Every finding on record at Life Care Center Of Raynham

Based on record review, observation, and staff interview, the facility failed to ensure that for four Residents (#28, #88, #78, and #143), of a total sample of 29 residents, infection control measures were implemented in order to prevent the potential development and spread of disease. Specifically, the facility failed: 1. For Residents #28 and #88, to ensure respiratory equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection; 2. For Resident #78, to remove feces from hands prior to providing meals; and 3. For Resident #143, to ensure Contact Precaution measures were followed in a manner to prevent the potential spread of infection for a Resident with non-recurrent Clostridium difficile, a germ that causes diarrhea and colitis (an inflammation of the colon) and can be life-threatening. Findings include: 1. Review of the Policy titled Oxygen Administration, issued on 12/3/18 and revised on 10/1/24, included but was not limited to the following: Policy: -To assure that oxygen is administered and stored safely within the healthcare centers or in and outside storage area. Infection Control: -Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set up or changed out -Store oxygen and respiratory supplies in bag labeled with resident's name name when not in use. A. Resident #28 was admitted in December 2020 with diagnoses which included chronic obstructive pulmonary disease (COPD-chronic lung disorders resulting in blocked air flow in the lungs), chronic respiratory failure with hypoxia, and Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicated the Resident had moderate cognitive impairment. Review of the current Physician's Order indicated: -Oxygen at 2 liters as needed, administer via an oxygen concentrator and nasal cannula. On 1/2/25 at 9:20 A.M., the surveyor observed Resident #28 seated in a wheelchair in his/her room. An oxygen concentrator was observed against the wall adjacent to the left upper side of the bed. The oxygen was not in use, however the the nasal cannula oxygen tubing was observed lying on the floor under the bed and not contained in a bag to protect it from environmental contaminants. The Resident utilized oxygen via the nasal cannula, as needed (PRN), and removed and replaced the nasal cannula adlib, without staff assistance or supervision. On 1/3/25 at 8:16 A.M., the surveyor observed Resident #28's oxygen tubing hanging on the left bed rail and was not contained in a bag to protect it from environmental contaminants. The oxygen tubing was dated 1/2/25. On 1/3/25 at 8:57 A.M., the surveyor observed Resident #28 lying in bed with the nasal cannula oxygen tubing that had been observed on the floor on 1/2/25 and hanging on the bed rail on 1/3/25 in the Resident's nose. On 1/3/25 at 11:54 A.M., the surveyor observed Resident #28's nasal cannula oxygen tubing lying on the floor at the left side of the Resident's bed. During an interview on 1/7/25 at 11:17 A.M., Unit Manager (UM) #2 said that the Resident's oxygen tubing should not be on the floor or hanging on the side rail. UM #2 said that the oxygen tubing should always be stored in a bag when not in use to prevent it from being contaminated and to prevent infection. During an interview on 1/7/25 at 3:54 P.M., the Director of Nursing (DON) said that the Resident's oxygen nasal cannula should not have been on the floor or hanging on the side rail. The DON said that respiratory equipment, such as nasal cannula oxygen tubing, should be stored in a bag when not in use, in order to maintain cleanliness and prevent contamination/infection. She said that due to the Resident's decreased cognition, he/she would not be capable of maintaining the respiratory equipment in a clean and safe manner to prevent contamination and/or the spread of infection. 50740 B. Resident #88 was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD- a disease caused by damage to the lungs), chronic respiratory failure, and dependence on supplemental oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/12/24, indicated the Resident was cognitively intact, as evidenced by a BIMS score of 15 out of 15. Further review of the MDS assessment indicated the Resident received oxygen therapy. Review of Resident #88's Physician's Orders indicated but was not limited to the following: -Change oxygen tubing and nebulizer circuit every night shift every Sunday (12/15/24) -Oxygen at 2 liters/minute (l/min) continuously per nasal cannula. Document every shift (12/10/24) Review of the January 2025 Treatment Administration Record (TAR) indicated the Resident's oxygen tubing was due to be changed on the night shift on 1/5/25. The treatment was signed by Nurse #8 and a chart code of 6 was entered, indicating Absent from facility with meds. Review of the Resident's record indicated the Resident was not out of the facility on the night shift on 1/5/25. On 1/6/25 at 8:59 A.M., the surveyor observed Resident #88 utilizing Oxygen at 2 l/min via nasal cannula. The oxygen tubing was dated 12/30. On 1/7/25 at 7:14 A.M., the surveyor observed Resident #88 utilizing Oxygen at 2 l/min via nasal cannula. The oxygen tubing was dated 12/30. During an interview on 1/7/25 at 8:58 A.M., Unit Manager #1 said oxygen tubing should be changed on admission, every Sunday night, and as needed. Unit Manager #1 said Resident #88's tubing should have been changed on the night shift 1/5/25, but the Resident uses longer extension tubing that may not have been available on the unit during that time. During an interview on 1/7/25 at 9:19 A.M., the DON said Resident #88's oxygen tubing should have been changed on the night shift on Sunday 1/5/25 as scheduled. The DON said if the extension tubing was not available at that time, the nurse should have notified someone on the next shift for it to be changed. During an interview on 1/7/25 at 4:33 P.M., Nurse #8 said he prepared new tubing for Resident #88 on 1/5/25 and left the new tubing hanging in a respiratory bag in the Resident's room ready for use. 36542 2. Review of the facility's policy titled Hand Hygiene for Residents, Families and Visitors, dated as reviewed on 6/3/24 indicated the following: -the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections -hand hygiene refers to a general term that applies to hand washing, antiseptic handwash, and alcohol-based hand rub -avoid touching eyes, nose or mouth with unwashed hands -the facility should assist either physically or through reminders to residents to perform hand hygiene after toileting and before meals Resident #78 was admitted to the facility in January 2021 with a diagnosis of dementia. Review of the MDS assessment, dated 12/10/24, indicated Resident #78 scored 3 out of 15 on the BIMS, indicating a severe cognitive impairment. Review of the care plans for Resident #78 included a Focus for behaviors including but not limited to the potential to smear feces. Interventions included but were not limited to the following: two staff members when possible related to accusatory behavior, administering medications as ordered, anticipating the needs of the Resident, discuss behaviors and reinforce why not appropriate/acceptable, offer tasks to divert attention, praise progress/improvement in behavior, provide a program of activities of interest. On 1/2/25 at 9:40 A.M., the surveyor observed Resident #78 in bed with a strong smell of feces in the room. The surveyor observed Resident #78 with feces on, around, and underneath the fingernails, on tips of fingers, on the Styrofoam cup and a crumpled tissue on the bedside table. During an interview on 1/2/25 at 9:45 A.M., the surveyor informed Unit Manager #3 of Resident #78 having feces on their hands. The Unit Manager said Resident #78 had a behavior of touching his/her feces. On 1/2/25 at 9:50 A.M., the surveyor observed a Certified Nursing Assistant (CNA) go into the room of Resident #78 to provide care. On 1/2/25 at 11:30 A.M., the surveyor observed Resident #78 in bed. The Resident continued to have feces all around the fingernail bed and under the fingernail on multiple fingers; the fingertips were stained an orange/brown color. Resident #78 was observed to use the side of their index finger to rub their right eye. The surveyor observed the same Styrofoam cup with feces on it on the bedside table. On 1/2/25 at 12:45 P.M., the surveyor observed Resident #78 to continue to have feces on his/her hands and to be eating a tuna sandwich. On 1/3/25 at 8:15 A.M., the surveyor observed Resident #78 in bed having breakfast. The fingertips were cleaned and no longer had the orange/brown stain, the nail beds were cleaned and there were no longer feces around the nail beds. There continued to be feces under the fingernails on a couple of fingers. On 1/3/25 at 12:28 P.M., the surveyor observed the Staff Development Coordinator (SDC) setting up lunch for Resident #78 and assisting him/her with eating. The Resident's nails continued to look the same from four hours prior. At 12:39 P.M., the SDC provided the Resident with a clothing protector while the Resident fed him/herself a grilled cheese sandwich. During an interview on 1/3/25 at 12:44 P.M., the SDC said the process was for staff to use hand sanitizer wipes to clean residents' hands prior to eating. She said she had not cleaned Resident #78's hands because she had started off feeding the Resident. During an interview on 1/3/25 at 12:46 P.M., Nurse #1 said Resident #78 had behaviors which included disrobing and playing with feces with no particular frequency. During an interview on 1/3/25 at 12:48 P.M., CNA #1 said she had provided care to Resident #78 the day before when the Resident had a bowel movement. She said she was cleaning the hands of Resident #78 when the Resident pulled them away. She said the Resident can be resistant to having his/her nails cleaned and that she had done the best she could to get the feces off the nails. During an interview on 1/3/25 at 12:52 P.M., Unit Manager #3 said the process was for staff to clean the hands of residents with hand sanitizer wipes. On 1/7/25 at 8:01 A.M., the surveyor observed Resident #78 in bed with dried feces around the fingernail beds and under the fingernails. On 1/7/25 at 8:15 A.M., the surveyor observed Resident #78 in bed self-feeding a biscuit with his/her hand. During an interview with observation on 1/7/25 at 8:16 A.M., Unit Manager #3 said one hand on the Resident looked cleaner than the other and that there were feces on the nails. She said she knew the staff had worked on the Resident's fingernails over the weekend and the CNA had cleaned the Resident's hands prior to getting breakfast but there were still feces on the nails. 49428 3. Review of facility's policy titled Transmission-Based Precautions and Isolation Procedures, revised 9/24/24, indicated but was not limited to: Policy: The facility will implement and utilize transmission-based precautions to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. Categories of Transmission-based Precautions: -Contact Precautions are intended to prevent transmission of pathogens that are spread by direct (such as person-to-person) or indirect contact with the resident or environment, and require the use of appropriate personal protective equipment (PPE), including a gown and gloves before or upon entering (such as before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. Procedure: -This facility will utilize the following Lippincott procedures: Contact Precautions Procedure Review of Lippincott Nursing Procedures- 9th edition, dated 2023, section titled Contact Precautions, indicated but was not limited to: -Equipment: gowns, gloves, plastic bags, contact precaution signs; -Perform hand hygiene; -Put on a gown and gloves before entering the patient's room to comply with contact precautions; -Handle all items that have come in contact with the patient as you would for a patient on standard precautions; -Remove and discard your gown and gloves before leaving the room; -Perform hand hygiene before leaving the patient's room. Review of Resident #143's MDS assessment, dated 11/14/24, indicated the Resident had enterocolitis due to Clostridium difficile (C. diff), not specified as recurrent. Review of Resident #143's current Physician's Orders included but were not limited to: -12/31/24, Dificid (an antibiotic) oral tablet 200 milligrams (mg), give 1 tablet by mouth two times a day for C. diff until 1/10/25; -12/31/24, Contact plus precautions for C. diff, every shift. Review of Resident #143's active care plan included, but was not limited to: -The Resident has C. Difficile infection, dated 1/2/25; -Contact plus precautions, dated 1/2/25. On 1/2/25 at 10:30 A.M., the surveyor observed a Contact Precautions sign hung outside of Resident #143's door. The surveyor observed CNA #1 enter the Resident's room and don (put on) gloves without using hand sanitizer or washing hands with soap and water. CNA #1 did not don a gown. CNA #1 wheeled the Resident into their bathroom. The surveyor did not observe CNA #1 exiting the Resident's room. On 1/2/25 at 10:46 A.M., the surveyor observed CNA #1 enter Resident #143's room without sanitizing or washing hands with soap and water. CNA #1 donned gloves and entered the Resident's bathroom. CNA #1 was not wearing a gown. CNA #1 was observed without gloves or a gown when she exited the bathroom with the Resident and wheeled the Resident to their bed. The surveyor did not see any gowns discarded in the Resident's bathroom trash can. During an interview on 1/2/25 at 11:45 A.M., CNA #1 said she did not notice the Contact Precautions sign outside of Resident #143's room. During an interview on 1/7/25 at 10:15 A.M., Unit Manager (UM) #3 said staff caring for residents with C. diff should be gowned and gloved and should wash their hands with soap and water when entering and exiting the resident's room. UM #3 said CNA #1 should have donned a gown and gloves and practiced appropriate hand hygiene upon entering and exiting Resident #143's room. During an interview on 1/7/25 at 1:50 P.M., the DON said staff should utilize the appropriate PPE stated on Precaution signs. The DON said CNA #1 should have donned gloves and a gown and should have cleaned her hands before and after entering the room.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food items were properly dated and stored in the main kitchen and kitchenettes; and 2. Ensure two of three ice machines were maintained in a clean and sanitary condition. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 4-602.11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's policy titled Food Safety, revised 4/26/23, indicated but was not limited to: Policy: Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Federal Regulation: 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Review of the facility's policy titled Safe Food Handling, revised 4/26/23, indicated but was not limited to: Policy: All food purchased, stored, and distributed is handled with accepted food-handling practices, and per federal, state and local requirements. Procedure: -Snacks and other food items sent from the food service department will be handled safely in regard to temperature, labeling and storage. Review of the facility's Use by Date Guide, revised 3/18/20, indicated but was not limited to: -The following guide can be used to determine a use by date when labeling opened or unopened food that must be used within a certain time frame. -Please note that this information is used when there are no guidelines on the containers of food. -In some cases, {Facility} may require a shorter timeframe on a food item to reduce the number of items under refrigeration. For example, the food code indicates that leftovers may be kept up to 7 days, however, {Facility} guidelines are for 3 days (72 hours). -All opened containers of food in the dry storage area should be placed in an enclosed container, labeled, and dated with the open date and the use by date. Any unopened cans/packs should be marked with the date received. After opening, then the above guideline is followed regarding opened containers of food. On 1/2/25 at 8:10 A.M., the surveyor observed the following during the initial kitchen tour in the main kitchen: -one bag of sliced pepperoni re-packaged in a freezer bag, no date; -one bag of mozzarella cheese, opened, no date; -one bag of breadsticks, out of original box, no date; -one bag of French fries, out of original box, no date; -one container of cottage cheese about 1/4 full, no date; -sliced cheese in plastic wrap, no date. On 1/2/25 at 11:21 A.M., the surveyor observed the following in the [NAME] Unit Kitchenette: -one bottle of vegetable juice, opened, no date; -two containers of prune juice, opened, no date; -20 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing. On 1/7/25 at 8:06 A.M., the surveyor observed the following in the [NAME] Kitchenette: -two containers of thickened water, opened, no date with manufacturer label stating After opening, may be kept up to 7 days under refrigeration; -two cartons of milk, opened, no date; -20 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing; -one carton prune juice, opened, no date. During an interview on 1/7/25 at 8:25 A.M., Dietary Staff #1 said they typically stocked and maintained the Unit Kitchenettes. Dietary Staff #1 said they were responsible for the refrigerator, freezer, cabinets, and microwave. Dietary Staff #1 and the surveyor observed the [NAME] Kitchenette together. Dietary Staff #1 said the nutritional shakes are not dated and could not confirm if any of the nutritional shakes in the Unit refrigerator were past the use within 14 days of thawing per manufacturer's instructions. During an interview on 1/7/25 at 8:30 A.M., the Food Service Director (FSD) and the surveyor observed the [NAME] Kitchenette. The FSD said any opened food or drink items stored in the unit kitchenettes should be labeled and dated with the date it was opened. The FSD said dietary staff maintained the Kitchenettes daily which included monitoring the labeling and dating of food and beverage items when they stocked the Kitchenettes. Dietary Staff #1 had already left the Kitchenette. The FSD and surveyor observed the refrigerator which still contained undated, opened containers of thickened water, milk, prune juice, and 20 thawed nutritional shakes. The FSD said all of the items should have a date when they were opened and the nutritional shakes should be labeled with a thaw date to ensure they are used within the 14 days stated by the manufacturer. On 1/7/25 at 9:06 A.M., the surveyor observed the following in the main kitchen: -one opened bag of cake mix, no date; -prune juice and thickened dairy, both opened with no date; -one container cottage cheese, opened and dated 12/19. During an interview on 1/7/25 at 9:06 A.M., the FSD said the cottage cheese was received on 12/19/24 and opened sometime that week. The FSD said any food or drink item that is opened should be labeled and dated with the date it was opened. On 1/7/25 at 10:10 A.M., the surveyor observed the following in the [NAME] Unit Kitchenette: -Lactaid milk, opened, no date with manufacturer label stating use within 14 days of opening; -12 nutritional shakes, thawed, no thaw date with manufacturer label stating use within 14 days of thawing. During an interview on 1/7/25 at 1:46 P.M., the Administrator said she expected the facility to comply with federal and state regulations when storing food, which included labeling and dating opened food/beverages and labeling and dating any undated items that are removed from the packaging. 2. Review of the facility's policy titled Preventative Maintenance - Ice Machines, revised 1/11/23, indicated but was not limited to: Policy: It is policy that all ice machines in the facility will be inspected by the in-house maintenance department on a monthly basis and the coils will be cleaned every quarter. Procedure: Monthly -Any problems will be reported to the maintenance department via a work order; -The maintenance department or outside vendor will inspect each ice machine monthly; -All areas will be checked for cleanliness. Quarterly -All quarterly procedures will be completed by maintenance or outside vendor. On 1/2/25 at 11:21 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on areas of the interior machine adjacent to where the ice was stored. On 1/7/25 at 8:06 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on areas of the interior machine where ice was made. Specifically, there was a thick layer of yellow and black residue at the top of the evaporator plate, a metal piece that produces ice by freezing the water that streams down the plate. Additionally, there was milder yellow residue on other parts of the condenser plate. The surveyor observed water running over the residue, freezing, and forming ice. On 1/7/25 at 8:06 A.M., the surveyor observed Nurse #6 in the [NAME] Kitchenette scooping ice from the ice machine into a water pitcher. Nurse #6 said she was preparing water for medication pass. Nurse #6 and the surveyor observed the ice machine's interior. Nurse #6 said the ice machine looked as if it needed cleaning and she did not feel comfortable using the ice for medication pass to the residents. During an interview on 1/7/25 at 8:25 A.M., the Director of Maintenance (DOM) said the maintenance department is responsible for monitoring and maintaining the ice machines. The DOM said the ice machine maintenance schedule is produced by the facility's TELS system, a building management platform. The DOM said the maintenance included checking and cleaning the interior of the ice machine. Additionally, the DOM said the ice machines are cleaned every three months by a vendor. The DOM and the surveyor observed the [NAME] Kitchenette ice machine and the DOM said the machine needed to be cleaned. On 1/7/25 at 10:10 A.M., the surveyor observed the [NAME] Unit ice machine with yellow and black residue on the same areas of the interior machine adjacent to where the ice was stored. The DOM said he also observed the residue inside of the ice machine. Review of the TELS Logbook indicated maintenance of the ice machines on [NAME] and Life Care Plus units were performed on 12/6/24 and 9/6/24, which included: sanitize interior of ice machine per manufacturer's instructions and clean out and sanitize the ice bin. The Logbook indicated maintenance on 12/6/24 was marked done on time by the DOM. The Logbook indicated maintenance on 9/6/24 was marked done on time by the Administrator. During an interview on 1/7/25 at 1:46 P.M., the Administrator said she would expect the ice machines to be maintained and function in a clean and sanitary condition at all times.

Based on interview and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#73), out of 29 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed for the use of an anticoagulant medication. Findings include: Review of the facility's policy titled Comprehensive Care Plans and Revisions, dated as revised 9/11/24, indicated but was not limited to: -the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that all comprehensive care plans are reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs Resident #73 was admitted to the facility in November 2020 with diagnoses which included a history of venous thrombosis and embolism (blood clot). Review of the Minimum Data Set (MDS) assessment, dated 10/9/24, indicated Resident #73 had received an anticoagulant medication. Review of Resident #73's Physician's Orders indicated but was not limited to: -Apixaban (anticoagulant) 2.5 milligrams (mg) two times a day, dated 5/9/24 Review of the November 2024, December 2024, and January 2025 Medication Administration Records (MAR) indicated he/she had received Apixaban as ordered. Review of Resident #73's care plan failed to indicate a care plan for the use of anticoagulant medication had been developed. During an interview on 1/7/25 at 12:15 P.M., Nurse #2 said residents on high-risk medications including an anticoagulant should have a care plan for it. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said Resident #73 was on an anticoagulant. Unit Manager #2 reviewed Resident #73's medical record and said there was no care plan for the anticoagulant medication but there should have been. During an interview on 1/7/25 at 1:50 P.M., the Director of Nurses (DON) said any resident on an anticoagulant should have a care plan for the use of the anticoagulant.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice for two Residents (#5 and #35), out of a sample of 29 residents. Specifically, the facility failed: 1. For Resident #5, to ensure a physician's order was in place for the use of compression stockings for bilateral lower extremity edema, swelling caused due to excess fluid accumulation in the body tissues; and 2. For Resident #35, to ensure a physician's order was in place for the use of an air mattress for pain. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #5 was admitted to the facility in December 2022 with diagnoses which included chronic diastolic heart failure, a cardiovascular condition that can cause swelling in the feet, ankles, or legs. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 12/2/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. During an observation with an interview on 1/7/25 at 9:30 A.M., the surveyor observed Resident #5 wearing white compression stockings that covered both legs. Resident #5 said he/she wears the leg stockings due to leg edema. Resident #5 said he/she wears the stockings during the day and they are removed at night. Review of Resident #5's active care plan indicated but was not limited to the following: -Resident is at increased risk for break in skin integrity due to decreased mobility, bilateral lower extremity edema, and incontinence; revised 11/21/23. Additionally, review of Resident #5's care plan failed to indicate a care plan for the use of compression stockings. Review of Resident #5's Physician's Orders failed to indicate an order for compression stockings. During an interview on 1/7/25 at 10:30 A.M., Nurse #1 said Resident #5 wears compression stockings daily due to edema. Nurse #1 reviewed the Resident's current physician's orders and could not find a treatment order to apply compression stockings to the Resident's legs. Nurse #1 said there should be a physician's order and a care plan for Resident #5's compression stockings. During an interview on 1/7/25 at 10:40 A.M., the Director of Nursing (DON) said if a resident is wearing compression stockings on a daily basis as a treatment, there should be a physician's order for the stockings and the use of the compression stockings should be included in the resident's care plan. The DON said Resident #5 should have a physician's order and care plan pertaining to the use of compression stockings for the Resident's bilateral lower extremity edema. 2. Resident #35 was admitted to the facility in April 2023 with diagnoses which included spinal stenosis, restless leg syndrome, and pain in both shoulders. Review of Resident #35's MDS assessment, dated 10/29/24, indicated but was not limited to the following: -no unhealed pressure ulcers; -no venous and arterial ulcers; -no other ulcers, wounds, and skin problems; -skin and Ulcer treatments included a pressure reducing device for bed; -the Resident had been on a scheduled pain medication regimen; -a pain assessment interview was conducted and the Resident reported frequent pain that frequently affected sleep and a pain intensity rating of 8 (on a 00 to 10 rating scale, with 10 being the highest level). -weight of 150 pounds; -a BIMS score of 15 out of 15, indicating the Resident was cognitively intact. On 1/2/25 at 10:15 A.M., the surveyor observed Resident #35's air mattress set to 250 pounds, normal pressure. During an interview on 1/6/25 at 10:10 A.M., the surveyor observed Resident #35 sitting in a chair near the foot of his/her bed. Resident #35 said he/she has an air mattress for pain. The Resident said staff manages the air mattress setting and the Resident was unsure of what the setting should be. The surveyor observed the air mattress setting to be around 240 pounds, normal pressure. The Resident said the air mattress was okay but he/she preferred it to be firmer. Review of Resident #35's active care plan indicated but was not limited to the following: -At risk for break in skin integrity related to decreased mobility, incontinence and polyneuropathy; -Pressure reducing mattress; -Resident #35 expresses right hip/sciatica pain due to spinal stenosis and decreased mobility; -Educate Resident and family regarding pain management; -Evaluate the effectiveness of pain interventions; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Observe and report to nurse Resident complaints of pain or requests for pain treatment; -Pain medications as ordered. Review of Resident #35's current Physician's Orders failed to indicate orders for an air mattress. During an interview on 1/6/25 at 4:30 P.M., Nurse #7 said Resident #35's skin was intact and the Resident used an air mattress to help with pain. Nurse #7 could not find a physician's order for an air mattress. During an interview on 1/6/25 at 4:35 P.M., Unit Manager #3 said if Resident #35 used an air mattress for pain, there should be an order and a care plan to reflect that. During an interview on 1/7/25 at 1:50 P.M., the DON said if Resident #35 has an air mattress as a treatment for pain, there should be a physician's order and the air mattress should be included in the Resident's care plan for pain.

Based on observations, interviews, and records reviewed, for one Resident (#14), out of five residents with pressure ulcers investigated and 29 total sampled residents, the facility failed to ensure Resident #14 received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection. Specifically, the facility failed to ensure the pressure ulcer was assessed by the Wound team as soon as it was identified, resulting in a delay in treatment, and to conduct daily assessments of the Resident's wound to monitor changes in the wound status between 5/21/24 and 5/30/24. Findings include: Review of the facility's policy titled Documentation and Assessment of Wounds, dated as revised 8/23/21, indicated but was not limited to: -A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform an as needed assessment/documentation if noted change has occurred i.e., wound has healed/resolved, appears infected, or appears to have declined. Review of the facility's policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, dated as revised 7/9/24, indicated but was not limited to: -a skin assessment/inspection should be performed weekly by a licensed nurse. Any changes or open areas are reported to the Nurse. Nurse will complete further inspection/assessment and provide treatment if needed. -measures to maintain and improve the residents' tissue tolerance to pressure are implemented in the plan of care -when skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident Review of the facility's policy titled Incident and Reportable Event Management, dated as revised 8/15/23, indicated but was not limited to: -Event Management includes but is not limited to, the following types of events: Pressure Ulcer/Injury (in house acquired) greater than stage 1 -To help reduce the risk of an event, all residents receive assistance and supervision as addressed in their care plan. If an event occurs, the facility will follow the 5 I's in an effort to minimize the potential for recurrence. 1. Incident (what happened or was reported as happening) 2. Injury (provide care and document the injury) 3. Interview (who saw the resident last or at the time of the event) 4. Investigate (why did it happen) 5. Intervention (what mitigation effort are we using) Resident #14 was admitted to the facility in November 2022 with diagnoses which included dementia and paraplegia (paralysis of the legs and lower body). Review of the Minimum Data Set (MDS) assessment, dated 12/4/24, indicated Resident #14 had a facility acquired pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence). Review of Resident #14's care plans indicated he/she had a pressure ulcer to coccyx (base of the spine, near the top of the buttocks), initiated on 5/30/24. Review of Resident #14's Weekly Skin Integrity Data Collection Tool, dated 5/15/24, indicated his/her skin was intact. Review of Resident #14's Progress Note, dated 5/21/24, completed by Nurse #3, indicated an open area was noted on his/her coccyx and measured approximately 1.05 centimeters (cm) x 1.01 cm with no drainage. Further review of the progress note indicated there was a new order for normal saline wash followed by triad (a zinc-oxide based sterile coating designed to manage low to moderate levels of drainage, while promoting a moist wound healing environment) to the area. During a telephonic interview on 1/7/25 at 1:17 P.M., Nurse #3 said when a wound is discovered a risk assessment should be initiated, the provider should be notified and new orders should be obtained. Nurse #3 said the facility wound team should be notified when a wound is identified and the wound should be assessed by the wound team as soon as possible. Nurse #3 said Resident #14 had a wound on his/her coccyx but did not recall if she was the one who discovered it or not. Review of Resident #14's Weekly Skin Integrity Data Collection (his/her weekly skin inspection), dated 5/22/24, completed by Nurse #4, failed to indicate any alterations in his/her skin integrity. During a telephonic interview on 1/7/25 at 2:19 P.M., Nurse #4 said a weekly head to toe assessment was completed weekly and any skin abnormalities should be documented. Nurse #4 said the facility wound team should be notified of any new findings. Nurse #4 said when skin status changed, the provider should be made aware and if a wound was not improving it should be documented. Nurse #4 said she did not remember Resident #14's skin status in May 2024. During an interview on 1/7/25 at 3:52 P.M., the Director of Nurses (DON) said when impaired skin integrity is noted the wound should be observed by the wound team as soon as possible and then weekly, on Tuesdays, during wound rounds. Review of the medical record failed to indicate the Wound team assessed Resident #14's new open area on his/her coccyx identified on 5/21/24 prior to or during wound rounds on Tuesday (5/28/24). Review of Resident #14's Weekly Skin Integrity Data collection, dated 5/29/24, completed by Nurse #5, failed to indicate any alterations in his/her skin integrity. During a telephonic interview on 1/7/25 at 2:23 P.M., Nurse #5 said weekly head to toe assessments were completed and if impaired skin was observed the wound team should be notified. Nurse #5 said she did not recall Resident #14's skin status in May 2024. Review of Resident #14's Skin/Wound Note, dated 5/30/24, completed by Nurse #8, indicated during care the Resident was noted to have a wound over his/her coccyx with no drainage. The surrounding skin was reddened with irritation and the wound bed was tacky with dark discoloration. The Resident denied pain or discomfort, the provider was made aware and new orders were obtained. Review of the Wound Observation Tool, dated 5/30/24, completed by the Assistant Director of Nurses (ADON)/Wound Champion, indicated but was not limited to: -Location: Coccyx -Type: Pressure -Stage: Unstageable -Specify: Slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture)/Eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) -Visible Tissue: Overall Impression: first observation, no reference -Visible Tissue: Slough tissue present (yellow, tan, white, stringy) in 50% of the wound bed -Drainage: Small amount of serous (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) drainage -Wound measurements: length 2.5 cm, width 3 cm, depth 0.1 cm -Additional comments: patient noted with open wound to coccyx, wound bed contains slough to center, edges slightly rolled and with minor maceration (the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture) -Treatment Plan: Santyl and Silvercel (a nonadherent dressing used to help manage wound fluid and protect from infection) Review of Resident #14's May 2024 Treatment Administration Record (TAR) indicated but was not limited to: -Triad to coccyx every shift, dated 3/13/24 -Normal saline wash to coccyx followed by triad daily in the evening, initiated 5/21/24 and discontinued 5/30/24 -Treatment to coccyx: Normal saline wash, apply Santyl ointment to base, cover with Silvercel dressing as secondary dressing (cut small piece to fit wound bed) then apply foam dressing, every evening shift, dated 5/30/24 Review of Resident #14's medical record failed to include evidence that the wound worsened between 5/21/24 and 5/29/24. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said Resident #14 had a facility acquired wound in his/her coccyx and was followed by the facility wound team and the wound clinic. Unit Manager #2 said when a wound was discovered the wound team should be notified and an assessment should be completed. Unit Manager #2 and the surveyor reviewed the medical record and Unit Manager #2 said the wound was discovered on 5/21/24 and there was no further documentation of the wound status until 5/30/24. During an interview on 1/7/25 at 12:53 P.M., the ADON/ Wound Champion said Resident #14 had a facility acquired wound on his/her coccyx. The Wound Champion said she was notified of the wound on 5/30/24 and completed both the risk assessment and wound observation tool on that date. The Wound Champion and the surveyor reviewed the medical record, and the Wound Champion said she was not aware that the wound was first identified on 5/21/24 and no risk assessment or wound observation tool had been initiated at that time. The Wound Champion said the expectation was for the wound team to see a new wound as soon as possible. Review of the Hospital Discharge Summary, dated 6/23/24, indicated but was not limited to: -He/she was sent to the hospital for concern of worsening infection due to abnormal labs and admitted due to an infected sacral ulcer -CT scan of the abdomen and pelvic showed a sacral decubitus with associated gas, without concern for osteomyelitis or abscess formation. -He/she was started on multiple antibiotics and an infectious disease consult was initiated -He/she required surgical intervention for debridement, and he/she underwent I&D for debridement on 6/19/24 which resulted in copious amounts of dark purulent fluid draining from his/her necrotic ulcer. -Wound measurements, post debridement, were 7 cm, x 3.5 cm x 2.5 cm with undermining all around with 2 cm at 2 o'clock, wound bed was 75% yellow/necrotic tissue an 25% red/moist, mild odor, moderate yellow serosanguinous (type of wound discharge that consists of a mix of clear and blood-tinged fluid. It is common after surgery or during wound healing, and may appear as a thin, pale red or pink fluid) drainage.

Based on observation, record review, and staff interview, the facility failed to ensure that appropriate care and services were implemented to prevent the development of urinary tract infections (UTI) for one Resident (#58), of a total sample of 29 residents. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Management issued 4/1/22 and Reviewed 9/10/24, indicated but was not limited to the following: Policy: The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed; -Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. General Urinary Catheter Maintenance Guidelines 2. -Maintain unobstructed urine flow b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #58 was admitted in September 2024 with diagnoses which included a history of UTIs and a chronic urinary catheter. Record review indicated that the Resident had been started on Augmentin (antibiotic), every 12 hours x 7 days for a urinary tract infection (UTI) on 1/3/25. The Resident had a past medical history of UTIs. On 1/3/25 at 8:34 A.M., the surveyor observed Resident #58 lying in bed with her/his eyes closed. The Resident's continuous drainage bag from the Foley catheter was observed to be attached to the bed frame and resting directly on the floor without being placed in a privacy bag. During an interview on 1/7/25 at 11:17 A.M., Unit Manager (UM) #2 said that the Resident's continuous drainage bag from the urinary catheter should not be resting on the floor and should always be contained in a privacy bag. UM #2 said that there is a risk for contamination and the policy is to make sure the catheter bag is always positioned so it does not touch the floor to reduce the risk of infection. During an interview on 1/7/25 at 3:48 P.M., the Director of Nurses said that the Resident's catheter bag should not have been resting on the floor.

Based on interview and record review, the facility failed to act upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#14), out of a total sample of 29 residents. Specifically, the facility failed to act on the Consultant Pharmacist's recommendation to consider an antidepressant medication dose reduction. Findings include: Review of the facility's policy titled Medication Regimen Review, dated as revised 8/17/23, indicated but was not limited to: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving MRR and the Director of Nursing to act upon the recommendations contained in the MRR -For those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR and provide an explanation as to why the recommendation was rejected -The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it -If the attending physician has decided to make no changes in the medication, the attending physician should document the rationale in the residents' health record -The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident either 30 or 60 days per applicable regulation Resident #14 was admitted to the facility in November 2022 with diagnoses which included dementia and depression. Review of Resident #14's medical record indicated he/she was seen by the Consultant Pharmacist in August 2024 and recommendations were made. The surveyor was unable to locate the August 2024 Consultant Pharmacist's recommendation in Resident #14's record. After inquiry, the facility provided Resident #14's August 2024 Consultant Pharmacist's Consultation Report. The document indicated but was not limited to: -Resident #14 was receiving two antidepressants for depression, Trazodone (antidepressant) 150 milligrams (mg) every hour of sleep and Venlafaxine Hydrochloride (antidepressant) 75 mg daily and they were due for a dose reduction -The pharmacist recommended the physician consider reducing Trazodone to 125 mg every hour of sleep or Venlafaxine to 50 mg daily -The physician response section was blank Further review of the September through December 2024 MRRs failed to indicate the pharmacist followed up and readdressed the GDR recommended in the August 2024 MRR. During an interview on 1/7/25 at 12:42 P.M., Unit Manager #2 said the process was for the Consultant Pharmacist's Consultation Reports to be provided to the provider for review. Unit Manager #2 said once the physician reviews the recommendation, and provides a response, any new orders are implemented. Unit Manager #2 said the complete Consultation Report forms are filed in the medical record and with the Director of Nurses (DON). During an interview on 1/7/25 at 10:31 A.M., the DON said she had reviewed Resident #14's medical record and the August 2024 Consultant Pharmacist's Consultation Report had not been addressed by the physician.

Based on interview, document review, and policy review, the facility failed to maintain an infection control and prevention program to help prevent the potential transmission of a communicable disease. Specifically, the facility failed to: 1. Implement outbreak testing for staff in accordance with their policy, state and national standards when the facility was experiencing an outbreak of COVID-19 infections; 2. Ensure all medication carts were maintained in a clean, sanitary manner, to reduce the risk of contamination of stored medications in three of the four medication carts observed; 3. Ensure for a. Resident #2's Oxygen and b. Resident #53's Oxygen equipment was maintained in a sanitary manner, to help decrease the risk of contamination and infection; and, 4. Ensure for Resident #20, the facility failed to ensure that the Resident's hand held nebulizer was maintained in a clean and sanitary condition. Findings include: 1. Review of the facility policy titled, Coronavirus (COVID-19) (SARS-CoV-2), last revised 6/27/2023, indicated but was not limited to the following: -Massachusetts-the facility should use this guidance in conjunction with the guidance outlined in the COVID-19 policy-Massachusetts addendum. -Facility should follow local and state health department guidelines and state regulations as well as current Centers for Medicare and Medicaid Services (CMS) and Center for Disease Control and Prevention (CDC) guidelines. Review of the facility policy titled, COVID-19 (SARS-CoV-2) HCP (healthcare personnel) testing, last revised 6/21/23, indicated but was not limited to the following: -The policy should plan to test in accordance with the accepted national standards such as the CDC, unless ordered more stringently by local and state health officials. Review of the Department of Public Health (DPH) Memorandum titled, Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 2023, indicated but was not limited to the following: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. Residents and staff who have recovered from COVID-19 in the last 30 days can be excluded from this testing. During an interview on 11/8/23 at 8:45 A.M., Infection Control (IC) Nurse said the Covid-19 outbreak started 9/25/23 with a dietary aide. She said the facility has not been able to clear seven days with no new cases and remain in outbreak testing. She said currently they are testing staff every other day on the [NAME] and Life Care Plus Unit. If a staff works on the affected unit, they are expected to test every other day while that unit is in outbreak testing. She said if they leave the unit to work on another unit, they are expected to continue to test every other day until they are negative for seven days then they can stop. An audit was performed using the facility weekly testing log crossed referenced with the nursing staff schedules on the [NAME] Unit for time frame 10/21/23 through 10/27/23. During this time frame all staff working on [NAME] Unit were expected to test every 48 hours and the results are as follows: -Twenty-nine staff tested correctly (Two staff members were not required to test due to a positive Covid-19 result in previous 30 days). -Thirteen staff did not test as required every 48 hours. (Three staff members were not on the testing log). An audit was performed using the facility weekly testing log crossed referenced with the nursing staff schedules on the [NAME] Unit for time frame 11/6/23 through 11/9/23. During this time frame all staff working on [NAME] Unit were expected to test every 48 hours and the results are as follows: -Twenty staff tested correctly (Five staff members were not required to test due to a positive Covid-19 result in previous 30 days). -Eighteen staff did not test as required every 48 hours. (Two staff members were not on the testing log). During an interview on 11/9/2023 at 2:00 P.M., The IC Nurse said the staff members test in the room next to her office and there is a list of staff members who are supposed to test. She said the staff know they are supposed to test if they work on an affected unit and they are also told by their managers. She said at the end of the week, she takes the testing log and inputs it into her spread sheet, but she does not reconcile the testing log with who worked and who is required to test. She said it is an honor system and the managers should be reminding staff to test. The IC Nurse said the following is a summary of what unit or department had to test every 48 hours: -Kitchen staff tested [DATE] through 10/1/23. -Life Care Plus tested [DATE] through 10/16/2023. -Rehab Department tested [DATE] through 10/12/2023. -[NAME] Unit 10/7/23 through 10/25/2023. -[NAME] Unit 10/9/23 to the present. -Kitchen staff 10/13/2023 through 10/21/2023. -Life Care Plus Unit 10/25/23 to the present. The IC Nurse continued and said it's harder to get compliance with the testing, the longer the outbreak goes on, the less compliance there is due to testing fatigue with the staff members. She said she can't confirm that everybody that was supposed to test completed their testing, she goes on the honor system and heavily relies on the department managers to have their staff test as they're supposed to. During an interview on 11/10/23 at 1:15 P.M., the Director of Nurses (DON) said it was her expectation that staff test every 48 hours if they are supposed. The surveyor and the DON reviewed the testing logs with numerous staff member working within the designated weeks who were required to be tested for Covid-19 and had not tested . The DON said some staff test on the unit and don't log it in or they test at their other place of employment. The DON said the staff should be logging all their tests in the testing log so they can track who has tested . 47646 2. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, dated as revised 7/21/22, indicated but was not limited to the following: - The facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. - The facility should ensure that medications and biologicals for each Resident are stored in the containers in which they were originally received. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated as revised 1/1/22, indicated but was not limited to the following: - The facility should ensure that dose preparation areas are well-lit and medication carts are clean and organized. - If a medication which is not in a protective container is dropped, the facility staff should discard it according to facility policy. - After medication administration, the facility staff should take all measures required by facility policy and applicable law, including, but not limited to; clean any reusable equipment or supplies. Review of the facility's Clinical Nurse Highlight document titled Medication Storage, dated March 2022, indicated but was not limited to the following: - Medication carts are clean, stocked, and organized. - Medications should be stored separately according to routes of administration. Further separate routes in medication carts (e.g., oral, injectables, liquids, eyes, ears, nose, inhalers). During an observation on 11/9/23 at 12:35 P.M., of the [NAME] unit's hall A medication cart, the surveyor and Nurse #7 observed the following: - Multiple scattered, loose, medication tablets, thin cardboard punchouts of pill packaging, medication dust, and a thick brown crust of dirt/grime were observed on the bottom surface and along the edges of the medication cart's second drawer. The drawer contained Residents' oral, ophthalmic, and inhaled packaged medications. The brown substance was also observed in ring shaped formations near the drawer's bottles of stored medication. - Drippings of a white opaque substance were observed on a multidose bottle of milk of magnesia and on a side panel of the cart's third drawer. During an interview on 11/9/23 at 12:40 P.M., Nurse #7 said he did not realize there were loose pills in the medication cart and the overnight nurses were assigned to clean out the carts at night. During an interview on 11/9/23 at 12:55 P.M., Unit Manager (UM) #3 said the medication cart drawers should not be dirty or contain any loose medications. During an observation on 11/9/23 at 1:36 P.M., of the [NAME] unit's A/C hall medication cart, the surveyor and Nurse #2 observed the following: - Multiple boxes of boxed eyedrops were stored in pharmacy bags in one small overflowing bin in the medication cart drawer. One pharmacy bag containing three boxes of a Resident's eye drops was ripped with a Quarter sized tear. The same overcrowded bin also contained an opened and punctured multidose vial of injectable insulin glargine and one opened multidose injectable Basaglar Insulin KwikPen (both injectable medications are used to control blood sugar). The insulins were observed mixed in amongst the ophthalmic medications. The multidose vial of insulin glargine was not contained in the manufacturer's boxed packaging and was observed stored and protruding out of, a small plastic pill crushing pouch with the medication stopper unprotected from contamination. - Small crumbles of medication, several strands of hair, a large ring of a dried milky white semi-translucent substance, and darkened circles of buildup of grime, were observed in the right side of the medication cart's second drawer. During an interview on 11/9/23 at 1:45 P.M., Nurse #2 said the eyedrops and insulin were stored in their typical storage location within the cart. During an observation on 11/9/23 at 2:16 P.M., of the [NAME] unit's hall B medication cart, the surveyor and Nurse #8 observed the following: - One multidose bottle of liquid antacid was stored in the medication cart drawer next to two multidose bottles of protein supplements containing thick red liquid. Splattered drops of a thick, red, sticky substance were observed on the antacid bottle, the bottom and side panels of the medication drawer, and in a small, ripped cardboard box containing a single packaged insulin syringe and ten individually packaged lancing needles. There was a large circular area of a dried milky white semi-translucent substance and multiple darkened circles with thick, brown, crusting accumulation of dirt observed in the cart's same drawer. During an interview on 11/9/23 at 2:20 P.M., Nurse #8 said the medication cart was not clean. During an interview on 11/9/23 at 3:41 P.M., the Director of Nursing (DON) said it is the expectation that medication carts are kept in a neat, clean, and organized manner without any loose medications or debris. The DON said the medication carts are professionally cleaned a few times a year but if a cart were to become dirty during a shift, she would expect that the assigned nurse would clean it at that time. She said it is the expectation that medication cart storage areas are checked routinely by Nursing staff for cleanliness, organization, and loose or expired medications. 48696 42742 3. Review of the facility's policy titled Oxygen Administration/Safety/Storage/Maintenance, revised September 2023, indicted but was not limited to the following: -Change oxygen supplies weekly and when visibly soiled. -Clean exterior of concentrators weekly with an EPA registered hospital disinfectant. -External filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and reinsert. Discard and replace when damaged. a. Resident #2 was admitted to the facility in February 2023 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and dependence on supplemental Oxygen. On 11/7/23 at 9:55 A.M., the surveyor observed Resident #2 lying in bed with a nasal cannula (NC) (lightweight tube which one end splits into two prongs which are placed in the nostrils from which a mixture of Oxygen (O2) and air flows) in place attached to an O2 concentrator delivering 2.5 Liters (L) of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter (sponge like filter that captures dust and other airborne pollutants that can clog the machine and get transferred into the oxygen supply you breathe) was 100% laden with a dusty gray matter. Resident #2 was observed to have a congested cough and said he/she had had it for a while. On 11/9/23 at 8:17 A.M., the surveyor observed Resident #2 lying in bed sleeping with a NC in place attached to an O2 concentrator delivering 2.5 L of Oxygen. The exterior of the concentrator was laden with dust and debris as well as evidence of a dried brown substance. The external filter was 100% laden with a dusty gray matter. Nurse #2 entered the room to observe the findings with the surveyor and said the 11pm-7am shift was responsible for cleaning the filters with soap and water once weekly on Sunday, but nurses were responsible for checking in between and cleaning as needed. Nurse #2 said the exterior concentrator and filter should have been cleaned as needed and didn't know they were like that. During an interview on 11/9/23 at 8:29 A.M., Unit Manager (UM) #2 said nurses should be monitoring in between to ensure both the filter and concentrator are clean. b. Resident #53 was admitted to the facility in October 2023 and had diagnoses including chronic respiratory failure, heart failure, morbid obesity, bacteremia (presence of bacteria in the bloodstream), obstructive sleep apnea (episodes of complete collapse of the airway or partial collapse with a decrease in oxygen saturation or arousal from sleep), and dependence on supplemental O2. On 11/7/23 at 9:31 A.M. and 11/9/23 at 7:29 A.M., the surveyor observed Resident #53 lying in bed sleeping with a NC in place attached to an O2 concentrator delivering 2 L of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter was 100% laden with a dusty gray matter. On 11/9/23 at 8:19 A.M., the surveyor observed Resident #53 lying in bed with a NC in place attached to an O2 concentrator delivering 2 L of Oxygen. The exterior of the concentrator was laden with dust and debris. The external filter was 100% laden with a dusty gray matter. Nurse #2 entered the room to observe the findings with the surveyor and said the exterior concentrator and filter should have been cleaned as needed and didn't know they were like that. During an interview on 11/9/23 at 8:30 A.M., UM #2 entered the Resident's room with the surveyor to observe the findings and said yes, I see what you mean. She said nurses should be monitoring to ensure both the filter and concentrator are clean and said a clogged filter is concerning as the Resident is receiving Oxygen. She said the equipment needed to be cleaned. During an interview on 11/13/23 at 4:52 P.M., the Director of Nursing said nurses should be checking the Oxygen equipment each shift, including the exterior concentrators and external filters, and clean as needed if visibly soiled. 15214 4. Resident #20 was readmitted in October 2023 with a history of COPD (chronic obstructive pulmonary disease), acute respiratory failure with hypoxia, and hypertensive heart disease/CHF (congestive heart failure). The facility policy for the care of respiratory equipment Chapter 13, Respiratory, of the Clinical Services Manual, Oxygen Administration/Safety Storage/Maintenance, reviewed on 9/26/2023, indicated for Infection Control: -Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. On 11/8/23 at 9:43 A.M., the Resident was observed resting quietly in bed with his/her eyes closed. The Resident's hand held nebulizer was observed resting on the nightstand and not enclosed or protected in any type of device to maintain it's cleanliness and prevent contamination. On 11/14/23 at 8:40 A.M., the Resident's hand held nebulizer was observed on the floor, between the nightstand and the right upper side of the Resident's bed. During an interview on 11/14/23 at 8:40 A.M., Nurse #8 said to the surveyor that she saw that the hand held nebulizer was on the floor. Nurse #8 did not explain why the equipment was not contained in a plastic bag or device to maintain its cleanliness. During an interview on 11/14/23 at 12:52 P.M., UM #3 said that the facility policy is that residents' respiratory equipment, like hand held nebulizers, must be kept in a plastic bag with the resident's name, and date when the equipment was changed. He said that the night shift are responsible for changing the devices and plastic bags weekly on Sunday.

Based on record review, policy review, and staff interview, the facility failed to ensure the resident representative was fully informed in advance and given information necessary to make health care decisions on behalf of the resident for two Residents (#34 and #54), out of a total sample of 28. Specifically, the facility failed: 1. For Resident #34, to ensure informed consent was obtained for the use of an antianxiety medication; and 2. For Resident #54, to ensure the Resident's healthcare proxy (HCP) provided informed consent for the use of antidepressant medications. Findings include: Review of the facility's policy titled Psychotropic Medication Informed Consent, dated as revised 10/4/22, indicated but was not limited to the following: -The facility will obtain consent or refusal to the use of Psychotropic Medications. This documentation will reflect that the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose and duration. -Staff should inform the resident and/or resident representative of the initiation, indication for use, and the benefits/risks associated with the use of psychotropic medications. -The medication should not be started until after approved by resident and, if appropriate, representative. 1. Resident #34 was admitted to the facility in October 2023 with diagnoses including: congestive heart failure, hypertension (high blood pressure), and non-Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #34 had severe cognitive impairment with a score 5 out of 15. Review of the medical record indicated Resident #34's Health Care Proxy was invoked in August 2023 giving his/her agent authority to make all health care decisions on Resident #34's behalf. Review of Resident #34's current Physician's Orders indicated but was not limited to: - Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 8 hours as needed for anxiety, dated 10/19/23 Review of the medical record failed to indicate informed consent had been obtained for the use of the Lorazepam. Review of the Medication Administration Record (MAR) for October and November 2023 indicated Resident #34 was administered the Lorazepam three times. During an interview on 11/9/23 at 4:47 P.M., Unit Manager #1 reviewed the medical record and could not locate an informed consent form for the Lorazepam. Unit Manager #1 said she could not find any evidence that informed consent was obtained for the use of Lorazepam from the Health Care Proxy. She said it is the expectation that informed consent be obtained prior to administering any psychotropic medication. During an interview on 11/10/23 at 10:15 A.M., the Director of Nursing and Consulting Staff #1 said they are aware of the missing Lorazepam informed consent, and it was not in place as it should have been. 49425 28450 2. Resident #54 was admitted to the facility in December 2022 with diagnoses including: dementia, mood disturbance and depression. Review of the Minimum Data Set (MDS) assessment, dated 6/16/23, indicated Resident #54 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15. Review of the medical record indicated Resident #54's Health Care Proxy was invoked on 12/20/22 giving his/her HCP authority to make all health care decisions on his/her behalf. Review of Resident #54's current November 2023 Physician's Orders indicated but was not limited to: - Aricept Tablet 5 MG give one tablet by mouth at bedtime for dementia. - Citalopram Hydrobromide Tablet 20 MG Give one tablet by mouth one time a day for depression. Review of the medical record failed to indicate informed consent had been obtained for the use of Aricept and Citalopram. Review of the Medication Administration Record (MAR) for November 2023 indicated Resident #54 was administered the Aricept and the Citalopram once a day. During an interview on 11/08/23 at 4:46 P.M., Unit Manager #2 said the informed consent was to be signed by the Health Care Proxy (HCP). She said the HCP visits frequently, she will ask him to sign the informed consent the next time he comes. During an interview on 11/09/23 at 10:15 A.M., Nurse #6 said she was not aware of the missing informed consent for Aricept and Citalopram. She reviewed the medical record, did not retrieve them, and said the consent was not in place. During an interview on 11/10/23 at 11:20 A.M., the Director of Nursing said she was not aware of the missing informed consent for Aricept and Citalopram, and it was not in place as it should have been. During an interview on 11/14/23 at 2:37 P.M., Unit Manager #1 reviewed the medical record and could not locate an informed consent form for the Aricept and the Citalopram. Unit Manager #1 said she could not find any evidence that informed consent was obtained for the use of the Citalopram and Aricept from the Health Care Proxy. She said it is the expectation that informed consent be obtained prior to administering any psychotropic medication.

Based on observation and staff interview, the facility failed to ensure that accident hazards were minimized for the residents on the [NAME] Unit, where staff failed to ensure that medications were secure, attended to, and not accessible to residents. Findings include: On 11/9/23 at 3:15 P.M., on the [NAME] Unit, Nurse #8 was observed carrying eight cards of medications she had received from the pharmacy and placed the medications on top of a medication cart that was positioned on the opposite side of the nurses station. Nurse #8 left the medication cards unsecured and unattended. Additionally, a full bottle of Colace tablets was observed on the counter next to where the med cart with the eight cards of medication was positioned. The bottle of Colace was also unsecured and unattended. On 11/9/23 at 3:18 P.M., the surveyor observed Nurse #8 walking away from the medication cart to get something from the nourishment kitchen for a resident. There were no nurses at the nurses' station at that time, and all of the medications remained unsecured and unattended. Nurse #8 was in the nourishment kitchen for 1-2 minutes while a Resident (#71) in a wheelchair was observed wheeling directly past the med cart with the medication resting on top of the med cart. During an interview on 11/9/23 at 3:25 P.M., Nurse #10, who arrived after the medications were left on the medication cart, said that a confused resident could take the medication and be placed at potential harm. During observation on 11/9/23 at 3:28 P.M., the surveyor picked up the unsecured bottle of Colace, handed it to Nurse #10, who placed it in the med cart. During an interview on 11/9/23 at 3:28 P.M., Nurse #10 said that the medication should have been secured in the med cart. Nurse #10 also said that she did not know how the bottle of Colace got left on the counter and that it could be harmful if a resident were to ingest the medication.

Based on document review, and interview, the facility failed to fully implement their antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to maintain a complete and thorough tracking system and follow the McGeer's criteria for usage of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship, last reviewed 5/19/23, indicated but was not limited to the following: -The Antibiotic Stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. -Assessment of residence suspected of having an infection. The facility will utilize the McGeer criteria when considering initiation of antibiotics. -Tracking: The process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of the SBAR and other clinical documentation during clinical meetings and ongoing reviews of completeness of prescribing documentation to include dose, root, duration, and indication for use. Review of the infection surveillance tracking system (line list) and report, dated 10/1/23, provided by the infection prevention nurse indicated the following: -Five catheter associated urinary tract infections (CAUTI) which were healthcare-associated infections (HAIs, acquired while resident resided at the facility), were treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. -Five urinary tract infections (UTI), were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. -One pneumonia which was HAIs was treated with antibiotics and did not meet the McGeer's criteria or have signs or symptoms recorded on the line listing. -Two soft tissue infections which were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection. -One cellulitis (skin infection) which were HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection. -One abscess which was HAIs and treated with antibiotics and did not meet the McGeer's criteria for infection or have signs or symptoms recorded on the line listing. Review of Resident #105's medical record indicated the following antibiotic use: -Physcian orders for Levaquin 750 milligrams one time a day by mouth every other day for UTI for four administrations, initiated on 10/26/23 and completed on 11/3/23. -Review of the line listing indicated resident #105 had a CAUTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #105's nursing note dated 10/22/23, indicated foley catheter patent, draining yellow urine with scant sediment. No odor. -Review of Resident #105's nursing note dated 10/26/23, indicated urinalysis and culture results reported to the physician with new orders for Levaquin 750 milligrams every other day times 4 doses, update MD when sensitivities are available. Review of Resident #105's nursing note dated 10/27/23, indicated resident continues with Levaquin for UTI. Foley catheter patent draining yellow urine. Review of Resident #105's nursing note dated 10/28/23, indicated resident continues with Levaquin for UTI. Foley catheter Patent draining yellow urine free from sediment. No physician notes available for review 10/26/23 through 11/3/23 during antibiotic use. Review of Resident #106's medical record indicated the following antibiotic use: A. Physician order for Macrobid 100 milligrams by mouth two times a day for a UTI for five days 10/5/23 through 10/10/23. -Review of the line listing indicated Resident #106 had a UTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #106's nursing note dated 10/5/23, indicated urinalysis and sensitivity results came back. Resident is positive for UTI. Reported to the physician, new orders from Macrobid 100 milligrams twice a day times 5 days. -Review of Resident #106's second nursing note dated 10/5/23, indicated resident on Macrobid for UTI, resident afebrile, no complaints of dysuria (painful urination), continues with occasional incontinence. No physician notes available for review for 10/5/2023 through 10/10/2023 during antibiotic use. B. Physcian orders for Cefpodoxime Proxetil 200 milligrams one tablet by mouth every 12 hours for UTI for five days 10/29/23 through 11/3/23. - Review of the line listing indicated, Resident #106 had a UTI diagnosed on [DATE], no signs or symptoms recorded, and the infection did not meet the McGeer's criteria for infection. -Review of Resident #106's nursing note dated 10/26/23, indicated Resident complained of dysuria, MD notified. New orders to obtain urine for urinalysis culture and sensitivity. New orders for UTI protocol. -Review of Resident #106's nursing note dated 10/27/23, indicated urinalysis reviewed by physician, culture and sensitivity pending at this time. -Review of Resident #106's nursing note dated 10/29/23, indicated culture and sensitivity positive for proteus mirabillis, per MD start Vantin 200 milligrams twice a day for five days, patient is confused, no behaviors noted patient is afebrile. -Review of Resident #106's nursing note dated 10/30/23, indicated patient continues on Vantin for UTI, afebrile. -Review of Resident #106's second nursing note dated 10/30/23, indicated resident continues on Vantin for UTI, no adverse reaction noted, voiding without difficulty, no complaints of dysuria or hematuria (blood in urine) noted. Resident afebrile. No physician notes available for review for 10/29/2023 through 11/3/2023 during antibiotic use. During an interview on 11/9/23 at 2:00 P.M., the surveyor and Infection Control (IC) Nurse reviewed the October line listing and observed it to be incomplete with numerous residents prescribed antibiotics without meeting the McGeer's criteria for infection and no documented signs and symptoms. The IC Nurse said she uses the census sheet and during morning report picks up people that have started on antibiotics, and she also views the dashboard in Point Click Care (PCC, the electronic medical record) and adds these residents to her line listing. She said she then goes back to look at the nurses' notes and hospital discharge summary to see if she can pick up signs and symptoms to see if they meet the McGeer's criteria for infection. The IC Nurse said the nurses don't always document the signs and symptoms, so she doesn't get them. She said there has been some issues when the on-call physician is informed of the urinalysis results are greater than 100,000 colony forming units/milliliter (CFU/ml, term used to describe the number of microorganisms) they start them on antibiotics right away and they don't always wait for the culture and sensitivity. She said if she catches it, she can review the antibiotic use with the physician, but has not documented any of these conversations with the physicians. The IC Nurse provided her October summary analysis to the surveyor and said for the month of October, there were 39 infections treated with antibiotics, 19 were present on admission, 20 were in house infections (HAI), and only 15% meet McGeer's criteria for infection. She said 15% was a low number for meeting McGeer's criteria. During an interview on 11/14/23 at 10:20 A.M., the Director of Nursing (DON) said it was her expectation the line listing includes tracking symptoms, organisms and following up with the physician if the McGeer's criteria was not met. She was not sure where they were documenting the conversations that were had with the physicians. The surveyor reviewed the October summary analysis provided by the IC Nurse indicating the McGeer's criteria was only met 15% for last month's infections which were treated with antibiotics. The DON said only 15% of the residents meeting the McGeer criteria was a low and she could not speak to the current line listing not being completed with residents' signs and symptoms who were on antibiotics.

Based on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were securely stored within locked compartments with only authorized personal having access to the keys, and labeled in accordance with currently accepted professional principles, which included the appropriate cautionary instructions, and expiration date when applicable. Specifically, the facility failed to: 1. Ensure medications were stored under proper temperature controls in two of the two medication storage rooms observed. 2. Ensure staff labeled the open-date on multi-dose vials of biologicals with shortened dates of expiration once accessed, in one of the two medication storage rooms observed. 3. Ensure all drugs were properly contained in packaging with appropriate labeling in three of the four medication carts observed. 4. Ensure all drugs and biologicals remained in locked compartments with only authorized personal having access to the keys, when left unattended on the [NAME] Unit. Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, dated as revised [DATE], indicated but was not limited to the following: - Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (vile, bottle, inhaler) when the medication has a shortened expiration date once opened. - If a multi-dose vial of an injectable medication has been opened or assessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. - The facility should ensure that medications and biologicals for each Resident are stored in the containers in which they were originally received. - The facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Review of the facility's policy titled General Dose Preparation and Medication Administration, dated as revised [DATE], indicated but was not limited to the following: - The facility should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) - If a medication which is not in a protective container is dropped, the facility staff should discard it according to facility policy. Review of the facility's Clinical Nurse Highlight document titled Medication Storage, dated [DATE], indicated but was not limited to the following: - Medication carts are clean, stocked, and organized. - Medications are properly labeled with the patient name, lot number, and expiration date. 1. During an observation on [DATE] at 11:36 A.M., of the Care Plus unit's medication storage room, the following was observed by the surveyor and Unit Manager (UM) #1: - Two unsealed and punctured vials of tuberculin purified protein derivative (Tubersol) (an injectable solution used to test for Tuberculosis) without a storage bag from the pharmacy, were observed in the medication storage refrigerator without a date of initial vial entry written on either the vial or box. - One open and used single patient prefilled Insulin Lispro Injection KwikPen (a medication used to control blood sugar) was observed stored in the medication storage room's refrigerator, next to other unopened vials of the Resident's prescribed insulin. An open date of [DATE] was observed written on the pen. During an interview on [DATE] at 11:43 P.M., UM #1 could not identify when the two vials of tuberculin had first been used. She said the bottles are supposed to be marked when first opened and should not be in the medication refrigerator without a date. She said the two vials of tuberculin required disposal as there was no way of telling how long they had been opened for. UM #1 also said the open Insulin Lispro KwikPen should not have been stored in the refrigerator. She said when the Resident's insulin dose changed, the pen should have remained in the medication cart at room temperature until it had expired or have been placed in the facility's black box for disposal. Review of the manufacturer's instructions for use for the three milliliter (ml) single-patient-use Insulin Lispro Injection KwikPen, dated as revised February 2020, indicated but was not limited to the following: - In-use (opened) Insulin Lispro Injection vials and Insulin Lispro Injection prefilled pens should be stored at room temperature, below 86 degrees Fahrenheit and must be used within 28 days or discarded. Do not refrigerate (open, in-use). Review of the manufacturer's instructions for tuberculin purified protein derivative (Mantoux), (Tubersol), dated [DATE], indicated but was not limited to the following: - A vial of Tubersol which has been entered and in-use for 30 days should be discarded. - Discard opened product after 30 days. 2. During an observation on [DATE] at 12:06 P.M., of the [NAME] unit's medication storage room, the following was observed by the surveyor and UM #3: - One open bottle of Bayshore Ketotifen Fumarate ophthalmic solution 0.025% (an antihistamine, used to treat allergy symptoms occurring in the eye) stored in the medication storage room's refrigerator with an observed refrigerator temperature of 38 degrees Fahrenheit. - One open bottle of [NAME] Brimonidine Tartrate ophthalmic solution 0.2% (a medication used to treat high fluid pressure in the eye) stored in the medication room's refrigerator with an observed refrigerator temperature of 38 degrees Fahrenheit. Review of the manufacturer's drug facts printed on the label for the Ketotifen Fumarate ophthalmic solution 0.025% indicated the medication should be stored at a temperature between 68 to 77 degrees Fahrenheit. Review of the manufacturer's drug facts printed on the label for Brimonidine Tartrate ophthalmic solution 0.2% indicated the medication should be stored at a temperature between 59 to 77 degrees Fahrenheit. During an interview on [DATE] at 12:24 P.M., UM #3 said the observed eye drops stored in the medication storage room's refrigerator should have been stored according to the manufacturer's instructions, not in the refrigerator. 3. During an observation on [DATE] at 12:35 P.M., of the [NAME] unit's hall A medication cart, the following was observed by the surveyor and Nurse #7: - Approximately 24 whole and/or partially crushed tablets of various medications were observed loose within the bottom of the medication cart's second drawer. The tablets were all unidentified, without packaging or labeling. During an interview on [DATE] at 12:40 P.M., Nurse #7 said he did not realize there were loose pills in the medication cart and the overnight nurses were assigned to clean out the carts at night. During an interview on [DATE] at 12:55 P.M., UM #3 said the medication cart should be clean, without any loose medications. 4. During an observation on [DATE] at 1:36 P.M., of the [NAME] unit's A/C hall medication cart, the following was observed by the surveyor and Nurse #2: - Two loose medication tablets and several smaller pieces of crushed pharmaceutical debris were observed in the second drawer of the medication cart. The pills were unidentified, without packaging or labeling. During an interview on [DATE] at 1:45 P.M., Nurse #2 said she was unaware there were loose pills in the medication cart. During an observation on [DATE] at 2:16 P.M., of the [NAME] unit's hall B medication cart, the following was observed by the surveyor and Nurse #8: - One loose tablet of medication was observed in the second drawer of the medication cart without packaging or labeling. During an interview on [DATE] at 2:20 P.M., Nurse #8 identified the pill as likely 5 mg of Eliquis (a medication used to treat and/or prevent blood clots) by its appearance. She did not know which Resident was missing the prescribed tablet of medication. During an interview on [DATE] at 3:41 P.M., the Director of Nursing (DON) said it is the expectation that all medications are appropriately labeled, secured, and stored according to the pharmacy and manufacturer's instructions. She said she expects multi-dose medications to be dated when opened, if needed, and for medication carts to be clean, neat, and organized, and without any medication left out or loose and unlabeled in the cart. 48696

Based on observation, interview, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#139) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medications), out of 28 sampled residents. Specifically, the facility failed to: a. ensure staff labeled the enteral formula container and water flush bag with the Resident's name, date and time hung, the administration rate, duration, and initials of the staff member hanging them. b. ensure staff programmed the Resident's enteral feeding pump (device used to deliver nutrition to patients who cannot consume food and drink by swallowing) properly with the ordered frequency of water flushes (used to maintain patency and provide hydration) causing the Resident to not receive approximately 675 milliliters (ml) of water flushes in a 20- hour period (2pm-10am) between 11/12/23 and 11/13/23; and Findings include: Review of [NAME] Procedures, eight edition (2019), titled Tube Feedings, indicated but was not limited to the following: -Verify the practitioner's order, including the patient's identifiers; enteral feeding device; prescribed enteral formula; administration method, volume, and rate; and type, volume, and frequency of water flushes. -Make sure the enteral formula container is labeled with the patient's identifiers; formula name; date and time or formula preparation; date and time the formula was hung; administration route; rate of administration; administration duration (if cycled or intermittent); initials of who prepared, hung, and checked the formula against the order; expiration date and time. -Label the enteral administration set with the date and time that it was first hung. -Flush the enteral feeding tube with at least 30 milliliters (ml) of water as ordered. -If using an enteral feeding pump, follow the manufacturer's instructions for setting the flow rate and starting the infusion. -If you're administering a continuous feeding, flush the enteral feeding tube every 4 hours with at least 30 ml of water, as ordered and tolerated, to maintain patency and provide hydration. Complications: -GI and other systemic problems -Constipation from inadequate hydration -Fluid and electrolyte imbalances Resident #139 was readmitted to the facility in April 2023 and had diagnoses including cerebral vascular accident (CVA), dysphagia (difficulty swallowing), and gastrostomy status. Review of the Minimum Data Set (MDS) assessment, dated 10/10/23, indicated Resident #139 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and had a feeding tube. Review of Physician's Orders indicated the following: -Enteral feed order, every 6 hours pump to provide 225 ml of water every 6 hours, 9/19/23 -Hold enteral feed from 10am-2pm one time a day (off 10am-2pm), 2/9/23 -Jevity 1.5, 60 ml/hour x 20 hours enteral feed via G-tube (on 2pm-10am) every shift for feeding order, (off 10am-2pm), document every shift amount consumed in ml, 9/19/23 Review of the G-tube Placement care plan, initiated 2/20/23, indicated the following: Focus: -CVA with dysphasia and nothing by mouth, G-tube placement for nutrition and meds. Interventions: -Observe and report as needed and signs and symptoms of dehydration a. On 11/7/23 at 9:04 A.M., the surveyor observed Resident #139 lying in bed. An enteral formula container and water flush bag were hanging from an intravenous (IV) pole and attached to an enteral feeding pump. The pump was turned off. The enteral formula container and water flush bag were not labeled with the patient's name, date, and time the formula was hung, administration route, rate of administration, administration duration (if cycled or intermittent), initials of who prepared, hung, and checked the formula against the order, and the expiration date and time. Resident Representative (RR) #1 said the Resident had been vomiting that morning so staff turned off the pump. RR #1 said the Resident received nutrition through his/her G-tube only and did not receive oral intake due to a history of stroke. During an interview on 11/7/2 at 9:18 A.M., the surveyor asked Nurse #1 what the flow rate was for the enteral feeding. Nurse #1 said she thought it was 80 ml/hour. Unit Manager (UM) #2 entered the room and said 80 ml/hour was incorrect and she thought it was 65 ml/hour. UM #2 said the feeding container and water flush bag should have been labeled including the flow rate but were not. Nurse #1 said the feeding was placed on hold around 8:00 A.M. that morning after the Resident started vomiting and she was waiting for an x-ray and lab work prior to resuming it per physician's orders. During an interview on 11/7/2 at 12:43 P.M., the surveyor observed the enteral feeding container and administration set no longer hanging. UM #2 said it had been removed while they were awaiting orders from the physician. She said when it was hung it should have been labeled with the Resident's name, date, and flow rate on a sticker or on the container itself. During an interview on 11/13/23 at 12:04 P.M., UM #2 said whenever staff hang a new feeding container or flush bag, they should be labeling them. During an interview on 11/13/23 at 4:24 P.M., the Director of Nursing (DON) said the enteral feeding container should have been labeled with the Resident's name, time hung, date, room number, and initials of who's hanging it. She said the flush bag should be labeled as well and changed every 24 hours. She said if the container gets swapped out for a new one, that should be labeled as well. The DON said the feeding pump should have been set to allow the Resident to receive the flushes every 6 hours when it's running and should have been programmed per physician's orders. She said whatever nurse is working each shift should ensure the settings are correct. b. On 11/13/23 at 7:17 A.M., the surveyor observed Resident #139 lying in bed. His/her enteral feeding container was labeled as hung on 11/13/23 at 1:10 A.M. and was infusing via an enteral feeding pump set at 60 ml/hour. A 1000 ml water flush bag was attached to the administration set and feeding pump. The flush bag was labeled as being hung on 11/12/23 at 2:00 P.M. by Nurse #2 with an infusion rate of 225 ml every six hours. The feeding pump setting for the water flushes was observed programmed at 225 ml every 0 hours, not every six (6) hours per physician's orders. No flush volume was indicated on the pump as having been infused. The 1000 ml water flush bag still had 1000 ml remaining in the bag. The administration set failed to indicate Resident #139 had received approximately 675 ml of water flushes (225 ml every 6 hours) in a 20- hour period from 2:00 P.M. on 11/12/23 to 10:00 A.M. on 11/13/23 to help maintain patency of the G-tube and to provide hydration to the Resident per physician's orders. During an interview on 11/13/23 at 11:46 A.M., Nurse #2 said she was assigned to the Resident that day. She said the Resident received the enteral feedings from 2pm-10am every day, with the feeding turned off from 10am-2pm. Nurse #2 said the Resident was supposed to receive 225 ml of water flushes every 6 hours and said she was the nurse who hung the flush bag the day before on 11/12/23. She said the pump was programmed properly at that time. On 11/13/23 at 11:56 A.M., the surveyor and Nurse #2 entered Resident #139's room and reviewed the programmed settings on the enteral feeding pump. Nurse #2 said the feeding pump was incorrectly set and should have indicated the water flushes were to be administered every 6 hours, not every 0 hours. She said whoever hung the most recent feeding container that morning at 1:10 A.M. should have made sure the pump was programmed properly. Nurse #2 said the flush bag was still full and was the same one she hung the day before. Nurse #2 said Resident #139 did not receive any of the water flushes and would flush his/her G-tube manually at this time. Nurse #2 said she was also responsible to check the pump settings at the beginning of her shift but didn't that day. During an interview on 11/13/23 at 12:04 P.M., Unit Manager (UM) #2 said Nurse #10 was assigned to the previous overnight shift and hung the new feeding container at 1:10 A.M. that morning. She said staff should be making sure the pump is set at the right settings when they hang a new container and should also be checking the settings at the beginning of their shift to ensure they're set per physician's orders. Nurse #10 was not available for interview.

Based on observation, record review, policy review, and interview, the facility failed to develop and implement a baseline care plan within forty-eight hours of admission that included instructions necessary to provide individualized care, for two Residents (#513 and #461) that use oxygen, out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Baseline Care Plan, dated as revised August 2023, indicated but was not limited to the following: - A baseline care plan will be developed for every resident within 48 hours of admission - The baseline care plan will provide an initial set of instructions needed to provide effective and person-centered care that meets professional standards of care - The baseline care plan must include the minimum healthcare information necessary to properly care for a resident - A comprehensive care plan may be developed in place of the baseline care plan if developed within 48 hours of the resident's admission. 1. Resident #513 was admitted to the facility in October 2023 with diagnoses which included chronic respiratory failure with hypoxia (not enough oxygen in tissues to sustain bodily functions), oxygen dependent, and sleep apnea. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #513 had severe cognitive impairment with a score of 5 out of 15. Review of the current Physician's Orders, dated October 2023, for Resident #513 indicated but was not limited to the following: - Continuous Oxygen 1-3 Liters delivered by nasal cannula (device used to deliver supplemental oxygen) - Monitor oxygen saturations (percent of oxygen in your blood) every shift - Monitor lung sounds every shift Review of the baseline care plan failed to indicate any interventions or care strategies necessary for the delivery and maintenance of oxygen therapy. During an interview on 11/10/23 at 8:37 A.M., Unit Manager (UM) #1 reviewed the record for Resident #513 and said there is no care plan in place for the management of the resident's oxygen therapy. She said the Resident should have had one created upon admission and did not. 2. Resident #461 was admitted to the facility in November 2023 with diagnoses including: Metabolic encephalopathy and chronic atrial fibrillation (an irregular heartbeat). Review of the admission nursing assessment indicated Resident #461 was alert and oriented. During an interview on 11/7/23 at 8:32 A.M., Resident #461 said he/she was new to using Oxygen since being in the hospital prior to arriving at the facility. Review of the baseline and current care plans for Resident #461 failed to indicate the Resident used Oxygen. During an interview on 11/8/23 at 4:51 P.M., UM #1 said the Resident is new to Oxygen use and will self-remove it at times. She said the nurses are monitoring oxygen saturations and lung sounds. During an interview on 11/9/23 at 7:43 A.M., Nurse #5 said the Resident self-removes his/her Oxygen frequently and feels he/she doesn't need it, she said the Resident requires close monitoring because of this. During an interview with observation on 11/9/23 at 7:46 A.M., the surveyor observed Resident #461 lying flat in bed, without his/her Oxygen in place, holding the tubing in his/her right hand. The Resident said they take the Oxygen off when they feel they don't need it because it is new to him/her and they do not want to end up having to use it long term. During an interview on 11/10/23 at 8:16 A.M., Nurse #9 said baseline care plans are created off of the hospital discharge summary, admission assessment and needs of the Resident. She said since Oxygen is new to the Resident, a baseline care plan should be in place, as the Resident would have a respiratory risk by having a new oxygen need. During an interview on 11/10/23 at 8:37 A.M., UM #1 said a baseline care plan should be created for new admissions for anything specific to their needs and diagnosis. She said Resident #461 frequently removed his/her oxygen placing him/her at an increased risk. She said there should have been a baseline care plan for Resident #461 that should have reflected the Resident's individual needs, but it was missed, and one was not in place until after the surveyor inquired. 49425

Based on observation, record review, and staff interview, the facility failed to ensure that for two sampled Residents (#41 and #64) with indwelling urinary catheters, out of a total sample of 28 residents, that the Residents' dignity was maintained. Specifically, the facility failed: 1. For Resident #41, to consistently place the Resident's urinary catheter continuous drainage (CD) bag in a privacy bag. 2. For Resident #64, to ensure that the Resident's CD bag was consistently placed in a privacy bag. Findings include: 1. Record review on 11/07/23 at 2:35 P.M. indicated that Resident #41 had a #20 suprapubic tube (catheter to drain urine from the bladder) with a 30 cc (cubic centimeter) balloon. On 11/7/23 at 9:15 A.M., the surveyor observed Resident #41's CD bag to be completely full of dark, amber-colored urine. The CD bag was attached to the lower, right frame of the bed. The CD bag was not contained in a privacy bag to conceal it from the view of others and afford the Resident privacy. On 11/7/23 at 2:40 P.M., the surveyor observed Resident #41's CD bag to be 1/3 full and draining dark yellow urine. The CD bag was not contained in a privacy bag to conceal it from the view of others. On 11/9/23 at 8:24 A.M., the surveyor observed Resident #41 lying in bed in their room with the door open. The Resident's CD bag was hanging from the right side of the bed frame and visible from the doorway. The CD bag was draining dark yellow to amber-colored urine. The CD bag was not inside the blue privacy bag that was hanging next to it. On 11/10/23 at 10:00 A.M., the surveyor observed Resident #41 lying in bed. The CD bag was attached to the bed frame and was not enclosed in a privacy bag. During an interview on 11/10/23 at 10:15 A.M., Unit Manager (UM) #3 said that it is the facility practice that a Resident's CD bag should always be in a privacy bag to maintain the Resident's dignity. 42742 2. Resident #64 was readmitted to the facility in November 2023 with diagnoses including bacteremia (bacteria in the blood), acute cystitis (infection in any part of the urinary system, the kidneys, bladder, or urethra) and had an indwelling urinary catheter device (inserted into the bladder to drain urine). On 11/7/23 at 9:43 A.M. and 10:27 A.M., the surveyor observed Resident #64 in bed with the privacy curtain open. His/her Foley catheter drainage bag (collects urine) was hanging from the side of the bed draining yellow urine. The drainage bag was fully exposed and not placed in a privacy bag to conceal it from public view. On 11/7/23 at 10:29 A.M., Nurse #1 entered the room with the surveyor, looked at the drainage bag, and said it was draining then left the room. Nurse #1 did not place the drainage bag in a privacy bag or pull the privacy curtain closed. During an interview on 11/9/23 at 3:02 P.M., UM #2 said the catheter bag should have been placed in a privacy bag. On 11/13/23 at 7:15 A.M., the surveyor observed Resident #64 in bed with the privacy curtain partially closed. His/her Foley catheter drainage bag was hanging from the side of the bed draining yellow urine. The drainage bag was in a privacy bag, however, the privacy bag only partially covered the catheter bag and did not fully conceal it from public view. During an interview on 11/13/23 at 2:18 P.M., Nurse #1 said Resident #64's Foley catheter bag should have been placed in a privacy bag. During an interview on 11/13/23 at 4:58 P.M., the Director of Nursing said Foley catheters should have dignity covers on them.

Based on observation, interview, and record review, the facility failed to ensure one Resident (#139), out of a total sample of 28 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to consistently implement orders from the physician to apply Geri sleeves (provides protection to skin on the arms) to the Resident's bilateral upper extremities. Findings include: Resident #139 was readmitted to the facility in April 2023 and had diagnoses including cerebral infarction, aphasia (language disorder that affects a person's ability to communicate) and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 10/10/23, indicated Resident #139 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of current Physician's Orders indicated the following: -Geri sleeves at all times bilateral upper extremities every day shift for protection, may remove for care, 6/4/23 -Eliquis (anticoagulant, can cause bleeding and bruising) Oral Tablet 5 milligrams (gm), give 1 tablet via G-tube two times a day for clot prevention, 2/7/23 Review of the skin impairment care plan, initiated 6/4/23, indicated the following: Focus: -The resident has impairment to skin integrity of the right upper/outer forearm (discoloration) related to anticoagulant therapy and arm-rest placement Interventions: -Geri sleeves bilaterally, padded arm rests, 6/4/23 On 11/9/23 at 7:24 A.M., the surveyor observed Resident #139 lying in bed. The Resident did not have bilateral upper extremity Geri sleeves applied per physician's order to help prevent impairment to skin integrity and none were observed in the room by the surveyor. No staff were present providing care to the Resident and no family members were present. During an interview on 11/9/23 at 1:57 P.M., Resident Representative (RR) #1 said the Resident was supposed to be wearing the Geri sleeves because he/she is always scratching. On 11/13/23 at 7:17 A.M., the surveyor observed Resident #139 lying in bed. The Resident did not have bilateral upper extremity Geri sleeves applied per physician's order to help prevent impairment to skin integrity and none were observed in the room by the surveyor. No staff were present providing care to the Resident and no family members were present. The surveyor observed Resident #139 scratching with his/her right hand. A piece of gauze and paper tape was observed on the Resident's right upper forearm. Resident #139 said he/she didn't know why it was there and was unable to answer if he/she had had blood drawn or if there was a wound. During an interview on 11/13/23 at 7:20 A.M., Nurse #2 said the Resident was supposed to be wearing the Geri sleeves unless care was being provided to him/her and would get them for him/her. During an interview on 11/13/23 at 1:08 P.M., Certified Nursing Assistant (CNA) #3 said she was assigned to the Resident that day and wasn't sure whether the Resident had Geri sleeves on that morning or not or if he/she was even supposed to have them on. CNA #3 said she thought they stopped putting them on him/her because the Resident kept taking them off. During an interview on 11/13/23 at 1:10 P.M., Unit Manager (UM) #2 said the physician's order was for the Resident to wear the Geri sleeves at all times because he/she picks at his/her skin. UM #2 said the Resident should have been wearing them. During an interview on 11/13/23 at 4:24 P.M., the Director of Nursing (DON) said Resident #139 should have been wearing his/her Geri sleeves at all times to protect his/her fragile skin on his/her arms. The DON said he/she does scratch, has gotten skin tears, and takes aspirin.

Based on observation, interview, and record review, the facility failed to ensure the proper care and treatment of a midline catheter (long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medication into the bloodstream) device in accordance with professional standards of practice and facility policy/protocol for one Resident (#64), out of a total sample of 28 Residents. Specifically, the facility failed to: a. ensure staff labeled and changed the midline catheter's transparent dressing as needed when visibly soiled; b. ensure staff properly monitored the Resident's upper arm circumference measurement to rule out potential adverse events; and c. ensure staff obtained a baseline insertion external catheter length measurement and properly monitored subsequent measurements to rule out potential migration of the catheter and notify the physician if the length had changed since the last measurement. Findings include: Review of the facility's Skills Checklist: Management of Midlines and Central Venous Access Devices (CVADs), dated 2021, indicated but was not limited to the following: -Dressings will be labeled with nurse's initials, date, and time. -Transparent dressings are changed upon admission 24 hours post insertion, weekly, and as needed. -Upper arm circumference (10 centimeters (cm) above antecubital fossa) and external catheter length is measured, and compared to insertion measurements, on admission, weekly with dressing changes, and whenever question of possible migration. -Seven local/systemic complications and common signs and symptoms include a. Infiltration and extravasation: swelling around intravenous (IV) site, changes in skin temperature around site, pain at site. b. Phlebitis: erythema at access site, pain may or may not be present, red streak along vein, tenderness, warmth, swelling, palpable venous cord. c. Occlusion: unable to infuse, no blood return on aspiration. d. Infection: erythema, edema, induration, warmth and drainage at insertion site, elevated temperature. Resident #64 was readmitted to the facility in November 2023 with diagnoses including bacteremia (bacteria in the blood) acute cystitis (infection in any part of the urinary system, the kidneys, bladder, or urethra) and had an indwelling urinary catheter device (inserted into the bladder to drain urine). During an interview on 11/7/23 at 8:56 A.M., Unit Manager (UM) #2 said Resident #64 was being treated with IV antibiotics via a midline catheter device for a urinary tract infection (UTI) and sepsis (a life-threatening complication of an infection). Review of current Physician's Orders indicated the following: -Observe site before and after administration of intermittent medications and during dressing changes, confirm observation every shift, 11/1/23 -IV: midline catheter - measure circumference upper arm (10 centimeters (cm) above antecubital) as needed with transparent dressing change, 11/1/23 -IV: midline catheter - measure circumference upper arm (10 cm above antecubital) every seven days with transparent dressing change, 11/2/23 -IV: midline catheter site - change transparent dressing as needed with dressing change - measure external catheter length - notify physician if length has changed since last measurement, 11/2/23 -IV: midline catheter site - change transparent dressing every day shift every 7 days, change catheter securement device with dressing change. Measure external catheter length, notify physician if length has changed since last measurement, 11/2/23 a. On 11/7/23 at 10:29 A.M., the surveyor observed the Resident's right upper extremity midline catheter device with Nurse #1 who said Resident #64 was receiving IV antibiotics for a UTI. The transparent dressing was labeled as being last changed on 11/1/23. The dressing was not labeled with the time or the nurse's initials who changed it. The dressing was stained with a moderate amount of dried sanguinous (bloody) fluid obscuring the insertion site. Nurse #1 said she wasn't sure how long the Resident had had the midline as she was not familiar with him/her and wasn't sure what the policy was for changing the dressing if it was new. Review of Skilled/Nursing Progress Notes indicated but was not limited to the following: 11/3/23 (10:34 A.M.) - midline transparent dressing changed on 11/1/23, next change 11/8/23 11/3/23 (2:16 P.M.) - midline right upper extremity, old drainage noted 11/4/23 - old blood at IV insertion site 11/5/23 - old blood at site During an observation with interview on 11/7/23 at 12:39 P.M., the surveyor observed the Resident's midline dressing with Unit Manager (UM) #2. The transparent dressing was labeled with the date 11/1/23. The dressing was not labeled with the time or the nurse's initials who changed it per facility protocol. The dressing was stained with a moderate amount of dried sanguinous fluid obscuring the insertion site. UM #2 said the dressing was changed upon admission on 11/1/23 but probably should have been changed as needed since then. She said she couldn't visualize the insertion site due to the drainage. Review of the November 2023 Medication Administration Record indicated an initial dressing change was performed on 11/1/23 at 7:53 P.M. then changed on 11/7/23 at 2:26 P.M. by Nurse #1 as evidenced by her initials. During an interview on 11/13/23 at 2:06 P.M., Nurse #1 said the dressing should have been changed as needed if soiled. She said she changed the dressing on 11/7/23 because there was a bloody gauze underneath the transparent dressing, and it obscured the entry site making it difficult to monitor for migration (dislodgement at the entry site) and infection. During an interview on 11/13/23 at 3:02 P.M., UM #2 said the dressing should be changed within 24 hours of admission, then once a week, and as needed if soiled. During an interview on 11/13/23 at 5:33 P.M., the Director of Nursing (DON) said the Resident's midline dressing should be changed as needed because staff need to be able to monitor the site underneath. b. Review of the facility's Midline Catheter Order Sheet and Midline Placement hospital document indicated Resident #64's midline catheter was inserted on 11/1/23. The documents did not indicate a baseline arm circumference measurement for Resident #64. Review of the November 2023 Medication Administration Record (MAR) indicated an admission dressing change was performed on 11/1/23 with an arm circumference measurement documented as being 33 cm. Review of a Nurse Progress note, dated 11/7/23, indicated Nurse #1 changed the midline dressing on 11/7/23 and measured the arm circumference at 29 cm. Review of the November 2023 MAR failed to indicate the arm circumference measurement of 29 cm had been documented, which was four (4) cm different from the previous measurement. During an interview on 11/13/23 at 2:02 P.M., Nurse #1 said she should have documented the Resident's arm circumference measurement on the MAR for comparison but did not. She said she did not look at the previous measurement for comparison and did not know what the baseline measurement was. She said she measured above the insertion line but wasn't sure as to where above the line. During an interview on 11/13/23 at 5:08 P.M., the DON said part of the physician's order was to document the arm circumference on the MAR and, even though Nurse #1's measurement was smaller, Nurse #1 should have still documented her measurement on the MAR. Consulting Staff #1 said the proper way to measure was 10 cm above the antecubital. c. Review of the facility's Midline Catheter Order Sheet indicated a baseline total catheter length of 10 cm with an insertion date of 11/1/23. Review of the order sheet and hospital Midline Placement document did not indicate a baseline measurement for the exposed (external) catheter length for comparison to monitor for potential migration of the catheter. Review of the medical record failed to indicate a baseline external catheter length measurement was obtained until 11/7/23, six days after the Resident was admitted with the midline catheter. Review of a Nurse Progress Note, dated 11/8/23, indicated a clarification by Nurse #1 that the external catheter was 4.5 cm, not 14.5 cm. Review of a Nurse Progress Note, dated 11/9/23, indicated Nurse #2 removed the midline catheter and the total catheter length was 10 cm. Further review of the medical record failed to indicate Physician #1 was notified of the catheter length measurement discrepancies. During an interview on 11/13/23 at 1:59 P.M., Nurse #1 said potential complications with a midline catheter included migration and said she would know if it's migrated by looking at the insertion site and by measuring for any discrepancy. During an interview on 11/13/23 at 2:11 P.M., Nurse #1 said she measured the external length wrong, and it should have been 4.5 cm, not 14.5 cm but did not document that on the MAR. She said she could not recall what the baseline external catheter length measurement was but said potentially it could have migrated. Nurse #1 said she did not have a conversation with the physician regarding the discrepancy. During an interview on 11/13/23 at 2:49 P.M., UM #2 said she did not know where the baseline measurements were for the Resident's midline catheter. She said it was inserted in the hospital, but the information should be in the chart. UM #2 was unable to locate the hospital insertion record in the Resident's medical record and said she would have to ask UM #1. During an interview on 11/13/23 at 2:59 P.M., UM #2 said staff were supposed to measure the external catheter length from the insertion site to the hub to monitor for migration and notify the physician if any deviation in measurement. She said the goal was to monitor appropriately to avoid adverse outcomes. During an interview on 11/13/23 at 3:42 P.M., UM #1 said she helped the admitting nurse complete the facility's Midline Catheter Order Sheet on 11/1/23 and said she was told by the hospital that the baseline total catheter length was 10 cm. She said the exposed external length was not established or documented on the MAR until 11/7/23. UM #1 said the order, if entered correctly, should have prompted a baseline external catheter measurement during the initial dressing change but didn't. UM #1 said when she looked at the dressing, it had a half dollar amount of sanguinous fluid but told the nurse on the unit to not change it if it was inserted the same day. She said she wasn't sure if it was changed the next day or not. UM #1 said she did not get a baseline arm circumference measurement from the hospital, but a nurse documented on the MAR on 11/1/23 that it was 33 cm. She said it was the facility's baseline measurement. During an interview on 11/13/23 at 5:14 P.M., the surveyor reviewed the medical record with Consulting Staff #1 who said the baseline external catheter length was 10 cm but that was the whole catheter length, not the exposed catheter length measurement. She said that's the part that was missing. On 11/13/23 at 5:44 P.M., the Assistant Director of Nursing (ADON) provided the surveyor with the hospital Midline Placement document and said there were no baseline measurements written on it. During an interview on 11/13/23 at 5:23 P.M., Physician #1 said she was not notified of any measurement discrepancies and there were no adverse events associated with the midline that she knew of. She said she understood the surveyor's concern for potential migration, and it could have been how staff were measuring. Physician #1 said staff are to be looking for signs of migration. She further said staff should be changing the midline dressing as needed if actively draining blood to see what is underneath the dried blood to assess the insertion site for erythema, trauma, and swelling.

Based on policy review, record review and interview, the facility failed to ensure psychotropic medications in use by Resident #34 were necessary to treat targeted behaviors or a diagnosis, out of a total sample of 28 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, dated as revised 10/24/22, indicated but was not limited to the following: -Facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors -Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to use -Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. -All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for Efficacy, risks, benefits, harm or adverse consequences. -Antipsychotic medications used to treat behavioral or psychological symptoms of Dementia must be clinically indicated, and supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause -Facility staff should monitor the resident's behavior using a behavior chart or assessment -Facility staff should monitor behavioral triggers, episodes, and symptoms, and document the number and or intensity of symptoms and resident response to interventions. Resident #34 was admitted to the facility in October 2023 with diagnoses including non-Alzheimer's dementia. Review of the most recent Brief Interview for Mental Status (BIMS) indicated Resident #34 had severe cognitive impairment with a score 5 out of 15. Review of the current Physician's orders, dated 11/9/23, indicated active medication orders for but not limited to: - Seroquel (antipsychotic) 50milligrams (mg) by mouth at bedtime for Dementia Review of the consent form in use by the facility for Seroquel indicated the reason for the medication was to maximize function and reduction of agitated behaviors. Review of the current care plans for Resident #34 failed to indicate any targeted behaviors for the use of the antipsychotic medication. Review of the progress notes dated October 2023 through November 2023 failed to indicate any behaviors for psychotropic medication usage. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate targeted behaviors for psychotropic drug effectiveness. During an interview on 11/9/23 at 2:49 P.M., Nurse #3 said he did not know what behaviors the Resident was receiving the medication for, therefore unable to determine if the medication was effective. During an interview on 11/9/23 at 2:54P.M., Nurse #4 said he is not aware of any targeted behaviors, and there were none indicated for the use of the antipsychotic in the medical record. During an interview on 11/9/23 at 2:56P.M., Unit Manager #1 said the expectation is to have targeted behaviors documented to identify the effectiveness of psychoactive medications and for this Resident they are not. During an interview on 11/10/23 at 8:49 A.M., the Social Worker stated there was no documentation regarding targeted behaviors for the antipsychotic use in the record, therefore, the staff has no way to know if the medication was effective for the behaviors it is supposed to be used for. She said she placed the necessary information in the medical record, after the survey team brought it to her attention. 49425

Based on observation, interview, and policy review, the facility failed to ensure staff established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1. Ensure staff performed hand hygiene following interactions with quarantined residents; 2. Ensure staff wore personal protective equipment (PPE) in accordance with practice standards and facility policy; and 3. Ensure staff changed their PPE following interactions with COVID-19 positive residents. Findings include: 1. Review of the facility's policy titled Coronavirus (COVID-19), dated as revised 9/6/22, indicated but was not limited to: perform hand hygiene with soap and water or alcohol-based hand rub - before and after all resident care - after removing PPE Posted signs in use by the facility for Quarantine indicated: Droplet/Contact Precautions and further instructions as follows but not limited to: - in addition to standard precautions staff and providers must clean hands when entering and exiting the room On 9/27/22 at 8:41 A.M., the surveyor observed a quarantine sign outside the door of Resident #2's room and Certified Nursing Assistant (CNA) #1 assisting the Resident within the room. The surveyor did not observe CNA #1 perform hand hygiene (HH) upon exiting the room. During an interview on 9/27/22 at 8:42 A.M., CNA #1 reviewed the posted quarantine sign with the surveyor and said she should have performed HH upon exiting the room and she did not. During an interview on 9/27/22 at 12:37 P.M., the Infection Preventionist (IP) and the Director of Nurses (DON) said all staff are expected to sanitize their hands upon entering and exiting all resident rooms. 2. Review of the facility's policy titled Personal Protective Equipment (PPE) for [CONDITION(S)]-CoV-2, dated as revised 6/28/22, indicated but was not limited to: - to simplify implementation facilities in counties with substantial or high transmission may consider implementing universal use of N95 or equivalent for all healthcare personnel (HCP) during all patient care in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Review of Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, indicated but was not limited to the following: Source control options for healthcare personnel include: - A NIOSH-approved N95 or equivalent or higher-level respirator, or - A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators, or - A well-fitting facemask Review of the CDC literature titled How to use your N-95 respirator, dated 3/16/22, indicated but was not limited to the following: - N95s must form a seal to the face to work properly - Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears During an interview on 9/27/22 at 8:03 A.M., the IP said the county transmission level was substantial (orange). She said the PPE expectations in the facility were N95s and eye protection on any unit with COVID-19 positive residents. For individual residents, the staff are to follow the signs as posted outside of the residents' doors for further PPE instructions. She said both the Life Care plus and [NAME] units had COVID-19 positive residents. On 9/27/22 at 1:04 P.M., the surveyor observed Housekeeper #1, on the [NAME] unit, with only one strap securing her N95 to her face as she moved in and out of resident rooms. During an interview on 9/27/22 at 1:05 P.M., Housekeeper #1 said she was wearing the mask and couldn't understand what was wrong. During an interview on 9/27/22 at 1:06 P.M., the Housekeeping Supervisor said he trains his staff in conjunction with the IP and an N95 should be secured with two straps around the head. The Housekeeping Supervisor observed Housekeeper #1 and said her mask was not secured properly as it should have been. 3. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, indicated but was not limited to the following: Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility's policy titled Personal Protective Equipment (PPE) for [CONDITION(S)]-CoV-2, dated as revised 6/28/22, indicated the facility will utilize appropriate PPE during the COVID-19 pandemic in accordance with CMS and CDC guidance. It further indicated but was not limited to the following: - put on a N95 respirator before entering into a patient room, if not already wearing one as part of source control - disposable respirators should be removed and discarded after exiting the patient's room or care area and closing the door - put on eye protection upon entry to the patient room - remove eye protection after leaving the patient room to clean and disinfect On 9/27/22 at 8:09 A.M., the surveyor observed a red isolation precautions sign posted outside of Resident #1's room. Nurse #1 exited the room, and said the Resident was positive for COVID-19. The surveyor did not observe Nurse #1 change his N95 mask or clean his reusable eye protection. During an interview on 9/27/22 at 8:10 A.M., Nurse #1 said he believes he should change his N95 and disinfect his eye protection but was informed that they could reuse masks and eye protection in extended use while in an outbreak. He said there is always PPE available in the facility and he has never had a situation arise when PPE was not available. On 9/27/22 at 8:27 A.M., the surveyor observed Rehab Staff #1, wearing a N95 mask and eye protection, don (put on) a gown and gloves prior to entering the room of Resident #1. Upon exiting the room, the surveyor did not observe Rehab Staff #1 change her N95 mask or disinfect her eye protection. During an interview on 9/27/22 at 8:30 A.M., Rehab Staff #1 said she had just checked what the process would be prior to coming to the unit and was told they could use their N95 masks and eye protection repeatedly without having to change it or disinfect it, even when leaving a COVID-19 positive room. She said she has never had any concerns with not having enough PPE in the facility and was just following what she was told to do. During an interview on 9/27/22 at 12:37 P.M., the IP and DON said they are following guidance from 4/12/22. Review of the 4/12/22 guidance indicated you must clean eye protection and change masks in between residents, unless caring for residents all in the same cohort (ie: a COVID unit or all confirmed COVID cases). The IP said the facility did not create a COVID unit and was not meeting the expectation or following their protocols as they should have been. Review of the facility's policy titled Personal Protective Equipment (PPE) for [CONDITION(S)]-CoV-2, dated as revised 6/28/22, indicated but was not limited to the following regarding the managing of resources and PPE use: - estimate the quantities of essential care materials and PPE that would be needed during an eight-week outbreak - monitor daily PPE use to identify when supplies will run low; use the PPE burn rate calculator - work with local health department and healthcare coalition to address shortages - any anticipated supply shortages of PPE should be reported to the local and state public health agency During an interview on 9/27/22 at 1:58 P.M., the Administrator said they began extended use of N95 respirators and eye protection as a way of ensuring they would not run out of PPE since they had a significant number of COVID-19 positive cases. She said they never created a COVID dedicated unit or had all COVID-19 positive residents in the same area. She said they did not run out of PPE, nor did she think she would have a problem getting more PPE. She said she believed the facility was doing the right thing, but on review of the current guidance and facility policies realizes now they were not, as they did not have to use a contingency plan for supplies or declare any type of emergency or disaster within the facility.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when two staff members witnessed Nursing Assistant (NA) #1 approach Resident #1 and direct inappropriate and insulting words at him/her. Findings include: Review of the Facility's Residents Rights Policy, dated 06/08/20, indicated the Facility must treat each resident with respect and dignity and care of each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality life, recognizing each resident's individuality. The Facility must protect and promote the rights of the resident. Resident #1 was admitted to the Facility in October 2019, diagnoses included Dementia with Behavioral Disturbances, [CONDITION(S)], and hypertension. Review of Resident #1's Minimum Data Set Assessment, dated 07/01/22, indicated he/she was severely cognitively impaired and had an invoked Health Care Proxy (HCP). Review of the Facility's Internal Investigation, dated 08/15/22, indicated that Nurse # 1 and Nurse #2 both witnessed Nursing Assistant (NA) #1 approached Resident #1, point her finger at Resident #1's face, and say in Portuguese Puta, puta, puta. (translations in English, whore, slut, prostitute). The Investigation indicated Resident #1 did not understand what it meant and only speaks English. During an interview on 09/12/22 at 3:21 P.M., Nurse #1 said she was standing at medication cart when she saw Resident #1 coming out of his/her room toward the nursing station and that Resident #1 appeared to be upset. Nurse #1 said she heard Resident #1 say I am not going back in there. Nurse #1 said she went to see what was going on, provided reassurance to Resident #1, and seated him/her at his/her favorite spot in front of the fish tank. Nurse #1 said very shortly afterwards, NA #1 came up to the nursing station and also seemed upset. Nurse #1 said then NA #1 proceeded to go over to Resident #1, got in his/her face, pointed her finger, and said several words to Resident #1 in Portuguese. During an interview on 09/19/22 at 1:00 P.M., Nurse # 2 said she was seated at the nursing station, and witnessed NA #1 come to the nursing station and that NA #1 seemed upset. Nurse #2 said she attempted to speak to and calm down NA #1, but that NA #1 went over to Resident #1 (who was seated at the nursing station) and point her finger at Resident #1's face and repeatedly called Resident #1 a Puta. Nurse #2 said that she understood what Puta means in English, that you are calling someone a whore. Nurse #2 said she told NA #1 to leave the unit and reported the incident to DON. Nursing Assistant #1 declined the Department of Public Health's request for an interview. During an interview on 09/07/22 at 12:35 P.M., the Director of Nursing (DON) said she interviewed Nursing Assistant (NA) #1, who admitted to approaching Resident #1 and calling him/her a Puta. The DON said NA #1 stated Resident #1 had called her derogatory names, that Resident #1 had called her the N word, and said she (NA#1) felt humiliated, but continued to provide care for Resident #1. The DON said that NA #1 had difficulty accepting that she (NA #1) could not speak to residents like that. The DON said Resident #1 had no recollection of anything inappropriate being said to him/her. During an interview on 09/07/22 at 1:30 P.M., The Executive Director said she and the DON interviewed NA #1, and said NA #1 had a hard time with why it was ok for residents' to say to things to her like the N word, but that it was not ok for her to respond back. The Executive Director said NA #1 admitted she called Resident #1 a Puta. The Executive Director said she speaks Portuguese, and understood what Puta meant. On 09/07/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 8/15/22, Resident #1 was immediately assessed for any signs of injury or emotional distress, none were noted, and he/she continues to be monitored by staff, with support provided as needed. B. On 08/15/22, all residents on NA #1's assignment were immediately assessed for the potential to be adversely affected by the Facility's identified area of concern. C. On 08/15/22, clinical and management staff conducted resident interviews to ensure their safety and determined if there were any other concerns. D. Starting on 08/16/22 through 08/31/22, re-education was provided to the majority of facility staff by the Director of Nursing (DON), Assistant Director of Nursing (ADNS), and Nursing Supervisor on the following: - the definition of the Elder Justice Act on Abuse/Neglect: - coping skills related to complex or stressful situations. E. During the August 2022 monthly QAPI meeting, the committee reviewed and discussed the incident and area of concern. F. The QAPI committee will continue to review the issue for two months to ensure substantial compliance. G. The Director of Nursing and/or designee are responsible for overall compliance.

Based on interview and record review for one of three sampled residents (Resident #1), the Facility failed to ensure that Certified Nurse Aide (CNA ) #1 used a gait belt when walking Resident #1 on 6/26/14, in compliance with his/her plan of care and Facility Policy. CNA #1 followed Resident #1 with a wheelchair, but failed to place a gait belt around his/her waist, as she walked him/her to the morning activity. Resident #1 lost his/her balance, fell to the floor and sustained a non-displaced fracture of the left hip. Findings include: The annual Minimum Data Set (MDS) assessment, dated 5/7/14, indicated Resident #1 received a score of ten on the Brief Interview for Mental Status (BIMS) cognitive assessment, which denoted moderate impairment. The CNA Care Plan (undated) indicated Resident #1 required extensive assistance of one with a gait belt for walking. Resident #1's Care Plan for Activities of Daily Living (ADL) deficit, dated 5/14/13, indicated Resident #1 required assistance with walking. Approaches included: provide the amount of assistance/supervision that is needed (i.e. stand-by, cueing/prompting, contact guard, and weight bearing); and provide adaptive/safety equipment such as a wheelchair and front wheel walker. The Incident Follow-up and Recommendation Form, dated 6/27/14, indicated Resident #1 was ambulating with CNA #1 and a wheelchair following him/her. Resident #1 turned left, lost his/her balance and fell . The Form indicated Resident #1 had a score of 22 on the Fall Risk Assessment, which indicated he/she was at high risk for falls. The Surveyor interviewed the Director of Nurses at 8:30 A.M. and throughout the day on 7/10/14. The Surveyor interviewed Unit Manager #1 at 10:12 A.M. on 7/10/14. The Surveyor interviewed Nurse #1 at 10:00 A.M. on 7/10/14. The Director of Nurses, Unit Manager #1 and Nurse #1 said staff, including CNA #1, were aware of the Facility's policy and procedure which indicated gait belts were required when transferring and ambulating residents. The Surveyor interviewed CNA #1 at 11:37 A.M. on 7/10/14. CNA #1 said she usually used a gait belt, but on 6/26/14, Resident #1 looked strong, so she did not use it. CNA #1 said she walked behind him/her with a wheelchair. CNA #1 said Resident #1 lost his/her balance and fell on his/her left side. The Progress Note, dated 9:30 A.M. on 6/27/14, indicated Resident #1 transferred to the hospital, where he/she was diagnosed with [REDACTED].

Based on interview and record review for one of four sampled residents (Resident #1), the Facility failed to ensure that Resident #1's bed sensor alarm was functioning at the time of Resident #1's fall at 11:40 P.M. on 8/13/12. Staff found Resident #1 on the floor next to his/her bed and the bed sensor alarm failed to sound. Resident #1 sustained a left distal radial fracture. Nurse #1, Certified Nurse Aide #2, Certified Nurse Aide #4 and Certified Nurse Aide #5 indicated that Resident #1 had a history of [REDACTED]. The Director of Nursing said the Facility's protocol was to check all alarms for function at the beginning of each shift. Resident #1's alarm was not checked when Resident #1 was put to bed at 9:45 P.M., during rounds at 10:30 P.M. or at the beginning of the 11:00 P.M to 7:00 A.M. shift (night shift), per facility protocol and despite Resident #1's history of deactivating and silencing the sensor alarm. Findings include: The Face Sheet indicated Resident #1 was admitted to the Facility August, 2011, and [DIAGNOSES REDACTED]. The Fall Risk Evaluation Form, dated 7/13/12, indicated that Resident #1 received a total score of twenty. According to the Form, a score of ten or higher indicated that a resident was at risk for falls. Resident #1's Falls Care Plan, dated 4/24/12, indicated that Resident #1 was at high risk for falls. Interventions included safety alarms on bed and chair. The Care Plan further indicated that Resident #1 attempted self transfers, and at times he/she used items to cover bed/chair alarms to mask the sound. The quarterly Minimum Data Set (MDS) assessment, dated 7/10/12, indicated that Resident #1 had problems with temporal orientation (orientation to year, month and day) and recall. The physician's orders [REDACTED]. The Corrective Action Form, dated 8/15/12, indicated that on 8/13/12 at 11:40 P.M., Resident #1 fell and sustained a fracture. The Form also indicated the following. Upon investigation, it was determined that the Certified Nurse Aide on the 11:00 P.M. to 7:00 A.M. shift (Certified Nurse Aide #4) failed to perform safety device checks at 11:00 P.M. upon arrival for her scheduled shift per protocol, and did not perform walking rounds at the start of the scheduled shift. The Form indicated that all staff received education numerous times regarding walking rounds and safety device checks. The Surveyor interviewed the Director of Nursing on 10/3/12 at 9:00 A.M. The Director of Nursing said the Facility's protocol required that staff check the placement and function of alarms at the beginning of each shift and do walking rounds of the unit to ensure resident safety. The Director of Nursing said Resident #1's alarm should have been checked for function at 11:00 P.M. on 8/13/12, in compliance with this protocol. The Surveyor interviewed Certified Nurse Aide #2 on 10/3/12 at 2:50 P.M. Certified Nurse Aide #2 said Resident #1 had a history of [REDACTED]. Certified Nurse Aide #2 said Resident #1 may have disconnected the alarm on the night of the fall. The Surveyor interviewed Certified Nurse Aide #4 on 10/3/12 at 1:00 P.M. Certified Nurse Aide #4 said Resident #1 had a history of [REDACTED]. Certified Nurse Aide #5 wrote a statement, dated 8/14/12, for the Facility's internal Investigation. According to the statement, Resident #1 took off the sensor alarm or tried to hide it. The statement indicated that Resident #1 complained about the noise. The Post Fall Investigation Questionnaire and Witness Statement, dated 8/14/12, indicated that Nurse #1 did rounds at 11:00 P.M. and Resident #1 was in bed. The next time Nurse #1 saw Resident #1 was at 11:40 P.M., after a CNA (identified during the investigation as Certified Nurse Aide #2) informed her that Resident #1 was lying on his/her left side on the floor. The Witness Statement indicated that at times, Resident #1 unplugged the alarm or put blankets on top of it, so staff would not hear it ringing. The Surveyor interviewed Nurse #1 on 10/3/12 at 1:45 P.M. Nurse #1 said the alarm was not functioning at the time of Resident #1's fall. The Incident/Accident Report, dated 8/13/12, indicated that Resident #1 sustained a fracture of the wrist as a result of the fall. The Incident Narrative Investigation Report, dated 8/20/12, indicated that Resident #1 was placed in bed by CNA #1 at 9:45 P.M., after being toileted at 9:30 P.M. According to the report, CNA #1 said she placed the bed sensor alarm on the bed but she did not check its function at that time. CNA #1 previously checked the alarm's function at the start of her shift at approximately 3:00 P.M. The Report indicated that CNA #1 said she performed rounds at 10:30 P.M. and observed Resident #1 awake in bed. The Report indicated that staff said Resident #1 unplugged his/her safety devices and/or attempted to mute the devices by placing blankets over them. The Report indicated that at the time of Resident #1's fall, the bed sensor alarm was unplugged from the box. The Surveyor interviewed the Director of Nurses on 10/3/12 at 9:00 A.M. The Director of Nursing said bed and chair sensor alarms should be checked during rounds at the beginning of each shift. During rounds, Safety Device Sign Off Sheets were to be signed, to indicate that the checks were completed. The Director of Nursing said Resident #1's alarm was not checked at the beginning of the 11:00 P.M. to 7:00 A.M. shift on 8/13/12. The Safety Check Sign Off Sheet for August 2012 indicated that Resident #1's alarm was checked at the beginning of the night shift on 8/13/12. The Director of Nursing said that during the course of the investigation, however, it was discovered that this Sheet was not accurate. Although it was documented that Resident #1's alarm was checked, it had not been checked at the beginning of the night shift. Staff failed to check the function of Resident #1's alarm, per Facility protocol. Resident #1, who was identified as being at high risk for falls and having a history of deactivating and silencing the sensor alarm, fell and sustained a fractured left wrist.. .