based on record review and interview, the facility failed to investigate two Resident to Resident altercations for 1 sampled Resident (#19) out of a total of 15 sampled Residents. Findings include: Review of a facility policy Facility policy titled Abuse Prohibition, revision date 5/2019 indicated: *Residents must not be subjected to abuse by anyone. *Resident-to-Resident altercations: willful act of verbal, physical, sexual, or mental anguish caused by one resident to another causing physical, mental or psychosocial harm regardless of the resident's cognition. *All employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse, any potential for abuse or allegation of abuse they are told about by residents, families or visitors. *Allegation of or actual abuse: -immediately but not later than 2 hours -this is also reported to the police, medical director and health care proxy -a 24 report of initial investigation results sent to department of public health -an investigation will be initiated immediately by the director of nurses, administrator, or designee when a report of abuse, neglect, mistreatment or misappropriation of resident property is reported. Resident #19 was admitted to the facility in February 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 6/6/22, revealed that Resident #19 was unable to be evaluated on the Brief Interview for Mental Status (BIMS) exam. The MDS further indicated Resident #19 required extensive assistance for personal hygiene tasks and was totally dependent in ambulation. Review of Resident #19's clinical record indicated he/she had been involved in two Resident to Resident altercations: *A progress note dated 3/31/22 indicated Resident #19 was pushed from behind by another Resident and lost his/her balance. The progress notes also indicated the physician and the Health Care Proxy (HCP) were notified of this incident. *A progress note dated 12/24/21 indicated staff witnessed Resident #19 push a male Resident and use foul language directed at him/her. The Resident calmed a bit and a short time later pushed a Certified Nursing Assistant (CNA) and grabbed the name tag off of a staff member. During an interview on 7/19/22 at 12:53 P.M., Unit Manager #3 said the expectation for any Resident-to-Resident event would be to report the incident, interview staff, and complete assessments on the Residents involved. Unit Manager #3 further said incident reports can be found with the Director of Nursing. During interviews with the Director of Nursing on 7/20/22 at 1:24 P.M., and on 7/21/22 at 9:00 A.M., the Director of Nursing (DON) said the expectation for reporting abuse is to report it within two hours, continue an in-house investigation, and re-notify of final outcome. The DON was unable to find investigations on the Resident-to-Resident events.

Based on observation, record review and interview the facility failed to ensure dignity was maintained for one Resident (#37) out of a total sample of 15 residents. Findings include: Resident #37 was admitted to the facility in February of 2021 and has diagnoses including [CONDITION(S)] with behavioral disturbances and muscle weakness. Review of Resident #37's Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #37 has a severe cognitive impairment, requires extensive assistance from staff for transfers, dressing, hygiene and had behaviors of rejecting care in 1-3 days in the last seven day look back period. On 7/19/22 at 4:29 P.M., the surveyor made the following observation: CNA #1 was standing behind Resident #37, who was sitting in his/her wheelchair in the hallway near his/her room. CNA #1 placed her gloved hands down the Resident #37's back, then removed her hands and said in a voice that could be heard by anyone nearby, you have poop and need to be changed. CNA #1 repeated this statement. Resident #37 said in an agitated tone, I don't want to be changed by you. At this time the Activities Director said to Resident #37 in a calm tone that she would see Resident #37 when he/she came back out. Resident #37 appeared visibly relaxed, CNA #1 took Resident #37 in to his/her room. During an interview on 7/19/22 at 4:47 P.M., the Director of Activities said she did not hear exactly what CNA #1 said to Resident #37 but saw Resident #37 become agitated. The Activity Director said she would have approached Resident #37 in a different way. The Activity Director said Resident #37 does display behaviors and his/her mood can change quickly. During an interview on 7/20/22 at 9:19 AM the Director of Nursing said she was made aware of what occurred between CNA #1 and Resident #37 and that she spoke to CNA #1. The DON said the language and approach CNA #1 used was inappropriate.

Based on record review and interview, the facility failed to report instances of Resident to Resident altercation for two sampled Residents (#2, #19,) out of a total of 15 sampled Residents. Review of a facility policy Facility policy titled Abuse Prohibition, revision date 5/2019 indicated: *Residents must not be subjected to abuse by anyone. *Resident-to-Resident altercation: willful act of verbal, physical, sexual, or mental anguish caused by one resident to another causing physical, mental or psychosocial harm regardless of the resident's cognition. *All employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse, any potential for abuse or allegation of abuse they are told about by residents, families or visitors. *Allegation of or actual abuse: -immediately but not later than 2 hours -this is also reported to the police, medical director and health care proxy. -a 24 hour report of initial investigation results sent to department of public health -an investigation will be initiated immediately by the director of nurse, administrator, or designee when a report of abuse, neglect, mistreatment or misappropriation of resident property is reported, Findings include: 1. For Resident #2, the facility failed to report a Resident to Resident altercation when Resident #7 pulled him/her out of his/her bed onto the floor. Resident #2 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she scored 12 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS), indicating moderate cognitive impairment. The MDS also indicated Resident #2 requires physical assistance for transfers out of bed and utilizes a wheelchair for mobility. Resident #7 was admitted to the facility in 7/5/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's most recent MDS dated [DATE] indicated he/she requires assistance with all activities of daily living and he/she was unable to complete the BIMS, indicating significant cognitive impairment. During an interview with Resident #2 on 7/19/22 at 7:57 A.M. Resident #2 reported There was a person just standing here in my room and he wouldn't leave. Then it got physical. Resident #2 said that the incident happened a few months ago. Review of the Resident #7 and Resident #2's incident reports indicated that on 3/1/22 at 1:15 A.M., staff heard Resident #2 calling out of help and yelling get out. Resident #7 had entered Resident #2's room thinking it was his/her room. Resident #7 believed Resident #2 was in his/her bed and pulled Resident #2 out of bed and he/she landed on the floor. Staff assisted Resident #2 back into bed and Resident #7 returned to his/her room. During an interview with the Director of Nursing on 7/19/22 at 11:47 A.M., she said that the incident was not reported to the state agency as neither Resident #2 nor Resident #7 was harmed. 2. For Resident #19 the facility failed to report two Resident to Resident altercations. Resident #19 admitted to the facility in February 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 6/6/22, revealed that Resident #19 was unable to be evaluated on the Brief Interview for Mental Status (BIMS) exam. The MDS further indicated Resident #19 required extensive assistance for personal hygiene tasks and was totally dependent in ambulation. Review of Resident #19's clinical record indicated he/she had been involved in two resident to resident altercations: *A progress note dated 3/31/22 indicated Resident #19 was pushed from behind by another resident and lost his/her balance. The progress notes also indicated the physician and the Health Care Proxy (HCP) were notified of this incident. *A progress note dated 12/24/21 indicated Staff witnessed Resident #19 push a male resident and use foul language directed at him/her. The Resident calmed a bit and a short time later pushed a Certified Nursing Assistant (CNA) and grabbed the name tag off of a staff member. During an interview on 7/19/22 at 12:53 P.M. Unit Manager #3 said the expectation for any resident-to-resident event would be to report the incident, interview staff, and complete assessments on the residents involved. Unit Manager further said incident reports can be found with the Director of Nursing. During interviews with the Director of Nursing on 7/20/22 at 1:24 P.M., and on 7/21/22 at 9:00 A.M., the Director of Nursing (DON) said the expectation for reporting abuse is to report it within two hours, continue an in-house investigation, and re-notify of final outcome. The DON said that neither of the incidents were reported to the state agency.

Based on observations, interviews and record review, the facility failed to assist Residents with activities of daily living for 2 Residents (#27 and #9) out of a total sample of 15 Residents. Findings include: Review of a facility policy titled, Resident Hygiene/ADL policy, undated, indicated: *The resident has the right to refuse any type of ADL care. Staff is to report any refusal to the charge nurse. Any ongoing care refusal that could result in harm will be referred to social service for the discussion with the resident/health care proxy and the PCP as needed *Residents may have their facial hair trimmed as needed as long as the resident approves. 1. Resident #27 was admitted to the facility in January 2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the most recent minimum data set assessment (MDS) completed on 6/2/22 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #27 is a two person plus assist with self-performing tasks, and a one-person physical assist for support with personal hygiene tasks. On 7/19/22 at 10:02 A.M., the surveyor observed Resident #27 with chin hair, Resident #27 told the surveyor that he/she would like the chin hair removed. During an interview with the Unit Manager #1 on 7/19/22 at 1:56 P.M., she said she was not aware that Resident #27 had chin hair, and the expectation during care is for the Certified Nurse Assistant (CNA) to remove the chin hair with the consent of the Resident. On 7/20/22 at 8:08 A.M., the surveyor observed Resident #27 with chin hair around his/her mouth area. She/he told the surveyor she/he would like the chin hair removed. During an interview with the Unit Manager #2 on 7/20/22 at 10:12 A.M., she said she asked the overnight staff to remove Resident #27's chin hair with his/her consent, she reviewed the progress notes to make sure Resident #27 did not refuse to get care, Unit Manager #2 stated there were no progress notes indicating Resident #27 refused care. Unit Manager #2 stated that CNAs are expected to remove chin hair from Residents with their consent during care. 2. Resident #9 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 4/10/22, revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #9 scored a 4 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #9 required extensive assistance for personal hygiene tasks. During an observation on 7/19/22 at 7:58 A.M., Resident #9 was observed sitting in a chair with chin hair present. During an interview/observation on 7/20/22 at 9:04 A.M., Resident #9 was observed with chin hair present. Resident #9 said he/she wants the hairs removed and always used to remove them. Resident #9 was observed on 7/20/22 at 9:55 A.M. after A.M., care with chin hair present on his/her face. During an interview on 7/20/22 at 10:28 A.M., Certified Nursing Assistant (CNA) #3 said she washes Resident #9 but does not assist with removing chin hair. During an interview on 7/20/22 at 10:32 A.M., Unit Manager #4 said facial hair should be removed if the resident consents.

Based on observation, interview, and record review, the facility failed to 1. maintain an environment to help prevent the transmission of COVID-19 (a respiratory illness caused by [MEDICAL CONDITION]), and 2. maintain transmission-based precautions to help prevent the transmission of COVID-19. Findings include: 1. On 7/7/2020 at 9:00 A.M., the surveyor observed two residents, Resident #1 and Resident #2, in room [ROOM NUMBER] on the 2nd floor unit. The surveyor observed a set up for Personal Protective Equipment (PPE) was in front of the entrance to the room. Review of the facility document titled 2nd floor census, dated 7/6/2020, indicated Resident #1 was to be on quarantine/isolation for COVID-19 as a new admission to the facility, and Resident #2 was a resident negative for COVID-19 (tested negative nor had signs or symptoms of the illness.) Review of the facility policy titled Novel Coronavirus Prevention and Response, dated 6/26/2020, indicated the following: -Procedure when COVID-19 is suspected or confirmed: -Place Resident in a private room (containing a private bathroom) -Restrict Resident to his/her room. -All new admission and readmissions should be placed in isolation for 14 days after admission and placed on contact/droplet precautions using the CDC signage of COVID-19 status unknown. A. In a private room then B. Cohort with a resident that has recovered from COVID-19 then C. Cohort with another new admission Review of the facility document LTC Respiratory Surveillance Line List, dated 7/7/2020, failed to indicate Resident #2 had ever tested positive for COVID-19 nor had any symptoms of the illness. Review of Resident #1's progress note dated 7/4/2020 indicated Resident #1 was admitted to the facility on [DATE] During an interview on 7/7/2020 at 9:45 A.M., Unit Manager #1 said Resident #1 was on full droplet precautions and quarantine for COVID-19 because he/she was a new admission. She said Resident #2 had been taken off quarantine precautions, and was negative for COVID-19. During an interview on 7/7/2020 at 10:20 A.M., the Assistant Director of Nursing (ADON) said Resident #1 was admitted on [DATE] and was put on quarantine for unknown COVID-19 status. She said Resident #1 was placed in room [ROOM NUMBER] with Resident #2, even though Resident #2 was negative for COVID-19 and susceptible to transmission of COVID-19, because Resident #1 was at risk for falls and room [ROOM NUMBER] would allow the staff to supervise him/her. She said Resident #1 and Resident #2 should be separated and he facility was working on moving Resident #2 to a different room. 2. On 7/7/2020 at 10:30 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 enter room [ROOM NUMBER], wearing a mask and face shield. the surveyor observed a sign at the door that indicated the resident in room [ROOM NUMBER], Resident #3, was on contact/droplet precautions and staff needed to gown and glove at the door before entering the room. the surveyor observed Resident #3 standing up, and CNA #1 assisting him/her to bed without a gown on. During an interview on 7/7/2020 at 10:32 A.M., CNA #1 said she entered the room without donning a gown because she was concerned Resident #3 was going to fall. On 7/7/2020 at 10:35 A.M., the surveyor observed housekeeper #1 delivering personal laundry to residents on the 2nd floor. The surveyor observed housekeeper #1 enter room [ROOM NUMBER] without donning a gown or gloves to deliver laundry for Resident #3. During an interview on 7/7/2020 at 10:40 A.M., housekeeper #1 said she should have followed the precautions listed at the door of room [ROOM NUMBER] before entering the room, but was unable to say why she did not follow the precautions. On 7/7/2020 at 11:00 A.M., the surveyor observed CNA #1 enter room [ROOM NUMBER], a room with a quarantined resident on droplet precautions, without donning a gown and proceeded to remove linens from a bed in the room. Review of the facility policy titled Novel Coronavirus Prevention and Response, dated 6/26/2020, indicated the following: -Procedure when COVID-19 is suspected or confirmed: -Implement MA DPH contact and droplet precautions. Wear gloves, gowns, goggles/face shields, and masks upon entering room and when caring for the resident. During an interview on 7/7/2020 at 10:55 A.M., Unit Manager #1 said rooms [ROOM NUMBERS] contained residents on quarantine, and any staff entering a quarantine room should don full PPE (gowns, gloves, mask, and eye protection) prior to entering the room.

Based on record review, policy review and interview, the consultant pharmacist failed to ensure that monthly pharmacist reviews included the identification and reporting of irregularities regarding the use of as needed (PRN) [CONDITION(S)] medication (which is limited to 14 days, unless otherwise documented by the prescribing practitioner that it is appropriate to extend beyond 14 days) for 2 residents (#44 and #47) out of 5 residents reviewed for unnecessary medications. Findings include: Review of the facility policy, Consultant Pharmacist Services Provider Requirements, dated October 2017, indicated: Procedures, Section B: The consultant pharmacist agrees to render the required service in accordance with local, state, and federal laws, regulations, and guidelines; facility policies and procedures; community standards of practice; and professional standards of practice. Section E. Specific activities that the consultant pharmacist performs include, but are not limited to: 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition), incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review (See 111A1: MEDICATION REGIMEN REVIEW (MONTHLY REPORT)), and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation. 2). Communicating potential or actual problems and other findings relating to medication therapy orders; including recommendations for changes in medication therapy and monitoring of medication therapy, as well as regulatory compliance issues, on a monthly basis to the responsible practitioner and facility leadership. 1. For Resident #44 - Resident #44 was admitted to the facility in 10/2014 with diagnoses including [CONDITION(S)] with severe [CONDITION(S)], anxiety and hallucinations. The Resident had a physician's order for [MEDICATION(S)] 50 mg per 1 ml, intramuscularly, every day monthly on the 25th. [MEDICATION(S)] is an anti-psychotic medication used to treat bi-polar disorder and [CONDITION(S)] and mental effects of disconnection from reality. Documentation indicated that the Resident received intramuscular injections based on non-compliance and refusal to take medications. Review of nursing progress notes and the nurse practitioner notes indicated that as the time from the injection to the time for the new month's shot neared, the medication seemed to wear off and the Resident needed a PRN dose to manage psychotic episodes. During review of Resident #44 's physician's order sheets, it was observed that orders for anti-psychotic medications on a continuous PRN [as needed] were written during a time span from 2/6/19 through 6/17/19. Review of the medical record indicated that the Pharmacist had conducted monthly reviews of the Resident's medications. However, it was observed that there were no notations and no reports of an irregularity with regard to the ongoing orders for the PRN anti-psychotic medication. The Pharmacist was interviewed on 6/27/19 at 10:05 A.M., the Pharmacist said she had reviewed medications at the facility since February of 2019. The Pharmacist said that she had reviewed the Resident #44's medications and noted [MEDICATION(S)] was prescribed for the Resident's agitation and delusions. Both the Psychiatric Nurse Practitioner and the Physician had written successive PRN orders for [MEDICATION(S)] for a period of 14 days. The Pharmacist said she thought the PRN medication had stopped after 14 days and was not aware that the PRN orders spanned from 2/6/2019 through 6/17/19. The Pharmacist said that she did not conduct regular reviews of the telephone orders where the PRN orders were written, so they were not addressed in her monthly reviews. As a result, the Pharmacist was not aware that they had started up again. The Pharmacist said that she was aware that a face to face evaluation was required by Federal regulations to write a PRN order for an anti-psychotic medication, but that it was not her role to make sure that the Nurse Practitioner made a face to face evaluation to write the order. The pharmacist failed to identify, document and communicate to the physician and facility administration, the irregularity that orders for the use of PRN [MEDICATION(S)] were active in Resident #44's medication regimen from 2/6/19 through 6/17/19. 2. For Resident # 47 - Resident #47 was admitted to the facility with diagnoses including dementia with behaviors. Record review indicated Resident #47 had telephone orders dated 4/26/19, 5/9/19, 5/28/19 and 6/17/19 for a PRN (as needed) antipsychotic medication, [MEDICATION(S)], that read: [MEDICATION(S)] 25 mg (milligrams) po (by mouth) q (every) 8 hrs prn (as needed) agitation x 14 days. Review of the physician and nurse practitioner visits indicated that none of the visits occurred on the dates the prescriber ordered a renewal of the PRN anti-psychotic medication. On 6/27/19 at 8:40 A.M. during an interview, the prescribing Nurse Practitioner (NP) and the Psychiatric Services NP said they evaluate the resident's use of the PRN anti-psychotic medication from review of the Medication Administration Records and a discussion with facility staff. The NPs were not aware that a face to face evaluation of the Resident must be conducted to write a PRN order for an anti-psychotic medication as per the facility policy and Federal requirements. During an interview on 6/27/19 at 9:46 A.M., the Pharmacist said she was aware that a face to face evaluation was required by Federal regulations to write a PRN order for an anti-psychotic medication. Review of the Medication Regimen Reviews dated 5/22/19 and 6/14/19 indicated that the Pharmacist failed to identify, document or report irregularities to the prescribing practitioner or facility administration that a face to face evaluation was required to write a PRN order for an anti-psychotic medication.

Based on observation, interview, medical record review and facility policy, the facility staff failed to ensure for 2 of 5 residents reviewed for unnecessary medications (#44 and #47) that PRN [as needed] orders for anti-psychotic drugs were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Findings included: 1. For Resident #44, the facility staff failed to ensure that the prescriber evaluated the resident prior to renewing an order for a PRN (as needed) antipsychotic medication. Resident #44 was admitted to the facility in 10/14 with diagnoses including [CONDITION(S)] with severe [CONDITION(S)], anxiety and hallucinations. The Resident had a physician's order for [MEDICATION(S)] 50 mg per 1 ml, intramuscularly, every day, monthly on the 25th. [MEDICATION(S)] is an anti-psychotic medication used to treat bi-polar disorder and [CONDITION(S)] and mental effects of disconnection from reality. Documentation indicated that the Resident received intramuscular injections based on non-compliance and refusal to take medications. Review of nursing progress notes and the nurse practitioner notes indicated that as the time from the injection to the time for the new month's shot neared, the medication seemed to wear off and the Resident needed a PRN dose to manage psychotic episodes. During review of Resident #44 's physician's order sheets, it was observed that orders for anti-psychotic medications on a continuous PRN [as needed] were written during a time span from 2/6/19 through 6/17/19. Resident #44 had telephone orders dated 6/4/19, 5/20/19, 2/20/19 and 1/6/19 that read: [MEDICATION(S)] 2.5 mg (milligrams) po (by mouth) q (every) 6 hrs prn agitation/[CONDITION(S)] x 14 days. Review of the physician and nurse practitioner visits indicated that none of the visits occurred on the dates the prescriber ordered a renewal of the PRN antipsychotic medication. Review of the Facility policy titled PRN Medication Policy for [CONDITION(S)] Medications revised 12/17, indicated that PRN orders for anti-psychotic medications are limited to 14 days and cannot be renewed, however, a new PRN order may be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medications. The evaluation of the resident must include directly examining the resident to determine if the medication is still needed. A report of the resident's condition from facility staff shall be insufficient for this purpose except in extenuating circumstances. Nurse #1 was interviewed on 6/26/19 at 9:32 A.M. and said that the Resident has hallucinations where she/he will pick things out of the air and tries to stand up when she/he cannot walk. The Resident has behaviors such as hitting when thrashing about, sleeps all day . will not get up and spits her/his meds out at times. Nurse #1 said this is why she/he gets the monthly shot - it keeps her/him calm and involved in care and activities. Nurse #1 said the intramuscular injection wears off as the month wears on and they can tell when a PRN is necessary, so they call for a PRN order to boost the monthly injection. Nurse #1 said the Resident needs the PRN boost about 2 - 3 times a month, sometimes none . related to break through from the intramuscular dose. The Psychiatric Nurse Practitioner [NP #2] was interviewed on 6/27/19 at 8:30 A.M. The Psychiatric NP said the Resident had a long history of non compliance with meds, so the Resident receives intramuscular injections. The Resident had failed all attempts for a gradual dose reduction. The Psychiatric NP said that as the injection wears off, she/he has hallucinations - so it has increased over time. The Psychiatric NP said that she has to order a PRN to boost the wear-off effects. The need for a boost occurs when the shot wears off - near the end of time when the Resident needs another shot . and the Resident needs the PRN to keep a baseline level. The Psychiatric NP said that the Resident's delusions cause great distress - tries to climb under bed, screams and tries to get out of bed when she/he cannot walk. The Psychiatric NP said that nursing staff see it coming and will call for a PRN. The Psychiatric NP said that she is not always present to evaluate the Resident face to face when an order for the PRN [MEDICATION(S)] is requested. The Psychiatric NP was not aware that a face to face evaluation of the Resident must be conducted to write a PRN order for an anti-psychiatric medication as per the facility policy and Federal requirements pertaining to prescribing anti-psychotic medications. 2. For Resident #47, the facility staff failed to ensure that the prescriber evaluated the resident prior to renewing an order for a PRN (as needed) anti-psychotic medication. Resident #47 was admitted to the facility with diagnoses including dementia with behaviors. The Resident had a PRN physician's order for [MEDICATION(S)], an anti-psychotic medication used to treat certain mental/mood conditions such as [CONDITION(S)] and [CONDITION(S)]. Review of Resident #47's physician's order sheets indicated telephone orders dated 4/26/19, 5/9/19, 5/28/19 and 6/17/19 for [MEDICATION(S)] 25 mg (milligrams) q (every) 8 hours PRN (as needed) agitation. Review of the physician and nurse practitioner visits indicated that none of the visits occurred on the dates when the prescriber ordered a renewal of the PRN antipsychotic medication. Review of the facility's policy: PRN Medication for [CONDITION(S)] and Antipsychotic Medications read: PRN orders for anti-psychotic medications are limited to 14 days and cannot be renewed, however a new PRN order may be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication. The evaluation of the resident must include directly examining the resident to determine if the medication is still needed. A report of the resident's condition from facility staff shall be insufficient for this purpose except in extenuating circumstances. On 6/27/19 at 8:40 A.M. during an interview with the resident's prescribing Nurse Practitioner (NP) and the Psychiatric Services NP, the surveyor inquired about the PRN [MEDICATION(S)] orders written for Resident #47. The NPs said that they evaluate the resident's use of the PRN anti-psychotic medication after review of the Medication Administration Records and a discussion with facility staff. The NPs were not aware that a face to face evaluation of the Resident must be conducted to write a PRN order for an anti-psychotic medication as per the facility policy and Federal requirements. On 6/27/19 at 8:50 A.M., the Surveyor provided the NPs copies of the facility's policy on PRN Medication for [CONDITION(S)] and Antipsychotic Medications.

Based on observation and interview, facility staff failed to ensure that medications were properly labeled and expired medications were not available for administration in 1 of 2 medication rooms and in 2 of 4 medication carts. Findings include: On 6/25/19 at 12:35 P.M., the surveyor observed the following medication available for administration in the 1st floor Back Side medication cart: - 1 [MEDICATION(S)] inhaler (an inhaled medication used to improve breathing) opened and undated, therefore unable to determine an expiration date. Manufacturer guidelines for [MEDICATION(S)] indicated the medication must be discarded 3 months after it is removed from it's foil pouch. Nurse #1 acknowledged that the [MEDICATION(S)] should have been labeled when opened. On 6/26/19 at 3:26 P.M., the surveyor observed the following solution available in the 1st floor medication refrigerator: -one multi use vial of [MEDICATION(S)] (a solution used as an aid in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 said the bottle should be labeled as to date opened and said that it was good for use within 28 days of opening

Based on records review and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure safety for Resident #1, who was cognitively impaired and had a history of [REDACTED].#1 into bed without placing his/her bed alarm on the bed as indicated in Resident #1's Care Plan. Resident #1 fell approximately 40 minutes later and was transferred to the emergency room where he/she was diagnosed and treated for [REDACTED]. Findings Include: The Policy, titled Fall Prevention and dated 3/18/10, indicated that a fall prevention plan will be initiated on all residents who are at risk for falling. A Falls Risk Assessment, dated 2/12/17, indicated that Resident #1 had a fall risk score of 24. The Falls Risk Assessment indicated that residents who scored greater than 10 should be considered to be at high risk for falls. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was admitted to the facility on [DATE] and Resident #1's Brief Interview for Mental Status (BIMS) indicated that Resident #1 was cognitively impaired with a score of 6 (scores of 0-7 indicate severe cognitive impairment). The MDS indicated that Resident #1 used a walker with ambulation, was not steady and required staff assistance when moving from seated to standing positions, transferring from a bed to a chair, and while walking. A Fall Risk Care Plan, dated 12/28/16, indicated that Resident #1 was at risk for falls due to weakness, lethargy, altered mobility, and he/she required assistance with ambulation, transferring, and toileting. An entry on the Care Plan, dated 2/1/17, indicated Resident #1 fell on [DATE]. The Care Plan indicated that Resident #1 required an alarm on his/her bed and chair. A Resident Care Card revised on 2/16/17 indicated that Resident #1 was to have an alarm on his/her bed and chair. A Physical Therapy Evaluation and Plan of Treatment, dated 2/13/17, indicated Resident #1 started Physical Therapy services on 2/13/17 for [DIAGNOSES REDACTED]. A Resident Incident Report, dated 2/18/17, indicated that Resident #1 fell in his/her room at 3:50 P.M. on 2/18/17. The Surveyor interviewed the Rehabilitation Manager on 5/22/17 at 11:55 A.M. The Rehabilitation Manager said when the Physical Therapist provided therapy services for Resident #1, on 2/18/17, the Physical Therapist assisted Resident #1 back into bed when they were finished and, approximately 40 minutes later, the Physical Therapist observed Resident #1 on the floor. The Rehabilitation Manager said the Physical Therapist did not put an alarm on Resident #1's bed when she assisted him/her into bed and the Physical Therapist did not know that Resident #1 required a bed alarm as a safety intervention. The Rehabilitation Manager said therapists should have knowledge of the safety interventions that are in place for residents. The Surveyor interviewed the Physical Therapist on 5/23/17 at 12:15 P.M. The Physical Therapist said she treated Resident #1 on 2/18/17, and assisted him/her into bed after they were finished but did not put an alarm on Resident #1's bed. The Physical Therapist said while she was working with another resident she heard a bang come from Resident #1's room, she ran into his/her room, and observed Resident #1 on the floor between his/her bed and the bathroom. The Physical Therapist said although she was aware that Resident #1 was at risk for falls, she was unaware that Resident #1 was supposed to have an alarm on his/her bed. The Physical Therapist said residents have Care Plans in their charts, but she was not aware that she was supposed to review Care Plans. A Nurse's Note, dated 2/19/17 and timed at 3:00 A.M., indicated that Resident #1 was admitted to the Hospital for evaluation and observation after a fall. The Hospital Discharge Summary, dated 2/19/17, indicated that Resident #1 was diagnosed and treated for [REDACTED].

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 received immediate assessment and intervention in response to a fall, resulting in delay in identification of a dislocated right shoulder. Resident #1's care was delayed by 1 hour and 45 minutes because CNA #1 failed to inform Nurse #1 that Resident #1 sustained a fall at 4:00 A.M. on 7/31/14, which resulted in Resident #1 having pain, and in Resident #1 not receiving timely evaluation and treatment of [REDACTED]. Findings included: Resident #1's [DIAGNOSES REDACTED].#1 was admitted during May 2014. Resident #1 had severely impaired cognition and a family member was his/her Health Care Agent. Resident #1's Fall Risk Care Plan, dated 5/16/14, indicated Resident #1 was at high risk for falling as he/she was unaware of his/her mobility limitations, was confused, and unable to follow directions.. The Facility's Accident and Incident policy, dated 10/1/09, indicated when staff witnessed an incident, accident, or adverse event they were to provide immediate assistance; summons help and remain with the person; will not move the individual until a licensed nurse examined him/her for possible injuries; and were to notify a physician, the Administrator, and Director of Nurses. The policy also indicated all accident, incidents, and adverse events will be reported to the Supervisor at the time the incident occurred. CNA #1 said that on 7/30/14 at 4:00 A.M., he assisted Resident #1 up from the floor where he/she had fallen. CNA #1 said that at the time of the fall, he did not notify Nurse #1, who arrived in the room moments after Resident #1 was back in bed, that Resident #1 had fallen. CNA #1 said Resident #1 did complain to him of right upper arm pain while he/she was using the toilet shortly after the 4:00 A.M. fall. CNA #1 said he did not notify Nurse #1 of Resident #1's complaint. Nurse #1 said Resident #1 woke at 5:15 A.M. and began yelling out regarding having pain in his/her right arm. Nurse #1 said Resident #1 could not tell her why his/her arm hurt and at 5:30 A.M., administered 650 milligrams (mg) of Tylenol to Resident #1 with little effect. Nurse #1 said at about 5:45 A.M. on 7/30/14, she instructed CNA #1 and CNA #2 to transfer Resident #1 from bed into his/her wheelchair as he/she continued to complain of right arm pain. Nurse #1 said at this time CNA #1 told her, maybe Resident #1 hurt his/her arm when he/she fell earlier. Nurse #1 said this was the first time she heard that Resident #1 fell during the shift. Nurse #1 said she immediately brought Resident #1 to the den near the nurses' station, telephoned Resident #1's nurse practitioner and Resident #1's Health Care Agent and, at 6:00 A.M., administered 2.5 mg of as needed [MEDICATION NAME] (narcotic pain medication) to Resident #1. Resident #1 was sent to the hospital for evaluation at 7:00 A.M. on 7/30/14 and was diagnosed with [REDACTED].

Based on observation, record review and staff interview, the facility failed to provide supervision to prevent accidents for 1 resident (#1), out of a sample of 15 residents. Findings include: For Resident #1, the facility failed to provide adequate supervision to prevent a fall during an outside activity on the patio which resulted in a fractured hip. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed the resident as being severely cognitively impaired, requiring limited assistance with transfers and not being steady while moving from a seated to a standing position without assistance. It further identified the resident as having a history of falls, requiring extensive assistance with locomotion while off the unit and utilizing a walker for mobility. A care plan that was in effect through 7/15/11 for "Impaired Mobility" included the following approaches: - Modality: walker - Assist resident with transfers with 1 assist as needed. - Walk resident with 1 assist as needed, usually just supervision. An incident report, dated 7/15/11, revealed the resident sustained [REDACTED].M. while attending an activity outside on the patio with other residents. According to the report, the following information was documented: the resident, who was cognitively impaired and had impulsive behaviors, had a fall that was not witnessed by staff but was witnessed by two other residents who were in attendance at the time. One resident stated Resident #1 was walking with his/her walker and reached forward for a ball. This resident thought Resident #1 may have hit his/her head on the bench. A second resident reported that Resident #1 was reaching for a brown ball when he/she slipped and fell on his/her left side. The resident was transferred to the hospital and diagnosed with [REDACTED]. Further review of the incident report indicated an intervention noted an inservice was provided to staff after this serious incident occurred. Resident #1 was observed on 1/31/12 at 2:30 P.M. sitting in the lobby in a reclining wheelchair. At 2:35 P.M., the resident was observed walking with physical therapy using a rolling walker. On 2/1/12 at 2:00 P.M., during an interview with the Administrator, Director of Nurses and Assistant Director of Nurses, the Director of Nurses gave the surveyor a written statement regarding the fall Resident #1 sustained. The statement revealed the resident was outside at an activity with other residents. The activity had finished, and the activity staff member was assisting another resident. Resident #1 was ambulating with his/her walker with the rest of the group, leaned over to reach for a ball, lost his balance and fell . After this incident, the Director of Nurses stated she sent a memo and met with activity staff and nursing staff regarding transport of residents to and from activities in the event there are not two activity staff present.