Every finding on record at Meadows of Central Massachusetts (The)

Based on interviews and records reviewed, the facility failed to ensure care and services were provided to one Resident (#29) out of a total sample of 17 residents, in accordance with professional standards of practice.Specifically, the facility failed to obtain laboratory services as ordered by the Physician, including Complete Blood Count (CBC), Liver Function Test (LFT), and Valproic Acid level, putting the resident at risk for adverse side effects related to the use of Depakote (anticonvulsant) medication.Findings include:Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated 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. Review of the facility policy titled Diagnostic Services, dated December 2021, indicated:-The facility will provide or obtain laboratory services only when ordered by a physician, physician's assistant, nurse practitioner, or clinical nurse specialist in accordance with state law, including scope of practice laws.-The facility will provide or obtain radiology and other diagnostic services to meet the needs of its residents. Review of the facility policy titled Physician Services, dated March 2022, indicated:-All physician or other health care professional verbal orders, including telephone orders, will be immediately recorded, dated, and signed by the person receiving the order.-All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Resident #29 was admitted to the facility in August 2018 with diagnoses that included Unspecified Psychosis, Alzheimer's Disease, and Dementia with Agitation. Review of Resident #29's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident:-was severely cognitively impaired with short- and long-term memory problems.-demonstrated behaviors on four to six days out of seven during the assessment period.-received antipsychotic, antidepressant, and anticonvulsant medications. Review of Resident #29's Physician's orders for October 2025 included:-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium), Give 3 capsules (TD= 375 mg) by mouth two times a day related to UNSPECIFIED PSYCHOSIS. Start date 4/9/25 and active.-Obtain Valproic Acid level, CBC, LFT 11/3/25 one time only for labs until 11/03/2025 23:59, start date 10/20/25, end date 11/3/25. Review of Resident #29's Medication Administration Record (MAR) for October 2025 indicated the Resident was administered Depakote Sprinkles Oral Capsule daily, as ordered by the Physician. Review of the Resident #29's Behavioral Health Note, dated 10/15/25, indicated:-Will recommend labs secondary to Depakote therapy, follow up as indicated.-Follow up: 2-6 weeks-Recommend valproic acid level, CBC, and LFT.-Discussion with nursing Review of Resident #29's Behavioral Health Note, dated 10/31/25, indicated:-Patient not due for treatment: Labs pending Further review of Resident #29's Medical Record failed to indicate evidence that lab testing was completed for valproic acid level, CBC, and LFT as ordered by the Physician on 11/3/25 or documentation of the reason why the order for laboratory services was not followed. During an interview on 1/30/26 at 8:40 A.M., the Unit Manager (UM#1) said that she did not recall any Valproic Acid level or lab services for Resident #29 from October or November 2025. UM#1 said the process for laboratory testing included obtaining a Physician Order, documenting the request in the laboratory communication book, and then the lab technician would refer to the laboratory book while in the facility. UM#1 was unable to provide further information relative to why the ordered lab services were not completed for Resident #29. During an interview on 1/30/26 at 1:34 P.M., the Director of Nursing (DON) said that she was unable to provide evidence that a lab services request was completed for Resident #29. The DON further said the ordered laboratory services were not completed for Resident #29 and should have been.

Based on the record review and interview, the facility failed to to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to: 1. Provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for three days for the period of 4/1/24 to 6/30/24. 2. Designate a Registered Nurse to serve as the Director of Nursing (DON) on a full time basis when no staffing waivers were in place. Findings include: 1. Review of the PBJ Staffing Data Report, dated Quarter 3: 2024 (April 1 - June 30), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1 -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low -No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours Review of the as worked nursing schedule provided by the facility failed to indicate that a Registered Nurse worked for eight hours in the facility on the following days: -4/27/24 -5/12/24 -6/21/24 During an interview on 10/10/24 at 2:53 P.M., the Administrator said he was not employed at the facility as the Administrator until July, 2024 so if there were no RNs on the as worked schedule for the dates in question, then a RN did not work on those days. The surveyor and the Administrator reviewed the as worked schedules, and he said that no RNs worked on 4/27/24, 5/12/24, and 6/21/24. The Administrator said the facility does not have any staffing waivers. The Administrator said he could not provide any documentation indicating that a RN worked on those days and there should be a RN working at least 8 hours every day. 2. During an interview at the Entrance Conference on 10/8/24 at 8:19 A.M., with the Administrator and the Director of Nursing, they said that the Director of Nursing (DON), who is a RN, did not work full time. The Administrator said the DON's working schedule was Monday, Tuesday, Wednesday, and Thursday and she worked 32 hours per week. The Administrator said the Assistant Director of Nursing (ADON), who is not a RN, covers on the other days (Friday, Saturday and Sunday). The Administrator said that the facility does not have any waivers for staffing in place. During an interview on 10/10/24 at 12:46 P.M., the ADON (a Licensed Practical Nurse [LPN]) said that the DON only worked 4 days a week, never more than 32 hours. The ADON said that staff would come to her with any clinical problems or questions on the days that the DON was not there (in the facility).

Based on observation, interview, record and policy review, the facility failed to ensure one Resident (#108) out of a total sample of 17 residents, was free of significant medication errors. Specifically, for Resident #108, the facility failed to ensure that: -pain medications were administered timely as ordered by the Physician, when the Resident experienced pain and scheduled pain medications were ordered, which increased the Resident's risk for prolonged pain. -intravenous (IV: administered directly into a vein) antibiotics (medications used to treat infection) were administered timely as ordered by the Physician, when the Resident required IV antibiotics to treat an active infection, which increased the Resident's risk for illness. -anticoagulant (blood thinner) medication was administered timely as ordered by the Physician, when the Resident had a diagnosis of chronic embolus (a blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream lodges in a blood vessel) and Thrombosis (blood clot that forms inside a vessel and obstructs normal blood flow) of bilateral femoral veins (large blood vessels in the upper thighs and pelvic region that carries blood from the legs to the heart) which increased the Resident's risk for embolus and thrombosis related complications. -anticonvulsant (used to treat seizures) medication was administered timely as ordered by the Physician, which increased the Resident's risk for convulsions (medical event that occurs when the brain's nerve cell activity is disrupted, causing the muscles to contract and relax uncontrollably). Findings include: Review of the facility's policy titled Medication Administration - General Guidelines, dated February 2019, indicated the following: -Medications are administered as prescribed . -Right resident, right drug, right dose, right route, right time are applied for each medication being administered. -Medications are administered in accordance with written orders of the Prescriber. -Medications are administered within 60 minutes of scheduled time. Review of the facility's policy titled Pain Assessment and Management, dated March 2016 and last reviewed December 2023, indicated the following: -Pain is an unpleasant sensory and emotional experience . -Breakthrough pain is pain that increases above the pain addressed by the ongoing analgesics (drug used to treat pain). -Management of a patient's pain includes . intervention . -A patient's self-report of pain will be accepted as the most reliable indicator of pain. -Pain assessments are conducted using a numeric pain scale from zero to ten. -Numeric pain level of one to three is interpreted as mild pain. -Numeric pain level of four to six is interpreted as moderate pain. -Numeric pain level of seven to 10 is interpreted as severe pain. Resident #108 was admitted to the facility in August 2024, with diagnoses including: Unspecified Cord Compression (pressure on the spinal cord that can affect one's body movements and function), Muscle Spasm (sudden, uncontrollable muscle contractions that are usually painful), Cutaneous Abscess (localized collection of pus in the skin characterized by pain and swelling) of Right and Left Lower Limbs, Chronic Embolism and Thrombosis of Bilateral Femoral Veins, and Unspecified Convulsions. Review of Resident #108's Pain Care Plan, initiated 8/5/24 and revised 8/13/24, indicated the following: -The Resident was at risk for breakthrough pain related to Quadriplegia (condition where all four limbs and body from the neck down are paralyzed. Can be caused by spinal cord injury or medical conditions), Cutaneous [Abscess] Left lower Limb, Chronic Disability, and Wounds. -The Resident's pain was alleviated by PRN (as needed) and scheduled medications. -Administer analgesia as per orders. -Meet the Resident's need for pain relief and respond immediately to any complaint of pain. Review of Resident #108's Spinal Injury Care Plan, dated 8/13/24, indicated the following: -The Resident had Quadriplegia related to Spinal Injury. -Give medications as ordered. -Pain management as needed . provide alternative comfort measures PRN. Review of Resident #108's Impaired Immunity Care Plan indicated the Resident was at risk for contracting infections due to impaired immune status. Review of Resident #108's Minimum Data Set (MDS) Assessment, dated 8/15/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -The Resident reported having frequent pain. -The Resident reported a pain level of eight out of 10 (severe). -The Resident was on a scheduled pain medication regime. Review of Resident #108's clinical record indicated the Resident was transferred to the hospital on 9/21/24 and returned to the facility 10/4/24 with a diagnosis of Aspiration Pneumonia (infection of the lungs caused by accidentally inhaling saliva, food, liquid, vomit and even small foreign objects). Review of Resident #108's October 2024 Physician orders indicated the following: -Baclofen (medication used to relieve muscle spasms, cramping, and tightness caused by medical problems, including . certain spinal injuries) Oral Tablet, give 25 mg (milligrams) by mouth three times a day related to Muscle Spasm, initiated 8/2/24 with no stop date. -Gabapentin (anti-seizure medication that can also be used to treat pain) Oral Tablet, give 900 mg by mouth three times a day related to cutaneous abscess of left lower limb, initiated 8/2/24 with no stop date. -Lidocaine (medication to treat pain) External Patch, apply to right shoulder topically one time a day for pain, initiated 8/3/24 with no stop date. -Tizanidine (short acting muscle relaxer used to relieve . muscle spasms caused by medical problems such as certain injuries to the spine) HCL Oral Tablet 2 mg, give 1.5 tablets by mouth two times a day for Muscle Spasm, initiated 10/4/24 with no stop date. -Apixaban (anticoagulant medication) Oral Tablet 5 mg, give 5 mg by mouth two times a day for anticoagulant, initiated 10/5/24 with no stop date. -Cefepime (antibiotic medication used to treat infection) HCL IV Solution Reconstituted, use one Gram (g) IV every six hours for Aspiration Pneumonia until 11/5/24, initiated 10/5/24. -Lamotrigine (anticonvulsant medication used to treat seizures) Oral Tablet 25 mg by mouth one time a day related to unspecified convulsions, initiated 8/3/24 with no stop date. -Vancomycin (antibiotic medication used to treat infection) HCL IV Solution, use 1250 mg IV every 12 hours for Aspiration Pneumonia until 10/9/24 . Trough (blood test used to monitor the use of Vancomycin) drawn 10/7/24 was less than 4.0. Dose increased from 1000 mg every 12 hours to 1250 mg every 12 hours. Next trough to be drawn 10/10/24. On 10/8/24 between 10:20 A.M. and 10:40 A.M., the surveyor observed the following: -Unit Manager (UM) #1 was standing at the medication cart in the hallway on the Unit. -Resident #108 positioned in bed, on his/her back, and was crying. -An IV pole and pump were positioned by the head of the Resident's bed. The surveyor did not observe any IV medications in use at this time. -The Resident had a PICC (Peripherally Inserted Central Catheter: long, thin tube that's inserted through a vein in one's arm and passed through to the larger veins near the heart) line present in his/her right upper arm. During an interview at the time, Resident #108 said he/she was experiencing pain and had not received any of his/her pain medication that was scheduled to be administered that morning. Resident #108 said that he/she knew medications were scheduled to be administered between 8:00 A.M. and 9:00 A.M., but that he/she had not received any of those medications yet. Resident #108 also said that he/she was supposed to receive IV antibiotic medication for an infection through his/her PICC line that morning but the IV antibiotic medication had not been administered as yet. -The surveyor activated Resident #108's call device as the call device was out of reach of the Resident. -Nurse #1 responded at 10:30 A.M., and Resident #108 told Nurse #1 that he/she was in pain and had not received his/her morning medications. -Nurse #1 said she would alert UM #1 that the Resident was in pain and requesting his/her medications. -Nurse #1 exited Resident #108's room, then returned with the Assistant Director of Nursing (ADON) to assist the Resident to reposition in bed. -Nurse #1 told Resident #108 that UM #1 was aware the Resident had not yet received his/her medication and that UM #1 was working on preparing the medications at that time. Review of Resident #108's Medication Administration Audit Report for 10/8/24 indicated the following: -Baclofen Oral Tablet 25 mg was scheduled for administration at 8:00 A.M. and was not administered until 11:06 A.M. -Gabapentin 900 mg was scheduled for administration at 8:00 A.M. and was not administered until 11:08 A.M. -Tizanidine HCL Oral Tablet 2 mg was scheduled for administration at 9:00 A.M. and was not administered until 11:09 A.M. -Lidocaine External Patch was scheduled for administration at 9:00 A.M. and was not administered until 11:09 A.M. -Lamotrigine Oral Tablet 25 mg was scheduled for administration at 8:00 A.M. and was not administered until 11:08 A.M. -Vancomycin HCL IV Solution 1250 mg was scheduled for administration at 9:00 A.M. and was not administered until 10:42 A.M. -Apixaban Oral Tablet 5 mg was scheduled for administration at 9:00 A.M. and was not administered until 11:08 A.M. -Cefepime HCL IV Solution 1g was scheduled for administration at 11:00 A.M. and was not administered until 12:35 P.M. During an interview on 10/8/24 at 5:02 P.M., Resident #108 said he/she did not receive his/her scheduled pain medications that morning until around 11:00 A.M. and his/her pain did improve after receiving the medications. Resident #108 also said that he/she had received an antibiotic medication through his/her PICC line that morning and that the antibiotic was not administered on time. During an interview on 10/9/24 at 7:50 A.M., UM #1 said she was the Nurse responsible for administering medications to Resident #108 during the day shift on 10/8/24. UM #1 said she thought that all scheduled medications were required to be administered within one hour before or after their scheduled times and that the Resident's scheduled 8:00 A.M. and 9:00 A.M. medications could be administered at the same time. UM #1 said when she completed Resident #108's pain assessment prior to administering the ordered pain medications on 10/8/24, the Resident reported a pain level of eight out of 10 (severe pain). UM #1 said she did not administer Resident #108's pain medications until somewhere around 11:00 A.M. on 10/8/24 and that these medications were administered late. UM #1 also said she administered IV Vancomycin to Resident #108 that same morning and that the IV Vancomycin was not administered until 10:42 A.M. During an interview on 10/9/24 at 10:10 A.M., the ADON said that Resident #108 experienced pain frequently, required IV antibiotics to be administered, required anticoagulation therapy, and required anticonvulsant medications. The ADON said that Resident #108 also experienced muscle spasms and that the muscle spasms were a component of the Resident's pain. The ADON said that all medications provided to Resident #108 for treatment for his/her pain, infection, anticoagulation, and anticonvulsant were time critical and should have been administered within a total of one hour of when the medications were ordered, so the medications should have been administered within the timeframe of a half hour before or after the medications' scheduled order time.

Based on observation, interview, record and policy review, the facility failed to implement infection control measures to stop the spread of infection for two Residents (#6 and #46) out of 17 sampled residents, and on one Unit out of two units. Specifically, the facility failed to: 1. Ensure that Enhanced Barrier Precautions (EBP) and Infection control practice were maintained for Resident #6. 2. Ensure that infection control practices were adhered to during a PICC (peripherally inserted central catheter - a long flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart) line dressing change for Resident #46. 3. Ensure that a glucometer machine (glucose meter: a small, portable device that measure the amount of glucose (sugar) in the blood) was appropriately disinfected between Resident use. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, revised August 2022, indicated: -Enhanced barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. -EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. -Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room. -EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Review of the facility's policy titled Central Line Dressing Change, revised June 2016, indicated: -During dressing change, don (put on) non-sterile gloves, carefully open central line dressing kit and remove mask and sterile gloves, remove non-sterile gloves and perform hand hygiene . -After dressing change remove gloves and perform hand hygiene . 1. Resident #6 was admitted to the facility in August 2024 with diagnoses including Stage 4 Pressure Ulcer (full thickness tissue loss that exposes bone, muscle, or tendon) of the left buttock. On 10/9/24 at 2:32 P.M., the surveyor observed Nurse #4 perform a wound dressing change for Resident #6. The surveyor observed: -Nurse #4 don gloves, and remove the old dressing from Resident #6's pressure area, discard the old dressing, and doff (remove) her gloves. -Nurse #4 then donned new gloves, cleansed the wound with wound cleanser, doffed her gloves, put on new gloves, and applied a new wound dressing to the wound bed. -Nurse #4 then reached into her pocket with the gloved hand and retrieved scissors. -Nurse #4 did not wear a gown, sanitize or clean her hands before donning gloves or after doffing gloves during the wound care observation. During an interview on 10/9/24 at 2:42 P.M., Nurse #4 said she was not aware Resident #6 was on Enhanced Barrier Precautions and that she needed to wear a gown because there was no sign at the door with instructions. Nurse #4 further said she forgot to bring hand sanitizer into the room and did not remember to sanitize hands after removing soiled gloves and before putting on clean gloves during the wound care. During an interview on 10/10/24 at 12:46 P.M. the Assistant Director of Nursing (who is also the facility Infection Preventionist[IP]) said the expectation is that when a Resident has a wound, Enhanced Barrier Precautions including wearing gowns and hand hygiene should be performed during wound care. 2. Resident #46 was admitted to the facility in August 2024, with a diagnosis of Unspecified Intestinal Obstruction (gastrointestinal condition in which digested material is prevented from passing normally through the intestines). Review of Resident #46's October 2024 Physician's orders indicated that the Resident was due for a PICC line dressing change on 10/8/24. On 10/8/24 at 1:11 P.M., the surveyor observed a dressing change being done by Unit Manager (UM) #1. The surveyor observed: -UM #1 remove the old PICC line dressing from Resident #46's left arm. -The Resident reminded UM #1 that she forgot to wear a mask. -UM #1 went to the door, donned a mask and a gown and then took the old dressing off the Resident's PICC line. -UM #1 doffed the gloves, and opened the central line kit that contained supplies for the dressing change. -UM #1 dropped the sterile gloves from the central line dressing kit. -UM #1 removed her gown, walked out of the Resident's room to the hallway to her medication cart and returned with another pair of gloves. -UM #1 donned the sterile gloves, cleaned the PICC line site and applied new dressings to the area. -UM #1 did not don another gown upon entering the Resident's room the second time. During an interview on 10/8/24 at 1:33 P.M., UM #1 said she forgot to sanitize her hands between donning and doffing gloves. UM #1 said she forgot to clean her hands when she left the Resident's room, and she forgot to wear a new gown when she re-entered the Resident's room, but she should have. During an interview on 10/10/24 at 12:46 P.M., the Assistant Director of Nursing (ADON: who is also the Infection Preventionist [IP]) said that PICC Line dressing changes should be done according to the facility policy. 3. On 10/10/24 at 8:05 A.M., during a medication administration pass, the surveyor observed Nurse #7 perform finger stick blood glucose check (a common way to measure blood sugar levels using a lancet and glucose meter/ glucometers) on a resident. Nurse #7 returned the blood glucose meter to the top of his medication cart, removed his gloves and sanitized his hands. The surveyor observed Nurse #7 continued to administer medications to other residents. -At 8:29 A.M., another Nurse came and retrieved the blood glucose meter from Nurse #7. During an interview at the time, Nurse #7 said he did not disinfect the blood glucose meter after he used it. Nurse #7 said that he would disinfect the blood glucose meter after he completed administering medications to all his assigned residents. During an interview on 10/10/24 at 8:51 A.M., UM #1 said the Nurses are expected to disinfect the glucose meter machine after each use. During an interview on 10/10/24 at 12:46 P.M. the ADON/ IP said that glucometers should be cleaned between residents per manufacturer's guidelines.

Based on observation, interview, record and policy review, the facility failed to provide a homelike environment, relative to accessibility of the call bell, for one Resident (#108) out of a total sample of 17 residents. Specifically, for Resident #108, the facility failed to ensure ready access to his/her call device when the Resident was dependent on staff for his/her care needs and was able to use an alternate call pad device (altered device for a call light that is activated by being tapped rather than pressed by a finger or thumb), which increased the Resident's risk for not having his/her care needs met timely and appropriately. Findings include: Review of the facility's policy titled Call Devices for Patients, dated March 2018 and last reviewed December 2023, indicated the following: -Appropriate devices shall be made available to help facilitate patient communication needs. -If the patient cannot demonstrate appropriate use of the standard call light, the Nurse shall evaluate the patient's ability to use alternative call devices, . -If the patient demonstrates appropriate use of an alternative call device, the Nurse shall secure the device proximal to the patient. Resident #108 was admitted to the facility in August 2024 with diagnoses including Unspecified Cord Compression (pressure on the spinal cord that can affect one's body movements and function). Review of Resident #108's Spinal Injury Care Plan, dated 8/13/24, indicated the Resident had Quadriplegia (complete paralysis of the body from the neck down) related to a surgical spinal injury. Review of Resident #108's Activities of Daily Living (ADL) Care Plan, dated 8/5/24, indicated the Resident had a self-care performance deficit related to Quadriplegia. Further review of the Resident's ADL Care Plan indicated: -The Resident was totally dependent on staff for eating and oral care. -The Resident required assistance of two staff to turn and reposition in bed. -Staff were to encourage the Resident to use his/her call device for assistance. Review of Resident #108's Minimum Data Set (MDS) Assessment, dated 8/15/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -The Resident demonstrated no rejection of care. -The Resident had limited functional range of motion in both of his/her upper and lower extremities. -The Resident required substantial/maximal assistance from staff for eating. -The Resident was dependent on staff for oral hygiene, bathing, dressing, bed mobility, and transfers. -The Resident did not walk and required the use of a wheelchair. -The Resident had frequent pain at a level of eight out of 10. On 10/8/24 at 10:20 A.M., the surveyor observed the following: -Resident #108 was positioned in bed, lying on his/her back, with both lower extremities elevated. -Quarter length side rails were in the up position on both sides of the bed. -The cord to the Resident's call device was attached to the wall and secured to the top of the side rail on the Resident's left side. -The cord was positioned between the Resident's side rail and mattress and the call pad device was observed to be dangling below the level of the Resident's bed, just above the floor. During an interview at the time, Resident #108 said he/she was thirsty, having pain, and could not locate his/her call pad device. Resident #108 said he/she needed the call pad device to alert staff when he/she needed assistance, because his/her ability to care for him/her self was very limited since his/her spinal injury. The Resident also said that his/her call device was supposed to be positioned on the mattress, near his/her left hand so that he/she could tap the call pad using the back of his/her hand. The Resident further said this was the only way he/she could activate the call pad device. During an interview on 10/8/24 at 10:37 A.M., Nurse #1 said that Resident #108's call pad device needed to be positioned so that the Resident could access the device and that use of the call pad device was how the Resident was able to alert staff when he/she needed something. On 10/9/24 at 8:45 A.M., the surveyor observed Resident #108 positioned in bed, lying on his/her back. The surveyor observed the Resident's call pad device was positioned on the mattress between the Resident's body and left arm, just below the Resident's left elbow. The surveyor observed Resident #108 rotate his/her arm outward two times consecutively, hitting the mattress with the back of his/her hand, then sigh loudly. During an interview at the time, Resident #108 said he/she was rotating his/her arm in an attempt to activate the call pad device, but he/she could not locate the call pad. Resident #108 said staff needed to position the call pad device so that he/she could rotate his/her arm outward in order to tap the device with the back of his/her hand, but the call pad was not in the right place. During an interview on 10/9/24 at 10:19 A.M., the Assistant Director of Nursing (ADON) said that Resident #108 was unable to position his/her own call pad device and that Resident #108 was dependent on staff to position the device for the Resident. The ADON said Resident #108 required the use of the call pad device in order to alert staff when he/she needed assistance. Please Refer to F697.

Based on observation, interview, record and policy review, the facility failed to identify and notify the Physician/Nurse Practitioner (NP) timely of a change in urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) condition for one Resident (#210) out of a total sample of 17 residents. Specifically, Resident #210, the facility failed to monitor and assess bleeding from the urinary catheter and notify the Physician/NP timely for required interventions, resulting in hospitalization for gross hematuria (excessive blood in the urine). Findings include: Review of the facility's policy titled Urinary Catheter Insertion, Maintenance and Removal, revised August 2024, indicated: -Indwelling urinary catheters may be beneficial to patients to assist with draining of urine. -To reduce the risk of infection and other negative outcomes, urinary catheters must be placed with care on the correct patients, maintained with appropriate technique, and removed when no longer necessary. Review of the facility's policy untitled and undated, indicated: -The facility shall promptly notify the resident and/or the resident representative and his or her Physician of changes in the resident's condition or status to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. -The Nurse will immediately notify the Resident, Resident's Physician and the Resident Representatives for the following (list not all inclusive): a) significant change in the Resident's physical, mental, or psychosocial status that is deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications. b) a need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). c) a decision to transfer or discharge the resident from the facility. -The Nurse will notify the Resident, Resident's Physician and the Resident Representatives(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. -Document the notification and record any new orders in the resident's medical record. -Educate the Resident and/or Representative about the proposed plan to treat, manage or monitor the Resident's change in condition. -Update the Resident's care plan, transcribe and implement the Provider's orders. Resident #210 was admitted to the facility in September 2024, with diagnoses including Urinary Retention (difficulty urinating and completely emptying the bladder) and ataxic gait (type of walking characterized by a lack of coordination and balance, resulting in unsteady, irregular and wide-based gait), acute embolism (a clot that breaks loose and travels to another part of the body, blocking blood flow in a large artery or branch) and Thrombosis (a blood clot that forms in a vein, artery, or the heart, narrowing the vessel and restricting blood flow) of unspecified deep veins of lower extremity (legs). On 10/8/24 at 10:19 A.M., the surveyor observed Resident #210 ambulating in the hallway with the Physical Therapist (PT). The surveyor observed that the Resident had a urinary catheter tubing that went down through his/her pants and was hung on the base of the walker (mobility device) while the Resident was ambulating. On 10/8/24 at 4:16 P.M., the surveyor observed Resident #210 ambulating in the hallway with the Physical Therapist and the Resident had a urinary catheter tubing that was observed down through his/her pants and hung on the base of the Resident's walker while he/she was ambulating. The surveyor observed that the urine in the urinary catheter tubing was bloody. Review of Resident #210's October 2024 Physician's orders did not indicate any orders for the care and maintenance of the Foley catheter. Further review of the Physician's orders indicated that the Resident was prescribed Eliquis (anticoagulant/blood thinner medication) 5 mg (milligrams) tablet two times a day, ordered on 10/1/24. Review of the Resident's Discharge Record from the hospital dated 9/30/24, indicated: -Urinary retention with history of Chronic Kidney Disease (CKD - when the kidneys are damaged and cannot filter blood the way that it should), Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), Foley catheter was placed in the ICU - Intensive Care Unit. -Foley was removed on 9/23/24. -Trial voiding was attempted on 9/24/24 but due to persistent retention and patient preference to avoid intermittent straight catheterization (insertion of a flexible tube through the urinary opening into the bladder; after the bladder is drained of urine the tube is removed), Foley was replaced. -Outpatient follow-up with Urology (medical and surgical specialty that manages the health of the urinary system) is recommended for voiding trial. -Foley catheter was last exchanged on 9/24/24. -Continue Flomax (alpha blocker medication that relaxes the muscles of the bladder to allow urine to flow more easily). During an interview on 10/8/24 at 4:38 P.M., the surveyor and Nurse #3 reviewed Resident #210's Physician's orders. Nurse #3 said that a Certified Nurses Aide (CNA) had reported to Nurse #3 that the Resident had blood in the urine. Nurse #3 said she would call the Physician for Foley catheter care orders and would also report the bleeding to the Physician. During an observation and interview on 10/9/24 at 8:15 A.M., Resident #210 said he/she could not understand why he/she was not getting better. The surveyor observed that the Foley catheter tubing remained with bloody urine. Review of Resident #210's October 2024 Medication Administration Record (MAR) indicated the Resident was administered the Eliquis medication at 8:00 A.M. on 10/9/24. During an interview on 10/9/24 at 11:30 A.M., Nurse #3 said she did not have time on 10/8/24 to notify the Physician about Resident #210's bloody urine observed in the Foley catheter tubing, and that she had asked a CNA to inform the Nurse working on the medication cart. During an interview at the same time, Nurse #2 said he was the Nurse that took care of Resident #210 on 10/8/24 from 7:00 A.M. to 11:00 P.M., but he was not aware that the Resident had a Foley catheter and had bloody urine. During an interview on 10/9/24 at 11:35 A.M., Unit Manager (UM) #1 said she was not aware Resident #210 had a Foley catheter and she had not been made aware that the Resident had bloody urine. During an interview on 10/10/24 at 11:45 A.M., the facility's NP said she was aware that Resident #210 had a Foley catheter on admission. The NP said she received a text message from UM #1 informing her that Resident #210 had hematuria on 10/9/24, and she gave an order to hold (not administer) the Resident's Eliquis for two days. The NP said she did not order any laboratory workup because UM #1 did not make it clear that the Resident had gross hematuria. The NP further said she gave an order on 10/10/24 for the Resident to be sent out to the hospital when UM #1 notified her that Resident #210 had gross hematuria. During an interview on 10/10/24 at 12:08 P.M., UM #1 said Nurse #3 had called a covering Physician on 10/9/24 during the 7:00 A.M. to 3:00 P.M. (Day) shift for Resident #210's Foley catheter to be changed, to obtain urine for urinalysis and sensitivity (laboratory test) but Nurse #3 passed the order on to the 3:00 P.M. -11:00 P.M. (Evening) Nurse Supervisor. UM #1 said the Evening Nurse Supervisor said he did not have time to follow through with the Physician's orders for Resident #210 and passed the orders on to the 11:00 P.M. to 7:00 A.M. (Night) shift. UM#1 further said the Night shift Nurse was able to re-insert a new Foley catheter at 4:00 A.M. on 10/10/24, after the Night shift Nurse noted that Resident #210's abdomen was distended. UM #1 said the newly inserted Foley catheter drained 1000 ml (milliliters) of bloody urine. UM #1 said she notified the NP when she (UM #1) came in for the morning shift at 7:00 A.M. and obtained orders from the NP to transfer Resident #210 to the hospital. During an interview of 10/10/24 at 12:52 P.M., the facility's Physician said he was aware the Resident had a Foley catheter, but it was up to nursing to ensure the care and services was provided. The facility Physician said he was not aware the Resident had bleeding in his urine.

Based on record and policy review, observation, and interview, the facility failed to develop a plan of care for appropriate treatment and services related to limited range of motion for one Resident (#42), out of a total sample of 17 Residents. Specifically, for Resident #42, the facility failed to develop a plan of care relative to positioning for the Resident after he/she was assessed and recommendations made by Rehabilitative Services for a specialty wheelchair and molded lateral supports (fitted equipment that help reinforce body support and reduce postural deformity). Findings include: Review of the facility policy titled Comprehensive Resident Centered Care Plans, last revised December 2021, indicated: -Updating care plans: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals. 2. Stand up meetings of the Director of Nursing (DON), Social Services Coordinator, MDS coordinator, Registered Dietician, Activities Director, and Therapy Professional are held to review the current status of skilled residents and determine needed interventions to meet resident goals. 3. The Care Plan will be updated and/or revised for the following reasons: >Significant change in the resident's condition >A change in planned interventions >Goals are obtained and new goals established to meet current resident needs and/or goals 4. Any revision, additions, or deletion to the plan of care will be dated and initialed. 5. Revisions involving the care of other disciplines are done through consultative and collaborative efforts and documented as above. Resident #42 was admitted to the facility in August 2022, with diagnoses including Traumatic Brain Injury (TBI - a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain), Contracture (a permanent shortening [as of muscle, tendon, or scar tissue] producing deformity or distortion) of right hand, Contracture of left hand, Contracture of left wrist, and Contracture of left elbow. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #42: -was rarely to never understood and severely cognitively impaired as evidenced by a staff assessment. -was dependent on staff for all ADLs (ADLS- activities related to personal care which include bathing, dressing, grooming and eating). -had abnormal posture, left and right foot drop (difficulty lifting the front part of the foot), and contracture to his/her left elbow. -that no therapies had been provided since the last comprehensive assessment. On 10/10/24 at 8:52 A.M., the surveyor observed Resident #42 seated in Geri chair (large padded recliner wheeled chair) with the head of the chair angled backwards with a pillow underneath his/her head, a pillow underneath his/her right arm, and a bolster (a long, thick pillow that is placed under other pillows for support) underneath his/her legs which were elevated. Review of Resident #42's Plan of Care relative to ADLs, initiated 9/1/22 and last revised 6/7/24, indicated: -Resident #42 had an ADL self care performance deficit related to diagnosis of TBI and contractures, initiated 9/1/22. -Resident able to answer yes/no questions, utilize his/her fingers. 1 finger means yes and 2 fingers means no, initiated 6/7/24. -Mobility: wheelchair assistance of (1) staff, initiated 11/10/22. -Bed Mobility: is totally dependent on two staff for repositioning and turning in bed, initiated 9/1/22 -Transfer: [Resident] is totally dependent on (2) staff and a mechanical lift for transfers, initiated 11/10/22. -PT/OT evaluation and treatment as per MD orders, initiated 9/1/22. Review of the Plan of Care relative to risk for falls, initiated 9/1/22 and last revised 12/1/23, indicated: -Resident #42 was at moderate risk for falls due to deconditioning, initiated 9/1/22. -Intervention: Bolsters to be in the chair when [Resident] in it [chair], last revised 12/1/23. -PT evaluate and treat as ordered or PRN, last revised 9/20/22. Review of Resident #42's Physician's orders indicated: -Physical Therapy Eval of [Resident's] recliner chair, initiated 6/7/24 and discontinued 6/21/24. Review of the Referral/Screen to Rehab Services form, dated 6/7/24, indicated: -Resident #42 was leaning to the side when he/she is in the chair. -Rehab results documented that no triggers were indicated to support skilled rehab intervention at this time. -Resident in Geri chair appears Resident unable to reposition self. -Tilt-in-space with molded lateral supports or lateral support on backside and leg positioner is appropriate. Review of the Nursing Progress Note, dated 6/7/24, indicated: -[Physical Therapy] had evaluated Resident #42 in Geri chair. -Resident was unable to reposition self. -Tilt-in-space with molded lateral support or lateral support on backside and leg positioner is appropriate. Further review of the medical record did not indicate that the Plan of Care relative to ADLs or positioning was reviewed or revised for Resident #42 after new interventions were recommended by Rehabilitative Services on 6/7/24. During an interview on 10/10/24 at 12:08 P.M., the Rehabilitation Director said that Resident #42 was screened by rehab as staff were not positioning him/her well in his/her chair. The Rehab Director said that Rehab Department completes the screening form after they have evaluated a Resident and then the Rehab Director will communicate the screening results to the Nursing department and it is nursing's responsibility to implement the rehab recommendations. On 10/10/24 at 1:10 P.M., the surveyor and the Rehab Director observed Resident #42 seated in a Geri chair with the head of the chair reclined, feet elevated with a bolster underneath the feet, and pillows under his/her head, and left and right arms. During an interview at the time, the Rehab Director said that the Resident was in a Geri Chair, not a Tilt-in-space chair. The Resident was observed to have a leg positioner in place. The Rehab director said that based on her observation of the Resident, she would not consider Resident #42's current position to be effective and that the interventions recommended on the 6/7/24 screening were not in place. During an interview on 10/10/24 at 1:24 P.M., Nurse #6 said when a Resident has specific positioning needs, therapy/rehab staff would put in Physician's orders, and nursing staff would then document those positioning needs under the Physician's order and in the Medication Administration Record (MAR). Nurse #6 said that Rehab staff and the Nursing Supervisors would educate the CNAs (Certified Nurses Aides) and the Nursing staff when new positioning devices were needed. Nurse #6 said that he was not aware of Resident #42 having any specialty positioning devices. During an interview on 10/10/24 at 1:34 P.M., Unit Manager (UM) #1 said that the Rehab Department would normally provide a Rehabilitation Screening Form with recommendations for a Resident and that she would then provide education to the Nursing staff on the rehab recommendations. UM #1 said that Resident #42's family had wanted him/her in a tilt-in-space chair and the rehab department would be responsible for ordering a specialty wheelchair. UM #1 said that she was unable to recall if any bolsters were in place for Resident #42 or if a tilt-in-space chair was ever ordered for the Resident. During an interview at the same time, the Rehab Director said she had molded lateral supports available in the facility but she was unsure if a tilt-in-space chair had been ordered. The Rehab Director said that she would complete a rehab screen today, evaluate if a tilt-in-space chair was necessary, and would start the process to add molded lateral supports for Resident #42.

Based on observation, interview, record and policy review, the facility failed to provide urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care and services according to professional standards of practice for three Residents (#210, #44 and #42) out of a total sample of 17 residents, which increased the Residents' risk for urinary catheter complications. Specifically, the facility failed to: 1. For Resident #210, identify that the Resident was admitted to the facility with a urinary catheter, resulting in delayed monitoring and assessment of the Resident's urinary catheter and obtaining Physician orders to implement catheter care and management when hematuria (blood in urine) was identified. 2. For Resident #42, obtain a Physician's order for a specific type of external urinary catheter. 3. For Resident #44, insert the right size of Foley catheter ordered by the Physician. Findings include: Review of the facility's policy titled Urinary Catheter Insertion, Maintenance and Removal. revised August 2024, indicated: -Indwelling urinary catheters may be beneficial to patients to assist with draining of urine. To reduce the risk of infection and other negative outcomes, urinary catheters must be placed with care on the correct patients, maintained with appropriate technique, and removed when no longer necessary. -Patients admitted with an indwelling catheter should be reviewed for need of catheter upon admission. Whenever available, the date of the catheter insertion should be noted in the electronic medical record. -Patients should be assessed daily for need of the urinary catheter and determine whether removal with the nurse-drive protocol may be followed. -Maintain proper securement of the catheter for the duration of dwell. Change securement device every seven days following manufacturer instructions. -Review catheter necessity and goal for discontinuation daily, and with each hand off. 1. Resident #210 was admitted to the facility in September 2024, with diagnoses including Urinary Retention (condition that occurs when a person is unable to empty their bladder completely or partially of urine), Ataxic Gait (type of walking characterized by a lack of coordination and balance, resulting in unsteady, irregular and wide-based gait), acute embolism (a clot that breaks loose and travels to another part of the body, blocking blood flow in a large artery or branch) and Thrombosis (a blood clot, forms in a vein, artery, or the heart, narrowing the vessel and restricting blood flow) of Unspecified Deep Veins of lower extremity. On 10/8/24 at 4:16 P.M., the surveyor observed Resident #210 ambulating with the Physical Therapist in the hallway. The surveyor observed that the Resident had a urinary catheter tubing that went down through his/her pants and was hung on the base of the walker (mobility device) while he/she was ambulating. The surveyor observed that the urine in the urinary catheter tubing was bloody. Review of Resident #210's October 2024 Physician's orders did not indicate any orders for the care and maintenance of the Foley catheter. Review of the Resident's Discharge Record from the hospital dated 9/30/24, indicated: -Urinary retention with history of Chronic Kidney Disease (CKD - when the kidneys are damaged and cannot filter blood the way that it should), Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), Foley catheter was placed in the ICU - Intensive Care Unit. -Foley was removed on 9/23/24. -Trial voiding was attempted on 9/24/24 but due to persistent retention and patient preference to avoid intermittent straight catheterization (insertion of a flexible tube through the urinary opening into the bladder; after the bladder is drained of urine the tube is removed), Foley was replaced. -Outpatient follow-up with Urology (medical and surgical specialty that manages the health of the urinary system) is recommended for voiding trial. -Foley catheter was last exchanged on 9/24/24. -Continue Flomax (alpha blocker medication that relaxes the muscles of the bladder to allow urine to flow more easily). During an interview on 10/8/24 at 4:38 P.M., the surveyor and Nurse #3 reviewed Resident #210's Physician orders and found no evidence of orders for urinary catheter care and maintenance. Nurse #3 said Resident #210 had no Physician orders for Foley catheter care and services because the Resident was not admitted with a Foley catheter, but the Resident had a Foley catheter while he/she was at the hospital. The surveyor and Nurse #3 reviewed the Discharge Record from the hospital for the Resident which indicated he/she had a Foley catheter on admission to the facility. During an interview on 10/8/24 at 5:00 P.M., the Assistant Director of Nursing (ADON) said she had been made aware that Resident #210 had no Physician orders for care and services of the Foley catheter and she would follow-up pertaining to the orders. During an interview on 10/8/24 at 5:02 P.M., the Director of Nursing Services (DNS) said she knew Resident #210 was admitted to the facility with a Foley catheter but was not aware that the Resident did not have Physician orders for the care and services of the Foley catheter and would follow-up pertaining to the orders. During an interview on 10/9/24 at 8:00 A.M., the MDS Nurse said she was made aware that Resident #210 had no Physician orders for the care and management of the Foley catheter and that she had obtained orders from the Physician and entered the orders into the Electronic Medical Record (EMR) on 10/9/24 at 7:41 A.M. On 10/9/24 at 8:15 A.M., the surveyor observed that the urine in Resident #210's Foley catheter tubing remained bloody. During an interview on 10/9/24 at 11:30 A.M., Nurse #3 said she did not have time to notify the Physician the previous day (10/8/24) about Resident #210's need for care and services of Foley catheter and or his/her bleeding. Nurse #3 said she had asked a Certified Nurses Aide (CNA) to inform the Nurse on the medication cart about the bloody urine in the Resident's urinary catheter. During an interview at the time, Nurse #2 said he was the Nurse that took care of Resident #210 on 10/8/24 from 7:00 A.M. to 11:00 P.M., but he was not aware that the Resident had a Foley catheter and had hematuria. During an interview on 10/9/24 at 11:35 A.M., Unit Manager (UM) #1 said she was not aware Resident #210 had a Foley catheter and she had not been made aware that the Resident had blood in his/her urine. During an interview of 10/10/24 at 12:52 P.M., the facility's Physician said he was aware the Resident had a Foley catheter, but it was up to nursing to ensure the urinary care and services was provided. 2. Resident #42 was admitted to the facility in August 2022, with diagnoses including Diffuse Traumatic Brain Injury (TBI - a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain) and Tracheostomy (a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea, or windpipe). On 10/9/24 at 9:58 A.M., the surveyor and Nurse #1 observed Resident #42. Nurse #1 said Resident #42 had an external type urinary catheter attached to a drainage bag. The surveyor and Nurse #1 reviewed the Resident's October 2024 Physician's orders and Nurse #1 said Resident #42 did not have orders for an external type urinary catheter. Nurse #1 said Resident #42 should have had orders for the external type urinary catheter. 3. Resident #44 was admitted to the facility in October 2022, with diagnoses including Traumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain) with Loss of Consciousness of Unspecified Duration and Acute Pyelonephritis (bacterial infection of the kidneys). Review of Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #44: -had cognitive loss and never understood others -was dependent on staff for bathing, dressing, grooming and toileting. Review of Resident #44's October 2024 Physician's orders indicated: -suprapubic catheter (a thin, flexible tube that drains urine from the bladder through a small incision in the lower abdomen) secondary to neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly) Depending on the type of neurological disorder causing the problem, the bladder may empty spontaneously (incontinence) or may not empty at all (retention with overflow leakage), 16 French with 30 ml (milliliters) of balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) ordered on 10/8/24. On 10/9/24 at 9:41 A.M., the surveyor and Nurse #1 observed that Resident #44 had a 20 French suprapubic urinary catheter with 30 ml balloon. Nurse #1 said the suprapubic urinary catheter size did not match the Physician's order. During an interview on 10/9/24 at 10:30 A.M., the Director of Nursing (DON) said all Residents are required to have Physician's orders for urinary catheter usage and Residents #210 and #42 should have Physician orders but they did not. The DON further said the facility staff should have followed the Physician's order for a 16 French (not 20 French) urinary catheter inserted for Resident #44, but they did not.

Based on observation, interview, record and policy review, the facility failed to provide care and services for assisted nutrition and hydration in accordance with the Physician order for one Resident (#46), who required Total Parenteral Nutrition (TPN: method of providing nutrition where a liquid formula is given into a vein through an intravenous catheter (IV) to provide most of the nutrients a resident needs, used when a resident cannot or should not eat or drink by mouth) of one resident who required TPN, out of a total sample of 17 residents. Specifically, the facility failed to provide Clinimix E (IV nutritional product containing amino acids [building blocks of protein] with electrolytes [electrically charged minerals that play important roles in the body] in Dextrose [simple sugar] with Calcium [mineral needed by the body]) and SMOFlipids (IV nutritional product containing calories and essential fatty acids) infusions to Resident #46 in accordance with the Physician's order, increasing the Resident's risk for malnutrition. Findings include: Resident #46 was admitted to the facility in August 2024, with diagnoses including Unspecified Intestinal Obstruction and Gastro-Esophageal Reflux Disease (GERD-gastro-esophageal reflux disease, a condition that causes heartburn or acid indigestion). Review of Resident #46's Hospital Discharge Summary, dated 8/11/24, indicated the following: -The Resident had been admitted to the hospital with a small bowel obstruction (SBO). -The Resident required TPN indefinitely due to concern and high risk for re-obstruction given complicated abdominal surgery history. -The Resident would require outpatient surgery follow-up for advancement of diet. -Nutrition was required to be administered via TPN through a PICC (Peripherally Inserted Central Catheter: long, thin tube that's inserted through a vein in one's arm and passed through to the larger veins near the heart) line. Review of Resident #46's Parenteral Nutrition Prescription Order Form, dated 9/26/24, indicated the following: -The Resident required Clinimix E 5% Amino/15% Dextrose 1 L (Liter). -The Resident was to receive a total volume of 2000 mL (milliliters; 2000 mL = 2 L) of Clinimix E, infused over 18 hours (56 mL/hour for one hour, then increase to 118 mL/hour for 16 hours, then decrease to 56 mL/hour for one hour, then stop for six hours). -The Resident required 50 G (grams) of SMOFlipids. -The SMOFlipids were to be infused separately from the Clinimix E at a rate of 20.8 mL/hour, infused over 12 hours. Review of Resident #46's active Care Plan indicated the following: -The Resident was at potential nutrition risk due to need for TPN. -The Resident was at potential risk for dehydration due to need for TPN. -Staff were required to provide medications as ordered. -Staff were required to provide IV fluids/TPN as ordered. Review of Resident #46's October 2024 Physician orders indicated the following: -Clinimix E 5% Dex (Dextrose) 15%. Infuse Clinimix 2000 mL IV cycled over 18 hours at initial rate of 56 mL x 1 hour. Then increase to 118 mL/hour x 16 hours. Then decrease to 56 mL/hour x 1 hour. Then stop for 6 hours ., initiated 9/30/24 with no stop date. -Document amount of TPN administered every shift, initiated 5/15/24 with no stop date. -Infuse SMOFlipid IV continuously at 20.8 mL/hour x 12 hours at room temperature. Infuse in a different line from TPN, initiated 9/26/24 with no stop date. Review of Resident #46's October 2024 Medication Administration Record (MAR) indicated the following: -The Resident received the total ordered dose of 2000 mLs Clinimix E that was ordered to be administered starting at 6:00 P.M. on 10/9/24 and ending at 12:00 P.M. on 10/10/24. -The Resident received the total ordered dose of SMOFlipids that were ordered to be administered starting at 6:00 P.M. on 10/9/24 and ending at 6:00 A.M. on 10/10/24 at 20.8 mL/hour (total dose of 249.6 mLs). On 10/10/24 at 1:22 P.M., the surveyor observed the following in Resident #46's room: -The Resident was positioned on the bed. -One 2000 mL bag of Clinimix E hung on an IV pole and the tubing from the bag was connected to one of the ports on the Resident's PICC line. -The IV pump administering the Clinimix E was running at a rate of 56 mL/hour. -The bag of Clinimix E was approximately one quarter full. -One 250 mL bag of SMOFlipids hung on another IV pole in the room. -The bag of SMOFlipids was not connected to the Resident's PICC line and the IV pump was not running. -The bag of SMOFlipids was approximately one third full. During an interview at the time, Resident #46 said the Clinimix E was still being infused from the prior evening but should have been done around noon time that day. Resident #46 also said he/she was unsure whether the SMOFlipids should have been infusing at that time. During an interview and observation on 10/10/24 at 1:50 P.M., Nurse #7 said he worked the prior evening (10/9/24) and hung Resident #46's Clinimix E and SMOFlipids for administration. Nurse #7 said he knew the Resident had a lab draw in the morning on 10/10/24 and that the infusions needed to be stopped in order to prepare for the lab to draw the Resident's blood. Nurse #7 said he reconnected the Clinimix E to continue the infusion for Resident #46 after the lab collected the blood sample, but he did not reconnect the SMOFlipids. Nurse #7 said that the SMOFlipids were not to be reconnected once they stopped infusing, but he did not know why. At this time, the surveyor and Nurse #7 observed Resident #46 and the bags of Clinimix E and SMOFlipids. Nurse #7 said there were approximately 400 mLs left in the Clinimix E bag that had not yet been infused and approximately 40 mLs left in the SMOFlipids bag that had not been infused from the prior evening. Nurse #7 said the Clininmix E was scheduled to be infused from 6:00 P.M. for 18 hours, and would be completed around 12:00 P.M. Nurse #7 also said the SMOFlipids were scheduled to be infused from 6:00 P.M. for 12 hours, and should have been completed around 6:00 A.M. Nurse #7 then turned to Resident #46 and said You're done. At this time, the surveyor observed Nurse #7 stop the Clinimix E infusion and disconnect the IV tubing from the Resident's PICC line port. Nurse #7 then removed the bags of Clinimix E and SMOFlipids from the IV poles and turn toward the room exit. Nurse #7 said that the Resident should not have left over Clinimix E and leftover SMOFlipids, but that the Resident was due for another infusion at 6:00 P.M. Nurse #7 said he needed to disconnect the Clinimix E because the Resident was supposed to have six hours between infusions and the Clinimix infusion was already stopped too late. Nurse #7 said that there was nothing he could do about the leftover Clinimix E and SMOFlipids other than discard it and that he would just need to let the Nurse coming in for the evening (3:00 P.M. through 11:00 P.M.) shift to start the Resident's next infusion late. Review of Resident #46's Comprehensive Metabolic Panel (CMP: blood test that measures proteins, enzymes, electrolytes, minerals and other substances in one's body) indicated the Resident's total protein level was 6.4 grams (g)/deciliter (dL) (normal reference range 6.6 - 8.7 g/dL). Review of a Physician's order, dated 10/10/24, indicated Dietitian Consult related to low protein. During an interview on 10/11/24 at 7:57 A.M., the Assistant Director of Nursing (ADON) said Resident #46 required TPN and required infusions of Clinimix E and SMOFlipids to be administered according to the Physician's orders. The ADON said if the Resident did not receive the ordered infusions within the scheduled time frame, the Nurse was required to call the Pharmacy to identify the shelf life of the Clinimix E and SMOFlipids after being removed from the refrigerator and opened, to determine whether it would be safe to continue to administer the infusions past the ordered timeframes. The ADON also said the Nurse was required to call the Physician and obtain orders whether to continue the infusions beyond the scheduled infusion timeframes and to obtain orders if the timeframes for the next infusions needed to be altered. The ADON said that there should not have been leftover Clinimix E or SMOFlipids on 10/10/24 from the Resident's infusions that were administered starting at 6:00 P.M. on 10/9/24. During an interview on 10/11/24 at 10:18 A.M., the Dietitian said that facility staff were responsible to alert her if a Resident's assisted nutrition and hydration was not being administered as ordered so that she could assess the Resident and coordinate with the Physician to ensure the Resident's nutrition and hydration needs were met. The Dietician said she worked in the facility on 10/10/24 and that no staff alerted her that Resident #46 did not receive his/her assisted nutrition as ordered. The Dietician said that as of the time of this interview with the surveyor, no facility staff had communicated to her that a new order had been placed for a Dietitian consult. During an interview on 10/11/24 at 11:46 A.M., the Nurse Practitioner (NP) said that the Physician was on vacation this same week. The NP said that staff at the facility were required to contact her or, if after hours, the on-call Practitioner relative to Resident needs. The NP said that Resident #46 received his/her primary nutritional needs via TPN. The NP also said she received no communication from facility staff on 10/10/24 relative to Resident #46 not having received the ordered doses of Clinimix E and SMOFlipids. The NP said that staff should have contacted her, or the on-call Provider/Practitioner if after 5:00 P.M., when the infusions of Clinimix E and SMOFlipids were not administered as ordered so that appropriate orders could have been obtained to ensure the Resident received proper nutrition. The NP said if she had been notified, she would have contacted the Pharmacy to identify the shelf life of the Clinimix E and SMOFlipids in order to determine whether the infusions could continue to run safely. The NP also said she would have reviewed the timing of the Resident's next infusion to determine whether the next infusion time needed to be altered.

Based on observation, record and policy review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided in a timely manner for one Resident (#108) out of a total sample of 17 residents. Specifically, the facility failed to provide pain management interventions in a timely manner for Resident #108 when the Resident was experiencing severe pain and was dependent on staff to receive pharmacological (medication) and non-pharmaceutical interventions to treat pain. Findings include: Review of the facility's policy titled Pain Assessment and Management, dated March 2016 and last reviewed December 2023, indicated the following: -Pain is an unpleasant sensory and emotional experience . -Breakthrough pain is pain that increases above the pain addressed by the ongoing analgesics (drug used to treat pain). -Management of a patient's pain includes individualized assessment, intervention, and evaluation of pain and pain relief. -A patient's self-report of pain will be accepted as the most reliable indicator of pain. -Pain assessments are conducted using a numeric pain scale from zero to ten. -Numeric pain level of one to three is interpreted as mild pain. -Numeric pain level of four to six is interpreted as moderate pain. -Numeric pain level of seven to 10 is interpreted as severe pain. -Pharmacological and non-pharmacological interventions may be used to treat a patient's pain. Resident #108 was admitted to the facility in August 2024, with diagnoses including: Unspecified Cord Compression (pressure on the spinal cord that can affect one's body movements and function), Muscle Spasm (sudden, uncontrollable muscle contractions that are usually painful), Cutaneous Abscess (localized collection of pus in the skin characterized by pain and swelling) of Right and Left Lower Limbs, Anxiety Disorder (group of mental disorders characterized by anxiety and fear), and Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of Resident #108's Pain Care Plan, initiated 8/5/24 and revised 8/13/24, indicated the following: -The Resident was at risk for breakthrough pain related to Quadriplegia (complete paralysis of the body from the neck down), Cutaneous Left lower Limb, Chronic Disability, and Wounds. -The Resident's pain was alleviated by PRN (as needed) and scheduled medications. -Administer analgesia as per orders. -Meet the Resident's need for pain relief and respond immediately to any complaint of pain. Review of Resident #108's Spinal Injury Care Plan, dated 8/13/24, indicated the following: -The Resident had Quadriplegia related to Spinal Injury. -Give medications as ordered. -Pain management as needed . provide alternative comfort measures PRN. Review of Resident #108's Minimum Data Set (MDS) Assessment, dated 8/15/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -The Resident reported having frequent pain. -The Resident reported a pain level of eight out of 10 (severe). -The Resident was on a scheduled pain medication regime. -The Resident received PRN pain medications and non-medication interventions for pain. Review of Resident #108's October 2024 Physician orders indicated the following: -Pain scale zero to 10 every shift for monitoring, initiated 8/2/24 with no stop date. -Acetaminophen Tablet 325 milligrams (mg), give two tablets by mouth every six hours as needed for Pain. Not to exceed three grams (3g) per 24 hours, initiated 8/2/24 with no stop date. -Baclofen (medication used to relieve muscle spasms, cramping, and tightness caused by medical problems, including . certain spinal injuries) Oral Tablet, give 25 mg by mouth three times a day related to Muscle Spasm, initiated 8/2/24 with no stop date. -Diclofenac Sodium (Non-Steroidal Anti-Inflammatory Drug [NSAID] used to treat pain) External Gel 1% (one percent) Topical (apply to the skin), apply to right shoulder topically two times a day for pain, initiated 8/5/24 with no stop date. -Gabapentin (anti-seizure medication that can also be used to treat pain) Oral Tablet, give 900 mg by mouth three times a day related to Cutaneous Abscess of Left Lower Limb, initiated 8/2/24 with no stop date. -Hydromorphone (opioid medication used to treat moderate to severe pain) HCl Oral Tablet 2 mg, give 4 mg by mouth every four hours as needed for moderate to severe pain, initiated 10/4/24 with no stop date. -Lidocaine (medication to treat pain) External Patch, apply to right shoulder topically one time a day for pain, initiated 8/3/24 with no stop date. -Tizanidine (short acting muscle relaxer used to relieve . muscle spasms caused by medical problems such as certain injuries to the spine) HCl Oral Tablet 2 mg, give 1.5 tablets by mouth two times a day for Muscle Spasm, initiated 10/4/24 with no stop date. On 10/8/24 between 10:20 A.M. and 10:40 A.M., the surveyor observed the following: -Unit Manager (UM) #1 was standing at the medication cart in the hallway on the Unit. -Resident #108 positioned in bed, on his/her back, and was crying. -Resident #108's call device was out of reach of the Resident. During an interview at the time, Resident #108 said he/she was experiencing pain and that he/she had not had any of his/her pain medications that was scheduled to be administered that morning. Resident #108 said that he/she knew medications were scheduled to be administered between 8:00 A.M. and 9:00 A.M., but that he/she had not received any of those medications as yet. -The surveyor activated Resident #108's call device for him/her. -Nurse #1 responded to the call device at 10:30 A.M. -Resident #108 told Nurse #1 that he/she was in pain and had not received his/her morning medications. -Nurse #1 said she would alert UM #1 that the Resident was in pain and requesting his/her medication. -Nurse #1 exited Resident #108's room, then returned with the Assistant Director of Nursing (ADON). Nurse #1 and the ADON assisted the Resident to reposition in bed. -The surveyor observed Nurse #1 tell Resident #108 that UM #1 was aware the Resident had not yet received his/her medication and that UM #1 was working on preparing the medications at that time. Review of Resident #108's Medication Administration Audit Report for 10/8/24 indicated the following: -Baclofen Oral Tablet 25 mg was due for administration at 8:00 A.M. and was not administered until 11:06 A.M. -Gabapentin 900 mg was due for administration at 8:00 A.M. and was not administered until 11:08 A.M. -Tizanidine HCl Oral Tablet 2 mg was due for administration at 9:00 A.M. and was not administered until 11:09 A.M. -Diclofenac Sodium External Gel 1% was due for administration at 9:00 A.M. and was not administered until 11:10 A.M. -Lidocaine External Patch was due for administration at 9:00 A.M. and was not administered until 11:09 A.M. During an interview on 10/8/24 at 5:02 P.M., Resident #108 said he/she did not receive his/her scheduled pain medications this morning until around 11:00 A.M. and that his/her pain did improve after receiving the medications. During an interview on 10/9/24 at 7:50 A.M., UM #1 said she was the Nurse responsible for administering medications to Resident #108 during the day shift on 10/8/24. UM #1 said that when she completed Resident #108's Pain Assessment prior to administering the ordered pain medications, the Resident reported a pain level of eight out of 10 (severe pain). UM #1 said she administered Resident #108's pain medications late on 10/8/24 and that once the pain medications were administered, the Resident reported that the medications were effective. During an interview on 10/9/24 at 10:10 A.M., the ADON said that Resident #108 experienced pain frequently and that all medications provided to Resident #108 for treatment of pain were time critical. The ADON said that the Resident's pain medications should have been administered within a total of one hour of when the medications were ordered, so the medications should have been administered within the timeframe of a half hour before or after the medications' scheduled order time. The ADON said Resident #108 received Baclofen and Tizanidine for muscle spasms, which was a component of the Resident's pain, and also received Gabapentin, Diclofenac Sodium External Gel, and Lidocaine External Patches to treat his/her pain. The ADON further said it was important for Resident #108's medications to be administered timely in order to treat the Resident's pain. Please Refer to F760.

Based on observation, record and policy review, and interview, the facility failed to ensure that one Resident (#6) out of a total sample of 17 resident was free of medication errors. Specifically, the facility failed to: -ensure that antibiotic medication (Clindamycin) ordered for Resident #6 was administered for seven days as ordered and not 12 days as indicated on the Medication Administration Record (MAR). Findings include: Review of the facility's policy titled Medication Management Administration of Medications, revised October 2024, indicated: -Licensed personnel may only administer medications that have been dispensed by the pharmacy, including those stocked in the automated drug distribution cabinet (ADC). -Medications will be obtained from the ADC or medication storage area for one patient at a time, then administered to that patient. Resident #6 was admitted to the facility in August 2024, with diagnosis of Stage 4 Pressure Ulcer (full thickness tissue loss that exposes bone, muscle, or tendon) of the left buttock. Review of Resident #6's October 2024 Physician orders indicated the following ordered medications: -Clindamycin (antibiotic used to treat bacterial infection) 150 mg (milligrams) four times a day for wound infection, ordered on 10/7/24 for 7 days. Review of the October 2024 Medication Administration Record (MAR) indicated: -Clindamycin medication was to be administered for 12 days from 10/7/24 to 10/19/24. During an interview on 10/9/24 at 8:53 A.M., Nurse #4 said the Clindamycin medication had not been delivered from the pharmacy. During an interview on 10/9/24 at 8:58 A.M., Nurse #2 said he had administered the Clindamycin medication four times on 10/8/24. Nurse #2 said the medication had not been delivered from the pharmacy therefore he borrowed the Clindamycin from another resident's medication. Nurse #2 said that he was not aware he could not borrow medications from another resident. During an interview on 10/9/24 at 2:46 P.M., Nurse #1 said the nursing staff are not expected to borrow medications from other residents. Nurse #1 further said the Clindamycin medication had been marked to be administered for 12 days on Resident #6's MAR. Nurse #1 said the Clindamycin medication should have been marked to be administered for 7 days as ordered.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles of practice. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or name brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. On 10/9/24 at 11:46 A.M., the surveyor and Nurse #5 reviewed the medication cart on the First Floor and observed the following: -One Albuterol Sulfate inhalation aerosol unit (inhaler) in a ziplock bag with no pharmacy label affixed to indicate the prescribed dose, strength, expiration date, route of administration or instructions and precautions for the medication. -A resident's name and room number were handwritten in black marker on the bag and the side of the inhaler. During an interview on 10/9/24 at 11:50 A.M., Nurse #5 said she did not know when the inhaler was opened. Nurse #5 said there was no label or date on the bag or inhaler. Nurse #5 said she knew which resident the inhaler was for, but there should be a pharmacy label with instructions on the inhaler. Nurse #5 said she was not sure when the inhaler was used or how long it had been there for. Nurse #5 said she had not administered the inhaler and she was going to dispose of the medication. During an interview on 10/10/24 at 10:15 A.M., the Assistant Director of Nursing (ADON), said the inhaler should have been labeled with the pharmacy label that has the required information about the medication. The ADON said the inhaler should not have been on the medication cart.

Based on observation, record review and interview, the facility failed to obtain treatment orders for one Resident (#20), out of three applicable Residents, in a total sample of 15 Residents. Specifically, the facility failed to obtain treatment orders when skin breakdown was initially observed and resulted in the development of a Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for Resident #20. Findings include: Resident #20 was admitted to the facility in January 2023 with a diagnosis of Cerebral Infarction (stroke). Review of the Minimum Data Set (MDS) Assessment, dated 5/19/23, indicated the Resident had a Staff Assessment for Mental Status completed which indicated: -the Resident was severely impaired for daily decision-making skills -had a Gastrostomy tube (G-tube: a surgically placed tube into the abdomen to give direct access for supplemental feeding) -had a Tracheostomy tube (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) -was totally dependent for Activities of Daily Life (ADL) Review of the most recent Norton_Scale (a pressure ulcer risk assessment tool), dated (2/10/23), indicated a score of 7 (a score less than 10 indicates the Resident is at a very high risk for development of a Pressure Ulcer). Review of the Weekly Skin Check Assessment, dated 5/4/23, indicated no open areas were found. The next Weekly Skin Check Assessment was completed on 7/2/23 (more than eight weeks after the 5/4/23 check). Review of the Potential Skin Integrity Care Plan, revised 2/9/23, interventions included: -to apply moisture barrier cream as needed for incontinence. -Keep skin clean and dry. -Use lotion on dry skin. Review of a Nurse's Note, dated 6/23/23, indicated that the Certified Nursing Assistant (CNA) reported two open areas on the right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). The note included the measurements of the two open areas: 1) 0.3 centimeters (cm) x 0.4 cm x 0.1 cm, with a red wound bed, no drainage and no signs or symptoms of an infection. 2) 2.5 cm x 2.8 cm x 0.1 cm, a red wound bed and no signs or symptoms of an infection. The note further indicated the areas were cleaned with normal saline, patted dry and covered with a protective dressing until further treatment options. Review of the medical record did not contain documentation that the Physician was notified of the open areas found on 6/23/23. Review of the next Weekly Skin Check Assessment completed on 7/2/23 indicated the following pressure areas: -Coccyx, Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with red or pink wound bed), measuring 2.5 cm in width. -Right buttock, Stage 2, measuring 2.0 cm in width. -Left buttock, Stage 2, measuring 2.0 cm in width. Further review of the Weekly Skin Check Assessment indicated an Alginate with silver (absorbs drainage from the wound and forms a gel-like covering over the wound, maintaining a moist environment for wound healing) and a border dressing were applied. There was no documentation to indicate specifically where the dressing was applied. There was no Physician order found in the medical record for this dressing. Review of the Wound Evaluation and Management Summary (Wound Physician Note), dated 7/6/23, indicated: -an Unstageable Deep Tissue Injury (DTI - an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the coccyx, with a measurement of 8.0 cm (length) x 4.5 cm (width) x 0.1 cm (depth). -the treatment was for Alginate Calcium (made with seaweed and absorbs exudate in the wound) with silver, apply twice a day for 30 days. Review of the Wound Evaluation and Management Summary, dated 7/11/23, indicated: -the coccyx wound was now a Stage 3 Pressure Ulcer (full thickness tissue loss) with a measurement of 6.0 cm x 4.5 cm x 0.1 cm. -the treatment included Alginate Calcium with silver twice daily for 25 days and Silver Sulfadiazine (used to prevent and treat wound infections), apply twice daily for seven days. Review of the Skin Evaluation, dated 7/12/23, indicated a Stage 3 Pressure Area to the coccyx that measured 6.0 cm length x 4.5 cm width x 0.1 cm depth. Review of the July 2023 Monthly Physician's orders indicated an order for treatment to the open area was not obtained from the Physician until 7/6/23, which was 13 days after the initial observation of the wound areas. The open areas progressed from reddened areas to a Stage 3 Pressure Ulcer. During an interview on 7/18/23 at 8:45 A.M. with Unit Manager (UM) #2, after reviewing the medical record, she said she was not aware Resident #20 had any open areas. UM #2 said Weekly Skin Checks should be done weekly and they were not consistently completed. UM #2 further said the Physician should have been notified when the areas were first identified on 6/23/23 to obtain treatment orders and not 13 days later which put the Resident at risk for further skin breakdown. During an interview on 7/18/23 at 12:55 P.M. with the Wound Physician, he said he was first made aware of the skin breakdown on the coccyx during the week of 7/2/23 and saw the Resident on 7/6/23. The area was a Deep Tissue Injury. The Wound Physician said he saw the Resident today (7/18/23) and the coccyx area was a Stage 3 Pressure Ulcer.

Based on policy review, record review and interview, the facility failed to provide appropriate treatment and services to prevent a decline in bladder continence for one Resident (#43) out of a total sample of 15 Residents. Specifically, the facility failed to provide treatment and services for Resident #43, who was cognitively intact, aware of his/her toileting needs and had a desire to maintain urinary continence. Findings include: Review of the facility's Quality of Care policy, dated June 2021, indicated: -The facility will ensure that the resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. Review of the facility's Bowel and Bladder Program policy, dated June 2021, indicated, but not limited to, the following: -All residents admitted to the facility will have a bowel and bladder Continence Evaluation performed at the time of admission, in conjunction with each quarterly and annual review, with any significant change in assessment and as deemed necessary by the Interdisciplinary Team (IDT). -The Unit Manager (UM) or designee along with the IDT will evaluate the appropriate program for the resident and refer to Restorative if appropriate. -When appropriate, the UM or designee will initiate the Restorative Bowel and/or Bladder Retraining Program (14 day program). -After the 14 days, the UM or designee will reevaluate the appropriateness to continue with the current plan or change the current plan. Resident #43 was admitted to the facility in April 2022 with a diagnosis including abnormal gait and mobility. During an interview on 7/13/23 at 9:10 A.M., Resident #43 said that he/she used to have a commode at the bedside, but it was taken away. Resident #43 said he/she asks for help to get to the bathroom, but is incontinent most of the time because he/she cannot hold urine while being walked to the bathroom. Resident #43 further said she/he wanted to be able to be continent of urine. Review of Resident #43's Bowel and Bladder Program Screener form, dated 4/4/22, indicated the following: -Always voids appropriately without incontinence. -Never incontinent of stool. -Always aware of need to toilet. Review of the Activities of Daily Living (ADL) care plan, initiated 4/4/22, indicated that for toileting: -Resident #43 was always continent of bladder and bowel. -Required continual supervision/cueing for toileting. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was: -cognitively intact as evidenced by a score of 14 out 15 on the Brief Interview for Mental Status (BIMS) assessment. -an extensive assist for transfers and toileting -occasionally incontinent of bladder and was continent of bowel Review of the MDS, dated [DATE], indicated the Resident was: -cognitively intact as evidenced by a score of 15 out of 15 on the BIMS -required supervised for transfers, ambulation and toileting -always continent of bladder. Review of the clinical record indicated the Resident sustained a fall on 2/15/23 while transferring off the commode. Review of Resident #43's Bladder Status Evaluation, dated 3/8/23, indicated the following: -Duration of bladder incontinence less than 6 months. -Always aware of the urge to void. -Motivated to be continent. -Voiding record initiated-not applicable. -Able to use the toilet and commode. -Type of incontinence-none. Review of the March 2023 Nursing Flow Sheet, indicated the Resident was always incontinent of bladder. Review of the clinical record indicated the Resident sustained a fall on 3/14/23 while trying to self-toilet. Review of the April 2023 Nursing Flow Sheet, indicated the Resident was always incontinent of bladder. Nursing Flow Sheet for May 2023 was not provided to the surveyor for review. Review of the June 2023 Nursing Flow Sheet, indicated the Resident was always incontinent of bladder. Review of the clinical record indicated no interventions and no care plan had been implemented for the Resident's bladder incontinence. During an interview on 7/14/23 at 1:16 P.M., Nurse #3 said the Resident had resided on the second floor and recently moved to the first floor. She said Resident #43 used the commode while residing on the second floor and currently needs assistance to get to the bathroom. During an interview on 7/14/23 at 1:16 P.M., UM #1 said that bladder evaluations are done annually, quarterly and when there is a significant change in status. During an interview on 7/14/23 at 3:19 P.M., the Director of Nurses (DON) and UM #1 both said that staff did not comprehensively assess the Resident's bladder incontinence when documentation of his/her incontinence began. Both the DON and UM #1 said interventions should have been implemented to see if the Resident's continence could have been restored.

Based on observation, record review and interview, the facility failed to follow infection control guidelines relative to: 1. Placing one Resident (#16) on Contact Precautions (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) when diagnosed with a Multidrug-Resistant Organism (MDRO) and an infection. 2. Not placing Residents that met criteria on Enhanced Barrier Precautions (use of gowns and gloves for specific high contact resident care activities associated with MDRO transmission). 3. Completing an assessment and creating a plan to minimize the risk of Legionella (a serious type of lung infection that occurs when small droplets of water are breathed in or accidentally swallowing water containing the Legionella bacteria) outbreak. Findings include: 1. Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with hypoxia, Venous Ulcer of left calf and Varicose (enlarged)Veins of bilateral legs. Review of the facility Infection Control: Precautions Policy, revised 5/2023, included, but not limited to: -Contact Precautions are implemented most often for residents who have an infection due to epidemiologically important organisms such as Multidrug-Resistant Organisms (MDROs). Review of the Minimum Data Set (MDS) Assessment, dated 5/19/23, indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the medical record indicated the Resident was presently being treated for Venous Ulcers (occur due to improper functioning of the valves in the legs) on bilateral legs. Review of a leg wound culture result, dated 6/9/23, indicated the presence of Methicillin Resistant Staphylococcus Aureus (MRSA-a MDRO) and Pseudomonas Aeruginosa (infectious bacteria). Review of a Physician Late Entry Progress Note, dated 6/27/23, indicated for the Resident to have a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) for the administration of two antibiotics due to the presence of the two bacteria. Review of a Wound Evaluation and Management Summary (Wound Physician Note), dated 7/11/23, indicated the leg wounds had moderate serous (clear fluid that leaks out of wounds) drainage. During an observation on 7/14/23 at 9:30 A.M., the surveyor observed the Resident was not on Contact Precautions. During an interview on 7/18/23 at 11:35 A.M., with the Assistant Director Nurses/Infection Preventionist (ADON/IP), she said she did a verbal assessment with the personnel at the hospital that is next door and the determination was made that since Resident #16's wound drainage was contained, Contact Precautions did not need to be initiated. During an interview on 7/18/23 at 1:43 P.M., with the ADON/IP, she said she reviewed Centers for Disease Control (CDC) guidelines and still determined that the Resident should not be placed on Contact Precautions. Review of the CDC, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of MDROs, updated (July 12, 2022), indicated the following: -Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions (a group of infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization (carrier) alone. -Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. In reviewing the CDC guidelines, Resident #16 should have been placed on Contact Precautions, as required. 37086 2. The facility failed to ensure that its staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of MDROs in nursing homes). EBP involves gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition, such as residents with wounds or indwelling medical devices), for the Residents that had indwelling devices such as urinary catheters, gastric tubes (g-tube: tube inserted directly into the stomach which is used to administer nutrients, medications and fluids), Intravenous (IV) lines (used to administer fluids/medications directly into a vein), and tracheostomies (an opening surgically created through the neck into the trachea to allow air to fill the lungs). Review of the facility's policy for Infection Control Precautions, dated May 2023, indicated the following: Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines. Centers for Disease Control and Prevention (CDC) chart is attached. -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact care for residents. -The difference between EBP and contact precautions is that EBP is recommended for residents with the following: wounds or indwelling medical devices such as catheters, g-tubes, regardless of Multi-Drug Resistant Organism (MDRO) status; and infection or colonization with an MDRO. -Examples of high contact resident care activities include: *dressing *bathing *transferring *providing hygiene *changing briefs or linens *device care such as central line, feeding tube *wound care Review of the facility's Matrix, provided to the survey team on day one of the survey, indicated the following: -A total of 21 residents had one or more of the following: *indwelling urinary catheter: 11 *tracheostomy: 8 *g-tube: 13 *peripheral inserted central catheter: 1 On 7/13/23, 7/14/23, 7/18/23 and 7/19/23 the survey team observed that there were no residents on EBP in the facility as evidenced by no signs on resident room doorways to indicate the resident (s) were on any kind of precaution and no Personal Protective Equipment (PPE- gowns, gloves, masks, eye protection) bins outside of any resident rooms. During an interview on 7/19/23 at 12:17 P.M., the ADON said the previous Director of Nurses (DON) had originally implemented EBP for the residents with indwelling medical devices, but later discontinued the EBP. During an interview on 7/19/23 at 1:19 P.M., the ADON said that there had been some confusion when the prior DON left. The ADON said at the time, the facility staff decided that the CDC guidance was just a recommendation and chose to not follow it. The ADON said that their policy stated that they follow federal regulations and national guidelines. She said there was so much confusion around the issue that she did not know if she should implement EBP or not. 31240 3. The facility failed to develop a water management plan, including assessing and monitoring areas for potential development of Legionella (a bacteria that can cause a serious type of lung infection) growth and outbreak. Review of the Centers for Disease Control and Prevention's Legionella Water Management Program, dated 3/25/21, indicated the following: -Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. -Developing and maintaining a water management program is a multi-step process that requires continuous review. Such programs are now an industry standard for many buildings in the United States. -Seven key elements of a Legionella water management program are to: *Establish a water management program team. *Describe the building water systems using text and flow diagrams. *Identify areas where Legionella could grow and spread. *Decide where control measures should be applied and how to monitor them. *Establish ways to intervene when control limits are not met. *Make sure the program is running as designed (verification) and is effective (validation). *Document and communicate all the activities. During an entrance meeting on 7/13/23 at 10:41 A.M., the Administrator said the facility had a Water Management Program and the documents would be provided. During an interview on 7/18/23 at 8:01 A.M., Maintenance Staff #1, said he did not manage or implement a water management program in the nursing home. He said that his Regional Manager may do it, but he was not aware of the program. On 7/19/23 at 1:08 P.M., the Director of Nurses (DON) provided a Water Management Plan, dated December 2022, that she said was from the facility's management company. Review of the document indicated it was for a hospital. The document indicated it was a process used to develop, implement and evaluate a Legionella Water Management Program for the hospital. During an interview on 7/19/23 at 2:12 P.M., the Administrator said the facility had no actual Water Management Plan that would monitor and assess for areas of hazards related to possible Legionella bacteria growth. The Administrator said that the Hospital (on the same campus as the Long Term Care Nursing Home) did have two areas in the Nursing Home tested for Legionella growth.

Based on record review and interview, the facility failed to ensure yearly Licensed Staff Competencies included the care and services for residents receiving Dialysis (process of removing excess water and toxins from the blood in people whose kidneys no longer perform these functions naturally) treatment. Findings include: Review of the facility Matrix (a form that identifies pertinent care categories for residents residing in the facility) indicated there were currently three residents residing in the facility that were receiving Dialysis treatments. Review of the yearly Licensed Staff Competency form indicated no competency was in place for the care and services of a Dialysis resident. During an interview on 7/18/23 at 4:31 P.M., the Assistant Director of Nurses (ADON) said the facility accepts residents requiring Dialysis treatments. She further said the yearly Licensed Staff Competencies did not include the care and services of a Dialysis resident as required.

Based on observation, policy review and interview, the facility failed to serve and distribute food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain appropriate cold food and beverage temperatures during meal service to minimize the risk of food-borne illness. Findings include: Review of the facility's Food Preparation policy, revised September 2017, indicated: -The Dining Service Director/Cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) and/or less than 135 degress F, per state regulation. -All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding, and less than 41 degrees F for cold food holding. During an observation of meal service on 7/18/23 at 11:53 A.M., the following were identified concerns: -Two large, full trays of pre-poured milk glasses were being served. No cooling system was in place underneath the trays of milk glasses. -A large tray containing pre-made sandwiches (including egg salad, tuna salad, and sliced ham) were being served. Another tray with two plates of chef salad with hard boiled eggs, cheese and sandwich meat were available for meal service. Neither tray contained a cooling system underneath the sandwiches or salads. During an interview on 7/19/23 at 12:20 P.M., the Food Service Manager (FSM) said the rack of trays including the pre-made sandwiches, salad and pre-poured milks had been moved out of the walk-in refrigerator at approximately 11:35 A.M. She said staff routinely remove the refrigerated items and bring them to the meal service area for each meal, and the rack remains there until the meal service is completed. On 7/19/23 at 12:23 P.M., the surveyor requested a temperature check of an egg salad sandwich and a milk. The temperatures were 64 degrees F and 53 degrees F, respectively. The FSM said the temperatures were too high for cold foods and beverages. She said the cold food and beverages should have been maintained over ice during the meal service to help minimize the potential for food-borne illnesses.

Based on document review, policy review and interview, the facility failed to conduct inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. Specifically, beds with air mattresses were not inspected to identify areas of possible entrapment. Findings include: Review of the facility's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, included: -Evaluation of the dimensional limits of gaps in beds is one component of overall assessment and mitigation strategy to reduce entrapment. -If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may pose a risk of entrapment. Review of the facility's Bed Gap Inspection form, dated 2/28/23, indicated the following beds had an air mattress and were not inspected: -102A -105A -105B -106B -114B -205B -207B -208B -214A -215A -215B -220B -222B -223A -223B -225B. During an interview on 7/18/23 at 8:01 A.M., Maintenance Staff #1 said bed rails are assessed for entrapment yearly except those beds with an air mattress on them. He said he has never done them and was not aware they needed to be inspected.

Based on record review and interview, the facility failed to ensure that staff completed a Significant Change in Status Assessment (SCSA) for one Resident (#43), out of total sample of 15 Residents. Specifically, the facility failed to ensure that its staff completed the SCSA following a decline in Resident #43's functional status after a fall that resulted in a hip fracture. Findings include: Review of the facility's Resident Assessment Instrument policy, dated September 2021, indicated: -A SCSA Minimum Data Set (MDS) is required if the resident has a decline or improvement from baseline in two or more areas of the resident's functional status. Resident #43 was admitted to the facility in April 2022 with diagnoses including a history of falls and an abnormal gait and mobility. Review of the MDS assessment, dated 1/6/23, indicated the Resident was: -independent with bed mobility -a limited assist for ambulation -supervised for transfers and toileting -continent of bladder and bowel Review of the clinical record indicated the Resident sustained an unwitnessed fall on 2/15/23 while transferring off the commode. The Resident was sent to the hospital and was found to have a left hip fracture requiring surgical repair. The record indicated the Resident was readmitted to the facility 2/22/23. Review of the Physical Therapy Plan of Care note, dated 2/25/23, indicated the Resident required moderate assistance with moving from supine (lying horizontally) to sitting and vice versa, needed a wheel chair, had pain in left hip with standing, and was unable to walk an appreciable distance with total assistance. Review of the clinical record indicated that a SCSA MDS was not completed within 14 days of the changes as required. During an interview on 7/14/23 at 3:19 P.M., after reviewing the record, the Director of Nurses (DON) and Unit Manager (UM) #1 said that a SCSA MDS should have been completed after Resident #43 returned from the hospital and had functional declines due to the hip fracture.

Based on observation, policy review, record review and interview, the facility failed to follow the care plan for one Resident (#23) and failed to develop a care plan for one Resident (#43), out of a sample of 15 residents. Specifically, the facility failed to ensure that its staff: 1. Followed the care plan related to the hourly rate an enteral feeding (liquid nutrients delivered via a tube that is inserted into the stomach) was to be administered for Resident #23. 2. Developed a care plan related to urinary incontinence (lack of voluntary control over urination or defecation) for Resident #43. Findings include: 1. For Resident #23 the facility failed to ensure its staff administered an enteral feeding per the Physician's order. Resident #23 was admitted to the facility in May 2022 with a diagnosis that included Gastrostomy (g-tube: a tube inserted directly into the stomach for nutrients, medications and fluids to be administered) status. Review of a Registered Dietician's (RD) progress note, dated 7/5/23, indicated that the Resident's caloric needs were met with the current order of Osmolite 1.5 at 60 milliliters (ml)/hour (hr) x 24 hours a day. Due to the concern of supply issues, an alternative order would be Osmolite 1.2 at 75 ml/hr x 24 hours a day. Review of the July 2023 Physician's orders, indicated the enteral feeding order was changed on 7/11/23 from Osmolite 1.5 at 60 ml/hr x 24 hours a day, to Osmolite 1.5 at 75 ml/hr x 24 hours a day. On 7/13/23 at 8:37 A.M., the surveyor observed Resident #23 lying in bed, with the head of the bed (HOB) elevated, and Osmolite 1.5 running at 75 ml/hr. On 7/14/23 at 11:10 A.M., the surveyor observed Resident #23 lying in bed, with the HOB elevated, and Osmolite 1.5 running at 75 ml/hr. On 7/19/23 at 8:43 A.M., the surveyor observed Resident #23 lying in bed, with the HOB, and Osmolite 1.5 running at 75 ml/hr. During an interview on 7/19/23 at 9:06 A.M., Unit Manager (UM) #2 and the surveyor reviewed the current enteral feeding orders. The surveyor asked why the rate of the feeding was changed since the RD indicated all of the Resident's needs were met with the Osmolite 1.5 at 60 ml/hr. UM #2 reviewed the orders and said the rate should not have been changed to 75 ml/hr. She said the rate was changed in error. 31240 2. Resident #43 was admitted to the facility in April 2022 with a diagnosis including abnormal gait and mobility. Review of the facility's Bowel and Bladder Program policy, dated June 2021, indicated, but not limited to, the following: -All residents admitted to facility will have a bowel and bladder Continence Evaluation preformed at the time of admission, in conjunction with each quarterly and annual review, with any significant change in assessment and as deemed necessary by the Interdisciplinary Team (IDT). -The Unit Manager (UM) or designee along with the IDT will evaluate the appropriate program for the resident and refer to Restorative if appropriate. -When appropriate, the UM or designee will initiate the Restorative Bowel and/or Bladder Retraining Program (14 day program). -After the 14 days, the UM or designee will reevaluate the appropriateness to continue with the current plan or change the current plan. During an interview on 7/13/23 at 9:10 A.M., Resident #43 said that he/she use to have a commode at the bedside, but it was taken away. Resident #43 said he/she asks for help to get to the bathroom, but is incontinent most of the time because he/she cannot hold it while walking to the bathroom. Resident #43 further said that he/she wanted to be able to be continent. Review of the Minimum Data Set (MDS), dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), required supervision for transfers, ambulation and toileting and always continent of bladder. Review of the clinical record indicated the Resident sustained a fall on 2/15/23 while transferring off the commode. Review of Resident #43's Bladder Status Evaluation, dated 3/8/23, indicated the following: -Duration of bladder incontinence less than six months. -Always aware of the urge to void. -Motivated to be continent. -Voiding record initiated-not applicable. -Able to use the toilet and commode. -Type of incontinence-none. Review of the March 2023 Nursing Flow Sheet, indicated the resident was always incontinent of bladder. Review of the clinical record indicated the Resident sustained a fall on 3/14/23 while trying to self-toilet. Review of the MDS, dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 14 out of 15 on the BIMS, was a limited assistance with transfers and ambulation, was supervised for toileting and was always incontinent of bladder. Review of the April 2023 Nursing Flow Sheet, indicated the resident was always incontinent of bladder. Review of the June 2023 Nursing Flow Sheet, indicated the resident was always incontinent of bladder. Review of the clinical record indicated no interventions and no care plan had been implemented for the Resident's bladder incontinence. During an interview on 7/14/23 at 3:19 P.M., the Director of Nurses (DON) and Unit Manager (UM) #1 both said that staff did not comprehensively assess the Resident's bladder incontinence when documentation of his/her incontinence began. Both the DON and UM #1 said a bladder incontinence care plan with goals and interventions should have been implemented. See F 690.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was a long-term care resident without any discharge plans, the Facility failed to permit Resident #1 to return to the Facility following a hospitalization on [DATE] and, as a result of the Facility's refusal to permit Resident #1's return, Resident #1 remained hospitalized for more than 80 days while the hospital sought other placement. Findings include: The Facility Policy, dated September 2021, titled Permitting Resident to Return to Facility, indicated that it is the policy of the Facility to permit residents to return to the Facility following hospitalization according to State and Federal Regulations. Review of Resident #1's most recent Minimum Data Set Assessment, completed 6/03/22 indicated his/her cognitive patterns were intact, he/she had no discharge plan and he/she did not express an interest in returning to the community. Review of Resident #1's Discharge Planning Care Plan, dated as initiated 12/17/21 and dated as last revised on 3/08/22, indicated that Resident expected to discharge home when his/her medical and rehabilitated goals had been met and interventions included education about progress, user friendly discharge instructions, and opportunities to discuss wished goals and concerns. During an interview on 11/14/22 at 12:15 P.M., the Director of Social Services said that although Resident #1 had been admitted to the Facility for rehabilitation, he/she remained bed bound at the time of his/her hospitalization on [DATE], and said there were no specific plans in place for his/her discharge. Review of Resident #1's Nursing Progress Notes indicated that on 8/26/22, Resident #1 complained of severe body aches, was examined by the Physician Assistant and agreed to be evaluated at the Hospital. Review of the 30 Day Notice of Intent to Transfer Resident #1, dated 8/26/22, indicated that the Facility sought to transfer Resident #1 to the hospital. During an interview on 12/01/22 at 9:50 A.M., Resident #1 said that on 8/26/22 he/she was admitted to the hospital when the Facility physician diagnosed him/her as having an infection. Resident #1 said that the Facility refused to permit him/her to return to the Facility after his/her hospitalization and said he/she spent more than 80 days in the hospital. Resident #1 said spending that length of time in a hospital (which is not intended or designed for long-term care placement of a resident who requires nursing home care) was stressful and uncomfortable. Resident #1 said that although the hospital made referrals to other long-term care facilities during his/her stay, no other facilities were able to offer him/her a long-term care bed. Resident #1 said that because he/she lived at the Facility for over a year and had not ambulated in over four years, he/she felt stressed out about what he/she would do for housing when the Facility refused to permit him/her to return. During an interview on 11/09/22 at 11:02 A.M., the Hospital Case Manager said that Resident #1 was admitted to the hospital on 8/26/22. The Hospital Case Manager said that on 8/29/22, the hospital determined that Resident #1 would be ready to return to the facility on [DATE]. The Hospital Case Manager said that when the hospital notified the Facility that Resident #1 was ready to return to the facility on [DATE], the Facility told the hospital that Resident #1 was discharged from the Facility to the hospital and the Facility would not permit Resident #1 to return. Review of the 30 Day Notice of Intent to Discharge Resident #1, dated 8/31/22, indicated that the Facility intended to discharge Resident #1 to the hospital effective 8/26/22. The Director of Social Services said that he completed Resident #1's 30 Day Notice of Intent to Discharge. The Director of Social Services said that he was initially notified by nursing staff that Resident #1 was going to be transferred to the hospital for an evaluation and said he was subsequently notified that the Facility decided not to permit Resident #1 to return to the Facility from the hospital. The Director of Social Services said that he spoke to Resident #1's next of kin and arranged for the next of kin to deliver the 30 Day Notice of Intent to Discharge to the hospital for Resident #1 to review. During an interview on 11/14/22 at 9:05 A.M., the Administrator said he did not work for the Facility when the decision was made not to permit Resident #1 to return from the hospital. The Administrator said around 10/15/22, (about 45 days after the hospital determined that Resident #1 was ready to return to the Facility and the Facility refused to permit his/her return), the hospital contacted him to ask the Facility to reconsider the decision not to permit Resident #1 to return. The Administrator said that he looked into the circumstance of Resident #1's transfer to the hospital and learned that Facility corporate personnel had decided not to permit Resident #1 to return from the hospital. The Administrator said that the hospital case management department told him that they had not been able to find a bed in a long term care facility for Resident #1 and he/she remained hospitalized without a discharge plan. The Administrator said that he did not permit Resident #1 to return to the Facility but offered to assist the hospital case management department with a bed search for Resident #1.

Based on record review and interview, the facility failed to ensure the necessary treatment and services were provided to promote healing and prevent infection of a pressure ulcer for one Resident (#25), out of a total sample of 19 residents. Findings include: Resident #25 was admitted to the facility in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 6/22/2021, indicated the Resident was totally dependent on staff for all activities of daily living including personal hygiene and bed mobility, at risk for pressure ulcer development, and had a suspected Deep Tissue Injury (DTI- intact or nonintact skin with a localized area of persistent, non-blanchable deep red, maroon, or purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister) in evolution. Review of the Weekly Skin Check Assessment, dated 10/13/21, indicated there was an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by the presence of slough (i.e. dead tissue), or eschar (i.e. dry leather-like necrotic tissue) pressure area of the sacrum (large triangular bone at the base of the spine) measuring 2.5 x 1.5 x 0.1 centimeters (cm-a unit of measurement). Review of the book titled Wound Care Essentials, 2020, 5th Edition, indicated wound documentation should be consistent and concise. Wound care should be implemented as ordered and documented after each treatment. Review of the Wound Progress Notes indicated the following: - on 10/5/21, there was an unstageable DTI of the sacrum measuring 1.7 x 1.2 x 0.1 cm of at least a 6 days duration and a treatment was put into place. -on 10/12/21, the unstageable DTI of the sacrum measured 2.5 x 1.5 x 0.1 cm. -on 10/26/21, the unstageable DTI of the sacrum measured 3 x 2 x 0.1 cm. -on 11/16/21, the sacral wound was classified as a Stage IV (wound with full thickness tissue loss with exposed bone, tissue, or muscle) pressure ulcer, measured 3.5 x 3 x 1 cm, and had deteriorated. Review of the 11/2021 Treatment Administration Record (TAR), indicated there were three treatments ordered for the sacral wound during the month: #1 11/1-11/12 Cleanse with normal saline (a salt water solution similar to body fluid), pat dry, apply Santyl (an ointment used to remove dead tissue from wounds to promote healing) followed by [MEDICATION(S)] ointment (a topical antibiotic) then calcium alginate (a dressing that can absorb wound drainage and reduce infection) followed by border dressing daily. Three of the eleven opportunities for the treatment were not documented as completed. #2 11/12-11/17 Cleanse with normal saline, pat dry, apply Santyl/[MEDICATION(S)] 1:1 (in equal parts), then calcium alginate followed by border dressing daily. Two of the six opportunities for treatment were not documented as completed. #3 11/17-11/22 Cleanse with Vashe solution (a solution intended for cleansing, irrigating, moistening, debridement, and removal of foreign material including microorganisms and debris from exudating and/or dirty wounds), leave soaked gauze in wound bed for 10 minutes. Pat dry. Apply Santyl/[MEDICATION(S)] 1:1 followed by calcium alginate, then border dressing, twice daily. One of the six opportunities on day shift and three of the six opportunities on evening shift for treatment were not documented as completed. Review of a 11/22/21 Nurse Progress Note indicated the Resident was lethargic, the sacral wound had a foul odor and the facility was awaiting the results of bone cultures to rule out [CONDITION(S)] (an infection of the bone). The Resident had been started on an antibiotic on 11/16/21 with no improvement noted, the medical provider was notified, and the Resident was sent to the emergency room for evaluation. Review of the Hospital discharge paperwork indicated the Resident was admitted for [CONDITION(S)]. Review of the wound notes from the hospital indicated there was a sacral wound present on admission and the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident had a Computerized Tomography scan (CT scan: a detailed series of x-ray images that create a cross sectional view) of the abdomen and pelvis that indicated the sacral pressure wound extended to the bone with erosion of sacral segment (the area of the spine between the lumbar 5th vertebra and the coccyx), and wound and bone cultures indicated the wound was infected with multiple organisms. The Admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/10/22 at 3:45 P.M., Unit Manager #1 reviewed the November 2021 TAR and said there were empty spaces where treatments were not signed off and clarified if the treatments were not documented then they were not done as ordered. During an interview on 3/10/22 at 3:50 P.M., the Director of Nurses reviewed the November 2021 TAR said there was missing documentation and the wound treatments were not signed off as done. She said if treatments were not documented then they were not done as ordered and resulted in Resident #25 being admitted to the hospital with a diagnosed infection.

Based on records reviewed and interviews, the Facility failed to ensure that they developed, through their Medical Director and trained Addiction Medicine/Care Specialist, policies and procedures; staff training, including the administration of [MEDICATION NAME] (medication for the treatment of [REDACTED]. Resident #1 was admitted on medication assisted treatment for [REDACTED]. Resident #1 was administered two doses of [MEDICATION NAME] by emergency personnel prior to transport to Hospital #3, where he/she was treated for [REDACTED]. Findings included: Resident #1 was admitted to the Facility in May 2016 with [DIAGNOSES REDACTED]. The Health Status Change note, dated 02/15/17, indicated that at 1:10 P.M., a Certified Nurse Aide (CNA) reported that Resident #1 was in his/her room sniffing a white powder. The note indicated that Resident #1 was checked at 1:15 P.M. and reported he/she was fine. The note indicated that at 1:30 P.M., Resident #1 was observed slumped over in his/her wheelchair, unresponsive to verbal commands, touch, and sternal rub (a grinding motion of the knuckles on another's breastbone, used to elicit response when otherwise unresponsive). The note indicated that the Physician was notified, 911 was called, and Resident #1 was monitored until the arrival of EMS (Emergency Medical Services). The note indicated that Resident #1's vital signs included a respiratory rate of 16 breaths per minute (average is 12 to 20 breaths per minute), which had decreased to 4 breaths per minute when EMS arrived. The note also indicated that Resident #1 was observed with a white powder to his/her nose. The Surveyor interviewed Nurse #2 at 9:07 A.M. on 03/16/17. Nurse #2 said CNA #3 told her that she saw Resident #1 sniffing a white powder. Nurse #2 said she checked on Resident #1, and he/she was not in any distress. Nurse #2 said that shortly after that, she walked by Resident #1's room and observed him/her slumped over, as if sleeping. Nurse #2 said she approached Resident #1 and attempted to wake him/her. Nurse #1 said Resident #1 did not respond to verbal commands or a sternal rub, so she yelled for help and 911 was called. Nurse #2 said she thought EMS administered [MEDICATION NAME] to Resident #1 in the Facility, as Resident #1 became alert prior to transport to Hospital #3. Nurse #2 said that the next day, Resident #1 did not tell her what he/she had ingested, but did say that the substance was not his/her medications. Nurse #2 said that at the time of the incident, she had not been trained on the administration of [MEDICATION NAME]. Documentation from Hospital #3 indicated that on 02/15/17, Resident #1 was administered [MEDICATION NAME] twice at the Facility by EMS, and was treated after a recreational opioid overdose at the Facility. The Health Status Change note, dated 02/17/17 at 8:37 A.M., indicated that on 02/15/17, the Director of Social Services observed a small plastic baggie containing a grayish powder in Resident #1's room. The Health Status Change note, dated 02/17/17 at 10:42 A.M., indicated that Resident #1 admitted to ingesting marijuana, and that he/she had sniffed either heroin or [MEDICATION NAME] (an opioid pain medication) on 02/15/17. The note indicated that Resident #1 reported receiving the substance via mail. The Substance Abuse Care Plan, dated 02/17/17, indicated that Resident #1 had a history of [REDACTED]. The Surveyor interviewed the Unit Manager at 2:04 P.M. on 03/02/17. The Unit Manager said that on 02/15/17, he observed Resident #1 unresponsive in his/her wheelchair, with very low respirations and not arousable at all. The Unit Manager said he observed a white powder on Resident #1's over-the-bed table. The Unit Manager said 911 was called, and EMS administered [MEDICATION NAME]. The Unit Manager said Resident #1 became responsive after the administration of the [MEDICATION NAME]. The Unit Manager said [MEDICATION NAME] was available in the Facility at the time of the incident and that he had been trained to administer it. The Unit Manager said he did not administer [MEDICATION NAME] to Resident #1 because EMS arrived and administered it. The Unit Manager said only nurses were trained on the signs and symptoms of a drug overdose. The Surveyor interviewed the Director of Social Services at 10:55 A.M. on 03/03/17. The Director of Social Services said she was present on 02/15/17 and observed Resident #1 slumped over in his/her wheelchair. The Director of Social Services said she also observed a plastic baggie containing a grayish powder on Resident #1's table, which was taken and given to the police department. The Director of Social Services said Resident #1's room was searched after he/she was taken to Hospital #3, and what was identified by police as an [MEDICATION NAME] (an opioid pain medication) tablet was found in his/her drawer. The Director of Social Services said Resident #1 told the police that he/she had been cheeking (the act of holding a pill in one's mouth instead of swallowing it) medications. The Director of Social Services said she spoke with Resident #1 on 02/16/17, and he/she told her that he/she had taken either heroin or [MEDICATION NAME], which he/she received in the mail. The Director of Social Services said she did not have a lot of experience with residents with substance use. The Director of Social Services said the Facility did not admit residents with those types of [DIAGNOSES REDACTED].#1 was admitted to Hospital #2 on medication assisted treatment for [REDACTED]. The Director of Social Services said there was no plan in place for the assessment and care planning of residents with substance abuse/use and/or addiction needs. The Director of Social Services said she did not address Resident #1's known history of polysubstance abuse because that was not why Resident #1 was admitted to the Facility. The Surveyor interviewed the Assistant Director of Nurses/Staff Development Coordinator (ADON/SDC) at 11:54 on 03/03/17. The ADON/SDC said the Facility did not have a policy on the administration of [MEDICATION NAME]. The ADON/SDC said the Facility had [MEDICATION NAME] in stock, but that it was only to be administered by physicians or Nurse Practitioners (NPs). The ADON/SDC said she would not have nurses administer [MEDICATION NAME] as they were not trained on the signs and symptoms of a drug overdose. The ADON/SDC said she was unable to locate any documentation of education for Facility staff regarding the use of [MEDICATION NAME], or substance use disorders, and she herself had not provided any educational programs on those topics. This statement conflicts with information provided by the Unit Manager at the time of his interview. The Surveyor interviewed the NP at 12:33 P.M. on 03/03/17. The NP said Resident #1 was sober when admitted to the Facility and had multiple medical complications, so his/her substance abuse/use was not considered an issue. The NP said it was not the responsibility of physicians or NPs to dispense medications in the Facility, such as [MEDICATION NAME]. The Surveyor interviewed the Director of Nurses (DON) at 2:25 P.M. on 03/03/17. The DON said she did not know Resident #1 was on medication assisted treatment for [REDACTED]. The DON said she thought the treatment was for pain. The DON said the Facility did not have a policy in place for the administration of [MEDICATION NAME], and staff had not received training on the administration of [MEDICATION NAME] or substance use disorders. The Surveyor interviewed Resident #1 at 2:52 P.M. on 03/03/17. Resident #1 said that on 02/15/17, he/she ingested what he/she believed was heroin and [MEDICATION NAME] mixed together. Resident #1 declined to say how he/she obtained the drugs, or the route of ingestion. Resident #1 said he/she had been sober for approximately a year prior to the incident, and wished to remain sober. Resident #1 said that since the incident, he/she had seen a counselor and was interested in further treatment, but had not received services prior to that. The Surveyor interviewed the Administrator at 4:42 P.M. on 03/03/17. The Administrator said that because of Resident #1's physical limitations at the time of admission, there was no assessment of his/her substance use disorder and history. The Administrator said he had not considered the ramifications of administering opioid pain medication to residents with a polysubstance abuse history, including opioid abuse, like Resident #1. The Surveyor interviewed the Physician at 12:40 P.M. on 03/10/17. The Physician said he was the Facility's Medical Director, and Resident #1's attending physician. The Physician said he had been working with Resident #1 since his/her admission to Hospital #2, where he/she was on medication assisted treatment for [REDACTED].#1's medication assisted treatment was not discontinued until after his/her admission to the Facility. The Physician said it was inappropriate not to train Facility staff on the administration of [MEDICATION NAME], to leave it to the physicians or NPs, as the physicians and NPs were not always available in the Facility. The Police Report, dated 02/15/17, indicated that EMS administered at least two doses of [MEDICATION NAME] to Resident #1. The report indicated that 2 bags of heroin and 4 [MEDICATION NAME] pills were seized by the police department. The Surveyor interviewed Nurse #1 at 3:18 P.M. on 03/02/17. Nurse #1 said she did not know if [MEDICATION NAME] was available in the Facility. Nurse #1 said she was not trained by the Facility on how to administer [MEDICATION NAME], substance use disorders, the signs and symptoms of a drug overdose or related topics. The Surveyor interviewed CNA #2 at 3:30 P.M. on 03/02/17. CNA #2 said she could not recall receiving training on substance use disorders and related topics. The Surveyor interviewed CNA #3 at 2:27 P.M. on 03/02/17. CNA #3 said she had not received training on substance use disorders and related topics at the Facility. There was no documentation at the time of survey that the Facility developed policies and procedures regarding the care and treatment of [REDACTED]. Resident #1 had no documented assessment of his/her substance use disorder or addiction needs prior to his/her overdose on 02/15/17.

Based on records reviewed, interviews and observations, for 2 of 3 residents with substance abuse/use issues (Resident #1 and Resident #3), the facility failed to ensure that they had a formalized program or process to ensure that they conducted comprehensive medical and interdisciplinary team assessments to determine each resident's immediate needs and the severity of the issue, risks, and strengths; and, identify all appropriate [DIAGNOSES REDACTED]. On 02/15/17, Resident #1 ingested an unknown substance and was administered two doses of [MEDICATION NAME] (medication for the treatment of [REDACTED].#3, where he/she was treated for [REDACTED]. - The Facility failed to ensure that they developed, through their Medical Director and trained Addiction Medicine/Care Specialist, policies and procedures; staff training; admission and discharge processes, as the relate to the resident with substance use disorders or addiction, prior to admitting residents with this known need. Resident #1 was prescribed opioids, but the plan of care did not include an evaluation of the risk for the use of opioids for residents with a history of substance abuse. Findings include: The Surveyor interviewed the Director of Social Services at 10:55 A.M. on 03/03/17. The Director of Social Services said she did not have a lot of experience with residents with substance use. The Director of Social Services said the Facility did not admit residents with those types of [DIAGNOSES REDACTED].(s) of choice, method of ingestion, when the drug was last used, or any potential triggers taht may result in possible relapse. The Surveyor interviewed the Assistant Director of Nurses/Staff Development Coordinator (ADON/SDC) at 11:54 on 03/03/17. The ADON/SDC said there was no policy on the administration of [MEDICATION NAME], and no plan in place to start trainings on the administration of [MEDICATION NAME], substance use disorders, or related topics because the Facility did not admit residents like that. The ADON/SDC said the Facility had [MEDICATION NAME] in stock, but that it was only to be administered by physicians or Nurse Practitioners (NPs). The ADON/SDC said she would not have nurses administer [MEDICATION NAME] as they were not trained on the signs and symptoms of a drug overdose. The Surveyor interviewed the Nurse Practitioner (NP) at 12:33 P.M. on 03/03/17. The NP said she was aware that the Facility had [MEDICATION NAME] on premises. The NP said it would be the responsibility of nursing staff to administer the [MEDICATION NAME] if needed, not the responsibility of physicians or NPs, which conflicted with statements from the ADON/SDC's interview. The Surveyor interviewed the Physician at 12:40 P.M. on 03/10/17. The Physician said he was the Facility's Medical Director, and Resident #1's attending physician. The Physician said it was inappropriate not to train Facility staff on the administration of [MEDICATION NAME], to leave it to the physicians or NPs, as the physicians and NPs were not always available in the Facility. 1. Resident #1 was admitted to the Facility in May 2016 with [DIAGNOSES REDACTED]. The Discharge Summary from Hospital #1 indicated that Resident #1 was on medication assisted treatment for [REDACTED]. The Patient Care Referral Form, dated 05/27/16, indicated that Resident #1 lived in a group home for substance abuse prior to his/her injury and subsequent hospitalization at Hospital #1. Documentation from Hospital #2 indicated that Resident #1 was on medication assisted treatment for [REDACTED]. The Psychosocial History and Profile, dated 06/01/16, indicated that Resident #1 had a history of [REDACTED]. There was no comprehensive medical and comprehensive interdisciplinary assessment for Resident #1's substance abuse needs, recent substance use, risk for relapse, or the determination of the least restrictive, but safe, setting for care. The Physician Note, dated 06/01/16 and electronically signed by the Physician, indicated that Resident #1's past medical history included polysubstance abuse, and was on medication assisted treatment for [REDACTED]. The Physician Note, dated 12/30/16 and electronically signed by the Physician, indicated that Resident #1 was ordered for and received PRN (as needed) doses of [MEDICATION NAME] every 4 hours, in addition to scheduled doses. The note indicated that Resident #1 complained of inadequate pain relief, and the Physician increased the dosage of the scheduled [MEDICATION NAME]. The Plan of Care for Resident #1 included [MEDICATION NAME], but there was no indication or assessment for the safe use of opioids for a resident with active substance use. The Health Status Change note, dated 02/15/17, indicated that at 1:10 P.M., a Certified Nurse Aide (CNA) reported that Resident #1 was in his/her room sniffing a white powder. The note indicated that Resident #1 was checked at 1:15 P.M. and reported he/she was fine. The note indicated that at 1:30 P.M., Resident #1 was observed slumped over in his/her wheelchair, unresponsive to verbal commands, touch, and sternal rub (a grinding motion of the knuckles on another's breastbone, used to elicit response when otherwise unresponsive). The note indicated that the Physician was notified, and 911 was called and Resident #1 was monitored until the arrival of EMS (Emergency Medical Services). The note indicated that Resident #1's vital signs included a respiratory rate of 16 breaths per minute (average is 12 to 20 breaths per minute), which had decreased to 4 breaths per minute when EMS arrived. The note also indicated that Resident #1 was observed with a white powder to his/her nose. Documentation from Hospital #3 indicated that on 02/15/17, Resident #1 was administered [MEDICATION NAME] twice by EMS, and was treated after a recreational opioid overdose at the Facility. The Health Status Change note, dated 02/17/17 at 8:37 A.M., indicated that on 02/15/17, the Director of Social Services observed a small plastic baggie containing a grayish powder in Resident #1's room. The Health Status Change note, dated 02/17/17 at 10:42 A.M., indicated that Resident #1 admitted to ingesting marijuana, and that he/she had sniffed either heroin or [MEDICATION NAME] (an opioid pain medication) on 02/15/17. The note indicated that Resident #1 reported receiving the substance via mail. The Substance Abuse Care Plan, dated 02/17/17, indicated that Resident #1 had a history of [REDACTED]. The Surveyor interviewed the Unit Manager at 2:04 P.M. on 03/02/17. The Unit Manager said that on 02/15/17, he observed Resident #1 unresponsive in his/her wheelchair, with very low respirations and not arousable at all. The Unit Manager said he observed a white powder on Resident #1's over-the-bed table. The Unit Manager said 911 was called, and EMS administered [MEDICATION NAME], after which Resident #1 became responsive. The Unit Manager said that when Resident #1 was admitted to the Facility, he/she was on medication assisted treatment for [REDACTED]. The Director of Social Services said she was present on 02/15/17 and observed Resident #1 slumped over in his/her wheelchair. The Director of Social Services said she also observed a plastic baggie containing a grayish powder on Resident #1's table, which was taken and given to the police department. The Director of Social Services said Resident #1's room was searched after he/she was taken to Hospital #3, and an [MEDICATION NAME] tablet was found in his/her drawer. The Director of Social Services said Resident #1 told the police that he/she had been cheeking (the act of holding a pill in one's mouth instead of swallowing it) medications. The Director of Social Services said she spoke with Resident #1 on 02/16/17, and he/she told her that he/she had taken either heroin or [MEDICATION NAME], which he/she received in the mail. The Director of Social Services said Resisdent #1 was admitted to Hospital #2 with a [DIAGNOSES REDACTED]. The Director of Social Services said she did not address Resident #1's known history of polysubstance abuse because that was not why Resident #1 was admitted to the Facility. The Director of Social Services said the Facility did not have a plan in place to address the needs of residents with substance use disorders, including assessments, care plans and what to do in response to an overdose, because they did not admit those types of residents. The NP said Resident #1 was sober when admitted to the Facility and had multiple medical complications, so his/her substance abuse/use was not considered an issue. The Surveyor interviewed the Director of Nurses (DON) at 2:25 P.M. on 03/03/17. The DON said she did not know Resident #1 was on medication assisted treatment for [REDACTED]. The Surveyor interviewed Resident #1 at 2:52 P.M. on 03/03/17. Resident #1 said that on 02/15/17, he/she ingested what he/she believed was heroin and [MEDICATION NAME] mixed together. Resident #1 declined to say how he/she obtained the drugs, or the route of ingestion. Resident #1 said he/she had been sober for approximately a year prior to the incident, and wished to remain sober. Resident #1 said that since the incident, he/she had had seen a counselor and was interested in further treatment, but had not received services prior to that. The Surveyor interviewed the Administrator at 4:42 P.M. on 03/03/17. The Administrator said that on 02/15/17, staff gave him a little bag containing a powdery substance that had been found in Resident #1's room. The Administrator said he did not know what the substance was. The Administrator said that because of Resident #1's physical limitations at the time of admission, there was no assessment of his/her substance use disorder and history. The Administrator said he had not considered the ramifications of administering opioid pain medication to residents with a polysubstance abuse history, including opioid abuse, like Resident #1. The Police Report, dated 02/15/17, indicated that first responders responded to a call from the Facility for a drug overdose. The report indicated that 2 bags of heroin and 4 [MEDICATION NAME] pills were seized by the police department. The report indicated that EMS administered at least two doses of [MEDICATION NAME] to Resident #1 prior to transport to Hospital #3. The Physician said he had been working with Resident #1 since his/her admission to Hospital #2, where he/she was on medication assisted treatment for [REDACTED].#1 was on a fair amount of narcotics and [MEDICATION NAME] (a medication used to treat pain, and narcotic drug addiction; Resident #1's medication assisted treatment), and he thought it was inappropriate to continue both. The Physician said he met with Resident #1 to discuss tapering off either the narcotics or the [MEDICATION NAME], and Resident #1 opted to wean off of the [MEDICATION NAME]. The Physician said Resident #1's medication assisted treatment was not discontinued until after his/her admission to the Facility. The Physician said he had concerns about the amount of [MEDICATION NAME] Resident #1 received and was working to reduce the dose, but that Resident #1 was reluctant because of his/her pain needs. The Substance Abuse Care Plan was not initiated until 02/17/17, 2 days after Resident #1's overdose. There was no documentation at the time of survey that there was a comprehensive medical and interdisciplinary team assessment was completed to determine Resident #1's immediate needs and the severity of the issue, risks, and strengths; to identify all appropriate [DIAGNOSES REDACTED]. 2. Resident #3 was admitted to the Facility in October 2016 with [DIAGNOSES REDACTED]. The Psychosocial History and Profile, dated 10/31/16, indicated that Resident #3 planned to return to his/her prior living arrangement upon discharge from the Facility. The profile indicated that Resident #3 drank daily, but had not had a drink in a month. The profile indicated that Resident #3 expected to return home and not drink. Resident #3's clinical record indicated that he/she was admitted to the Facility 3 times from October 2016 through the date of survey. The Psychosocial History and Profile, dated 01/30/17, indicated that Resident #3 planned to return to his/her prior living arrangement upon discharge from the Facility. The profile indicated that Resident #3 drank daily, but had not had a drink in several months. There was no documentation at the time of survey that there was a comprehensive medical and interdisciplinary team assessment was completed to determine Resident #3's immediate needs and the severity of the issue, risks, and strengths; to identify all appropriate [DIAGNOSES REDACTED].