Every finding on record at Life Care Center of Auburn

Based on records reviewed and interviews for one of three residents (Resident #1), whose Physician's Orders indicated he/she was NPO (nothing by mouth) with medications to be administered via his/her percutaneous endoscopic gastrostomy tube (PEG tube, a flexible tube inserted through the abdominal wall into the stomach to deliver nutrition, fluids and medications directly), the Facility failed to ensure he/she was free from a significant medication error when Nurse #1 administered a medication to him/her orally instead of through his/her PEG tube placing him/her at risk for aspiration (when food, liquid, or saliva enters the airway and lungs).Findings include:Review of the Facility Policy titled Administration of Medications, dated as revised on 09/09/25, indicated the Facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.Review of the Facility's Incident Report, dated 03/28/26, indicated that Resident #1 was found by his/her 7:00 A.M. - 3:00 P.M. nurse having a blue crushed substance in his/her mouth and that there was a cup of water on his/her bedside table.Resident #1 was admitted to the Facility in March 2026, diagnoses included Dysphagia (difficulty swallowing), Pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, Hypothyroidism (a condition where the thyroid gland does not produce enough hormones to meet the body's needs), with a history of Aspiration Pneumonia (a lung infection caused by inhaling foreign material such as food, drink, vomit, or saliva), was non-verbal and developmentally delayed.Review of Resident #1's Physician's Orders for March 2026 indicated he/she had the following orders:NPO (nil per os, meaning nothing by mouth), use PEG tube for feeding and medication, initiated 03/24/26.Levothyroxine (a medication used to treat hypothyroidism) 137 micrograms (mcg) tablet via PEG tube one time a day for low thyroid hormone, initiated on 03/26/26.Review of Resident #1's March 2026 Medication Administration Record (MAR) indicated Nurse #1 administered 137 mcg of Levothyroxine on 03/28/26 to Resident #1.During a telephone interview on 04/26/26 at 10:40 A.M., Nurse #2 said he was working the 7:00 A.M. - 3:00 P.M. shift on 03/28/26, and when he entered Resident #1's room to administer his/her 8:00 A.M. medications and PEG tube feeding. Nurse #2 said while he was assessing Resident #1, he noticed there was a blue substance in and around his/her mouth and a cup of water on his/her bedside table. Nurse #2 said he was concerned by this observation because he knew Resident #1 could not have anything by mouth and he said it looked as though he/she had eaten and/or drank something. Nurse #2 said Resident #1's medical record and nursing assignment sheet clearly indicated he/she was NPO and said if he/she ate or drank anything it would put him/her at risk for aspiration.During a telephone interview on 04/25/26 at 1:55 P.M., Nurse #1 said she worked the 11:00 P.M. - 7:00 A.M. shift on 03/27/26 into 03/28/26 and said Resident #1 was on her assignment.Nurse #1 said she entered Resident #1's room that morning, said she told him/her that she had his/her thyroid medication and elevated the head of his/her bed. Nurse #1 said she placed the pill in Resident #1's open mouth, followed by a sip of water and said he/she began to cough. Nurse #1 said she elevated the head of Resident #1's bed further, he/she stopped coughing and when she left his/her room, he/she appeared comfortable. Nurse #1 said she did not realize she made a medication error until Unit Manager #1 contacted her to ask if she gave Resident #1 medication orally. Nurse #1 said looking back, she remembered that Nurse #2 told her that Resident #1 was NPO at the start of her shift and said giving Resident #1 medication orally was an oversight and a mistake on her part.During an interview on 04/23/26 at 3:30 P.M., Unit Manager #1 said one of the nurses called her on the morning of 03/28/26 to tell her they were concerned that a nurse had given Resident #1 his/her medication orally, that there was a blue substance on his/her mouth and a cup of water on his/her table. Unit Manager #1 instructed the nurse to call the Director of Nursing to report this incident.Unit Manager #1 said Resident #1's Physician's orders clearly indicated he/she was NPO and all his/her medications were to be administered through his/her PEG tube.During an interview on 04/23/26 at 4:15 P.M., the Director of Nursing (DON) said Nursing staff called her on 03/28/26 to tell her they suspected Nurse #1 had given Resident #1 a medication orally because he/she was found by Nurse #2 to have a blue substance in and around his/her mouth and that there was a cup of water left on his/her bedside table.The DON said she spoke with Nurse #1 on the phone and asked her if she had given Resident #1 his Levothyroxine orally that morning. The DON said Nurse #1 told her she did not remember doing so.The DON said she told Nurse #1 that Resident #1 was found with a blue substance in his/her mouth and that there was a cup of water at his/her bedside. The DON said after describing how Resident #1 was found, Nurse #1 told her she must have given him/her his medication orally in error. The DON said she verified that Resident #1's Levothyroxine pill was blue in color and said Nurse #1 signed off on administering Levothyroxine to Resident #1 on 03/28/26.The DON said Resident #1's Physician's Orders clearly indicated in his/her medical record that he was NPO, that all of his/her medication administration instructions indicated they were to be administered via his/her PEG tube, and said Nurse #1 did not follow Physician Orders which put Resident #1 at risk for aspiration. On 04/24/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 03/31/26, which addressed the area of concern as evidenced by:A) On 03/28/26, Resident #1 was transferred to the hospital for evaluation but chose not to return to the Facility. B) On 03/28/26, the Unit Manager provided verbal education to Nurse #1 regarding implementing Physician's Orders.C) Nurse #1 was also required to and completed eight hours of nursing education modules, which included medication administration, was required to demonstrate competency through written evaluation, and required to undergo observations by the SDC during medication administration passes. D) The Staff Development Coordinator (SDC) and/or her designee will continue to provide additional education to all clinical staff regarding the rights of medication administration, as needed.E) On 03/29/26, Nursing staff completed education modules assigned by the SDC that included: Enteral tube drug installation, oral drug administration, and oral medication adherence. After completion of the education modules, the SDC required Nursing staff to demonstrate competency via in person demonstration and written evaluations. F) On 03/30/26, the Director of Clinical Services conducted a house-wide audit to determine whether there were any other residents who were NPO and receiving medication per the enteral route - none were found. Additional audits were scheduled to be completed weekly, going forward to ensure continued compliance.G) On 03/30/26, Facility Administration conducted an ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting and approved an action plan as follows: conduct a facility wide audit to determine whether there were any other residents in the facility who were NPO and received medications per the enteral route with audits to be conducted weekly x4 then monthly thereafter until compliance is achieved.H) Results of Audits will be brought to and discussed during QAPI meetings, to review for continued compliance.I) The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for two Residents (#101 and #4) out of a total sample of 30 residents. Specifically, 1) for Resident #101, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required for the Resident on Enhanced Barrier Precautions (EBP), and that hand hygiene was performed before donning (putting on) PPE and during provision of urinary catheter care, placing the Resident at increased risk of contamination and the spread of infections. 2) for Resident #4, the facility failed to ensure that the appropriate PPE was worn as required when providing urinary catheter care, placing the Resident at increased risk of the spread of infections. Findings include: Review of CDC Guideline for Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised 6/28/24, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. -Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. -Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Review of the facility policy titled Enhanced Barrier Precautions, revised 4/22/25, indicated the following: -EBP are indicated for residents with any of the following: >wound and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO {Multi-Drug-Resistant Organism} >indwelling medical device examples include urinary catheters . -The facility should develop a process to communicate which residents require the use of EBP for all high-contact care activities. The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on Enhanced Barrier Precautions. -Examples of high-contact resident care activities requiring gown and glove use include: >device care or use: central line, urinary catheter Review of the facility policy titled Hand Hygiene, reviewed 6/3/24, indicated the following: -Associates perform hand hygiene (even if gloves are used) in the following situations: >before and after contact with the resident. 1) Resident #101 was admitted to the facility in March 2021 with diagnoses including Alzheimer's Disease and Neuromuscular Dysfunction of the Bladder. Review of Resident #101's Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident had an indwelling urinary catheter. Review of Resident #101's June 2025 Physician orders indicated: -an active order initiated on 6/6/25 for Enhanced Barrier Precautions (EBP), Diagnosis: Foley [type of indwelling urinary catheter] Catheter. On 6/13/25 at 2:40 P.M., during an Indwelling Urinary Catheter observation with Nurse #1, the surveyor observed: -Nurse #1 did not perform hand hygiene, donned gloves only and entered Resident #101's room. -Nurse #1 performed a hands-on assessment of the size of Resident #101's indwelling urinary catheter. -Nurse #1 doffed gloves and performed hand hygiene before exiting the Resident's room. During an interview on 6/13/25 at 3:01 P.M., the surveyor, Nurse #1, Unit Manager (UM #1), reviewed the EBP sign at Resident #101's door. Nurse #1 said he had performed a hands-on assessment of the Resident's catheter but did not believe he needed to wear a gown. UM #1 said that any hands-on care of the catheter required a gown according to the EBP sign. Nurse #1 said that he had recently washed his hands but had not done so between using the computer at the nurses station and donning the gloves to assess Resident #101. UM #1 said that Nurse #1 should have performed hand hygiene before donning PPE and entering the Resident's room. 2) Resident #4 was admitted to the facility in March 2025 with diagnoses including incomplete Paraplegia and Neuromuscular Dysfunction of the Bladder. Review of Resident #4's MDS assessment dated [DATE], indicated the Resident had an indwelling urinary catheter. Review of Resident #4's June 2025 Physician orders indicated: -an active order initiated 4/2/25 for EB, Diagnosis: catheter, drains, wounds, colostomy. On 6/13/25 at 2:45 P.M., during an Indwelling Urinary Catheter observation with UM #2, the surveyor observed the following: -UM #2 performed hand hygiene, donned gloves only and entered Resident #4's room. -UM #2 performed a hands-on assessment of the size of Resident #4's indwelling urinary catheter. -UM #2 doffed gloves and performed hand hygiene before exiting the Resident's room. During an interview on 6/13/25 at 2:47 P.M., the surveyor and UM #2 observed the EBP sign outside Resident #4's door. UM #2 said the sign indicated a gown and glove were required for care of the indwelling urinary catheter. UM #2 said she had not worn a gown when she completed the hands-on assessment of the indwelling urinary catheter but should have due to infection control and potential contamination concerns.

Based on observations, interviews, and record reviews, the facility failed to identify a change in condition relative to bilateral lower extremity edema (swelling) in a timely manner, for one Resident (#37) out of a total sample of 30 residents. Specifically, the facility failed to: -identify the onset of Resident #37's bilateral lower extremity edema in a timely manner when the Resident had previously been assessed to have no edema. -assess the Resident's bilateral lower extremity edema timely once the bilateral lower extremity (BLE) edema was identified, putting the Resident at risk for delayed assessment and treatment. Findings include: Review of the facility's Policy and Procedure titled Heart Failure, Long-Term Care, revised 1/13/25, indicated the following: -In Residents with Chronic Heart Failure, . drug therapy, diet changes, and activity restrictions usually help control symptoms. -Nursing interventions: >Inspect dependent areas, including the lower extremities for edema, note the amount and degree of pitting if present. -Monitoring: >Extremities, for peripheral edema and other signs and symptoms of fluid overload. Resident #37 was admitted to the facility in May 2025, with diagnoses including Malignant Neoplasm of Pancreas, Hypertension (HTN), Atrial Fibrillation (A-Fib), Stage Two Chronic Kidney Disease, and Chronic Heart Failure with Preserved Ejection Fraction. Review of Resident #37's Activities of Daily Living (ADL) Care Plan initiated 5/16/25, indicated: -Assist with mobility and ADLs as needed. Review of Resident #37's Nursing admission assessment dated [DATE], indicated: -Resident has a diagnosis of Heart Failure. -Resident had no edema. -Resident was admitted for palliative care (specialized care focused on improving one's quality of life for people with serious illness [es]). Review of the Nurse Practitioner (NP) Encounter Note dated 5/19/25, indicated Resident #37: -was newly admitted to the facility for long term, palliative care. -had a diagnosis of Chronic Heart Failure. -presented with no acute joint swelling. -presented with no edema. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #37: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -did not exhibit any refusal of care. -required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for bathing and showering. Review of Resident #37's Physician orders indicated: -Furosemide (Lasix: diuretic medication used to remove excess fluid from the body) Oral Tablet 20 mg (milligrams), Give 1 tablet by mouth in the morning for CHF, dated 5/16/25. -Dabigatran Etexilate Mesylate (anticoagulant [blood thinning] medication) Oral Capsule. Give 150 mg by mouth every 12 hours for anticoagulants, dated 5/16/25. -Hydralazine (vasodilator medication that relaxes blood vessels and allow blood to flow more easily) HCl Oral Tablet 25 mg. Give 1 tablet by mouth two times a day for antihypertensives, dated 5/16/25. -No weights for comfort [sic], dated 5/22/25. -Diltiazem (medication used to treat high blood pressure, chest pain, and to control heart rate) HCl Oral Tablet 120 mg. Give 3 tablets by mouth one time a day for calcium channel blockers dated 5/16/25, with a discontinue date of 6/9/25. -Cardizem (Diltiazem HCl) Oral Tablet. Give 360 mg by mouth one time a day for prophylaxis dated 6/5/25, with a discontinue date of 6/10/25. -Cardizem LA Oral Tablet Extended Release 24 Hour 360 mg. Give 1 tablet by mouth in the morning for rate, bp (blood pressure), dated 6/10/25 with no discontinue date. On 6/12/25 at 8:16 A.M., the surveyor observed the following: -Resident #37 was sitting in a chair beside his/her bed, with both feet positioned on the floor. -The Resident wore a shoe with Velcro closures and open toe on his/her left foot and a slipper on his/her right foot. -The top of the Resident's right foot (portion not covered by the slipper) to just above the right ankle was puffy and shiny. During an interview at the time, Resident #37 said he/she had swelling in both lower extremities. Resident #37 said the swelling was new and began a couple of days prior. Resident #37 said he/she did not know what the swelling was from. The Resident then removed his/her slipper and open toe Velcro enclosure shoe and the surveyor observed an indentation in the skin across the top of the Resident's right foot where the top edge of the slipper made contact with the Resident's skin. The surveyor also observed that the top of the Resident's left foot was puffy and shiny. On 6/13/25 at 9:05 A.M., the surveyor observed the following: -Nurse #1 was passing medications for residents on the same side of the Unit where Resident #37 resided. -Resident #37 was sitting in a chair beside his/her bed, with both feet positioned on the floor. -The Resident wore slippers on both feet. -A portion of the tops of the Resident's feet not covered by the slippers and the Resident's ankles were visible to the surveyor. -The portion of the tops of the Resident's feet and ankles visible to the surveyor were puffy and shiny, and the right foot and ankle was larger than the left foot and ankle. During an interview at the time, Resident #37 said he/she still had swelling in his/her feet and he/she did not know why they were swollen. Resident #37 said he/she should really get after someone to look at his/her feet because he/she did not think anything was being done to address the swelling. During an interview on 6/13/25 at 9:05 A.M., Certified Nurses Aide (CNA) #1 said she frequently provided assistance with ADL care for Resident #37. CNA #1 said the Resident completed much of his/her own sponge bathing and dressing, with supervision and verbal reminders to be thorough, and that the Resident required assistance to bathe in the shower. CNA #1 said that Resident #37 had recently been requiring more supervision and cues while bathing as the Resident was starting to forget to bathe certain parts of his/her body. CNA #1 said she had provided Resident #37 with assistance to shower on 6/11/25, and that the Resident's feet looked swollen at that time. CNA #1 further said she did not think the Resident's feet looking swollen was new, so she did not alert the Nurse. CNA #1 said if she thought the swelling was new, she would have told the Nurse so that the Nurse could follow-up with the Resident. During an interview on 6/13/25 at 9:20 A.M., Nurse #1 said he worked regularly at the facility and provided care for Resident #37 often and that he was responsible for the Resident's care on 6/12/25. Nurse #1 said he was not aware of Resident #37 having any edema in his/her lower extremities. Nurse #1 then said he would see the Resident and alert the Physician if the Resident had lower extremity swelling. During an interview on 6/13/25 at 9:35 A.M., Nurse #1 said the Physician was in the facility and that he had alerted the Physician of Resident #37 having lower extremity edema. During a follow-up interview on 6/13/25 at 3:00 P.M., Nurse #1 said he thought the Physician had seen Resident #37 that day because he asked the Physician to see the Resident. Nurse #1 reviewed the Resident's clinical record and said he did not see a progress note from the Physician, so the Physician probably did not make any new orders for the Resident. Nurse #1 said that Physician was good about alerting the Nurses if he had new orders or changes in treatment for residents on the Unit. Review of Resident #37's clinical record on 6/17/25 at 7:23 A.M. failed to include any evidence that Resident #37's lower extremity edema had been assessed. During an interview on 6/17/25 at 7:35 A.M., Unit Manager (UM) #1 said she would have to look into whether Resident #37's lower extremity edema had been assessed. On 6/17/25 at 7:48 A.M., UM #1 requested the surveyor accompany her to observe Resident #37's lower extremities. The surveyor and UM #1 observed the following: -Resident #37 was lying in bed, covered with bed sheets and his/her lower extremities were not exposed. -UM #1 uncovered Resident #37's lower extremities, with the Resident's permission. -The top of the Resident's left foot to the front of the left lower ankle were puffy. -The top of the Resident's right foot to just above the right ankle was puffy and the skin had a firm, tight appearance. -UM #1 swept her hands, palm side down, over the Resident's front lower legs. During an interview at the time, UM #1 said this was the Resident's baseline and depending on who completed an assessment and how they completed the assessment, would determine whether or not a Resident had edema. UM #1 then said Resident #37 did not have any edema upon admission to the facility, and that the Resident did not currently have pitting edema. The surveyor then observed UM #1 complete the following: -UM #1 used a finger and thumb to apply pressure to Resident #37's right lower extremity, above the ankle, and the Resident's left ankle. -The surveyor observed impressions remaining in the areas of the Resident's lower extremities where UM #1 had applied pressure. During an interview at the time, UM #1 said Resident #37 did have pitting edema. During an interview immediately after exiting Resident #37's room, UM #1 said she was not sure if the Physician assessed the Resident on 6/13/25. UM #1 said the Physician may have seen the Resident and not provided new orders. UM #1 then said she would see whether the Physician was in the facility at this time and would update the surveyor on the results of the Physician's assessment of the Resident. During an interview on 6/17/25 at 9:37 A.M., the Director of Nursing (DON) said she spoke with the Physician and the Physician was unable to assess Resident #37 on 6/13/25 because the Resident was in an outdoor activity. The DON said Resident #37 would be assessed by a Provider on this date (6/17/25). Review of Resident #37's Physician orders dated 6/17/25, indicated: -Furosemide Oral Tablet 20 mg. Give 1 tablet by mouth in the morning for CHF. On hold from 6/17/25 to 6/20/25. -Furosemide Oral Tablet 40 mg. Give 40 mg by mouth one time a day for BLE edema for 3 Days. -BMP (basic metabolic panel: blood test used to measure several key substances in the blood, including kidney function markers) one time only for increase in diuretic for 1 Day, ordered 6/17/25 with a start date of 6/20/25. During an interview on 6/17/25 at 12:19 P.M., Physician Assistant (PA) #1 said nursing staff requested she assess Resident #37 on 6/17/25 for new onset of swelling in the Resident's lower extremities. PA #1 said the swelling was a new problem for the Resident. PA #1 said when she assessed the Resident on 6/17/25, the Resident had significant pitting edema, more in the right lower extremity than the left lower extremity. PA #1 said the Resident had 3 plus (+) pitting edema in the right lower extremity and 2+ pitting edema in the left lower extremity. PA #1 said she attributed Resident #37's lower extremity edema to the Resident's CHF. PA #1 said it was important for a new onset of edema to be identified and reported to the Provider right away so the Provider can assess the edema and provide instructions for care. PA #1 further said after assessing Resident #37 on 6/17/25, she provided an order to double the Resident's Furosemide and ordered a BMP to be drawn to ensure the increase in Furosemide did not impact the Resident's kidney function. During a follow-up interview on 6/17/25 at 1:30 P.M., UM #1 said if a Resident experienced a new onset of edema, the Nurse was responsible to write a Nursing Note or Health Status Note indicating the change of condition. UM #1 said the Nursing or Health Status Note would be where the Nurse would record the assessment of a Resident's edema. UM #1 said Nurse #1 should have completed a Nursing or Health Status Note relative to Resident #37's change in condition with an assessment related to the Resident's lower extremity edema on 6/13/25, but Nurse #1 did not. During an interview on 6/17/25 at 1:53 P.M., the Physician said he was not aware Resident #37 had any lower extremity edema until 6/13/25. The Physician said he was unable to assess the Resident while he was at the facility on 6/13/25, because the Resident was engaged in an outdoor activity. During an interview on 6/17/25 at 2:30 P.M., the DON said communication was left for PA #2 to assess Resident #37 on 6/14/25 for lower extremity edema after the Physician was unable to assess the Resident on 6/13/25. The DON said PA #2 worked at the facility on 6/14/25 and did not assess the Resident. The DON further said she did not know why PA #2 did not assess the Resident and that PA #2 was now on vacation. During an interview on 6/17/25 at 3:55 P.M., Nurse #2 said she was assigned to provide nursing care for Resident #37 that day (6/17/25) and that Nurse #1 did not work at the facility on 6/17/25. Nurse #2 said Residents with CHF required monitoring for changes including shortness of breath, decreased physical functioning, fatigue, and edema. Nurse #2 said some Residents with CHF may require daily weights to assist with monitoring their condition. Nurse #2 said if a Resident was not to be weighed daily, the Nurse was responsible to ask the Resident if they were experiencing any changes that were related to CHF and also observe the Resident for symptoms, including edema. Nurse #2 said orders or instructions for monitoring a Resident's symptoms of CHF and diuretic use would not be indicated in a Resident's record, but Nurses were responsible to monitor for any change in symptoms for Residents with CHF at a required frequency of every shift.

Based on interviews, and record reviews, the facility failed to notify the state mental health authority (Pre-admission Screening and Resident Review [PASRR] Office) promptly of the need for Resident Review for one Resident (#12) out of a total sample of 30 total residents, when the Resident experienced a significant change in his/her mental condition from his/her initial Level I PASRR. Specifically, the facility failed to notify the PASRR Office of the need for Resident Review when Resident #12, who was diagnosed with Depression, acquired new diagnoses of Delusional Disorders and Hallucinations during his/her stay at the facility and a new medication treatment of Seroquel (antipsychotic medication) was implemented. Findings include: Resident #12 was admitted to the facility in February 2024 with diagnoses including Depression. Review of Resident #12's Level I PASRR dated 2/2/24, indicated the following: -no documented diagnosis of a mental illness or disorder (MI/D: Schizophrenia, Somatoform Disorder, Delusional Disorder, Mood, PTSD, Severe Anxiety/Panic Disorder, Schizoaffective Disorder, Other Psychotic Disorder, Paranoia, Personality Disorder, other mental disorder that may lead to chronic disability). -screen for serious mental illness (SMI) was negative. -A Level II PASRR Evaluation was not indicated. Review of Resident #12's Physician Order dated 2/5/24, indicated: -Mirtazapine (antidepressant medication) Tablet 7.5 mg (milligrams), Give 1 tablet by mouth at bedtime for Depression. Review of Resident #12's Behavioral Health Visit Note dated 2/29/24, indicated: -was seen by Behavioral Health for initial evaluation and medication adjustment with chief complaint of recent delusional thoughts. -there was a concern during evening/night shifts that the Resident was becoming confused and having psychotic thoughts ranging from delusions to possible visual hallucinations (VHs). -family reported this was happening at home, though the frequency/intensity/examples were unknown. -will start with a recommendation for PRN(as needed) Trazodone and see how [he/she] responds. Review of Resident #12's Medical Diagnosis Listing indicated: -A new diagnosis of Delusional Disorders (mental illness where individuals hold strong, persistent beliefs that are not based on reality) was added on 2/29/24. -A new diagnosis of Hallucinations (sensing things such as visions, sounds, or smells that seem real but are not) was added on 3/1/24. Review of Resident #12's Physician orders dated 3/1/24, indicated: -Seroquel (Quetiapine Fumarate: antipsychotic medication) Oral Tablet, Give 12.5 mg by mouth at bedtime related to Hallucinations. Review of Resident #12's March 2024 Medication Administration Record (MAR) indicated the ordered Seroquel began being administered to the Resident on 3/2/24. Review of Resident #12's Behavioral Health Visit Note dated 3/14/24, indicated the following: -was seen by Behavioral Health for medication management with a chief complaint for delusional thoughts. -Seroquel (antipsychotic medication) had been added to the Resident's medication regimen on 3/1/24. -Per facility staff, the Resident had not exhibited any further delusional thinking nor hallucinations. Review of Resident #12's Behavioral Health Visit Note dated 12/30/24, indicated a gradual dose reduction (GDR) of Seroquel was recommended. Review of Resident #12's clinical record indicated: -Physician order to discontinue Seroquel Oral Tablet (Quetiapine Fumarate). Give 12.5 mg by mouth at bedtime related to Hallucinations on 12/31/24. -Physician order dated 12/31/24, with a discontinue date of 1/24/25, for Seroquel Oral Tablet, Give 12.5 mg by mouth at bedtime every other day for antipsychotics related to hallucinations. -Physician order dated 1/24/25, with no discontinue date, for Seroquel Oral Tablet. Give 25 mg by mouth at bedtime for antipsychotics related to Hallucinations. -Physician Order, dated 1/24/25, for Seroquel Oral tablet. Give 12.5 mg by mouth at bedtime for antipsychotics related to hallucinations for three days. Review of Resident #12's MARs from March 2024 through 6/16/25, indicated Seroquel was administered to the Resident as ordered by the Physician. Review of Resident #12's clinical record failed to include any evidence that Resident #12 was referred to the PASRR Office for Resident Review when the Resident experienced a change in mental condition from his/her initial Level I PASRR, dated 2/2/24. During an interview on 6/13/25 at 12:10 P.M., the Social Worker (SW) said Resident #12 had not been referred to the PASRR Office for Resident Review when the Resident experienced a change in mental condition from his/her initial Level I PASRR and required changes to be implemented to his/her psychotropic medication regimen. The SW said Resident #12 should have been referred to the PASRR Office for Resident Review when he/she was newly diagnosed with Delusional Disorders, Hallucinations, and required treatment with antipsychotic medication.

Based on record reviews, and interviews, the facility failed to complete Comprehensive Minimum Data Set (MDS) Assessments that accurately reflected the status of two Residents (#14 and #141) out of a total sample of 30 residents. Specifically, 1. For Resident #14, the facility failed to accurately code for Hospice services when Resident #14 was ordered for and had been receiving Hospice services during the assessment period. 2. For Resident #141, the facility failed to accurately code for discharge return anticipated when the Resident was transferred to the hospital for evaluation of an acute change in health status. Findings include: Review of the CMS Resident Assessment Instrument (RAI) Manual 3.0, located at CMS.gov included but was not limited to: -The RAI process has multiple regulatory requirements which require the assessment accurately reflects the resident's status. 1. Resident #14 was admitted to the facility in December 2016, with diagnoses including Multiple Sclerosis (MS) and Dementia. Review of Resident #14's Medical Record included but was not limited to: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of a total possible score of 15. -The Resident had an invoked Health Care Proxy (HCP: person that can make decisions related to health care when someone is unable to do so themselves), effective 7/18/18. -The Resident had a Physician's order for Hospice services, effective 3/27/25. Review of Resident #14's Person-Centered Care Plan, revised on 4/4/25, included but was not limited to: -The Resident was admitted to Hospice Services on 3/27/25. Review of Resident #14's MDS with assessment reference date of 4/11/25, failed to indicate that the Resident received Hospice Services. During an interview on 6/16/25 at 10:45 A.M., MDS Nurse #1 said that the facility followed the RAI manual guidelines for coding of MDS assessments. MDS Nurse #1 said Resident #14 had been receiving Hospice Services since 3/27/25. MDS Nurse #1 said that the Hospice Services should have been coded on the Resident's MDS dated [DATE], because Hospice Services were in place. MDS Nurse #1 said that Resident#14's MDS data was inaccurate and did not reflect the Resident's status. 2. Resident #141 was admitted to the facility in July 2023 with diagnoses including Hypertension (HTN) and Atrial Fibrillation (A-Fib). Review of Resident #141's Medical Record included but was not limited to: -A Nursing Progress Note dated 3/22/25, indicated the Resident was unresponsive with abnormal vital signs, had shortness of breath, discomfort and low oxygen levels of 79% when breathing room air. -A Physician's order to send the Resident to the hospital for evaluation, effective 3/22/25. Review of the Resident's MDS with reference date of 3/22/25, included but was not limited to: -Resident #141 was discharged with return not anticipated. During an interview on 6/18/25 at 11:55 A.M., MDS Nurse #1 said at the time of the hospital transfer the facility had expected the Resident to return. MDS Nurse #1 said that the Resident passed away while at the hospital. MDS Nurse #1 said that the MDS coding was inaccurate because the facility did not have reason to believe that the Resident was not going to return to the facility at the time of the Resident's transfer to the hospital for evaluation. MDS Nurse #1 said that the MDS assessment should have been coded as discharge return anticipated but was not coded as required.

Based on interviews and records reviewed, for two of five sampled residents (Resident #1 and #4), the Facility failed to ensure that after being made aware of allegations of potential sexual abuse by a staff member that they obtained and maintained evidence that a thorough investigation was completed, including conducting and documenting assessments of both residents and obtaining and documenting staff member interviews. Findings include: The Facility Policy titled Abuse-Conducting an Investigation, last reviewed 6/17/24, indicated that all allegations of abuse are promptly and thoroughly investigated. The Policy indicated alleged victims will be examined for signs of injury, including a physical examination or psychosocial assessment. The Policy indicated the investigation was expected to include, although not be limited to, interviews with the alleged victim and their representative, the alleged perpetrator and witnesses. The Facility Policy titled Abuse-Reporting and Response-No Crime Suspected, last reviewed 6/17/24, indicated that at the time that an incident is reported, the nurse will immediately assess the resident. 1) Resident #1's medical record indicated he/she was admitted to the Facility during August of 2020. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated his/her cognitive patterns were severely impaired. During an interview on 1/03/25 at 1:20 P.M., Certified Nurse Aide (CNA) #1 said that on 11/15/24 around lunch time (exact time unknown), she went to Resident #1's room, the bathroom door was closed and Resident #1 was not in the room. CNA #1 said that when she tried to open the bathroom door, it would not open. CNA #1 said that she knocked and tried the door again after a few seconds and said she was able to open the door. CNA #1 said that Housekeeper #1 and Resident #1 were alone in the bathroom. CNA #1 said that she reported finding Resident #1 alone in the bathroom with Housekeeper #1 to Nurse #1, the Director of Nurses and the Assistant Director of Nurses. During an interview on 1/03/25 at 4:00 P.M. with the Administrator and the Director of Nursing, they said that on 11/15/24, Nurse #1 reported that Housekeeper #1 was alone in the bathroom with Resident #1. The Director of Nursing and Administrator said that they initiated an investigation of CNA #1's observation and determined that nothing untoward happened to Resident #1. The Director of Nursing said that during the investigation, she and the Assistant Director of Nursing saw Resident #1 seated in his/her bedroom. The Director of Nursing said that Resident #1 looked OK, his/her clothes were not disheveled and his/her behavior was at baseline. The Director of Nursing said that she did not conduct a physical assessment of Resident #1, or ask another nurse to conduct a physical assessment, and instead relied on CNA #1's statement that she had provided incontinence care to Resident #1 after finding him/her alone in the bathroom with Housekeeper #1 and his/her incontinence brief and clothing appeared undisturbed. Review of the Facility's Internal Investigation, dated 11/21/24, indicated there was no documentation to support the Facility having had Resident #1 examined by a nurse or documented interviews with Housekeeper #1, other staff working on Resident #1's unit at the time of the alleged incident, or Resident #1's representative. 2) Resident #4's medical record indicated he/she was admitted to the Facility during August of 2024 and discharged during December 2024. Resident #4's MDS Assessment, dated 11/14/24, indicated his/her cognitive patterns were intact. During a telephone on 1/08/25 at 3:30 P.M., CNA #4 said that during Resident #4's admission in the facility, (exact date unknown), Resident #4 told her that he/she felt like Housekeeper #1 was stalking him/her and always staring at him/her. CNA #4 said that she reported CNA #4's complaint to one of the nurses. During a telephone interview on 1/08/25 at 2:15 P.M., the Occupational Therapy Assistant said that sometime in September 2024 (exact date unknown), Resident #4 expressed concerns to her about Housekeeper #1. The Occupational Therapy Assistant said Resident #4 told her that Housekeeper #1 was always around him/her, always in the hallway outside of his/her room and he/she could always hear his voice. The Occupational Therapy Assistant said that Resident #4's perception was that he/she got too much attention from Housekeeper #1. The Occupational Therapy Assistant said that she reported Resident #4's comments to the Director of Nursing. The Occupational Therapy Assistant said that, a day or two later (exact date unknown), Resident #4 complained a second time to her about Housekeeper #1, saying that he/she felt uncomfortable with the degree that he was around him/her and she reported Resident #4's second complaint to Unit Manager #2 or #3. The Occupational Therapy Assistant said that Resident #4 was fearful, anxious and upset when talking about Housekeeper #1. The Director of Nursing said that the Occupational Therapy Assistant had told her about concerns that Resident #4 reported. The Director of Nursing provided a Written Statement, dated 9/04/24 and signed by herself, which indicated that Resident #4 had told an Occupational Therapy Assistant that he/she thought Housekeeper #1 was weird, that he spent a lot of time in his/her room and he must think that he/she was his/her boyfriend. The Written Statement indicated the Director of Nursing investigated Resident #4's concern by speaking to him/her and that he/she said he/she was not afraid of Housekeeper #1, worried or concerned and stated he/she felt safe and comfortable. Review of the Facility's Internal Investigation, dated 9/04/24, indicated there was no documentation to support the Facility having had Resident #4 examined by a nurse or documented interviews with Housekeeper #1, other staff working on Resident #4's unit at the time of the alleged incident, or Resident #4's representative during the investigation of the allegation.

Based on interviews and records reviewed, for two of five sampled residents (Residents #1 and #4), the Facility failed to ensure they reported allegations of abuse by Housekeeper #1 to the Department of Public Health (DPH) as required, when after being notified by staff that Housekeeper #1 potentially sexually abused Residents #1 and #4, the Director of Nursing and the Administrator did not report the allegations to the DPH, as required. Findings include: The Facility Policy titled Abuse-Reporting and Response-No Crime Suspected, last reviewed 6/17/24, indicated that all alleged violations, must be reported to the administrator of the Facility and to other officials in accordance with State law through established procedures, including the State Survey and Certification Agency. 1) Resident #1's medical record indicated he/she was admitted to the Facility during August of 2020. Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 10/30/24, indicated his/her cognitive patterns were severely impaired. During an interview on 1/03/25 at 1:20 P.M., Certified Nurse Aide (CNA) #1 said that on 11/15/24 around lunch time (exact time unknown), she went to Resident #1's room, the bathroom door was closed and Resident #1 was not in the room. CNA #1 said that when she tried to open the bathroom door to see if Resident #1 was inside, the door would not open. CNA #1 said that she knocked and tried the door again after a few seconds and said she was able to open the door. CNA #1 said that Housekeeper #1 and Resident #1 were alone in the bathroom. CNA #1 said that she reported finding Resident #1 alone in the bathroom with Housekeeper #1 to Nurse #1, the Director of Nurses and the Assistant Director of Nurses. During an interview on 1/03/25 at 4:00 P.M. with the Administrator and the Director of Nursing, they said that Nurse #1 had reported to the Director of Nursing on 11/15/24 that Housekeeper #1 was found alone in the bathroom with Resident #1. The Director of Nursing and Administrator said that they initiated an investigation into CNA #1's observation and determined that nothing untoward happened to Resident #1. The Director of Nursing and Administrator said that they did not report the allegation to the Department of Public Health. The Administrator said that she did not think CNA #1's report was an allegation of abuse or having to do with harm to Resident #1, but thought it was an instance in which staff of the nursing department was telling on another department. 2) Resident #4's medical record indicated he/she was admitted to the Facility during August of 2024 and discharged during December 2024. Resident #4's most recent MDS Assessment, dated 11/14/24, indicated his/her cognitive patterns were intact. During a telephone interview on 1/08/25 at 3:30 P.M., CNA #4 said that, sometime during Resident #4's stay in the facility (exact date unknown), Resident #4 told her that he/she felt like Housekeeper #1 was stalking him/her and always staring at him/her, CNA #4 said that she reported Resident #4's complaint to one of the nurses (exact name unknown). During a telephone interview on 1/08/25 at 2:15 P.M., the Occupational Therapy Assistant said that Resident #4 expressed concerns to her about Housekeeper #1. The Occupational Therapy Assistant said Resident #4 told her that Housekeeper #1 was always around him/her, always in the hallway outside of his/her room and he/she could always hear his voice. The Occupational Therapy Assistant said that Resident #4's perception was that he/she got too much attention from Housekeeper #1. The Occupational Therapy Assistant said that she reported Resident #4's concerns to the Director of Nursing. The Occupational Therapy Assistant said a day or two later (exact date unknown), Resident #4 complained a second time about Housekeeper #1, saying that he/she felt uncomfortable with the degree that Housekeeper #1 was around him/her. The Occupational Therapy Assistant said she reported Resident #4's concerns a second time, reporting them to Unit Manager #2 or #3. The Occupational Therapy Assistant said that Resident #4 was fearful, anxious and upset when talking to him/her about Housekeeper #1. The Director of Nursing said that the Occupational Therapy Assistant told her about concerns that Resident #4 had reported regarding Housekeeper #1. The Director of Nursing provided a Written Statement, dated 9/04/24, (written and signed by herself) which indicated that Resident #4 told Occupational Therapy Assistant that he/she thought Housekeeper #1 was weird, that he spent a lot of time in his/her room and he must think that he/she was his/her boyfriend. The Written Statement indicated the Director of Nursing investigated Resident #4's concern by speaking to Resident #4 and he/she said he/she was not afraid of Housekeeper #1, worried or concerned and stated he/she felt safe and comfortable. The Director of Nursing said that based on her conversation with Resident #4, she did not report the allegation to the Department of Public Health.

Based on interviews and records reviewed, for two of five sampled residents (Residents #2 and #3), the Facility failed to ensure staff implemented and followed the Facility Abuse Prohibition Policy, when Resident #2 and the family member of Resident #3 (Family Member #1) reported allegations of abuse by Housekeeper #1 to multiple staff members and staff did not immediately report the allegations to their immediate Supervisor, Administrator or designee. Findings include: The Facility Policy titled Abuse-Reporting and Response-No Crime Suspected, last reviewed 6/17/24, indicated that all associates are mandated to immediately report suspected resident abuse/neglect to their immediate supervisor and/or Facility representative. 1) Resident #2's medical record indicated he/she was admitted to the Facility during December of 2022. Resident #2's most recent Minimum Data Set (MDS) Assessment, dated 12/06/24, indicated his/her cognitive patterns were intact. During an interview on 1/03/25 at 12:20 P.M., Housekeeper #2 said that at some point after 11/15/24 (exact date unknown), Resident #2 told her about an incident he/she had with Housekeeper #1. Housekeeper #2 said that Resident #2 told her about an incident in which he/she was awakened by Housekeeper #1 giving him/her a kiss on the cheek. Housekeeper #2 said that she did not immediately report Resident #2's allegation to her immediate supervisor or the Administrator. During an interview on 1/03/25 at 1:45 P.M., the Administrator said that Housekeeper #2 came to her after speaking with the Surveyor 1/03/25 and reported that Resident #2 had previously told her that Housekeeper #1 had kissed him/her on the cheek. 2) Resident #3's medical record indicated he/she was admitted to the Facility during May of 2024. Resident #3's most recent Minimum Data Set (MDS) Assessment, dated 5/18/24, indicated his/her cognitive patterns were moderately impaired. During a telephone interview on 1/08/25 at 1:02 P.M, Family Member #1 said that, at some point during Resident #3's stay at the Facility (between May and July 2024, exact date unknown), Resident #3 told her that Housekeeper #1 came into his/her room and put his hands under his/her shirt. Family Member #1 said that she reported Resident #3's allegation about Housekeeper #1 to Nurse #2. During a telephone interview on 1/08/25 at 3:30 P.M., Nurse #2 said that Family Member #1 told her about an incident in which Resident #3 alleged Housekeeper #1 put his hands under his/her shirt. Nurse #2 said that she reported Family Member #1's allegation however, said she could not be certain to whom and said she thought she reported the allegation to Unit Manager #2, Unit Manager #3 or the Assistant Director of Nursing. During telephone interviews with Unit Manager #1 on 1/09/25 at 3:50 P.M., Unit Manager #2 on 1/10/25 at 11:30 P.M. and the Assistant Director of Nursing on 1/14/25 at 10:10 A.M., they said Nurse #2 did not report Family Member #1's allegation that Housekeeper #1 put his hands under Resident #3's shirt to them.

Based on observation, interview and record review, the facility failed to provide pain management that was consistent with professional standards of practice for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility staff failed to offer Resident #18 prescribed pain medication prior to an identified painful dressing change procedure. Findings include: Review of the facility policy titled, Pain Assessment and Management dated 9/12/23, indicated the following: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -Based on the assessment, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and/or his/her representative, develops, implements, monitors, and revises as necessary interventions to prevent or manage each individual resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal. Review of the facility policy titled Treatment of Wounds dated 3/31/23, indicated the following: -Policy: 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. -Procedure: This facility will utilize the Lippincott procedures: Traumatic wound care: abrasion, lacerations, and puncture wounds. Review of the Lippincott Manual of Nursing Procedures-9th edition (2023), Traumatic Wound Management indicated the following: -Treat the patient's pain, as needed and ordered, using nonpharmacologic or pharmacologic approaches, or a combination. -Base the treatment plan on evidence-based practices and the patient's clinical condition, past medical history, and pain management goals. -Give the patient prescribed medication before painful dressing changes. Resident #18 was admitted to the facility in April 2023 with diagnoses including peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and non-pressure chronic ulcer of the skin. Review of the Minimum Data Set (MDS) Assessment, dated 1/31/24, indicated Resident #18: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15 points. -had almost constant, severe pain, that affected sleep and day-to-day activities. -received scheduled pain medication. -did not receive PRN (as needed) pain medication. -did not receive non-medication interventions for pain. Review of the At Risk for Pain care plan, revised 11/14/22, indicated the following intervention: -Anticipate the Resident's need for pain relief and respond immediately to any complaint of pain. Review of the Physician's Progress Note, dated 3/26/24, indicated the following: -Left foot dorsal ulcer: small, about 0.5 centimeters (cm), fibrinous debris (inflammatory fluid that forms at the site of tissue injury). -Continue Oxycodone PRN (as needed) for pain management AND Oxycontin 10 milligrams (mg) daily BID (twice a day). Review of the April 2024 Physician's orders indicated the following: -Left foot (dressing change, ordered to be done daily): *cleanse with normal saline (a mixture of salt and water often used to cleanse wounds), pat dry. *Apply silver sulfadiazine (an antibiotic cream used to prevent and treat infection) to top of left foot. *Cover with ABD pad (a bulky pad used where high absorbency is needed to manage heavy draining wounds) and wrap with KLING wrap (rolled gauze). *Secure with tape. -Oxycodone HCL ER 12-hour 10 mg (an extended-release opioid pain reliever, also known as Oxycontin)-give one tablet by mouth every 12 hours for moderate to severe pain. -Oxycodone HCL oral capsule 5 mg (an opioid pain reliever used to treat moderate to severe pain) - give 5 mg by mouth every six hours as needed for pain. -Acetaminophen oral tablet 325 mg - give three tablets by mouth every eight hours as needed for pain. Review of the Medication Administration Record (MAR), dated 4/8/24, indicated the Resident was administered the following medications: -Oxycodone HCL ER 12-hour 10 mg, one tablet at 8 A.M. -Acetaminophen oral tablet 325 mg, three tablets at 12:30 A.M. On 4/8/24 at 2:25 P.M., during a dressing change observation, the surveyor observed Nurse #1 began to cut the gauze wrap off the Resident's left foot when the Resident winced and told the Nurse to be careful. While Nurse #1 was removing the outer dressing, the Resident yelled STOP and began to cry. After Nurse #1 removed the outer dressing, she reached a small gauze pad covering the wound and the Resident said, it hurts so much and asked the Nurse to pour water, or whatever is in the bottle on it first. Nurse #1 then proceeded to soak a gauze pad with saline solution and placed it over the wound. The Resident screamed and said, it is like a knife being twisted! After the Resident screamed out in pain, the surveyor intervened and asked Nurse #1 to pause the dressing change and assess the Resident. Nurse #1 stopped and asked the Resident if he/she would like to take pain medication. The Resident responded by saying it won't work, it takes 45 minutes for it to work, you should have given me a pain pill before you started. Nurse #1 then proceeded to remove the gauze, cleanse, and re-dress the wound while the Resident was wincing and crying. When the dressing change procedure was completed, the Resident rated his/her pain level as nine out of ten and said he/she was going to be in pain all night. During an interview on 4/8/24 at 3:10 P.M., Nurse #1 said that she should have informed the Resident as to when she was going to do the dressing change and should have offered him/her pain medication prior to starting the dressing change procedure. Nurse #1 said she had asked the Resident if he/she wanted a pain pill during the dressing change, but the Resident said it would take too long to work and Nurse #1 determined it would only take five minutes to finish the dressing and that the Resident wanted the dressing change to be finished. Review of the April 2024 MAR indicated the following: -Gabapentin 100 mg - give 1 capsule by mouth every 8 hours: 6:00 A.M., 2:00 P.M. and 10:00 P.M. -Oxycodone HCL ER 12-hour 10 mg - give one tablet by mouth every 12 hours: at 8:00 A.M. and 8 P.M. Further review of the April 2024 MAR indicated that Oxycodone 5 mg PRN every 6 hours was administered as follows: -4/1/24 at 12:14 A.M. and 2:41 P.M. (administered after a dressing change completed at 1:45 P.M., pain level documented as 9 out of 10) -4/2/24 at 12:30 A.M. and 4:00 P.M.(administered after a dressing change at 3:20 P.M, pain level documented as 7 out of 10) -4/4/24 at 12:24 A.M. and 1:35 P.M. (prior to dressing change at approximately 3:00 P.M, pain level documented as 7 out of 10) -4/5/24 at 2:00 P.M.(prior to the dressing change at approximately 3:00 P.M., pain level documented as 8 out of 10) and 9:53 P.M. -4/7/24 at 10:01 P.M. -4/8/24 at 3:45 P.M. (after the dressing change observed by the surveyor) During an interview on 4/8/24 at 3:15 P.M., the Director of Nurses (DON) said the Resident should have been assessed and medicated if needed for pain prior to the dressing change. During an observation and interview on 4/8/24 at 4:00 P.M., approximately one hour after the dressing change procedure, the surveyor observed the Resident lying in bed. Resident #18 said he/she had received a pain pill after the dressing change and rated his/her pain level as 4 or 5 out of 10 at the current time. During an observation on 4/9/24 at 12:17 P.M., the surveyor observed the Resident lying in bed. The Resident said that his/her foot had hurt all night but not as bad as when the dressing was being changed. During an interview on 4/10/24 at 9:45 A.M., Nurse Practitioner (NP) #1 said the Resident is very sensitive to any touch of his/her foot. NP #1 said that at one point the Resident had been hospitalized and his/her narcotics had been discontinued but the NP has gradually been adding them back while the Resident is deciding if he/she is going to have surgery. NP #1 said that she would expect that the Resident with a known sensitivity would have been pre-medicated for pain prior to a dressing change. Please refer to F726

Based on observation, interview, record and policy review, the facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for one Resident (#85), out of a total sample of 25 residents. Specifically, the facility staff failed to: -Assess the fit and use of an orthopedic surgical shoe (type of shoes that provides support and stability for the foot after an injury or surgery) for Resident #85 who had a high risk of developing pressure ulcers due to a history of Diabetes (condition that result in too much sugar [glucose] in the blood). -Provide skin care and treatments timely for ulcers on the right plantar foot, back of right ankle and right heel, resulting from the use of an orthopedic surgical shoe. Findings include: Review of the facility policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, reviewed March 2023, indicated the following: - A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and - A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. -Skin observations also occur throughout points of care provided by Certified Nursing Assistance (CNA) during activity of daily living (ADL) care (bathing, dressing, incontinent care, etc.) Any changes or open areas are reported to the Nurse. -Nurse will complete further inspection/assessment and provide treatment if needed. -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. -Successful pressure injury treatment involves relieving pressure, restoring circulation, promoting adequate nutrition and, if possible, resolving or managing related disorders. Resident #85 was admitted to the facility in March 2024, with diagnoses including Diabetes with Neuropathy (condition that results in too much sugar in the blood resulting in high blood glucose[sugar] with nerve damage) and Peripheral Vascular Disease (PVD - circulatory disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #85: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of a total 15. -Had range of motion impairments affecting one side upper extremity. -Was dependent on staff for putting on and taking off footwear. -Required assistance from staff with upper and lower dressing, rolling side to side, lying to sitting and with transfers. -Was at risk for pressure ulcers -Had no pressure ulcers/injuries -Had two venous and arterial ulcers (no location identified). Review of the April 2024 Physician's orders, included the following: -Diabetic foot care, initiated 3/8/24 -Monitor heels every shift, initiated 3/7/24 -Bilateral heels: Apply skin prep, initiated 3/7/24 Review of the Norton Plus Pressure Ulcer Scale (used to determine whether a patient is at high risk of pressure ulcer development) dated 3/29/24, indicated a total score of 11 indicating moderate risk (high risk - score of 10 and below, moderate risk - score of 11-15) for skin breakdown. Review of the Weekly Wound assessment dated [DATE], indicated Resident #85 had the following: -Pink heels (the Weekly Wound Assessment did not specify one or both heels). Review of the Physical Therapy Treatment encounter dated 3/22/24, indicated Resident #85: -Had an x-ray taken of the right foot due to a loud crack experienced when ambulating to the bathroom [in the Resident's room in the facility]. -The x-ray report was negative, but the Resident is experiencing significant pain with putting pressure on the right foot. -Physician Assistant (PA) requested a right soft cushion orthopedic surgical shoe. Review of the Physical Therapy (PT) Treatment encounter dated 3/25/24, indicated Resident #85: -Was unable to initiate steps due to pain in right lower extremity. -Was wearing the right cast shoe (a soft cushion surgical shoe that provides support and stability for the foot after an injury or surgery). -Received pain medication prior to the therapy session. Review of the Physical Therapy Treatment encounter dated 3/28/24, indicated Resident #85: -continues to report pain in the right heel with weight bearing. -declined all additional standing and therapy activities. -An Orthopedic appointment was scheduled for 4/4/24 due to right heel pain. Review of the Physical Therapy Treatment encounter dated 3/29/24, indicated Resident #85: -had pain in the right heel with weight bearing. -declined gait training and standing activities. Review of the Physical Therapy Treatment encounter dated 4/2/24, indicated Resident #85: -had pain in right heel/ankle with weight bearing. -had pain medication prior to the PT session. Review of the Resident's Orthopedic Consultation dated 4/4/24, indicated the following: -Fracture of the Right Calcaneus with Achilles Tendon Disruption (an injury that is usually painful and likely to affect the ability to walk). -Skin Care for ulcers right plantar, right heel and back of right ankle. -Keep NWB (non weight bearing- for a certain period of time following injury or surgery you are not allowed to put any weight through the operated or injured limb to allow it to heal as much as possible). -Monitor skin back of [right] ankle. Review of the Physician's Progress Note, 4/5/24 indicated Resident #85: -Was seen by the Physician's Assistant (PA) on 3/22/24, for complaints of acute left [error] ankle pain when walking back from the bathroom. -Had an x-ray of right ankle 3/21/24 that showed no acute fracture. -Was seen by the PA on 3/26/24, for complaints of right heel pain, not able to bear weight without significant pain, is wearing a post-operative [soft cushion surgical]shoe on the [right foot] for support. -Was seen by the PA on 4/2/24, and continued with right heel pain, relieved with Tramadol (pain medication). -Orthopedic appointment scheduled 4/4/24. Review of the Nursing Progress Note dated 4/9/24, indicated Resident #85: -had a Deep Tissue Injury (DTI-purple or maroon localized area of discolored intact skin or fluid filled blister due to damage of underlying soft tissue from pressure) to the back of right heel, origin believed to be from back of the ortho (orthopedic) shoe. Further Review of the medical record indicated that Resident #85 was provided the surgical shoe (also referred to as post-op shoe/orthopedic shoe) on 3/22/24 and continued wearing it on the right foot until after the orthopedic appointment on 4/4/24. Review of the Physician's orders dated 4/10/24 (6 days after the ulcers were identified by the Orthopedic Physician), indicated the following: -Monitor DTI to right heel, initiated 4/10/24 -Maintain NWB to RLE (right lower extremity), initiated 4/9/24 -Monitor CSM (circulatory, motor, sensory- a physical exam of a resident whenever there is a high index of suspicion that there may be circulatory or neurological impairment to a limb) to right lower extremity (RLE), initiated 4/9/24 -Pain Assessment/Interventions prior to PRN (as needed) pain medication administration: Location of pain: ankle med interventions prior to administering pain medication, initiated 4/10/24 -Skin prep to bilateral heels and moisturize legs and feet two times a day, initiated 4/10/24 -Offload (minimizing or removing weight placed on the foot to help prevent and heal ulcers) pressure at all times, initiated 4/10/24 -Right plantar foot care, assess daily, clean foot with soap and water, pat dry, apply betadine to the small round Diabetic Ulcer on the mid-foot and cover with a padded dressing. -For Diabetic foot care assessments, initiated 4/10/24 Review of the current Diabetes Care Plan, initiated 3/7/24, indicated Resident #85 will have no complications related to Diabetes through the next review date. Review of the care plan, Unstageable DTI pressure ulcer right heel or potential for pressure ulcer development related to immobility, initiated 4/4/24, indicated Resident #85 -Pressure ulcer will show signs of healing and remain free from infection by/through next review date. -Administer treatments as ordered. -Assess wound healing. -Educate the resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Follow facility policies/protocol for the prevention/treatment of skin breakdown. Review of the Weekly Wound assessment dated [DATE], indicated Resident #85 had the following: -Right heel DTI pressure wound-unstageable acquired in facility 1.3 centimeters (cm) length by (x) 0.3 cm width x 0 cm depth. During an interview on 4/9/24 at 12:32 P.M., the Director of Nurses (DON) said that Resident #85 had an Orthopedic appointment on 4/4/24 with recommendations for the fracture of the Right Calcaneus with Achilles Tendon Disruption and the ulcers located on the right foot and heel areas. The DON further said the Resident had been ordered an orthopedic surgical shoe for comfort prior to the Orthopedic appointment. During an interview on 4/10/24 at 9:11 A.M., Nurse #3 and Physician Assistant (PA) #2 reviewed the medical record and Nurse #3 said Resident #85 had a new DTI to the right heel due to the orthopedic surgical shoe. Nurse #3 said the DTI was identified on 4/4/24 during the Orthopedic appointment but Nurse #3 only evaluated Resident #85 on 4/9/24 during the facility's weekly skin rounds. Nurse #3 said the last skin evaluation for Resident #85 was completed on 4/3/24 and not again until 4/9/24. PA #2 said she ordered the orthopedic surgical shoe for Resident #85 for comfort after the x-rays to the right heel on 3/22/24 were negative. Nurse #3 reviewed the Orthopedic consult from 4/4/24 and said when the Orthopedic Physician identified ulcers on the right plantar surface, right heel and back of right ankle, there was no evidence that any Physician orders for treatments were put into place and Resident #85 continued to wear the orthopedic surgical shoe. Nurse #3 said when a resident returns from a consultation the recommendations should be given to the medical provider and therapy department. Nurse #3 further said that based on the Orthopedic consultation, the Director of Nurses (DON) should have been notified and a skin assessment should have been completed immediately by the nursing staff to identify the areas of skin breakdown. Nurse #3 said Resident #85's skin was not assessed after the Orthopedic consult on 4/4/24 until weekly skin rounds on 4/9/24. During a follow-up interview on 4/10/24 at 9:26 A.M., PA #2 said she was notified of the Fracture of the Right Calcaneus on 4/4/24 and Resident #85 was still using the orthopedic surgical shoe that was provided on 3/22/24 in the facility, to keep the right foot off of the ground. PA #2 further said that she never saw any ulcers on Resident #85's feet and that she relies on the facility staff to assess those areas. PA #2 said she was not aware of any current skin breakdown. During an interview on 4/10/24 9:35 A.M., Resident #85 said he/she had pain in his/her right foot yesterday, and there is an ulcer. Resident #85 further said that he/she wears the orthopedic surgical shoe all of the time. During a follow-up interview 4/10/24 at 10:45 A.M., PA #2 said she saw Resident #85 on 3/22/24 after the first set of x-rays and there were no ulcers or open areas to the right foot and an orthopedic surgical shoe was given to the Resident at that time. PA #2 reviewed the medical record and found no evidence of an order for the orthopedic surgical shoe or instructions for care of the orthopedic surgical shoe. PA #2 said that facility staff should have done an assessment to make sure that the shoe was not too tight and that the Resident should only have the orthopedic shoe on when out of bed. PA #2 said because the Resident is Diabetic and at risk for skin breakdown, the facility staff should be doing foot care daily. PA #2 reviewed the Orthopedic consult dated 4/4/24 and said that her initials are on the consult and when she initialed the recommendation, the facility staff should enter the orders into the medical record and obtain follow-up. PA #2 said that she did not inspect Resident #85 right foot between 4/4/24 and 4/8/24. PA #2 further said that Resident #85 did not have proper treatment in place to treat the ulcerations to his/her right foot. During an interview and observation on 4/10/24 at 12:35 P.M., Resident #85 said that staff had not been removing the orthopedic surgical shoe at night and that he/she remained in the shoe throughout the night. Resident #85 said he/she had pain because of the ulcer. The surveyor, PA #2, and Nurse #3 viewed Resident #85's right foot ulcerations. During an interview on 4/10/24 at 12:59 P.M., PA #2 said the skin breakdown on the plantar surface of the right foot was the beginning of a diabetic ulcer. PA #2 further said that there is a DTI on the right heel and that orders would be put in place to treat the areas.

Based on interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of a significant change in physical status for one Resident (#102) out of a total sample of 25 residents, resulting in a lack of medical evaluation of the Resident's status relative to weight loss. Specifically, the facility staff failed to notify Resident #102's NPP of the Resident's severe weight loss (greater than five percent (%) in one month and greater than seven point five % in three months) when: a. Staff identified the Resident had a severe weight loss. b. The NPP requested to be notified if the severe weight loss was verified. Findings include: Review of the facility's policy titled Changes in Resident's Condition or Status, dated 11/26/18 and reviewed 8/9/23, indicated the following: -Facility would notify a resident's primary care provider (PCP: Physician/NPP) of changes in the resident's condition or status. -Notable changes included weight loss in excess of 5% of a resident's body weight. Review of the facility's policy titled Weights and Heights: Weight Monitoring Long-Term Care, revised 8/21/23, indicated the following: - Weight loss in adults can result from various conditions. - A decrease in weight of 5% or more in a month or of more than 10% in six months should be reported to the PCP for further evaluation. Resident #102 was admitted to the facility in October 2021 with diagnoses including: Diverticulitis (small, bulging pouches that can form in the lining of the digestive system and can cause abdominal pain, nausea, and vomiting) and Dysphagia (difficulty swallowing). Review of Resident #102's active Nutrition Care Plan initiated 5/4/22, indicated: -The Resident was at increased nutrition risk. -The Resident had a history of weight loss. -One of the Resident's goals was to maintain a stable weight. -Facility staff were to report significant weight loss to the Physician. Review of Resident #102's Minimum Data Set (MDS) Assessment, dated 1/31/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of 15 total possible points. -The Resident experienced signs and symptoms of a swallowing disorder. -The Resident did not have weight loss. Review of Resident #102's Plan of Care Note, dated 2/14/24, indicated: -The Resident was nutritionally stable. -Meal intakes ranged from 76%-100%. -The Resident's weight was stable. Review of a Physician's order dated 2/26/24, indicated: Weekly weights due to weight loss. Review of Resident #102's Weight Record indicated the following: -189.9 lbs. on 11/20/23 -189.6 lbs. on 1/26/24 -173.8 lbs. on 2/29/24 (indicating severe weight loss). Review of Resident #102's Weight Change Note, dated 3/5/24, indicated: -The Resident's weight was 173.8 lbs. -The Resident's weight loss was 16 lbs (severe). Further review of the Weight Change Note indicated the Resident's weight was much lower than his/her usual body weight (UBW) and that a re-weigh was requested. Review of Resident #102's Weight Record indicated the Resident was next re-weighed on 3/14/24 and was 173.8 lbs. Review of Resident #102's Weight Change Note, dated 3/15/24, indicated: -The Resident's UBW was upper 180s. -The Resident had no change in appetite. -Another re-weigh was requested. Review of Resident #102's Weight Change Note, dated 3/19/24, indicated: -Another re-weigh was requested for review with the Unit Manager (UM). -The Resident continued with good meal intakes. -The Resident's UBW ranged around 180s with most recent weight of 173.9 lbs. Review of Resident #102's clinical record included no evidence that facility staff notified the Resident's NPP of the Resident's severe weight loss at any time after weekly weights were ordered on 2/26/24. During an interview on 4/9/24 at 3:21 P.M., the Registered Dietician (RD) said she had been monitoring Resident #102 for weight loss since February 2024, when it was identified that the Resident had a potential severe weight loss. The RD said the severe weight loss was first identified on 2/26/24 and that she recommended weekly weight monitoring and requested the Resident be re-weighed to determine whether the severe weight loss was accurate. The RD said an order was obtained for weekly weight monitoring for Resident #102 on 2/26/24, and if the severe weight loss was verified, the NPP was to be notified. The RD said re-weights for Resident #102 were obtained on 3/14/24 and 3/18/24, both of which indicated severe weight loss, but she could not provide any evidence the NPP was notified. The RD further said she was not sure what the Resident's current weight was because the facility staff had not weighed the Resident for three consecutive weeks. Review of Resident #102's Weight Record indicated a weight was obtained on 4/9/24 at 4:08 P.M., following the surveyor's inquiry, and that the Resident weighed 171.8 lbs. During an interview on 4/10/24 at 8:10 A.M., the NPP said facility staff were required to notify her when a resident was identified to have a significant change in weight. The NPP said if a resident's weight changed significantly, facility staff would re-weigh the resident and that once the re-weight was obtained, facility staff were to notify her if the new weight confirmed a significant change in weight. The NPP said when staff notified her of a resident's significant change in weight, she would consult with the Physician and evaluate the resident for any medical concerns that could be related to the significant weight change. The NPP said she ordered weekly weights to be completed for Resident #102 in February 2024 when facility staff identified that the Resident had a potential severe weight loss. The NPP said facility staff communicated they would re-weigh the Resident to determine whether the weight loss was accurate. The NPP also said she requested facility staff to notify her if Resident #102's severe weight loss was identified to be accurate. The NPP said Resident #102 had not been feeling well over the previous two days with stomach upset, so that may have contributed to the Resident's most recent weight change from 173.9 lbs to 171.8 lbs, but this occurred after the Resident's confirmed severe weight loss on 3/14/24. The NPP further said facility staff did not notify her of Resident #102's severe weight loss until 4/9/24, but they should have notified her when the Resident's re-weight was obtained on 3/14/24, when severe weight loss was confirmed, so that a medical evaluation could have been initiated.

Based on observation, interview, record and policy review, the facility failed to provide nutrition care and services for one Resident (#102) out of a total sample of 25 residents, with a history of weight loss. Specifically, facility staff failed to do the following when Resident #102 experienced severe weight loss (greater than: five percent[%] in one month, 7.5% in three months, and 10% in six months): a. Obtain weekly weights as ordered by the Physician. b. Monitor weights weekly as recommended by the Registered Dietician (RD). c. Coordinate care among the facility's interdisciplinary team (IDT), to include Resident #102's Physician/Non Physician Practitioner (NPP). d. Evaluate for causative factors relative to Resident #102's severe weight loss to determine if the Resident's weight loss was avoidable. Findings include: Review of the facility's policy titled Weights and Heights: Weight Monitoring, Long-Term Care, dated 8/21/23, indicated: -Residents were weighed as ordered by their Physician. -Weighing a resident in a Long-Term Care facility was an important part of assessing a resident's health. -Following a routine weighing schedule helps detect weight changes. -Some residents require frequent weight assessments. -Weight loss in older adults can result from various conditions. -Unplanned weight loss in residents is associated with increased mortality. -A decrease in five percent (%) or more in a month or 10% in six months should be reported to the Practitioner (Physician/NPP) for further evaluation. Review of the facility's policy titled Physician Orders, dated 2/26/24, indicated: -A Physician or NPP must provide orders for the resident's immediate care and ongoing care of the resident. -The facility is obligated to follow and carry out the orders of the prescriber (Physician/NPP) . Resident #102 was admitted to the facility in October 2021 with diagnoses including: Diverticulitis (small, bulging pouches that can form in the lining of ones digestive system and cause abdominal pain, nausea, and vomiting) and Dysphagia (difficulty swallowing). Review of Resident #102's active Nutrition Care Plan, initiated 5/4/22, indicated: -The Resident was at increased nutrition risk. -The Resident had a history of weight loss. -The Resident's goals included maintaining a stable weight. -Facility staff were to monitor and record weights as ordered. -Facility staff were to report significant weight loss to the Physician. Review of Resident #102's Weight Record indicated the following weights: -191 pounds (lbs) on 8/15/23 -189.9 lbs on 11/20/23 -189.6 lbs on 1/26/24 -173.8 lbs (indicating severe weight loss had occurred) per Weight Record dated 2/29/24 Review of Resident #102's Minimum Data Set (MDS) Assessment, dated 1/31/24, indicated: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of 15 total possible points. -The Resident experienced signs and symptoms of a swallowing disorder. -The Resident did not have weight loss. Review of Resident #102's Plan of Care Note, dated 2/14/24, indicated: -The Resident was nutritionally stable. -Meal intakes ranged from 76%-100%. -The Resident's weight was stable. Review of a Health Status Note, dated 2/22/24, indicated Resident #102 was experiencing difficulty swallowing and the Resident's diet texture was changed to a puree (soft, pudding consistency) diet. Review of a Physician's order, dated 2/26/24 with no stop date, indicated: -Weekly weights due to weight loss. Review of a Physician's Encounter Note, dated 2/27/24 indicated the following: -The Resident had been treated for a urinary tract infection (UTI) in February 2024. -The Physician evaluated the Resident on 2/27/24 for a rash, per Nursing request, and treatment was initiated. Further review of the Physician's Encounter Note indicated no evidence that the Resident was seen relative to weight loss. Review of Resident #102's Weight Change Note, written by the RD and dated 3/5/24, indicated: -The Resident's weight was 173.8 lbs as of 2/29/24. -The Resident's weight loss was 16 lbs (severe). Further review of the Weight Change Note indicated the Resident's weight was much lower than his/her usual body weight (UBW) and that a re-weight was requested. Review of Resident #102's clinical record indicated: -The Resident was not re-weighed until 3/14/24. -The Resident's weight on 3/14/24 was 173.8 lbs. (indicating severe weight loss). Review of Resident #102's Weight Change Note, dated 3/15/24, indicated: -The Resident's UBW was upper 180s. -The Resident had no change in appetite. -Another re-weigh was requested. Review of Resident #102's Weight Change Note, written by the RD and dated 3/19/24, indicated: -Another re-weigh was requested for review with Unit Manager (UM) #2. -The Resident continued with good meal intakes. -The Resident's UBW ranged around 180s with most recent weight on 3/18/24 of 173.9 lbs. Review of Resident #102's clinical record indicated the following: -No evidence that facility staff alerted the Resident's Physician/NPP of the Resident's severe weight loss or requested the Physician/NPP to evaluate the Resident for severe weight loss any time after the Resident was re-weighed on 3/14/24 and severe weight loss was documented. -No evidence any weights had been obtained and monitored after 3/18/24. On 4/7/24 at 8:59 A.M., the surveyor observed Resident #102 sitting in the dining room, eating breakfast. The surveyor observed pureed food items that covered the entire surface of the Resident's plate. The surveyor observed Resident #102 feed him/her self all of the food. When the Resident was done eating, he/she said I'm still hungry. At the time, the surveyor observed a facility staff member make a phone call and request more food for Resident #102. Review of an NPP Encounter Note, dated 4/8/24, indicated the NPP saw the Resident for nausea, loose stools, and vomiting two times that morning, which was reported by Nursing staff. Further review of the NPP Encounter Note indicated no evidence the Resident was evaluated for severe weight loss. On 4/9/24 at 7:47 A.M., the surveyor observed Resident #102 sitting upright in bed. During an interview at the time, Resident #102 said he/she had not been feeling well the previous day (4/8/24) and had experienced nausea and loose stools. Resident #102 said he/she did not think he/she ate any solid food the previous day, but drank a lot of fluids. Resident #102 also said he/she was hungry and wanted to eat breakfast. Resident #102 further said his/her food was made to be soft, and when asked whether the Resident liked the soft food, the Resident said, I'm all for it. Bring it on. On 4/9/24, between 9:09 A.M. and 9:29 A.M., the surveyor observed the following: -Resident #102 was sitting upright in bed. -Certified Nurse Aide (CNA) #2 delivered and set up Resident #102's meal tray on the Resident's rolling table which was positioned in front of the Resident. -The Resident's breakfast tray contained double portions of pureed toast and eggs, one bowl of hot cereal, one cup of coffee, and one small cup of cranberry juice. -CNA #2 sat at Resident #102's bedside while the Resident ate breakfast. -CNA #2 removed Resident #102's breakfast tray at 9:29 A.M. -The surveyor observed that Resident #102 had eaten the double portions of pureed toast and eggs, and drank all of the coffee and cranberry juice. -The surveyor observed that Resident #102 did not eat the bowl of hot cereal. During an interview on 4/9/24 at 9:31 A.M., CNA #2 said Resident #102 always received double portions and always ate very well. CNA #2 also said that Resident #102 would ask for additional food at times, and staff would provide it for him/her. When the surveyor asked how the facility monitored residents' weights, CNA #2 said that CNAs were to weigh residents on the residents' shower days and then enter the weights into the computer. CNA #2 said when CNAs entered the weights into the computer, the entry would automatically carry over to the residents' electronic administration records for the Nurses to review. CNA #2 further said when CNAs weighed residents, they did not need to tell the Nurses what the weights were because the weights were already in the computer for the Nurses to review. CNA #2 said CNAs also recorded resident weights in the Weight Book on the unit for the Dietitian to review. The surveyor observed the unit's Weight Book which included a list of residents who required weekly weights for the current week. Resident #102 was indicated on the current list. No other weeks' lists were stored in the Weight Book. When the surveyor asked about the previous weeks weights, CNA #2 said she was not sure whether anyone kept the previous weeks' lists of resident weights, but that Unit Manager (UM) #2 may have known where the lists were kept. During an interview on 4/9/24 at 9:35 A.M., UM #2 said the weight lists in the Unit's Weight Book were used by the RD. UM #2 said the RD may have had the previous weeks' weights for residents in the Dietary Office. UM #2 also said she would have to review Resident #102's clinical record to identify the Resident's current weight. /18/24. UM #2 further said she knew the Resident refused care at times, so there was a potential the Resident refused to be weighed. Review of Resident #102's Weight Change Note, written by the RD and dated 3/19/24, indicated: -Another re-weigh was requested for review with Unit Manager (UM) #2. -The Resident continued with good meal intakes. -The Resident's UBW ranged around 180s with most recent weight on 3/18/24 of 173.9 lbs. Review of Resident #102's clinical record indicated the following: -No evidence that facility staff alerted the Resident's Physician/NPP of the Resident's severe weight loss or requested the Physician/NPP to evaluate the Resident for severe weight loss any time after the Resident was re-weighed on 3/14/24 and severe weight loss was documented. -No evidence any weights had been obtained and monitored after 3/18/24. On 4/7/24 at 8:59 A.M., the surveyor observed Resident #102 sitting in the dining room, eating breakfast. The surveyor observed pureed food items that covered the entire surface of the Resident's plate. The surveyor observed Resident #102 feed him/her self all of the food. When the Resident was done eating, he/she said I'm still hungry. At the time, the surveyor observed a facility staff member make a phone call and request more food for Resident #102. Review of an NPP Encounter Note, dated 4/8/24, indicated the NPP saw the Resident for nausea, loose stools, and vomiting two times that morning, which was reported by Nursing staff. Further review of the NPP Encounter Note indicated no evidence the Resident was evaluated for severe weight loss. On 4/9/24 at 7:47 A.M., the surveyor observed Resident #102 sitting upright in bed. During an interview at the time, Resident #102 said he/she had not been feeling well the previous day (4/8/24) and had experienced nausea and loose stools. Resident #102 said he/she did not think he/she ate any solid food the previous day, but drank a lot of fluids. Resident #102 also said he/she was hungry and wanted to eat breakfast. Resident #102 further said his/her food was made to be soft, and when asked whether the Resident liked the soft food, the Resident said, I'm all for it. Bring it on. On 4/9/24, between 9:09 A.M. and 9:29 A.M., the surveyor observed the following: -Resident #102 was sitting upright in bed. -Certified Nurse Aide (CNA) #2 delivered and set up Resident #102's meal tray on the Resident's rolling table which was positioned in front of the Resident. -The Resident's breakfast tray contained double portions of pureed toast and eggs, one bowl of hot cereal, one cup of coffee, and one small cup of cranberry juice. -CNA #2 sat at Resident #102's bedside while the Resident ate breakfast. -CNA #2 removed Resident #102's breakfast tray at 9:29 A.M. -The surveyor observed that Resident #102 had eaten the double portions of pureed toast and eggs, and drank all of the coffee and cranberry juice. -The surveyor observed that Resident #102 did not eat the bowl of hot cereal. During an interview on 4/9/24 at 9:31 A.M., CNA #2 said Resident #102 always received double portions and always ate very well. CNA #2 also said that Resident #102 would ask for additional food at times, and staff would provide it for him/her. When the surveyor asked how the facility monitored residents' weights, CNA #2 said that CNAs were to weigh residents on the residents' shower days and then enter the weights into the computer. CNA #2 said when CNAs entered the weights into the computer, the entry would automatically carry over to the residents' electronic administration records for the Nurses to review. CNA #2 further said when CNAs weighed residents, they did not need to tell the Nurses what the weights were because the weights were already in the computer for the Nurses to review. CNA #2 said CNAs also recorded resident weights in the Weight Book on the unit for the Dietitian to review. The surveyor observed the unit's Weight Book which included a list of residents who required weekly weights for the current week. Resident #102 was indicated on the current list. No other weeks' lists were stored in the Weight Book. When the surveyor asked about the previous weeks weights, CNA #2 said she was not sure whether anyone kept the previous weeks' lists of resident weights, but that Unit Manager (UM) #2 may have known where the lists were kept. During an interview on 4/9/24 at 9:35 A.M., UM #2 said the weight lists in the Unit's Weight Book were used by the RD. UM #2 said the RD may have had the previous weeks' weights for residents in the Dietary Office. UM #2 also said she would have to review Resident #102's clinical record to identify the Resident's current weight. UM #2 reviewed Resident #102's clinical record and said no weights had been entered into the record since 3/18/24. UM #2 further said she knew the Resident refused care at times, so there was a potential the Resident refused to be weighed. Review of Resident #102's CNA Behavior Monitoring Report indicated no evidence that the Resident refused care provided by CNAs between 2/26/24 and 4/9/24. Review of Resident #102's clinical record indicated no evidence the Resident refused to be weighed between 2/26/24 and 4/9/24. During an interview on 4/9/24 at 3:21 P.M., the Registered Dietician (RD) said she had been monitoring Resident #102 for weight loss since February 2024, when the Resident was identified to have had a potential weight loss. The RD said the weight loss was first suspected on 2/26/24 and she recommended weekly weight monitoring and requested the Resident be re-weighed at that time to determine whether the severe weight loss was accurate. The RD said an order was obtained for weekly monitoring of Resident #102's weights on 2/26/24, and if the severe weight loss was verified, the NPP was to be notified that Resident #102 had severe weight loss. The RD said Resident #102 was weighed on 2/29/24, which was 173.8 lbs (down from 189.9 lbs on 11/20/23 and 189.6 on 1/26/24, indicating severe weight loss). The RD then said she requested another re-weight which was not obtained for Resident #102 until 3/14/24, and again on 3/18/24, which indicated severe weight loss had occurred over the last three months. The RD said she was not sure what the Resident's current weight was because facility staff had not weighed the Resident for three consecutive weeks. The RD further said there was no evidence the NPP had been alerted to Resident #102's severe weight loss so that the Resident could be evaluated for causative factors for weight loss and new interventions implemented. Review of Resident #102's Weight Record indicated the Resident's weight was obtained on 4/9/24 at 4:08 P.M., following the surveyor's inquiry, and that the Resident weighed 171.8 lbs. During an interview on 4/10/24 at 8:10 A.M., the NPP said facility staff were required to alert her when a resident was identified to have a severe change in weight. The NPP said if a resident's weight changed significantly, facility staff would re-weigh the resident and that once the re-weight was obtained, facility staff were to alert her if the re-weight confirmed the significant weight change. The NPP said when staff notified her of a resident's significant change in weight, she would confer with Nursing staff, the Speech Therapist if there had been a change in diet texture, consult with the Physician, and evaluate the resident for any medical concerns that could be related to the significant weight change. The NPP said she was aware Resident #102 had experienced difficulty swallowing and that the Resident's diet texture had been changed to pureed texture, but that the Resident continued to have a good appetite and eat well when the diet texture was changed. The NPP said she ordered weekly weights to be completed for Resident #102 in February 2024 when facility staff identified the Resident had a potential severe weight loss and that facility staff communicated they would re-weigh the Resident to determine whether the weight loss was accurate. The NPP also said she requested facility staff to alert her if Resident #102's weight loss was identified to be accurate. The NPP further said facility staff did not alert her that Resident #102's re-weight confirmed severe weight loss until 4/9/24, following the surveyor's inquiry, but the staff should have alerted her on 3/14/24 when the Resident's re-weight confirmed severe weight loss. The NPP said since the Resident had been receiving double portions at meals and eating well, alerting her to the severe weight loss would have prompted a medical evaluation of the Resident's condition. The NPP also said she was aware Resident #102 had not been feeling well over the previous two days with stomach upset, so that may have contributed to the Resident's most recent weight change from 173.9 lbs to 171.8 lbs, but this occurred after facility staff re-weighed the Resident on 3/14/24 and severe weight loss was indicated. The NPP said since facility staff did not alert her to Resident #102's severe weight loss, no medical evaluation had been initiated to determine causative factors, or to initiate interventions to treat the Resident's weight loss.

Based on observation, interview, record and policy review, the facility failed to ensure that staff adhered to infection control standards for four residents (#18, #95, #58, and #44) out of a total sample of 25 residents, on two out of three Units observed (Primrose and Magnolia). Specifically, the facility staff failed to: 1. Wear appropriate Personal Protective Equipment (PPE) while performing nephrostomy care (nephrostomy-an artificial opening between the kidney and the skin which allows for the drainage of urine) and wound care for Resident #18, who was on Enhanced Barrier Precautions (EBP-an infection control intervention used to reduce transmission of multidrug-reisitant organisms [MDRO-an umbrella term for bacteria and other microorganisms that are resistant to antibiotics and other drugs designed to kill them] that employs targeted gown and glove use during high contact resident care activities), on the Primrose Unit. 2. Wear appropriate PPE while performing wound care for Resident on #95, who was on EBP, on the Magnolia Unit. 3. Perform appropriate hand hygiene for two Residents (#58 and #44) when the Residents were housed in the same room, and Resident #58 was on Contact Precautions (an infection control intervention used to prevent the transmission of infectious agents which are spread by direct or indirect contact) on the Primrose Unit. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions, dated 3/21/24 indicated: -The facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria during high-contact resident care activities. EBP are indicated for residents with any of the following: -Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. -Wounds generally include chronic wounds .Examples of chronic wounds include .pressure ulcers (Injury to the skin and underlying tissue resulting from prolonged pressure on the skin), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins). -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheotomies (surgical construction of an opening in the windpipe for the insertion of a catheter or tube to facilitate breathing). -High Contact Care Activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, medical device care or use, and wound care. -The facility should develop a process to communicate in which residents require the use of EBP for all high contact resident care activities. The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on Enhanced Barrier Precautions. -Examples of high contact resident care activities requiring a gown and glove use include . device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. -Enhanced Barrier Precautions should not be used for residents who are infected or colonized with an MDRO in the presence of one of the following situations .: -All residents who have another infection (e.g. C-difficile, Norovirus, scabies) or condition for which Contact Precautions is recommended . in CDC Guideline for Isolation Precautions. 1. Resident #18 was admitted to the facility in April 2023 with diagnoses including peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), non-pressure chronic ulcer of the skin and renal ureter calculus (kidney stone in a ureter) and nephrostomy. On 4/8/24 at 2:10 P.M, the surveyor observed the following posted on a sign outside of Resident #18's door: STOP-ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST: -Clean their hands, before entering and when leaving room. PROVIDERS AND STAFF MUST ALSO: -Wear gloves and a gown for the following High-Contact Resident Care Activities. >Dressing Bathing/Showering >Transferring >Changing Linens >Providing Hygiene >Changing briefs or assisting with toileting >Device care or use: central line, urinary catheter, feeding tube, tracheostomy >Wound Care: any skin opening requiring a dressing. On 4/8/24 from 2:10 P.M. through 2:35 P.M., the surveyor observed Nurse #1 put on gloves and proceed to remove and re-apply a dressing to Resident #18's nephrostomy tube site. Nurse #1 did not wear a gown. After hand sanitizing and changing her gloves, Nurse #1 proceeded to remove and re-apply a dressing to the Resident's left foot. Nurse #1 did not wear a gown. During an interview on 4/8/24 at 3:10 P.M., Nurse #1 said that she should have worn a gown while doing the dressing changes to reduce the risk of infection. 48206 2. Resident #95 was admitted to the facility in August 2023 with diagnoses including Pressure Ulcer of Left Heel, Pressure Ulcer of Right Heel, Pressure Ulcer of Unspecified Part of Back, and Pressure Ulcer of Sacral Region (buttocks). During an observation and interview on 4/10/24 at 7:51 A.M, the surveyor observed signage outside of Resident #95's room, which indicated Enhanced Barrier Precautions. The EBP sign indicated that staff were to wear gloves and a gown when providing care. The surveyor entered Resident #95's room and observed the Resident's bed was elevated with his/her left foot exposed and uncovered and Nurse #2 was measuring the Resident's wounds on the left foot. The surveyor observed Nurse #2 wearing gloves, but she was not wearing a gown as indicated by the EBP sign outside of the room. During an interview on 4/10/24 at 8:06 A.M., Nurse #2 said that she should have worn a gown in addition to gloves before she measured Resident #95's foot wounds, but she did not. 42761 3. Review of the facility's policy titled Transmission-Based Precautions (TBP: actions implemented in order to prevent or control infections) and Isolation Procedures, dated 9/15/23, indicated: -The facility would implement and utilize TBPs to ensure the mitigation of infection spread to ensure standards of infection prevention and control are followed. -Contact Precautions (type of TBP) were intended to prevent transmission of pathogens that are spread by direct (person to person) or indirect contact with the resident or environment. -The use of soap and water is more effective at removing spores than the use of alcohol-based hand rubs (ABHRs). -Alcohol does not kill spores of Clostridioides difficile (C. diff: contagious germ [bacterium] that causes diarrhea and colitis [an inflammation of the colon]). Resident #58 was admitted to the facility in November 2014 with a diagnosis of Escherichia (E.) Coli (bacteria found in the environment, foods, and intestines of people and animals). Resident #44 was admitted to the facility in September 2023 with a diagnosis of C. difficile. Review of Resident #44's April 2024 Physician's orders indicated: -Contact Precautions every shift due to C. difficile. -The Physician order was initiated on 3/27/24 and had no end date. On 4/9/24 at 10:00 A.M., the surveyor observed the following sign posted outside Resident #58's and Resident #44's shared room: -Staff were required to adhere to Contact Precautions when entering the Residents' room. -Staff were required to perform hand hygiene before entering and when leaving the room. -The picture image next to the instructions for hand hygiene indicated ABHR. On 4/9/24, from 10:00 A.M. through 10:29 A.M., the surveyor observed the following from the hallway outside of Resident #58's and Resident #44's shared room: -Housekeeper #1 performed hand hygiene using the ABHR immediately outside of the Residents' door and put on a pair of gloves and a disposable gown. -Housekeeper #1 walked to Resident #44's side of the room and removed the Resident #44's breakfast tray from the Resident's bedside table. -Housekeeper #1 then passed the breakfast tray to a staff member in the hallway. -Housekeeper #1 removed her gloves and gown, then performed hand hygiene using the ABHR. -Housekeeper #1 reached into the bin of clean Personal Protective Equipment (PPE: equipment one wears to protect themself from germs), removed a disposable gown and put it on, then put on a new pair of gloves. -Housekeeper #1 walked to Resident #58's side of the room, removed a small trash bag that was secured to Resident #58's rolling bedside table, then replaced the small trash bag with a new trash bag. -Housekeeper #1 then emptied the small trash can next to Resident #44's bed by removing the bag, then walked back to Resident #44's side of the room and emptied the small trash can located by Resident #44's bed. -Housekeeper #1 then took both trash bags from the small trash cans and placed them into the large trash bin that was positioned immediately inside the room's doorway. -The surveyor observed that the large trash bin contained disposable gowns and gloves. -Housekeeper #1 removed the trash bag containing disposable gowns and gloves from the large trash bin inside the room's doorway, then removed her gown and gloves and performed hand hygiene using ABHR. -Housekeeper #1 then exited Resident #58's and #44's shared room with the large bag of trash and with bare hands, proceeded to the Utility Room, used the door handle to open the door of the Utility Room, and discarded the trash. -Housekeeper #1 then walked back to Resident #58's and Resident #44's shared room, performed hand hygiene using ABHR, reached into the clean PPE bin, and retrieved and put on a new disposable gown. -Housekeeper #1 then retrieved a new pair of gloves from the top of the Housekeeping cart and put them on. -Housekeeper #1 then used a cleaning rag to wipe down Resident #58's pillows, mattress, and bed's footboard. -Housekeeper #1 did not wash her hands with soap and water at any time during the surveyor's observation. During an interview on 4/9/24 at 10:29 A.M., Housekeeper #1 said staff were required to adhere to instructions posted on the signs outside of residents' rooms if any TBPs were required. Housekeeper #1 also said she always performed hand hygiene before entering and upon exiting a resident's room, as well as in between glove changes and that she used the ABHR provided by the facility. Housekeeper #1 said she knew that Contact Precautions were required to enter Resident #58's and Resident #44's shared room because Resident #44 had an infection. Housekeeper #1 then said hand hygiene was required in between cleaning each Resident's environment in the room. Housekeeper #1 further said she did not know whether soap and water was required for hand hygiene when coming into contact and cleaning Resident #44's environment, but that she would find out. During a follow-up interview on 4/9/24 at 10:35., Housekeeper #1 said she spoke with Unit Manager (UM) #2 regarding hand hygiene requirements when working in Resident #44's room. Housekeeper #1 said she should have used soap and water for hand hygiene instead of ABHR because ABHR would not kill the germs from Resident #44's infection. Housekeeper #1 said performing hand hygiene with soap and water was important to keep the infection from spreading to Resident #58, and also to other residents and staff. The surveyor and Housekeeper #1 observed the Contact Precaution sign posted outside of Resident #44's and 58's shared room which indicated a picture of ABHR next to the instructions for hand hygiene and Housekeeper #1 said she was following the sign. During an interview on 4/9/24 at 10:50 A.M., UM #2 said Resident #44 was actively being treated, and was symptomatic for C. difficile. UM #2 also said Resident #58 did not have C. difficile. UM #2 said she thought staff had been educated to use soap and water for hand hygiene after handling items in Resident #44's environment. The surveyor and UM #2 discussed the sign posted outside of Resident #44's and Resident #58's shared room relative to the sign indicating use of ABHR for hand hygiene, and UM #2 said she thought staff were educated to use soap and water. During an interview on 4/9/24 at 11:04 A.M., the Director of Nurses (DON) said Resident #44 had C. difficile and that all staff were required to perform hand hygiene using soap and water anytime they came in contact with Resident #44 and the Resident's environment. The DON also said she did not realize the sign indicated use of ABHR for hand hygiene and that the sign needed to be fixed so staff knew to use soap and water instead of ABHR.

Based on observation, interview, and policy review, the facility failed to adhere to professional standards of practice for food service safety in the facilty's main kitchen, and for one Resident (#86) out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. Ensure that three Dietary Staff (#3, #4, and #2) wore hair restraints while they worked in the food preparation and food service areas of the facility's main kitchen, increasing the risk for contamination of food and the spread of foodborne illness. 2. Re-heat Resident #86's meal in a safe and appropriate manner to prevent accidental burns and kill microorganisms that may cause foodborne illness. Findings include: 1a. Review of the facility policy titled, Associate Conduct and Dress Code dated December 2022, indicated: -Dietary staff must wear hair restraints; hair net, hat and/or beard restraint, to prevent hair from contacting food. 1. On 4/7/24 at 7:20 A.M., the surveyor observed the following in the main kitchen during the initial kitchen visit: -Dietary Staff #3 was covering small bowls of chocolate mousse with plastic wrap. -Dietary Staff #4 walked through the food service and food preparation areas while food was being prepared for the residents' breakfast meals. -Neither Dietary Staff #3 or Dietary Staff #4 wore hair restraints during the surveyor's observation. During an interview on 4/7/24 at 7:36 A.M., Dietary Staff #4 said all staff who worked with food in the kitchen were required to wear restraints. Dietary Staff #4 then said he was covering bowls of chocolate mousse in preparation for the residents' lunch meals that day and that he was not wearing a hair restraint, but he should have been. During an interview on 4/7/24 at 7:38 A.M., Dietary Staff #3 said he sometimes wore a hair restraint when he worked in the kitchen, but that he usually did not, and that he was not wearing a hair restraint when the surveyor observed him in the food preparation area. The surveyor observed Dietary Staff #3 walk from the food preparation area into the dry food storage area and back into the food preparation area. Dietary Staff #3 did not don (put on) a hair restraint. During an interview on 4/7/24 at 7:40 A.M., the Food Service Director (FSD) said all staff working in the kitchen were required to wear hair restraints. The FSD further said that both Dietary Staff #3 and Dietary Staff #4 should have been wearing hair restraints while they worked in the food preparation and food service areas of the kitchen, as required by the facility's policy. 50138 1b. On 4/8/24 at 7:50 A.M., the surveyor observed the following during the follow-up visit to the main kitchen: -Dietary Staff #2 prepared food items on the service line with an improperly placed hair restraint on top of her head. -Large amounts of hair from the front, back and sides of Dietary Staff #2's head were hanging outside of the hair restraint. During an interview at the time, the FSD said Dietary Staff #2's hair restraint was not placed properly and should have been placed to cover all of Dietary Staff #2's hair. During interview on 4/9/24 at 3:14 P.M., the Assistant FSD said she was aware that dietary staff did not wear hair restraints while they worked in the kitchen on 4/7/24 and 4/8/24. The Assistant FSD said hair restraints were important for food safety and to prevent hair from falling into the residents' food. The Assistant FSD further said that it was the facility's expectation that hair restraints would be worn in the kitchen by all dietary staff. 45435 2. Review of the facility policy titled Food Temperature Control, dated 3/5/2024 indicated the following: -Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures. -Food reheated in the microwave is heated so that all parts of the food reach 165 degrees Fahrenheit (F) and food is rotated, stirred, covered and allowed to stand covered for two minutes after reheating. Resident #86 was admitted to the facility in March 2024 with a diagnosis of Alzheimer's disease (a progressive disease that affects memory, thinking and behavior). On 4/8/24 at 8:43 A.M., during an observation on the Gardenia unit, the surveyor observed Resident #86's breakfast tray being removed from the Resident's room and delivered to the unit dining room where the Resident was sitting. The surveyor observed CNA #1 remove the plate containing scrambled eggs and toast, and bring it into the unit kitchenette to re-heat. The surveyor observed CNA #1 returning the breakfast plate to the Resident without checking the temperature of the re-heated food. During an interview on 4/8/24 at 8:50 A.M., CNA #1 said the Resident's breakfast meal was cold because it had been delivered to his/her room instead of the dining room. CNA #1 said that she had re-heated the Resident's plate in the microwave oven for one and a half minutes. CNA #1 said that she did not know how long she was supposed to heat up the food, and that there was no thermometer to check the temperature of the reheated food. CNA #1 said that after she takes the food out of the microwave, she holds her hand over the top of the food to see if it is warm. During an interview on 4/8/24 at 10:33 A.M., the Food Service Director (FSD) said nursing staff typically call the main kitchen for a new tray if food needs to be re-heated. The FSD said that Resident's families are allowed to use the microwave to reheat food and that she was unaware that staff were using the microwave to reheat resident meals. The FSD said that she placed thermometers and the policy for reheating resident food in the kitchenettes today.

Based on observation, interview, and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility staff failed to provide the correct topical wound medication as ordered by the Physician resulting in removal and re-application of the dressing causing additional discomfort to the Resident. Findings include: Review of the facility policy titled Treatment of Wounds, dated 3/31/23 indicated the following: -Policy: 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. -Procedure: This facility will utilize the Lippincott procedures: Traumatic wound care: abrasion, lacerations, and puncture wounds. Review of the Lippincott Manual of Nursing Procedures -9th Edition (2023), Traumatic Wound Management indicated the following: -Apply antibacterial ointment, if prescribed, following safe medication administration practices to help prevent infection. Resident #18 was admitted to the facility in April 2023 with diagnoses including peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and non-pressure chronic ulcer of the skin. Review of the Minimum Data Set (MDS) Assessment, dated 1/31/24, indicated Resident #18: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15 points. -had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of the damage within the ulcer cannot be confirmed because the wound bed is obscured by dead tissue) that was present on admission. Review of the Wound Consultant's note, dated 3/11/24, indicated that the Resident had a wound on his/her left heel and a wound on his/her left dorsal foot (the upper surface of the foot) and was ordered to have daily dressing changes. Review of the Physician orders dated April 2023, indicated the following: -Left foot: *cleanse with normal saline (a mixture of salt and water often used to cleanse wounds), pat dry. *Apply Silver Sulfadiazine (an antibiotic cream used to prevent and treat infection) to top of left foot. *Cover with ABD pad (a bulky pad used where high absorbency is needed to manage heavy draining wounds) and wrap with KLING wrap (rolled gauze). *Secure with tape. Every day shift for wound care. -Left heel: *clean with normal saline and thoroughly dry. *Apply nickel thick amount of Santyl (an ointment that is used to remove dead tissue from chronic skin ulcers) with damp to dry 4 x 4 CDD (4-inch by 4-inch gauze dressing). *wrap with KERLIX fluff (rolled gauze) and paper tape. Every day shift. During a dressing change observation on 4/8/24 at 2:25 P.M., the surveyor observed the following: -Nurse #1 cut the gauze wrap off the Resident's left foot then reached a small gauze pad covering the left foot dorsal wound. -Nurse #1 soaked off the gauze on the left dorsal foot with normal saline. The surveyor observed that the wound measured approximately 0.5 centimeters (cm) in diameter, the wound bed was beefy red with white fibrous material and very tender to touch. -Nurse #1 cleansed and dried the wound, then proceeded to apply Santyl to a cotton swab and placed the Santyl in the wound bed. -Nurse #1 then applied Silver Sulfadiazine cream to a cotton swab and placed the Sulfadiazine cream on top of the Santyl, then applied an ABD pad to the top of the foot. -Nurse #1 then proceeded to the left heel wound where she cleansed and dried the wound. The surveyor observed the wound to measure approximately 0.5 cm in diameter, the wound bed contained dry yellow material, and appeared non-tender to touch. -Nurse #1 applied Santyl to a cotton swab and placed the Santyl in the heel wound bed, then applied Silver Sulfadiazine cream to a cotton swab and placed the Silver Sulfadiazine cream on top of the Santyl. -Nurse #1 then applied an ABD pad to the bottom of the foot and wrapped the foot, including both wound dressings, in gauze wrap. During an interview on 4/8/24 at 4:08 P.M., Nurse #1 said that she put Santyl and Silver Sulfadiazine on both wounds. The surveyor and Nurse #1 reviewed the Physician's orders and Nurse #1 said that she did the wound treatment incorrectly and that she would notify the Unit Manager (UM) of the mistake. During an interview on 4/8/24 at 4:31 P.M., the UM said Nurse #1 should have put Silver Sulfadiazine cream on the wound on the top of the left foot, and Santyl on the wound on the Resident's left heel. During an interview on 4/9/24 at 1:30 P.M., Physician #1 said he had been made aware of the wound care errors and said that utilizing both Santyl and Silver Sulfadiazine on the same wound is counterproductive to healing. Physician #1 said that he had recommended cleansing the area with normal saline and applying the treatment as ordered, Silver Sulfadiazine to top of left foot wound and Santyl to the left heel wound. Please refer to F697

Based on observation, interview, and record review, the facility failed to provide services and to assist with obtaining a specialist consultation for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility staff failed to provide assistance for Resident #102, who had an indwelling urinary catheter (flexible tube inserted into the bladder to drain urine), to obtain a consultation with a Urologist (Physician who specializes in treatment of the urinary tract) when: a. The Resident developed a Ventral Erosion (complication of an indwelling urinary catheter that can result in a partial or full thickness wound and can increase one's risk for urinary tract infection [UTI]) of his/her [genitalia]. b. The Resident's Physician ordered facility staff to obtain a consultation appointment with a Urologist for Resident #102. Findings include: Resident #102 was admitted to the facility in October 2021 with diagnoses including: Neuromuscular Dysfunction (lack of muscle control) of the Bladder and Retention of Urine (when the bladder does not completely empty upon urinating). Review of Resident #102's Health Status Note, dated 2/2/24 and written by Nurse #3, indicated: -The Resident had a new order to obtain a urine sample for urinalysis (UA: urine specimen test used to detect a UTI) culture and sensitivity (C&S: set of tests performed on a clinical specimen, where isolation of bacteria is followed by antibiotic susceptibility testing) due to increased sediment (crystals, bacteria, or blood) in the Resident's Foley (also known as a urinary catheter) catheter urine. -The Resident should also be seen by Urology re: Ventral Erosion of [genitalia]. Review of a Physician's order, dated 2/2/24 with no stop date, indicated: -Patient should see Urology re: Ventral Erosion of [genitalia]. On 4/7/24 at 8:57 A.M., the surveyor observed a catheter tube exiting Resident #102's pant leg. The surveyor further observed the catheter tube led to a urine collection bag that was secured under the Resident's chair. On 4/9/24 at 12:19 P.M., the surveyor observed Resident #102 sitting up in bed. The Resident's lower body was covered with bed linens and the surveyor observed a catheter tube draining clear light yellow urine into a urine collection bag that was secured to the frame of the Resident's bed. During an interview at the time, Resident #102 said he/she had a urinary catheter and that he/she sometimes experienced an aching pain in his/her [genitalia], but had no pain at that moment. Resident #102 also said he/she did not think he/she had seen a specialist for the urinary catheter, and then said he/she probably should. Review of Resident #102's clinical record indicated no evidence the Resident had been seen by a Urologist at anytime since the Physician's order on 2/2/24, for the Resident to be seen by Urology. Review of the Primrose Unit's 2024 Appointment Book indicated no evidence Resident #102 had a Urology appointment scheduled anytime between 2/2/24 and 12/31/24. During an interview on 4/9/24 at 4:00 P.M., Medical Record Staff #1 said one of her job duties was to schedule appointments for residents to be seen by specialists. Medical records Staff #1said she did not recall being asked to schedule an appointment with a Urologist for Resident #102 anytime since February 2024, but that she would look into whether the appointment should have been scheduled and get back to the surveyor. During an interview on 4/9/24 at 5:00 P.M., the Director of Nurses (DON) responding to the inquiry made to Medical Record Staff #1, said appointments for residents to see specialists should be made when orders for appointments are obtained. The DON said an appointment for Resident #102 to be seen by a Urologist had not been scheduled until 4/9/24, after the surveyor's inquiry, and that the Resident would not be seen until August 2024. The DON further said that the Urology appointment should have been scheduled for Resident #102 when the order was obtained on 2/2/24.

Based on observation, interview, and record reviewed the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility failed to: -ensure that Nurse #1 had the specific competencies and skills necessary to provide appropriate pain management prior to administering dressing change procedure resulting in poor pain control for Resident #18. -ensure that Nurse #1 had the specific competencies and skills necessary to perform wound care during a dressing change resulting in the Physician orders not being followed for the wound treatment procedure and potential compromise of healing for the Resident. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment, dated 5/20/23, indicated the following services and care offered based on Residents' needs: -Pain management- assessment for pain, pharmacological and nonpharmacological pain management. -Skin integrity-pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Resident #18 was admitted to the facility in April 2023 with diagnoses including peripheral vascular disease (PVD -a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and non-pressure chronic ulcer of the skin. Review of the Minimum Data Set (MDS) Assessment, dated 1/31/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 14 out of a possible 15 points. -The Resident had almost constant, severe pain, that affected sleep and day to day activities. -received scheduled pain medication. -did not receive PRN (as needed) pain medication. -and did not receive non-medication interventions for pain. -The Resident had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of the damage within the ulcer cannot be confirmed because the wound bed is obscured by dead tissue) that was present on admission. Review of the At Risk for Pain Care Plan, revised 11/14/22, indicated the following: -Anticipate the Resident's need for pain relief and respond immediately to any complaint of pain. Review of the Skin Integrity Care Plan, revised 2/29/24, indicated the following: -wound treatment as ordered. Review of the Physician's orders dated April 2024, indicated the following: -Oxycodone HCL ER 12-hour 10 milligram (mg) (an extended-release opioid pain reliever)- give one tablet by mouth every 12 hours for moderate to severe pain. -Oxycodone HCL oral capsule 5 mg (an opioid pain reliever used to treat moderate to severe pain) - give 5 mg by mouth every six hours as needed for pain. -Acetaminophen oral tablet 325 mg - give three tablets by mouth every eight hours as needed for pain. -Left foot: *cleanse with normal saline (a mixture of salt and water often used to cleanse wounds), pat dry. *Apply silver sulfadiazine (an antibiotic cream used to prevent and treat infection) to the top of the left foot. *Cover with ABD pad (a bulky pad used where high absorbency is needed to manage heavy draining wounds) and wrap with KLING wrap (rolled gauze). *Secure with tape. Every day shift (7:00 A.M. to 3:00 P.M.) for wound care. -Left heel: *clean with normal saline and thoroughly dry. *Apply nickel thick amount of Santyl (an ointment that is used to remove dead tissue from chronic skin ulcers) with damp to dry 4 x 4 CDD (4-inch by 4-inch gauze clean dry dressing), *wrap with KERLIX fluff (rolled gauze) and paper tape. Every day shift. On 4/8/24 at 2:25 P.M., during a dressing change observation, the surveyor observed Nurse #1 began to cut the gauze wrap off the Resident's left dorsal foot (area of foot facing upwards when standing) when the Resident winced and told the Nurse to be careful. The Nurse proceeded to remove the outer dressing, causing the Resident to yell STOP and began to cry. Resident #18 said that it hurts so much, when Nurse #1 proceeded with removing the outer dressing, and reached for the gauze pad covering the wound. The Resident and asked Nurse #1 to pour water, or whatever is in the bottle on the dressing first. Nurse #1 then proceeded to a soak a gauze pad with saline solution and placed it over the Resident's wound, which caused the Resident to scream and say, the pain felt like a knife being twisted. The surveyor intervened and asked Nurse #1 to pause the dressing change and assess the Resident after the Resident screamed out in pain. Nurse #1 stopped and asked the Resident if he/she would like to take pain medication. The Resident responded that the pain medication would not work as it takes 45 minutes for it to work, and the Nurse should have given the pain pill before starting the dressing change. The surveyor further observed Nurse #1 proceed with the dressing change procedure as follows: >Left dorsal foot: -to soak off the gauze, cleanse the wound with normal saline and dried the wound. -apply Santyl to a cotton swab and placed the Santyl in the wound bed. -apply Silver Sulfadiazine cream to a cotton swab and placed the Sulfadiazine cream on top of the Santyl, -then applied an ABD pad to the top of the foot. >Left heel wound: -Nurse #1 cleansed and dried the wound. -applied Santyl to a cotton swab and placed the Santyl in the heel wound bed. -then applied Silver Sulfadiazine cream to a cotton swab and placed the Silver Sulfadiazine cream on top of the Santyl. -then applied an ABD pad to the bottom of the foot and wrapped the foot, including both dressings, in gauze wrap. When the dressing was completed by Nuse #1, the Resident rated his/her pain level as nine out of ten and said he/she was going to be in pain all night. During an interview on 4/8/24 at 3:10 P.M., Nurse #1 said that she should have informed the Resident when she was planning to do the dressing change and should have offered him/her pain medication prior to starting the dressing change procedure. Nurse #1 said she had asked the Resident if he/she wanted a pain pill during the dressing change, but the Resident said the pain pill would take too long to work and the Resident wanted the dressing change to be finished. During an interview on 4/8/24 at 3:15 P.M., the Director of Nurses (DON) said the Resident should have been assessed and medicated if needed for pain prior to the dressing change. During an interview on 4/8/24 at 4:08 P.M., Nurse #1 said that she put Santyl and Silver Sulfadiazine on both wounds. The surveyor and Nurse #1 reviewed the Physician's orders and Nurse #1 said that she did the treatment incorrectly and that she would notify the Unit Manager (UM) of the mistake. Review of Nurse #1's Education File indicated the following: -Facility Associate Orientation Checklist dated 4/26/23, indicated no evidence of training or competency in pain management or wound care. -Facility on-line training certificates dated April 2023, indicated no documented evidence of training or competency in pain management or wound care. -In-service education attendance, dated 6/5/23 and 3/8/24, indicated no documented evidence of trainng or competency in pain management or wound care. During an interview on 4/10/24 at 8:10 A.M., the surveyor and the Staff Development Coordinator (SDC) reviewed Nurse #1's Education File. The SDC said Nurse #1 had been hired in April 2023 and had completed general orientation, facility on-line computer trainings, and had attended two in-services since she was hired. The SDC said she was not sure of the content of the facility on-line training courses and did not know if the online trainings included pain management or wound care. The SDC further said that the in-service training provided on 6/5/23 and 3/8/24 did not include training on pain management or wound care. The SDC said that after general orientation new Nurses are assigned a preceptor and that pain management and wound care training may have been done by the preceptor. The SDC indicated that a skill check sheet would have been completed, but she could not provide the skills check sheet when the surveyor requested it. The SDC said she was not sure who decided when a Nurse had completed training and was ready to work independently. The SDC said that she was not aware of any education or training offered to Nurse #1 related to pain management or wound care and that she did not have any evidence of competency in those areas. During an interview on 4/10/24 at 10:41 A.M., the SDC said she checked with the Scheduler and determined that the facility had not yet implemented the skills check list for newly hired Nurses. During an interview on 4/10/24 at 12:21 P.M., the Administrator said the SDC had been hired three or four months ago. The Administrator said that she was not sure who decides when a Nurse is ready to come out of training and work independently and said that she would check with the DON because she wanted to connect the dots. The facility failed to provide any evidence to the surveyor of training or competency in pain management or wound care for Nurse #1 by the end of survey.

Based on interview and record review, the facility failed to accurately complete, encode and transmit Minimum Data Set (MDS) Assessments as required for three Residents (#101, #164, and #131) out of a total sample of 25 residents. Specifically, the facility failed to: 1. Elecronically transmit a Discharge MDS Assessment for Resident #101, within 14 days of completing the Discharge MDS Assessment. 2. Complete a Death in Facility Tracking Record for Resident #164, when the Resident expired at the facility. 3. Complete a Discharge MDS Assessment for Resident #131, within 14 days of the Resident's discharge from the facility when the Resident's return to the facility was not anticipated. Findings include: 1. Resident #101 was admitted to the facility in [DATE] with a diagnosis of Congestive Heart Failure (CHF - a condition in which the heart does not pump blood the way it should resulting in fluid build-up in the lungs, arms, feet and other organs). Review of Resident #101's MDS Assessment, dated [DATE], indicated the Resident was discharged from the facility on [DATE]. Further review the MDS Assessment indicated that the MDS Discharge Assessment had not been transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of the final completion date as required. 2. Resident #164 was admitted to the facility in [DATE] with a diagnosis of Hypertension (HTN - high blood pressure). Review of Resident #164's medical record, indicated that the Resident expired in the facility on [DATE]. Further review the medical record did not contain any evidence that a Death in Facility Tracking Record had been completed for Resident #164. 3. Resident #131 was admitted to the facility in [DATE] with a diagnosis of Spinal Stenosis (a narrowing of space in the spinal canal). Review of Resident #131's Discharge MDS Assessment, dated [DATE], indicated the Resident was discharged from the facility on [DATE], but the MDS Discharge Assessment was not completed until [DATE] (six days past the completion due date of [DATE]). During an interiew on [DATE] at 2:45 P.M., the MDS Nurse said the facility was required to follow the CMS RAI (Resident Assessment Instrument) instructions for resident MDS data completion and processing. The MDS Nurse said Resident #101 had been discharged from the facility on [DATE] and the MDS was completed on [DATE]. The MDS Nurse then said Resident #101's Discharge MDS Assessment should have been transmitted to the CMS system no later than [DATE], but the Discharge MDS Assessment was never transmitted. The MDS Nurse also said Resident #164 expired in the facility on [DATE] and the facility never completed the required Death in Facility Tracking Record, but a Death in Facility Tracking Record should have been completed for Resident #164 and transmitted to the CMS system within 14 days of the Resident's death. The MDS Nurse further said that Resident #131 had been discharged from the facility on [DATE], so the Discharge MDS Assessment should have been completed by [DATE], but it was not completed until [DATE] (six days past the due date for completion). The MDS Nurse said that timely completion and processing of MDS data was important because it could affect facility data.

Based on interviews, record reviews, and policy review, the facility failed to ensure its staff provided the Resident and/or the Resident Representative with a written notice regarding the facility's Bed-Hold Policy upon transfers out of the facility for three Residents (#7, #140 and #122), out of a total of 29 sampled residents. Findings include: Review of the facility policy titled Bed-Hold Policy, dated 8/16/22, indicated the facility will provide written information to the Resident or Resident Representative of the nursing facility policy on bed-hold period and the residents return to the facility to ensure that the Residents are made aware of the facility's bed-hold and reserve bed payments policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. 1. Resident #7 was admitted to the facility in February 2017. Review of a Nurse Progress Note dated 6/9/22, indicated Resident #7 was transferred to the hospital. Review of the clinical record indicated no documented evidence that the Resident or Resident Representative was provided with a written Notice of Bed-Hold upon transfer, as required. 2. Resident #140 was admitted to the facility in October 2022. Review of the Nursing Home to Hospital Transfer Form, dated 10/20/22, indicated the Resident was sent to the hospital on 10/20/22. Review of the clinical record indicated no documented evidence that the Resident or Resident Representative was provided with a written Notice of Bed-Hold upon transfer, as required. During an interview on 12/1/22 at 2:37 P.M., Social Worker (SW) #1 said nursing staff are responsible for sending the Bed-Hold policy with the Residents when they are transferred out of the facility to the hospital and that he was responsible for providing this information to the Resident Representatives. SW #1 said that he was unable to find evidence that this was completed as required for Resident #7 and Resident #140. 44129 3. Resident #122 was admitted to the facility in June 2022. Review of the Resident's medical record indicated he/she was transferred to the hospital on 6/18/22 and 10/5/22. Further review of the Resident's medical record did not include evidence the notice of bed-hold policy and return was provided to the Resident and/or his/her Representative as required. During an interview on 12/1/22 at 2:37 P.M., the SW#1 said there was no evidence the notice of bed-hold policy and return was provided to the Resident and his/her Representative as required.

Based on interviews and record reviews, the facility failed to ensure its staff provided a Notice of Transfer and Discharge to the Resident and/or Resident Representative in writing upon transfer from the facility for four Residents (#7, #140, #122 and #78), out of a sample of 29 residents. Findings include: 1. For Resident #7, the facility failed to ensure its staff provided the necessary notices of transfer/discharge to the Resident and/or his/her Representative. Resident #7 was admitted to the facility in February 2017. Review of a Nurse Progress Note, dated 6/9/22, indicated Resident #7 was transferred to the hospital. Review of the clinical record indicated no documented evidence that a Notice of Discharge was provided to the Resident and/or his/her Representative, as required. 2. For Resident #140, the facility failed to ensure its staff provided the necessary notices of transfer/discharge to the Resident and/or his/her Representative. Resident #140 was admitted to the facility in October 2022. Review of the Nursing Home to Hospital Transfer form dated 10/20/22, indicated the Resident was sent to the hospital on 10/20/22. Review of the clinical record indicated no documented evidence that a Notice of Discharge was provided to the Resident and/or his/her Representative as required. During an interview on 12/1/22 at 2:37 P.M., Social Worker (SW) #1 said residents and/or their representatives should receive a Notice of Transfer and Discharge when the resident was transferred to the hospital. SW #1 said there was no evidence that this was completed for Resident #7 and Resident #140 as required. 44129 3. For Resident #122 the facility failed to ensure its staff provided the necessary notices of transfer/discharge to the Resident, his/her Representative, and the State Ombudsman. Resident #122 was admitted to the facility in June 2022. Review of the Resident's medical record indicated he/she was transferred to the hospital on 6/18/22 and 10/5/22. Further review of the Resident's medical record did not include evidence that the facility staff provided notices of transfer/discharge to the Resident, his/her Representative, and the State Ombudsman. During an interview on 12/1/22 at 2:37 P.M., SW#1 said there was no evidence that these notices were provided as required. 42741 4. For Resident #78 the facility failed to ensure its staff updated the Ombudsman timely regarding a transfer of the Resident to the hospital. Resident #78 was admitted to the facility in March 2020. Review of the Nursing Home to Hospital Transfer form dated 10/15/22, indicated Resident #78 was sent from the facility to the hospital on 10/15/22. Review of a Nursing Note, dated 10/22/22, indicated the Resident returned to the facility on [DATE]. Review of the fax cover letter and Notice of Transfer and Discharge packet provided by SW #2 indicated the Ombudsman was not notified of Resident #78's transfer to the hospital until 12/1/22 after the Resident had already returned to the facility and after the Surveyor had asked if the Ombudsman had been notified of the Resident's transfer to the hospital on 10/15/22. During an interview on 12/5/22 at 1:42 P.M., SW #2 said he usually sent the Notice of Transfer and Discharge letters to the Ombudsman monthly but Resident #78's letter from 10/15/22 was not sent until 12/1/22.

Based on interviews and records reviewed, for five of eight sampled Residents (Resident #1, Resident #2,Resident #4, Resident #5 and Resident #6), the Facility failed to implements its abuse prevention policy when: -Certified Nurse Aides (CNA) #1, #2 and #3 and Nurse #2 did not understand the requirements to report abuse immediately and told the Surveyor on 3/16/16 that they would wait until the end of their shift, despite having received abuse training 2/4/16. -The Facility staff failed to identify that Nurse #1's negative attitude, loud demeanor and antagonistic and provocative responses to Resident #1's behavioral symptoms created situations where abuse was likely to occur. - The Facility failed to implement corrective action monitoring for Nurse #1 after she was disciplined for insubordination 9/28/15, and for an allegation of verbal abuse and insubordination on 11/8/15. -The Assistant Director of Nurses, who was at the time the Acting Interim Director of Nurses, failed to thoroughly investigate an allegation made on 11/8/15, that Nurse #1 told Resident #4 that she would no longer care for him/her. The scope of the Assistant Director of Nurse's investigation was limited to repeated interviews with Resident #4 and did not include efforts to identify and interview other potential witnesses of the alleged incident. -The Assistant Director of Nurses, who was at the time the Acting Interim Director of Nurses, failed to thoroughly investigate the circumstances of falls with injuries incurred by Resident #5 and Resident #6 and give consideration to whether the absence of care planned safety equipment constituted neglect on behalf of a staff member. - Nurse #1 was not removed from the resident care area after she verbally abused Resident #1 on 2/1/16 and subsequently verbally abused Resident #2 and continued to verbally abuse Resident #1 throughout the remainder of the 11:00 P.M. to 7:00 A.M. shift. -The Assistant Director of Nurses, who was at the time the Acting Interim Director of Nurses, failed to report an allegation made on 11/8/15, that Nurse #2 told Resident #4 that she would no longer care for him/her to the Administrator or to the State Agency and, instead, placed written statements of interviews with Resident #4 in a soft file. -The Director of Nurses failed to accurately report to the State Agency the circumstances of falls with injuries incurred by Resident #5 and Resident #6. The reports sent to the State Agency did not accurately indicate the absence of care planned safety equipment at the time of the fall, for Resident #5 and Resident #6 and the full extent of Resident #6's injuries. Findings include: 1) The Surveyor interviewed CNA #1 at 11:30 A.M. on 3/15/16. CNA #1 said that if she witnessed abuse by a nurse during the 11:00 P.M. to 7:00 A.M. shift she would report the alleged incident to the Nurse Manager when the Nurse Manager arrived to the Facility in the morning. The Surveyor interviewed CNA #2 at 7:30 A.M. on 3/16/16. CNA #2 said that if she witnessed a nurse abuse a resident during the 11:00 P.M. to 7:00 A.M. shift she would not be sure what to do. CNA #2 said that CNAs did not have the authority to send nurses home and she did not have contact numbers for the administrative staff. CNA #2 said that she thought that there may be contact numbers at the nurses' station, but those could be hard to access if the nurse was the accused. CNA #2 said that she had been told that she could go to another unit and call administration, but she was not sure whether that would be possible. The Surveyor interviewed CNA #3 at 10:00 A.M. on 3/16/16. Although CNA #3 said that allegations of abuse needed to be reported to administration immediately, when the Surveyor asked specifically how he would report, CNA #3 said that he would write down his statement about the alleged event and give it to the Nurse Manager when she arrived at 7:00 A.M., which was the end of his shift. CNA #3 said that although he knew that staff members accused of abuse were typically suspended, he would not ask to another nurse during the 11:00 P.M. to 7:00 A.M. shift to intervene with an accused nurse sooner because he never knew what kind of relationships the nurses had with each other. CNA #3 said that he would wait and discuss allegations with the Nurse Manager when she arrived around 7:00 A.M. at the end of his shift. The Surveyor interviewed Nurse #2 at 12:10 P.M. on 3/16/16. Nurse #2 said that her responsibility following an allegation of abuse was to make residents safe and notify someone. Nurse #2 said that she thought allegations needed to be reported immediately and she thought immediately meant within twenty-four hours. Nurse #2 said that there were no supervisors in the Facility during the 11:00 P.M. to 7:00 A.M. shift and it was difficult to know when situations warranted waking someone up in the middle of the night. Nurse #2 said she would likely wait until 7:00 A.M. when the Nurse Manager and Assistant Director of Nurses arrived to the Facility. 2) CNA #1 said she worked with Nurse #1 during the 11:00 P.M. to 7:00 A.M. shift for about five months. CNA #1 said that Nurse #1 was very loud and direct in her interactions with residents and staff and she intimidated some staff members. CNA #2 said she worked with Nurse #1 during the 11:00 P.M. to 7:00 A.M. for more than a year. CNA #2 said Nurse #1 was loud, foul mouthed and swore. CNA #2 said Nurse #1 [***] ed continuously during every 11:00 P.M. to 7:00 A.M. shift. CNA #2 said Resident #1 was the only resident on the unit who tried to get out of bed during the 11:00 P.M. to 7:00 A.M. shift and occasionally staff positioned Resident #1 at the nurses' station so that the nurses could assist in providing supervision to Resident #1. CNA #2 said that Nurse #1 could not handle Resident #1 being at the nurses' station and the situation was awful. CNA #2 said that each time Resident #1's personal alarm sounded, Nurse #1 would yell what are you doing or where are you going in an aggressive tone. CNA #2 said that Nurse #1 usually yelled for the CNAs to respond to Resident #1, but if Nurse #1 chose to intervene, she moved very quickly and approached Resident #1 too closely. CNA #2 said Nurse #1 got in Resident #1's face and asked questions loudly about what he/she was doing. CNA #2 said that she never spoke to anyone about her observations of Nurse #1 because, she thought everyone dealt with residents behaviors differently. CNA #3 said that he worked with Nurse #1 during the 11:00 P.M. to 7:00 A.M. shift for more than a year. CNA #3 said Nurse #1 had a difficult time dealing with Resident #1 who was on occasion brought out to the nurses' station at night for monitoring. CNA #3 said on 1/26/16, Nurse #1's response to Resident #1's behavioral symptoms increased Resident #1's degree of agitation. CNA #3 said that Resident #1 was brought to the nurses' station on 1/26/16, because he/she was not staying in bed. CNA #3 said that he was able to get Resident #1 settled into a recliner chair and relaxed, but after awhile Resident #1 resumed trying to stand unassisted and activated his/her personal alarm. CNA #3 said that after each alarm activation, he took Resident #1 to the bathroom or for a walk, offered him/her a snack or drink and eventually settled Resident #1 back into the recliner chair. CNA #3 said this this cycle repeated many times during the night. CNA #3 said that on one occasion, Nurse #1 responded to Resident #1's sounding alarm before he could. CNA #3 said that Nurse #1 approached Resident #1 very quickly, placed her face directly in front of Resident #1's face and yelled words to the effect, where are you going, why don't you sit down. CNA #3 said Resident #1 reacted by swatting his/her arms upward and his/her hand made contact with Nurse #1's face. CNA #3 said that Resident #1 did not hit Nurse #1 but made contact with Nurse #1 because of the way she approached him/her. CNA #3 said and Resident #1's clinical record indicated Resident #1 was transferred to the hospital for evaluation. Resident #1's nurses' note and Hospital Transfer Form, dated 1/26/16, indicated Resident #1 was violent and aggressive and punched a nurse in the mouth. CNA #3 said that Nurse #1 asked him for a statement about the incident with Resident #1 and he wrote one. CNA #3 said that no one ever spoke to him about the incident before the Surveyor and, if someone had, he would have told them that Nurse #1 had difficulty dealing with Resident #1's behaviors and her responses increased his/her agitation. CNA #3 said Nurse #1's intervention with Resident #1 actually provoked his/her swatting Nurse #1's face. CNA #3 said that he saw the Nurse Manager with his statement about the incident, but she never spoke with him about it. CNA #2 said that Nurse #1 asked her for a written statement about the incident in which Resident #1 hit Nurse #1 and CNA #2 wrote a statement indicating that she had not seen the incident and gave it to Nurse #1. The Surveyor interviewed the Director of Nurses and the Administrator throughout the day on 3/16/16. The Director of Nurses and the Administrator said that there was no incident report for the incident which Resident #1 allegedly hit Nurse #1 and there were no written statements. The Surveyor interviewed the Nurse Manager at 12:10 P.M. on 3/16/16. The Nurse Manager said she could not remember whether she ever saw any written statements about Resident #1 hitting Nurse #1. The Nurse Manager said she checked a drawer at the nurses' station where she kept things that were not filed with incident reports or in resident records but she was unable to locate the statement CNA #2 and CNA #3 said that they wrote. 3) Nurse #1's personnel file contained a written warning form which indicated that she was disciplined 9/28/15 for insubordination which could lead to poor customer service and poor patient care. The area for subsequent meetings to review expectations was blank. Nurse #1's personnel file indicated that she was disciplined on 11/8/15 regarding an allegation of verbal abuse of a resident and for frequent reports from staff members of negativity. The area on the Corrective Action Form regarding when a review of expectation would occur was blank and the Form had not been signed by the Supervisor or Executive Director. The Surveyor interviewed the Assistant Director of Nurses at 12:00 P.M. on 3/16/16. The Assistant Director of Nurses said that Nurse #1's loud negative sputtering was a problem and she had been counseled for it. The Surveyor asked the Director of Nurses whether Nurse #1's demeanor in resident care areas in front of and when interacting with residents was being monitored in any objective way following her two disciplinary warnings and the Director of Nurses said that Nurse #1 was not being followed or monitored for her behaviors and interactions with residents. 4) The Assistant Director of Nurses said she was the Acting Interim Director of Nurses on 11/8/15 when Nurse #3 reported an allegation made to her by Resident #4 that Nurse #1 verbally abused Resident #4. The Assistant Director of Nurses said that she investigated the allegation and, because Resident #4 was confused and often accusatory, the allegation could not be substantiated. The Surveyor reviewed the soft file regarding Resident #4's allegation. The file contained a statement from Nurse #3, which indicated Resident #4 alleged Nurse #1 was rude and told him/her that she was not going into his/her room again. Although the file contained statements from several interviews with Resident #4 and a statement from Nurse #1, it did not contain any evidence of attempts to determine when the alleged incident occurred and attempts to interview staff members who may have been in a position to witness the alleged incident. The Surveyor interviewed Nurse #3 at 10:00 A.M. on 3/17/16. Nurse #3 said Resident #4 told her that Nurse #1 told him/her words to the effect, you can lay there and die I am not going to help you. The Assistant Director of Nurses said she could not recall whether she interviewed Nurse #3 about her conversation with Resident #4. The Assistant Director of Nurses said that she did not have any notes from an interview with Nurse #3. The Surveyor asked the Assistant Director of Nurses whether she was aware that Nurse #3 said Resident #4 told her that Nurse #1 told him/her that he should could lay there and die because she was not going to help him/her and the Assistant Director of Nurses said that she was not. 5) The Incident Report, dated 2/18/16, was reviewed and indicated Resident #5 was found on the floor in the day room at 11:00 A.M. on 2/14/16, next to a recliner chair. The Incident Report indicated Resident #5 was unable to state what had happened and complained of hip pain. The Incident Report indicated Resident #5 was subsequently diagnosed with [REDACTED]. The nurse's note for 11:00 A.M. on 2/14/16 was reviewed and indicated that when Resident #5 was found on the floor, a body alarm was found attached to Resident #5's chair. The Surveyor asked the Director of Nurses whether she investigated Resident #5's fall and she said that she did. The Surveyor asked the Director of Nurses whether Resident #5's alarm was sounding when Resident #5 was found on the floor. Although the Director of Nurses said that the investigation indicated Resident #5's alarm was attached, Housekeeper #1's written statement indicated that the alarm was not attached. The Director of Nurses said staff members could not remember whether the alarm was sounding when Resident #5 was on the floor. The internal investigation contained a written statement from a CNA which indicated that she and another CNA brought Resident #5 into the bathroom together prior to Resident #5 being brought to the day room. The written statement makes no mention of Resident #5's chair alarm. The Director of Nurses said she read the statement and spoke to one of the CNAs who assisted Resident #5 in the bathroom, but she could not recall whether she asked either CNA about activating and applying Resident #5's alarm after he/she was assisted in the bathroom. Resident #6's clinical record was reviewed and indicated that his/her fall risk was assessed as high on 1/14/16. Resident #6's Interim Care Plan, dated 1/14/16, indicated Resident #6's fall risk interventions included a bed alarm. The Investigation File, dated 1/22/16 indicated that at 7:10 A.M. when CNA #6 approached Resident #6, Resident #6 immediately started to complain to CNA #6 that his/her right shoulder hurt. CNA #6's written statement indicated that CNA #6 talked Resident #6 into getting out of bed and every movement caused Resident #6 tremendous pain. The Surveyor interviewed CNA #6 at 12:40 P.M. on 3/22/16. CNA #6 said that she did not think to stop and get the nurse before transferring Resident #6 out of bed because Resident #6 was spirited and she did not want Resident #6 to get out of bed unassisted. CNA #6 said that after she transferred Resident #6 out bed, she told Nurse #8 The Incident Report, dated 1/22/16, was reviewed and indicated Resident #6 had no reported falls or incidents on the 11:00 P.M. to 7:00 A.M. shift but his/her roommate reported that Resident #6 self transferred during the night and fell back onto the bed landing on his/her elbow. The Incident Report indicated Resident #6 had no complaints of pain on 11:00 P.M. to 7:00 A.M. shift, and first complained of pain on the 7:00 A.M. to 3:00 P.M. shift when CNA #6 was getting him/her out of bed. The Incident Report indicated, Resident #6 was complaining of severe pain to his/her right upper extremity, was guarding his/her right arm, and he/she had decreased range of motion. The nurses' note for 4:08 P.M. on 1/22/16, written by Nurse #8, was reviewed and indicated that at 7:10 A.M., CNA #6 reported that Resident #6 was complaining of severe right upper extremity pain. The nurses' note indicated Nurse #8 assessed Resident #6, a stat x-ray of his/her right shoulder was ordered, and [MEDICATION NAME] (central [MEDICATION NAME] medication, classified as synthetic Opioid) 50 milligrams was given to Resident #6 for pain. The nurse's note indicated that the x ray results indicated a non-displaced fractured of Resident #6's right clavicle (collar bone) and Resident #6 was sent to Hospital for evaluation and treatment. The Hospital Discharge Summary, dated 1/26/16, indicated Resident #6 was diagnosed with [REDACTED]. The Surveyor asked the Director of Nurses if she investigated Resident #6's fall, and she said that she did. The Surveyor asked the Director of Nurses if she interviewed the 11:00 P.M. to 7:00 A.M., nursing staff regarding the status of Resident #6's alarms or about their observations of Resident #6 during the 11:00 P.M. to 7:00 A.M. shift and she said that she did not. The Director of Nurses said that because Resident #6's roommate was alert, oriented and a reliable witness, she did not interview 11:00 P.M. to 7:00 A.M. shift staff members. The Surveyor asked the Director of Nurses whether she reviewed the statement from CNA #3 who worked during the 11:00 P.M. to 7:00 A.M. shift, which indicated he responded to Resident #6's roommate's sounding call light and found Resident #6 standing in front of his/her dresser and she said that she did. The Surveyor asked the Director of Nurses whether she asked CNA #3 about the status of Resident #6's bed alarm when he found Resident #6 out of bed and she said that she did not. The Surveyor asked the Director of Nurses if she reviewed the statements written by the 7:00 A.M. to 3:00 P.M. staff, including CNA #6's statement which indicated she talked Resident #6 into getting out of bed despite his/her immediate complaints of pain and tremendous pain with every movement and she said she had but she did not see a need to investigate the incident further. 6) Nurse #2 said that when she arrived to work the 11:00 P.M. to 7:00 A.M. shift, which started on 2/1/16 and ended on 2/2/16, Nurse #1 told her that they only way they were going to get the Facility to do something about Resident #1 was to document his/her behaviors carefully. Nurse #2 said that Resident #1 was a confused resident who exhibited behavioral symptoms during the night and in the past Nurse #1 had difficulty dealing with Resident #1. Nurse #2 said that during the 11:00 P.M. to 7:00 A.M. shift which started on 2/1/16 and ended on 2/2/16, Nurse #1 really went off on Resident #1 and verbally abused him/her. Nurse #2 said that on three separate occasions, after CNA #3 settled Resident #1 in a recliner chair near the nurses' station, Nurse #1 responded to Resident #1's sounding personal alarm. Nurse #2 said that Nurse #1 approached Resident #1 quickly, stood right in front of him/her, leaned close to his/her face and stated words to the effect, where are you going crazy man. Nurse #2 said that each time Resident #1 reacted to Nurse #1 by asking for his/her spouse and Nurse #1 told Resident #1 words to the effect, you can't go home, your spouse is afraid of you because you hit him/her and now you're with us. Nurse #2 said that Resident #1 reacted to Nurse #1's statements by trying to grab her and Nurse #1 called for CNA #3 to help her with Resident #1. Nurse #2 said that this scenario repeated three times until after the third time, CNA #3 took Resident #1 with him on his rounds. CNA #3 said that at one point during the 11:00 P.M. to 7:00 A.M. shift, which started on 2/1/16 and ended on 2/2/16, he heard the sound of shouting at the nurses' station and responded. CNA #3 said that Nurse #1 told him that Resident #1 was not staying in his/her recliner chair. CNA #3 said that because he knew from previous shifts that Nurse #1 had difficulty dealing with, and on occasion provoked Resident #1's behavioral symptoms, he took Resident #1 with him for the remainder of the night. CNA #3 said that later during the shift, CNA #2 told him that Nurse #1 had verbally abused Resident #1. CNA #2 said that she observed two incidents with Nurse #1 and Resident #1 at the nurses' station during the 11:00 P.M. to 7:00 A.M. shift which started on 2/1/16 and ended on 2/2/16. CNA #2 aid that Nurse #1 got upset and yelled at any resident who triggered their alarm, but on this night, Nurse #1 went beyond that with yelling at Resident #1. CNA #2 said that when Resident #1 triggered his/her alarm at the nurses' station, Nurse #1 moved toward Resident #1 very quickly, got into his/her personal space and loudly yelled words to the effect, what are you doing where are you going. CNA #2 said that when Resident #1 told Nurse #1 that he/she wanted to go home, Nurse #1 told Resident #1 words to the effect, you beat your spouse now your spouse doesn't want you and you are here with us. CNA #2 said Resident #1 became really upset and tried even harder to climb out of the recliner chair. CNA #2 said Nurse #1 called for CNA #3 and CNA #3 settled Resident #1 back into the recliner chair. CNA #2 said that about an hour later she observed a second incident in which Nurse #1 intervened when Resident #1 activated his/her personal alarm and told Resident #1 words to the effect, do you want me to call the cops, do you want me to have you restrained, do you want me to have them take you to the cuckoo house. CNA #2 said that when Nurse #1 called CNA #3 to help with Resident #1, CNA #3 removed Resident #1 from the area near the nurses' station. CNA #2 said that after the second incident in which Nurse #1 verbally abused Resident #1, which she estimated occurred around 4:00 A.M., she spoke to Nurse #2. CNA #2 said she told Nurse #2 that Nurse #1's behavior needed to be reported and Nurse #2 told her that she knew it did and she would take care of it. CNA #2 said that after speaking with Nurse #2 she went into the bathroom behind the nurses' station. CNA #2 said that from the bathroom, she heard Resident #2 ask Nurse #1 whether she could use the telephone to call his/her partner. CNA #2 heard Nurse #1 tell Resident #2 words to the effect, your partner wants nothing to do with you, he doesn't want to see you, you have nobody. CNA #2 said that she heard Resident #2 tell Nurse #1 that's all your fault and Nurse #1 told Resident #2 words to the effect, it's not my fault that you were a drunk and fell down the stairs and that is the reason that you are here with nowhere to go. CNA #2 said that she spoke to CNA #1 about Nurse #1's statements to Resident #2 and CNA #1 told her that that Nurse #1 had verbally abused Resident #2 earlier in the shift as well. CNA #1 said that Resident #2 required a shower during the 11:00 P.M. to 7:00 A.M. shift which started on 2/1/16 and ended on 2/2/16 after an episode of incontinence and when, she told Nurse #1 that she would be with Resident #2 in the shower room, Nurse #1 told Resident #2 words to the effect, this is what happens when you drink, you end up like this. Nurse #2 said that after the shower, CNA #1 brought Resident #2 to the nurses' station. Nurse #2 said that Resident #2 asked to go back to bed, but Nurse #1 told Resident #2 that he/she had to stay up in his/her wheelchair. Nurse #2 said that Resident #2 asked the reason why, and Nurse #1 told Resident #2 words to the effect, if we put you to bed you make a mess so you have to stay here for us to watch you. Nurse #2 said Resident #2 began to cry and asked to call his/her partner. Nurse #2 said Nurse #1 told Resident #2 that his/her partner was not going to visit him/her anymore because he/she was too much trouble and his/her partner was all done with him/her. CNA #1 said that after the shower she took Resident #2 to his/her room and Resident #2 asked for a small stuffed animal, which was very important to him/her and which she held almost all the time. CNA #1 said that when she gave Resident #2 the stuffed animal, Nurse #1 stated words to the effect, if you don't start acting like and adult, I' m going to take your stuffed animal and throw it in the trash. CNA #1 said that she kept Resident #2 with her for the remainder of the night. The Surveyor asked CNA #1, CNA #2, CNA #3 and Nurse #2 whether they notified anyone of Nurse #1's abusive behavior during the night shift and they said that they did not. CNA #1, CNA #2 and CNA #3 said they left the Facility in the morning without telling anyone, but they knew that Nurse #2 was aware because she had been a witness. Nurse #2 said that she intended to go home and get some sleep before returning to the Facility with a written statement, but she ran into the Assistant Director of Nurses in the parking lot after she left the Facility and she told her about the alleged incidents. The Surveyor asked CNA #1, CNA #2, CNA #3 and Nurse #2 whether they took steps to prevent further abuse to residents after the incidents that they witnessed. Although CNA #1 and CNA #3 said that they took Resident #1 and Resident #2 with them as they worked in order to minimize their exposure to Nurse #1, CNA #1, CNA #2, CNA #3 and Nurse #2 said that no steps were taken to prevent Nurse #1 from abusing the remaining Facility residents. 7) The Assistant Director of Nurses said she was the Acting Interim Director of Nurses on 11/8/15 when an allegation that Nurse #1 verbally abused Resident #4 was reported by Nurse #3. The Assistant Director of Nurses said that because the allegation could not be substantiated, the investigation documents were held in a soft file and were not reported to the Administrator or the State Agency. The Administrator said she started at the Facility on 10/31/15 and was not aware of the allegation of abuse reported to the Assistant Director of Nurses on 11/8/15 and the allegation was not reported to the State Agency. 8) The Director of Nurses said she investigated Resident #5's fall at 11:00 A.M. on 2/14/16 and reported Resident #5's fall and resulting left [MEDICAL CONDITION] to the State Agency. Although the investigation statements and nurses' note are contradictory with regard to whether Resident #5's alarm was applied and sounding at the time of the fall, the report to the State Agency made no mention of a chair alarm as a safety precaution. The Director of Nurses said she investigated Resident #6's fractured clavicle of uncertain etiology on 1/22/16 and completed the report to the State Agency. Although the report to the State Agency indicated Resident #6 was diagnosed with [REDACTED]. The Surveyor asked the Director of Nurses the reason that all the fractures were not included in the report submitted to the State Agency and the Director of Nurses did not reply.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's care plan was implemented. Resident #1's care plan indicated he/she required assistance from one when eating and his/her [DIAGNOSES REDACTED].#1 heard yelling from another Resident's Family Member and it was determined Resident #1 spilled coffee, and the black coffee was observed in a puddle in Resident #1's lap. Resident #1 sustained second [MEDICAL CONDITION] his/her abdomen and first [MEDICAL CONDITION] the right /thigh. - CNA #1 said on 6/21/15, he obtained the water to prepare the coffee for Resident #1 from a water dispenser, and although he described it as being words to the effect of, very very hot, but CNA #1 did not know the temperature at the time it was served to Resident #1. - Resident #1, who was cognitively impaired, was left alone with the hot coffee, which was not consistent with his/her plan of care. Findings include: Resident #1 was admitted to the Facility in June of 2015. This Resident's pertinent [DIAGNOSES REDACTED]. The Temperature of Hot Beverage Policy stated that the temperature of hot beverages should be between 145 degrees Fahrenheit (F.) and 155 degrees F. at delivery. The plan of care, related to Resident #1's activities of daily living, dated 6/11/15, included for staff to have an assist of one for eating. The Admission Minimum Data Set (MDS) Assessment, of 6/8/15, indicated Resident #1 had a brief interview for mental status score of 4, was severely cognitively impaired and for eating was a one person physical assist. Review of the investigation report of 6/21/15 indicated that Resident #1 was in the Assisted Dining Room and seated at a table having a cup of coffee, when the coffee spilled on his/her abdomen. Other Residents and another Resident's family member were in the Assisted Dining Room. Resident #1 sustained second [MEDICAL CONDITION] his/her abdomen and first [MEDICAL CONDITION] the right /thigh. There was no indication Resident #1 received assistance from staff when consuming the coffee, which was not consistent with the plan of care. Interview with the Unit Coordinator at 8:45 A.M. on 10/1/15, the Unit Coordinator said that on 6/21/15 Certified Nursing Assistant (CNA) #1 obtained hot water for Resident #1's coffee out of the bubbler in the Nurses' Station which is extremely hot, and that the water from that bubbler is not for Residents. The Unit Coordinator said that Residents and Family Members get their coffee out of the Coffee Machine in the Dinning Room, and that water is a lower temperature. The Unit Coordinator said that Resident #1 knew that he/she burned herself because he/she yelled when the hot coffee hit his/her skin. The Unit Coordinator said from that Resident #1 sustained blistering (2nd degree burns) on the right and left abdomen and redness on the right thigh (1st degree burn). The Surveyor interviewed Nurse #1 at 11:55 A.M. on 10/1/15. Nurse #1 said she heard yelling from another Resident's Family Member in the Dinning Room, and that Resident #1 had spilled coffee on him/her self. Nurse #1 observed a black puddle in Resident #1's lap. The Surveyor interviewed CNA #1 at 1:15 P.M. on 10/2/15. CNA #1 said Resident #1 was in the Assisted Dining Room after lunch on 6/21/15, and Resident #1 wanted a cup of coffee. CNA #1 obtained a plastic mug and a packet of instant coffee; he then filled the mug with hot water from the hot/cold bubbler in the Nurses' Station because Resident #1 likes real hot black coffee. CNA #1 then brought the cup of coffee to Resident #1, who was sitting at a table in the Assisted Dining Room. CNA #1 then left to obtain cookies in the Kitchenette for Resident #1. Resident #1 was left unsupervised and unassisted with a hot cup of coffee. CNA #1 said that he mixed the hot water from the bubbler prior to giving Resident #1 the cup of coffee because he said words to the effect of, it (the hot water from the bubbler) is very very hot. He said that he did not know the temperature of the water prior to giving Resident #1 the cup of coffee. Despite the first and second [MEDICAL CONDITION] #1 sustained on 6/21/15, the hot water for beverages was still at unsafe water temperatures on the Surveyor visit on 10/1/15. The Surveyor observed that the hot water temperatures for beverages taken with the Maintenance Worker at 9:15 A.M. and 9:45 A.M. on 10/1/15 were as follows: On the unit where Resident #1 resided: in the Assisted Dining Room (a patient care area) - the coffee machine water temperature was 170 degrees Fahrenheit (F.), and the hot water dispenser water was 180 degrees F. The hot water bubbler in the Nurses' Station was 170 degrees F. In the Lobby (a patient care area) - the coffee machine water temperature was 158 degrees F., and the hot water dispenser water was 184 degrees F. The Surveyor interviewed the Administrator at 9:50 A.M., and both the hot water dispensers were immediately taken out of service. The Coffee Machine on the unit where Resident #1 resided in the Assisted Dinning Room and the Lobby were later serviced by a vendor and the temperature was decreased to 155 degrees F.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure a staff member was present to supervise the Assisted Dinning Room or to assist Resident #1 when a hot beverage was left with Resident #1. On 6/21/15, Nurse #1 heard yelling from another Resident's Family Member that Resident #1 had spilled coffee, and the black coffee was observed by Nurse #1 in a puddle in Resident #1's lap. Resident #1 sustained second degree burns on his/her abdomen and first degree burns to the right /thigh. - CNA #1 said he obtained the water to prepare the coffee for Resident #1 from a water dispenser, and although he described it as being very very hot, did not know the temperature at the time he served it to Resident #1. The Unit Coordinator said the water was obtained from a water dispenser not intended for resident use. - Resident #1's plan of care indicated his/her [DIAGNOSES REDACTED]. On 6/21/15, Resident #1 was left alone with the hot coffee, which was not consistent with his/her plan of care. - On 10/1/15, the Surveyor observed the water dispensers exceeded the temperatures as outlined in the Facility's Hot Temperature Policy. Findings include: Resident #1 was admitted to the Facility in June of 2015. This Resident's pertinent [DIAGNOSES REDACTED]. The Abuse Prevention Managing Incidents and Falls policy, stated that, all residents will benefit from a safe environment and an individualized plan of care. The plant/operations/maintenance, housekeeping, and nursing departments cooperate to provide a safe and sanitary environment for residents. The Temperature of Hot Beverage Policy stated that the temperature of hot beverages should be between 145 degrees Fahrenheit (F) and 155 degrees F at delivery. The Admission Minimum Data Set (MDS) Assessment, of 6/8/15, indicated Resident #1 had a brief interview for mental status score of 4, was severely cognitively impaired and for eating required physical assistance from one person. The plan of care, related to Resident #1's activities of daily living, dated 6/11/15, included for Resident #1 to have assistance from one for eating. The investigation report, dated 6/21/15, indicated that Resident #1 was in the Assisted Dining Room and seated at a table having a cup of coffee, when the coffee spilled on his/her abdomen. Other Residents and another Resident's family member were in the Assisted Dinning Room. The staff members were educated not to use the employee water dispenser. Resident #1 sustained second degree burns on his/her abdomen and first degree burns to the right /thigh. Interview with the Unit Coordinator on the Gardenia Unit at 8:45 A.M. on 10/1/15, the Unit Coordinator said that on 6/21/15 Certified Nursing Assistant (CNA) #1 obtained hot water for Resident #1's coffee out of the bubbler in the Nurses' Station which was extremely hot and that the water from that bubbler was not for Residents. The Unit Coordinator said that Residents and Family Members get their coffee out of the Coffee Machine in the Dining Room, and that water is a lower temperature. The Unit Coordinator said that Resident #1 knew that he/she burned herself because he/she yelled when the hot coffee hit his/her skin. The Unit Coordinator said from that Resident #1 sustained blistering (2nd degree burns) on the right and left abdomen and redness on the right thigh (1st degree burn). The Surveyor interviewed Nurse #1 at 11:55 A.M. on 10/1/15. Nurse #1 said she heard yelling from another Resident's Family Member in the Dining Room, and that Resident #1 had spilled coffee on him/her self. Nurse #1 observed a black puddle in Resident #1's lap. The Surveyor interviewed CNA #1 at 1:15 P.M. on 10/2/15. CNA #1 said Resident #1 was in the Assisted Dinning Room after lunch on 6/21/15, and Resident #1 wanted a cup of coffee. CNA #1 said obtained a plastic mug and a packet of instant coffee; he then filled the mug with hot water from the hot/cold bubbler in the Nurses' Station because Resident #1 likes real hot black coffee. CNA #1 said he then brought the cup of coffee to Resident #1, who was sitting at a table in the Assisted Dinning Room. CNA #1 said he then left to obtain cookies in the Kitchenette for Resident #1. Resident #1 was left unsupervised and unassisted with a hot cup of coffee. CNA #1 said that he mixed the hot water from the bubbler prior to giving Resident #1 the cup of coffee because he said, it (the hot water from the bubbler) is very very hot. CNA #1 said he did not know the temperature of the water prior to giving Resident #1 the cup of coffee. Despite the first and second degree burns Resident #1 sustained on 6/21/15, the hot water for beverages was still at unsafe water temperatures during the Surveyor visit on 10/1/15. The Surveyor observed that the hot water temperatures for beverages taken with the Maintenance Worker at 9:15 A.M. and 9:45 A.M. on 10/1/15 were as follows: On the unit where Resident #1 resided: in the Assisted Dining Room (a patient care area) - the coffee machine water temperature was 170 degrees Fahrenheit (F), and the hot water dispenser water was 180 degrees F. The hot water bubbler in the Nurses' Station was 170 degrees F. In the Lobby (a patient care area): the coffee machine water temperature was 158 degrees F., and the hot water dispenser water was 184 degrees F. The Surveyor interviewed the Administrator at 9:50 A.M., and both the hot water dispensers were immediately taken out of service on. The Coffee Machine on the unit where Resident #1 resided, in the Assisted Dining Room and the Lobby were later serviced by a vendor and the temperature was decreased to 155 degrees F.