Every finding on record at Maristhill Nursing & Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for 5 Residents (#56, #82, #62, #73 and #2) out of sample of 30 residents. Specifically,1. For Resident #56, the facility failed to set oxygen as ordered by the physician.2.For Resident #82, the facility failed to clean the concentrator filter as ordered by the physician.3. For Resident #62, the facility failed to clean the concentrator filter.4. For Resident #73, the facility failed to clean the concentrator filter, keep the water bottle off the floor and keep an oxygen cannula clean.5. For Resident #2, the facility failed to clean the concentrator filter and keep an oxygen cannula clean.Findings include:A review of the facility policy titled 'Oxygen Administration' with a revision date of 5/9/25 indicated the following: -Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences Resident #56 was admitted to the facility in May 2025 with diagnoses including tachycardia. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate impairment. On 9/30/25 at 8:34 A.M., the surveyor observed Resident # 56 sleeping, wearing a nasal cannula with Oxygen running at 3 Liters. On 10/1/25 at 7:38 A.M., the surveyor observed Resident #56 sitting in a chair next to his/her bed, wearing a nasal cannula. Oxygen was running at 4.5 Liters. A review of Resident #56's October 2025 physician's orders indicated the following: -PRN (as needed) at 1-2L to maintain O2 sat above 93% as needed for SOB (Shortness of Breath), start date 5/6/25. A review of a Comprehensive Metabolic Panel (CMP) dated 9/5/25, 7/7/25 and 6/14/25 respectively indicated the following Carbon Dioxide (CO2) levels, 35mmol/L (millimoles per liter) -High, 34mmoL/L (millimoles per liter) -High, and 37mmol/L (millimoles per liter) -High. (The normal reference range is 22-33mmoL/L (millimoles per liter). During an interview at 10/2/25 at 7:43 A.M., UM #2 said oxygen should be set as ordered. Unit Manager #2 said if the Resident changes the oxygen settings, the Nurses should make sure the Oxygen setting is correct at all times. During an interview, observation and medical record review on 10/2/25 at 7:01 A.M., the Surveyor, Director of Nurses, Nurse #7 and Nurse #8 observed Resident #56 sleeping, wearing the nasal cannula. The Oxygen level was set at 5 Liters. The DON, Nurse #7 and Nurse #8 said oxygen should be set as ordered by the physician. Nurse #8 and the DON reviewed Resident #56's physician's orders and said the Oxygen should be set at 1-2 Liters. The DON said if the Resident changes the oxygen setting, Nurses should make sure the settings are set correctly. The DON reviewed Resident #56's most recent Comprehensive Metabolic Panel (CMP) dated 9/5/25, 7/7/25, and 6/14/25. She said the Carbon dioxide (CO2) levels were high. The DON said if the Oxygen is set that high, the Resident is at risk of retaining CO2, which would then cause shortness of breath. Review of facility policy titled Oxygen Administration, dated as revised 5/9/25, indicated the following: -Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. -1. Oxygen is administered under orders of a physician except in the case of an emergency. -7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. 2. Resident #82 was admitted to the facility in June 2025 with diagnoses that included shortness of breath and COPD (Chronic Obstructive Pulmonary Disease). Review of the most recent MDS Assessment, dated 7/1/25, indicated a brief interview for mental status exam score of 15 out of a possible 15, indicating that the Resident was cognitively intact. The MDS also indicated the use of oxygen therapy. On 9/30/25 at 12:20 P.M., The surveyor observed the Resident sitting up in his/her chair. The Resident was receiving oxygen at 2.5 lpm (liters per minute) via nasal cannula. The filter on the oxygen concentrator was covered in a thick layer of dust. On 10/01/25 at 7:11 A.M., The surveyor observed the Resident sleeping in his/her bed. The Resident was receiving oxygen at 2.5 lpm via nasal cannula. The filter on the oxygen concentrator was covered in a thick layer of dust. Review of Resident #82's active Physician orders indicated the following: -Oxygen: Change tubing and clean air filter weekly, dated 6/6/25. Review of the Resident's active care plan, dated as initiated 4/14/25, indicated the following: The Resident has oxygen therapy r/t CHF, COPD exacerbations. During an interview on 10/1/25 at 9:50 A.M., Nurse #5 said that the night nurses clean or change the oxygen filters on the concentrators once a week. During an interview and observation on 10/1/2025 9:54 A.M., Unit Manager #1 said that the night nurses clean the filters weekly. The surveyor and the Unit Manager observed the oxygen concentrator filter for Resident #82 and he said it was dusty and dirty. He said the Resident could breathe that in and it should not be that dusty after just a few days. During an interview on 10/1/25a at 1:15 P.M., the Director of Nurses said that she would expect that the nurses are cleaning the entire filter not just the inside. She said that the dust build up could trigger a reaction for a resident if not cleaned properly and regularly. 3. Resident #62 was admitted to the facility in February 2025 with diagnoses including chronic obstructive pulmonary disease, heart failure and hemiplegia. Review of the Minimum Data Set assessment, dated 8/12/25, indicated Resident #62 was cognitively intact, scoring a 13 out of 15 on the Brief Interview for Mental Status exam. Further review indicated the use of oxygen therapy. On 9/30/25 at 8:05 A.M. the surveyor observed Resident #62 in bed receiving oxygen via nasal cannula. The surveyor also observed the oxygen filter to be covered in a thick covering of dust. On 10/1/25, at 9:00 A.M. the surveyor observed Resident #62 in bed receiving oxygen via nasal cannula. The surveyor also observed the oxygen filter to be covered in a thick covering of dust. 4. Resident #73 was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease and heart disease. Review of the minimum data Set assessment, dated 9/19/25, indicated Resident #73 was cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicted Resident #73 was receiving oxygen therapy. On 9/30/25 at 8:20 A.M. the surveyor observed Resident #73 in bed receiving oxygen (O2) therapy via nasal cannula. The surveyor also observed an O2 cannula on the wheelchair and an O2 bottle on the floor. The surveyor also observed the O2 filter to be covered in a thick covering of dust. 5. Resident #2 was admitted to the facility in May 2025 with diagnoses including chronic obstructive pulmonary disease, heart failure and diabetes. Review of the Minimum Data Set assessment indicated Resident #2 was cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #2 was receiving oxygen therapy. On 9/30/25 at 8:24 A.M. the surveyor observed Resident #2 in bed receiving oxygen (O2) therapy via nasal cannula. The surveyor also observed an O2 cannula on the wheelchair. The surveyor also observed the O2 filter to be covered in a thick covering of dust. During an interview on 10/01/25 at 10:15 A.M. Nurse #6 said that the O2 filters should be cleaned. During an interview and observation on 10/1/25 10:18 A.M., Unit Manager #1 said that the night nurses are supposed to clean the filters weekly.

Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards on three of three units. Specifically,1.The facility failed to ensure medications were labeled in accordance with acceptable professional standards, to include open dates on medications with shortened expiration dates in three medication carts on three of three units.2. The facility failed to secure and lock an unattended medication cart on the first-floor unit.Findings include:Review of the facility policy titled medication Storage, dated revised 5/9/25, indicated that all medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each mediation room. 1a. On 9/30/25 at 2:50 P.M. the surveyor observed the following in the first-floor medication cart: One bottle of Latanoprost eye drops (used to treat glaucoma) open, without a label. One bottle of Latanoprost eye drops not opened, received at the facility on 9/17/25. Review of the manufacturer's directions indicated refrigerating the eye drops until opened. One bottle of Liquacel liquid protein open, without a date opened. Review of the manufacturer's directions indicated to discard the bottle three months after opening. During an interview on 9/30/25 at 2:50 P.M. Unit Manager #1 said that the eye drops should be labeled with an open date when opened because they are only good for 30 days. He then said that he didn't know the liquid protein was good for only three months after opening. 1b. On 9/30/25 at 3:05 P.M. the surveyor observed the following in the third-floor medication cart: One bottle of injectable Lidocaine (used to prevent pain). One Arnuity Ellipta inhaler (used to treat asthma) open without a date opened and received from the pharmacy 7/7/25. Review of the manufacturer's directions indicated that the inhaler is good for six weeks after opening. One Incruse inhaler (used to treat asthma) open without a date opened and received from the pharmacy 5/3/25. Review of the manufacturer's directions indicated that the inhaler is good for six weeks after opening. During an interview on 9/30/25 at 3:05 P.M., Nurse #3 said that all the unlabeled medications should have been labeled with a date of when opened. 1c. On 9/30/25 at 3:10 P.M. the surveyor observed the following in the second-floor medication cart: Two tubes of Visguard eye lubricant open without a date opened and received from the pharmacy 8/14/25. One bottle of Timolol eye drops, open without a date opened and received from the pharmacy 7/16/25. One tube of Erythromycin eye ointment, open, without a pharmacy label or date opened. One bottle Netarsudil ophthalmic solution (used to treat glaucoma) open without a date opened and received from the pharmacy 4/21/25. One Trelegy inhalers (used to treat asthma) open without a date opened and received from the pharmacy 5/4/25. Review of the manufacturer's directions indicated that the inhaler is good for six weeks after opening. One Breo inhaler (used to treat asthma) open without a date opened and received from the pharmacy 12/12/24. Review of the manufacturer's directions indicated that the inhaler is good for six weeks after opening. One Breo inhaler open, without a date opened and received from the pharmacy 6/16/25. Review of the manufacturer's directions indicated that the inhaler is good for six weeks after opening. During an interview on 9/30/25 at 3:20 P.M., Nurse #2 said that all the unlabeled medications should have been labeled with a date of when opened. During an interview on 10/1/25, at 12:45 P.M., the Director of Nursing said that all inhalers, eye drops and other medications with shortened expiration dates after opening should be labeled with the date of when opened. 2. On 9/30/25 at 8:09 A.M., the surveyor observed an unlocked and unattended medication cart First Floor Unit. Two residents were observed sitting in the hallway in wheelchairs in close vicinity to the unlocked medication cart. The surveyor was able to gain entry to medication cart which was storing over the counter and prescription medications. During an interview and observation on 9/30/25 at 8:11 AM Unit Manager #1 said the medication carts should be locked when they are unattended by nursing staff. During an interview on 10/1/25 at 1:24 P.M., the Director of Nurses said that she would expect that all medication carts are locked when unattended by staff.

Based on observation and interview, the faciliy failed to 1. provide appropriate hand hygiene after glove changes and 2. appropriately label and date items in the unit kitchenettes on 2 of 3 units. Findings include: Review of the facility policy titled Hand Washing, dated 2021, indicated the following: When to wash hands: i: Before donning disposable gloves for working with food and after gloves are removed. Review of the facility policy, undated, indicated the following: Any items for residents must be labeled with name, room number, and date. All refrigerated commercially prepared items must be discarded within 72 hours. All home/or restaurant prepared foods must be discarded within 24 hours. The following observations were made in the first floor dining room on 9/30/25: 8:27 A.M. the server removed gloves, did not wash or sanitize, and put on new gloves.8:32 A.M., the server served one meal, took off his gloves and put new gloves on without performing hand hygiene.The server removed gloves and changed them without hand hygiene at 8:34 A.M., 8:35 A.M., 8:36 A.M., and 8:40 A.M.On 9/30/25 at 12:58 P.M. and 1:00 P.M., the server on the first floor removed gloves, placed them on the counter and put on new gloves without performing hand hygiene. During an interview on 10/1/25 at 9:30 A.M., the Food Service Director said that staff should perform hand hygiene when changing gloves. During an interview on 10/1/25 at 11:39 A.M., the Infection Preventionist said that when staff are changing their gloves, they need to sanitize their hands between glove use. 2. During an observation on 9/30/25 at 8:10 A.M., the following was observed in the second floor kitchenette.a fast food milkshake that was unlabeled and undated. a container of peppermint stick ice cream in the freezer that was unlabeled and undated. a container of expired eggnog that was unlabeled and undated.a blender bottle filled with some liquid that was unlabeled and undated.During an observation on 9/20/25 at 9:20 A.M., the following was observed in the 3rd floor kitchenette.a frozen cup of red substance that was unlabeled and undated. a container of ice cream that was unlabeled and undated. During an interview on 10/1/25 at 9:35 A.M., the Food Service Director said that food that is in the kitchenette should be labeled and dated when opened and kept for 72 hours, according to their policy. He said it is everyone's responsibility to throw food out of the fridge.

Based on observations and interview the facility failed to 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 diseases and infections. Specifically, 1. The facility failed to maintain Enhanced Barrier Precautions (EBP) while caring for a resident with a gastrostomy tube.Findings include:Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).Resident #53 was readmitted to the facility in September 2025 with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status. Review of the Minimum Data Set (MDS) Assessment, dated 8/11/25, indicated that the Resident was independent with cognitive skills for daily decision making. On 9/30/25 at 7:53 A.M. the surveyor observed Resident #53 in bed and receiving tube feeding. On the doorway of Resident #53's room was a sign indicating for staff to maintain Enhanced Barrier Precautions. On 09/30/25 at 7:57 A.M., the surveyor observed Nurse #4 with Resident #53. Nurse #4 entered the Resident's room with only gloves on and then elevated the head of the bed then assessed and touched the Resident's gastrostomy tube. On 9/30/25 at 8:06 A.M., the surveyor observed Nurse #4, while wearing only gloves, disconnect the Resident's tube feeding and check the Resident's vital signs. During an interview on 10/1/25 at 11:36 A.M., the Infection Preventionist said that Enhanced Barrier Precautions (EBP) are utilized during direct high contact care of a resident. Residents with foley catheters, feeding tubes, or open wounds would be on EBP. If a nurse is touching a feeding tube or disconnecting a tube feed, a gown should have been worn in addition to gloves. During an interview on 10/1/25 at 1:22 P.M., the Director of Nurses said that staff should be wearing a gown and gloves when managing the Resident's feeding tube feeding.

Based on observation, record review and interview the facility failed to assess two Residents (#10 and #18), out of a total sample of 30 residents, for the ability to self-administer medications and determine if it was clinically appropriate.Findings include:Review of the facility policy titled Resident Self Administration of Medication, dated revised 5/9/25, indicated that when determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following:a. the medications are appropriate and safe for administration.b. the resident's physical capacity to swallow without difficulty, open medication bottles .c. the resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for.d. the resident's capability to follow directions and tell time to know when to take the medications.e. the resident's comprehension of instructions . including the dose, timing and signs of side effects and when to report to staff. 1. Resident #10 was admitted to the facility in April 2025 with diagnoses including Alzheimer's disease, heart disease and diabetes. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #10 scored a 6 out of 15 on the Brief Interview for Mental status exam indicating severe cognitive impairment. On 10/1/25 at 7:35 A.M. the surveyor observed Resident #10 to have a bottle of tums, Nystop powder (a medicated antifungal powder) and artificial tears at the bedside on top of the over the bed table. Review of the physician's orders failed to indicate an order for the self-administration of medications. Review of the medical record failed to indicate Resident #10 was assessed for the ability to self-administer medications.2. Resident #18 was admitted to the facility in June 2024 with diagnoses including psychotic disorder and high blood pressure. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #18 was cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status exam. On 10/1/25 at 8:28 A.M. the surveyor observed Resident #18 to have a bottle of Nystop powder (a medicated antifungal powder) at the bedside on top of the over the bed table. During an interview on 10/1/25 at 8:28 A.M. Resident #18 said the antifungal powder was for red arms. Review of the physician's orders failed to indicate an order for the self-administration of medications. Review of the medical record failed to indicate Resident #18 was assessed for the ability to self-administer medications. During an interview on 10/01/25 at 10:15 A.M. Nurse #6 said that Residents #10 and #18 had not been assessed to have medications at bedside and they should not be there.

Based on observations, interviews, and record review, the facility failed to assess the use of an abdominal binder as a potential restraint for one Resident (#40) out of a total sample of 30 residents.Findings include:Review of the facility policy titled Restraint Free Environment, dated 5/9/25, indicated Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Resident #40 was admitted to the facility in March 2025 with diagnoses that included cerebral infarction, epilepsy, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 8/12/25, indicated he/she was assessed by nursing staff to have severe cognitive impairment. Further review of the MDS indicated no restraints used. Further review of the MDS indicated the Resident was dependent on staff for activities of daily living. Review of Resident #40's physician order dated 6/13/25, indicated Apply Abdominal binder every shift May remove for care/skin assessment/prn (as needed) for comfort. Review of Resident #40's care plans failed to indicate a restraint care plan or potential restraint. Review of Resident #40's medical record failed to indicate a restraint assessment was completed. During an interview on 10/1/25 at 9:15 A.M., Certified Nurse Aide (CNA) #1 said the Resident does try to pull out his/her g-tube (gastrostomy tube- a tube inserted through the abdomen that brings nutrition directly to the stomach) all the time and wears an abdominal binder to stop him/her from getting at it. During an interview and observation on 10/1/25 at 9:18 A.M., Nurse #1 said she is not sure if the Resident is able to remove the abdominal binder and wears it all the time to prevent him/her from removing his/her g-tube. Nurse #1 said she is not sure if a restraint assessment and care plan needs to be completed for the use of an abdominal binder. During an interview on 10/1/25 at 9:26 A.M., the Nursing Supervisor said an abdominal binder is not considered a restraint and would not need to be assessed. The Nursing Supervisor said it does restrict the resident from pulling out his/her g-tube. During an interview on 10/2/25 at 8:16 A.M., the Director of Nurses (DON) said a restraint assessment and care plan should be completed on a Resident who wears an abdominal binder.

Based on record reviews and interviews, the facility failed to ensure one Resident (#27) was free from unnecessary psychotropic medications by ensuring a reassessment of an as needed (PRN) dose of Haldol (an antipsychotic medication) after 14 days, out of a total sample of 30 residents. Findings include: Review of facility policy titled Use of Psychotropic Medication(s), dated as reviewed 5/9/25, indicated the following:-PRN (as needed) orders for antipsychotic medications only, shall be limited to 14 days with no exceptions, If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. Resident #27 was admitted to the facility in September 2025 with diagnoses that included dementia and parkinsonism. Review of Resident #27's most recent Minimum Data Set (MDS) Assessment, dated 9/15/25, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15, indicating that the Resident had moderate cognitive impairment. The MDS further indicated the use of antipsychotic medications on an as needed basis only. Resident #27 was unable to participate in an interview about his/her medications. Review of active physician orders, as of 10/1/25, indicated the following:-Haloperidol Lactate Oral Concentrate (an antipsychotic medication) 2 mg/ml, give 0.5 ml by mouth every 4 hours as needed for agitation only if combative, dated 9/9/25. Review of the medical record indicates that the as needed Haldol order remained an active order after 22 days. Review of the September 2025 Medication Administration Record (MAR) indicated that the Resident received as needed doses of Haldol on 10 occasions. Review of Nurse Practitioner (NP) progress notes dated 9/9/25, 9/16/25, 9/23/25 and 9/30/25 failed to address the use of Haldol. Review of Resident #27's care plan indicated the following:-The Resident uses psychotropic medication, Haldol, related to agitation/ anxiety as needed per hospice orders, initiated 9/11/25. During an interview on 10/1/25 at 12:52 P.M., Unit Manager #1 said that all psychotropic medications ordered on an as needed basis require a 14 day stop date and reevaluation by a provider. Unit Manager #1 said that hospice recommended continuing the order on 9/23/25 but there was not a Physician or Nurse Practitioner visit to assess the Resident and determine the need to continue, and there should have been. During an interview on 10/1/25 at 1:17 P.M., the Director of Nurses said that psychotropic medications, especially antipsychotic medications, require a 14 day stop date and reevaluation by the Physician or Nurse Practitioner for continued use. She said that continued use requires a face-to-face visit and the orders require a 14 day stop date.

Based on record review and interview, the facility failed to develop a person- centered comprehensive care plan for one Resident (#53) out of a total sample of 30 residents. Specifically, for Resident #53, the facility failed to develop a person-centered comprehensive care plan for a pacemaker.Findings include:Review of facility policy titled Use of Pacemaker, dated as revised 5/9/25, indicated the following:-All residents with a pacemaker will be monitored according to standard protocol and plan of care.-All documentation about the pacemaker will be placed in the residents' chart and part of their permanent record.-All immediate care staff will be aware that the resident has a pacemaker. Resident #53 was readmitted to the facility in September 2025 with diagnoses that included sick sinus syndrome. Review of the Minimum Data Set (MDS) Assessment, dated 8/11/25, indicated that the Resident was independent with cognitive skills for daily decision making. Review of the Physician Discharge Summary from the acute care hospital, dated 9/23/25, indicated the following:-history of SSS (sick sinus syndrome) s/p PPM (permanent pacemaker) 2014. Review of Resident #53's physician orders failed to indicate orders for monitoring to include the Resident's paced rate. Review of Resident #53's active care plan failed to indicate a plan of care around the management of a pacemaker, to include cardiologists name, the paced rate and next pacemaker check. Review of the Nurse Practitioner Progress note, dated 7/24/25, indicated the following:-5. Sick sinus syndrome Clinical Notes: S/p (status post) pacemaker previously, had replacement 5/30/25 Followed [by cardiology]. Review of Nursing progress notes dated 5/30/25 indicated the following:Resident returned from his/her cardio appointment, Pacemaker Generator Changed. Has dressing on his/her left side of the chest. Discharge instructions relayed to NP (Nurse Practitioner) and is in agreement. Instructions are Remove dressing on Wednesday, 6/4/25 and then apply dry and clean dressing for 4 more days, May shower after four days, do not remove steri strips they will fall off, report any bleeding or infection, Tylenol for pain, Limit arm motion and lifting for a week, Follow up in 2-3 Weeks. Patient is stable at this time. Plan of care ongoing. During an interview on 10/1/25 at 1:02 P.M., Unit Manager #1 said that residents who have a pacemaker should have a care plan indicating the cardiologist and paced rate of the pacemaker. Unit Manager reviewed the active medical record for Resident #53 and said that there was no active care plan present. Unit Manager #1 said that he is not sure if Resident #53 still has a pacemaker. During an interview and observation on 10/01/25 at 1:11 P.M., Resident #53 was observed sitting up in his/her wheelchair in the dining room. Resident #53 said that he/she has a pacemaker that was just replaced four months ago and pointed to his/her chest indicating the location of the pacemaker.During an interview on 10/1/25 at 1:20 P.M., the Director of Nurses said that when residents have a pacemaker, there should be an active person-centered care plan indicating the resident's cardiologist, manufacturer and paced rate.

Based on observation, record review and interview, the facility failed to ensure one Resident (#40) received care in accordance with professional standards of practice, out of a total sample of 30 residents. Specifically, for Resident #40, the facility failed to ensure nursing completed a weekly skin assessment per the physician order. Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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. Resident #40 was admitted to the facility in March 2025 with diagnoses that included cerebral infarction, epilepsy, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 8/12/25, indicted he/she was assessed by nursing staff to have severe cognitive impairments. Review of Resident #40's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation) 9/30/25, indicated he/she scored a 12 indicating high risk. Review of Resident #40's physician order dated 5/2/25, indicated Weekly Skin Assessment every day shift Friday. Review of Resident #40's September 2025 's Treatment Administration Record (TAR), indicated on 9/19/25 and 9/26/25 that the weekly skin check was completed. Review of Resident #40's medical record indicated the last completed skin check was on 9/12/25. The skin check from 9/12/25 indicated foot evaluation was completed and there was an open lesion noted to the left heel and the skin issue was not evaluated. During an interview and observation on 10/1/25 at 9:18 A.M., Nurse #1 said Resident #40 is at risk for skin breakdown and skin checks should be completed weekly and if the resident refuses a nursing progress should be written and not signed off on the treatment as administered. During an interview on 10/1/25 at 9:26 A.M., the Nursing Supervisor said if a skin check is completed it would be under the assessment tab in the electronic medical record and if the resident ever refused a weekly skin check, then a nursing note should have been written. During an interview on 10/2/25 at 10:02 A.M., the Director of Nurses (DON) said weekly skin checks should be completed weekly as ordered. Review of Resident #40's medical record failed to indicate the Resident refused the skin checks on 9/19/25 and 9/26/25.

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#40) who was assessed to be at high risk for developing pressure ulcers, out of a total sample of 30 residents. Specifically, for Resident #40, the facility failed to notify the provider of an open skin lesion of his/her left heel.Findings include: Resident #40 was admitted to the facility in March 2025 with diagnoses that included cerebral infarction, epilepsy, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 8/12/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Review of Resident #40's Braden Scale (Scale for Predicting Pressure Ulcer Risk Evaluation) 9/30/25, indicated he/she scored a 12 indicating high risk. Review of Resident #40's medical record indicated the last completed skin check was on 9/12/25. The skin check from 9/12/25 indicated foot evaluation was completed and there was an open lesion noted to the left heel and the skin issue was not evaluated. During an interview and observation on 10/1/25 at 9:18 A.M., Nurse #1 said he/she has a yellow scab about the size of a dime and is not sure how long the area has been there, but it needs a treatment, and his/her heels are red. During an interview on 10/1/25 at 9:26 A.M., the Nursing Supervisor said he does not remember completing the skin check on 9/12/25 that says there is an open area on the left heel. The Nursing Supervisor said if an area is identified on a skin check, then the doctor or Nurse Practitioner should have been notified, and a treatment should have been ordered if the area was open. Review of Resident #40's medical record failed to indicate an order was put in place for the open lesion on the left heel from 9/12/25 to 10/1/25. The medical record also failed to indicate that the doctor or nurse practitioner was notified or aware of the area on the left heel.

Based on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#53) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 30 sampled residents. Specifically, the facility failed to ensure that the head of the bed was elevated to prevent potential aspiration while receiving enteral feedings. Findings include: Review of facility policy titled Care and Treatment of Feeding Tubes, revised 5/9/25, indicated the following:-It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.-The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. Resident #53 was readmitted to the facility in September 2025 with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status. Review of the Minimum Data Set (MDS) Assessment, dated 8/11/25, indicated that the Resident was independent with cognitive skills for daily decision making. On 9/30/25 at 7:53 A.M. the surveyor observed the Resident lying flat in bed, awake. A tube feeding was running at 120 ml (milliliters) per hour. The Resident was restless and exhibiting a congested cough. A hard neck collar was in place on the Resident. The surveyor immediately notified the nurse. Review of Resident #53's active Physician orders indicated the following:-Jevity 1.2 cal at 120 ml/hr (milliliters per hour) x 14 hours from 6:00 P.M. to 8:00 A.M., dated 9/23/25.-Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped, dated 9/23/25. Review of the Nutrition Assessment, dated 9/24/25, indicated the use of tube feeding. During an interview and observation on 9/30/25 at 7:57 A.M. the surveyor reported to Nurse #4 that the Resident was lying flat, coughing and receiving his/her tube feeding. The nurse and the Unit Manager observed the Resident in bed. The nurse raised the head of the bed and said the Resident should not be lying flat in bed and should be at least 45 degrees elevation, but he/she was not. During an interview on 9/30/25 at 8:12 A.M., Unit Manager #1 said that the Resident was lying flat and should not have been. He said that the Resident should have been elevated at least 45 degrees. During a follow up interview on 10/1/25 at 1:01 P.M., Unit Manager #1 said that he interviewed a Certified Nurses Aide who had assisted the Resident around 7:00 A.M. the previous day and put the head of the bed down to perform care and forgot to put the head of the bed back up. He said this placed the Resident at risk of aspiration. During an interview on 10/1/25 at 1:22 P.M., the Director of Nurses said that the head of the bed should be elevated at least 30-45 degrees when a Resident is receiving a tube feeding to prevent the risk of aspiration.

Based on observations, record and interviews, the facility failed to provide behavioral health care services in a person-centered environment for one Resident # 88 out of a sample of 30 Residents. Specifically, the facility failed to implement psychiatric recommendations provided after the Resident expressed suicidal ideations. Findings include: A review of the facility policy titled 'Behavioral Health Services' revised 5/9/25 indicated the following:-It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychological functioning and well-being.-The facility will ensure that necessary behavioral health services are person centered and reflect the resident's goals of care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety.Resident #88 was admitted to the facility in September 2021 with diagnoses including suicidal ideations and multiple sclerosis.A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating moderate impairment.A review of Resident #88's psychiatric note dated 6/6/25 indicated the following:-Psych progress notes-HPI (History of Present Illness): Asked to see the pt (patient) in order to evaluate the safety of giving him/her back colored pencils and sharpener, in light of his/her recently trying to cut himself/herself with a plastic knife, I believe. At 4 pm, pt (patient) in gown in bed. Alert, responsive, O x 3 (Oriented to person, place and time. Affect [NAME] (cooperative), polite, able to smile and laugh at times. Pt (patient) describes continuing thoughts of desire to cut himself/herself. He/she says he/she has cut his/her wrists off and on over the decades, never required suturing but may have led to his/her stay at a psychiatric hospital in his/her 40s. [sic]Recommendations:-Given his/her persistent thoughts of hurting him/herself, I would not return his/her pencils and sharpener. [sic]A review of Resident #88's care plan initiated 8/20/25 indicated the following intervention:-Resident is allowed to have colored pencils for coloring but no pencil sharpeners, staff will sharpen his/her pencils for him/her when it is needed.On 9/30/25 at 1:22 P.M., the surveyor observed sharp coloring pencils on the Resident's windowsill.During an interview on 9/30/25 at 1:22 P.M., Resident #88 said he/she loves to use coloring pencils to color. He/she said coloring is his/her favorite activity. He/she said staff are always available to give him/her the coloring pencils on the windowsill whenever he/she wants to color. The Resident said he/she last used the coloring pencils about 2-3 weeks ago.On 10/1/25 at 7:48 A.M., the surveyor observed Resident #88 getting prepared for Activities of Daily Living Care, (ADL) by a Certified Nurse's Assistant (CNA#2). Sharp coloring pencils in a carton, and sharp coloring pencils in a pencil holder were observed on the Resident's windowsill.During an interview on 10/1/25 at 7:49 A.M., CNA #2 said she takes care of the Resident most mornings. She said if the Resident requests his/her coloring pencils, she gives them to him/her because he/she likes to color. On 10/2/25 at 7:09 A.M., the surveyor observed Resident #88 sleeping, a box of sharp coloring pencils, and sharp coloring pencils in a pencil holder were observed on the Resident's windowsill.During an interview on 10/1/25 at 12:11 P.M., the Activities Director said Resident #88's favorite activity is coloring. The Activities Director said he/she loves to use coloring pencils instead of crayons because he/she loves how they color. The Activities Director said the Resident does not participate in most public activities; he/she loves to color in his/her room. The Activities Director said staff are always available to give him/her coloring pencils as he/she is not able to transfer on his/her own.During an observation, interview and medical record review on 10/2/25 at 7:26 A.M., Unit Manager #2 observed the sharp coloring pencils on the Resident's windowsill with the surveyor. The Unit Manager reviewed the 6/6/25 psychiatric recommendation and said Resident #88's psychiatric recommendations should be followed at all times since the Resident has a history of suicidal ideations.During an observation, interview and medical record review on 10/2/25 at 8:08 A.M., the Social Worker and the surveyor observed sharp coloring pencils on the Resident's windowsill. The Social Worker reviewed the 6/6/25 psychiatric recommendation and said if the psychiatric recommendations do not recommend sharp coloring pencils, the sharp coloring pencils should not be in the Resident's room.During an interview and medical record review on 10/2/25 at 8:10 A.M., the Director of Nurses reviewed the 6/6/25 psychiatric recommendation and said psychiatric recommendations should be followed and implemented in the Resident's plan of care.During an interview on 10/2/25 at 9:30 A.M., the Psychiatrist said all the recommendations he makes should be implemented in the plan of care. The Psychiatrist said he has no concerns with Resident #88 having sharp coloring pencils in his/her room but could not provide documentation that stated so. The Psychiatrist said the facility asked him to write a late entry progress note today indicating he did not have any concerns with the Resident having sharp coloring pencils in his/her room.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required assistance from staff with personal hygiene, the Facility failed to ensure that during the provision of personal care that staff took necessary steps to maintain his/her safety to prevent an incident resulting in an injury, when on 01/22/25, a Certified Nurse Aide (CNA) used an electric curling iron to curl Resident #1's hair, he/she sustained a second-degree burn (partial thickness, involves both the outer (epidermis) and underlying layer (dermis) of skin, they cause pain, redness, swelling, and blistering) to the upper left side of his/her forehead, which required treatment. Findings Include: Review of the Facility's Policy titled, Electric Safety for Residents, dated as revised January 2011, indicated that the resident will be protected from injury associated with the use of electric devices, including electrocution, burns and fire. Review of the Facility's Policy titled, Activities of Daily Living (ADLs), Supporting, dated as revised March 2018, indicated the following: -residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene -appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care) Resident #1 was admitted to the Facility in January 2025, diagnoses included polyosteoarthritis (arthritis in five or more joints), hypertension, atrial fibrillation, weakness, and hyperlipidemia (high cholesterol). Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she was alert, oriented, cognitively intact, able to make his/her own decisions and required staff assistance with personal hygiene. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/26/25, indicated that on 01/22/25 Resident #1's nursing assistant brought her curling iron to work and at approximately 11:30 A.M. the nursing assistant proceeded to comb and curled Resident #1's hair, while in the process he/she sustained a burn on the left upper side of his/her forehead measuring 2.0 centimeters (cm) by 0.3 cm. Review of Resident #1's Nurse Progress Note, dated 01/23/25, (written by Nurse #2), indicated that around 4:00 P.M. Nurse #2 noticed skin redness with peeled skin on Resident #1's left upper forehead measuring 2.0 cm by 0.3 cm. The Note indicated that Nurse #2 asked Resident #1 what happened, he/she stated that the morning Certified Nurse Aide (CNA) (later identified as CNA #1) accidentally touched the curling iron to his/her forehead yesterday (01/22/25), when she (CNA #1) was curling his/her hair. The Note further indicated that the on-call provider was notified and gave an order to apply Vaseline to the affected area (left upper forehead) daily for seven days. During an interview on 02/24/25 at 10:25 A.M., Resident #1 said CNA #1 had brought her own curling iron to work (could not recall exact date) to curl his/her hair and said he/she got a burn mark on his/her forehead from the curling iron. Resident #1 said he/she felt the curling iron burn his/her forehead, did a little jump and said, ouch, that hurts, and CNA #1 stopped curling his/her hair the minute it happened. Resident #1 said the skin on his/her forehead peeled off, got crusty, and the nurses were putting some type of cream on the burn to his/her forehead. During an interview on 02/25/25 at 2:25 P.M., Nurse #3 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/22/25 and 01/23/25 and was assigned to Resident #1 on both days. Nurse #3 said on 01/22/25 she was not aware that CNA #1 had curled Resident #1's hair with a curling iron. Nurse #3 said she did not notice a red area on Resident #1's forehead either day (01/22/25 or 01/23/25) because Resident #1's hair covered his/her forehead and that he/she had not complained of any pain or discomfort. During an interview on 02/24/25 at 2:52 P.M., (which included review of her written statement) Nurse #2 said on 01/23/25 around 4:00 P.M. she went to take Resident #'1 vital signs, noticed that he/she had an area of redness on the upper left side of his/her forehead with a piece of skin peeling off and measured the red area to be 2.0 cm by 0.3 cm. Nurse #2 said she asked Resident #1 if he/she fell or bumped his/her head and said Resident #1 told her that CNA #1 had touched his/her forehead with a curling iron yesterday (01/22/25). Nurse #2 said she notified the on-call provider and obtained an ordered to apply Vaseline daily for seven days to the affected area. During an interview on 02/24/25 at 1:54 P.M., CNA #1 said she worked the 7:00 A.M. to 3:00 P.M. shift on 01/22/25 and was assigned to provide care to Resident #1. CNA #1 said on 01/22/25 she had extra time and decided to curl Resident #1's hair because she wanted him/her to look pretty. CNA #1 said she went to her car to get her curling iron and brought it into the Facility. CNA #1 said she curled the sides and back of Resident #1's hair first then curled his/her bangs downward towards his/her forehead with the curling iron. CNA #1 said she held the curling iron in place for about two seconds because Resident #1's hair was very fine and thin. CNA #1 said the curling iron was hot and close to Resident #1's forehead, but she did not see or realize that the curling iron had touched his/her forehead and said that Resident #1 did not flinch or say anything while she curled his/her hair. CNA #1 said she was assigned to Resident #1 the following day (01/23/25), said she did not notice any redness or burn mark on his/her forehead, and that if she had seen an area on his/her forehead she would have told the Unit Manager immediately. CNA #1 said she did not know that she could not bring a curling iron into the Facility to curl a resident's hair and said if she had known she would not have brought the curling iron into work to curl Resident #1's hair. Review of Resident #1's Physician Progress Note, dated 01/24/25, indicated Resident #1 was seen after he/she experienced some kind of burn on his/her forehead and the burn mark had blistering. Review of Resident #1's Physician Orders, dated 01/24/25, indicated to discontinue Vaseline and to apply Silver Sulfadiazine (a topical antibiotic used to treat and/or prevent infection to second and third-degree burns) to forehead twice daily. Review of Resident #1's Nurse Progress Note, dated 01/24/25, (written on the 3:00 P.M. to 11:00 P.M. shift by Nurse #2), indicated that Resident #1 had a burn on his/her upper left forehead with visible redness, and little swelling measuring 2.0 cm by 0.3 cm. Nurse #2 said on 01/24/25 Resident #1's burn to his/her forehead still had redness with some swelling and a small area that was yellow in color. Nurse #2 said that Resident #1 was seen by the Physician earlier that day (01/24/25) and the treatment order to his/her forehead was changed to Silver Sulfadiazine twice a day. During an interview on 02/25/25 at 11:59 A.M., the Physician said he saw Resident #1 on 01/24/25, he/she had sustained a second-degree burn to his/her forehead. The Physician said Resident #1's burn was red with a blister, and said he gave an order to apply Silver Sulfadiazine twice a day. Review of Resident #1's Nurse Practitioner Progress Note, dated 01/27/25, indicated that Resident #1 had a scabbed (dry, crusty layer that forms over a wound) abrasion to his/her forehead (hairline) after he/she was noted to have a burn. During an interview on 02/24/25 at 12:15 P.M., the Nurse Practitioner (NP) said when she saw Resident #1 on 01/27/25, the burn to his/her forehead was pink with a scabbed over appearance and that she gave an order for a wound consult to be done as a second set of eyes. Review of Resident #1's Physician Orders, dated 01/27/25, indicated for nursing to arrange for a wound consult for his/her forehead wound. Review of Resident #1's Initial Wound Evaluation and Management Summary, dated 01/30/25 (written by the Wound Physician), indicated Resident #1 had a burn wound with undetermined thickness to his/her forehead from a curling iron, measuring 1.0 cm in length by 2.0 cm in width, depth was un-measurable due to the presence of dried fibrinous exudate (type of inflammatory fluid that forms in response to tissue injury), and the scabbed area measured 1.70 cm. The Summary indicated that Resident #1's wound was undergoing autolytic debridement (method of wound care that uses the body's own enzymes to remove dead tissue) and to apply Silver Sulfadiazine once daily for 30 days. During an interview on 02/25/25 at 11:33 A.M., the Wound Physician said he saw Resident #1 on 1/30/25 for a burn to his/her forehead which had a scab over it. The Wound Physician said if there is a scab over a wound, he cannot determine the depth or thickness of the wound and said that Resident #1's burn was a second-degree burn because first-degree burns do not scab over. During a telephone interview on 02/25/25 at 1:17 P.M., the Director of Nursing (DON) said Resident #1 sustained a second-degree burn to his/her forehead from a curling iron that CNA #1 used to curl his/her hair. The DON said CNA #1 should not have brought in her own personal curling iron into the Facility to curl Resident #1's hair because it was not in her (CNA #1) scope of practice and said that CNA #1 was not a licensed hairdresser. The DON said that CNAs should only be washing residents' hair, towel drying, and brushing and combing their hair. The DON said it is her expectation that all nursing staff abide to the Facility's policy for providing ADLs to residents and not to use electric hair styling devices on residents.

Based on observations, record review and interview, the facility failed to implement treatment orders recommended by the Wound Physician for three Residents (#74, #40 and #55) out of a total of 22 sampled Residents. Specifically: 1. For Resident #74, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 2. For Resident #40, the facility failed to implement the Wound Physician's treatment order for offloading heels while in bed. 3. For Resident #55, the facility failed to transcribe and consistently implement a treatment order for wound care to the coccyx as ordered by the Wound Physician. Findings include: Review of the facility policy titled Pressure Ulcers, dated and revised 1/27/21 indicted the following: - The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. - The Unit Nurse will: provide wound care as prescribed by the physician 1. Resident #74 was admitted to the facility in March 2024 with diagnoses including venous insufficiency, pressure ulcer to right heel and muscle weakness. Review of Resident #74's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she is cognitively intact. The MDS also indicated Resident #74 is dependent on staff for all bed mobility tasks. On 10/8/24 at 7:37 A.M., Resident #74 was observed lying in bed with both heels directly on the bed. On 10/9/24 at 6:52 A.M., Resident #74 was observed lying in bed with both heels directly on the bed. Two pressure relieving boots were observed on the chair next to the bed. During an interview at this time, Resident #74 said he/she does not wear the pressure relieving boots while in bed. During observations on 10/9/24 at 8:33 A.M. and 9:20 A.M., Resident #74 was observed lying in bed with both heels directly on the bed. Review of the Wound Physician note dated 10/3/24, indicated Resident #74 has a stage 4 pressure wound to the right heel that has been present for over 206 days. The Wound Physician recommended the following: -Off-load wound; Pressure off-loading boot. Review of Resident #74's physician orders indicated the following order: -Pressure relief boots to both feet every shift, every shift for wound care, initiated on 6/14/24. Review of Resident #74's skin impairment care plan, last revised, 7/9/24, indicated the following interventions: -Administer treatments as ordered and monitor for effectiveness. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. During an interview on 10/9/24 at 10:04 AM Nurse #4 and Nurse #5 said Resident #74 has an open wound to his/her right heel and should have pressure protective booties. Both nurses said all recommendations from the wound doctor should be followed. During an interview on 10/09/24 10:23 A.M., the Director of Nursing said she would expect all recommendations from the Wound Physician to be followed. 45984 2. Resident #40 was admitted to the facility in March 2021 with diagnoses including type 2 diabetes mellitus and non-pressure chronic ulcer of the right heel and midfoot. Review of Resident #40's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental Status score of 0 out of 15 indicating severe cognitive impairment. Further review of Resident #40's MDS indicated he/she is at risk for developing pressure ulcers/injuries and currently has one stage 3 pressure ulcer. The MDS further indicated that the Resident requires substantial/maximal assistance with all activities of daily living. The surveyor made the following observations: - On 10/8/24 at 7:38 A.M., Resident #40 was sleeping in his/her bed, his/her heels were directly on the mattress. A pressure relieving boot was observed behind the Resident's television. - On 10/9/24 at 7:22 A.M. and 8:15 A.M., Resident #40 was sleeping in his/her bed, his/her heels were directly on the mattress. A pressure relieving boot was observed behind the Resident's television. Review of Resident #40's physician's order dated 7/29/24 indicated the following: - Offload right heel in foam boot when in bed every shift for wound treatment Review of Resident #40's most recent Wound Evaluation dated 10/3/24 completed by the wound doctor indicated the following: - Non-Pressure wound of the right heel full thickness, Recommendations: off-load wound; float heels in bed Review of Resident #40's care plan for potential for pressure ulcer development dated and revised 2/22/23 indicated the following interventions: - Follow facility policies/protocols for the prevention/treatment of skin breakdown Review of Resident #40's skin check dated 10/8/24 indicated the following: - Skin issue #002: Right heel, issue type: pressure ulcer/injury. Pressure ulcer staging: stage 4 pressure ulcers During an interview on 10/9/24 at 8:19 A.M., Nurse #1 said Resident #40 has a pressure ulcer to his/her right heel. The surveyor and Nurse #1 observed Resident #40's right heel which was treated with a bandage and was directly on the mattress. Nurse #1 said she was not sure if his/her right heel should be offloaded. The surveyor showed Nurse #1 Resident #40's offloading boot behind the television and she was not sure why it was there. Nurse #1 and the surveyor reviewed Resident #40's physician's orders and Nurse #1 said Resident #40 should be wearing the boot while in bed to offload his/her heel. During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing said physician's orders should be followed and Resident #40 should be wearing a boot on his/her right heel to offload his/her heel. 46339 3. Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, pressure ulcer of the buttock. Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident had a stage 2 pressure ulcer. Review of Resident #55's nurses notes dated 8/12/24 indicated the following: - Seen by NP (Nurse Practitioner) today. Family member was in and so was Hospice nurse. Coccyx needs calazinc and silverdene 3xaday. Review of physician orders indicated the following. -Order date 8/9/24: Barrier cream to buttocks every day shift for skin tear. -Order date 8/12/24: Apply half [NAME] zinc half silverdene to coccyx area three times a day for open area to coccyx. Review of the Treatment Administration Record (TAR) from 8/12/24 to 10/10/24 failed to include documentation to support that nursing transcribed the order for half [NAME] zinc half silverdene to coccyx area three times a day for open area coccyx. Therefore, there was no documentation to support that nursing was consistently implementing the physician's order for wound care. During an interview on 10/9/24 at 2:05 P.M., Unit Manager #1 said when orders are received, they should be transcribed accurately to show on the TAR. During an interview on 10/10/24 at 8:17 A.M., the Director of Nursing said the treatment should have been scheduled to appear on the TAR. The documentation was put under no documentation category and the nurses would have not been able to see if a treatment order had been scheduled in the TAR.

Based on observation and interview, the facility failed to ensure staff followed proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Review of the facility policy titled, General Food Preparation and Handling, dated 2021, indicated the following: -Bare hands must never touch ready to eat raw food directly. Disposable gloves are single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and off after removing gloves. On 10/8/24 at 8:12 A.M., the following was observed on the third-floor unit during the breakfast meal: -The server changed gloves twice without washing his hands in between. -The server touched the serving utensils, plastic wrap, plates and toaster buttons potentially contaminating his gloves. He then put eight pieces of toast into and out of the toaster and buttered them with the potentially contaminated gloves. On 10/8/24 at 12:54 P.M., the following was observed on the third-floor unit during the lunch meal: -The server prepared a tuna fish sandwich while wearing one glove. The server touched the bread packaging and the serving utensil to scoop the tuna, potentially contaminating the one glove. The server then made the sandwich and with both the gloved and bare hand, held the bread to cut it and place it on a plate. On 10/9/24 at 8:42 A.M., the following was observed on the third-floor unit during the breakfast meal: - The server was wearing a glove on one hand. With the gloved hand, touched utensils, and the bread packaging, potentially contaminating the glove. He then opened a package of bread and with the potentially contaminated gloved hand removed pieces of bread to place them in the toaster. He then removed the bread and placed on the serving station using the gloved hand. -The Food Service Director (FSD) was wearing a glove on one hand. With the gloved hand, he opened a package of bread, potentially contaminating the glove, and removed pieces of bread to place them in the toaster. He then removed the bread and placed on the serving station using the gloved hand. -The server aid touched two pieces of bread with his bare hand. During an interview on 10/9/24 at 8:59 A.M., the FSD said he consistently completes hand hygiene training with the kitchen staff. The FSD said once a glove comes in contact with an object other than food, it becomes contaminated and then cannot come in contact with food.

Based on record review, policy review and interviews, the facility failed to report allegations of abuse to the state agency within two hours as required for one Resident (#65) out of a total sample of 22 residents. Specifically, on 10/8/24 at 9:00 A.M., the Director of Nursing (DON) was made aware of Resident #65's allegations of abuse. The DON did not report to the state agency until 10/9/24 at 11:15 P.M., when the surveyor inquired about the follow up, more than 24 hours after becoming aware of the allegations. Findings include: Review of the facility policy Abuse, Neglect, Mistreatment, Exploitation & Misappropriation of Property Policy Including Elder Justice Act, revised September 2018, indicated the following: -When staff have knowledge of an allegation of abuse or a serious bodily injury of unknown source then an immediate report (within 2 hours of knowledge) of the incident will be sent to the Department of Public Health via HCFRS (health care facility reporting system). Administrator and the DON must be notified immediately. A computerized report will be filed via HCFRS virtual gateway system by DON, Assistant DON, Administrator or authorized user. -The Director of Nursing Services coordinates the investigations of alleged violations. Resident #65 was admitted to the facility in September 2024 with diagnoses including personal history of transient ischemic attack (TIA) (mini stroke), and cerebral infarction without residual deficits, pressure ulcer of left buttock stage 3. Review of Resident #65's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. The MDS further indicated the Resident depended on staff for activities of daily living. On 10/8/24 at 8:23 A.M., the surveyor observed Resident #65 lying in his/her bed, the Resident told the surveyor that he/she had experienced unpleasant treatment by one of the certified nursing assistants (CNA #2) that worked on the evening shift. The Resident said that the CNA #2 would come into his/her room and raise the television volume extremely loud just to bust his/her chops, the Resident further said that the CNA #2 would also close the window blinds without asking the Resident and the Resident felt like CNA #2 was showing control over him/her. Resident #65 also said that at times he/she would call to get assistance with activities of daily living care (incontinence care) and the CNA #2 would tell him/her that they did not require the care. The Resident told the surveyor that those experiences reminded him of the previous facility he/she had been at and received similar mistreatment. On 10/8/24 at 9:00 A.M., the Surveyor reported the Resident's concerns to Unit Manager #2 who said she was going to report that information to the DON immediately. On 10/9/24 at 11:15 A.M., the surveyor followed up with the DON in regard to Resident #65's concerns, the DON said that she had sent the social worker to follow up with the Resident and had not reported the allegations to the Department of Public health. The DON said that the concerns brought forth were allegations of abuse and should have been reported within 2 hours of knowledge. During an interview on 10/10/24 at 8:50 A.M., Social Worker (SW) #2 said she had followed up with the Resident when the DON had asked her to investigate but failed to immediately report back to the DON of the Resident's concern of alleged emotional abuse. Social Worker #2 said she interviewed the Resident and did not know how to write it down hence causing the delay in reporting back to the DON. During an interview on 10/10/24 at 9:20 A.M., the DON said there was a delay in reporting of the alleged abuse to the Department of Public health.

Based on record review, policy review and interview, the facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation for one Resident (#61), out of a total sample of 22 residents. Specifically, for Resident #61, the facility failed to accurately complete a Level 1 PASARR indicating that the Resident had a diagnosis of schizotypal disorder which is a SMI, resulting in a Level II PASARR evaluation not being completed as required. Findings include: Review of facility policy titled Admission Criteria' date revised March 2019, indicated the following but not limited to: -All new admissions and readmission are screened for mental disorders (MD), intellectual disorder (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. -If the level 1 screen indicates that the individual may meet the criteria for MD, ID, or RD, he/she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. Resident #61 was admitted to the facility in June 2024 with diagnoses including schizotypal disorder. Review of Resident #61's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored an 8 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicted the Resident had an active diagnosis of schizotypal disorder. Review of the hospital admission information referral date 6/11/24, indicated Resident #61 had an active diagnosis of schizotypal personality disorder. Review of the PASARR Level I screen for serious mental illness, dated 6/18/24 indicated NO to the following questions: -Does the applicant have one of the following documented diagnoses of a mental illness or disorder (MI/D)? During an interview on 10/9/24 at 10:27 A.M., Social Worker (SW) #1 said the PASARR form is completed by a nurse outside of the facility and the SW is the back up to ensure the PASARR is completed prior to admission into the facility. The SW said with an admitting diagnosis of a serious mental illness the PASARR should have been completed accurately for the Resident to be reviewed and prompted a Level II evaluation. During an interview on 10/10/24 at 8:21 A.M., the Director of Nursing said the Level 1 PASARR should have been accurately documented upon the Resident's admission to the facility.

Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed for one Resident (#63) out of a total sample of 22 Residents. Specifically, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker for Resident #63. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with, revised 12/15, indicated the following: Purpose: -The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker Monitoring: -Monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia's. -The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. -Make sure the resident has a medical identification care that indicated he or she has a pacemaker. The medical record must contain this information as well. When the resident is transferred to another facility, this information must be communicated to the receiving facility in the discharge summary. Documentation: -For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission. a. The name, address, and telephone number of the cardiologist. b. Type of pacemaker. c. Type of leads. d. Manufacturer and model. e. Serial number. f. Date of implant. g. Paced rate. Resident #63 was admitted to the facility in April 2023 with diagnoses that included heart failure, paroxysmal atrial fibrillation, presence of cardiac pacemaker, and chronic systolic heart failure. Review of Resident #63's most recent Minimum Data Set (MDS) assessment, dated 7/26/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident is cognitively intact. Review of Resident #63's physician orders and care plans, failed to indicate a paced rate, serial number, frequency of pacemaker checks and cardiologist information. During an interview on 10/8/24 at 8:41 A.M., Resident #63 said he/she feels his/her heart if fluttering and has not had his/her pacemaker checked recently. During an interview on 10/10/24 at 7:51 A.M., Unit Manager #3 said she was not aware Resident #63 was experiencing any heart fluttering and will arrange for the Resident to see the cardiologist. Unit Manager #3 said she would expect a care plan to be put in place on admission with all the pacemaker information. During an interview on 10/10/24 at 8:23 A.M., the Director of Nursing said a pacemaker care plan should have been out in place with the paced rate, cardiologist information, frequency of checks and the serial number so the nurses are aware.

Based on observation, record review and interview, the facility failed to provide services that met professional standards of practice for one Resident #55 out of a sample of 22 residents. Specifically, for Resident #55 the facility failed to ensure nursing implemented Teds (compression) stockings according to the physician's orders. Findings include: Resident #55 was admitted to the facility in July 2024 with diagnoses including dementia, instability of left knee, and localized edema (fluid retention). Review of Resident #55's Minimum Data Set Assessment (MDS) dated [DATE], indicated the Resident scored a 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident was dependent on staff for activities of daily living. On 10/9/24 at 7:11 A.M., the surveyor observed the Resident lying in bed, the Resident did not have ted stockings on his/her legs. On 10/9/24 at 9:10 A.M., the surveyor observed Resident #55 sitting in his/her broda chair being wheeled to the dining room he/she did not have teds stocking on as his/her legs were exposed. On 10/9/24 at 12:07 P.M., the surveyor observed the Resident sitting in the dining room he/she did not have teds stocking on. On 10/9/24 at 2:00 P.M., the surveyor observed the Resident lying in bed, he/she did not have teds stocking on. Review of the most current physician orders indicated the following: -Teds to both legs while out of bed one time a day for edema. Review of the Treatment Administration Record (TAR) for date 10/9/24 at 6:00 AM was signed off indicating the Resident had teds stocking on. During an interview on 10/9/24 at 2:35 P.M., Unit Manager #1 said physician orders should be completed as ordered and that Resident #55 should have the teds stockings on. During an interview on 10/10/24 at 8:16 A.M., the Director of Nursing said the teds stockings should be completed as ordered.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#1) out of a total sample of 22 residents. Specifically, the facility failed to provide assistance with weekly showers for Resident #1. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), undated, indicated the following: - A program of activities of daily living (ADL) is provided to residents to prevent disability and return residents to a maximum level of independence. - Hygiene: Frequent showers or baths are scheduled and assistance provided when required. Resident #1 was admitted to the facility in September 2022 with diagnoses including chronic congestive heart failure and bradycardia. Review of Resident #1's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental score of 15 out of 15 indicating intact cognition. Further review of the Resident's MDS indicated that the Resident is dependent on staff for all activities of daily living and does not refuse care. During an interview on 10/8/24 at 7:52 A.M., Resident #1 said he/she cannot remember the last time he/she had a shower and would like a shower if the staff think it is safe enough. Resident #1 then said he/she only receives bed baths. During a subsequent interview on 10/9/24 at 1:28 P.M., Resident #1 said staff members do not ask her if he/she would like a shower, they just give him/her a bed bath and he/she would really like a shower. Review of the facility's document titled B Floor Shower List indicated that Resident #1 is to receive a shower on the 7:00 A.M. shift on Thursdays. The document continued to say Any resident can have a shower on request. Review of Resident #1's shower log for the past 31 days indicated that Resident #1 has only received bed baths and no showers. Review of Resident #1's ADL self-care performance deficit care plan, dated and revised 3/9/23 indicated the following intervention: - BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. Review of Resident #1's medical record failed to indicate that the Resident refused showers at any point. During an interview on 10/9/24 at 1:51 P.M., Certified Nursing Assistant (CNA) #1 said all residents get showers at least once per week. CNA #1 said Resident #1 used to not want showers so they were only providing bed baths to him/her. CNA #1 said they stopped asking Resident #1 if he/she would like a shower. The surveyor and CNA #1 then asked Resident #1 if he/she would like a shower and Resident #1 said he/she would like to have a shower. During an interview on 2:14 P.M., Nurse #1 said the expectation is that all residents receive a shower weekly if they would like one and that staff should be offering to shower each resident at least once a week. Nurse #1 said if she knew Resident #1 wanted a shower she would have provided one. During an interview on 10/10/24 at 7:55 A.M., the Director of Nursing (DON) said all residents should be offered a shower at least weekly and the shower schedule should be followed. The DON continued to say any refusals should be documented and CNAs should be asking if residents would like a shower instead of residents asking staff members to receive a shower.

Based on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to ensure nursing staff were competent related to 1) Medication Reconciliation for new admissions and 2) Medication Administration. 1) Resident #1 who was newly diagnosed in February 2022 with [CONDITION(S)] (CML, a slowly progressing and uncommon type of blood-cell cancer), he/she began [CONDITION(S)] treatment as an outpatient, but due to severe adverse effects of [MEDICATION(S)] and [MEDICATION(S)] ([CONDITION(S)] medications) he/she required admission to the Hospital, and his/her [CONDITION(S)] medications were discontinued at the time. Resident #1 was then transferred to the Facility in [DATE], for short term placement related to his/her skilled nursing care needs, and his/her Hospital Discharge Summary clearly indicated that neither of Resident #1's [CONDITION(S)] medications were to be restarted until he/she was seen by his/her Oncologist. -However, upon admission to the Facility, the Nurse who completed his/her admission failed to accurately reconcile Resident #1's medications, and he/she was administered the [CONDITION(S)] medication [MEDICATION(S)] twice a day during his/she stay in the Facility (11 days). As a result of being administered the [MEDICATION(S)], on [DATE] Resident #1 experienced an acute change with a decline in medical status, was transferred to the Hospital Emergency Department, where he/she was diagnosed with septic shock (condition sometimes occurring in severe [CONDITION(S)], in which the blood pressure fails and the organs in the body fail to receive sufficient oxygen), was immediately admitted to the Intensive Care Unit (ICU), placed on Comfort Measures, and died on [DATE]. 2) On [DATE], Resident #2 was administered his/her roommates' (Resident #3) medications as well as all his/her own medications. The Nurse said she had initially started to dispense Resident #3's medications into a medication cup, said she had become distracted and stepped away from the medication cart briefly, but had not administered Resident #3's medications. The Nurse said when she returned the medication cart, said she proceeded to dispense Resident #2's medications, and unknowingly put them into medication cup that contained Resident #3's medications, and said she administered all the medications in the cup to Resident #2. Approximately one hour later Resident #2 became nauseous and began to exhibit behavioral symptoms including agitation, which were new to him/her, and that was when the Nurse realized she administered Resident #2 his/her medications as well as Resident #3's medications. Findings Include: 1) Review of the Facility Policy titled, Reconciliation of Medications on Admission, dated as revised [DATE], indicated that it is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission to the Facility. The Policy indicated Reconciliation of Medication on Admission is the process of: -comparing pre-discharge medications to post-discharge medications -creating an accurate list of both prescribed and over the counter medications that includes: -drug name -dosage -frequency -route -last dose taken for all medications, and -indication for use for the purpose of preventing unintended changes or omissions at transition points in care Review of the Facility Investigation, dated [DATE], indicated the Director of Nurses received a telephone call from the Hospital Quality Staff Member informing her that a Hospital-Led investigation determined that Resident #1 passed away as a direct result of a medication error involving [MEDICATION(S)], having received the medication while at the Facility despite indication that [MEDICATION(S)] should not have been administered. The Investigation findings concluded that Nurse #1 did not read the complete discharge summary, which led to the discrepancy of [MEDICATION(S)] being administered to Resident #1. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted [DATE], indicated Resident #1's death was due to a medication error. Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Discharge Summary Hospital Course Brief Summary, dated [DATE], indicated Resident #1 was admitted to the Hospital on [DATE], with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Summary indicated, that on [DATE], Resident #1 was started on [MEDICATION(S)] as an outpatient by his/her Oncologist, and was subsequently admitted to the Hospital on [DATE], with concerns for Tumor Lysis Syndrome (TLS) in the setting of [MEDICATION(S)]. The Summary indicated the [MEDICATION(S)] was held during his/her hospitalization . The Summary also indicated that Resident #1's hospitalization was complicated by acute [CONDITION(S)] for which he/she required emergent hemodialysis (a mechanical process of purifying the blood of a person whose kidneys do not work normally), bilateral severe hydronephrosis (excess fluid in the kidney due to a backup of urine) with obstructive kidney stones, and he/she required placement of bilateral nephrostomy tubes (catheter that ' s inserted through your skin and into your kidney, helps drain urine from your body). Review of Resident #1's Hospital Discharge Summary, Medication List, dated [DATE], indicated there was a shaded arrow on the far left preceding the medication name clearly marked with word START in bold letters inset in the arrow, which indicated he/she was to be administered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -START-[MEDICATION(S)] (cholesterol medication) 300 milligrams (mg) tablet, take 0.5 tablets (150 mg total) by mouth daily -START-[MEDICATION(S)] (anticoagulant) 5 mg tablet, take one tablet (5 mg total) by mouth two times a day -START-[MEDICATION(S)] (stimulant [MEDICATION(S)])10 mg suppository, place one suppository (10 mg total) rectal daily as needed -START-[MEDICATION(S)] (antibiotic) 500 mg tablet, take one tablet (500 mg total) by mouth two times a day before meals for four days -START-[MEDICATION(S)] (vitamin D) 200 micrograms (mcg)/milliliter(ml) (8,000 unit/ml) drops, take 6.3 ml (50,000 Units total) by mouth once a week for eight doses -START-[MEDICATION(S)] (vitamin B) One mg tablet, take one tablet (1 mg total) by mouth daily -START-Lactobacillus Rhamnosus (GG) (probiotic)10 billion, take one capsule by mouth daily -START-[MEDICATION(S)] (pain relief) 4 percent (%), place one patch onto the skin daily -START-[MEDICATION(S)] (mineral) 400 mg (241.3 mg elemental) tablet, take one tablet (400 mg total) by mouth daily -START-[MEDICATION(S)] (antihypertensive) 50 mg 24-hour tablet, take one tablet (50 mg total) by mouth daily -START-[MEDICATION(S)] (treats occasional constipation) 17-gram packet, take 17 grams (G) by mouth daily Further review of the Hospital Discharge Summary, Medications List indicated the following medications did not have a START arrow preceding the medication name, and therefore were Not to be administered: -[MEDICATION(S)] ([CONDITION(S)] medication) 100 mg tablet take one tablet (100 mg total) by mouth daily -[MEDICATION(S)] ([CONDITION(S)] drug) 500 mg capsule, take 1,500 mg by mouth two times a day Review of Resident #1's Hospital Discharge Instructions and Important Events, indicated to please carefully review reconciled medication list and to only restart taking [MEDICATION(S)] and/or [MEDICATION(S)] as directed after consulting with Oncologist, after his/her follow-up appointment scheduled for [DATE]. Review of Resident #1's Medication Reconciliation Form/New Admission and Readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1, indicated the following medications, doses, strength, and frequency for his/her medications to be verified by a Physician, or Nurse Practitioner upon admission: -[MEDICATION(S)] 300 mg tablet, take 0.5 mg tablets by mouth (PO) every day -[MEDICATION(S)] 5 mg tablet, take one tablet PO twice a day (BID) -[MEDICATION(S)] 10 mg suppository, place one suppository rectal daily -[MEDICATION(S)] 500 mg tablet, take one tablet PO BID before meals for four days -[MEDICATION(S)] 100 mg tablet, take one tablet PO daily -[MEDICATION(S)] 200 mcg/ml (8,000 units/ml) drops, takes 6.3 ml (50,000 units total) PO one a week for 8 doses -[MEDICATION(S)] 1 mg, take one tablet PO daily -[MEDICATION(S)] 500 mg capsule, take 1500 mg PO BID -Lactobacillus Rhamnosus (GG) 10 billion, take one capsule PO daily -[MEDICATION(S)] 4%, place one patch onto the skin daily -[MEDICATION(S)] 400 mg take one tablet PO daily -[MEDICATION(S)] 50 mg 24-tablet, take one tablet (50 mg) PO daily. and -[MEDICATION(S)] 17 gram, take 17 grams PO daily Further review of the Reconciliation Form, indicated that the following information was incomplete and left blank: -Last Dose, Date, and Time of all medications listed -MD/NP/PA approval, nurse to place a check mark for yes to indicate medication has been approved or nurse to place an X for no to indicate medication was not approved -See MD orders for Clarification -the reconciled medication telephone order from (provider name) the signature line was left blank and had no provider name listed indicating who verified Resident #1 ' s admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Physician's Orders, dated [DATE], indicated that in addition all of his/her other medications, the orders included nursing to administer: - [MEDICATION(S)] Tablet 100 mg PO daily starting on [DATE] - [MEDICATION(S)] Capsule 500 mg, give 1,500 mg PO twice daily starting on [DATE] Further review of the Resident #1's Physician's Orders indicated that Nurse Practitioner #1 signed the Order's on [DATE]. Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated [DATE], indicated that Resident #1's White Blood Count (WBC) was noted to have improved, and he/she was to start [MEDICATION(S)] 100 mg daily on discharge. The NP wrote that further management of his/her CML was to be done outpatient and that she reviewed and reconciled Resident #1's medications. During an interview on [DATE] at 2:20 P.M., Resident #1's Nurse Practitioner (NP) said she did read the Hospital Discharge Summary, however, said she did not remember reading that his/her [MEDICATION(S)] should not have been started. Review of Resident #1's Physician's Progress Note, dated [DATE], indicated Resident #1's WBC was noted to have improved from 300 thousand (k) to less than (>) 73 k (normal is 4.5 k to 11 k), Resident #1 did not require further [MEDICATION(S)] during his/her hospitalization , Oncology recommend starting [MEDICATION(S)] on discharge as an outpatient and that his/her current medications were reviewed from the Hospital Discharge Summary. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 during his/her stay in the Facility. Further review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., and during his/her eleven day stay, Resident #1 received a total of 22 doses of [MEDICATION(S)] (despite the Hospital Discharge Summary clearly indicating the medication was not to be started until he/she was seen for follow-up by the Oncologist). During an interview on [DATE] at 2:06 P.M., Nurse #1 said when she was completing Resident #1's Medication Reconciliation, said she only looked at the Medication List on the Hospital Discharge Summary. Nurse #1 said she did see the word START in the shaded arrow preceding the names on some of medications and said she knew a couple of the medications did not have the START arrow in front of them but said since all the medications were on the same page and on the same list, she just put them together on the Medication Reconciliation Form to be verified. Nurse #1 said she did verify Resident #1's admission medications with a covering Nurse Practitioner (NP), however Nurse #1 said she never discussed or informed the NP that there were no arrows saying START next to the medications [MEDICATION(S)] or [MEDICATION(S)]. Nurse #1 said she did not receive a lot of training when she got to the Facility. Nurse #1 said the Rehabilitation Unit where she was assigned to work, was staffed entirely with Traveling Nurses like herself. Nurse #1 said that she was not used to doing admissions, and said admissions were usually completed by a Facility's Admission Nurse or the Nursing Supervisor in her experience. Nurse #1 said she did not receive any education or training from the Facility specifically related to Admission Medication Reconciliation and said she did not know how to complete the Medication Reconciliation Form correctly. Nurse #1 said she did not review all of Resident #1's Hospital Discharge Summary and said she only realized she made a transcription error, when it was presented to the Facility. During an interview on [DATE] at 12:08 P.M., the Assistant Director of Nurses (ADON) said, when the Facility was notified by the Hospital Quality Staff of concerns regarding a medication incident involving Resident #1, said that was when she fully reviewed Resident #1's Hospital Discharge Summary. The ADON said that Resident #1's [MEDICATION(S)] should not have been administered until his/her outpatient Oncology follow-up (scheduled for [DATE]). The ADON said that Resident #1's admission, including medication reconciliation, was not second reviewed by any of the other nurses. During an interview on [DATE] at 1:09 P.M., the Director of Nurses (DON) said on [DATE], she received a call from the Hospital Quality Staff informing the Facility of the avoidable medication error. The DON said that Nurse #1 did not read the complete Hospital Discharge Summary when she was completing Resident #1 ' s admission and said that the Medication Reconciliation Form was also not filled out completely or accurately. The DON said it was her expectation, with a new and/or re-admission, that the nurse read the residents ' Hospital Discharge Summary in its entirety and as part of the admission process and the nurse must complete the Medication Reconciliation's Form accurately. During an interview on [DATE] at 3:22 P.M., Resident #1's Oncologist said when Resident #1 was discharged from the Hospital on [DATE] to the Facility, his/her labs had significantly improved and were stable. The Oncologist said the plan was for Resident #1 to be discharged to the Facility to gain strength in order for Oncology to develop and begin Resident #1's new treatment plan for his/her CML. The Oncologist said Resident #1's Hospital Discharge Summary clearly indicated not to administer [MEDICATION(S)] and the [MEDICATION(S)] until he/she could follow-up with Oncology and said an appointment had been scheduled for [DATE], which was also noted on the Discharge Summary. The Oncologist said when Resident #1 was transferred to the Hospital Emergency Department on [DATE], his/her blood laboratory work was very bad. The Oncologist said she was sure it was because Resident #1 had been receiving [MEDICATION(S)] while at the Nursing Facility. The Oncologist said, Resident #1 was immediately admitted to the Intensive Care Unit, was placed on Hospice and on [DATE], Resident #1 died . 2) Review of the Facility Policy titled, Medication Administration-General Guidelines, dated ,d+[DATE], indicated the following: -prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] -medications are administered in accordance with written orders of the prescriber -medications are to be administered at the time they are prepared -the person who prepares the medication for administration is the person who administers the dose -verify medication are correct three times; when pulling medication package from medication cart, when dose is prepared, and before the dose is administered -residents are identified before medication administration using at least two resident identifiers: identification band, photograph in the medical record, verify resident with another nursing personnel -explain the type of medication being administered and the procedure -medications are administered within 60 minutes of scheduled time; and -observe resident for medication actions/reactions Resident #2 was admitted to the Facility in February 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDS) assessment dated , [DATE], indicated he/she was significantly cognitively impaired, with both long and short-term memory loss, and was not always able to make him/herself understood. Review of Resident #2's Health Care Proxy, dated [DATE], indicated he/she lacked the capacity to make or communicate health care decision and was invoked. Review of Resident #2's Facility Incident Report, dated [DATE] at 6:10 P.M., indicated Nurse #2 inadvertently administered an uncertain number of Resident #3's evening medications to Resident #2 along with all Resident #2's Physician's Ordered medications. During an interview on [DATE] at 10:24 A.M., with Nurse #2 and review of Nurse #2's written witness statement, dated [DATE], regarding the medication error on [DATE], indicated the following: Nurse #2 said she was preparing Resident #3's medications at the medication cart, remembers starting by placing Resident #3's over the counter medications and his/her medication for puritis (itching) into a medication cup, had not administered them to Resident #3, when she briefly stepped away from the medication cart to respond to a resident alarm that was sounding. Nurse #2 said she returned to the medication cart, and upon return, Resident #2's Health Care Agent (HCA) was waiting to speak with her and asked her (Nurse #2) to get Resident #2's medications ready. Nurse #2 said knowing Resident #2 was resistant to taking medications, and having the HCA present helped, so she proceeded to get Resident #2's medications ready. Nurse #2 said she dispensed Resident #2's medications into the medication cup that was on top of the medication cart (which already had some of Resident #3's medications it in). Nurse #2 said she finished dispensing Resident #2's medications but did not realize she had mixed Resident #2's medication in with Resident #3's medication. Nurse #2 said she proceeded to Resident #2's room and administered the medications to Resident #2. Nurse #2 said approximately one hour after administering Resident #2 his/her medications, she noticed his/her HCA with an emesis basin and observed that Resident #2 was restless and attempting to remove his/her clothes. Nurse #2 said Resident #2's HCA asked her if she was certain, she had administered Resident #2 the correct medications, and said the HCA asked why the medication had been a shade of blue. Nurse #2 said that was when she realized she had made the medication error and had given some, if not all of Resident #3's evening medications to Resident #2 along with his/her own medication. Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (antidepressant) 25 mg tablet, give one tablet PO at bedtime -[MEDICATION(S)] (used to treat manic episodes of [CONDITION(S)]) capsule 150 mg, give one capsule PO at bedtime: time due 6:00 P.M. -[MEDICATION(S)] [MEDICATION(S)] (antihypertensive) tablet 25 mg, give one tablet PO at bedtime: time due 6:00 P.M. -[MEDICATION(S)] (antipsychotic) tablet 0.25 mg, give one tablet PO at bedtime; time due 6:00 P.M.; and -[MEDICATION(S)] ([MEDICATION(S)], anticoagulant) tablet 2.5 mg, give one tablet PO at bedtime: time due 6:00 P.M. Review of Resident #3's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (statin, used to treat high cholesterol) tablet 20 mg, give one tablet PO daily: time due at 5:30 P.M. -[MEDICATION(S)] (sedative, used to treat anxiety) tablet 0.5 mg, give one tablet PO in the evening: time due at 5:30 P.M. -[MEDICATION(S)] (cognition-enhancing medication) tablet 5 mg, give one tablet PO in the evening: time due at 5:30 P.M. -[MEDICATION(S)] (antihistamine) tablet 7.5 mg, give one tablet PO at bedtime: time due at 6:00 P.M. -Guaifenesin Extended Release (cough, cold medication used to expectorate [MEDICATION(S)]) tablet 12-hour release 600 mg, give one tablet every 12 hours PO: time due at 6:00 P.M. During an interview on [DATE] at 12:50 P.M., the Assistant Director of Nurses (ADON) said on [DATE], that it was the first shift Nurse #2, who was an Agency Nurse, worked at that Facility. The ADON said it was the expectation of the Facility that all nurses, including agency and traveling nurses, would administer medications with the six rights in mind and said Nurse #2 had not done that, which led to the medication error. During an interview on [DATE] at 1:09 P.M., the Director of Nurses (DON) said Nurse #2 told her that she had been distracted by Resident #2's HCA when the HCA approached her at the medication cart to ask about Resident #2's medications. The DON said Nurse #2 did not ensure the six rights of each Resident. The DON said she expects all nurses to administer medications knowing the Six Rights.

Based on records reviewed and interviews for two of four sampled residents (Resident #1 and Resident #2), the Facility failed to ensure they were free from significant medication errors that adversely impacted their health. 1) Resident #1 who was newly admitted to the Facility in [DATE], and due to a medication reconciliation error upon admission, he/she was administered [MEDICATION(S)], a [CONDITION(S)] medication, that had been discontinued during his/her Hospital admission secondary to severe adverse side effects. Resident #1 was administered [MEDICATION(S)] two times a day for his/her entire stay at the Facility (11 days). Resident #1 experienced a significant change with a decline in medical status and required transfer to the Hospital Emergency Department on [DATE], where he/she was diagnosed with septic shock (condition sometimes occurring in severe [CONDITION(S)], in which the blood pressure fails and the organs in the body fail to receive sufficient oxygen), was admitted to the Intensive Care Unit (ICU), placed on Comfort Measures, and died on [DATE]. 2) During the evening shift on [DATE], Nurse #2 administered Resident #2 his/her evening medications and also administered some of Resident #3's medications to him/her in error. Nurse #2 said she had initially started to dispense Resident #3's evening medications but reported she got distracted and briefly stepped away for her medication cart (leaving the cup of medications on top of the cart). When Nurse #2 returned to her cart, she then started to dispense Resident #2's medications, putting them into the medication cup on top of the cart (cup that already contained some of Resident #3's medications). Nurse #2 then proceeded to administered all of the medications in the cup to Resident #2. Approximately one hour later Resident #2 became nauseous and began to exhibit behavioral symptoms including agitation, which were new to him/her. Findings Include: Review of the Facility Policy titled, Reconciliation of Medications on Admission, dated as revised [DATE], indicated that it is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission to the Facility. Review of the Facility Policy titled, Medication Administration-General Guidelines, dated ,d+[DATE], indicated the following: -prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] -medications are administered in accordance with written orders of the prescriber -medications are to be administered at the time they are prepared -the person who prepares the medication for administration is the person who administers the dose -verify medications are correct three times; when pulling medication packages from medication cart, when dose is prepared, and before the dose is administered -residents are identified before medication administration using at least two resident identifiers: identification band, photograph in the medical record, verify resident with another nursing personnel -explain the type of medication being administered and the procedure -medications are administered within 60 minutes of scheduled time and -observe resident for medication actions/reactions 1.) Resident #1 was admitted to the Facility in [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Discharge Summary: Hospital Course Brief Summary, dated [DATE], indicated that on [DATE], Resident #1 was started on [MEDICATION(S)] as an outpatient by his/her Oncologist, and was subsequently admitted to the Hospital on [DATE], with concerns for Tumor Lysis Syndrome (TLS) in the setting of [MEDICATION(S)]. The Summary indicated Resident #1 was not administered [MEDICATION(S)] during his/her hospitalization . Review of Resident #1's Hospital Discharge Summary, Medication List, dated [DATE], indicated there was a shaded arrow on the far left preceding the medication name clearly marked with word START in capital letters inset in the arrow, which indicated which medications the Facility should start and be administered by nursing. Further review of the Hospital Discharge Summary Medications list indicated the following medications did not have the word START inset in an arrow preceding the medication name and were therefore Not to be administered. -[MEDICATION(S)] 500 milligrams (mg) capsule, take 1,500 mg by mouth two times a day -[MEDICATION(S)] ([CONDITION(S)] medication) 100 mg tablet take one tablet (100 mg total) by mouth daily Resident #1's Hospital Discharge Instructions and Important Events also indicated to please carefully review reconciled medication list. The Instructions indicated Resident #1 was only to start taking [MEDICATION(S)] and [MEDICATION(S)] after consulting with Oncologist, after his/her follow-up appointment scheduled for [DATE]. Review of Resident #1's Medication Reconciliation Form/New Admission and Readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Reconciliation Form, indicated that the signature line for the reconciled medication telephone order was left blank and there was no provider name listed indicating who verified Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Physician's Orders, dated [DATE], indicated the Nurse Practitioner signed Resident #1's Physician's Orders on [DATE], which included orders for: - [MEDICATION(S)] Capsule 500 mg, give 1,500 mg by mouth (PO) twice daily starting on [DATE] - [MEDICATION(S)] Tablet 100 mg PO daily starting on [DATE] Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated [DATE], indicated that Resident #1's White Blood Count (WBC) was noted to have improved, and he/she was to start [MEDICATION(S)] 100 mg daily on discharge. The NP wrote that further management of his/her CML was to be done outpatient and that she reviewed and reconciled Resident #1's medications. During an interview on [DATE] at 2:20 P.M., Resident #1's Nurse Practitioner (NP) said she did read the Hospital Discharge Summary, however, said she did not remember reading that his/her [MEDICATION(S)] and [MEDICATION(S)] should have never been started. Review of Resident #1's Physician's Progress Note, dated [DATE], indicated Resident #1's WBC was noted to have improved from 300 thousand (k) to less than (>) 73 k (normal is 4.5 k to 11 k), Resident #1 did not require further [MEDICATION(S)] during his/her hospitalization , Oncology recommend starting [MEDICATION(S)] 100 mg every day upon discharge as an outpatient and his/her current medications were reviewed from the Hospital Discharge Summary. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1, while in the Facility. Resident #1's first dose of [MEDICATION(S)] 1,500 mg PO twice a day was administered on [DATE] at 9:00 P.M. and during his/her eleven day stay in the Facility, Resident #1 received a total of 22 doses of [MEDICATION(S)], (a [CONDITION(S)] medication that never should have been administered). Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted [DATE], indicated Resident #1's death was due to a medication error. Review of the Facility Investigation, dated [DATE], indicated the Director of Nurses received a telephone call from the Hospital Quality Staff Member informing her that a Hospital-Led investigation determined that Resident #1 passed away as a direct result of a medication error involving [MEDICATION(S)], having received the medication while in the Facility despite indication that [MEDICATION(S)] should not have been administer. The Investigation findings concluded that Nurse #1 did not read the complete Hospital Discharge Summary, which led to the discrepancy of [MEDICATION(S)] being administered to Resident #1. During an interview on [DATE] at 2:06 P.M., Nurse #1 said when she was completing Resident #1's Medication Reconciliation Form she only looked at the medication list from his/her Hospital Discharge Summary. Nurse #1 said she did see the arrows in front of some of the medications indicating to START the medications, and said she knew a couple of the medications did not say START in front of them, but she said all the medications were on the same page, on the same list, so she just put them together on the Medication Reconciliation Form. Nurse # 1 said she did verify Resident #1's admission medications with a covering Nurse Practitioner (NP), however Nurse #1 said she never discussed or informed the NP that there were no arrows saying START next to the medications [MEDICATION(S)] or [MEDICATION(S)]. Nurse #1 said there was an oncoming nurse after her shift, and thought that nurse would be the second nurse to verify Resident #1's medications with the twenty-four-hour checks. During an interview on [DATE] at 12:08 P.M., the Assistant Director of Nurses (ADON) said, when the Facility was notified of the incident by the Hospital Quality Staff, that was when she fully read Resident #1's Hospital Discharge Summary. The ADON said that Resident #1's [MEDICATION(S)] should not have been administered until after his/her Oncology follow-up. The ADON said that Resident #1's admission, including the medication reconciliation, was not reviewed by any additional staff. During an interview on [DATE] at 1:09 P.M., the Director of Nurses (DON) said on [DATE], she received a call from the Hospital Quality Staff informing the Facility of the avoidable medication error. The DON said that Nurse #1 did not read the complete Hospital Discharge Summary when she was admitting Resident #1 and said that the medication reconciliation form was not filled out completely or accurately. During an interview on [DATE] at 3:22 P.M., Resident #1's Oncologist said when Resident #1 was discharged from the Hospital on [DATE] his/her labs had significantly improved and were stable. The Oncologist said Resident #1's discharge summary instructions said not to give [MEDICATION(S)] and/or [MEDICATION(S)] until he/she had a follow-up oncology appointment. 2) Resident #2 was admitted to the Facility in February 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Facility Incident Report, dated [DATE] at 6:10 P.M., indicated Nurse #2 inadvertently administered an uncertain number of Resident #3's evening medications to Resident #2 along with Resident #2's prescribed medications. Review of Resident #2's Admission Minimum Data Set (MDS) assessment dated , [DATE], indicated he/she was significantly cognitively impaired, with both long and short-term memory loss, impaired decision-making abilities, and he/she was not always able to make him/herself understood. Review of Resident #2's Health Care Proxy, dated [DATE], indicated he/she lacked the capacity to make or communicate health care decision and was invoked. During an interview on [DATE] at 10:24 A.M., with Nurse #2 and review of Nurse #2's written witness statement, dated [DATE], regarding the medication error on [DATE], indicated the following: Nurse #2 said she was preparing Resident #3's medications at the medication cart, remembers starting by placing Resident #3's over the counter medications and his/her medication for purists (itching) into a medication cup, had not administered them to Resident #3, when she briefly stepped away from the medication cart to respond to a resident alarm that was sounding. Nurse #2 said she returned to the medication cart, and upon return Resident #2's Health Care Agent (HCA) was waiting to speak with her and asked her (Nurse #2) to get Resident #2's medications ready. Nurse #2 said knowing Resident #2 was resistant to taking medications, and having the HCA present helped, so she proceeded to get Resident #2's medications ready. Nurse #2 said she dispensed Resident #2's medications into the medication cup that was on top of the medication cart (which already had some of Resident #3's medications it in). Nurse #2 said she finished dispensing Resident #2's medications but did not realize she had mixed Resident #2's medication in with Resident #3's medication. Nurse #2 said she proceeded to Resident #2's room and administered the medications to Resident #2. Nurse #2 said approximately one hour after administering Resident #2 his/her medications, she noticed his/her HCA with an emesis basin and observed that Resident #2 was restless and attempting to remove his/her clothes. Nurse #2 said Resident #2's HCA asked her if she was certain she had administered Resident #2 the correct medications, and said the HCA asked why the medication had been a shade of blue. Nurse #2 said that was when she realized she had made the medication error and had given some, if not all of Resident #3's evening medications to Resident #2 along with his/her own medication. Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (antidepressant) 25 mg tablet, give one tablet PO at bedtime -[MEDICATION(S)] (used to treat manic episodes of [CONDITION(S)]) capsule 150 mg, give one capsule PO at bedtime: time due 6:00 P.M. -[MEDICATION(S)] (antihypertensive) tablet 25 mg, give one tablet PO at bedtime: time due 6:00 P.M. -[MEDICATION(S)] (antipsychotic) tablet 0.25 mg, give one tablet PO at bedtime: time due 6:00 P.M. and -[MEDICATION(S)] ([MEDICATION(S)], anticoagulant) tablet 2.5 mg, give one tablet PO at bedtime, time due: 6:00 P.M. Review of Resident #3's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (statin, used to treat high cholesterol) tablet 20 mg, give one tablet PO daily: time due at 5:30 P.M. -[MEDICATION(S)] (sedative, used to treat anxiety) tablet 0.5 mg, give one tablet PO in the evening: time due at 5:30 P.M. -[MEDICATION(S)] (cognition-enhancing medication) tablet 5 mg, give one tablet PO in the evening: time due at 5:30 P.M. -[MEDICATION(S)] (antihistamine) tablet 7.5 mg, give one tablet PO at bedtime: time due at 6:00 P.M. -Guaifenesin Extended Release (cough, cold medication used to expectorate [MEDICATION(S)]) tablet 12-hour release 600 mg, give one tablet every 12 hours PO: time due at 6:00 P.M. During an interview on [DATE] at 12:50 P.M., the Assistant Director of Nurses (ADON) said on [DATE], that was the first shift for Nurse #2, who was an Agency Nurse, worked at the Facility. The ADON said it is the expectation of the Facility that all nurses, including agency and traveling nurses, would administer medications with the six rights in mind and said Nurse #2 had not done that which led to the medication error. During an interview on [DATE] at 1:09 P.M., the Director of Nurses (DON) said Nurse #2 told her that she had been distracted by Resident #2's HCA when the HCA approached her at her medication cart to ask about Resident #2's medications. The DON said Nurse #2 did not ensure the six rights of each resident.

Based on record review and interviews, for one of four sampled residents, (Resident #1), the Facility failed to ensure that Resident #1's safety alarm functioned as he/she required a safety alarm at all times per the plan of care. The Director of Nurses (DON) said Resident # 1 had a history (approximately 2 months) of disconnecting his/her safety alarm, and on 11/4/13 at 7:20 A.M. Resident #1 got out of bed, his/her safety alarm failed to sound (because he/she disconnected the safety alarm), fell and sustained a fractured left hip. Findings include: The Face Sheet indicated that Resident #1 was admitted to the Facility September 2013 and [DIAGNOSES REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 7:35 A.M. on 12/17/13 and 7:00 A.M. on 12/23/13. The DON said Resident #1 was at high risk for falls and had a history of [REDACTED].#1's admission to the Facility he/she had a fall that resulted in a right humerus fracture which on admission was conservatively treated by wearing a sling for 6 weeks. The admission fall risk assessment, dated 9/5/13, indicated that Resident #1 was at high risk for falls due to confusion at all times, a history of falls, decreased coordination with gait and mobility, and the effects of medications. The admission nurse's note, dated 9/5/13, indicated that Resident #1 was at high risk for falls due to very limited insight, impulse control, and the effects of dementia. The potential for falls care plan approaches, dated 9/6/13, included observe, record, and report all unsafe conditions, anticipate needs, encourage to ask for assistance, call light within reach, answer call light promptly, nonslip footwear at all times, bed in lower and locked position, safety alarms at all times, assist with transfers, ambulation, and toileting needs. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 1:15 P.M. on 12/17/13. The Surveyor interviewed CNA #2 at 6:00 A.M. on 12/18/13. CNA #1 and CNA #2 said the bed alarm box remained attached to the head board of Resident #1's bed even though he/she routinely disconnected the bed alarm several times each shift. CNA #1 and CNA #2 said Resident #1 was able to turn in bed and disconnect the bed alarm box. CNA #1 and CNA #2 said they routinely made the nurses aware of the problem. CNA #1 and CNA #2 said Resident #1 required physical assistance with transfers, ambulation, and toileting needs but was routinely found ambulating and self toileting in his/her bedroom after he/she had disarmed the bed alarm. CNA #1 and CNA #2 said the nurses and Unit Manager #1 were aware of the concern. The Surveyor interviewed Nurse #1 at 6:45 A.M. on 12/18/13. The Surveyor interviewed Nurse #2 at 12:15 P.M. on 12/17/13. . Nurse #1 and Nurse #2 said Resident #1 had a history of [REDACTED].#1 during report. The Surveyor interviewed Unit Manager #1 at 7:50 A.M. on 12/11/13. Unit Manager #1 said she was aware that Resident #1 had routinely disconnected his/her bed alarm. Unit Manager #1, Nurse #1, and Nurse #2 said Resident #1 had learned how to disconnect his/her bed alarm that was attached to the head board of the bed. Unit Manager #1, Nurse #1, and Nurse #2 said that Resident #1 was routinely found ambulating in his/her bedroom and self toileting in his/her bathroom unassisted after he/she had disconnected the bed alarm. The Admission Minimum Date Set (MDS) Assessment, dated 9/17/13, indicated that Resident #1 required extensive assistance during transfers and ambulation while using an assistive device. The MDS indicated that Resident #1 required extensive assistance during toileting and for all personal hygiene needs. The MDS indicated that Resident #1 was not steady during transitions or while walking and was only able to stabilize with human assistance. The MDS indicated that Resident #1 had no falls at the Facility. The MDS indicated that Resident #1 had a history of [REDACTED]. The DON said Resident #1 had two falls at the Facility. The DON said Resident #1's first fall (without injury) at the Facility was on a weekend of 11/3/13 followed by a second fall the morning of 11/4/13 that resulted in an injury. The DON said she reviewed all falls and prior to the investigation of the falls on 11/3/13 and 11/4/13, she was not aware that Resident #1 had a history of [REDACTED]. The actual falls care plan, dated 11/3/13, indicated a psychiatric evaluation. The actual falls care plan, dated 11/6/13, indicated that as of 11/3/13, the approaches included place Resident #1 close to nurses' station if possible, monitor closely, and provide 1:1 observation as needed. Unit Manager #1 said Resident #1's plan of care for falls included safety alarms at all times and once awake he/she required continual supervision while out of bed in his or her wheelchair or assistance with ambulation. The DON said Resident #1's usual routine included visual supervision while awake; Resident #1 was observed by staff as he/she was seated in a wheelchair by the nurses' station or while in the dayroom/dining room, and was physically assisted when he/she ambulated on the unit with a rolling walker. CNA #2 said she was assigned to Resident #1's personal care needs during the night (11:00 P.M. on 11/2/13 to 7:00 A.M. on 11/3/13) shift. CNA #2 said she assisted Resident #1 with toileting at 6:00 A.M. on 11/3/13 and left Resident # 1 resting comfortably in bed with the bed alarm on and functioning, and the call light within reach. Nurse #1 said he was assigned to Resident #1's nursing care needs during the night (11:00 P.M. on 11/2/13 to 7:00 A.M. on 11/3/13) shift. Nurse #1 said he responded to a loud noise from Resident #1's bedroom and found Resident #1 seated on the bathroom floor. Nurse #1 said on 11/3/13 at approximately 6:15 A.M. Resident #1's bed alarm did not sound because he/she disconnected the alarm when he/she got out of bed without assistance. Nurse #1 said Resident #1 fell in his/her bathroom and had no apparent injury. CNA #1 and CNA #2 said they routinely checked that bed and chair alarms were on and functioning at the beginning of each shift per Facility policy. CNA #1 said she was assigned to Resident #1's nursing care needs during the day shift on 11/4/13. CNA #1 said she did not check Resident #1's bed alarm during morning rounds because Resident #1 was sleeping comfortably so she began assisting his/her Roommate with personal morning care. CNA #1 said shortly after 7:15 A.M. on 11/4/13 she completed the Roommate's personal care and observed Resident #1 lying across the bed sideways with his/her feet touching the floor. CNA #1 said Resident #1 was restless and refused care. CNA #1 said she did not ensure that the bed alarm was on and functioning, and she notified Nurse #1 and Unit Manager #1 that Resident #1 was left in an unsafe condition. Unit Manager #1 and Nurse #1 said on 11/4/13 they immediately responded to Resident #1's bedside after CNA #1 reported that Resident #1 was left unsupervised in an unsafe condition. Unit Manager #1 and Nurse #1 said on 11/4/13 Resident #1's bed alarm did not sound because he/she disconnected the alarm when he/she got out of bed without assistance. Unit Manager #1 and Nurse #1 said Resident #1 fell and was transferred to the Hospital for evaluation due to left hip pain. The day shift nurse's note, dated 11/4/13 indicated that Nurse #1 found Resident #1 seated on his/her bedroom floor. The nurse's note did not include an assessment. The nurse's note indicated that the covering Physician was notified and Resident #1 was transferred to the Hospital, per physician's orders [REDACTED]. The DON said Resident #1's second fall at the Facility with injury was on 11/4/13 (Monday) at 7:20 A.M. when he/she had been left unsupervised while lying across the bed in an unsafe position. The DON said Resident #1 disconnected his/her bed alarm, got out of bed without assistance and fell . The DON said CNA #1 should have remained with Resident #1 to ensure he/she did not fall. The DON said Resident #1 was transferred to the Hospital where it was determined he/she sustained a fractured left hip. The Hospital Discharge Summary, dated 11/8/13, indicated that Resident #1 sustained a fracture of the left hip due to a fall at the Facility that required hospitalization for a left hip open reduction and internal fixation (surgical repair). The Surveyor interviewed Physician #1 at 1:30 P.M. on 12/24/13. Physician #1 said Resident #1 sustained a fracture of the left hip due to a fall at the Facility that required hospitalization and surgery.

Based on staff interviews and record review, the facility failed to prevent the falls for 2 residents (Resident's #1 and #6 ) from a sample of 10 applicable residents with falls in a total sample of 19 residents. Findings include: 1. For Resident #6, the facility failed to prevent the resident's fall on 3/11/13 which resulted in a fractured right proximal humerus and a laceration to the forehead requiring sutures. Review of Resident #6's clinical record on 4/18/13 indicated that the resident was admitted to the facility in 3/2013 with [DIAGNOSES REDACTED]. The nurses' assessment notes, dated 3/10/13, indicated that the resident had good short term memory, was able to understand others and be understood, was able to use the call bell to ring for assistance, had right sided weakness, and was able to ambulate with a rolling walker with the assistance of one staff member. The note indicated that the resident required the assistance of one staff member to transfer from the bed to the wheelchair, and to transfer to and from the toilet due to the resident's decreased physical strength and endurance. Review of the resident's physician orders, dated 3/10/13, indicated that either a pressure pad chair and/or bed alarm was to be used every shift for safety. Review of the resident's Treatment Administration Record (TAR), dated 3/10/13, indicated that a pressure chair alarm was required and the placement of the alarm was to be checked every shift. The resident's Fall Assessment, dated 3/11/13, indicated that the he/she was at high risk for falls. Documentation in the nurses' assessment note, dated 3/11/13 at 7:33 P.M., indicated that the resident was found on the floor in a supine position with the rolling walker in front of him/her. The note indicated that the Nurse Practitioner (NP) was notified and ordered the resident transferred to the hospital for an evaluation. The note further indicated that the family was notified of the resident's fall and his/her impending transfer to the hospital for an evaluation. Documentation on the Incident Report, dated 3/11/13 at 7:36 P.M., indicated that the family member told the Certified Nurse Assistant (CNA) that the resident was in the bathroom and the family member was leaving the facility. The Report indicated that the CNA would check the resident shortly after she finished with another resident. The Report indicated that the resident was found on the bathroom floor with a laceration to the forehead and complaining of pain in the right shoulder. Documentation in the nurses' assessment notes, dated 3/11/13 at 11:53 P.M. indicated that the resident was returning to the facility with a fractured right humerus and sutures to his/her forehead. During an interview with the Director of Nurses (DON) on 4/18/13 at 3:15 P.M., she said that during her investigation of the resident's falls, she learned that one of the nurses showed the family member how to remove the chair alarm so he/she could take the resident to the bathroom. The DON said the same nurse told her that the family member to call when the resident was finished so the nurse could escort the resident back to the safely of a chair. She said when the nurse checked the resident, the resident was sitting in a straight back chair with the family member. She said she was unsure whether she was told that the chair alarm was in place. The DON said the family member told her that he/she informed a CNA that he/she left the resident alone in the bathroom because he/she needed to go home. The DON said the resident was found on the floor by the charge nurse before the CNA returned to assist him/her. The DON said because the CNA was unable to assist the resident immediately, the CNA should have told the charge nurse that the resident was alone in the bathroom and she was unable to assist her. The DON said the resident fell as a result of being left alone and unassisted in the bathroom. 2. For Resident #1 the facility failed to ensure that appropriate interventions and adequate supervision was in place to prevent the resident from falling. Resident #1 was admitted to the facility in February 2010 with [DIAGNOSES REDACTED]. On 4/18/13, review of the resident's significant change Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) exam, this indicated that the resident's cognition was moderately impaired. The MDS also indicated that the resident required extensive staff assistance for transferring, bathing, and dressing. Review of the resident's most recent Fall Care Plan, dated 12/28/12, indicated that the resident was a high risk for fall with injury. This was related to decline in cognitive status, decline in functional status, dementia, unsteady gait, loss of balance, decreased endurance, and decrease in muscle strength. Interventions as of 12/28/12 were as follows: * Re-evaluate quarterly and as needed * Update physician with changes as needed * Call light within reach * Bed in lower, locked positioned remove bed comforter when resident is in the room for nap Review of the resident's fall incident reports indicated the following: On 1/7/13 at 5:30 P.M., the resident had an unwitnessed fall. This occurred in the resident's room. The resident was last seen sitting in a straight back chair. The staff responded to an alarm sounding and found the resident on the floor. Staff observed the resident was unable to bear weight on his/her left foot. The facility obtained an X-ray of the left foot which showed a possible nondisplaced fracture of the first proximal phalanx near the IP(interphalangeal joint) joint. Resident did not require any surgical intervention or splinting. Fall Care plan was updated to include the following: * Monitor for left foot pain *Offer medication for discomfort On 3/20/13 at 5:00 P.M., the resident had an unwitnessed fall. This occurred in the resident's room. Nurse #2 brought the resident into her/his room to perform a test. When Nurse #2 completed the test, she left the resident unattended in his/her room. The nurse responded to the roommate calling for help and found the resident on the floor. The resident sustained [REDACTED]. The skin tear was treated with steristrips. She also sustained a "bump" to the temporal area of his/her head. Staff did not document any measurements of this "bump". Ice was applied. Fall Care Plan was updated to include the following: * Call light within reach (this intervention had already been in place since 12/28/12.) * Nurses to monitor where about, may ambulate with one assist During interview on 4/24/13 at 1:10 P.M., Nurse Manager #1(NM#1) said that even though it was not in the care plan, staff knew that since the resident's fall in January 2013, that this resident was to have close supervision at all times. She continued to say that close supervision meant that while the resident was out of bed, he/she should not be left alone. NM#1 was not sure why the care plan wasn't updated to reflect this change.