Every finding on record at Life Care Center Of Attleboro

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for three Residents (#7, #32, and #104), out of a total sample of 24 residents.Specifically, the facility failed:1. For Resident #7, to ensure Metoprolol Tartrate (a medication used to lower blood pressure and/or heart rate) was not administered when the Resident's systolic blood pressure (SBP) was below 110 millimeters of mercury (mmHg) or the Resident's heart rate (HR) was below 65 beats per minute as instructed in the physician's order; and 2. For Residents #32 and #104, to ensure that the nurse observed the Residents taking the medications and not leave the medications at the Residents' bedside. Findings include:Review of the facility's policy titled Administration of Medications, reviewed 9/9/25, indicated, but was not limited to, the following:-The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.-Medication error – This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:1. The prescriber's order2. Manufacturer's specifications regarding the preparation and administration of the medication or biological; or3. Accepted professional standards and principles which apply to professionals providing services.-Staff who are responsible for medications administration will adhere to the 10 Rights of Medication Administration*Right Assessment. Note the resident's history and any parameters around drug administration. Review of the facility's policy titled Physician Orders, reviewed 2/27/25, indicated, but was not limited to, the following: -The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. Resident #7 was admitted to the facility in April 2025 with diagnoses including atrial fibrillation, heart failure, and end stage renal disease on renal dialysis. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 8/5/25, indicated he/she was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #7's Physician's Orders indicated, but was not limited to, the following:-Metoprolol Tartrate Tablet Give 12.5 milligram (mg) by mouth two times a day for atrial fibrillation **Hold for SBP less than 110 or HR less than 65** (order date 8/1/25) Review of Resident #7's Medication Administration Record (MAR) for the month of August 2025 indicated, but was not limited to, the following:- Metoprolol Tartrate was administered 17 times when the Resident's SBP was less than 110 mmHg or HR was less than 65 as documented on the MAR Review of Resident #7's MAR for the month of September 2025 indicated, but was not limited to, the following:- Metoprolol Tartrate was administered 7 times when the Resident's SBP was less than 110 mmHg or HR was less than 65 as documented on the MAR Further review of Resident #7's medical record failed to indicate nursing documentation related to the reason for medication administration or that the physician was contacted and ordered the medication to be given when the Resident's vital signs were noted to be outside of the order's parameters. During an interview on 9/22/25 at 2:19 P.M., Nurse #1 reviewed Resident #7's August 2025 MAR with the surveyor, who identified the dates which indicated the Resident's vital signs were outside of the physician's ordered parameters for Metoprolol. Nurse #1 confirmed the MAR indicated the medication had been administered despite the Resident's vital signs being documented outside of the parameters ordered. Nurse #1 said when the Resident's vital signs were out of parameters ordered, the medication should have been held and not administered. During an interview on 9/22/25 at 3:50 P.M., the Director of Nursing said she had reviewed the Resident's MAR and noticed the medication was administered numerous times when the Resident's vital signs were outside of the ordered parameters. The Director of Nursing said it was her expectation that the physician's orders would be followed when nurses administer medications. 2. During an observation with interview on 9/17/25 at 9:09 A.M., the surveyor entered the room of Resident #104 and observed a plastic medication cup with a large, pink tablet inside it on the Resident's bedside table. The Resident said that he/she thought the medication was for his/her stomach. The Resident said that Nurse #3 left the medication at the bedside for him/her to take on their own. Resident #104 said that often, Nurse #3 would leave medication at the bedside and leave the room before he/she took them. During an observation with interview on 9/17/25 at 9:50 A.M., the surveyor entered Resident #32's room and observed a medication cup containing applesauce and a crushed white substance which the Resident was spooning it into his/her mouth. Resident #32 said that Nurse #3 had placed the medication at the bedside, instructed him/her to take it, and left the room before he/she took the medication. The Resident said the medication crushed and mixed in the applesauce was Tylenol. During an interview on 9/17/25 at 10:00 A.M., Nurse #3 said that he left medications at the bedsides of Residents #32 and #104. Nurse #3 said that he left a Tums at Resident #104's bedside and did not wait until the Resident took it before leaving the Resident. Nurse #3 said that he left Tylenol crushed in applesauce at Resident #32's bedside and did not wait with the Resident to ensure that he/she took all the medication. Nurse #3 said that he knows he is supposed to stay with residents and observe that they take all the prescribed medication before leaving them. He said that's the facility policy and he didn't follow it. During an interview on 9/18/25 at 10:06 A.M., the surveyor informed the DON of their observations of Nurse #3's failure to observe Residents #32 and #104 consume their prescribed medications before leaving the Resident as per standards of practice for medication administration. The DON said that Nurse #3 failed to follow the facility policy for medication administration. She said that it is not safe or appropriate to leave medications at a resident's bedside. She said the nurse is responsible for staying with the resident until the resident is finished taking all the prescribed medication. The DON said that it is a safety concern if the nurse fails to ensure that a resident takes all the medication as ordered by the physician.

Based on record review and interviews, the facility failed to ensure that dialysis services included ongoing, collaborative, and complete documentation of communication between the facility and dialysis center regarding the Resident's dialysis care and treatment for one Resident (#168), of a total sample of 23 residents. Findings include: Resident #168 was admitted in May 2024 with diagnoses which included end-stage renal disease (ESRD). Review of the facility's policy titled Area of Focus: Dialysis, dated 11/23/2022, included but was not limited to the following: General Guidelines: -Assess for any signs/symptoms of infection, such as redness or edema at the vascular access site. -Assess vascular access site for signs of clotting every 8 hours. -Monitor for any complaints of pain or discomfort at vascular access site. -Document in the clinical record: dialysis treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and physician and responsible party notification. -Document any pertinent or relevant observations and information including compliance/non-compliance with food and fluid restrictions. When: Pre-Dialysis -Any concerns are communicated to the resident/responsible party, physician, and dialysis facility, as appropriate. Day of Dialysis: -Check medications the resident is taking, especially blood pressure and cardiac medications -Initiate the Pre-/Post-Dialysis Communication Form to be sent to the dialysis clinic with the resident. Post-Dialysis: -Obtain vital signs of resident upon return from dialysis and complete the Pre-/Post-Dialysis Communication Form. -Follow routine dialysis instructions on dialysis transfer form. -Transcribe any diet, medication, and/or orders received with resident from the dialysis facility. -Monitor vascular access site on a routine basis. Notify physician if any unusual problems note (tenderness, bleeding). Post-Dialysis: -Obtain vital signs of resident upon return from dialysis. Review of the medical record indicated that Resident #168 went to the dialysis center every Monday, Wednesday, and Friday. Review of Resident #168's care plan for dialysis indicated for nursing to complete the Pre-/Post-Dialysis Communication Form on dialysis days. During an interview on 8/16/24 at 10:30 AM, Unit Manager (UM) #2 said that the Resident had an arteriovenous (AV) fistula in his/her left arm and that a care plan for dialysis was developed and included nursing to complete the Pre-/Post-Dialysis Communication Form on dialysis days. Review of Resident #168's Pre-/Post-Dialysis Communication Forms from 7/8/24 through 8/19/24 indicated there were 18 communications forms. Of the 18 Pre-/Post-Dialysis Communication Forms reviewed, 15 of the communication forms for the facility were incomplete and were missing information such as the condition of the access site, bruit and thrill (an assessment of the AV fistula function), vital signs, and/or the Resident's weight. Of the 18 Pre-/Post-Dialysis Communication Forms reviewed, 14 of the communication forms from the dialysis center were incomplete, but not limited to the following missing clinical information: The condition of the access site, vital signs, pre-/post-dialysis weights, type of vascular access/site, presence or absence of the bruit/thrill (assessment for AV fistula function). Further review of the dialysis center's Pre-/Post-Dialysis Communication Forms indicated that on 7/10/24, 7/17/24, 7/26/24, and 7/31/24, the communication forms were completely blank and lacked any of the required information pertaining to the Resident's care and treatment at the dialysis center. During an interview on 8/21/24 at 7:58 A.M., the Director of Nursing (DON) said that the facility nursing staff are responsible for making sure the Dialysis Communication Form is complete prior to the Resident leaving for dialysis. Upon return to the facility, nursing is responsible for ensuring the form is complete and contains all the required information from the dialysis center. The DON said that if the Resident returns from the dialysis center with an incomplete Dialysis Communication Form, nursing is responsible for calling the dialysis center to obtain the missing information. The DON reviewed the Dialysis Communication Forms, from both the facility and the Dialysis Center, from 7/8/24 to 8/19/24, for the Resident, and said that they were incomplete. She said she was not aware that the dialysis documentation on the Dialysis Communication Forms was not being completed in their entirety by the facility and the dialysis center. The DON said her expectation was that her staff must ensure that the dialysis paperwork is complete for both the facility and the dialysis center and that it include weights, treatment provided, vital signs, status of the IV access, etc. as outlined on the Dialysis Communication Form.

Based on interview and record review, the facility failed to assess a history of trauma and failed to assess for triggers to avoid potential re-traumatization for one Resident (#88) with a history of trauma, out of a total sample of 23 residents. Findings include: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma. SAMHSA-HRSA Center for Integrated Health Solutions. Substance Abuse and Mental Health Services Administration, 11/30/2016. Review of the facility's policy titled Trauma-Informed Care, dated as reviewed in 8/22/23, indicated the following: -The facility will use a multi-pronged approach to identify residents with PTSD (post-traumatic stress disorder) or history of trauma. The approach would include assessing the residents for indicators of trauma upon admission/re-admission and with change of condition. -The facility will use the Trauma Informed Care Assessment in the electronic medical record to assess the resident's experience of seventeen possible negative life events. -The facility should collaborate with the resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals to develop and implement an individualized plan of care. -In situations where a trauma survivor is reluctant to share his/her history, the facility should still attempt to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger for the resident. Resident #88 was admitted to the facility in June 2024 with a diagnosis of dementia. Review of the care plans indicated Resident #88 utilized an antidepressant medication related to anxiety and agitation as evidenced by calling out and had an isolated incident of being combative during care. Interventions included: attempt to redirect with conversation about the daughter; having family visits with daughter; behavioral health services. On 8/15/24 at 8:50 A.M., the surveyor observed Resident #88 in bed and the Resident was heard repeatedly calling out. On 8/15/24 at 1:53 P.M., the surveyor observed Resident #88 attending a small group activity and repeatedly calling out. Review of the nursing progress notes indicated Resident #88 was often calling out, restless, and agitated. Review of the electronic and paper medical record failed to include a psychosocial history or trauma assessment. During an interview on 8/20/24 at 10:15 A.M., Social Worker #1 said when residents are admitted to the facility, the social workers complete a psychosocial history and a trauma assessment. She said sometimes she completes the assessments on paper. She reviewed her soft file in the Social Service office for Resident #88 and found an undated paper Social Service Assessment. The Social Worker said Resident #88 was unable to answer some of the questions due to dementia and she could not remember if she had contacted the family to obtain the history. The Social Worker pulled a blank Trauma Assessment form out of the soft file and said she did not have a Trauma Assessment for Resident #88. Review of the undated Social Service Assessment did not include any information regarding if Resident #88 was assessed for a history of trauma. During an interview on 8/20/24 at 2:45 P.M., Social Worker #1 said she had reached out to the family of Resident #88. The family had indicated Resident #88 had a significant trauma history and did not like to discuss their trauma. She said, in addition, Resident #88 had experienced the loss of their child, who was also their care giver two years prior. The Social Worker said a Trauma Assessment should have been completed for Resident #88 during the admission process.

Based on record review and staff interviews, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for one Resident (#46), out of a total sample of 23 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, revision date 10/24/2022, indicated but was not limited to the following: -PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days. - For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record. - Where Physician/Prescriber orders a psychotropic medication for a resident, facility should ensure that the Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. Resident #46 was admitted to the facility in January 2021 with diagnoses including diabetes, anxiety, and dementia with agitation. Review of the Minimum Data Set (MDS) assessment, with a reference date of 7/17/24, indicated that Resident #46 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Review of the Physician's Orders indicated but was not limited to the following: -Lorazepam Intensol Oral Concentrate two milligrams/milliliter (ml) give 0.5 ml by mouth every one hours as needed for anxiety. (7/12/24) Further review of the Lorazepam PRN order failed to indicate a stop date or re-evaluation date as required. Review of July 2024 and August 2024 Medication Administration Records (MAR) indicated Lorazepam Intensol Oral Concentrate was administered as needed on 7/26/24. Further review of the medical record failed to indicate documentation that Resident #46's PRN order for Lorazepam was re-evaluated by the attending physician to determine that it was appropriate to extend beyond 14 days as required. During an interview on 8/21/24 at 8:17 A.M., Unit Manager #1 said Resident #46 had been admitted to Hospice. The Hospice company had an order set which included the use of PRN Lorazepam. Unit Manager #1 said all psychotropic PRN orders should be written for 14 days and then re-evaluated and extended if needed. Unit Manager #1 said she could not see any documentation that the physician had substantiated the continued use of Lorazepam PRN and extended the duration of use. During an interview on 8/21/24 at 10:27 A.M., the Director of Nurses (DON) said she had been made aware of the issue with the Lorazepam order for Resident #46 by Unit Manager #1. The DON said all psychotropic PRN medications, including Lorazepam, should be written for 14 days only and then re-evaluated with a documented rationale and a new duration date for evaluation.

Based on observation and interview, the facility failed to ensure residents in 3 of 4 dining rooms had a comfortable and homelike dining experience. Findings include: During dining observations throughout survey from 7/25/23 through 7/28/23, the surveyors observed the following on [NAME], Bristol, [NAME] Units, and the main dining room: 1. [NAME] Unit: -7/25/23 from 8:25 A.M. to 8:34 A.M., the surveyor observed three residents seated at two tables in the unit dining room. All three residents were served their meal from the food truck to the table. All meal plates remained on the trays and residents were observed to eat breakfast off the serving trays that were placed directly on the table. Both tables in the dining room had tablecloths on them. Facility staff did not ask each resident if they wanted their plates, cups, and utensils to remain on the trays, or placed on the table. The surveyor approached each table and asked the residents if they preferred to eat their meals off trays or want them placed on the table. All three residents at the table said they did not know they could have the plates removed from the trays and placed on the table. -7/26/23 at 12:11 P.M., the surveyor observed six residents seated at tables in the unit dining room. All six residents were served their meal from the food truck to the table. All meal plates remained on the trays and residents were observed to eat lunch off the serving trays that were placed directly on the table. Both tables in the dining room had tablecloths on them. Facility staff did not ask each resident if they wanted their plates, cups and utensils to remain on the trays, or placed on the table. The surveyor approached each table and asked the residents if they preferred to eat their meals off trays or want them placed on the table. Four residents said they did not know they could have their plates removed off the trays and placed on the table, and two residents did not respond. 2. Bristol: -7/25/23 from 12:06 P.M. to 12:26 P.M., the surveyor observed five residents seated at two tables in the unit dining room. All five residents were served their meal from the food truck to the table. All meal plates remained on the trays and residents were observed to eat lunch off the serving trays that were placed directly on the table. Neither of the two tables had tablecloths. Facility staff did not ask each resident if they wanted their plates, cups and utensils to remain on the trays, or placed on the table. -7/26/23 at 8:45 A.M., the surveyor observed three residents seated at a table in the unit dining room. All three residents were served their meal from the food truck to the table. All meal plates remained on the trays and residents were observed to eat breakfast off the serving trays that were placed directly on the table. Neither of the two tables had tablecloths. Facility staff did not ask each resident if they wanted their plates, cups, and utensils to remain on the trays, or placed on the table. 3. [NAME]: - 7/28/23 at 12:00 P.M., the surveyor observed staff assisting residents seated at three tables to eat their lunch meal in the unit dining room. All meal plates remained on the trays and residents were observed to eat lunch off the serving trays that were placed directly on the table. There were no tablecloths on any of the tables. Facility staff did not ask each resident if they wanted their plates, cups, and utensils to remain on the trays, or placed on the table. 4. Main Dining Room: -7/26/23 at 12:05 P.M., the surveyor observed 11 residents in the main dining room eating lunch. Blue tablecloths and white placemats were placed on each table. All 11 residents were served their meals with plates, cups and utensils directly on the table. -7/27/23 at 12:03 P.M., the surveyor observed 11 residents in the main dining room eating lunch. Blue tablecloths and white placemats were placed on each table. All 11 residents were served their meals with plates, cups and utensils directly on the table. During an interview with Unit Manager #3, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Corporate Nurse on 7/27/23 at 10:17 A.M., the DON said each resident can have their meal served either on the tray or placed on the table. However, the DON and Unit Manager #2 said that residents are not asked daily if they want their meal served on the tray or on the table. The DON said residents that eat meals in the main dining room are always served their meals directly on the table with tablecloths, and not on trays. They could not explain why the dining experience was more institutional on the [NAME], Bristol, and [NAME] units and homelike in the main dining room.

Based on record review, policy review, and staff and family interviews, the facility failed to ensure that for two Residents (#17 and #64), of a total sample of 22 residents, care and treatment of the residents met professional standards of quality. Specifically, the facility failed to ensure: 1. For Resident #17, care and treatment to the Resident's implanted cardiac pacemaker met professional standards of quality and were in accordance with the facility's policy, and follow-up care for a pacemaker and Implantable Cardiac Defibrillator (ICD) met current standards of practice; and 2. For Resident #64, a physician's order for discharge from the facility was obtained. Findings include: 1. Review of the facility's policy titled The Permanent Pacemaker policy, revised on 9/3/2022, indicated: -Resident with pacemakers will have a record of when it was last checked and the date of when the next check is due. The facility will assist in facilitating the check of the pacemaker in accordance with the schedule set by the resident's cardiologist. Procedure: 1. The practitioner's office or device manufacturer contacts the nursing unit to schedule an appointment for pacemaker checks. 2. On the scheduled date and time, the licensed nurse gathers testing equipment, explains procedures to resident, and provides privacy. 3. The nurse will follow the instructions for the transmission of data that has been given by the practitioner's office or follow the device manufacturer's instructions on how to submit a transmission. 4. Document completion of the transmission and in abnormal issues, if any, in the nurses' note and document schedule in resident care plan. 5. If the patient becomes symptomatic (e.g., bradycardia, syncope), the licensed nurse will notify the practitioner and inquire whether a pacemaker check should be completed at that time. Review of the American College of Cardiology/American Heart Association guidelines for implantation of cardiac pacemakers and antiarrhythmia devices indicated After implantation of a pacemaker, careful follow-up and continuity of care are absolute requirements. Programming at implantation must be reviewed before the patient is discharged and further refined at subsequent follow-up visits as indicated by interrogation and testing. Gregoratos G, Cheitlin MD, Conill A, [NAME] AE, fell ows C, [NAME] TB Jr, [NAME] RA, [NAME] MA, Naccarelli GV, Saksena S, Schlant RC, [NAME] MJ. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the ACC/AHA Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol. 1998;31:1175-1206. Resident #17 was admitted to the facility in June 2022 with diagnoses which included atherosclerotic heart disease, non-rheumatic aortic valve stenosis, transcatheter aortic valve replacement (prosthetic heart valve), hypertensive heart disease with heart failure, chronic combined systolic (congestive) and diastolic (congestive) heart failure, atrial fibrillation, biventricular pacemaker and ICD, and chronic obstructive pulmonary disease (COPD). Review of the Hospital Discharge documentation indicated the Resident had a biventricular pacemaker and ICD, and a follow up appointment with his/her cardiologist on 11/8/22 at 2:45 P.M. Review of the care plan for the care of the pacemaker, dated 6/16/22, indicated the following: Focus: The resident has a pacemaker related to (r/t) atrial fibrillation. Goals: The resident will remain free of signs and symptoms (s/sx) of altered cardiac output through review date. The resident will maintain heart rate within acceptable limits as determined by MD/pacemaker settings through review date. Interventions: -Labs as ordered -Observe and report as needed (PRN) any s/sx of CHF [Congestive Heart Failure]: dependent edema of legs and feet, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia), lethargy and disorientation. -vital signs daily and as needed (PRN) -weight as ordered The care plan for the care and treatment of the pacemaker did not list any information about the manufacturer, type, serial number, or ongoing monitoring, or follow-up visits with the cardiologist to ensure proper functioning of the pacemaker, in accordance with professional standards. On 7/26/23 at 9:37 A.M., the surveyor observed the Resident lying in bed with his/her eyes closed. The Resident's pacemaker transmitter was not observed at the bedside. During an interview on 7/26/23 at 2:33 P.M., Nurse #2 said that sometimes the pacemaker monitor is kept at the bedside or in the medication room. She said that they haven't had to check the Resident's pacemaker since he/she was admitted and no follow up appointments with the cardiologist had occurred since admission. Nurse #2 reviewed Resident #17's care plan and said that there was no additional information about the pacemaker, to include pacemaker settings, in the care plan. Initial record review on 7/26/23 indicated there was no information/consultation paperwork regarding a cardiology or follow-up appointment for the Resident's pacemaker. On 7/27/23, Unit Manager (UM) #2 obtained a consultation note from the Resident's last cardiology appointment dated 5/11/22. Review of the note written by the cardiac nurse practitioner at the Boston area hospital on 5/11/22, indicated that, there were no programing or medication changes today and the patient will follow up with (cardiologist) in clinic in 4 months. The consult listed the Resident as having a Boston Scientific CRT-D pacemaker/defibrillator. During an interview on 7/28/23 at 9:53 A.M., UM #2 explained that when a resident is admitted with a cardiac pacemaker, they check the pacemaker, fill out the Pacemaker/Defibrillator Tracking form and follow up to see if there are any scheduled cardiology appointments. UM #2 said that she was not aware of the follow up cardiology appointment that was to be scheduled four months from 5/11/22 per the Boston area hospital, nor was she aware of the 11/8/22 appointment with the local cardiologist. Additionally, UM #2 said that once she became alerted by the surveyors on 7/28/23, of the lack of cardiology and pacemaker follow-up, she contacted the cardiologist's office who informed UM #2 that the Resident had a pacemaker transmitter at his/her home. UM #2 said that she would call the Resident's family member to see if he had the transmitter. On 7/28/23, the surveyor reviewed the Resident's Pacemaker/Defibrillator Tracking Form. The only information contained on the form, dated 6/15/22, was: -Admitting nurse -pacemaker present -pacemaker serial number -What is the date of the resident's last pacemaker check? unknown The following information was blank on the Pacemaker/Defibrillator Tracking Form: -Cardiologist's name -Office Phone # -Date of Next Pacemaker Check -Copy of Pacemaker Card -Add to Care Plan The Pacemaker Check Dates and nurse conducting the checks were also blank on the form from the date of admission (June 2022) to the present. During interviews with the Assistant Director of Nursing (ADON) and UM #2 on 7/28/23 at 1:05 P.M. and 1:20 P.M., the ADON said they had found Resident #17's pacemaker transmitter in the [NAME] Unit's medication room today and placed it in the Resident's room with the green light on, which indicated it was transmitting, and that the cardiologist's office was notified. They said the Resident's family member had dropped off the transmitter unbeknownst to them. UM #2 said, It was an error on our part and We didn't know we had it. The ADON said, that in November 2022, the Resident missed an appointment with the cardiologist due to COVID-19. She did not say why the cardiology appointment was not rescheduled once the COVID infection resolved. They said that there was no information in the medical record, they were waiting to hear back from the cardiologist, and there was no record of any follow-up by the facility regarding the Resident's cardiac pacemaker, for more than a year following admission. During an interview on 7/28/23 at 1:33 P.M., the Resident's family member said that he had dropped off the Resident's transmitter months earlier to a nurse on the [NAME] Unit. He said that he did not think that the Resident was seen by a cardiologist recently, and that he was unaware that the pacemaker check and cardiology care had not been provided since admission in June 2022. He said that the family had not canceled any cardiology appointments, nor were they aware that the Resident had any. Additionally, the Resident's family member said that he had not spoken to anyone about holding off on any cardiology appointments, for any reason, to check the pacemaker. 34145 2. Resident #64 was admitted to the facility for short term rehabilitation in June 2023 following an acute hospitalization for pneumonia and left posterior lower cellulitis. Review of the 7/12/23 Minimum Data Set assessment indicated Resident #64 had a planned discharge on 7/12/23, and his/her return to the facility was not anticipated. Review of a 7/11/23 Nursing Progress Note in the medical record indicated Resident #64 would be discharged from the facility to home with homecare services on 7/12/23. Further review of the medical record failed to indicate a physician's order was obtained for discharge from the facility. During an interview on 7/28/23 at 10:29 A.M., the Assistant Director of Nursing reviewed Resident #64's entire medical record and said no physician's order was obtained for the Resident's planned discharge on 7/12/23.

Based on observation, interview, and policy review, the facility failed to ensure that acceptable infection control and prevention measures were implemented during a dressing change, for three Residents (#34, #84, and #95), of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #34, to ensure staff wore appropriate personal protective equipment including a gown and performed appropriate hand hygiene during a wound dressing change; 2. For Resident #84, to ensure staff performed appropriate hand hygiene during a wound dressing change; and 3. For Resident #95, to ensure staff performed appropriate hand hygiene during a wound dressing change. Findings include: Review of the facility's policy titled Treatment of Wounds, last reviewed 3/31/23, indicated but was not limited to the following: -It is the intent of this center that a resident having a wound receives necessary medical treatment to prevent infection, deterioration, or development of wounds in keeping with the resident's medical condition. -the facility will utilize the [NAME] procedures: Traumatic Wound Care: Abrasions, Lacerations, and Puncture wounds. -provided to the surveyor with the policy was the procedure titled, Critical notes: Pressure Injury Management, long term care: -Perform hand hygiene -Put on gloves and as needed, other personal protective equipment. -Position the resident to allow access to the pressure injury site. -Remove the old dressing carefully. -Discard the used dressing in the plastic bag. -Remove and discard your gloves. -Perform hand hygiene. -Put on new gloves. -Inspect the wound. -Clean the wound with sterile normal saline solution, wound cleaner, or potable tap water. -To mechanically clean the wound, clean it gently with a gauze pad moistened with sterile normal saline solution, wound cleaner, or potable water, working from the center towards the edge of the wound. -Irrigate the wound if adherent material is present in the wound using wound irrigation device. -Pat the wound dry with a sterile gauze pad, then discard the pad. -Clean the peri-wound skin with a pH-balanced skin cleaner. -Remove and discard your gloves. -Perform hand hygiene. -Put on new gloves. -Reassess the skin; reassess the condition of the skin surrounding the wound and the wound bed. -Cover the wound with composite dressing. Review of the facility's policy titled Area of Focus: Basic Skin Management, last reviewed 11/28/22, indicated but was not limited to the following: -Care is provided utilizing a clean technique. Procedure and competencies are located on village square in [NAME]. Review of the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent the spread of multi drug resistant organisms (MDRO), updated 7/12/22, indicated but was not limited to: -Expanded residents for whom enhanced barrier precautions (EBP) applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). -enhanced barrier precautions are infection control interventions designed to reduce transmission of resistant organizations that employs targeted gown and glove use during high contact resident care activities. 1. Resident #34 was admitted to the facility October 2022 with diagnoses which included diabetes, peripheral vascular disease, stroke, and dementia. Review of the current Physician's Orders indicated: -Enhanced barrier precautions diagnosis: Diabetes mellitus ulcer to left great toe, initiated 7/27/23. -Wound care to left great toe for pressure injury. Cleanse with normal saline followed by bacitracin followed by dry protective dressing, initiated 5/30/23. On 7/27/23 at 9:45 A.M., the surveyor observed a sign posted outside Resident #34's room indicating Enhanced Barrier Precautions, Everyone must: -Clean their hands, including before entering and when leaving the room. -Providers and staff must also: -Wear gloves and gown for following high contact resident care activities. -Wound care: any skin opening requiring a dressing. On 7/27/23 at 9:45 A.M., two surveyors observed Nurse #5 provide wound care to Resident #34's left great toe. Nurse #5 set up her supplies, washed her hands in the bathroom and applied a pair of gloves. Nurse #5 was observed removing the old dressing on the left great toe, cleaning the wound with normal saline solution, applying bacitracin and then a dry protective dressing (DPD). Nurse #5 did not perform hand hygiene or change her gloves after removing the old dressing/cleansing the wound, before proceeding with clean procedure applying bacitracin to the wound bed and DPD to the left great toe. In addition, Nurse #5 was not wearing a gown during the dressing change. During an interview on 7/27/23 at 1:36 P.M., Nurse #5 said she does not know why she didn't put a gown on when she changed Resident #34's dressing. Nurse #5 insisted she changed her gloves after removing the old dressing on the left great toe. 2. Resident #84 was admitted to the facility in May 2023 with diagnoses which included diabetes and unstageable pressure ulcer left heel and stage 4 coccyx wound. Review of the current Physician's Orders indicated: -Enhanced barrier precautions diagnosis: coccyx wound, initiated 6/13/23. -Three liters normal saline 1/8th strength Dakin's (antiseptic) solution for closed pulse irritation (CPI) for left heel wound five times a week for four weeks, initiated 7/11/23. -Wound care left heel, clean with sterile water, apply Iodosorb (cadexomer iodine) ointment followed by Allevyn heel cup (foam dressing) and Kling wrap. On 7/27/23 at 10:15 A.M., two surveyors observed Nurse #5 provide wound care to Resident #84's left heel. Nurse #5 put on gown and gloves entering Resident #84's room and set up her supplies and placed a clean disposable absorbent pad (disposable incontinent brief) at the foot of the bed. Nurse #5 assisted Resident #84 back into bed, placing his/her sneakers on the clean absorbent pad, then removed the sneakers. Nurse #5 was observed to clean the left heel using a gauze pad and sterile water, then place the heel back down on the absorbent pad. She opened the Iodosorb ointment tube and applied some to a cotton swab. Nurse #5 applied the Iodosorb ointment to the left heel, placed the heel cup on and wrapped the ankle with Kerlex wrap. Nurse #5 was not observed to perform hand hygiene and change her gloves after she cleaned the heel wound, prior to applying the Iodosorb ointment and the heel cup. Nurse #5 did not change the clean absorbent pad after removing the Resident's sneakers that had been in contact with the ground. During an interview on 7/27/23 at 1:36 P.M., Nurse #5 said she changed her gloves after cleaning the heel wound. The surveyor said to her you did change your gloves and performed hand hygiene after transferring the Resident back to bed, but not after cleaning the heel wound, prior to applying the cream and dressing. During an interview on 7/27/23 at 4:10 P.M., the Director of Nurses said it is her expectation they (nurses) follow the procedure for wound care, which included hand hygiene, changing gloves after cleaning wound, and wearing gown if a resident is on EBP. The DON said Nurse #5 had informed her she had a discussion with a surveyor about not wearing the gown into the Resident's room on EBP but said Nurse #5 insisted she changed her gloves after cleaning both wounds. The surveyor reviewed with the DON, there were two surveyors who did not observe Nurse #5 perform hand hygiene and change her gloves after cleaning both wounds this morning. 27189 3. Resident #95 was admitted to the facility in January 2023 with diagnoses including pressure ulcer of the sacral region, unstageable. Review of a Physician's Order, dated 7/25/23, indicated the following: -Wound care to Stage 4 coccyx wound: -Cleanse with Normal Saline, followed by Iodoform packing strips (type of wound dressing that consists of cotton gauze strips impregnated with iodoform, an antimicrobial solution) and cover with an Allevyn dressing (absorbent dressing). -Change every other day on the day shift (7:00 A.M.-3:00 P.M.), and as needed for soiled, loose, or missing dressing. On 7/26/23 at 10:15 A.M., with the Resident's permission, the surveyor observed Nurse #9 perform Resident #95's dressing change of the coccyx. Upon entering the room, the surveyor observed that the dressing supplies were in place on the Resident's overbed table. Nurse #9 said she had already washed her hands, wiped down the overbed table, and sanitized her scissors (needed to cut the Iodoform packing). The surveyor observed Nurse #9 position Resident #95 and don (put on) a pair of gloves. Nurse #9 removed the old, soiled dressing, discarded the dressing into a plastic bag and doffed (removed) her gloves. Nurse #9 donned another pair of gloves and cleansed the wound with the Normal Saline and doffed her gloves. Nurse #9 donned another pair of gloves, cut a piece of Iodoform gauze, placed the Iodoform gauze into the Resident's wound and doffed her gloves. Nurse #9 donned another pair of gloves and covered the wound with the Allevyn dressing. Each time that Nurse #9 changed her gloves, no hand hygiene was performed. During an interview on 7/26/23 at 11:30 A.M., Nurse #9 said that she was unaware that she had to perform hand hygiene each time she changed her gloves. During an interview on 7/26/23 at 3:15 P.M., Unit Manager #1 reviewed the facility's policy and said that Nurse #9 should have performed hand hygiene when she changed her gloves.

Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#303), out of a total sample of 22 residents, that staff developed and implemented a baseline care plan or comprehensive care plan within 48 hours as required for the Resident's high aspiration risk due to his/her diagnosis of Zenker's diverticulum (the muscle between the throat and esophagus, known as the cricopharyngeus muscle, over-tightens, causing the throat above it to pouch out. Overtime, the pouch can enlarge as the muscles below it tighten excessively. Food can catch in this pouch or it can cause an obstruction). Findings include: Review of the facility's policy titled Baseline Care Plan, last revised 8/17/22, included but was not limited to: -A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care -Procedure: complete the baseline care plan in the electronic health record within 48 hours of each new admission; update the baseline care plan as needed to reflect current needs until the comprehensive care plan is developed Resident #303 was admitted to the facility following an acute hospitalization in July 2023 with diagnoses including Zenker's diverticulum. Review of the admission Minimum Data Set assessment indicated it was in process. Review of hospital documentation indicated Resident #303 was evaluated in the hospital for difficulty breathing and lower back pain. The Resident was diagnosed and treated for aspiration pneumonia (infection of the lungs or large airways. Aspiration pneumonia occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed). The hospital's Speech Therapist (ST) performed a clinical swallow evaluation and indicated Resident #303 presented with delayed coughing following the swallow of pureed texture and coughing with audible signs of regurgitation likely due to Zenker's diverticulum. The Resident had a Reflux Symptom Index score (a scoring tool that consists of nine items used to assess various symptoms associated with laryngopharyngeal reflux (LPR) of 16 (a score of more than 13 is considered abnormal and reflects LPR). The ST indicated the Resident was a high risk for aspiration and presented with overt signs of airway compromise and recommended safe strategies for safe swallowing including to take small bites/sips (1/2 - 1 teaspoon). Review of the medical record failed to indicate a baseline care or comprehensive plan with the identified problem, goals, and interventions for high aspiration risk had been developed within 48 hours of his/her admission as required. During an interview on 7/26/23 at 1:30 P.M., Unit Manager #1 could not explain why a baseline or comprehensive care plan had not been developed within 48 hours to address Resident #303's high aspiration risk.

Based on observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#303), out of 22 sampled residents. Specifically, the facility failed to implement care plan interventions for the Resident's high risk for aspiration. Findings include: Review of the facility's policy titled Blue Tray/Thicken Liquids Policy and Procedures, undated, included but was not limited to: -Safe feeding-swallowing instructions are located in the care plans -The Blue Trays will serve as a warning to the designated feeder or caregiver that special feeding/swallowing instructions are in effect. Resident #303 was admitted to the facility in July 2023 with diagnoses including Zenker's diverticulum (the muscle between the throat and esophagus, known as the cricopharyngeus muscle, over-tightens, causing the throat above it to pouch out. Overtime, the pouch can enlarge as the muscles below it tighten excessively. Food can catch in this pouch or it can cause an obstruction). Review of the admission Minimum Data Set assessment indicated it was in process. Review of the comprehensive care plans included, but was not limited to: -Problem: The resident has a swallowing problem related to swallowing assessment result (7/20/2023) -Interventions: Alternate small bites and sips; small sips/small bites per intake; use a teaspoon for eating; Blue tray aspiration and reflux precautions (7/20/23) -Goal: The Resident will have clear lungs, no signs and symptoms of aspiration through the review date; The Resident will have no choking episodes when eating through the review date; The Resident will not have injury related to aspiration through the review date (7/20/23) Review of Resident #303's Certified Nursing Assistant (CNA) Care Plan Kardex as of 7/26/23 included but was not limited to: -Eating/Nutrition: Alternate small bites and sips; use a teaspoon for eating -Blue tray aspiration and reflux precautions Review of a 7/17/23 Speech Therapy Evaluation and Plan of Treatment indicated the Resident presented with moderate oropharyngeal dysphagia and recommendations to increase the Resident's safety and reduce risk of aspiration included thin liquids and mechanically altered solids with use of slow rate, alternate bites/sips, small bites/sips, and supervision at meals. On 7/25/23 from 12:15 P.M. to 12:35 P.M., the surveyor observed Resident #303 seated at a table in the Bristol Unit dining room eating his/her lunch meal independently from a blue tray. The Resident used a soup spoon and not a teaspoon as indicated on the comprehensive care plan. The Resident scooped food onto the soup spoon that was overflowing off of the spoon with large bites and did not alternate with sips of liquid. CNA #3 was in the dining room assisting other Residents and did not cue Resident #303 to use a teaspoon or alternate bites and sips. On 7/26/23 at 7:30 A.M., the surveyor observed Resident #303 in his/her room seated in a wheelchair at the bedside eating breakfast. The Resident was using a soup spoon to eat scrambled eggs and not a teaspoon according to the care plan. The Resident scooped food onto the soup spoon that was overflowing off of the spoon with large bites and did not alternate with sips of liquid. Nurse #4 was in the room with Resident #303 and did not cue the Resident to use a teaspoon or alternate bites and sips. On 7/26/23 at 12:03 P.M., the surveyor observed Resident #303 in his/her room in a wheelchair at the bedside eating lunch with a family member at his/her side. The Resident was using a soup spoon to eat pasta, ground meat and sauce and not a teaspoon according to the care plan. The Resident scooped food onto the soup spoon that was overflowing off of the spoon with large bites and did not alternate with sips of liquid. During an interview with Unit Manager #1, the Director of Nursing, and Corporate Nurse #1 on 7/26/23 at 1:30 P.M., Unit Manager #1 said Resident #303 should be given a teaspoon and not a soup spoon while eating as well as other interventions indicated on the care plan.

Based on observation, record review, policy review, and interview, the facility failed to implement their policy and provide quality of care treatment for one Resident (#32), out of a sample of 22 residents. Specifically, the facility failed to: a. Document an observation/assessment for an open purpura (red or purple discoloration of skin) to the right upper arm identified on 7/20/23 and document an observation/assessment with a change in condition of the open purpura when it was documented to be infected on 7/23/23 requiring five days of antibiotics. In addition, the facility failed to implement their wound care template to document the daily skin condition including drainage, odor, surrounding care, and condition of the skin tear, and b. Document the daily condition of a skin tear to the right upper chest wall identified on 7/24/23, by not implementing the wound care template for daily skin condition to include drainage, odor, surrounding skin and skin tear outcome 7/24/23 to 7/26/23. The skin tear was evaluated on 7/28/23 and was found to have worsened. Findings include: a. Review of the facility's policy titled area of focus: Basic Skin Management, reviewed on 11/28/22, indicated but was not limited to the following: -The skin care program is directed by the facility's interdisciplinary team. -If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document in assessment/observation, obtain treatment orders, and notify MD and responsible party. -Orders are required for skin and wound care. There are wound care protocol orders in electronic medical record under orders-treatment template. -Wound assessment/observations are required at a minimum weekly and when there is a change. To view or update an assessment/observation access resident's electronic medical record. -Nursing administration (Director of Nurses, unit managers, supervisors) should monitor the wound care program daily utilizing electronic medical record to review timely completion of assessments and evaluations (Bradens/[NAME] (pressure risk assessments), weekly skin assessment, Wound Observation Tools (WOT). -Additionally, electronic Interact skin alerts should be reviewed and risk management for skin changes reviewed and updated. -A review of the medication administration record (MAR) is utilized to review if treatment/wound care admissions have occurred and should be reviewed for possible medication discrepancy reports if needed. Resident #32 was admitted to the facility in March 2021 with diagnoses which included diabetes mellitus, iron deficiency, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 6/28/23, indicated Resident #32 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident had mild cognitive impairment. Review of Resident #32's current care plan indicated the following: Focus: -Resident has the potential for impaired skin integrity related to decreased mobility, incontinence, pain, diabetes mellitus, anemia, and decreased strength and endurance. -7/17/23-left temporal picked scab -7/23/23- right upper arm open -7/25/23- right chest wall open purpura Interventions/Tasks: -Identify/document potential causative factors and eliminate/resolve where possible. -Monitor skin during routine care and notify nurse of any changes in skin condition observed. -Weekly treatment documentation to include measurements of each area of skin breakdowns with length, depth, type of tissue, and exudate in any other notable changes or observations. During an interview on 7/25/23 at 5:00 P.M., Family Member (FM) #2 said he/she was aware of the open area to the right arm which got infected. Review of the medical record indicated the following: -No initial wound observation/assessment for the open purpura right upper arm on 7/20/23. -No nursing note documentation for the open purpura right upper arm 7/20/23 to 7/22/23. -No change of condition wound observation/assessment when the open purpura was identified to be infected with cellulitis (Bacterial infection of the skin) on 7/23/23. -No documentation the open purpura right upper arm was cleaned and dressing applied on 7/20/23 through 7/23/23. -No wound template initiated on the [DATE]/20/23 through 7/28/23 to document the daily skin condition for drainage, odor, surrounding skin and skin tear condition. Review of the MAR indicated, the right upper arm open purpura, 7/20/23 to cleanse open purpura on right upper arm with normal saline, followed by opsite (clear elastic film dressing) every day shift, every three days (initiated 7/20/23). The first treatment recorded on the MAR was completed on 7/23/23. Review of a physician/prescriber's telephone order indicated Nurse Practitioner #1 wrote orders on 7/23/23 for Resident #32 to start Keflex (antibiotic) 500 milligrams orally twice a day for 5 days. Further review of the nursing notes indicated the following: -On 7/23/23, Health Status Note indicated cephalexin (Keflex) capsule 500 milligrams, give one capsule by mouth 2 times a day for right arm wound infection for 5 days question Cellulitis. -On 7/24/23 at 4:24 A.M., Infection Note, indicated resident started on Keflex, right upper arm skin tear infection without adverse reactions. No voiced complaints of pain or discomfort. Area red and warm, with some swelling noted. Will continue to monitor. -On 7/26/23 at 3:22 P.M, Health Status Note indicated continues antibiotic for right arm Cellulitis. Area continues with redness and warmth, denies pain. Will continue to monitor. -On 7/27/23 at 12:45 P.M., Infection Note indicated, resident continues Keflex/right arm Cellulitis without adverse reactions. No voice complaints of pain or discomfort. Will continue to monitor. -On 7/27/23 at 12:48 P.M., Health Status note indicated, denies and no signs or symptoms of pain and or discomfort noted. Resident continues Keflex related to right arm skin tear. No adverse reactions noted. Review of Physician's and Nurse Practitioner's (NP) notes in the electronic medical record and paper chart indicated there was no documentation of the condition of the wound, signs and symptoms of an infection until the physician's note dated 7/27/23. During an interview on 7/28/23 at 2:00 P.M., NP #1 said she was asked by nursing to see Resident #32 on 7/23/23 because his/her doctor was away, and she prescribed antibiotics for cellulitis in the right upper arm. She said she did not document the condition of the skin; she thought the nurses were monitoring the condition of the wound. The plan was to have the Resident's physician evaluate the wound when he returned from vacation. Further review of the Physician's notes indicated Resident #32 was seen by his/her physician on 7/27/23 and the note indicated the following: -A diagnosis of Cellulitis in the right arm and wound infection. The patient was started on cephalexin (Keflex) for the right arm skin tear with wound infection and Cellulitis. His/Her erythema (redness) has improved. No significant discharge at this point. He/She remains afebrile. Cellulitis and wound infection appear to be doing well at this point. Continue local wound care. During an interview with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Unit Manager #3 on 7/28/23 at 8:05 A.M., the surveyor reviewed the concerns of the lack of documentation for the left upper arm open purpura until the Resident was seen by NP #1 on 7/23/23 and diagnosed with cellulitis. Unit Manager #3 said she thought the nurse practitioner documented in her notes the condition of the wound because she started her on the antibiotics. The ADON said the nurses should have documented the right upper arm wound, including measurements and should have been documenting on the MAR using the wound template. She showed the surveyor the wound template orders, which included documenting the wound drainage, odor, surrounding skin condition, and the skin tear condition. The ADON said there is glitch in the system, the template disappears and the orders for the template must be re-entered. We reviewed the MAR and the wound template did not populate for the nurses to document daily the condition of the right upper wound. b. During an interview on 7/25/23 at 12:56 P.M., the surveyor observed what looked like to be a large skin tear on Resident #32's right upper chest that extended down below his/her shirt line. The surrounding tissue had a large purplish discoloration; no dressing on the right upper chest wound. During an interview on 7/25/23 at 5:00 P.M., FM #2 said he/she was not aware the Resident had a new right open area on the right chest. Resident #32 showed FM #2 the open area and FM #2 said it looked gnarly and was concerning. Review of the medical record indicated the following: -No documentation 7/24/23 and 7/25/23 in medical record documenting the right upper chest wound. -Late entry nursing note, dated 7/26/23 at 3:57 P.M., which indicated the certified nursing assistant (CNA) reported resident received a skin tear while he/she was being boosted in the wheelchair. CNA asked the resident to give herself/himself a hug while boosting and he/she accidentally scraped himself/herself with his/her nails. The area measures 2 centimeters (cm) long and 0.2 cm wide by 0.1 cm depth. Small amount of bloody drainage noted. Area washed with normal saline followed by dry protective dressing (DPD). -No wound template initiated on the [DATE]/24/23 through 7/26/23 to document the daily skin condition for drainage, odor, surrounding skin and skin tear condition. -7/27/23 the wound template was initiated, and indicated no drainage, no odor, skin pink, surrounding skin condition is not applicable, and the wound is improved. Review of the nursing Wound Observation Tool (WOT) documentation, dated 7/28/23, indicated the following: -Location: Anterior aspect of right chest -Overall impression: Worsening -Skin tear presented in an L shape with area of wound edges furthest apart measuring 0.3 cm. Wound edges open. Wound has increased in size. Peri-wound minimal ecchymotic (blood or bleeding under the skin) discoloration peri-wound. Review of the current Physician's Orders indicated the following: -7/24/23: Wash open purpura to chest area with normal saline, apply Xeroform followed by dry protective dressing. Change daily until healed. Discontinued on 7/26/23. There was no wound template populated in this order set to daily document the condition of the skin for drainage, odor, surrounding skin and skin tear condition. - New orders written on 7/26/23: Skin tear care to the right chest wall, wash with normal saline, followed by Xeroform, and dry product protective dressing daily. Document drainage, odor, surrounding skin, and skin tear outcome. During an interview with the Administrator, the DON, the ADON, and Unit Manager #3 on 7/28/23 at 8:05 A.M., the surveyor reviewed the concerns and the lack of documentation for the right upper chest skin tear first identified 7/24/23. There was no documentation until the late entry nursing note written on 7/26/23, describing the wound to be 2 cm in length. Unit Manager #3 said she has seen the wound and said the length is now larger than 2 cm and thought maybe the Resident increased the size when she took the dressing off on Tuesday (7/25/23), but there is no documentation the wound got bigger. The ADON said the nurses should have been documenting on the MAR using the wound template. We reviewed the MAR and the wound template did not populate for the first set of orders written 7/24/23 to 7/26/23.

Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary respiratory care and services for three Residents (#303, #304, and #155), out of a total sample of 22 residents. Specifically, the facility failed to ensure: 1. For Resident #303, Oxygen was administered according to Physician's orders, and equipment (nebulizer tubing and masks) was properly stored; 2. For Resident #304, Oxygen was administered according to Physician's orders; and 3. For Resident #155, a physician's order was obtained for the use of Oxygen. Findings include: Review of the facility's policies titled Oxygen Administration/Safety/Storage/Maintenance, last reviewed 10/7/22, and Pulse Oximetry, last reviewed 10/7/22, included but were not limited to: -Infection Control: store respiratory supplies in bag labeled with resident's name when not in use Review of the American Association of Respiratory Care (AARC) Clinical Practice Guideline titled Oxygen Therapy in the Home or Alternate Site Health Care Facility indicated Oxygen therapy should be administered in accordance with the physician prescription. (https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf) 1. Resident #303 was admitted to the facility in July 2023 with diagnoses including acute respiratory failure with hypoxia (not enough oxygen in the blood). Review of the July 2023 Physician's Orders included but was not limited to: -Oxygen at 2 liters/minute continuously per nasal cannula (a lightweight flexible tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), document every shift (7/16/23) -Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/milliliters (ml), 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath (7/14/23) On 7/25/23 at 9:37 A.M., the surveyor observed Resident #303 lying in bed sleeping. An oxygen concentrator was at the bedside, on and set to 3.5 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. A nebulizer machine was noted on the bedside table. The mask and tubing were lying on the bedside table and were exposed to the environment and were not properly stored in a plastic bag. On 7/26/23 at 7:30 A.M., the surveyor observed Resident #303 in his/her room eating breakfast. The oxygen concentrator was on and set to 3 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. A nebulizer machine was noted on the bedside table. The mask and tubing were lying on the bedside table and were exposed to the environment and were not properly stored in a plastic bag. On 7/26/23 at 12:03 P.M., the surveyor observed a nebulizer machine on the bedside table. The mask and tubing were lying on the bedside table and were exposed to the environment and were not properly stored in a plastic bag. On 7/27/23 at 9:07 A.M., the surveyor observed Resident #303 seated in a wheelchair at his/her bedside. The oxygen concentrator was on and set to 3 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. A nebulizer machine was noted on the bedside table. The mask and tubing were lying on the bedside table and were exposed to the environment and were not properly stored in a plastic bag. At 9:08 A.M., Nurse #4 entered the Resident's room. Nurse #4 confirmed that Resident #303's oxygen concentrator was set to 3 liters/minute and should be set to 2 liters/minute according to physician's orders. She said the Resident's nebulizer equipment is supposed to be stored in a plastic bag when not in use and it was not. On 7/28/23 at 11:07 A.M., the surveyor observed Resident #303 lying in bed resting. A portable oxygen tank was on the floor at the Resident's bedside. The tank was on and set to 3 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. During an interview on 7/28/23 at 11:10 A.M., the surveyor asked Nurse #7 and Nurse Practitioner #1 to come into the Resident's room to examine his/her oxygen. Nurse #7 said the Certified Nursing Assistants must have brought the Resident back to his/her room after lunch and not reconnected the tubing to the concentrator. She said the flow rate on the portable tank was set to 3 liters and should be set to 2 liters according to physician's orders. 2. Resident #304 was admitted to the facility in June 2023 with diagnoses including acute respiratory failure with hypoxia. Review of the July 2023 Physician's Orders included, but was not limited to: -Oxygen (O2) at 1 liter/minute per nasal cannula as needed to maintain O2 saturation of 92% or greater (6/11/23) On 7/25/23 at 9:55 A.M., the surveyor observed Resident #304 lying in bed resting. The oxygen concentrator was on and set to 2 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. During an interview on 7/25/23 at 2:08 P.M., the surveyor observed Resident #304 lying in bed awake. The oxygen concentrator was on and set to 2 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. Resident #304 said that he/she uses oxygen continuously and has done so since he/she was admitted to the facility in June. On 7/26/23 at 10:00 A.M., the surveyor observed Resident #304 lying in bed awake. The oxygen concentrator was on and set to 2 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. On 7/27/23 at 8:52 A.M., the surveyor observed Resident #304 lying in bed awake. The oxygen concentrator was on and set to 2 liters/minute. The oxygen tubing was connected to the concentrator with the nasal cannula in place in the Resident's nostrils. During an interview on 7/27/23 at 9:18 A.M., Nurse #4 looked at Resident #304's concentrator and said it was set to 2 liters. She said she thought the Resident is supposed to have oxygen continuously between 2 and 3 liters/minute. Nurse #4 reviewed the physician's orders and said the order is for 1 liter/minute as needed, and not continuously. She said the concentrator should be set to 1 liter and not 2 liters, and the order should be written for continuous use and not as needed. 3. Resident #155 was admitted in July 2023 with diagnoses which included lung transplant and Chronic Obstructive Pulmonary Disease (COPD). Record review on 7/28/23, indicated that on 7/23/23 at 11:00 P.M., the Resident experienced a change in his/her medical status, was observed talking to herself, hallucinating, skin was clammy and could not be easily redirected. At that time, his/her oxygen saturation was checked and found to be in the low 80's. According to the nursing progress note, the Resident's oxygen saturation did not increase with repositioning. The nurses note indicated the Resident was placed on 2 liters of Oxygen via nasal cannula and his/her oxygen saturation increased to 88%. The Oxygen was increased further to 3 liters per minute via nasal cannula and the Resident's oxygen saturation increased to 94%. Further record review on 7/28/23, indicated that there was no physician's order for Oxygen on 7/23/23, following the change in the Resident's clinical status and the Resident's need for Oxygen. During an interview on 7/27/23 at 10:17 A.M., Unit Manager (UM) #1 said that the Resident's physician's order for Oxygen was not obtained at the time it was required on 7/23/23, and was only ordered on 7/27/23 at 3:00 P.M. UM#1 said that it is the facility's policy that a physician's order is obtained when a Resident's clinical condition requires the use of Oxygen.

Based on observations, interviews, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to ensure staff a) Performed hand hygiene when indicated; b) Donned (applied) and doffed (removed) appropriate Personal Protective Equipment (PPE) when indicated; and c) Prevented the potential cross contamination of clean PPE. Findings include: Review of the facility's policy titled Personal Protective Equipment (PPE) for [CONDITION(S)]-CoV-2, dated 11/29/21, indicated the following: -The facility will provide and utilize the appropriate PPE for the care of residents during the COVID-19 pandemic in accordance with Centers for Medicare and Medicaid Services (CMS) and Center for Disease Control (CDC) guidance. -The facility will provide and ensure associates use respirators and other PPE for exposure to residents with suspected or confirmed COVID-19. - The facility will provide and ensure associates wear respirators for aerosol-generating procedures on a person with suspected or confirmed COVID-19. - This policy is meant to supplement the Personal Protective Equipment Policy that PPE use outside of COVID-19. The guidance indicated that: Staff who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use of a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Review of the PPE Donning Checklist indicated the following prior to entering the room: - Perform hand hygiene using hand sanitizer - Put on gown or upper torso covering with sleeves - Put on NIOSH-approved N95 filtering facepiece respirator or higher, if not already in place (perform hand hygiene before and after touching or adjusting the respirator) - Put on face shield or goggles, if not already in place Review of the PPE Doffing indicated the following prior to exiting the room - Remove gloves - Remove gown or upper torso covering with sleeves. Disrobe in a manner that prevents touching of the outside of the garment -Exit the room and perform hand hygiene - Remove and discard respirator/facemask - Perform hand hygiene after removing the respirator/facemask and before putting on a new one 1. On 1/26/22 at 11:45 A.M. on the COVID Unit, the surveyor observed the Infection Preventionist (IP) entering Resident #1's room to assist Certified Nursing Assistant (CNA) #1 in positioning Resident #1. The surveyor observed the IP not performing hand hygiene before donning his gloves and did not apply his isolation gown prior to entering the room, as required by the facility. 2. On 1/26/22 at 11:48 A.M., the surveyor observed CNA #2 on the [NAME] Unit come out of a resident's room holding a dirty gown in her hands and put it in a plastic bag. CNA #2 was observed not performing hand hygiene after removing the gown and after placing the bag in the receptacle container. During an interview at 11:49 A.M., CNA #2 said the gown should be removed prior to leaving the room, put in a plastic bag, and carried to the receptacle container at the end the hall. CNA #2 said handwashing should be performed before donning and after doffing. 3. On 1/26/22 at 11:50 A.M., the surveyor observed Housekeeper #1 come out of room [ROOM NUMBER] without his facemask; a resident was nearby. Then he walked across to room [ROOM NUMBER] picked up a walker from the floor and placed it against the wall; he did not sanitize his hands and continued to walk down the hall to the housekeeping closet. Housekeeper #1 opened the housekeeping closet and applied a pair of gloves. At no point during the observation did the surveyor observe Housekeeper #1 perform hand hygiene before and after touching the walker, or before donning his gloves. 4. On 1/26/22 at 12:00 P.M., the surveyor observed CNA #3 applying a new facemask while still holding the dirty mask in her hands. CNA #3 failed to perform hand hygiene before and after removing the mask. 5. On 1/26/22 at 12:02 P.M., the surveyor observed Housekeeper #2 come out of room [ROOM NUMBER], go across the hall to the PPE Cart outside of room [ROOM NUMBER] to obtain a mask, and then leave the PPE cart open, exposing the contents and subjecting them to potential cross contamination. During an interview on 1/26/22 at 2:20 P.M., the surveyor reviewed the observations with the IP. The IP said that full PPE is required when entering the Residents' room on the COVID-19 Unit. The IP said he did not think about sanitizing his hands and applying an isolation gown prior to entering Resident #1's room. The IP confirmed that: - Housekeeper # 1 did not wear a mask while in the hallway; - CNA #2 did not place her gown in a plastic bag prior to exiting the room; - CNA #3 did not discard the dirty facemask prior to applying a new one and perform hand hygiene; and - Housekeeper #2 failed to close the precaution cart after opening it.

Based on observations, staff interviews, and facility policy based on Center for Disease Control Guidelines, the facility failed to implement their policy and procedures for appropriate use and availability of personal protective equipment (PPE) for residents who required transmission based precautions to prevent possible spread of infection on 1 of 3 units. Findings include: The facility policy for Transmission-based Precautions and Isolation Procedures (last revised 5/7/2020) included the following: -Make PPE readily available near the entrance to the resident's room -Don appropriate PPE upon entry into the environment (room) of a resident on transmission- based precautions During observation on the Capron Unit hallway A on 6/17/20 at 9:45 A.M., CNA (certified nursing assistant) #1 was observed standing outside a resident's room at a plastic drawer [MEDICATION NAME] which contained personal protective equipment including gowns, masks, and gloves. Two large, colorful signs were adhered to the door frame of the resident's room. One sign indicated a resident inside the room had an infection, and was on droplet precautions. The second sign had printed images and instructions which indicated that before entering the room, the following PPE must be donned (put on): gown, mask or respirator, goggles or face shield, and gloves. CNA #1 said that the resident was on droplet precautions, and was on her assignment. The surveyor noted that there was no eye protection worn by the CNA, and no eye protection was in the PPE drawer [MEDICATION NAME]. The CNA said that she thought it might be in her bag in the documentation room. The CNA and surveyor went to the documentation room, looked in her bag, and said that it was not there, and that she must have left them in her car. During interview with Nurse #1 at 9:50 A.M., she said that there were no goggles or face shields on the unit, and that she would have to call central supply to get some. During observation on the Capron Unit hallway B on 6/17/20 at 10:00 A.M., a call light above a resident's room illuminated and sounded. A plastic drawer [MEDICATION NAME] was outside the resident's room and contained personal protective equipment including gowns, masks, and gloves. Two large, colorful signs were adhered to the door frame of the room. One sign indicated a resident inside the room had an infection, and was on droplet precautions. The second sign had printed images and instructions which indicated that before entering the room, the following PPE must be donned (put on): gown, mask or respirator, goggles or face shield, and gloves. Nurse #1 was observed to approach the resident's room, open the drawer and don a gown and gloves (she was already wearing a mask). The nurse did not don any type of eye protection, and then entered the resident's room. A few minutes later, Nurse #1 was observed to doff (removed) the gloves and gown, sanitized her hands and left the room. During interview with Nurse #1 at 10:08 A.M., she said that the resident in the room is on droplet precautions and she should have worn eye protection, but that it was not available on the unit. She said that she would need to ask her supervisor for eye protection. During interview with the Assistant Director of Nursing/Infection Control Nurse at 10:10 A.M., she said that staff must wear all required PPE when entering a resident's room, and that it should be available on the units and accessible to all staff.

Based on observation, record review, and staff interviews, the facility failed to ensure that for 2 residents (#160 and #38), of a total sample of 23 residents, that adequate supervision and safety interventions were developed and consistently implemented to maintain each residents' safety and prevent injury. Findings include: 1. Resident #160 was admitted in October 2019 with diagnoses which included, fall with fractured left hip, hemiarthroplasty (surgical repair), diabetes mellitus, hypertension, [CONDITION(S)], [CONDITION(S)] (stroke), [CONDITION(S)], and dementia. Upon readmission to the facility on [DATE], following a fall on 11/3/19, and an additional diagnosis of left hip dislocation which required surgical intervention. Record review on 1/8/20, indicated that according to an Admission MDS (Minimum Data Set), signed as being completed 10/15/19, indicated that the Resident had a BIMS (Brief Interview for Mental Status) score of 15 out 15, hearing was adequate with the use of a hearing aid, the Resident's vision was severely impaired, and the Resident experienced trouble concentrating on things, such as reading the newspaper or watching television. Additionally, the MDS indicated that the Resident required extensive assistance with all ADLs (Activities of Daily Living), to include bed mobility, transfers, and ambulation. Functional Abilities and Goals on the Admission MDS included, but not limited to, the following: -Sit to lying-01, Dependent -Lying to sitting on side of bed-01, Dependent -Sit to Stand-01, Dependent -Chair/bed-to-chair transfer-01, Dependent -Toilet transfer-01,Dependent, Discharge Goal-04, Supervision or touching assistance The MDS further indicated that the Resident was frequently Incontinent of both bowel and bladder and no trial of a toileting program had been attempted upon admission. The Care Plan developed by the facility on 10/3/19, indicated that the Resident had a dx (diagnosis) of dementia with an activated HCP (health care proxy-person designated to make health care decision for the resident), On 10/3/19, a Fall Risk Assessment was conducted which assessed the Resident's Fall Risk Score to be 28, which indicated he/she was at high risk for falls (>10 indicated at Risk for Falls). During interview with the Clinical Coordinator on 1/9/20 at 11:30 A.M., she indicated that the facility had assessed the Resident on admission to be at Risk for Falls. She said that the Resident had periods of forgetfulness and would do things spontaneously and without warning, placing him/her at risk for further falls and injury. She also said that the Resident was admitted with a history of multiple falls at home, had fractured his/her hip during a recent fall, for which he was hospitalized , underwent a fractured left hip repair, and was admitted to the facility for rehabilitative services. The Initial Care Plan developed by the facility included the following interventions: -Assist with ADLs, -call light within reach -Fall Risk Assessment, -orient to room -provide consistent staff and routine for his/her care -1/4 side rails to assist with mobility -face and speak clearly when communicating - bed in lowest position and locked -gripper socks. The care plan did not indicate how the facility would provide supervision of the Resident, with a history of falls, to ensure his/her safety. On 10/10/19 at 7:18 P.M., the incident report indicated that Resident #160 was found on the bathroom floor at 6:15 P.M., was self-toileting, and was getting him/herself up from the toilet. The Resident's Fall Risk Assessment was 20. According to the Care Plan Revisions, the following interventions were added following the fall: -Therapy, bladder pattern completed, 10/12/19, 10/13/19, 10/14/19 -offer toileting to Resident before meals, upon waking, bedtime and as needed On 10/27/19 at approximately 7:00 P.M., the incident report indicated the Resident was observed sitting on the floor in their room in front of the wheelchair with his/her back up against the wheelchair with his/her head resting on the wheelchair. According to the Care Plan Revisions, the following interventions were added following the fall: -Encourage activities and involvement out of room -Dycem to wheelchair cushion -Keep personal items within reach while in wheelchair and bed. The care plan revisions did not include any additional interventions to provide supervision to the Resident to prevent further falls and potential injury. On 11/1/19 at approximately 5:00 P.M., the incident report indicated that Resident #160 had slid down the bathroom door and was found on the floor, under a puddle of water, and a cup in hand. The Resident was not being supervised. According to the Care Plan Revision , the following interventions were added following the fall: -Medication review with anti-hypertensive order changes, monitor BP (blood pressure) and HR (heart rate) every shift until 11/7/19. No additional interventions were implemented following the fall to address the need for additional supervision to address the Resident's continued risk for falls and injury. On 11/3/19 at 7:10 P.M., the incident report indicated that Resident #160 reportedly got up from the wheelchair, used the walker, lost his/her balance, and fell to the floor. The RN walked into the room and found the patient lying on the floor next to his/her bed facing towards the window. The patient was alert and verbal, stated he/she was trying to stand up and lost his/her balance. The patient said he/she did not hit his/her head. The RN noticed the patient's left lower leg was unable to straighten up and was in an abducted (away from the body) position. The RN further indicated that based on the pain scale, the pain level was 7/10. The physician was called and ordered the facility to send the patient to the hospital for evaluation. The Resident was sent to the emergency room for evaluation/treatment, and was treated for a left hip dislocation that required surgical revision. According to the Care Plan Revisions, the following interventions were added following the fall and dislocated left hip on 11/3/19: -Be sure over-bed table is next to resident before leaving room -Family to notify staff when leaving -Provide activities that minimize the potential for falls while providing diversion and distraction such as books on tape/games on tablet. No additional interventions were implemented to provide increased supervision of the Resident. The Resident returned to the facility in November 2019. The Resident had an increased risk for falls, with a Fall Risk Assessment score of 23. On 11/12/19 at 12 :00 P.M., the Resident's spouse was in visiting and left the Resident unattended without notifying staff. According to the incident report, the Resident was last seen by the nurse, sitting up in his/her wheelchair in his/her room at approximately 11:45 A.M. The incident report indicated that the Resident's spouse was in to visit at approximately 11:30 and stopped at the nurses station to speak to a staff member. The spouse reportedly left the Resident's room without staff being aware. At 12:00 P.M., another resident reported, someone in 101 B is on the floor. The Resident was found in the supine position on the floor with two CNAs assessing his/her vital signs. A family meeting was held with the spouse and the spouse's daughter, nursing, social services, and therapy. The spouse agreed to inform staff when the spouse is leaving from his/her visit with the Resident. The following interventions were identified following this unwitnessed fall: -Hourly checks for 24 hours - pain management with non-verbal pain scale - hearing aids and teeth to be placed -activities of interest discussed No additional interventions were implemented to provide increased supervision of the Resident. An incident report dated 12/8/19 at 5:30 P.M. indicated that the Resident was found lying flat on his/her back. He/She stated that he/she was trying to get into the wheelchair independently. No injuries were identified and vital signs were stable. According to the Care Plan Revisions, the following interventions were added following the fall on 12/8/19: -apply hearing aids to bilateral ears in A.M., remove P.M. -falling Star program -enjoys playing games on table and listening to music/books -extensive assist of 2 for transfers -restorative therapy 6 x week for ambulation with rolling walker-2 assist -transfer and bilateral lower extremity therapeutic exercises in seated position including ankle pumps, knee extensions, hip abductions and mini marches left leg and left hamstring stretch. No additional interventions were implemented following this unwitnessed fall, to provide greater supervision and prevent further falls and injury. On 1/3/20 at 3:30 A.M., the CNA went to answer the call light in the Resident's room, she found that the Resident's roommate was calling. The CNA indicated in her statement, that while toileting the Resident's roommate, the Resident, who had fallen and was lying on the floor, called out to the CNA, Hey, I'm over here, I'm okay, I'm on the floor. The CNA indicated that the Resident's curtain was pulled so she didn't notice he/she wasn't in bed. The CNA indicated that she called for the nurse. She also indicated that the bed was lowered all the way to the floor and his/her call light was in reach. The Resident said to the CNA that he/she had to use the bathroom and he/she removed the urinary catheter. According to the Care Plan Revisions and timeline of the Resident's falls, the following interventions were added following the fall on 1/3/20: -15 minute checks while in bed on 11-7 -enjoys playing cribbage with his spouse during visits -enjoys attending men's/women's group activities -associate stationed outside room During interview on 1/9/20 with the Clinical Care Coordinator, she said that Resident #160 fell 8 times since admission in October . The surveyor said to the Clinical Coordinator that the Resident was observed in his/her room, unsupervised, on multiple occasions throughout the survey. The surveyor said to the Clinical Care Coordinator, that on 1/9/20 at 8:50 A.M., the Resident was observed lying in bed in his/her room with his/her breakfast tray placed on the over -bed table. The Resident was finishing his/her breakfast and sipping from a coffee mug. The Resident was unsupervised and his/her bed was observed to be in a high position, approximately 4 feet off the floor. The Clinical Care Coordinator said that the Resident's bed should not be in a high position and acknowledged the Care Plan on 10/3/19, indicated that the bed was to be in the lowest position and locked. The Clinical Care Coordinator said that she understood that the interventions to maintain the Resident's safety had been ineffective in maintaining the Resident's safety. The DON said to the surveyor that the Resident had experienced 8 falls since admission, to include the fall on 11/3/19 that was unwitnessed/unsupervised, and resulted in a left hip dislocation that required admission to the hospital for surgical repair. The DON said that in spite of interventions implemented by the facility, the Resident continued to fall, while in his/her room, unsupervised, and remained at risk for falls.

Based on interview and policy review, the Facility failed to ensure that a water management plan was developed and implemented as part of their ongoing risk management for Legionella infection or other waterborne pathogens with a system of surveillance that included a facility risk assessment, testing protocols, ongoing monitoring of control measure locations, and annual water testing. Findings include: During interview on 1/3/20 at 3:20 P.M. the Administrator and Maintenance Director Administrator identified themselves as members of the Water Management team, however, they do not have meetings, have not conducted a risk assessment, and have no Water Management policy or plan as required.

Based on medical record review and interviews, the facility failed to ensure providing pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Specifically the facility failed to provide a prescribed medication for 11 days to a resident, failed to have a plan in place if the family was unable to provide the medication, and failed to pursue alternative sources to obtain the medication, resulting in missed medication administrations (11 days) for 1 resident (#64) out of a total sample of 23 residents. Findings include: Resident #64 was admitted to the facility in August 2019 with a [DIAGNOSES REDACTED].#64 had orders for Fingolimod (Gilenya) (an immunosuppressive medication) capsule 0.5 mg (milligrams) with start date of August 2019, to be given by mouth one time per day for [MEDICAL CONDITION]. Family supplies the medication. A review of the December 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of the nursing notes from 12/19/2019 thru 12/29/2019 indicated the Fingolimod capsule 0.5 mg was not available. There was no indication that an alternate plan to obtain the medication was developed. During an interview on 01/07/20 at 12:30 P.M., the Director of Nurses (DON) said she was not aware Resident #64 missed 11 doses (11 days) of Fingolimod medication. She said she was not sure why Resident #64's family was supplying the medication, but she would find out. During an interview on 01/07/20 at 01:17 P.M., the DON said Resident #64 was involved in a trial with the Fingolimod medication through his/her neurologist's office. She said the facility's pharmacy did not have access to the medication and that the family has to secure the medication directly from the manufacturer. The DON said the medication was not available for 11 days in December because the family had a death and was unable to get the medication and bring it in. During a phone interview on 01/07/20 at 03:42 P.M., Resident #64's Health Care Proxy (HCP) said the Fingolimod (Gilenya) was never part of a clinical trial, it was Resident #64's regular [MEDICAL CONDITION] medication. She said when the resident was admitted to the facility, she was told the pharmacy does not carry Fingolimod. The HCP said due to the cost, she applied for free medication through the manufacturer and was approved for a one year supply. The HCP said, the only reason Resident #64 ran out of medication was because the nurse called the HCP for more medication as the nurse was giving Resident #64 the last pill the facility had. She said due to the holidays and paperwork involved, it took 11 days to get the new supply of medication to the facility. The HCP is still not clear why the pharmacy does not provide the Fingolimod medication. During a phone interview on 01/08/20 at 09:32 A.M., the facility Pharmacy Specialty Center was called and Customer Service Representative #1 said she spoke with a pharmacist and they do dispense Fingolimod (Gilenya) and there has been no shortage of the medication in the last month. During an interview on 01/08/20 at 09:09 A.M., the DON said she could not provide documentation the facility attempted to obtain Fingolimod from the pharmacy or other sources. She is now aware Fingolimod is a FDA approved medication and is not part of a clinical trail. The DON said the facility did not pursue the Specialty Center through their pharmacy, because at the time Resident #64 was admitted it was understood the family would provide the medication per hospital records. She said there was no plan in place if the family was unable to provide the medication.

Based on documentation review and staff interview, the Facility failed to accurately assess the Residents profile by listing types of care that the resident population requires and is provided. The Facility Assessment tool had no specific information: a. for the required 12 hour/year education of NA (Nurse Aide) staff and no information of completing annual competencies for nursing staff. b. regarding the initiation of the Antibiotic Stewardship program. c. for the assessing of Residents' safety with bed rails for entrapment, the role of the Maintenance department in evaluating the bed frames and bed rails. d. for resources necessary to assess the risk and management of building water to reduce the risk of growth and spread of Legionella and other water borne pathogens in the water. Findings include: The Facility failed to accurately conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Review of the Matrix for Providers completed by the Director of Nursing indicated that 15 residents residing in the facility had an indwelling catheter. The Resident Support/Care Needs failed to identify that their resident population required, and was provided catheter care. The Assessment Tool for staffing resources needed to provide competent support and care for their Resident population failed to list specific information for staff training, education and competencies necessary to provide the level and types of support and care needed for their resident population. The Assessment was noted to include various orientation topics, but had no specific information for ongoing training such as, the certified nurse assistant training of 12 hours of education annually. There was no information of resources for training of licensed nurses and of completing competencies for all nursing staff for daily care and emergencies. The Assessment had no documentation of their facility based and community based risk assessment ,and resources considered for the Infection Control program or the new Antibiotic Stewardship program. The Assessment did not include resources to be designated for the Maintenance department to assess the risk of entrapment and safety for the use of bed rails with mattresses and frames, and failed to identify bed rail management. After reviewing the Facility Assessment Tool on 1/3/20, the Administrator was interviewed at 2:45 P.M., and reviewed the Assessment document. He said that corporate provides a template for the assessment and that he customized to their facility. The Administrator said the information we reviewed should had been included, and that he didn't know he had to be that specific.

Based on observation and staff interview, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions. Findings include: During an initial tour of the kitchen on 1/2/20 at 12:21 P.M., the following kitchen/food sanitation concerns were observed: - A large plastic-framed rack containing aluminum pans was observed to have a significant amount of crumbs and food on the lower racks on the left side and the upright corner braces were observed with food residue on them. -A portable food utility cart was noted to be coated with a significant amount of dirt and food debris, especially in the corners. -On 1/3/20 at 1:12 P.M. the facility's large, walk-in cooler was observed to contain multiple undated meat products. They included wrapped pieces of corned beef, roast beef, and turkey, covered in plastic wrap with no labeling of the date they were placed in the cooler. -A stainless steel pan was observed with a large amount of vegetable soup covered with plastic wrap with no date to indicate when the soup was prepared and placed in the cooler. -Two large white plastic flour/oats containers were observed with food residue along the top edge where the cover sits on the container. - On 1/3/20 at 11:30 A.M., multiple boxes of fresh produce/fruit were observed on the kitchen floor adjacent to the cooler. -On 1/3/20 at 1:15 P.M., the multiple boxes of fresh produce/fruit remained directly on the kitchen floor where they previously had been observed at 11:30 A.M. During interview with the FSS (Food Service Supervisor) on 1/2/20 and 1/3/20, the FSS acknowledged the concerns over kitchen sanitation, and said that he would address the issues identified with the kitchen staff.

Based on observation, policy review, record review, Resident and staff interviews, the facility failed to ensure for 1 Resident (#11), out of a total sample of 23 residents, that medications were not self administered without an assessment, a physician's orders [REDACTED]. Findings include: On 1/2/20 at 10:40 A.M., a bottle of Ammonium [MEDICATION NAME] 12% lotion and a spray bottle of [MEDICATION NAME] Sore Throat spray were observed on an over-bed table alongside Resident #38's bed. January 2020 physician's orders [REDACTED]. -Ammonium [MEDICATION NAME] 12% lotion (initiated 11/20/19) -[MEDICATION NAME] Sore Throat Spray Liquid 0.1 - 33% Give 2 applications by mouth every 6 hours as needed for sore throat (initiated 8/27/19) Review of the Facility's Self Administration of Medication policy (last reviewed 4/15/19), included the following: -If the resident desires to self administer medication, an order for [REDACTED]. -If the resident demonstrates the ability to safely self administer medications, a further assessment of the safety of bedside mediation storage is conducted. -The resident will document on the Bedside Medication Record each time a medication is taken. Notation of each dose self administered is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who reviewed the Bedside Documentation Record. Review of the most recent quarterly Minimum Data Set, with a reference date of 11/6/19, indicated that Resident #38 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15, required assistance from staff for activities of daily living, and had ointments/medications applied to areas other than the feet. The Informed Consent Administration of Medications form, signed by Resident #38 and a facility staff nurse on 6/5/19, indicated that the resident wished to have the medication nurse administer all medications. During interview with Resident #38 on 1/6/20 at 11:50 A.M., a bottle of Ammonium [MEDICATION NAME] 12% lotion and a spray bottle of [MEDICATION NAME] Sore Throat spray were observed on an over-bed table alongside the Resident's bed. Resident #38 said that he/she self applies the lotion to his/her skin because it can get itchy sometimes, self administers the throat spray on occasion for a sore throat and keeps it on the over-bed table. The Resident said that no one had conducted an assessment for self administration or told him/her that the medications had to be stored. The Resident also said that he/she does not document when he/she self administers the medications. During interview with Unit Manager #3 on 1/6/20 at 1:08 P.M., she said that Resident #38 had not had an assessment to ascertain if he/she was capable of self administering the lotion and throat spray, and did not have physician's orders [REDACTED].

Based on observation and staff interview, the Facility failed to ensure that a safe, clean, comfortable and homelike environment was provided to residents for 1 unit (Newport) of 3 unit dayroom/dining rooms in the facility. Findings include: During observation of the Newport Dayroom/Dining room on 1/2/20 at 11:54 A.M., a long strip of coving (prefabricated decorative molding fitted at the junction of the wall and ceiling around a room) was missing from half of the wall (underneath the window extending to the right wall) exposing approximately a 5 inch width by approximately 8 foot long area of drywall. Circular spots of a black substance were observed in several areas along the exposed drywall. During interview on 1/8/20 at 2:10 P.M., the surveyor along with the Administrator and Maintenance Director observed the exposed drywall in the Newport Dayroom. The Maintenance Director said that in November 2019, the coving began to peel off, and the wall started to bubble up in areas. He said that he realized that moisture was coming through the wall from the outside, because the landscaping mulch was graded too high along the outside of the building. The Maintenance Director said that he regraded the mulch outside to stop the moisture from coming through the wall, sprayed the exposed drywall with a bleach solution twice, and wiped off the area. He said that he did not have a professional come in to test the black substance to ascertain what it was, how to properly treat it, or to ensure that it was gone after cleaning it. He said that it was his opinion that the black substance was mildew. The surveyor pointed out that the black substance remained on the wall. The Maintenance Director then took his hand and rubbed it along the wall where the black substance was, and it did not come off. The Maintenance Director had said that he did not open up the wall to visually inspect the area, and could not say if the black substance was in-between the walls.

Based on record review, observation and interview with staff, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 1 (#27) residents in a total sample of 27 residents. For Resident #27, the facility failed to ensure that the resident was immediately attended to after expressing "he/she did not feel very well and could he/she get help." Findings include: For Resident #27, the facility failed to ensure that the resident was immediately attended to after expressing "he/she did not feel very well and could he/she get help." On 2/11/14, at 11:12 A.M., the Surveyor was reviewing the Medication Administration Record [REDACTED]. Nurse #2 was seated directly in front of the Surveyor at a computer terminal. Nurse #1 and Unit Manager #3 were working at the opposite end of the station. The area in front of the nurses station was congested with medication carts, treatment carts and residents. While the Surveyor was standing at the medication cart, Resident #27 tapped the Surveyor's arm and asked for help. Resident #27 said he/she did not feel very well and needed help. The Resident was observed seated in a wheelchair, appeared anxious, hands were tremulous, was pale and distraught. The Resident repeated his/her request for help and again said he/she did not feel well. Nurse #2 looked up from the computer terminal and looked at the Surveyor. The Surveyor asked the Nurse to assist the resident, as he/she had reported not feeling well. Nurse #2 half stood up and looked over the nurses' station counter and said the resident was not her patient, that the resident lived on the Capron unit and then sat back down. Nurse #2 made no effort to assist the resident and did not make any attempt to get another staff to help the resident. The Surveyor repeated to Nurse #2 that the resident had stated he/she did not feel well and the Nurse continued to work on the computer terminal. The Surveyor looked at Unit Manager #3, who was observing the situation, and although she got up, there was no interaction, before she began pushing the resident down the hallway. Upon Unit Manager #3's return from the Capron unit, she said the resident has a history of panic attacks and was having one. During interview on 2/11/14 at 11:50 A.M., the Surveyor inquired about Nurse #2's response to the situation with Resident #27 with Unit Manager #3. She said that Nurse #2 should have gotten up and ensured that the resident received the help he/she required. Unit Manager #3 said she would talk with Nurse #2.

Based on record review, observation and interview with staff, the facility failed to provide appropriate respiratory treatment and services to manage and improve the resident's respiratory status, for one resident (#14) in a total sample of 27 residents. Findings include: For Resident #14, the facility failed to ensure the PEP (positive expiratory pressure) and the incentive spirometer therapy was implemented in an effective manner to treat the resident's persistent lobar collapse with [MEDICATION NAME] obstruction. Resident #14 had been admitted to the facility for short term rehabilitative services following a hospitalization for an acute onset of [MEDICAL CONDITION] and pneumonia. The resident had other [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was alert, oriented, capable of being understood and capable of making his/her needs known. The MDS indicated the resident required minimal assistance in activities of daily living and was frequently incontinent of urine. The MDS indicated the resident used diuretics, oxygen and received physical and occupational therapy. Per record review on 2/10/14, Resident #14 has a complicated medical history that includes respiratory and cardiac conditions. The resident had been admitted in November 2013 for short term rehabilitation for deconditioning and respiratory monitoring. Shortly after his/her admission, the resident was rehosptalized on [DATE] for a [MEDICATION NAME] obstruction with mucus impaction, pleural effusion and [MEDICAL CONDITION]. According to the medical record, the resident was rehospitalized twice following his/her admission to the facility, the first readmission was from 11/11/13 to 11/20/13 and the second from 1/31/14 to 2/7/14. According to the discharge records from both hospitalization s, the resident had been hospitalized for [REDACTED]. The resident was admitted to the facility for management with PEP therapy and incentive spirometer to improve, treat and prevent [MEDICATION NAME] obstruction and lobar collapse. PEP (positive expiratory pressure) therapy is a treatment using positive expiratory pressure. The patient exhales through a fixed-orifice resistor and this generates a pressure build up that is transmitted into airways and props them open during exhalation. This allows air to get behind mucus and moves it forward for airway clearance. The ultimate purpose is to mobilize secretions and therefore requires monitoring for secretion clearance and breath sounds. On 1/16/14, the physician's progress note indicated the resident was noted to have some cough with sputum and ordered a one time dose of a diuretic and a chest X-ray. On 1/18/14, he ordered PEP therapy and on 1/20/14 ordered the PEP therapy continued in conjunction with incentive spirometer treatment. On 1/21/14, 1/24/14 and 1/28/14, the physician's progress note indicated the resident continued with some sputum, had a productive cough and had some increased shortness of breath. The physician wanted the resident to continue with the PEP therapy, nebulizers and the incentive spirometer. On 1/29/14, the physician documented that despite the PEP and incentive spirometer treatment the resident had a [MEDICATION NAME] obstruction with a collapsed lung. On 1/31/14, the resident had been sent to his/her Pulmonologist, who subsequently admitted the resident to the hospital with a collapsed lung and mucus impaction. Although, the physician had documented in his progress notes for the respiratory treatment to include the PEP and an incentive spirometer, there was no order for the incentive spirometer. The treatment administration records (TAR) and physician orders [REDACTED]. Further review, indicated that the initial physician's telephone order, dated 1/18/14, did not include any parameters, specifications or number of times the PEP was to be used daily, however, the TAR indicated that the PEP was to be done 4 times daily. According to the TAR, the PEP therapy was started on 1/20/14. The TAR indicated that on 1/18/14, 1/19/14 and 1/22/14 the resident did not receive the PEP therapy. On 1/20/14, 1/21/14, 1/24/14 and 1/28/14 the resident received the treatment 2 times a day, not 4 times as ordered. On 1/26/14 and 1/27/14 the resident received the treatment three times, not 4 times as ordered, and on 1/31/14 the resident had received the treatment 4 times. However, the record indicated that the resident was not in the facility on this day as he/she was hospitalized after seeing his/her Pulmonologist. Review of the February 2014 TAR indicated the resident had received the treatments as ordered, 4 times daily. Further review of the medical record failed to indicated that following the PEP therapy the nursing staff assessed the resident's breath sounds for secretions, and did not document how the resident responded to the treatment. During interview and observation on 2/10/14 at 10:50 A.M., Resident #14 was in room and had an incentive spirometer and a PEP resistor was on his/her tray table. The resident said that the PEP resistor helped clear mucus in his/her lungs. The resident said he/she did the PEP therapy first, followed by the incentive spirometer. The resident said he/she does the treatment him/herself and when he/she thought needed it. The resident did not know how many times per day he/she did and that the nursing staff did not assist or participate in the treatments. The resident said he/she exhaled into the resistor, coughed and then used the spirometer. The resident said that no one had assessed him/her to self administer the treatment. During interview on 2/11/14 at 1:40 P.M., Nurse #5 said she said she did not usually work on Newport unit, where Resident #14 lived, but knew what PEP therapy was. The nurse knew that PEP meant positive expiratory pressure and described the device. The nurse said that usually the PEP was left in the resident's room and that the resident was explained how to use it. The nurse said the resident was to blow into the resistor (not exhale or cough) and that other than providing the instruction she did not assess for secretions or do anything else. The nurse did not know how and if she had received training at the facility or if there was a policy. She said she learned about it from working on the units. During interview on 2/11/14 at 2:00 P.M., Nurse #1 said that she assisted the resident with the PEP treatment and incentive spirometer twice daily (not 4 as ordered). She said that she tried to correlate it with the medication administration. Nurse #1 said that the resident did the other two treatments independently. The nurse said she first had the resident use the incentive spirometer, and then the PEP resistor. The surveyor informed her that the resident had said that he/she did not receive any assistance from staff and that he/she said he/she used the PEP first and then the spirometer. Nurse #1 said she did not know. The nurse was asked about monitoring for secretions and or any respiratory symptoms following the treatment, she said that none were done. The nurse was not aware of any education, training and or policy/procedure for PEP treatments that she had received at the facility. During interview on 2/12/14 at 8:20 A.M., the Director of Nurses stated there was no facility policy and procedure for the PEP therapy and had no staff inservice and education.

Based on record review and staff interview the facility failed for 1 (#11) of 25 sampled residents to provide timely notification to the physician when there was a change in condition. Findings include: For Resident #11, three facility nurses failed to notify the physician when a significant bruise developed on the resident's right leg. Resident #11, a long term care resident, had [DIAGNOSES REDACTED]. Per record review, on 8/29/12, the 11-7 nurse documented that she notified the physician following identification of an 11 inch by 4 inch bruise of unknown origin on the right posterior thigh that continued to below the knee that was determined on 8/29/12 to be a right [MEDICAL CONDITION]. Review of the nurse's notes and clinical record prior to 8/29/12 revealed no documentation related to a bruise of unknown origin. Review of the facility incident investigation witness statements indicated that on 8/27/12 at 6:00 A.M., a CNA reported to the 11-7 nurse that the resident's right leg seemed to be positioned wrong when getting the resident dressed. Further review of the witness statements indicated that CNA staff repeatedly reported that the resident had a bruise of unknown origin, which was reported to 3 licensed staff on 8/27/12 at 4:00 P.M., 8/28/12 at 6:00 A.M., and 8/28/12 at 1:30 P.M. Review of the nurse's statements confirmed the presence of a bruise each time the CNA staff reported their observations but failed to notify the physician as required. Refer to F 309

Based on staff interview, investigation statements completed by staff and record review the facility failed for 2 residents (#11, #9) of 25 sampled residents to ensure that each resident received proper care and treatment for [REDACTED].#9.) Findings include: 1. For Resident #11, the facility nurses failed to properly evaluate and treat when 3 facility nurse aides reported to 3 facility nurses on 4 occasions that the resident had a misalignment/bruise on the right leg from 8/27/12 to 8/29/12. Staff continued to transfer and care for the resident without consideration of the change in condition. On 8/29/12, the resident was found to have a broken right hip. Resident #11, a long term care resident had [DIAGNOSES REDACTED]. Review of the most recent minimum data set (MDS) assessment with a reference date of 9/12/12 and quarterly assessment dated [DATE], indicated that the resident was cognitively impaired was dependent on staff for all activities of daily living including bed mobility and transfers. The resident was care planned for alteration in skin integrity that was updated on 5/24/12 due to a skin tear during a shower chair transfer and on 8/29/12 for a bruise to the right hip with fracture. Per record review, review of the 8/18/12 nurse's notes indicated that the resident was stable at baseline. The weekly skin check (completed on 8/25/12) indicated the resident had no bruises. A review of the incident investigation witness statements indicated that on 8/27/12 at 6:00 A.M.(written on 8/30/12) , certified nurse aide (CNA) #1 sought out the 11-7 Nurse #1 because the resident's right leg seemed to be positioned wrong when CNA #1 was getting the resident dressed. Nurse #1's statement for 8/27/12 indicated that CNA #1 summoned the nurse to the room "felt her foot was funny- I got to the room (resident) was lying sideways on the right hip and I asked how she was dressing the resident this way." Nurse #1 and CNA #1 repositioned the resident. Nurse #1 indicated that the resident's range of motion was good and the resident was able to bear weight when transferred to the wheelchair. Nurse #1 failed to document the encounter in the nurses notes. There was no evidence that Nurse #1 ensured follow up evaluation and treatment for [REDACTED]. According to the MDS assessments the resident was dependent on staff for care and required a 2 person assist for bed positioning, transfers, bathing and dressing. Per 3 staff statements, all written on 8/29/12, on 8/27/12 at 4 P.M. CNA #2 and CNA #4 called Nurse #2 to the resident's room to look at a bruise on the resident's right leg. CNA #4 described a "large bruise to the right thigh area." Nurse #2 wrote that he/she found a round bruise approximately 3" in diameter with a yellow perimeter. Nurse #2 failed to document the encounter in the nurses notes. There was no evidence that Nurse #2 ensured follow up evaluation and treatment for [REDACTED]. Per 2 staff statements, written on 8/29/12 and 8/30/12, on 8/28/12 at 6 A.M. CNA #1 called Nurse #1 to the resident's room regarding a bruise on the right leg. Nurse #1, who failed to document the encounter with the resident from 8/27/12, wrote that the resident had a bruise on the "posterior knee" approximately 8 cm around that looked "old." Nurse #1 failed to document the encounter in the nurses notes. There was no evidence that Nurse #1 ensured follow up evaluation and treatment for [REDACTED]. Per 2 staff statements, written on 8/29/12, on 8/28/12 at 1:30 P.M. CNA #1 called Nurse #3 to the resident's room regarding a bruise on the right leg. Nurse #3 wrote that the resident had a large bruise on the posterior right thigh extending to the knee. Nurse #3 wrote that he/she provided assistance to CNA #1 to transfer the resident back to bed. Nurse #3 failed to document the encounter in the nurses notes. There was no evidence that Nurse #3 ensured follow up evaluation and treatment for [REDACTED]. A nurse's note, dated 8/29/12 at 4:47 A.M., indicated that Nurse #4 was summoned to the room by CNA #3 to observe a bruise to the resident's right posterior thigh that extended below the knee with slight discoloration to the posterior calf. The bruise was assessed as red/purple in color approximately 11 inches long and 4 inches wide. The resident denied pain and was repositioned off the affected side. The physician was notified and gave orders to obtain an x-ray. On 8/29/12 at 7:00 P.M. the x-ray results reported to the Nurse Practitioner indicated the resident had a right [MEDICAL CONDITION]. New orders included to begin bed rest and obtain an orthopedic consult. On 8/30/12 arrangements were made arrangement for the resident to be seen by the orthopedic physician on 9/4/12 (the earliest available date due to the holiday weekend). On 9/4/12, the resident was sent for the scheduled orthopedic appointment at 9:30 A.M. accompanied by the Director of Nurses. The orthopedic physician recommended a CT (computerized tomography) exam of the hip which revealed an acute intertrochanteric right [MEDICAL CONDITION]. On 9/4/12 the orthopedic physician indicated "there are no plans to do surgery and to treat the fracture non-operatively. On 11/2/12 at 10:30 A.M., during interview with the facility Director of Nurses, the DON said that multiple staff had failed to provide timely care and treatment for [REDACTED]. 2. Resident #9 had a [DIAGNOSES REDACTED]. The resident also had a physician order [REDACTED].) tests, via fingerstick twice a day (6 A.M. and 4:30 P.M.) and received insulin based on a sliding scale according to the blood sugar results. The sliding scale read as follows: [MEDICATION NAME] 100 units/1 ml inject subcutaneously per sliding scale as directed: If BS 0-200, give 0 insulin. If BS 201-250, give 2 units subcutaneously. If BS 251-300, give 4 units subcutaneously. If BS 301-350, give 6 units subcutaneously. If BS 351-400, give 8 units subcutaneously. If BS less than 70 or greater than 400 call the physician. Review of the Medication Administration Records (MAR) for the months of May 2012 through October 2012 indicated that the blood sugar tests and sliding scale insulin were not administered according to the physician orders. The MAR for the month of May 2012 indicated the following: 5/5/12 at 4:30 P.M. - BS result of 224- no documented evidence that 2 units of insulin were administered as ordered 5/7/12 at 4:30 P.M. - BS of 226- no documented evidence that 2 units of insulin were administered as ordered 5/13/12 at 4:30 P.M. - BS 239- no documented evidence that 2 units of insulin were administered as ordered 5/20/12 at 4:30 P.M. - BS 232- no documented evidence that 2 units of insulin were administered as ordered 5/23/12 at 4:30 P.M. - BS 205- no documented evidence that 2 units of insulin were administered as ordered 5/27/12 at 4:30 P.M. - BS 207- no documented evidence that 2 units of insulin were administered as ordered 5/29/12 at 4:30 P.M. - BS 208- no documented evidence that 2 units of insulin were administered as ordered The MAR for the month of June 2012 indicated the following: 6/4/12 at 6 A.M. and 4:30 P.M. - no blood sugar tests were administered 6/14/12 at 6 A.M.-BS 212- no documented evidence that 2 units of insulin were administered as ordered 6/16/12 at 4:30 P.M. - no blood sugar test was administered 6/21/12 at 4:30 P.M. - BS 219- no documented evidence that 2 units of insulin were administered as ordered 6/24/12 at 4:30 P.M. - BS 213- no documented evidence that 2 units of insulin were administered as ordered The MAR for the month of July 2012 indicated the following: 7/2/12 at 4:30 P.M. - BS 230- no documented evidence that 2 units of insulin were administered as ordered 7/9/12 and 7/13/12 at 4:30 P.M. - no blood sugar tests were administered 7/18/12 at 4:30 P.M. - BS 208, no documented evidence that 2 units of insulin were administered as ordered 7/28/12 at 4:30 P.M. - BS 219 - no documented evidence that 2 units of insulin were administered. The MAR for the month of August indicated the following: 8/2/12, 8/3/12 and 8/25/12 at 5:30 P.M. - no blood sugar tests were administered 8/13/12 at 5:30 P.M.- BS 202- no documented evidence that 2 units of insulin were administered as ordered The MAR for September 2012 indicated the following: 9/5/12 at 5:30 P.M. - BS 209- no documented evidence that 2 units of insulin were administered as ordered 9/8/12 at 5:30 P.M. - BS 212- no documented evidence that 2 units of insulin were administered as ordered 9/20/12, 9/21/12 and 9/25/12 at 5:30 P.M. - no blood sugar tests were administered The MAR for the month of October 2012 indicated the following: 10/3/12 and 10/18/12 at 5:30 P.M. - no blood sugar tests were administered 10/23/12 at 5:30 A.M. - BS 208- no documented evidence that 2 units of insulin were administered as ordered Interview with the nurse manager on 11/1/12 at 10:30 A.M. indicated that blood sugar results and insulin administration were to be recorded on the MAR. Interview with the Director of Nurses on 11/2/12 at 10:50 P.M. indicated that a previously used Sliding Scale Insulin form was to be reinstituted immediately following staff education.

Based on record review, review of investigative reports, and interview, the facility failed for 1 resident (#11) of a total sample of 25 residents, to ensure that each resident received adequate assistance and modifications when positioning and transferring to prevent injury and accidents. Findings include: For Resident #11, the facility failed to ensure that the resident was transferred safely and in accordance with the plan of care and failed to evaluate the resident's needs and transfer status after a change in condition. Resident #11, a long term care resident, had [DIAGNOSES REDACTED]. Review of the most recent minimum data set (MDS) assessment with a reference date of 9/12/12 and quarterly assessment dated [DATE], indicated that the resident was cognitively impaired, and was dependent on staff for all activities of daily living including bed mobility and transfers. The resident was assessed at high risk for potential injury due to the resident's non ambulatory status, [DIAGNOSES REDACTED]. The care plan included for the resident to be assisted by 2 staff members for all positioning and stand/pivot transfers. Per record review, a nurse's note dated 8/29/12 at 4:47 A.M. indicated that the nurse was summoned to the room by a certified nurse aide (CNA) to observe a bruise to the resident's right posterior thigh that extended below the knee with slight discoloration to the posterior calf. The bruise was assessed as red/purple in color, approximately 11 inches long and 4 inches wide. The physician was notified and gave orders to obtain an x-ray. On 8/29/12 at 7:00 P.M. the x-ray results indicated the resident had a right hip fracture. New orders included to begin bed rest. Per review of the facility incident investigation related to the fractured hip, witness statements indicated that on 8/27/12 at 6:00 A.M., a CNA reported to the 11-7 nurse that the resident's right leg seemed to be positioned wrong when getting the resident dressed. The 11-7 nurse statement for 8/27/12 (written on 8/30/12) indicated that the CNA summoned the nurse to the room "felt her foot was funny- I got to the room (resident) was lying sideways on the right hip and I asked how she was dressing the resident this way." The nurse and the CNA repositioned the resident. The 11-7 nurse indicated on the witness statement (there was no documented evidence in the clinical record) that the resident's range of motion was good and the resident was able to bear when transferred to the wheelchair. The facility investigation did not address the inappropriate single person care delivered to the resident. Per review of additional statements from the investigation, facility nurse aides reported to facility nurses that the resident had a significant bruise to the right leg on 8/27/12 at 4 P.M. and on 8/28/12 at 6 A.M. and 1:30 P.M.. Despite the reports by staff and observations of a significant bruise approximately 8 cm in diameter and questions of misalignment of the leg on 8/27/12 at 6 A.M., staff failed to evaluate the need to change the resident's transfer status. The 9/4/12 nurse's note indicated that the orthopedic physician, who had evaluated the resident earlier that day, contacted the nurse to report the resident had an acute right hip fracture. The physician indicated "there are no plans to do surgery and to treat the fracture non-operatively." On 9/5/12 the resident was evaluated by the Occupational Therapist and the Director of Nurses for change of transfer status from a 2 person to 4 person sheet transfer with a licensed nurse to be present at all times. On 11/2/12 at 10:30 A.M. the facility Director of Nurses (DON) was interviewed by the surveyors regarding the resident's transfer status. The DON explained that staff on the day shift were transferring the resident by 2 staff intertwining their arms with the resident's arms and grabbing the gait belt and using their free hand to grab the resident's thigh area and lifting the resident in a "seated" position from bed to chair. The DON said that nurse aide staff began transferring the resident in this manner after they determined that the resident could no longer bear weight effectively. The DON said that the nurse aide staff did not inform the licensed staff about the change, and that the transfer as described was dangerous to the resident. The DON determined that staff were doing this some time prior to the bruising being noted on 8/27/12, and continued to transfer the resident in this manner until the hip fracture was identified on 8/29/12.