Every finding on record at Medford Rehabilitation and Nursing Center

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure medication carts were locked while a nurse was not present on the Pleasant View Unit and ensure nursing staff secured medications in the medication cart prior to leaving the cart unattended during medication pass. Findings include: Review of the facility policy titled Storage of Medications, dated September 2018, indicated the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On 7/30/24 at 10:11 A.M., the surveyor observed a medication cart unlocked and unsupervised on the Pleasant View unit. The Surveyor observed Nurse #5 walk away from the mediation cart and into a resident's room and stand behind a privacy curtain. The medication cart was unlocked, and the surveyor was able to open the medication cart and gain access inside. The unlocked medication cart and medications were left accessible and unattended in the hall, and one resident was observed near the medication cart and one housekeeping staff member was a short distance from the medication cart.During an interview on 7/30/25 at 10:18 A.M., Nurse #5 said he should not have left the medication cart unlocked and unattended. During an interview on 7/31/25 at 1:22 P.M., the Director of Nursing said medication and treatment carts must be locked when the nurse is not at the cart. 2. On 7/30/24 at 9:40 A.M., the surveyor observed Nurse #5 remove medications from the medication cart and placed them on top of the medication cart. The surveyor observed Nurse #5 open one box containing 2 medication packets on top of the medication cart, place the packets on top of the medication cart and walk into a resident's room. The nurse was not within sight line of the medication cart. The surveyor observed a resident and staff members walking by the unlocked medication cart.On 7/30/24 at 9:53 A.M., the surveyor observed Nurse #5 remove medications from the medication cart and placed them on top of the medication cart. The surveyor observed Nurse #5 open one box containing four medication packets on top of the medication cart, place the packets on top of the medication cart and walk into a resident's room behind a privacy curtain. The nurse was not within sight line of the medication cart. The surveyor observed a resident and staff members walking by the unlocked medication cart multiple times.During an interview on 7/30/25 at 10:20 A.M., Nurse #5 said he should not have left medications on top of the medication cart unattended and walked away and said medication must be stored and locked inside of the medication cart. During an interview on 7/31/25 at 1:24 P.M., the Director of Nursing said medication carts must be always locked when unattended and said medications should not be left on top of the medication cart or left unattended and must be stored properly.

Based on observation, interviews, and records reviewed, the facility failed to meet professional standards of practice for 5 Residents (#106, #3, #82, #117, and #99) out of a total sample of 31 residents. Specifically: 1. For Resident #106, the facility failed to ensure nursing implemented physician orders for blood sugar checks and failed to administer medications as ordered.2. For Residents # 3, #82, #117, and #99, the facility failed to implement physician orders blood sugar checks and for insulin administration prior to the breakfast meal. Findings include:1. On 7/29/25 the following observations were made on the Pleasant View Unit:-At 7:31 A.M., the surveyor observed Nurse #2 on the Pleasant View unit and there were no other nurses observed on the unit. Nurse #2 said he was the only nurse present on the unit at this time and had the keys to both medication carts. On 7/29/25 at 7:59 A.M., Resident #106 said he/she has not received morning medications and could not eat breakfast until the medications were given. The surveyor observed a breakfast tray on the Residents overbed table. The food items remained covered and untouched.-At 8:39 A.M., breakfast carts had arrived and all breakfast meal trays were delivered and set up was completed. Residents on the unit were observed eating breakfast in their rooms and in the dining room. -At 9:01 A.M., Nurse #2 said he has not given shift report or counted off his medication cart with any oncoming nurses yet and said Nurse #3 is helping with breakfast and will get report and count off the medication cart after breakfast.On 7/29/2025 at 9:10 A.M., Resident #106 said he/she still has not eaten breakfast and said she has yet to receive any morning medications. The surveyor observed a breakfast tray on the Resident's overbed table. The food items remained covered and untouched. Resident #106 told Certified Nursing Assistant (CNA) #2 that he/she can't eat until he/she has taken the morning medication.-At 9:27 A.M., the surveyor observed Nurse #4 at a medication cart. Nurse #4 said he was asked to come to the Pleasant View unit to help until the scheduled nurse arrived and said he has not administered any medications or obtained any blood sugars at this time.-At 9:28 A.M., Nurse #3 and Unit Manager #1 said they have not given any medications and have not taken any blood sugars. Nurse # 3 said she has residents who require blood sugar checks and required insulin before breakfast, but she did not get a shift report because the Unit Manager talked to the overnight Nurse #2. Unit Manager #1 said she was not given any blood sugar readings from the overnight nurse and said she does not know who needs blood sugar checks. The surveyor along with Nurse #3 and Unit Manager #1 looked at the Electronic Medical Records (EMAR) for Resident #106. Nurse #3 said Resident #106 has not received any morning medications and said the blood sugar check is not documented in the medical record. Nurse # 3 and Unit manager # 1 said they do not know his/her blood sugar level as it was not documented or reported. Unit Manager #1 said blood sugar levels were not reported from the overnight nurse and said they should be in the EMAR. Nurse #3 said she has not obtained any blood sugars or administered any medications to residents as she was assisting with the breakfast meal. -At 9:31 A.M., Nurse #2 said he has not given shift report or counted off his medication cart with any oncoming nurses yet and said the Unit Manager is going to take his cart.-At 9:40 A.M., Nurse #1 said she just arrived and has not obtained shift report or completed narcotic count on the medication cart. Nurse #1 said she has not obtained any blood sugars or administered any medications and was not given any blood sugar information.Resident #106 was admitted to the facility in March 2021 with diagnoses including type two diabetes, gastro-esophageal reflux disease, anxiety and dementia.Review of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #106 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 which indicated moderately impaired cognition.Review of the active physician orders for Resident #106 indicated the following:-Check FSBS BID (fasting sugar blood sugar two times per day) and PRN (as needed) two times a day for DM2 (type two diabetes). Start Date: 5/27/25. Scheduled for 6:30 A.M., and 4:30 P.M.- Pepcid Oral Tablet 20 MG (milligrams) (Famotidine) Give 1 tablet by mouth two times a day for GERD (gastro esophageal reflux disease). Start Date: 9/23/23. Scheduled for 6:30 A.M., and 4:30 P.M.- Simethicone Oral Tablet Chewable 80 MG (Simethicone) Give 1 tablet by mouth before meals and at bedtime for bloating & gas distress. Start Date: 10/02/23. Scheduled for 6:30 A.M., 11:30 A.M., 4:30 P.M., 9:00 P.M.-Diazepam Tablet 5 MG Give 1 tablet by mouth three times a day for Muscle spasms. Start Date 7/25/25. Scheduled for 6:00 A.M., 2:00 P.M., and 10:00 P.M.Review of Resident #106's July 2025 Medical Administration Record (MAR) indicated the following:-Check FSBS (Finger Stick Blood Sugar) BID contained no documentation and was not documented as completed.- Pepcid Oral Tablet 20 MG no documentation and was not documented as completed.- Simethicone Oral Tablet Chewable 80 MG no documentation and was not documented as completed.-Diazepam Tablet 5 MG no documentation and was not documented as completed.Review of the administration history report provided by the facility indicated the physician order for FSBS BID, Pepcid Oral Tablet 20 MG., and Simethicone Oral Tablet Chewable 80 MG, was not documented as completed until 9:49 A.M. Diazepam Tablet 5 MG was not documented as completed until 9:30 A.M.Further review of the administration report indicated Nurse #3 documented an administration time that was inconsistent with the observations made in the EMAR and confirmed by interview with surveyor.During an interview on 7/29/25 at 10:26 A.M., Nurse Practitioner #1 said she expects blood sugar checks to be followed as ordered and said Resident #106 should have had her blood sugar checked this morning before breakfast and said Simethicone and Pepcid should have been administered prior to the breakfast meal. NP #1 said Diazepam should have been given when scheduled and said she has written new one-time orders for the medications to be given as Resident #106 needs them. During an interview on 7/29/25 at 10:35 A.M., Consulting Staff #1 said physician orders must be administered as ordered and documented in the medical record at the time of administration.During an interview on 7/30/25 at 1:10 P.M., the Director of Nurses said she expects orders to be followed and said she expects staff to obtain blood sugar levels when they are ordered and prior to breakfast.2. On 7/29/25 at approximately 8:05 A.M., the surveyor reviewed physician orders for blood sugar checks and insulin administration on the Pleasant View unit. The following residents did not have physician orders for insulin administration completed as ordered by the physician - Residents #3, #82, #117, #99.2a. Resident #3 was admitted to the facility in June 2020 with diagnoses including type two diabetes, unspecified cirrhosis of liver, anxiety and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment, dated 6/20/25, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated severe cognitive impairment.Review of the active physician orders for Resident #3 indicated the following:-HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 units 0 units ; 151 - 200 = 2 units 2 units; 201 - 250 = 4 units 4 units ; 251 - 300 = 6 units 6 units; 301 - 350 = 8 units 8 units; 351 - 400 = 10 units 10 units; 401 - 450 = 12 units 12 units ; 451 - 500 = 14 units 14 units and notify on call provider also, subcutaneously two times a day for DM2. Start Date 6/24/25. Scheduled for 7:30 A.M., and 4:30 P.M.During an interview on 7/29/25 at 9:28 A.M., Nurse #3 and Unit Manager #1 said they have not given any medications and have not completed any blood sugar checks. The surveyor along with Nurse #3 and Unit Manager #1 looked at the Electronic Medical Records (EMAR) for Resident #3. Nurse #3 said she has not obtained any blood sugars or administered any medications to Resident #3 and said he/she is overdue and has already had breakfast. Review of Resident #3's EMAR at 10:07 A.M., failed to indicate the blood sugar was completed and contained no documentation The EMAR was highlighted red and indicated overdue in the medical record. Review of the administration history report provided by the facility indicated the medication was not documented as administered until 2:51 P.M. Further review of the administration report indicated Nurse #3 documented an administration time that was inconsistent with the observations made in the EMAR and confirmed by interview with surveyor.During an interview on 7/29/25 at 10:35 A.M., Consulting Staff #1 said physician orders must be administered as ordered and documented in the medical record at the time of administration. During an interview on 7/30/25 at 1:10 P.M., the Director of Nurses said she expects orders to be followed and said she expects staff to obtain blood sugar levels when they are ordered and prior to breakfast. 2b. Resident #82 was admitted to the facility in September 2024 with diagnoses including type two diabetes, chronic kidney disease and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment, dated 6/20/25, indicated Resident #82 was unable to complete a Brief Interview for Mental Status (BIMS) exam which indicated severe cognitive impairment.Review of the active physician orders for Resident #82 indicated the following:-Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 BS >400 Give 12 Units and notify MD/NP for further orders, subcutaneously three times a day for Monitoring glucose level BS >400 Give 12 Units and notify MD/NP for further orders. Start Date: 6/24/25. Scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M.-Insulin Lispro Injection Solution Inject 2 unit subcutaneously three times a day for control glucose level. Start Date 9/7/24. Scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M.Finger stick blood sugar four times a day. Start Date 12/20/24. Start Date 12/20/24. Scheduled for 6:30 A.M., 11:30 A.M., and 4:30 A.M., and 8:00 P.M.During an interview on 7/29/25 at 9:31 A.M., Nurse #3 said she has not administered any medications and has not obtained any blood sugars. The surveyor along with Nurse #3 looked at the Electronic Medical Records (EMAR) for Resident #82. Nurse #3 said she has not obtained any blood sugars or administered any medications to Resident #82 and said he/she is overdue and has already had breakfast. Review of Resident #82's EMAR at 10:07 A.M., failed to indicate the physician order for the Insulin Lispro 100 UNIT/ML per sliding scale or the order for Insulin Lispro 2 units was completed and contained no documentation. The EMAR was highlighted red and indicated overdue in the medical record. Review of the administration history report provided by the facility indicated the Insulin Lispro 100 UNIT/ML per sliding scale and the Insulin Lispro 2 units were not documented as administered until 11:15 A.M.Further review of the administration report indicated Nurse #3 documented an administration time that was inconsistent with the observations made in the EMAR and confirmed by interview with surveyor.2c. Resident #117 was admitted to the facility in July 2023 with diagnoses including type two diabetes, chronic kidney disease and obesityReview of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #117 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 indicating intact cognition.Review of the active physician orders for Resident #117 indicated the following:-Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 14 unit subcutaneously two times a day for DM before breakfast and lunch. Start Date 5/4/25. Scheduled for 8:00 A.M., 12:00 P.M.- Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401+ Call MD/NP, subcutaneously with meals for DM. Start Date 5/4/25. Scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M.-Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 45 unit subcutaneously one time a day for diabetes. Start Date 3/21/25. Scheduled for 8:00 A.M.During an interview on 7/29/25 at 9:33 A.M., Nurse #3 said she had not administered any medications and had not obtained blood sugars. The surveyor along with Nurse #3 looked at the Electronic Medical Records (EMAR) for Resident #117. Nurse #3 said she has not obtained any blood sugars or administered any medications to Resident #117 and said he/she is overdue and has already had breakfast. 2d. Resident #99 was admitted to the facility in July 2020 with diagnoses including type two diabetes, dysphagia, vitamin deficiency and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #99 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating intact cognition.Review of the active physician orders for Resident #99 indicated the following:-Accu check three times daily before meals. Three times a day for DM2, Call MD/NP if BS<70 or >400. Start Date: 2/16/23. Scheduled for 6:30 A.M., 11:30 A.M., and 4:30 P.M.- Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 5 unit subcutaneously before meals for diabetes Hold for NPO (nothing by mouth). Start Date: 5/17/25. Scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M.- Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale: if 0 - 200 = 0; 201 - 250 = 2; 251 - 300 = 4; 301 - 350 = 6; 351 - 400 = 8; 401+ = 10. Call NP/MD, subcutaneously three times a day for Diabetes. Start Date 5/16/25. Scheduled for 7:30 A.M., 11:30 A.M., and 4:30 P.M.- Insulin Degludec FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 30 unit subcutaneously one time a day for DM2. Start Date 2/22/25. Scheduled for 8:00 A.M.During an interview on 7/29/25 at 9:35 A.M., Nurse #3 said she had not administered any medications and had not obtained blood sugars. The surveyor along with Nurse #3 looked at the Electronic Medical Records (EMAR) for Resident #99. Nurse #3 said she has not obtained any blood sugars or administered any medications to Resident #99 and said he/she is overdue and has already had breakfast.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one nurse observed made 4 errors out of 30 opportunities, resulting in a medication error rate of 13.33%. Those errors impacted one Resident (#4), out of four residents observed.Findings include: Review of the facility policy, Administering Medications, dated as revised April 2024, indicated:-Medications are administered in a safe and timely manner, and as prescribed.-Medications are administered in accordance with prescriber orders, including any required time frame.-Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).-Medications administration times are determined by resident need and benefit and as per MD order. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medication;b. Preventing potential medication or food interactions; andc. Honoring resident choices and preferences, consistent with his or her care plan.-The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. For Resident #4, the facility failed to ensure nursing administered medications as prescribed.Resident #4 was admitted to the facility in June 2024 with diagnoses of cognitive communication deficit, gastro esophageal reflux disease, anemia, and anxiety.On 7/30/25 at 10:15 A.M., the surveyor observed Nurse #5 administer medications to Resident #4 including: -One Baclofen Tablet Give 5 MG (milligram) tab (tablet).-Two Depakote Sprinkles Oral Delayed Release capsules. -One Furosemide Tablet 20 MG tablet.Review of the physician's orders indicated the following:-Baclofen Tablet Give 5 MG by mouth two times a day for Muscle spasms. Scheduled for 8:00 A.M., and 8:00 P.M. Start Date 5/25/25.-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsules by mouth two times a day for Mood Disorder. Scheduled for 8:00 A.M., and 8:00 P.M. Start Date 3/28/25.- Furosemide Tablet 20 MG Give 0.5 tablet by mouth two times a day for BLE (bilateral lower extremity) Edema (swelling). Scheduled for 8:00 A.M., and 8:00 P.M. Start Date 5/6/25.The medications were administered more than two hours after they were scheduled at 8:00 A.M.During an interview on 7/30/25 at 9:42 A.M., Nurse #5 said he should have administered the medication at the correct ordered time or within one hour of the time they were due. During an interview on 7/30/24 at 2:01 P.M., Unit Manager #1 said nursing should follow the physician's order and administer medications within one hour before or after the scheduled time. During an interview on 7/31/24 at 1:15 P.M., the Director of Nurses said nursing should follow the physician's order and administer medications within one hour before or after the scheduled time.

Based on observations, interviews, and record review, the facility failed to maintain accurate medical records for one Resident (#106), out of a total sample of 31 residents. Specifically, the facility failed to accurately document medication administration.Findings include: Resident #106 was admitted to the facility in March 2021 with diagnoses including type two diabetes, gastro-esophageal reflux disease, anxiety and dementia.Review of the Minimum Data Set (MDS) assessment, dated 5/8/25, indicated Resident #106 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 which indicated moderately impaired cognition.On 7/29/25 at 7:59 A.M., Resident #106 said he/she has not received morning medications and could not eat breakfast until the medications were given. The surveyor observed a breakfast tray on the Resident's overbed table. The food items remained covered and untouched.Review of Resident #106's physician orders indicated: -Check FSBS BID (finger stick blood sugar two times per day) and PRN (as needed) two times a day for DM2 (type two diabetes). Start Date: 5/27/25. Scheduled for 6:30 A.M., and 4:30 P.M.- Pepcid Oral Tablet 20 MG (milligrams) (Famotidine) Give 1 tablet by mouth two times a day for GERD (gastro esophageal reflux disease). Start Date: 9/23/23. Scheduled for 6:30 A.M., and 4:30 P.M.- Simethicone Oral Tablet Chewable 80 MG (Simethicone) Give 1 tablet by mouth before meals and at bedtime for bloating & gas distress. Start Date: 10/02/23. Scheduled for 6:30 A.M., 11:30 A.M., 4:30 P.M., 9:00 P.M.-Diazepam Tablet 5 MG Give 1 tablet by mouth three times a day for Muscle spasms. Start Date 7/25/25. Scheduled for 6:00 A.M., 2:00 P.M., and 10:00 P.M. Review of Resident #106's July 2025 Medication Administration Record (MAR), failed to indicate Resident #106 was administered the medication as ordered by the physician and did not contain documentation of administration.During an interview on 7/29/25 at 9:01A.M., Nurse #2 said Resident #106 took all his/her morning medications and said he did not document them in the medical record. During an interview on 7/29/25 at 9:28 A.M., Unit Manager #1 reviewed the electronic medical record with the surveyor and said Resident #106 did not receive his/her morning medications and said she would expect the nurse to document when medications are administered in the medical record. Review of the administration history report provided by the facility indicated the physician order for FSBS BID, Pepcid Oral Tablet 20 MG., and Simethicone Oral Tablet Chewable 80 MG, was not documented as completed until 9:49 A.M. Diazepam Tablet 5 MG was not documented as completed until 9:30 A.M.During an interview on 7/29/25 at 10:35 A.M., Consulting Staff #1 said physician orders must be administered as ordered and documented in the medical record at the time of administration. During an interview on 7/30/25 at 1:14 P.M., the Director of Nurses (DON) said she expects orders to be followed and said she expects staff to obtain blood sugar levels and administer medications when they are ordered and to document at the time of administration.

Based on observation, record review and interview, the facility failed to ensure that an assessment for self-administering medication was completed and that the second floor remained free of unattended and unsecured medications for one Resident (#11) out of a total sample of 31 Residents. Specifically, for Resident #11, the facility failed to ensure the Resident was assessed to self-administer an inhaler and ensure it was secured safely in the Resident's room.Findings include: Review of the facility policy titled Administering Medications, dated [DATE], indicated the following:Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safelyReview of the facility policy titled Medication, Self Administration, dated and revised [DATE], indicated the following:When a resident requests medication self-administration, initiate the process to assess resident's capability. The resident must meet the following criteria:Knowledge of medications and medication scheduleSelf-administration including packaging, reading label, opening containersAbility to administer medications properly, e.g. inhalers as neededSecure medications at the nursing station. Keep a limited quantity in a locked drawer at resident's bedside. Assure that resident and nursing both have a key. Instruct resident in medication self-administration procedure. Including:obtaining medication, administering medication according to physician order, recording administration on documentation record.Resident #11 was admitted to the facility in [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified dementia and anxiety disorder.Review of Resident #11's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has COPD or chronic lung disease.The surveyor made the following observations:- On [DATE] at 7:43 A.M., Resident #11 was using the bathroom in his/her room, on the Resident's bedside table was an inhaler that was not secured. No staff were present in the room. At 8:39 A.M., the inhaler was still on the bedside table, Resident #11 told the surveyor that he/she takes the inhaler when he/she needs it to breathe. Resident #11 then told the surveyor he/she is independent with everything and staff do not help him/her take the inhaler.- On [DATE] at 8:50 A.M., Resident #11 was using the bathroom in his/her room, in the middle of the Resident's bed was an inhaler that was not secured. No staff were present in the room.- On [DATE] at 7:41 A.M., Resident #11 was sitting up on his/her bed. Resident #11 told the surveyor that his/her inhaler was in his/her sweatshirt pocket, the Resident pulled the inhaler out of the right pocket of the sweatshirt to show the surveyor.Review of Resident #11's physician's orders failed to indicate an order for self-administering medications. Review of Resident #11's care plans failed to indicate a care plan to self-administer medications. Review of Resident #11's medical record failed to indicate that an assessment was completed allowing Resident #11 to self-administer medications such as inhalers and to store them in his/her room. During an interview on [DATE] at 9:11 A.M., Certified Nursing Assistant (CNA) #1 said Resident #11 is typically independent with most activities of daily living and he supports the resident as needed. CNA #1 then said he has noticed that at times, Resident #11 gets out of breath when completing tasks.During an interview on [DATE] at 9:20 A.M., Unit Manager #1 said Resident #11 is independent with ADLs and he/she needs to take his/her time with things due to his/her breathing. Unit Manager #1 said Resident #11 has an inhaler and when he/she needs to use it he/she will ask staff for it and staff need to supervise him/her when he/she uses it. Unit Manager #1 said Resident #11 is not assessed to self-administer medications including his/her inhalers and he/she should not have any inhalers at his/her bedside without staff present and she did not know the Resident had an inhaler in his/her room. Unit Manager #1 said inhalers expire every 28 days and if staff do not know that the Resident has an inhaler then they cannot monitor the expiration date. Unit Manager #1 said if the inhaler is expired it would not work as effectively if Resident #11 needs it.During an interview on [DATE] at 10:36 A.M. with the Director of Nursing (DON) and Corporate Nurse #1, the DON said if a resident requests to self-administer medication then the facility completes an assessment form for each medication and how to safely self-administer it. Once completed, the Nurse Practitioner or Medical Doctor would approve it and put in a physician's order for self-administering medications. The DON then said any medication at the bedside needs to be locked and secured so other residents do not have access to it. The surveyor and Corporate Nurse #1 reviewed Resident #11's medical record together and she said she could not locate an assessment for Resident #11 to self-administer medications including inhalers. Corporate Nurse #1 said in order for Resident #11 to keep an inhaler on his/her person there needs to be an assessment to ensure Resident #11 can safely administer the inhaler and store it.

Based on record reviews and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for two Residents (#13 and #15), out of 31 sampled residents. Specifically:For Resident #13 the facility failed to ensure the MDS assessment was accurately coded for significant weight gain (section K).For Resident #15 the facility failed to ensure the MDS assessment was accurately coded for the use of tobacco.Findings include:1.Resident #13 was admitted to the facility in November 2024 with diagnoses of mild cognitive impairment and psychotic disorder.Review of the most recent Minimum Data Set (MDS) assessment, dated 5/22/25, indicated the Resident scored a 13 out of 15 on the Brief Interview for Mental Status exam (BIMS) indicating the Resident was cognitively intact.Review of Resident #13's weights indicated the following:-On 1/7/25 the Resident weighed 99.5 lbs. (pounds).-On 2/14/25 the Resident weighed 122.2 lbs. which indicated a significant weight gain of 22.02% in one month.Review of the quarterly MDS dated [DATE] section K failed to indicate significant weight gain was coded.During an interview on 7/31/25 at 10:04 A.M., the Registered Dietitian said she should have coded significant weight gain on the quarterly MDS. 2. Resident #15 was admitted to the facility in May 2025 with diagnoses including nicotine dependence cigarettes.Review of the Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of a 15 on the Brief Interview for Mental Status exam (BIMS) indicating the Resident was cognitively intact.On 7/30/25 at 9:30 A.M., the surveyor observed Resident #15 sitting outside smoking, the Resident was wearing a smoking apron.Review of Resident #15's care plan date initiated 5/22/25: Resident is able to smoke with apron and with supervision.Review of the admission MDS dated [DATE] section J failed to indicate the use of tobacco.During an interview on 7/30/35 at 10:34 A.M., the MDS Nurse said she should have coded in the MDS section J that the Resident uses tobacco.

Based on observations and interviews, the facility failed to ensure a home-like environment on the [NAME] unit. Specifically, the facility failed to 1a. ensure room [ROOM NUMBER]'s bathroom was cleaned thoroughly of urine residue and 1b. ensure the shower room was in good working condition.Findings include:The surveyor made the following observations:1a. On 7/29/25 at 9:51 A.M., there was a strong urine odor in the hallway near room [ROOM NUMBER]. Upon further observation, in room [ROOM NUMBER]'s bathroom, there was urine on the floor around the toilet, the floor was sticky, and the floor had a greenish color from the urine stain.On 7/30/25 at 6:37 A.M., there was a strong urine odor from room [ROOM NUMBER]'s bathroom, the floor was wet and sticky.On 7/30/25 at 1:14 P.M., room [ROOM NUMBER]'s bathroom floor was wet and sticky with a strong urine odor.During an interview on 7/30/25 at 2:12 P.M., Certified Nursing Assistant (CNA #4) said that the bathroom floor in room [ROOM NUMBER] is always wet and she cleans every time she sees it wet.During an interview on 7/30/25 at 2:19 P.M., Housekeeper #2 said she always cleans the bathroom in room [ROOM NUMBER] but can't seem to keep the floor dry.During an interview on 8/1/25 at 8:20 A.M., Housekeeper #1 said the residents' bathrooms are cleaned twice a day in the morning and in the afternoon. She said room [ROOM NUMBER]'s bathroom tiles may need to be removed as they are soaked with urine, and it makes it difficult to get rid of the urine odor.1b. On 7/29/25 at 8:47 A.M., in the [NAME] unit shower room, the surveyor observed a chipped toilet seat and the wall in the shower room had missing tiles.During an interview on 8/1/25 at 8:15 A.M., the Maintenance Director said the toilet seat should be replaced due to chipping, and the tiles should be replaced as they have been falling off the wall.

Based on observation and interview, the facility failed to implement an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task.Findings include:Review of the Facility's Policy titled, Handwashing/Hand Hygiene, undated, indicated: -It is the expectation of the facility that all personnel wash their hands appropriately in accordance with current standards of practice.-Alcohol hand cleanser may be used as a hand cleansing agent unless hands are visibly soiled. -Hands are to be washed before and after patient contact.During medication administration pass on 7/30/25 the following were observed:-Nurse #5 at 9:40 A.M. was observed picking up keys to lock the medication cart and then placing two fingers inside a plastic cup of water to carry the cup into a resident room. -Nurse #5 at 9:41 A.M. was observed entering a resident room to administer medications and did not perform hand hygiene.-Nurse #5 at 9:43 A.M. was observed entering a resident room to administer medications, touched the bathroom door handle and did not perform hand hygiene.-Nurse #5 at 9:47 A.M. was observed removing a lidocaine patch from a resident's right shoulder without wearing gloves. The Nurse then exited the resident's room and did not perform hand hygiene During an interview on 7/30/25 at 9:51 A.M., Nurse #5 acknowledged he should have performed hand hygiene prior to entering any resident room, should not have placed his fingers inside of the cup of water and said he should have worn gloves to remove the old lidocaine patch from the resident's shoulder and performed hand hygiene. During an interview on 7/31/25 at 1:22 P.M., the Director of Nurses (DON) said she expects staff to perform hand hygiene before entering a resident's room and said she expects staff to wear gloves when coming into contact with a resident. The DON said hand hygiene should be performed before and after glove use.

Based on record review and interviews, the facility failed to ensure proper hiring and use of five out of seven Certified Nursing Aides (CNAs) reviewed. Specifically, the facility failed to: 1) Ensure that two of seven CNA's reviewed were not employed as CNA's for more than four months after hire without having completed the competency evaluation program approved by the State. 2) Ensure that three of seven CNA's reviewed were not employed as CNAs prior to enrolling in a State-approved training and competency evaluation program. Findings Include: Review of the Massachusetts Nurse Aide Registry information for employers indicated the following: - You can employ a Nurse Aide who has not yet completed training for no more than 90 days. The Nurse Aide must not be used on a temporary, per diem, leased, or any basis other than a permanent employee. You can employ a Nurse Aide who has not yet taken and passed the CNA test for no more than 4 months. Review of the facility policy, titled Competency of Nursing Staff, effective 3/20/24, indicated, but was not limited to, the following: - All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. Review of the facility policy, titled Nurse Aide Qualifications and Training Requirements, effective 7/12/24, indicated, but was not limited to, the following: - Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay. - Individuals applying for the position of nurse aide must: f. Must have a valid, unencumbered CNA license. g. For new nurse aide graduates from nurse aide school, should only work as a Nurse Aide no more than 4 months from the Nurse Aide graduation date. 1a) Review of CNA #5's employee file indicated the CNA was hired on 8/15/22 for the position of CNA. Review of the Massachusetts Nurse Aide Registry failed to indicate that CNA #5 was ever issued a Nurse Aide Certification. Review of the Facility's Nursing Aides Tracker Sheet indicated that CNA #5 had passed the knowledge exam on 4/3/24 but still needed to schedule the skills test. Review of CNA #5's timecards indicated that CNA #5 had worked as a CNA for a total of 1,012.75 hours in the last six months, after over a year without having passed the CNA test. Review of the CNA assignment sheets indicated that CNA #5 was assigned to provide care to an assignment of residents on four separate days since 7/4/24, after over a year without having passed the CNA test. 1b) Review of CNA #2's employee file indicated the CNA was hired on 2/21/24 for the position of CNA. Further review of CNA #2's employee file indicated the CNA had failed to pass the Certified Nurse Aide Knowledge exam on 5/25/24. Review of the Massachusetts Nurse Aide Registry failed to indicate that CNA #2 was ever issued a Nurse Aide Certification. Review of CNA #2's timecards indicated that CNA #2 had worked as a CNA for a total of 87 hours after 6/21/24 (four months after hire) without having passed the CNA test. Review of the CNA assignment sheets indicated that CNA #2 was assigned to provide care to an assignment of residents for a total of 7 days since 7/4/24 (greater than four months after hire) without having passed the CNA test. 2a) Review of CNA #4's employee file indicated that the CNA was hired on 2/20/24 for the position of CNA. Review of the Massachusetts Nurse Aide Registry failed to indicate that CNA #4 was ever issued a Nurse Aide Certification. Review of the Facility's Nursing Aides Tracker Sheet indicated that CNA #4 was hired on 2/20/24 but did not begin the CNA class until 4/16/24. Review of CNA #4's timecards indicated that CNA #4 had worked as a CNA for a total of 382 hours after being hired on 2/20/24, and before beginning the CNA class on 4/16/24. Review of the Nursing Schedule indicated CNA #4 was scheduled to work 31 times as a CNA in February and March of 2024, prior to beginning the CNA class. 2b) Review of CNA #1's employee file indicated that the CNA was hired on 3/5/24 for the position of CNA. Review of the Massachusetts Nurse Aide Registry failed to indicate that CNA #1 was ever issued a Nurse Aide Certification. Review of the Facility's Nursing Aides Tracker Sheet indicated that CNA #1 was hired on 3/5/24 but did not begin the CNA class until 4/16/24. Review of the Nursing Schedule indicated CNA #1 was scheduled to work 15 times as a CNA in March of 2024, prior to beginning the CNA class. Review of CNA #1's timecards indicated that CNA #1 had worked as a CNA for a total of 262.5 hours before beginning the CNA class. 2c) Review of CNA #3's employee file indicated that the CNA was hired on 6/11/24 for the position of CNA. Review of the Massachusetts Nurse Aide Registry failed to indicate that CNA #3 was ever issued a Nurse Aide Certification. Review of the Facility's Nursing Aides Tracker Sheet indicated that CNA #3 did not begin the CNA class until 7/9/24. Review of the CNA assignment sheets indicated that CNA #3 was assigned to provide care to an assignment of residents on three separate days between 7/4/24 and 7/9/24 before beginning the CNA class. Review of CNA #3's timecards indicated that CNA #3 had worked as a CNA for a total of 153 hours before beginning the CNA class. During an interview on 7/11/24 at 1:33 P.M., the scheduler said she tracks CNA's who were hired but have not completed the CNA class via the Nursing Aides Tracker Sheet. The scheduler said CNAs should not work until they have been enrolled in the CNA class. The scheduler said for those CNAs enrolled in the CNA class must pass the knowledge and skills exams within four months, and that if they have not passed the exams within four months, they must be taken off the schedule. During an interview on 7/11/24 at 2:52 P.M., the Administrator said that upon hire CNAs should already be enrolled in the CNA class, and that CNAs should not be working as CNAs until they enroll in the CNA class. The Corporate Director said that if a CNA failed to pass the CNA exams within four months the CNA must be suspended from working until they complete the CNA class and pass the exam.

Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for nursing staff on the weekends. Findings Include: Review of the facility assessment indicated the following: ii. Attach or describe individual staff assignments. - Administrator, Director of Nursing (DON), and Unit Managers meet daily to make sure staff assignments can meet our resident needs. We aim to have consistent RN (Registered Nurse) and CNA (Certified Nursing Aide) assignments as often as possible. During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 2, 2024 (January 1 - March 31) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. During an interview on 7/11:00/24 at 9:28 A.M., Nurse #1 said that weekends are tough in regard to staffing. During an interview on 7/12/24 at 11:00:08 A.M., the Scheduler said it's hard to get enough nurses on the schedule. During an interview on 7/12/24 at 9:48 A.M. the Administrator provided the surveyor with a nursing schedule denoted with the minimum number of nursing staff needed to care for residents at the facility daily. The Administrator said that the minimum nursing staffing levels, with the exception of having three supervisors working, would also be expected to be met on the weekends. Review of the provided nursing schedule indicated the following minimum number of staff needed daily: -The [NAME] Unit required one charge nurse, two nurses, one nursing aide (NA), and six CNAs from 7:00 A.M. to 3:00 P.M., two nurses and five CNAs from 3:00 P.M. to 11:00 P.M., and two nurses and two CNA's from 11:00 P.M., to 7:00 A.M. -The Pleasant View Unit required two nurses, one NA, and four CNAs from 7:00 A.M. to 3:00 P.M., two nurses and five CNAs from 3:00 P.M., to 11:00 P.M., and one nurse and two CNAs from 11:00 A.M., to 7:00 A.M. -The Mystic Unit required one charge nurse, two nurses, one nurse aide, and four CNAs from 7:00 A.M. to 3:00 P.M., two nurses and three CNAs from 3:00 P.M., to 11:00 P.M., and one nurse and two CNAs from 11:00 P.M., to 7:00 A.M. Review of the weekend staff schedule for May and June of 2024 indicated that the facility was staffed below their determined minimum for 13 of 18 weekend days.

Based on record review and interviews the facility failed to ensure grievances voiced in the monthly Resident Council meetings were adequately addressed or resolved. Findings Include: Review of facility policy titled Grievance policy, dated as effective June 2021, indicated the following: -All residents at [the facility] shall be afforded the right to voice their grievances/ concerns with the expectation of a resolution, without the fear of discrimination or reprisal. Grievances can range from issues with care and treatment, to the behavior of staff and/ or of other concerns during their stay. -A grievance investigation and subsequent final report should be completed no later than seven (7) days from the receipt. Included in the grievance book provided to the survey team from the facility included Standards of Practice for resident and family grievances, undated. This standard of practice indicated the following: -Standard: it is policy of this facility to provide an opportunity for residents and/or their family members to express concerns to staff at any time. Our goal is to resolve resident and family concerns on a timely basis by utilizing resources within the facility. Through an interdisciplinary approach, improvements will be made to maximize the care of the resident and maintain the highest quality of care. Review of the Resident Council meeting minutes from January 2024 to June 2024 indicated the following: -Concerns with call light response time in January 2024, February 2024, March 2024 and April 2024. -Concerns with staff using cell phones and ear buds in resident care areas, sometimes while caring for residents including during the medication pass in January 2024, February 2024, March 2024, April 2024, May 2024 and June 2024. -Concerns with receiving scheduled showers in February 2024, March 2024, April 2024, May 2024. -Concerns with staff speaking foreign languages, other than English, in resident care areas in March 2024, April 2024, May 2024 and June 2024. During initial screening on 7/9/24 residents expressed the following concerns: -Two residents on the Pleasant View Unit expressed concerns with staff response to call lights. -Four residents on the Mystic unit expressed concerns with staff response to call lights. -Two residents on the Mystic unit expressed concerns with staff speaking foreign languages in resident care areas. -Two residents on the [NAME] unit expressed concerns with not receiving showers. -Three residents expressed concern with staff speaking foreign languages in resident care areas. During the Resident Group Interview on 7/10/24 residents expressed the following concerns: -11 out of 22 residents said that call lights are not answered timely. It was expressed that this was across all shifts and days. Residents also expressed that when the light is answered they are often told I'm not your Certified Nurses Assistant (CNA), so I'll get them to help you. -7 out of 22 residents expressed that they are not receiving showers regularly in the facility. One resident said that it has been over 3 weeks since he/she had a shower. Two residents expressed feeling as though they need to beg staff to provide them with showers. -19 out of 22 residents expressed that staff often congregate either right outside or sometimes in their rooms, speaking languages other than English, or talking loudly on their cell phones. Residents expressed often feeling as if the staff are talking about them in languages other than English. Review of the grievance book provided by the facility to the survey team indicated the following: -No grievances were filed in the month of May. -One grievance was filed in the month of June. During an interview on 7/11/24 at 11:53 A.M., the Director of Nurses, Administrator and Corporate Director were made aware of the concerns that came out of the Resident Group Interview. They said that if the same concerns are coming up month after month in the Resident Council meetings, then the concerns or grievances are not being addressed. The Administrator said the residents may need more communication about the process and the resolution of the grievance. The Corporate Director said that some staff are still learning English, but should not be speaking foreign languages in a resident care area. During an interview on 7/12/24 at 7:46 A.M., Social Worker #2 said that following the note taking for the Resident Council meeting minutes she lets the corresponding Department Head know about the concerns or grievances discussed in the meeting. She said that formal grievances are not filed based on the concerns brought up in Resident Council. She said that if the same issues are coming up month after month, they need a tighter system to resolve the resident's concerns and to follow up with them.

Based on observation, interview and policy review the facility failed to ensure that residents are informed of their rights and of all rules and regulations governing resident conduct and responsibilities during their stay in the facility. Specifically, 22 out of 22 residents who attended the Resident Council Meeting on 7/10/24 said that they were not aware of the Resident's rights and that they are not reviewed regularly with them. Findings Include: Review of facility policy titled Resident Rights, dated as 5/9/24, indicated the following: -[The Facility] will ensure that each resident remains informed of his/ her rights, as well as all the rules and regulations governing resident conduct and responsibilities during their stay. -To assure that our residents, staff, and visitors are continually informed and aware of resident rights, grievance procedures, responsibilities to the facility, etc., large print copies are posted or available in several areas which may include the main lobby area, resident's lounges, employee's lounge, activity room and nurses' station. Review of Resident Council Meeting minutes from January 2024- June 2024 failed to indicate that any resident rights were reviewed during the meeting. During the Resident Group Interview held on 7/10/24 at 10:30 A.M., the Resident Council President said that he/she was not aware of the Resident's Rights. He/she said that they may have been reviewed upon admission to the center but that was many years ago, and no one has reviewed any resident rights since then. Twenty two out of 22 Residents in the meeting agreed that they were not aware of their rights in the center and no one in attendance in the meeting could identify where to find a copy of Resident's Rights in the center. The residents who attended the meeting further said they don't know if they are able to exercise their rights because they do not know what they are. On 7/11/24 during a tour of the first- floor [NAME] Unit there were no postings of Resident Rights, where many residents who attended the resident council meeting reside, including the Resident Council President. During an interview on 7/11/24 at 7:53 A.M., the Activities Director said that at least one staff member is invited to attend the monthly resident council meetings to take notes, but it is not necessarily her. She said she has been the Director since April 2024 but has only attended one meeting. She said that during that meeting no Resident's Rights were reviewed. During an interview on 7/11/24 at 7:58 A.M., Social Worker #2 said that she typically attends the resident council meetings as the note taker. She said that Resident's Rights are not typically reviewed in the meetings. During an interview on 7/11/23 at 10:13 A.M., the Corporate Director said that residents should be aware of their rights and where to find them in the facility. She said that they are reviewed at admission but should continue to be reviewed so residents are aware of their rights.

Based on record review and interview, the facility failed to develop and implement a care plan related to suicidal and homicidal ideation for one Resident (#56) out of a total of 25 sampled residents. Findings include: Resident #56 was admitted to the facility in November 2017 with diagnoses including psychotic disorder with delusions, major depressive disorder and anxiety disorder. Review of Resident #56's most recent Minimum Data Set assessment dated [DATE] indicated he/she scored 13 out of a possible 15 on the Brief Interview for Mental Status Exam indicating intact cognition. Review of the Resident #56's nurse progress notes indicated: 5/31/24 6:37 P.M.: Abrupt behavioral shift, yelling and striking out on staff. Pt (patient) declared that he/she intended to end his/her own life and that he/she would kill everyone if he/she managed to obtain his/her uncle's gun from the CIA. Order obtained to send resident to ER (emergency room ) for additional assessment. Review of Resident #56's care plans on 7/9/24 failed to indicate any care plan identifying Resident #56's suicidal or homicidal ideations which resulted in his/her subsequent hospitalization . During an interview on 7/11/24 at 7:10 A.M., Social Worker #1 said that the expectation would be for staff to initiate a care plan if a resident has expressed suicidal or homicidal comments resulting in a hospitalization , the expectation would be for a care plan to be initiated During an interview on 7/12/24 8:25 A.M., the Corporate Director said that care plans should be initiated for residents who express suicidal or homicidal ideation.

Based on observation, record review and interview the facility failed to ensure residents were provided a dignified existence and self-determination, out of a total sample of 25 residents. Specifically: 1. The facility failed to ensure staff spoke with one Resident (#59) with respect and courtesy. 2. The facility failed to ensure staff received permission to look through and remove personal effects for one Resident (#49). 3. The facility failed to ensure staff spoke in a language understood by residents during care and resident areas. , Findings Include: Review of the facility policy Maintaining Resident Dignity dated 3/20/24, indicated: -The facility promotes care for Resident's in a manner and in an environment that maintains or enhances each Resident's dignity and respect in full recognition of his or her individuality. Areas of focus include: 6. Respecting the Resident's room and personal space. Respecting Resident's Social Status 1. Respecting resident's social status includes speaking respectfully, listening carefully, treating resident with respect (e.g., addressing the resident with a name of the Resident's choice, not excluding Resident's from conversion or discussing Resident's in community setting); and focusing on resident as individuals when they talk to them and addressing Resident's as individuals when providing care and services. Activities -Respecting the dignity of individuals and groups engaged in formal and informal activities is essential to Residents' quality of life and satisfaction with the nursing home experience. Respecting The Resident's Room and Personal Space -Staff strive to create a dignified, homelike environment in the facility for the Resident's, one essential aspect of the process includes the resident's room and personal space. Best Practices may include: 1. Staff members knocking on the resident's door and waiting for a reply. For Resident's not able to reply, knocking and announcing one's presence while slowly enter the room. Attempting to make eye contact with the resident and stating identity and purpose for entering the room. 3. Staff requesting permission before picking up or moving an item on the Resident's nightstand or bureau drawers or closets. There may be special significance attached to the particular item and the resident may want to keep the item in that location. 4. Respecting the Resident's private space and property (e.g., not moving or inspecting resident's personal possessions without permission) 1. Resident #59 was admitted to the facility in August 2023 with diagnoses including dementia, residual schizophrenia, cerebral infarction, and adult failure to thrive. Review of Resident #59's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #59 scored 14 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact. The MDS also indicated Resident #14 requires maximum assistance with self-care activities. During an observation on 7/10/24 at 1:14 P.M., Resident #59 was observed sitting outside in the designated smoking area with 13 other Resident's. Resident #59 finished smoking a cigarette and asked the Activities Director for another cigarette. The surveyor heard the Activities Director say, No that's it, you don't have anymore cigarettes!. Resident #59 became agitated, raised his/her voice and said he/she has more cigarettes and paid $20.00 for more cigarettes. The Activities Director responded to the Resident saying, No you didn't stop asking, and then called another staff member on the phone. A second staff member brought over a new pack of cigarettes and gave one to Resident #59. The Activities Director then walked away from Resident #59 while another staff member assisted the Resident. During an observation on 7/10/24 at 1:28 P.M. the Activities Director was observed pushing Resident #59 in his/her wheelchair from the outside smoking area back into the facility. The Activities Director said to Resident #59, You're all done!, and proceeded to push the wheelchair through the sliding glass doors, back into the facility. Resident #59 said he/she was not done and wanted to sit in the cool area he/she was wheeled into before being pushed back into his/her room. The Activities Directed told the Resident No and proceeded to push him/her towards a second door. Resident #59 said No, let me cool off!, and the Activities Directed replied with Fine!, and stopped pushing the wheelchair. During an observation on 7/10/24, at 1:30 P.M., the Activities Director began shouting No, no, no you have Resident's outside. Where should you be right now?, to Activities Assistant #1 who was inside speaking to Resident #59 while wiping down clothing protectors. Resident #59 was observed shaking his/her head and appeared frustrated with the Activities Director. During an observation on 7/11/24, at 12:07 P.M., the Activities Director was observed walking by Resident #59 who was sitting in the hall. Resident #59 said I want to go out for a cigarette. The surveyor heard the Activities Director shout from the elevator You get three that's it! and proceeded to go down the elevator. During an interview on 7/12/24 at 7:56 A.M., the Activities Director said Resident #59 has a short temper and staff are aware of approaches that work to redirect the resident and that she feels guilty responding to him/her the way she did. The Activities Director said she has a lot going on and should not be so short with the Resident and take time to speak calmly and address his/her needs. During an interview on 7/12/24 at 9:41 A.M., the Director of Nursing (DON) said staff should be professional and should speak to all Resident's in a respectful and dignified manner. The DON said Resident's and staff should treat each other with respect in front of one another and take the time to speak with Resident's and not just walk by. Staff should try to de-escalate any behaviors and not ignore them. 2. Resident #49 was admitted to the facility in January 2017 with diagnoses including aphasia, dysphagia, vascular dementia, major depressive disorder, and muscle weakness. Review of Resident #49's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was unable to complete a Brief Interview for Mental Status exam. The MDS also indicated Resident #49 is dependent on staff for all self-care activities. Further review of the MDS indicated Resident #49 is a Portuguese speaking resident. During an interview on 7/10/24 at 8:35 A.M., Resident # 49's roommate, Resident #65 reported that Corporate Nurse #1 entered the room on 7/9/24 and began removing lotions and creams from Resident #49's personal belongings. Resident #65 said two creams were removed from Resident #49's bureau. Resident #65 said the Corporate Nurse attempted to go through his/her belongings looking for things that shouldn't be there and wanted to go through the bureau. Resident #65 said he/she told the corporate nurse no and to not open his/her bureau or go through any personal items in the room. During an interview on 7/11/24 at 9:44 A.M., Corporate Nurse #1 said she did go into Resident #49's room on 7/10/24 and removed house stock items. The surveyor and Corporate Nurse walked into Resident #49's room as the corporate nurse said she was not familiar with Resident #49. The surveyor asked Corporate Nurse #1 how she communicated with Resident #49, and she reported she asked Resident #49 if she could remove items and he/she said yes. The surveyor then asked the corporate nurse if she used a communication book during her interaction and she said no and that she was not aware that Resident #49 had a communication book or spoke another language. During an interview on 7/12/24 at 9:46 A.M., the Director of Nursing (DON) said items should not be removed from resident rooms without consent and said all staff should communicate with residents and family members appropriately. During an interview on 7/12/24 at 9:52 A.M., Corporate Director #1 said Resident #49 is nonverbal, uses a binder to communicate, and staff should ask permission first before removing any items, explain the process and use the correct communication methods appropriate for the resident. 36876 3. During initial interviews, multiple residents reported staff speaking foreign languages during care and in the hallways of the units. One resident reported that he/she felt uncomfortable when staff speak in a language other than English because he/she thought they could be talking about him/her. Review of the Resident Council Meeting minutes dated 4/10/24, 5/8/24 and 6/12/24 indicated that residents reported staff speaking foreign languages had been discussed. On 7/11/24 at 7:50 A.M., the surveyor observed staff speaking in a language other than English in the hallways on the [NAME] Unit where nearby residents could hear the conversation. On 7/11/24 at 10:41 A.M., the surveyor observed staff speaking in a language other than English in doorway of resident room on Mystic Unit while residents were in the room. On 7/11/24 at 11:10 A.M., the surveyor observed staff speaking in a language other than English in the hallway on the [NAME] Unit where nearby residents could hear the conversation. During an interview on 7/12/24 at 8:25 A.M., the Corporate Director said staff should not be speaking in languages other than English in front of residents.

Based on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#114) who had a history of trauma out of a total sample of 25 residents. Specifically, for Resident #114, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include: Review of the facility policy titled Trauma Informed Care, dated 5/2024, indicated the following: Policy: -[NAME] Rehab and Nursing Center ensures that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Purpose: -To train and assist staff to avoid re-traumatization of those residents who have survived trauma and create an environment where the resident feels safe and secure. Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. -Upon admission the facility will assess each resident with a mental or psychosocial adjustment difficulty or a history of trauma and/or post-traumatic stress disorder in order to ensure they receive appropriate treatment and services. A questionnaire in PCC will be utilized for each resident by the social services department in order to identify the trauma and/or pot-traumatic disorder and to gather trigger information so that our understanding their traumatic events can be detailed and specific. Additional information may be obtained from the medical record, physical and emotional assessments, from the resident, from family members who have shared this information. -Trauma specific interventions for a resident will be placed in their individualized person-centered care plan upon admission and assessment. Care plans and interventions will be reviewed quarterly and more often, if necessary, based on any change in the residents' physical and psychosocial well-being. As we evaluate our interventions, we will be sensitive to the need for professional referral to psychological/mental health services and personnel as well as ways to communicate our plans to staff in order to enlist their support. Resident #114 was admitted to the facility in April 2023, with diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), bipolar, and schizophrenia. Review of Resident #114's most recent Minimum Data Set (MDS) assessment, dated 7/4/24, indicated that Resident #114 had a Brief Interview for Mental Status exam score of 14 out of 15 indicating he/she is cognitively intact. Review of Resident #114's care plan failed to indicate the development of a comprehensive trauma informed care plan with identified resident specific triggers and interventions for his/her diagnosis of PTSD. During an interview on 7/11/24 at 8:18 A.M., Nurse #1 said if a resident is identified with PTSD, there should be a care plan developed with specific triggers for staff to better care for the resident. During an interview on 7/11/24 at 8:46 A.M., Social Worker #1 said a care plan should be developed with specific identified triggers and if the resident does not want to discuss the trauma and/or identify triggers we respect the residents wishes as not to retraumatize them. Social Worker #1 was asked if a resident chooses not to discuss the trauma or identify triggers would that be documented in the medical record, she said yes. During an interview on 7/11/24 at 9:19 A.M., the Director of Nursing said if PTSD is identified following a trauma informed assessment a care plan will be developed with triggers identified and if the resident chooses not to discuss the trauma or identify triggers, their wish is respected, and it should be documented in the medical record. Review of the medical record failed to indicate the resident declined to discuss his/her trauma or identify triggers.

Based on observation and interview, and record review, the facility staff failed to provide the necessary services to ensure one Resident (#49) was able to effectively communicate his/her needs out of a total sample of 25 Residents. Findings include: Review of the facility policy titled Communication with Residents- Staff with Limited English Proficiency, dated 5/4/24, indicated the following: -It is the policy of the facility to ensure that all staff members, including those with limited English proficiency (LEP), can effectively communicate with residents to provide the highest standard of care and service. This policy aims to promote understanding, ensure accurate information exchange, and maintain safety and well-being of all residents. Procedure: 2. Provision of Language Assistance Services -Provide access to professional interpreter for LEP staff when necessary. -Utilize bilingual staff members to assist with communication, ensuring they are proficient in both languages. -Provide translated written materials in the primary languages spoken by staff with LEP. 4. Use of Interpretation Services -Utilize telephone or video interpretation services when on-site interpreters are not available. 5. Clear and Effective Communication -Use visual aids, gestures, and written materials to support verbal communication. 7. Monitoring and Evaluation -Regularly review and assess the effectiveness of communication strategies and language assistance services. - Make necessary adjustments to the policy and procedures based on feedback and evaluation results. Responsibilities -Management: Responsible for implementing and overseeing this policy providing resources for language assistance services and ensuring compliance. Human Resources: Responsible for assessing language proficiency during hiring, providing access to training, and maintaining records of language assistance services. Resident #49 was admitted to the facility in January 2017 with diagnoses including aphasia, dysphagia, vascular dementia, major depressive disorder, and muscle weakness. Review of Resident #49's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #49 was unable to complete a Brief Interview for Mental Status exam. The MDS also indicated Resident #49 is dependent on staff for all self-care activities. Further review of the MDS indicated Resident #49 is a Portuguese speaking resident. Review of Resident #49's communication care plan indicated the following: -Resident has a communication problem related to Expressive Aphasia, Portuguese primary language, and Neurological symptoms due to cerebral infarct. Primary language is Portugese [SIC], dated as revised 7/2/24. - Residents primary language is Portuguese Creole - utilize staff and family members to assist with communication as able, dated as revised on 1/09/23. -Speak on an adult level, speaking clearly and slower than normal, dated 11/29/21. -Utilize translation service as needed, dated 7/0/24. -Converse with [Resident] while providing care, dated 10/13/23. -Turn [Resident] TV on in the a.m. on Spanish channel, dated 10/13/23. -Give clear explanation of all care activities prior to an as they occur during each contact, dated 8/11/23. -Identify yourself at each interaction. Face him/her when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc., dated as revised 12/2/21. Review of Resident #49's active ADL flow sheet (form indicating type and level of care assistance needed), failed to indicate Resident #49's primary language is Portuguese. During an observation on 7/9/24 at 8:27 A.M., Resident #49 was observed laying in bed. There was no communication book visible in the room. During an observation on 7/10/24 at 8:35 A.M., Resident #49 was observed sitting up in bed. Certified Nursing Assistant (CNA) #1 entered the room and was observed placing folded towels on Resident #49's bed, then walked into the Resident's bathroom, began gathering personal care items, and then walked out of the room. CNA #1 did not knock on the door, introduce herself, or speak to Resident #49 during the observation. There was no communication book visible in the room. During an observation on 7/10/24 at 11:08 A.M., Resident #49 was observed laying in bed. There was no communication book visible in the room. During an observation on 7/11/24 at 9:01 A.M., Resident #49 was observed sitting up in bed eating breakfast with CNA #11. There was no communication book visible in the room. CNA #11 was not speaking to Resident #49 during the meal observation. During an observation on 7/12/24 at 12:18 P.M., the surveyor observed CNA #1 sitting next to Resident #49, spooning food into the Resident's mouth. CNA #1 did not explain what was on the lunch tray and made no attempts to communicate with the Resident during lunch. There was no communication book visible in the room. During an interview on 7/10/24 at 12:38 P.M., CNA #9 said Resident #49 can hear and understand very little English but can communicate well in Portuguese. During an interview on 7/10/24 at 12:18 P.M., CNA #1 was asked how she communicates with Resident #49, and she replied I don't know, he/she can hear but I turn him/her. I don't know. His/her daughter comes in to do that. CNA #1 was unable to provide any further details and denied the use of a communication book when asked. During an interview on 7/10/24 at 2:17 P.M., Nurse #2 said Resident #49 can understand Portuguese and some Spanish and that he/she doesn't communicate very well but can understand if you ask questions in his/her language and nod his/her head. During an interview on 7/11/24 at 9:17 A.M., Unit Manager #2 said Resident #49 has a communication book that staff can use to communicate because he/she does not speak English. Unit Manager #2 said she expects staff to use the book to communicate with Resident #49 and said staff should be speaking with Residents during mealtimes and when providing care. During an interview on 7/12/24 at 9:46 P.M., Director of Nurses (DON) said Resident #49 should have a communication book at the bedside and staff should be utilizing translation services to communicate with the Resident. The DON said communication care plan should be followed by all staff. During an interview on 7/12/24 at 9:48 A.M., Corporate Director #1 said Resident #49 is nonverbal, uses a binder to communicate, and she expects all staff to explain the procedures and follow the plan of care when communicating with the Resident.

Based on observation, interview, and record review, the facility failed to ensure nursing implemented a physician's order for Continuous Positive Airway Pressure (CPAP) mask to be worn at bedtime for one Resident (#117), out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Continuous Positive Airway Pressure (CPAP), dated 11/28/23, indicated the purpose of CPAP is to improve ventilation and oxygenation in an effort to avoid respiratory failure, intubation, and/or hospitalization in residents who present with chronic heart failure (CHF), obstructive sleep apnea (OSA), pulmonary edema or other causes of severe respiratory impairment. Procedure: 1. Review residents' chart for order, diagnosis, indications, settings, supplemental oxygen and other applicable information. 2. CPAP order should be transcribed onto TAR (Treatment Administration Record). Specific CPAP pressures (settings) should be documented on TAT; Supplemental oxygen liter flow as well as any other appropriate clinical data should be documented on TAR. 3. Order CPAP thru vendor (if needed) and give ordered settings; if resident using their won CPAP check settings are consistent with current order and Nurse Manager/designee should adjust as needed. 12. CPAP should be documented on TAR by a licensed nurse. Resident #117 was admitted to the facility in April 2024 with diagnoses including obesity, anxiety disorder, gastro-esophageal reflux disease and primary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 5/2/24, indicated Resident #117 had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated moderate cognitive impairment. Review of Resident #117's active physician orders, dated 6/25/24, indicated: - Continuous Positive Airway Pressure (CPAP) machine to be worn at bedtime at 4-20 cm pressure, check placement every evening and night shift for CPAP. - CPAP-Daily cleaning of CPAP. Wash mask with warm soapy water, rinse and hang up to dry daily in the morning. Clean canister with water and refill with distilled water. - CPAP: Weekly cleaning: wash filter on the back of machine with warm water, squeeze it dry and use a towel to remove moisture, soak mask, tubing and chamber in 1 cup of vinegar and 3 cups of water for 30 minutes and then air dry. Every day shift every Sun for C-PAP CARE, dated 6/26/24. Review of the plan of care related to CPAP /BiPap Therapy Obstructive Sleep Apnea, dated 7/3/23, indicated: Encourage Resident's use of CPAP/BiPAP. Review of the June and July 2024 Medication Administration Record (MAR) and TAR failed to indicate documentation of the CPAP machine. Further review of the June and July 2024 MAR and TAR indicated the following: Unscheduled other Orders CPAP: 4-16 cmH2O (inhalation & exhalation). During an observation on 7/9/24 at 7:30 A.M., Resident #117 was sleeping in bed without the CPAP facemask applied to his/her face. The CPAP machine was off, and the facemask was in a bag located on the nightstand. During an observation on 7/10/24 at 7:31 A.M., Resident #117 was sleeping in bed without the CPAP facemask applied to his/her face. The CPAP machine was off, and the facemask was in a bag located on the nightstand. During an interview on 7/10/24 at 9:43 A.M., Resident #117 said staff never put the CPAP facemask on at night and that he/she has asked staff to apply the facemask. During an observation on 7/11/24 at 7:15 A.M., Resident #117 was sleeping in bed without the CPAP facemask applied to his/her face. The CPAP machine was off, and the facemask was in a bag located on the nightstand. The CPAP facemask remained in the same position throughout the survey and remained in the same bag and location on the nightstand, visible to staff. During an interview on 7/10/24 at 12:37 A.M., Certified Nurses Aid (CNA) #9 said Resident #117 wears a CPAP at night to help him/her sleep. During an interview on 7/10/2 at 2:13 P.M., Nurse #2 said Resident #117 did not have on a CPAP facemask this morning and said evening staff apply the facemask at bedtime and staff remove it in the morning. Nurse #2 said Resident #2 has orders for CPAP to be applied and that orders should be followed. During an interview on 7/11/24 at 8:46 A.M., Unit Manager #2 said Resident #117 should be wearing his/her CPAP at bedtime and said staff need to follow physician's orders. Unit Manager #2 said Nurses need to document in the MAR and TAR to ensure orders are followed. During an interview on 7/12/24 at 9:34 A.M., The Director of Nurses (DON) said Resident #117 should be wearing his/her CPAP and orders must be followed. The DON said the facility reached out to the resident's prior assisted living facility, obtained the sleep study information, and ordered the CPAP machine so Resident #117 could use it. The DON said physician orders and care plan's are expected to be followed.

Based on record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed and/or implemented for two Residents (#114 and #107) out of a total sample of 25 residents. Specifically: 1. For Resident #114, the facility failed to apply booties per his/her physician's order. 2. For Resident #107, the facility failed to implement a rehab screening per the plan of care. Findings include: Review of the facility policy Adaptive Devices/Equipment, dated 5/2024, indicated the following: Policy: -The goal of [NAME] Rehabilitation and Nursing center is to ensure residents requiring the use of adaptive equipment and devices will have the equipment available in accordance with the MD orders and residents plan of care. Procedure: -[NAME] Rehab and Nursing Center will assess the need for adaptive equipment-adaptive devices and equipment include splints, boots, air mattresses etc. -Once the device has been ordered by the MD/NP, nursing will assess for placement and function and document in the resident record. 1. Resident #114 was admitted to the facility in April 2023, with diagnoses including paraplegia, rhabdomyolysis, and post laminectomy syndrome. Review of Resident #114's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #114 had a Brief Interview for Mental Status exam score of 14 out of 15 indicating he/she is cognitively intact. On 7/9/24 at 8:51 A.M. and 12:45 P.M., 7/10/24 at 7:35 A.M., and 7/11/24 at 6:55 A.M., Resident #114 was observed lying in his/her bed without his/her bilateral lower extremity booties. On 7/10/24 at 3:02 P.M., Resident #114 was observed sitting up in his/her wheelchair without his/her bilateral lower extremity booties. Review of Resident #114's physician's orders indicated the following: - Apply Prevalon boots (Heel Protectors) to bilateral feet at all times (when in bed and out of bed) as resident tolerates. May remove for hygiene and care, every shift for Preventive Treatment, initiated 6/6/24. During an interview on 7/11/24 at 8:24 A.M., Nurse #1 said if a resident has an order for booties, it should be indicated on the Treatment Administrative Record (TAR) and should be applied per the physician's orders. During an interview on 7/11/24 at 9:23 A.M., the Director of Nursing said a resident should be assessed, the staff will be educated on the application of the booties, and a plan of care should be developed and followed per the physician's orders. Review of the medical record failed to indicate Resident #114 refused to wear his/her booties or that his/her booties were applied to his/her feet daily. 36876 2. Resident #107 was admitted to the facility in November 2022 with diagnoses including Alzheimer's disease and vascular dementia. Review of the Resident #107's most recent Minimum Data Set assessment dated [DATE] indicated Resident #107 is severely cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #107's clinical record indicated he/she sustained a fall on 1/10/24 resulting in hospitalization and a diagnoses of nasal fracture and sutures. Review of Resident #107's fall investigation and fall care plan indicated that in response to the fall, the facility interventions included a referral to rehab. Review of Resident #107's physical therapy notes indicated he/she was not evaluated or screened by physical therapy until 2/13/24. During interviews on 7/10/24 at 11:49 A.M. and 7/11/24 at 7:10 A.M., the Rehab Director said that referrals to screen residents after a fall can be relayed verbally, by phone or through written requests. The Rehab Director said that the department attempts to screen residents within 24 hours of the request. The Rehab Director said that Resident #107 had not been seen by the rehab department in January 2024. During an interview on 7/12/24 at 8:25 AM the Corporate Director said that rehab referrals after a resident sustains a fall are usually completed within 24 hours of the request. She was not aware that Resident #107 did not receive a rehab evaluation per his/her plan of care until 2/13/24.

Based on employee record review and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility failed to complete a CORI (criminal offender registry information) check before hire for two of the 13 employee files reviewed. Findings Include: Review of the facility policy, titled The seven (7) components of a systemic approach to abuse prohibition, effective 3/2/24, indicated, but was not limited to, the following: 1. Screen: - All potential employees for a history of abuse neglect, or mistreating residents as defined by the applicable requirements. This includes attempting to obtain information from previous and/or current employers and checking with the appropriate licensing boards and registries. (sic.) c. Complete the CORI check and review findings - all applicants with history of abuse, allegations abuse, mistreatment, or neglect or 2) misappropriation of resident property or exploitation will not be eligible for hiring. (sic.) Review of Certified Nursing Aide (CNA) #5's employee file indicated that CNA #5 was hired in August of 2022. Further review of CNA #5's employee file failed to indicate that a CORI check was ever completed. Review of CNA #5's timecards indicated the CNA had worked as recently as 7/11/24. Review of CNA #7's employee file indicated that CNA #7 was hired in March 2004. Further review of CNA #7's employee file failed to indicate that a CORI check was ever completed. Review of the CNA assignments indicated that CNA #7 had worked as recently as 7/8/24. During interviews on 7/12/24 at 8:34 A.M., and 11:36 A.M., Human Resources said that CORI checks should be completed before a prospective employee can begin working and she could not find CORI checks for CNA #5 or CNA #7.

Based on observations, record review, policy review and interview, the facility failed to identify and assess the use of side rails as a potential restraint for one Resident (#47) out of a total sample of 25 residents. Findings Include: Review of facility policy titled Restraints, dated 2/2/24 indicated the following: -1. A physical restraint is any manual method or physical or mechanical device, material or equipment or material attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or normal access to one's body. Any device that prevents a resident from freely and easily arising out of a chair or bed is considered a restraint. -3. Devices that restrict the resident's movements for resident safety are considered a restraint: -Bedrails (Resident must be able to easily and voluntarily get in and out of bed using a bedrail; must be able to easily and voluntarily release the bedrail) -14. A bed mobility assessment will be completed for each resident to assess the need for side rails. Full or half side rails can be a restraint and the dangers of side rail use should be carefully addressed before applying them to a resident's bed. Review of facility policy titled Side Rail Policy/ Bed Safety, dated as revised 7/30/18, indicated the following: -Our facility shall strive to provide a safe sleeping environment for the resident. -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/ or legal guardian. Resident #47 was admitted to the facility in November 2020 with diagnoses that include severe protein malnutrition, dementia, restlessness and agitation and low back pain. Review of Resident #47's most recent Minimum Data Set (MDS) Assessment, dated 5/23/24, indicated a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15, indicating that the Resident has severe cognitive impairment. The MDS also indicated that Resident #47 is dependent for activities of daily living (ADLS) and substantial/max assistance for bed mobility. On 7/9/24 at 8:29 A.M., Resident #47 was observed laying in his/her bed. Both the head of the bed and foot of the bed were elevated and the Resident was in the divot of the bed. Bilaterally, both exits to the bed were blocked by 1/2 side rails. On 7/9/24 at 9:18 A.M., Resident #47 was observed laying in bed. Both the head of the bed and foot of the bed were elevated. Bilaterally, both exits to the bed were blocked by 1/2 side rails. On 7/10/24 at 7:29 A.M., Resident #47 was observed laying in bed with the foot of the bed elevated. One foot, which had an offloading boot applied, was caught in one of the bilateral 1/2 side rails. On 7/11/24 at 6:39 A.M., Resident #47 was observed laying in bed sleeping with the head of the bed elevated, bilateral 1/2 side rails are in place and up. Review of Resident #47's physician's orders indicated the following: -1/4 side rails as enablers, dated 2/1/24. Review of Resident #47's physician's orders failed to indicate an order for 1/2 side rails. Review of Resident #47's Nursing Annual/Quarterly Assessment, dated 5/16/24, indicated that no devices (including side rails) are being used and that a bed rail evaluation was not completed. Review of Resident #47's active ADL care plan indicated 1/4 side rails as enablers, dated 2/1/24. Review of Resident #47's active care plans failed to indicate a plan of care for restraints. Review of Resident #47's medical record failed to indicate an assessment to determine if the use of bilateral 1/2 side rails would be a potential restraint. Further review failed to indicate an interdisciplinary bed rail assessment was completed. During an interview on 7/11/24 at 8:35 A.M., Unit Manager #1 said that the side rails on Resident #47's bed look like 1/2 rails but she doesn't think they are. During an interview on 7/11/24 at 8:42 A.M., Certified Nursing Aid (CNA) #8 said that Resident #47's side rails are longer than other residents because he/she is restless and moves around a lot in bed. She said that sometimes Resident #47 tries to swing his/her legs out of the bed on one side and his/her head on the other, so she feels the side rails keep him/her safe. She further said that the side rails on Resident #47's bed appear to cover half the length of his/her bed. During an interview on 7/11/24 at 8:47 A.M., the Corporate Director said no side rail assessment was completed to evaluate the use of side rails for Resident #47. She said she agrees it is not 1/4 rails on the bed as per the physician's orders and that their was no restraint risk assessment completed to assess the potential for the current side rails to act as a restraint.

Based on observation, record review and interview the facility failed ensure residents identified as being at risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for 2 Residents (#125 and #88) out of a total of 28 sampled Residents. Findings include: Review of the facility's Fall Prevention policy, revised 11/21/21 indicated: Policy: A fall prevention plan will be initiated on all Residents who are at risk for falling. Each Resident will be assessed for risk factors and predisposition. Process: 2. A fall risk assessment will be completed and Residents scoring at risk for falls will have the following interventions. 3. Interventions will be documented on the Residents' care plan and on the CNA (Certified Nurses Aide) care card. the Care plan process will be initiated with individualized interventions and will be reviewed and revised as needed. *If a fall occurs and investigation will be initiated at the time of the incident to determine probable cause and implement further interventions to prevent reoccurrence. After a fall: Update the resident's care plan with new interventions. Communicate interventions to staff caring for this Resident. 1. Resident #125 was admitted to the facility in September 2022 with diagnosis including dementia, chronic obstructive pulmonary disease and anxiety. Review of Resident #125 Minimum Data Set, dated dated [DATE] indicated he/she scored 10 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is moderately cognitively impaired. Further review of the MDS indicated Resident #125 requires physical assistance of 1 person with bathing, dressing and ambulation. On 5/23/23 at 9:26 A.M., the surveyor observed Resident #125 laying in bed. Resident #125 was thin/frail, confused and his/her call light string was tied to a handbell. Review of Resident #125's care plans indicated: Focus: Resident has ADL (actives of daily living) self-care performance deficit and physical mobility r/t (due to) activity intolerance, confusion, dementia, 9/28/22. Interventions: Ambulation: Resident requires staff supervision to walk and as necessary. Educate and encourage resident to use assistive devices as needed to provide increased function and safety. Focus: Resident at risk for falls due to confusion, 9/28/22. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance, 9/28/22. Review of Resident #125's fall incident report dated 10/8/22 indicated that at 5:25 P.M., Resident #125 was yelling for help and was found by staff seated on the floor next to his/her bed. The incident report indicated: Resident confused, did not give clear information on what he/she was attempting to do. Interventions implemented in response to the fall included: Encourage use of walking device, remind resident to request assist with transfers and ambulation. The interventions implemented to prevent reoccurrence were interventions already in place effective 9/28/22. Additionally, reminders for Resident #125's would be ineffective due to his/her cognition. Review of Resident #125's fall incident report dated 10/13/22 indicated that at 8:00 P.M., the nurse on the unit responded to a commotion and found Resident #125 on the floor next to his/her bed yelling that he/she had fallen. Resident #125 was sent to the hospital and diagnosed with a fractured left wrist, pubic bone fracture and sacral fracture. During an interview with the Director of Nursing on 5/24/23 she said that after a Resident falls, the expectation is for his/her care plan to be updated with new interventions. She said that education and reminders are not appropriate interventions for Residents with dementia. 16372 2. For Resident #88, who was identified as high risk for falls, the facility failed to develop appropriate interventions to prevent fall. Record review indicated Resident #88 had 2 falls since admission, with one resulting in an injury. Resident #88 was admitted to the facility in 2/2023 with diagnoses including fracture of unspecified part of neck of right femur, dementia and repeated falls. The Minimum Data Set (MDS) dated [DATE], indicated Resident #88 scored a 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #88 had severely impaired cognition. In addition, the MDS indicated Resident #88 needed extensive assistance for transfers, bed mobility and locomotion. Resident #88 also had a fall with a fracture prior to admission. Review of a care plan developed initiated on 2/24/23 for falls r/t (related to confusion, deconditioning, gait/balance problems and unaware of safety needs included the following interventions: - Anticipate and meet the resident's needs. - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. - Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. A fall risk assessment conducted on 3/9/23 indicated Resident #88 was identified as high risk for falls. Record review indicated on 3/9/23 at 1:00 P.M., Resident #88 had an unwitnessed fall in his/her room. Per the nurse's note, Resident #88 was observed on the floor in front of his/her wheelchair with the right leg caught on the leg rest. Resident #88 complained of pain to the right hip and right pelvis. The Nurse Practitioner was notified and ordered an X-ray. The X-ray revealed a dislocated right hip prosthesis. Resident #88 was transferred to the hospital for an evaluation and was diagnosed with a right hip dislocation and osteoporosis. Resident #88 underwent closed reduction surgery (Closed reduction is a procedure to set (reduce) a broken bone without cutting the skin open. The broken bone is put back in place, which allows it to grow back together in better alignment). Review of the facility's investigation indicated Resident #88 was last seen approximately 25 minutes prior to the fall in his/her room. Resident #88's roommate's husband stated Resident #88 tried to get up from the wheelchair and fell . Resident #88 returned to the facility on [DATE]. The fall care plan was updated on 3/13/23 to include the following intervention: - WBAT to RLE (weight bearing as tolerated to right lower extremity). There were no interventions developed to provide supervision to prevent further falls for Resident #88. Record review indicated on 5/19/23 at around 2:35 P.M., Resident #88 had another unwitnessed fall. Review of the nurses' notes indicated Resident #88's roommate stated Resident #88 fell from the wheelchair. Resident #88 was found on the floor in his/her room lying in front of the wheelchair. Resident #88 was assessed for injuries, no apparent injuries were noted. The fall care plan was updated to include the following: - PT consult. Resident will be put back to bed for a nap after lunch. - Provide activities that promote exercise and strength building where possible. There were no interventions put in place to provide supervision to prevent further falls for Resident #88. On 5/23/23 at 8:30 A.M., Resident #88's door to his/her room was closed. Resident #88 was observed in bed sleeping. At 10:30 A.M., the door to Resident #88's room was closed. Resident #88 was in the room sitting in his/her wheelchair. On 5/24/23 at 8:45 A.M., Resident #88's door to his/her room was again closed. Resident #88 was in bed eating breakfast. Certified Nursing Assistant (CNA) #4 was interviewed at that time and stated the door was always closed and she was not sure why it was closed. During an interview with the Director of Nursing on 5/25/23 at 3:00 P.M., she stated reminding a resident with dementia to use a call light and to educate about safety are not effective.

Based on observation, record review and interview the facility failed to ensure standards of quality of care for 2 Residents (#18 and #44), out of a total sample of 28 residents. Specifically, 1). for Resident #18 the colonoscopy preparation instructions were not followed, resulting in the procedure not occurring as planned and Resident #18 requiring hospitalization for dehydration and 2). for Resident #44 A. to ensure daily treatment to his/her right second toe was provided in accordance with the physician's orders, resulting in failure to monitor the wound for changes, pain, signs and symptoms of infection. Further, the treatment that was provided included a dressing which was not indicated by the physician's order potentially resulting in keeping the area moist and not dry. B. failed to identify, report, monitor and obtain treatment orders for an area on Resident #44's right third toe, which was observed as an area of black scabbed skin consistent with eschar (dark scab of dead skin.) and C. failed to identify an area on the base of the right great toe that had a dressing and protective bandage applied, with no order or treatment plan for monitoring the area, or plan to provide a treatment or dressing. Findings include: 1. For Resident #18, the facility failed to ensure that hospital recommendations for his/her colonoscopy bowel preparation were done in accordance with professional standards of practice. Resident #18 was transferred to the emergency department due to dehydration caused by the facility's failure to ensure his/her colonoscopy preparation was followed as recommended. Resident #18 was admitted to the facility in October 2021 with diagnoses including hypertension, depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/16/23, indicated that the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated that Resident #18 was cognitively intact. During an interview on 5/23/23 at 8:00 A.M., Resident #18 said that on 5/16/23 he/she was scheduled for an outpatient colonoscopy procedure, but he/she was transferred to the emergency department due to low blood pressure and a change in mental status. Resident #18 said that he/she was dehydrated due to inappropriate administration of his/her colonoscopy prep. Resident #18 said that he/she received the bowel preparation kit for four straight days (5/13/23 through 5/16/23). Resident #18 told said that he/she spent two days at the hospital receiving IV (intravenous) fluids and his/her blood pressure was monitored until it was stabilized. Review of Resident #18's medical record indicated the Resident had been scheduled to have a colonoscopy (an exam to check for irritated tissues, polyps or cancer in the large intestine and rectum) on 5/16/23 at 12:00 P.M. Further review of Resident #18's medical record indicated recommendations for the Resident's colonoscopy bowel prep including the following: -Three days before the colonoscopy: begin a low-residue diet. -The day before the colonoscopy: -Begin a clear liquid diet as soon as you wake up. Be sure to drink plenty of clear liquids throughout the day. -At 7:00 P.M., give suprep bowel prep kit (an osmotic laxative used for cleansing the colon as preparation for colonoscopy) dose #1: must complete step 1 to 4 before going to bed. -Step 1: pour 6-ounce bottle of suprep liquid into a mixing container. -Step 2: add cool drinking water to 16-ounce line on the container and mix. -Step 3: drink all the liquid in the container. -Step 4: drink two more 16-ounce containers of clear liquid over the next hour. -The day of colonoscopy: -6 hours before the schedule procedure time: -suprep dose #2: drink the second 6-ounce bottle of suprep, following the same 4 steps as last night. Review of Resident #18's physician's orders indicated the following: -An order dated 5/10/23 for suprep bowel prep kit oral solution 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate), give 6-ounce of suprep bowel oral solution (177 ml), mix with cold water on 5/13/23. -An order dated 5/10/23 for suprep bowel kit oral solutions 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate), give 16-ounce of suprep bowel oral solution (473 ml), mix with cold water on 5/14/23. -an order to give stat (immediately/without delay) suprep bowel kit oral solutions 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate, give 32-ounce of suprep bowel oral solution (946 ml), mix with cold water. Review of the May 2023 Electronic Medication Administration Record (EMAR) indicated the following. -On 5/13/23 at 7:00 P.M., Resident #18 received 6-ounces of suprep bowel oral solution, mixed with cold water. -On 5/14/23 at 10:00 A.M., Resident #18 received 16-ounces of suprep bowel oral solution, mixed with cold water. -On 5/15/23 10:17 P.M., Resident #18 received 32-ounces of suprep bowel oral solution, mixed with cold water. On 5/23/23 at 1:42 P.M., Nurse Practitioner (NP) #1 was interviewed via telephone. She said she was aware of Resident #18's colonoscopy and preparation. She said she would follow whatever the recommendations were as far as colonoscopy prep. The surveyor reviewed the physician's order for colonoscopy prep with NP #1 and she said she wrote an order for suprep bowel oral solutions to start on 5/13/23 and 5/14/23 and a stat order 5/15/23 through 5/16/23. She said she was aware that Resident #18 was transferred to a hospital emergency department for evaluation and treatment on the day of his/her colonoscopy, but she was not aware that Resident #18's dehydration was caused by the colonoscopy prep. On 5/23/23 at 1:54 P.M., Unit Manager (UM)#1 was interviewed, and she said she reviewed and carried out the NP order for suprep bowel oral solution from 5/13/23 through 5/15/23. She said Resident #18 received the suprep bowel solution kit on 5/13/23, 5/14/23, 5/15/23, and 5/16/23. During a follow up interview on 5/24/23 at 8:05 A.M., Resident #18 said he/she spent most of his/her time using the bathroom and that a few times he/she did not make it to the toilet. Resident #18 said he/she felt shaky and dizzy from 5/14/23 through the day of his/her colonoscopy procedure. Resident #18 said on 5/16/23, the day of his/her colonoscopy, the nurse gave him/her another suprep bowel oral solution at 6:00 A.M. Review of Resident #18's hospital report dated 5/16/23 indicated Resident #18 was scheduled for an outpatient colonoscopy but was referred to the emergency department due to abnormal laboratory results and was diagnosed with an acute kidney injury due to dehydration caused by the colonoscopy prep. Resident #18 received albumin (used to treat low blood volume) intravenously (IV) at the hospital. On 5/24/23 at 1:27 P.M., NP #1 was interviewed via telephone. She said she was not the NP on call the weekend of 5/13/23 and 5/14/23. She said she was not aware Resident #18 had a complaint of dizziness and being shaky while on call for the weekend of 5/13/23 and 5/14/23. She said the report that she received from the nurses at the facility was that Resident #18 was taking fluids well. On 5/26/23 at 10:25 A.M., Nurse #4 was interviewed via telephone. Nurse #4 said she worked on 5/15/23 during the evening, 3:00 P.M.-11:00 P.M. shift and was the nurse providing care for Resident #18. Nurse #4 said she gave suprep bowel oral solution for Resident #18 around 10:00 P.M. On 5/26/23 at 12:24 P.M., Nurse #8 was interviewed via telephone. Nurse #8 said she worked on 5/15/23 during the 11:00 P.M.-7:00 A.M. overnight shift and was the nurse providing care for Resident #18. Nurse #8 said she gave suprep bowel oral solution for Resident #18 around 6:00 A.M. on 5/16/23. The facility failed to follow recommendations for colonoscopy prep for Resident #18, resulting in the Resident receiving an excessive amount of the preparation solution and developing an acute kidney injury with dehydration requiring an acute transfer and intravenous fluids and medications. 36431 2. Resident #44 was admitted to the facility in March 2023, with diagnoses that include but are not limited to cerebral infarction, depression, dependence on renal dialysis, end stage renal disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (dead tissue caused by lack of blood supply). Review of the facility's policy, titled Skin Management Program, Skin Assessment and Surveillance, not dated indicated, in part, the following: To minimize the development of pressure ulcers through the systemic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. 2. Residents will undergo a weekly body check by the licensed nurses. The facility will utilize the weekly body check form. 3. Certified Nursing Assistants will inspect the skin of each resident during care and whenever skin care is provided and report to the license nurse of the following changes in skin condition but not limited to: Redness, inflammation or swelling, skin breaks, cracks or blisters, discoloration, pain and tenderness, 4. Licensed Nurses will respond to reports of skin problems and assess the resident's skin as soon as possible. 5. If an area is identified, the physician will be notified, and a treatment will be obtained. 11. Licensed Nurses on the units shall monitor the completion of preventative and restorative measures and routines. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of 3/15/23 indicated Resident #44 scored a 15 out of 15 on the Brief Interview for Mental Status Exam indicating intact cognition, required extensive assistance with daily care including bed mobility, bathing, dressing and hygiene. Further review of the MDS identified Resident #44 as having diabetic foot ulcer(s). Review of Resident #44's medical record indicated the following: *N Adv Skilled Evaluations dated: 3/11/23, 3/12//23, 3/15/23, 3/19/23, 3/23/23, 3/25/23, 3/27/23, 4/4/23, 4/17/23 all indicated skin issue location #1 Right toe, diabetic foot ulcer, the skin note is blank with no further documentation of description of the skin issue (wound), odor, tunneling, undermining, treatment schedule or status of the wound. *Mass-Skin check-weekly dated 4/24/23, is skin intact? no. Findings of skin check right toe: Second dorsal toe: necrotic (dead tissue.). Treatments Wash right second dorsal toe-clean with wound cleaner, pat dry, apply iodine (a topical treatment used to treat and prevent infection,) skin prep. *N ADV Skilled Evaluation dated 4/27/23 indicated skin issue location #1 right toe, skin issue #1, other skin issue, description Necrosis, wound odor: No, tunneling: No, Undermining: No, treatment schedule: daily, status: no change. *Mass-Skin check-weekly dated 5/16/23, is skin intact? no. Findings of skin check: site and description not filled in and left blank. Treatments Wash right second dorsal toe-clean with wound cleaner, pat dry, apply iodine skin prep. *A care plan, focus: Resident has Diabetes Mellites, dated 3/11/23 with interventions dated 3/11/23, Check all of body for breaks in skin and treat promptly as order by the doctor. *Review of Resident #44's physician's order summary report indicated the following: Diabetic Foot Care, every evening shift for monitoring dated 3/9/23. *A Nurse Practitioner progress note dated 3/13/23 which did not include an assessment or plan related to the right necrotic dorsal toe. *A Physician's progress note dated 3/30/23 which did not indicate any assessment/nor addressed Resident #44's right necrotic dorsal toe. *A Podiatrist visit progress note dated 4/11/23 indicated podiatric diagnosis (es) right 2nd toe dry gangrene: type 2 Diabetes Mellitus with peripheral. Circ. Disorders, onychomycosis: peripheral Neuropathy. Recommend New Orders: Yes, right 2nd toe dry gangrene, please keep the area dry and clean daily betadine painting is recommended. Please monitor for any signs of infection or converting to wet gangrene, consult vascular surgeon for appropriate treatment. Review of the Physician's orders indicated the following: -Wash Right second dorsal toe-Clean with wound cleaner, pat dry, apply iodine skin prep. Every day shift for arterial wound, dated 3/10/23. During an interview on 5/23/23 at 10:15 A.M., Resident #44 was observed resting in bed wearing yellow antiskid socks with protective boots on both feet. Resident #44 said he/she had a dressing on his/her right foot that was done over a week ago, and since then no one has taken his/her sock off to look at it. Resident #44 said he/she had pain in his/her right foot and has a black toe on his/her right foot. Resident #44 said he/she had an upcoming appointment for his/her toe in June. During an interview on 5/23/23 at 3:44 P.M., Nurse #2 (who worked the day shift) said she had not done the treatment for Resident #44 yet. The surveyor asked Resident #44, and he/she agreed the surveyors could be present for the treatment. On 5/23/23 at 4:39 P.M., the treatment was observed by the surveyors. Nurse #2 and Nurse #3 were present and completed the treatment. The following was observed: -The yellow slipper sock was removed from Resident #44's right foot. -Resident #44 grimaced and said it hurt. -A gauze bandage was around Resident #44's foot, covering his/her toes. -Tape on the dressing was dated 5/11/23 with initials VC. This was 13 days prior to the observation. -Nurse #3 removed the dressing, which had dark colored stain/drainage on it. -Resident #44's foot was scaley and dry, with flakes of skin landing on the blue protective boot holding his/her foot up. -Right black second toe: - - was black/with a buildup of gold coloring and a small white patch located over the black dead tissue. - - bottom had clear fluid on the edge at the bottom of the toe wound. - - wound was observed to be lifting toward the bottom of the black second toe wound. - Right third toe: -A dark scabbed area was observed (no identified and no treatment ordered). Right great toe: -A quarter inch foam dressing was observed, held in place by a blue bandage beneath the right great toe. -Nurse #3 cleaned the second black toe with wound cleaner and patted it with iodine. -Nurse #2 placed a pad on the second black toe and used gauze to wrap Resident #44's toes and foot (not indicated on the physician's order to use a dressing.) -No treatment was provided for the black area on the third toe. During an interview with Nurse #2 and Nurse #3 on 5/23/23 at the conclusion of Resident #44's treatment, Nurse #2 said Resident #44 was admitted with gangrene of the right second toe. Nurse #2 said the dressing that was removed was dated 5/11/23 and acknowledged the dressing change was to be completed daily. Nurse #3 said they do not always have a third nurse and sometimes treatments do not get done. Nurse #3 said this was her first-time providing treatment of Resident #44's toe. Nurse #2 said she did not know if the wound/gangrene toe looked different or had changed. Further, Nurse #2 and Nurse #3 said they did not know about the dressing that was at the base of Resident #44's right great toe and Resident #44's only treatment was for his/her right second toe. Neither Nurse #2 nor Nurse #3 acknowledged the black area on Resident #44's third toe. Review of Resident #44's medical record did not indicate an order for a treatment or dressing to the area below Resident #44's right great toe. The medical record including progress notes, skin assessments and care plans failed to indicate any documentation of why there was a dressing, what the dressing was treating, or a plan to remove the treatment with a dressing. During a telephone interview on 5/23/23 at 5:20 P.M. the Physician said Resident #44 had the necrotic toe for longer than a year. The Physician said it was a dead toe with gangrene due to Resident #44's poor vascular condition. The surveyor informed the Physician that the dressing that was removed on 5/23/23 was dated 5/11/23. The Physician said the treatment should have been completed as ordered. The Physician said it would be speculation but due to the treatment not being done, along with no monitoring of the dead toe there would be a natural progression that could result in auto necrosis. During subsequent telephone interviews on 5/24/23 at 3:35 P.M., and 5/25/23 at 12:45 P.M., the Physician said he may have last seen Resident #44's right second toe on 3/30/23 and he did not document about the condition of the right toe in his progress note. He said he determined a vascular consult was missed in January and one is set up for June. The Physician said the right toe should be left open to air with no dressing applied. He said the dressing left on would make the area less dry. The Physician said he saw Resident #44's right toe last night, (5/24/23), after removing a dressing. He said he observed a natural lifting at the proximal edge that could be the natural progression of the eschar (dead tissue.) He said the toe should be left open to air after the iodine is painted on the toe. The Physician said he did not change the treatment but may consider changing the treatment based on the lifting at the base of toe but will wait until after a wound consultation is completed. The Physician said he did see the area on the third right toe last evening (5/24/23.) The Physician said it was eschar and could have been there in the past or possible new onset to due chronic ischemia and the beginning of a new dry gangrene. He said he reviewed an image taken at the hospital dated 4/8/23 which indicated the presence of the lesion on the right third toe. The Physician said he was not made aware by facility staff, nor was there a treatment for the area on Resident #44's right third toe. Regarding the treatment observed under the great right toe, the Physician said he speculates the podiatrist may have shaved the side of Resident #44's right foot and put a duoderm dressing on for protection. The Physician said he reviewed the area on 5/24/23 and there was a pink circular area under the dressing. The physician said he was not aware that the dressing was there and that there was no order to monitor the area or to provide any treatment. Review of the podiatrist treatment note dated 4/11/23 did not indicate any treatment to the area below the right greater toe. Orthopedic exam indicated bunion deformity none. During an interview on 5/25/23 at 8:05 A.M., the Regional Corporate Nurse said she was made aware that the dressing to Resident #44's right toe was not completed as ordered and this was disappointing. Regional Nurse reviewed the photo of Resident $44's right foot, that revealed the dark area on the right third toe and the dressing to the right side under his/her right great toe. She acknowledged the area on the right third toe and said it would need to be reviewed. Regional Cooperate Nurse said the area below the great toes looked to be a bunion protector and should have an order and a care plan in place. During an interview on 5/24/23 at 4:30 P.M., Resident #44 said he/she had pain in his/her right toes from neuropathy and said he/she has had increased pain in the last 3 weeks.

Based on record review and staff interviews, for one Resident (#22) of 28 sampled residents , the facility failed to develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care for him/her, resulting in a fall, requiring nine stitches to his/her right ear. Findings include: Resident #22 was admitted to the facility in January 2023 with diagnosis including dementia, and depression. Review of his/her most recent Minimum Data Set (MDS) dated [DATE] indicated that he/she is severely cognitively impaired and requires extensive 1-person physical assist with ambulation, transfer, bed mobility and toilet use. Review of the facility policy titled comprehensive person-centered care plan-baseline care plan, dated 12/12/22 indicated: -The Baseline Care Plan must be developed and implemented within 48 hours of a resident's admission (both new admissions and re-admissions). The baseline care plan must include the instructions and healthcare information necessary to properly care for a resident including, but not limited to the following: -initial goals based on admission orders. -physician orders. -dietary order -therapy services -social services -PASARR recommendations, if applicable. -The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It must be based on the admission orders, information about the resident available from the transferring provider and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff must implement interventions to assist the resident to achieve care plan goals and objectives. Review of the nurse progress notes dated 1/24/23 indicated that Resident #22 was found in the social service office across from the day room. Resident #22 was lying on the floor next to a table and had a cut/laceration on his/her right ear. Resident #22 was transferred to the Emergency Department for further evaluation. Resident #22 returned from the hospital on the same day with nine stitches on his/her right ear. Review of Resident #22's admission falls risk assessment indicated the following: -history of falls within the last 6 months. Resident #22 had fallen 1-2 times. -total incontinence with bladder and bowel. -unable to independently come to a standing position. -uses and assistive devices (cane/walker) Review of the record indicated that a baseline care plan was created on 1/20/23. Further review of the baseline care plan failed to address Resident #22's risk for falls within 48 hours of admission. During an interview with Nurse #5, on 1/25/23 at 10:20 A.M., she told the surveyor that Resident #22 fell and obtained laceration on his/her right ear 4 days after admission. She told the surveyor that Resident #22 was assessed and identified as high fall risk during the admission. She acknowledged that the fall care plan and interventions for Resident #22 were not initiated until Resident #22's fall on 1/24/23.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) was assessed by Nursing to be at increased risk for elopement, and required a wander guard bracelet, the facility failed to ensure that in an effort to maintain Resident #1's safety to prevent an incident of elopement, that staff implemented and followed facility policy and procedures when responding to a sounding alarm. On 10/20/22 at approximately 5:30 A.M., Resident #1, eloped from the facility unbeknownst to staff, and was found by the Police at approximately 7:00 A.M., wandering down the street, dressed in pajamas and slippers, the temperature was in the high 30's, he/she was shivering, and transported to the Hospital Emergency Department for evaluation. Findings Include: The Facility's Policy, Door Alarm Responses, dated as revised on 07/28/22, indicated the purpose of the Door Alarm Response is to ensure and maintain resident safety and to prevent resident elopement from the facility. The Policy indicated staff must identify the cause of the sounding alarm. The Policy indicated when staff respond to door alarms, staff must immediately do the following; - assess surrounding location for the cause of the alarm activation, - notify the supervisor if unable to identify the cause, - the supervisor will notify nursing units staff to immediately complete a head count of all residents to determine if a resident is missing, - and in the event a resident is determined to be missing, a Code White will be announced. The Policy indicated staff to notify the Administrator and Director of Nursing immediately and proceed with the Facility's Elopement Policy. Resident #1 was admitted to the facility in July 2022 with diagnoses which include: Temporal Neurocognitive Disorder (frontal lobe dementia), anxiety disorder, altered mental status, cognitive communication deficit, abnormal gait and mobility and muscle weakness. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/13/22, indicated he/she had severe cognitive impairment. Resident #1's Plan of Care for Falls, dated as initiated on 10/28/21, (reviewed and renewed with the quarterly MDS in 10/2022) indicated Resident #1 was at a risk of falls due to diagnosis of frontal lobe dementia with decreased safety awareness and history of wandering in the facility. Resident #1's Plan of Care for Wandering, dated as revised on 10/28/21, (reviewed and renewed with the quarterly MDS in 10/2022) indicated Resident #1 was an elopement risk and wandered related to his/her frontal lobe dementia. The Care Plan indicated interventions related to Wandering included Resident #1 will be supervised when off of the unit. Resident #1's Plan of Care for Activities of Daily Living - Ambulation, dated as initiated on 11/04/21 (reviewed and renewed with the quarterly MDS in 10/2022), indicated Resident #1 required continual supervision and staff to escort him/her to his/her destination. Review of the Facility Incident Report, dated 10/20/22, indicated that Resident #1 eloped approximately at 5:30 A.M., (on 10/20/22) was found by Police at approximately 7:30 A.M., and was transferred to the hospital. Review of the Facility's Investigation Report, dated 10/26/22, indicated the Facility was contacted by the local Police of Resident #1's elopement. The Report indicated that at approximately 5:30 A.M., one of the facility's door alarm sounded, Nurse #1 checked the unit doorways and stairwell staircases. The Report indicated Nurse #1 turned off the sounding alarms when he did not see any residents. The Report further indicated Nurse #1 did not follow Facility's Policy and Procedures, did not activate the Code White (Elopement Emergency Response Code) in order to identify a missing resident. The Report indicated Nurse #1 did not follow up with staff to ensure all residents were accounted and on the unit. The Report indicated that Nurse #1 shut off the sounding door alarm without properly investigating the cause of the sounding alarm. Review of the Police Report, dated 10/20/22, indicated Resident #1 was found by Police Officers at approximately 7:00 A.M., walking down the street in his/her pajamas, shaking and shivering profusely as the temperature outside was in the high 30's at that time. The Report indicated Resident #1 was wearing a thin long sleeve shirt, pajama pants and slippers. The Report indicated Resident #1 had snot coming out of his/her nose that appeared to be frozen to his/her face, he/she appeared to be in a semi-catatonic state and initially presented as non-verbal. The Report indicated that Resident #1 was transported to the local hospital. During an interview on 11/21/22 at 11:27 A.M., Nurse #1 said on 10/20/22 approximately 5:45 A.M., he heard an alarm sounding. Nurse #1 said he checked the elevator and proceeded to the two exits where he heard the sounding alarm coming from. Nurse #1 said he was unable to see any residents in the area, so he turned off the alarm manually on the second floor unit. Nurse #1 said an alarm was still sounding so he proceeded down the exit door stairwell (leading to the first floor) and said the exit door leading to the outside of the facility alarm was sounding. Nurse #1 said he turned off the external exit door sounding alarm and entered the first floor through the internal door, looked out the window on the first floor and did not see any residents outside. Nurse #1 said he informed Certified Nurse Aide (CNA) #1 and CNA #2 to check the residents on the unit. Nurse #1 said he did not call Code White, did not step outside the exit alarming door to see if a resident was outside and did not follow up with the CNA's to ensure all the residents were on the unit. Nurse #1 said he was unaware Resident #1 was missing until the Police called the facility to let them know Resident #1 was found and had been transported to the hospital. During an interview on 11/21/22 at 10:55 A.M., Certified Nurse Aide (CNA) #1 said on 10/20/22 Resident #1 was sleeping when she entered his/her room at 5:00 A.M. CNA #1 said she had been providing care to residents and she did not hear the sounding alarm. CNA #1 denied that Nurse #1 asked her to check to ensure all the residents were accounted on the unit. CNA #1 said she completed her rounds with CNA #2 and left the facility at 7:00 A.M. During an interview on 11/21/22 at 6:20 P.M., Certified Nurse Aide (CNA) #2 said on 10/20/22 Resident #1 was sleeping when she entered his/her room at 5:00 A.M. CNA #2 said she had been providing care to residents and she did not hear the sounding alarm. CNA #1 denied that Nurse #1 asked her to check to ensure all the residents were accounted on the unit. CNA #2 said she completed her rounds with CNA #1 and left the facility at 7:00 A.M. During an interview on 11/16/22 at 5:21 P.M., the Director of Nursing (DON) said on 10/20/22 Resident #1 exited the facility from a staircase exit doorway and was later found by the local Police. The DON said Nurse #1 did not follow the Elopement Policy and Procedures. The DON said Nurse #1 did not call Code White and turned off the alarms prior to accounting all the residents were on the unit. The DON said Nurse #1 did not follow up with CNA #1 and CNA #2 to ensure that they completed the resident head count on the unit. The DON said her expectation is that Nursing staff are able to recognize an elopement and not being notified by the local Police of the facility's elopement. The DON said staff are expected to follow the Facility's Policies and Procedures. On 11/16/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A) Resident #1 was readmitted to the facility on [DATE] and was placed on frequent checks on all shifts for 24 hours. Resident #1 continues to wear his/her wanderguard bracelet and Resident #1's Plan of Care was updated. B) On 10/20/22, all residents at risk for elopement were reviewed to ensure the following were completed; proper placement and functioning of all wander guards, completion of the Elopement Risk Assessment, updating Plan of Care and the Elopement Book, Physician Wander Guard Orders and the Physician Orders were documented on the resident's Treatment Administration Record (TAR). C) On 10/20/22 and 10/21/22, the Administrator audited all facility Maglocks to ensure the doors opened properly, had correct signage, the emergency door released after 15 seconds, exit signs illuminated and had an audible alarm. All systems were deemed to be fully functional. D) On 10/20/22, 10/27/22, 11/03/22, 11/10/22, 11/11/22, the Nursing Management Team conducted audits to ensure the following were completed; Physician Wander Guard Orders, the Wander guard had proper placement and functioning, residents supervised on and off of the unit and residents Plan of Care were completed and updated. E) On 10/20/22 the Nursing Management Team conducted Educational In-services for all staff on the Facility's Elopement Prevention and Procedure Policy. The staff education included the following; the Elopement Binders located at each Nurses Station and the Front Reception desk, provide supervision to any resident at risk for Elopement when off the unit, outside door entrance alarms sounding need to be investigated before shutting off any alarm, Elopement Assessment/Evaluations are completed on admission/quarterly and change of condition and Wander guard placement/functioning properly on resident's at risk for elopement. F) On 10/20/22, 10/21/22, 10/25/22, 10/26/22, 11/03/22 and 11/10/22, the Nursing Management Team conducted Code White Drills in the facility. G) Weekly Audits and Code White Drills were conducted 10/20/22 through 11/15/22 by Nursing Management Team. H) On 11/04/22, the Elopement Root Cause Analysis, results of the Weekly Audits, and Code White Drills were discussed at the Quality Assurance & Performance Improvement (QAPI) committee meeting. I) Monthly Audits and Code White Drills will be conducted by Nursing Management Team until the spring of 2023. Results of these audits will be brought to QAPI committee meetings by the Nursing Management Team. J) The Administrator/and or designee are responsible for overall compliance.

Findings include: Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR) and Emergency Response Team, dated ,d+[DATE], indicates the following: Policy: The facility will have an Emergency Response Team (Nurse) available on each shift of every day to immediately respond to all Code Blue (medical emergency) situations prior to the arrival of emergency personnel. Cardiopulmonary Resuscitation (CPR) will be performed on those residents whom are found to be unresponsive, without a Do Not Resuscitate (DNR) order in place and are determined to not be clinically dead. Nursing staff certified CPR providers will perform CPR under those circumstances. Procedure: In the event that a resident is found unresponsive and/or is not breathing a staff member should initiate the following steps: Any staff member that discovers an unresponsive resident will immediately overhead page Code Blue and the location 3 times. This will ensure that all CPR certified personnel respond. A CPR certified staff member will check the resident's status using the CAP protocol: Chest Compressions, Airway, Breathing. If the resident's wishes are to receive CPR, it will commence immediately. If the resident is on a soft surface, log roll him/her onto a CPR board before initiating compressions. Inform Certified Nursing Assistant (CNA) scheduled on unit to call Code Blue. Resident #193 was admitted in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #193's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated [DATE], indicated should Resident #193 need CPR administered, Resident #193 wanted resuscitation to be attempted. Review of the current physician's orders indicated Resident #193 was a Full Code. During an interview on [DATE] at 2:45 P.M., Resident #67 said he/she was the roommate of Resident #193. Resident # #67 said he/she found Resident #193 unresponsive in bed at around 6:00 A.M. on [DATE]. Resident #67 said he/she went to the hallway to find CNA #1 and Nurse #1 who were standing right outside of the room. Resident #67 said that CNA #1 came into the room and emptied the urinal and left the room. Resident #67 said that Nurse #1 came in the room to assess Resident #193 and left the room to call a Code Blue. Resident #67 said that Nurse #1 came back to the room and didn't initiate CPR until about 15 minutes after Resident #67 had notified CNA #1 and Nurse #1 of Resident #193's status. Review of Resident #67's most recent Minimum Data Set assessment dated [DATE] indicated Resident #67 scored a 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. Review of Resident #193's Nursing progress note, dated [DATE], indicated that at 7:15 A.M. an RN pronouncement of death was completed after the 911 team left the facility. Resident #193 was absent of respirations, apical pulse, and blood pressure. Further review of Resident #193's medical record failed to indicate any further documentation of the events that took place including what time and how staff were alerted Resident #193 was unresponsive, which staff began CPR and at what time, and when emergency services were contacted. Review of Nurse #1's witness statement provided by the facility, dated [DATE], indicated the following: On [DATE] around 6:15 A.M., while walking in the hallway to use the bathroom .[Resident #67] alerted this writer that his/her roommate was not feeling good. I went right away into the room. I found patient unresponsive. I ordered a CNA to stay with the patient while I called Code Blue Twice: [NAME] Unit. Nurses from two other units came and we started to perform CPR until emergency department arrived. Nurse #1 was interviewed on [DATE] at 4:14 P.M. and [DATE] at 12:54 P.M., about this incident. During these interviews, Nurse #1 said that on [DATE] at approximately 5:30 A.M., he saw Resident #193 in bed and told him/her that his/her medications would be running a little late. Nurse #1 said that he was familiar with Resident #193 and knew Resident #193 was a full code and that Resident #193's code status was on his report sheet. Nurse #1 said on [DATE] between 6:00 A.M. and 6:30 A.M., Resident #67 told him Resident #193 was not feeling well. Nurse #1 said CNA #1 went into Resident #193's room with him and Resident #193's head was in the bed and his/her legs were dangling off the side of the bed. Nurse #1 said that Resident #193 did not have a pulse and was not breathing. Nurse #1 told CNA #1 to stay in the room while he went to call a Code Blue because Nurse #1 thought it would be faster than having CNA #1 make the call. Nurse #1 said he returned to Resident #193's room with the code cart, which included a backboard, (a device used to assist providing CPR on a soft surface). Nurse #1 said he waited for Nurse #2 to arrive and then he and Nurse #2 transferred Resident #193 to the ground before initiating CPR. Nurse #1 could not say why the backboard was not used instead of transferring Resident #193 to the ground. Nurse #1 said that it is the expectation that a nurse initiates CPR and not a CNA. Nurse #1 said that he did not know if CNA #1 was CPR certified. When asked why he did not perform CPR alone, Nurse #1 said that one cannot perform CPR alone. Nurse #1 said that this was not his first time he has had to do CPR. Nurse #1 acknowledged that he left Resident #193, who was a full code, not breathing and had no pulse with a CNA, rather than initiating CPR immediately and further acknowledged that he also waited for additional staff to arrive before initiating CPR on the Resident. During an interview on [DATE] at 3:30 P.M., Nurse #2 said that when he arrived to Resident #193's room after the Code Blue was paged, Resident #193 was on the bed with Nurse #1 in the room. Nurse #2 said that he and Nurse #1 then transferred Resident #193 to the ground and began CPR until paramedics arrived. During an interview on [DATE] at 2:24 P.M., Nurse #3 said that she heard the Code Blue over the speaker around 6:00 A.M. or a little after. Nurse #3 said that the code cart was in the room upon arrival and Resident #193 was in the bed and CPR had not been started. Nurse #3 said that she went to call 911 as Nurse #1 and Nurse #2 were transferring Resident #193 to the floor. During an interview on [DATE] at 7:19 A.M., CNA #1 said that she was first alerted that something was wrong with Resident #193 when his/her roommate, Resident #67, had said there was an emergency. CNA #1 said she went into the room and saw Resident #193 in bed, unresponsive, laying on his/her back with his/her mouth open and that he/she didn't look normal. CNA #1 said she went to get Nurse #1 who came into the room, assessed Resident #193, and left to call a code blue. CNA #1 said that CPR was not started until Nurse #2 arrived and after Resident #193 was transferred to the floor. CNA #1 said that she is not certified to perform CPR and that is the nurse's job. During an interview on [DATE] at 12:36 P.M., Unit Manager #1 said that she came in around 6:30 A.M. that morning with the Staff Development Coordinator and said Nurse #3 was on the phone with 911. UM #1 said when she arrived to Resident #193's room both Nurse #1 and Nurse #2 were in the room and had just transferred Resident #193 to the floor and CPR had not yet been initiated. UM #1 said that she grabbed the Ambu bag (a hand-held device used to provide positive pressure ventilation to people who are not breathing or not breathing adequately) from the code cart and began bagging while Nurse #1 was doing chest compressions. The Automated External Defibrillator (AED) machine was retrieved by Nurse #2 upon her arrival to the room, but that a shock was not advised. CPR was continued until Emergency Medical Services (EMS) arrived. Review of the Fire Department report indicated that first responders were dispatched at 6:41 A.M. and upon arrival, staff were performing CPR. The Fire Department then took over CPR upon arrival. Review of the Emergency Medical Services (EMS) report indicated that an ambulance was dispatched at 6:43 A.M. and arrived at 6:46 A.M. EMS arrived at patient side at 6:47 A.M. and took over CPR upon arrival. Ultimately, Resident #193 was pronounced dead at the scene. During an interview on [DATE] at 2:08 P.M., the Director of Nursing (DON) said that if a resident is found unresponsive, the staff member should call for help and CPR should be performed immediately. The DON said that she didn't know many details about the incident. The DON said that CPR can be started by one person and that the Nurse should stay with a resident that is unresponsive to begin CPR right away. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] as evidenced by: -On [DATE] the facility provided education to nursing staff related to emergency response, CPR and code blue policies and procedures. -On [DATE] the facility provided education to nursing staff related to delegation of tasks during an emergency. -On [DATE] and [DATE] the facility provided CPR Recertification to all 18 licensed staff members regardless of current CPR training status. -On [DATE], [DATE], [DATE] and [DATE] the facility observed nursing staff competency for CPR. -On [DATE], [DATE] and [DATE] the facility conducted mock code blue drills to determine compliance with training status.

Based on record review and staff interview, the facility failed to 1. ensure that emergency medical care was provided in accordance with the resident's wishes and accepted standards of professional nursing practice for 1 Resident (#193) out of a total of 36 sampled Residents. Specifically, the facility failed to ensure Nurse #1 followed professional standard of practice by failing to abide by its policy by A) failing to delegate the announcement of the Code Blue (medical emergency) to CNA #1 B) failing to initiate CPR (Cardiopulmonary Resuscitation) immediately in accordance with Resident #193's wishes and C) failing to follow the facility policy regarding use of a back board and transferred the Resident from the bed to the floor before initiating CPR. 2. The facility failed to obtain pain medications as ordered for 1 Resident (#7) out of a total of 38 sampled residents. 3. The facility failed to ensure that professional standards of care were followed during the administration of blood pressure medications with physician ordered parameters. 4. The facility failed to ensure nursing standards of practice were adhered to for one Resident (#132) the administration of medication out of a total of 38 sampled residents. Findings include: 1. As of [DATE], the facility identified 108 out of 138 residents as Full Code (if a person's heart has stopped beating and/or they stopped breathing, all resuscitation procedures are to be provided to keep them alive), resulting in the likelihood for serious injury or death for all residents identified as a full code. The Immediate Jeopardy began on [DATE] when Resident #193 was found by Nurse #1 without respirations and without a pulse. Nurse #1 was aware this resident was a full code and failed to immediately initiate CPR (Cardiopulmonary resuscitation), left Resident #193's room to call a Code Blue, failed to delegate this task to a CNA (Certified Nursing Assistant) present in the Resident's room, waited for a second nurse to arrive and transferred the resident from the bed to the floor, significantly delaying the initiation of CPR efforts. Resuscitation attempts were unsuccessful and Resident #193 was pronounced dead at the facility. A partial extended survey was initiated on [DATE] after the deficiencies were identified. The Administrator was informed of the Immediate Jeopardy, was sent a letter by the state agency, and provided with the Immediate Jeopardy templates on [DATE]. On [DATE], the facility submitted, and the Department accepted, a removal plan indicating the immediate action that the facility will take to prevent serious harm from occurring or recurring. On [DATE] it was determined that the Immediate Jeopardy could be removed, and the deficient practice corrected effective [DATE]. 44 CMR: BOARD OF REGISTRATION IN NURSING [DATE] (Effective [DATE]) - corrected 244 CMR - 9 244 CMR 3.00: REGISTERED NURSE AND LICENSED PRACTICAL NURSE: (2) General Criteria for Delegation. Delegation of nursing activities to unlicensed persons shall comply with the following requirements:(c) The nursing activity must be one that a reasonable and prudent nurse would determine to be delegatable within the scope of nursing judgment; would not require the unlicensed person to exercise nursing judgment; and that can be properly and safely performed by the unlicensed person involved without jeopardizing the patient's/client's welfare (5) Nursing Activities That May Not Be Delegated. By way of example, and not in limitation, the following are nursing activities that are not within the scope of sound nursing judgment to delegate: (a) Nursing activities which require nursing assessment and judgment during implementation; (b) Physical, psychological, and social assessment which requires nursing judgment, intervention, referral or follow-up; (c) Formulation of the plan of nursing care and evaluation of the patient's/client's response to the care provided. Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR) and Emergency Response Team, dated ,d+[DATE], indicates the following: Policy: The facility will have an Emergency Response Team (Nurse) available on each shift of every day to immediately respond to all Code Blue (medical emergency) situations prior to the arrival of emergency personnel. Cardiopulmonary Resuscitation (CPR) will be performed on those residents whom are found to be unresponsive, without a Do Not Resuscitate (DNR) order in place and are determined to not be clinically dead. Nursing staff certified CPR providers will perform CPR under those circumstances. Procedure: In the event that a resident is found unresponsive and/or is not breathing a staff member should initiate the following steps: Any staff member that discovers an unresponsive resident will immediately overhead page Code Blue and the location 3 times. This will ensure that all CPR certified personnel respond. A CPR certified staff member will check the resident's status using the CAP protocol: Chest Compressions, Airway, Breathing. If the resident's wishes are to receive CPR, it will commence immediately. If the resident is on a soft surface, log roll him/her onto a CPR board before initiating compressions. Inform Certified Nursing Assistant (CNA) scheduled on unit to call Code Blue. Resident #193 was admitted in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #193's Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST), dated [DATE], indicated should Resident #193 need CPR administered, Resident #193 wanted resuscitation to be attempted. Review of the current physician's orders indicated Resident #193 was a Full Code. During an interview on [DATE] at 2:45 P.M., Resident #67 said he/she was the roommate of Resident #193. Resident #67 said he/she found Resident #193 unresponsive in bed at around 6:00 A.M. on [DATE]. Resident #67 said he/she went to the hallway to find CNA #1 and Nurse #1 who were standing right outside of the room. Resident #67 said that Nurse #1 came in the room to assess Resident #193 and left the room to call a Code Blue. Resident #67 said that Nurse #1 came back to the room and did not initiate CPR until about 15 minutes after Resident #67 had notified CNA #1 and Nurse #1 of Resident #193's status. Review of Resident #193's Nursing progress note, dated [DATE], indicated that at 7:15 A.M. an RN pronouncement of death was completed after the 911 team left the facility. The medical record failed to indicate any further documentation of the events that took place including what time and how staff were alerted Resident #193 was unresponsive, which staff began CPR and at what time, and when emergency services were contacted. A. The facility failed to delegate the announcement of Code Blue to CNA #1. During an interview on [DATE] at 7:19 A.M., CNA #1 said that she was first alerted that something was wrong with Resident #193 when his/her roommate, Resident #67, had said there was an emergency. CNA #1 said she went into the room and saw Resident #193 in bed, unresponsive, laying on his/her back and that he/she didn't look normal. CNA #1 said she went to get Nurse #1 who came into the room, assessed Resident #193, and left to call a code blue. CNA #1 said that CPR was not started until Nurse #2 arrived and after Resident #193 was transferred to the floor. CNA #1 said that she is not certified to perform CPR and that is the nurse's job. Nurse #1 was interviewed on [DATE] at 4:14 P.M. and [DATE] at 12:54 P.M., about this incident. Nurse #1 said on [DATE] between 6:00 A.M. and 6:30 A.M., Resident #67 told him Resident #193 was not feeling well. Nurse #1 said CNA #1 went into Resident #193's room with him and Resident #193's head was in the bed and his/her legs were dangling off the side of the bed. Nurse #1 said that Resident #193 did not have a pulse and was not breathing. he said he was familiar with Resident #193, knew Resident #193 was a full code and that Resident #193's code status was on his report sheet. Nurse #1 told CNA #1 to stay in the room while he went to call a Code Blue because Nurse #1 thought it would be faster than having CNA #1 make the call. Nurse #1 said that it is the expectation that a nurse initiates CPR and not a CNA. Nurse #1 said that he did not know if CNA #1 was CPR certified. B. The facility failed to initiate CPR immediately according to Resident #193's wishes. During an interview on [DATE] at 4:14 P.M., Nurse #1 said he returned to Resident #193's room with the code cart, which included a backboard, (a device used to assist providing CPR on a soft surface). Nurse #1 said he waited for Nurse #2 to arrive and then he and Nurse #2 transferred Resident #193 to the ground before initiating CPR. Nurse #1 could not say why the backboard was not used instead of transferring Resident #193 to the ground. When asked why he did not perform CPR alone, Nurse #1 said that one cannot perform CPR alone. Nurse #1 said that this was not his first time he has had to do CPR. Nurse #1 acknowledged that he left Resident #193, who was a full code, not breathing and had no pulse with a CNA, rather than initiating CPR immediately and further acknowledged that he also waited for additional staff to arrive before initiating CPR on the Resident. C. The facility failed to follow the facility policy regarding use of a back board and transferred the Resident from the bed to the floor before initiating Cardiopulmonary Resuscitation (CPR). During an interview on [DATE] at 4:14 P.M., Nurse #1 said he returned to Resident #193's room with the code cart, which included a backboard, (a device used to assist providing CPR on a soft surface). Nurse #1 said he waited for Nurse #2 to arrive and then he and Nurse #2 transferred Resident #193 to the ground before initiating CPR. Nurse #1 could not say why the backboard was not used instead of transferring Resident #193 to the ground. During an interview on [DATE] at 3:30 P.M., Nurse #2 said that when he arrived to Resident #193's room after the Code Blue was paged, Resident #193 was on the bed with Nurse #1 in the room. Nurse #2 said that he and Nurse #1 then transferred Resident #193 to the ground and began CPR until paramedics arrived. Nurse #2 could not say why they did not utilize the backboard on the code cart. During an interview on [DATE] at 2:24 P.M., Nurse #3 said that she heard the Code Blue over the speaker around 6:00 A.M. or a little after. Nurse #3 said that the code cart was in the room upon arrival and Resident #193 was in the bed and CPR had not been started. Nurse #3 said that she went to call 911 as Nurse #1 and Nurse #2 were transferring Resident #193 to the floor. Nurse #3 did not say the staff utilized the backboard available on the code cart. During an interview on [DATE] at 2:08 P.M., the Director of Nursing (DON) said that if a resident is found unresponsive, the staff member should call for help and CPR should be performed immediately. The DON said that the code carts have back boards to be used during CPR but in an emergency, CPR can be initiated on a soft surface. The DON said that she didn't know many details about the incident. The DON said that CPR can be started by one person and that the Nurse should stay with a resident that is unresponsive to begin CPR right away. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] as evidenced by: -On [DATE] the facility provided education to nursing staff related to emergency response, CPR and code blue policies and procedures. -On [DATE] the facility provided education to nursing staff related to delegation of tasks during an emergency. -On [DATE] and [DATE] the facility provided CPR Recertification to all 18 licensed staff members regardless of current CPR training status. -On [DATE], [DATE], [DATE] and [DATE] the facility observed nursing staff competency for CPR. -On [DATE], [DATE] and [DATE] the facility conducted mock code blue drills to determine compliance with training status. See Ftag 678. 2. Resident #7 was admitted in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. According to the MDS, Resident #7 received scheduled pain medication and should have a pain assessment completed. During an interview on [DATE] at 10:30 A.M., Resident #7 said that he/she has not been getting his/her [MEDICATION(S)] patch and that he/she has not received it for 5 days. Review of the physician orders for [DATE] indicated that Resident #7 had a scheduled [MEDICATION(S)] patch for 25 micrograms per hour every 72 hours. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11:46 A.M., Nurse #7 said that she called the pharmacy on Monday when she realized that she was out of [MEDICATION(S)] patches. When Nurse #7 came in two days later, she believed that the [MEDICATION(S)] patches had been delivered from the pharmacy and they hadn't so she had to follow up with the pharmacy again. Nurse #7 said that she passed on the information to the following shift on Monday and was not sure why it was not followed up on. Nurse #7 said that typically, when there are about ,d+[DATE] of any medication, Nurse #7 will let the Nurse Practitioner know. Nurse #7 said that the pharmacy has not been delivering medication on time. During an interview on [DATE] at 7:46 A.M., Nurse Practitioner #1 said that she cannot remember if she was notified about the [MEDICATION(S)] patch, but that she should have been notified. 3.) The facility failed to ensure that professional standards of care were followed during the administration of blood pressure medications with physician ordered parameters. On [DATE] at 8:39 A.M., the surveyor observed Nurse #6 administer medications to Resident #51. Included in the administration was [MEDICATION(S)] (to treat high blood pressure) 10 milligrams. Blood pressure was not observed to be taken for Resident #51prior to the administration of the medication. Review of the [DATE] physician orders for Resident #51 indicated that [MEDICATION(S)] is to be held if systolic blood pressure is less than 100. During an interview on [DATE] at 8:45 A.M., Nurse #6 said that she said she was not aware of the parameters and had not obtained a blood pressure. After review of the order, she said she should have obtained a blood pressure before administering the [MEDICATION(S)]. 4. For Resident #132 the facility failed to ensure nursing standards of practice were adhered to for the administration of medication. Review of the facility's policy entitled, subject Administration of Medications-General. Policy: Medication are administered in a safe and timely manner, and as prescribed. Under procedure, the policy included: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care team has determined that they have the decision-making capacity to do so safely. Resident #132 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #132's Minimum Data Set, dated dated dated [DATE] indicated the Resident scored 10 out of 15 on the brief interview of mental status assessment, which indicated a moderate cognitive impairment. During an interview on [DATE] at 8:03 A.M., in Resident #132's room, he/she was observed eating his/her breakfast with a medication cup with multiple pills inside, placed on the breakfast tray. No nursing staff was in the room or nearby. Resident #132 said the nurse left the medication with him/her. Resident #132 said there were five pills in the cup including an anti-[CONDITION(S)] medication, and diabetic medication. During an interview on [DATE] at 8:15 A.M., Nurse #8 said Resident #132 knows his/her medications and that she poured the meds and had literally just left them for him/her. Nurse #8 said it is expected that nursing staff wait and have residents take medications under the supervision of the nurse. On [DATE] at 8:03 A.M., review of Resident #132's medical record indicated a document titled, Self Administration of Medications Informed Consent and Assessment, dated and signed by Resident #132 on [DATE], and indicated Resident #132 checked off he/she wishes to have the medication nurse to administer my medications.

Based on interview and record review, the facility failed to manage pain for 1 Resident (#7) out of a total sample of 38 residents. Findings include: Resident #7 was admitted in April, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. According to the MDS, Resident #7 received scheduled pain medication and should have a pain assessment completed. During an interview on 6/23/22 at 10:30 A.M., Resident #7 said that he/she has not been getting his/her [MEDICATION(S)] patch and that he/she has not received it for 5 days because the pharmacy has not delivered it. Resident #7 said that he/she has a 6 or 7 out of 10 pain and has been in pain for the last few day in his/her hands and knees. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no indication in the clinical record that the Nurse Practitioner was notified or an alternative medication was given to Resident #7 to address his/her pain. During an interview on 6/23/22 at 11:46 A.M., Nurse #7 said that she called the pharmacy on Monday, 6/20/22, when she realized that she ran out of [MEDICATION(S)] patches. Nurse #7 said that when she came in two days later, she realized that the [MEDICATION(S)] patches had not been delivered by the pharmacy so she had to follow up with the pharmacy again. Nurse #7 said that she had passed on the information to the following shift on Monday and was not sure why it was not followed up on. Nurse #7 said that, typically, when there are about 8-10 of any medication left, Nurse #7 will let the Nurse Practitioner know. Nurse #7 said that the pharmacy has not been delivering medication on time. During an interview on 7/5/22 at 7:46 A.M., Nurse Practitioner #1 said that she cannot remember if she was notified about Resident #7's [MEDICATION(S)] patch, but that she should have been notified.

Based on record review, interview, policy review and observation, the facility 1.) Failed to ensure wound care treatment was provided, as ordered, resulting in a hospitalization for infection for 1 Resident (#92); 2.) (a) Failed to ensure Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) Failed to ensure that 1 Resident (#108) was not given medication that he/she had a documented allergy to; 4.) Failed to identify a new area of skin breakdown for 1 Resident (#84); and 5.) Failed to implement the resident's plan of care for blood glucose monitoring and insulin administration for 2 Residents (#122 and #298) out of a total sample of 41 residents. Findings include: 1.) For Resident #92, the facility failed to ensure wound care treatment was provided, as ordered by the physician, resulting in a hospitalization for an infection. Resident #92 was admitted to the facility in February 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident scored 8 out of 15 on the Brief Interview for Mental Status indicating moderate cognitive impairment. Additional review of Resident #92's MDS indicated the resident required extensive assistance from staff for mobility and self-care tasks. During an interview on 4/21/21 at 10:14 A.M., Resident #92 said he/she did not have any wounds on his/her foot/leg when first admitted to the facility. Resident #92 reported that since admitted , he/she has developed wounds to his/her left foot and leg and that these wounds have required him/her to be hospitalized . Resident #92 said that he/she has treatment to these wounds and that his/her wound care is not always done by the nursing staff. Review of Resident #92's medical record indicated the following interdisciplinary care plans: -Skin Breakdown, Potential care plan, dated 2/6/20, with an intervention to perform skin checks weekly and as needed (PRN). -Skin Breakdown, Actual care plan, dated 2/25/21, with interventions to perform treatment, as ordered, to assess wound areas with treatment changes and document a comprehensive assessment a minimum of weekly and to notify medical doctor (MD) of lack of progress in healing or deterioration. Further review of Resident #92's medical record indicated the following: -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Wash left leg wound with Vashe (a solution to cleanse wounds), pat dry, apply calcium alginate (an absorbent dressing), abdominal pad, wrap with Kerlix bandage daily *Wash right shin wound with Vashe, pat dry, apply calcium alginate, abdominal pad, wrap with Kerlix bandage daily *Wash left dorsal medial foot with Vashe, pat dry, apply Santyl (a topical treatment used for wound debridement and healing), calcium alginate, cover with sterile dry protective dressing and Kerlix daily *Wash left dorsal 5th toe with Vashe, pat dry, apply Santyl, calcium alginate, abdominal pad and sterile dressing, wrap with Kerlix -A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #92's Wound Evaluation & Management Summary, dated 3/30/21, indicated: -Venous wound of the left leg wound progress: no change -Venous wound of left dorsal medial foot wound progress: improved -Venous wound of the left dorsal fifth tow wound progress: improved Review of Resident #92's April 2021 Daily Wound Condition documentation indicated: -4/1/21(2 days after wound evaluation note): Left leg wound surrounding tissue was inflamed and an odor to the wound was present; left dorsal medial foot surrounding tissue was inflamed, with the wound edges being macerated (oversaturated skin from prolonged exposure to moisture) and an odor to the wound was present; left dorsal 5th toe surrounding tissue was inflamed and an odor to the wound was present. -4/2/21: Left leg wound surrounding tissue was inflamed and an odor to the wound was present; left dorsal medial foot surrounding tissue was inflamed, with the wound edges being macerated (oversaturated skin from prolonged exposure to moisture) and an odor to the wound was present; left dorsal 5th toe surrounding tissue was inflamed and an odor to the wound was present. Review of Resident #92's Treatment Administration Record (TAR) from April 2021 failed to indicate that: - Daily wound treatments were provided as ordered on 4/3/21 or 4/4/21. - Weekly skin checks were completed as ordered on 4/2/21 and 4/9/21. Resident #92's medical record also failed to indicate any documentation that the Physician or Nurse Practitioner was notified of the inflammation of Resident #92's skin surrounding his/her wounds or of the presence of odor of the wounds, a change in the condition of the wound first identified on 4/1/21. Resident #92's medical record indicated the resident had a scheduled appointment with Vascular Surgery on 4/5/21. Review of Resident #92's Vascular Surgery consultant note, dated 4/5/21, indicated that Resident #92 reported to the consulting vascular surgeon that his/her wounds are not being cared for and that his/her wounds and lower extremity swelling are getting worse. The Vascular Surgery note indicated that there are brawny skin changes bilaterally with [CONDITION(S)] (swelling) to the knees. There are multiple wounds on the left foot with foul smelling drainage and fibrinous exudate in the base. The vascular surgical consultation note further indicated that Resident #92 presented to the clinic with foul smelling drainage from his/her foot wounds in the setting of progression of his/her lower extremity [CONDITION(S)], and decrease in his/her strength and mobility. Resident #92 will be referred to the Emergency Department for workup including a full set of labs, arterial and venous noninvasive imaging to rule out [CONDITION(S)] (an infection of the bone). The note further indicated that Resident #92 was in need of better wound care and will be admitted to the hospital to achieve this. Review of Resident #92's hospital paperwork indicated the resident was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's medical record, dated 4/9/21, indicated the following new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - For left foot wounds: wash with Vashe (a solution to cleanse wounds), pat dry, apply Santyl (a topical treatment used for wound healing), cover with calcium alginate (an absorbent dressing), abdominal pad, wrap with Kerlix bandage, change twice daily and as needed (PRN). - For left shin wound area: wash with Vashe solution, pat dry, apply calcium alginate, followed by abdominal pad and Kerlix bandage, change twice daily and as needed (PRN). Further review of Resident #92's TAR from April 2021 failed to indicate wound care was provided, as ordered, on five dates: 4/17/21, 4/18/21, 4/19/21, 4/20/21, and 4/21/21. During an interview on 4/27/21 at 12:30 P.M., the Director of Nursing (DON) said that treatments completed should be documented. The DON further said that if a treatment is not documented then it wasn't done. The DON also said Resident #92 was admitted to the hospital from the wound clinic appointment secondary to the status of his/her wounds. 2.) (a) For Resident #88, the facility failed to ensure daily weights were obtained as ordered, resulting in the need for a medical intervention. Resident #88 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #88's Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident is cognitively intact and scored 15 out of 15 on the Brief Interview for Mental Status. Review of Resident #88's medical record indicated the following physician order, dated 4/8/21: - Daily weights standing at 6 A.M. Notify MD/Nurse Practitioner of weight gain of more than 2 pounds from previous day. Review of Resident #88's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #88's medical record failed to indicate daily weights were obtained past 4/9/21. Additional review of Resident #88's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Start [MEDICATION(S)] (a diuretic medication used to treat fluid retention) 2.5 milligrams PO (oral) x 1 increased right leg swelling/ fluid overload. During an interview on 4/23/21 at 7:24 A.M., Nurse (RN) #3 said Resident #88 has orders for daily weights. RN #3 reviewed Resident #88's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 was unable to say if the Nurse Practitioner/Physician had ever been notified of the weights not being done. During an interview on 4/23/21 07:28 A.M., RN #4 said she thinks Resident #88 might weigh himself/herself independently. RN #4 was unable to provide any documentation of weights and said that no one had ever reviewed if Resident #88 had weighed himself/herself. RN #4 said there was no way to determine if there had been any change in Resident #88's weight since the order for daily weights had been written. During an interview on 4/27/21 at 9:51 A.M., Nurse Practitioner (NP) #1 said daily weights are important for people with Congestive Heart Failure to help keep an eye on symptoms. During an interview on 4/27/21 at 1:59 P.M., NP#1 said Resident #88's weight fluctuates and daily weights are important. NP#1 said Resident #88 had some leg swelling and symptoms of fluid overload a few weeks ago and she ordered a one-time medication to try to help with the symptoms. 2.) (b) For Resident #88, the facility failed to monitor and re-assess skin by not completing skin checks, as ordered by the physician. Review of facility policy titled 'Diabetic Foot Care', effective date 2/1/17, indicated that residents with diabetes are at high risk for nerve and vascular damage that can cause loss of sensation, poor circulation and poor healing of foot ulcers. Diabetic residents should receive foot care daily. Review of facility policy titled 'Skin Assessments', effective date 2/5/19, indicated that weekly, on the assigned days and shift, the unit manager is to notify the Certified Nursing Assistant assigned to the resident that a skin check will be completed at the time of the shower/ bath. Completion of the skin check is documented by the nurse initialing the appropriate space on the Treatment Administration Record. Resident #88 was admitted to the facility in September 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #88's Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident is cognitively intact and scored 15 out of 15 on the Brief Interview for Mental Status. Review of Resident #88's April 2021 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Weekly skin checks on Tuesdays 7-3 -Diabetic Foot Care at bedtime -[MEDICATION(S)] Cream- apply to bilateral feet twice daily until resolved Further review of Resident #88's medical record failed to indicate that any weekly skin checks had been performed for the month of April; diabetic foot care was not documented as performed, and as ordered, on three dates: 4/5/21, 4/8/21, and 4/13/21. [MEDICATION(S)] cream to bilateral feet was not applied, as ordered, on multiple dates including: 4/6/21 to 4/9/21, 4/13/21, and 4/17/21 to 4/20/21. During an interview on 4/22/21 at 1:16 P.M., Resident #88 said he/she is diabetic and is not getting foot care. On 4/22/21 at 2:43 P.M., Nurse (RN) #1 observed Resident # 88's feet with the surveyor. Resident #88's toenails were long, thick and discolored and his/her bilateral feet had thick calluses and reddened, dry skin. RN #1 acknowledged that Resident #88 had calluses and long, thick toenails. RN #1 said foot care is important for diabetic residents. During an interview on 4/22/21 at 3:14 P.M., RN #2 said that skin checks are documented in the Treatment Administration Record. She acknowledged that Resident #88 had not had skin checks completed for the month of April 2021. During an interview on 4/22/21 at 3:44 P.M., the Director of Nursing said that weekly skin checks should have been completed for Resident #88, as required. 3.) For Resident #108, the facility failed to ensure that he/she was not given a medication that he/she had a documented allergy to. Review of facility policy titled 'Medication Administration: General', revised 2/10/18 indicated that accepted standards of practice will be followed. Resident #108 was admitted to the facility in October 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #108's Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively intact and scored 15 out of 15 on the Brief Interview for Mental Status Exam. Review of Resident #108's medical record indicated a documented allergy to [MEDICATION(S)] (Nonsteroidal anti-[CONDITION(S)] drug used to treat fever and pain). This allergy was documented on Resident #108's Physician Orders, and Nurse Practitioner/ MD progress notes. Additional review of Resident #108's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #108's medical record failed to indicate any documentation that Resident #108 was not allergic to [MEDICATION(S)] or any order to override Resident #108's [MEDICATION(S)] allergy. Review of Resident #108's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - January: 1/20/21, 1/21/21, 1/22/21, 1/24/21, 1/25/21, 1/26/21, 1/27/21, 1/28/21, 1/29/21, 1/31/21. - February: 2/3/21, 2/5/21, 2/6/21, 2/7/21, 2/8/21, 2/9/21, 2/10/21, 2/11/21, 2/13/21, 2/16/21, 2/17/21, 2/18/21, 2/19/21, 2/20/21, 2/21/21, 2/22/21, 2/24/21, 2/25/21, 2/27/21, 2/28/21. -March: 3/3/21, 3/6/21, 3/7/21, 3/8/21, 3/10/21, 3/13/21, 3/14/21, 3/15/21, 3/19/21, 3/20/21, 3/21/21, 3/22/21, 3/23/21, 3/24/21, 3/25/21, 3/26/21, 3/27/21, 3/30/21, 3/31. -April: 4/1/21, 4/3/21, 4/5/21, 4/9/21, 4/11/21, 4/12/21, 4/13/21, 4/14/21, 4/15/21, 4/16/21, 4/17/21, 4/18/21, 4/21/21. Further review of Resident #108's medical record failed to indicate any documentation that nursing had consulted with the Physician/ Nurse Practitioner about the documented allergy to report the discrepancy between the listed allergy and the medication ordered. During an interview on 4/23/21 at 12:02 P.M., the Director of Nursing (DON) said that if a resident has a listed allergy to a medication then they should not be given the medication. During an interview on 4/23/21 at 1:04 P.M., Nurse Practitioner (NP) #1 said that she was the one who wrote the order for Resident #108's [MEDICATION(S)]. NP #1 said she asked Resident #108 about the listed allergy and was told the resident was not allergic. NP #1 said that she never documented that Resident #108 was not allergic to [MEDICATION(S)] and that she should have. NP #1 acknowledged her clinical notes and the order sheets indicated Resident #108 had an [MEDICATION(S)] allergy and was prescribed [MEDICATION(S)]. During an interview on 4/23/21 at 1:09 P.M., the DON said the expectation is that the nurse who is administering the medications should look for potential allergies and notify the Physician or Nurse Practitioner if they identify an allergy to clarify if the allergy is correct. The DON acknowledged this had not been done and that the resident received multiple doses of the medication. During a telephone interview on 4/29/21 at 10:50 A.M., Pharmacist #1 said that part of a resident's medication rights include ensuring a resident does not receive a medication that he/she is allergic to. Pharmacist #1 said that the nurse administering medication is responsible for double checking for allergies prior to administration and notifying the physician of any potential medication issues. 4.) For Resident #84, the facility failed to identify a new area of skin breakdown. Review of Facility Policy Titled Skin Integrity Management- Wound Prevention, dated 1/1/16, indicated it is the policy to identify residents that are at high risk for alterations in skin integrity and implement interventions to prevent skin breakdown. Skin checks are completed weekly by a licensed nurse and findings are noted on the skin check assessment sheet. Any resident that is being treated by an external wound center is to have weekly wound assessments performed by the Unit Manager. Review of Facility Policy Titled Diabetic Foot Care, dated 2/1/17, indicated diabetic foot care is performed and documented every evening. Resident #84 was admitted to the facility in February 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #84's Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact and scored 14 out of 15 on the Brief interview for Mental Status (BIMS) score. The MDS for Resident #84 also indicated the resident required extensive assistance from staff for Activities of Daily Living (ADL). Further review of Resident #84's MDS indicated the resident was at risk for developing pressure ulcers. Review of Resident #84's January 2021 Treatment Administration Record (TAR) indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #84's medical record failed to indicate any documentation of changes in skin integrity or any new areas of concern. Review of Resident #84 medical record indicated a new Physicians order from the Wound Clinic, dated 2/1/21, for the following: -Right heel necrotic (premature death of cells) area: Apply Santyl (topical [MEDICATION(S)] agent) followed by normal saline moistened gauze, dry protective dressing and wrap with kling daily. During an interview on 4/22/2021 at 3:51 P.M., the Director of Nursing (DON) said checking the skin of the feet should be done nightly with diabetic foot care. During interviews throughout the day on 4/27/2021, the DON said any changes to the skin noted during diabetic foot care should be documented on the Treatment Sheet. The DON further said there was no documentation of Resident #84's new skin breakdown to the right heel and was unable to say what happened. The DON was unable to produce documentation with regard to Resident #84's wound of the right heel. 5.) For Resident #122, the facility failed to implement the resident's plan of care for blood glucose monitoring and insulin administration. Resident #122 was admitted to the facility in March 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On the Minimum Data Set (MDS) assessment, dated 3/23/21, Resident #122 scored 13 out of 15 on the Brief Interview for Mental Status, indicating intact cognition. During an interview on 4/26/21 at 8:39 A.M., Resident #122 said during the 7:00 A.M. - 3:00 P.M. shift on 4/25/21, his/her blood sugars were not assessed by the nurse on duty. During that shift, his/her blood sugar had been over 300 (A blood sugar level less than 140 mg/dL is considered normal.) when assessed on the 3:00 P.M. - 11:00 P.M. shift that day. Resident #122 also said he/she has missed doses of insulin. Review of Resident #122's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 3/16/21, for [MEDICATION(S)] (Long acting insulin administered to absorb and lower blood sugar) 110 unit/ml Inject 15 units subcutaneously daily. -An order, dated 3/22/21, for Accu-Checks (a blood test system for determining blood sugar levels) for Fasting Blood Sugars (FSBS) four times daily followed by sliding scale for 7:30 A.M., 11:30 AM., 4:30 P.M., and 8:00 P.M. -An order, dated 3/16/21, for [MEDICATION(S)] (rapid acting insulin administered to absorb and lower blood sugar) subcutaneous injection 100/ml four times daily. -Orders, dated 3/22/21, for [MEDICATION(S)] sliding scale as follows: -FSBS 149-199: no insulin -FSBS 200-249: Give 2 units -FSBS 250-299: Give 3 units -FSBS 300-349: Give 4 units -FSBS 350-399: Give 5 units -FSBS 400-449: Give 6 units FSBS 450 or greater: Call the Physician or Nurse Practitioner. Review of Resident #122's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -4/1/21 at 7:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M. -4/3/21 to 4/8/21 at 11:30 A.M., -4/8/21 at 8:00 P.M., -4/10/21 and 4/11/21 at 4:30 P.M. and 8:00 P.M. -4/13/21 at 7:30 A.M., and 11:30 A.M., -4/16/21 at 8:00 P.M., -4/19/21 at 4:30 P.M. and 8:00 P.M., -4/20/21 at 11:30 A.M., -4/23/21 at 8:00 A.M., -4/25/21 at 7:30 A.M. and 11:30 A.M., Further Review of Resident #122's MAR from April 2021 indicated the following: -The MAR failed to indicate the ordered 15 units of [MEDICATION(S)] were administered on 4/12/21 and 4/21/21. -The MAR failed to indicate the correct doses of [MEDICATION(S)] insulin were administered on the following dates: -4/22/21 at 8:00 P.M., Resident #122's blood sugar level was 279, the MAR failed to indicate Resident #122 received 3 units of [MEDICATION(S)] insulin at 8:00 P.M., as ordered. -4/17/21 at 7:30 A.M., Resident #122's blood sugar level was 238, the MAR failed to indicate Resident #122 received 2 units of [MEDICATION(S)] insulin at 7:30 A.M., as ordered. -4/22/21 at 4:30 P. M., Resident #122's blood sugar level was 383, the MAR failed to indicate Resident #122 received 5 units of [MEDICATION(S)] insulin at 4:30 P.M., as ordered. -4/25/21 at 8:00 P.M., Resident #122's blood sugar level was 215, the MAR failed to indicate Resident #122 received 2 units of [MEDICATION(S)] insulin at 8:00 P.M., as ordered. Review of Resident #122's Diabetic plan of care, dated 3/16/21, indicated the following: -Resident #122 has insulin dependent diabetes mellitus -Assess and record blood glucose levels -Administer insulin The facility failed to provide a policy for monitoring blood glucose levels and administration of insulin. During an interview on 4/26/21 at 8:43 A.M., Nurse #7 said blood sugars should be documented for all scheduled blood sugar checks and anytime insulin is administered, it should be documented. She said insulin ordered on a sliding scale should be administered as ordered, based on the blood sugar level of the resident. During an interview on 4/26/21 at 8:50 A.M., Unit Manager (UM) #2 said all blood sugars should be obtained and documented as ordered, and insulin ordered for sliding scale dosage should be administered per blood sugar level and the dose and time of administration should be documented in the MAR. 6.) For Resident #298, the facility failed to implement the resident's plan of care for blood glucose monitoring and insulin administration. Resident #298 was admitted to the facility in April 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #298's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - For Insulin Detemir (A long acting insulin administered to absorb and lower blood sugar) 100 unit/ml Inject 20 units subcutaneously twice daily. - For Accu-Checks(a blood test system for determining blood sugar levels) for Fasting Blood Sugars (FSBS) four times daily followed by sliding scale for 6:30 A.M., 11:30 AM., 5:00 P.M., and 8:00 P.M. - For NovoLog (A rapid acting insulin administered to absorb and lower blood sugar) subcutaneous injection 100/ml four times daily. Orders dated 4/5/21 for NovoLog sliding scale as follows: -FSBS 150-199: Give 2 units -FSBS 200-249: Give 4 units -FSBS 250-299: Give 6 units -FSBS 300-349: Give 8 units -FSBS 350-399: Give 10 units -FSBS Greater than 400: Call Physician/Nurse Practitioner Orders dated 4/14/21 to administer NovoLog 10 units subcutaneously before meals three times daily with a NovoLog sliding scale as follows: -FSBS 150-199: Give 4 units -FSBS 200-249: Give 6 units -FSBS 250-299: Give 8 units -FSBS 300-349: Give 10 units -FSBS 350-399: Give 12 units -FSBS Greater than 400: Give 14 units then Call Physician/Nurse Practitioner Review of Resident #298's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -4/6/21 at 11:00 A.M., -4/8/21 at 11:00 A.M., -4/14/21 at 6:30 A.M., -4/18/21 at 6:30 A.M., -4/19/21 at 5:00 P.M., -4/23/21 at 8:00 P.M., Further Review of Resident #298's MAR from April 2021 failed to indicate the correct doses of NovoLog insulin were administered on the following dates and times: -4/7/21 at 8:00 P.M., blood sugar level was 380, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 11:00 A.M., as ordered. -4/10/21 at 11:00 A.M., blood sugar level was 247, the MAR failed to indicate Resident #298 received 4 units of NovoLog insulin at 8:00 P.M., as ordered. -4/10/21 at 8:00 P.M., blood sugar level was 400, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 8:00 P.M., as ordered. -4/11/21 at 11:00 A.M., blood sugar level was 202, the MAR failed to indicate Resident #298 received 4 units of NovoLog insulin at 11:00 A.M., as ordered. -4/11/21 at 5:00 P.M., blood sugar level was 230, the MAR failed to indicate Resident #298 received 4 units of NovoLog insulin at 5:00 P.M., as ordered. -4/12/21 at 11:00 A.M., blood sugar level was 275, the MAR failed to indicate Resident #298 received 4 units of NovoLog insulin at 11:00 A.M., as ordered. -4/12/21 at 8:00 P.M., blood sugar level was 370, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 8:00 P.M., as ordered. -4/13/21 at 6:30 A.M., blood sugar level was 294, the MAR failed to indicate Resident #298 received 6 units of NovoLog insulin at 6:30 A.M., as ordered. -4/14/21 at 11:00 A.M., blood sugar level was 497, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 11:00 A.M., as ordered. -4/14/21 at 11:00 A.M., blood sugar level was 398, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 5:00 P.M., as ordered. -4/14/21 at 8:00 P.M., blood sugar level was 270, the MAR failed to indicate Resident #298 received 6 units of NovoLog insulin at 8:00 P.M., as ordered. -4/15/21 at 6:30 A.M., blood sugar level was 399, the MAR failed to indicate Resident #298 received 4 units of NovoLog insulin at 6:30 A.M., as ordered. -4/15/21 at 8:00 P.M., blood sugar level was 300, the MAR failed to indicate Resident #298 received 8 units of NovoLog insulin at 8:00 P.M., as ordered. -4/16/21 at 5:00 P.M., blood sugar level was 350, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 5:00 P.M., as ordered. -4/16/21 at 8:00 P.M., blood sugar level was 250, the MAR failed to indicate Resident #298 received 6 units of NovoLog insulin at 8:00 P.M., as ordered. -4/17/21 at 6:30 A.M., blood sugar level was 358, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 8:00 P.M., as ordered. -4/17/21 at 5:00 P.M., blood sugar level was 311, the MAR failed to indicate Resident #298 received 10 units of NovoLog insulin at 5:00 P.M., as ordered. -4/18/21 at 5:00 P.M., blood sugar level was 492, the MAR failed to indicate Resident #298 received 14 units of NovoLog insulin at 5:00 P.M., as ordered, nor did the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -4/20/21 at 8:00 P.M., blood sugar level was 384, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 8:00 P.M., as ordered. -4/21/21 at 5:00 P.M., blood sugar level was 351, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 5:00 P.M., as ordered. -4/22/21 at 11:00 A.M., blood sugar level was 333, the MAR failed to indicate Resident #298 received 11 units of NovoLog insulin at 11:00 A.M., as ordered. -4/24/21 at 5:00 P.M., blood sugar level was 385, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 5:00 P.M., as ordered. -4/25/21 at 8:00 P.M., blood sugar level was 380, the MAR failed to indicate Resident #298 received 12 units of NovoLog insulin at 8:00 P.M., as ordered. Review of Resident #298's Diabetic plan of care, dated 4/5/21, indicated the following: -Resident #298 had insulin dependent diabetes -Administer insulin -Assess and record blood sugars 4 times daily. The facility failed to provide a policy for monitoring blood glucose levels and administration of insulin. During an interview on 4/26/21 at 8:43 A.M., Nurse #7 said blood sugars should be documented for all scheduled blood sugar checks, and anytime insulin is administered it should be documented. She said insulin ordered to be administered on a sliding scale should be administered as ordered based on the blood sugar level of the resident. During an interview on 4/26/21 at 8:50 A.M., Unit Manager (UM) #2 said all blood sugars should be obtained and documented as ordered, and insulin ordered for sliding scale dosage should be administered per blood sugar level and the dose and time of administration should be documented in the MAR.

Based on record review and interview the facility staff failed to obtain a treatment order for a newly developed wound in a timely manner for 1 Resident (#95) out of a total sample of 21 Residents. Findings include: Resident #95 was admitted to the Facility in 11/2018 with [DIAGNOSES REDACTED]. Review of the discharge assessment minimum data set ((MDS) dated [DATE] indicated the Resident was dependent on staff for most of his/her activities of daily living. Review of Resident #95's medical record indicated the Resident was readmitted to the facility on [DATE] after an acute hospitalization for Urosepsis (infection beginning in the urinary system that spreads into the bloodstream). Further review of Resident #95's medical record indicated that the Resident's skin was intact other that a previously identified sacral wound. Review of Resident #95's weekly skin assessment, dated 4/8/19, did not indicate a wound was present on the left lower extremity. Review of Resident #95's nursing progress notes indicated on 4/11/19, a new wound was identified on the Resident's left lateral ankle. The note from 4/11/19 indicated that the physician or nurse practitioner (NP) was notified of the change in condition with a new order pending. There was no description of the wound. Review of Resident #95's nursing progress notes from 4/12/19 and 4/13/19 failed to indicate there was any follow up to obtain an order for [REDACTED]. - 11:00 P.M. shift) indicated an open area was noted to the left lower extremity (LLE) and NP was notified, three days after initial discovery of the new wound despite the licensed nurse's documentation on 4/11/19 that indicated an order was pending with no follow up to obtain or implement treatment orders for the new wound. Review of Physician/NP progress notes, Resident #95's physician orders, and Resident #95's treatment administration record (TAR) from 4/2019 failed to indicate an order for [REDACTED]. Further review of Resident #95's physician orders [REDACTED]. During an interview on 5/23/19 at 1:00 P.M., Nurse Practitioner #1 said she could not recall the specific date she was notified about the wound, but remembered being called on an offshift and giving an order for [REDACTED].>Review of Resident #95's wound physician consult dated 4/16/19 indicated the Resident had an arterial wound of the left medial ankle measuring 10 centimeters (cm) by 10 cm with unmeasurable depth secondary to eschar (necrotic tissue) covering the wound. The consult report also indicated the wound had moderate purulent (filled with pus) exudate (drainage) with odor with the objective of treatment to control infection. Further review of the consult report indicated recommendations for treatment to apply [MEDICATION NAME] daily to the wound and cover with a secondary dressing. Further review of Resident #95's medical record indicated the Resident was transferred to an acute care hospital on [DATE] secondary to lethargy. Review of Resident #95's hospital reports from 4/2019 indicated a necrotizing (a serious bacterial infection that destroys tissue under the skin) infection to the wound on his/her left lower extremity. The hospital recommended debridement of the wound or amputation. The responsible person declined those interventions and Resident #95 returned to the facility for hospice treatment.

Based on record review, and staff interview, the facility failed to develop a comprehensive care plan for 1 Resident (#18) in a total sample of 24 sampled Residents. Findings include: On 6/8/16, review of the Resident's medical record indicated that the facility failed to ensure that there was a comprehensive plan of care addressing the Resident's pacemaker including documentation of rate setting parameters, (upper and lower), and interventions for monitoring the function of the device. Resident #18 was admitted to the facility in August, 2008 with [DIAGNOSES REDACTED]. The facility did not have a Pacemaker Policy or Procedure. Craven & Hirnle's Nursing Procedures (2012) identifies documentation for a pacemaker to include: The type of pacemaker used, The serial number, The manufacturer's name, The pacemaker rate settings (upper and lower parameters)' The date of implementation. and The Cardiologist's name. On 6/8/16, review of Resident #18's medical record indicated no evidence of any documentation related to the pacemaker parameters, monitoring needs or orders for pacemaker checks. On 6/8/16 at 10:30 A.M., during interview Unit Manager #2 she confirmed with the Surveyor that no comprehensive care plan addressing the Resident's pacemaker including interventions for identifying rate setting and monitoring of the function of the device.

Based on record reviews, interviews and observations, the facility failed to provide a comprehensive effective behavioral health program to treat and manage residents' substance abuse to prevent relapse for 2, (#8 and #23), of 24 sampled residents. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's admission paperwork from the hospital to the facility on [DATE] indicated he/she had a known history of alcohol, (almost half gallon of alcohol daily), cocaine and heroin use. Review of Resident #8's clinical record on 6/8/16 indicated a physician's orders [REDACTED]. Although the resident was admitted in October with a known history of substance abuse, review of Resident #8's Drug and [MEDICAL CONDITION] Care Plan indicated that a standardized care plan was initiated 2/25/16 which read: Resident/Customer shall follow Center policies related to alcohol and/or drugs. Upon request the policy given to surveyors was dated 5/1/16 and when requested a copy of the facility's drug and alcohol policy prior to 5/1/16 was not available during the survey. On 5/2/16 the Resident's care plan was updated with the following statement: Continuously attempts to manipulate nursing to document incorrect times 'as needed' narcotics are given in order to receive extra doses. On 5/16/16 an incident occurred in which it was found that Resident #8 was hoarding his prescribed [MEDICATION NAME]. The record and related surveyor interviews indicated the following: a.) Review of the facility's incident dated 5/16/16 and Nurse #1's progress note indicated that when Nurse #1 entered the room the resident was observed with a white powered substance in his/her hand. A room search was done in Resident #8's room and five 10mg tablets of [MEDICATION NAME] were found hidden in Resident #8's prosthetic leg. The report indicated that Resident #8 said he/she was saving the medications for when he/she had pain. These documents also indicated that a gradual dose reduction of the resident's [MEDICATION NAME] was to be done due to non-compliance and that the DON and Nurse Practitioner (NP) were notified, and the NP ordered the room searched and to check Resident #8's mouth twice after each med pass. b.) The record indicated that teaching was done with the resident on 5/16/16 to include non-pharmacological options for pain and the DON held a meeting with the resident, and that a 30 day notice of discharge was to be given to the resident. As of 6/8/16, the discharge notice was not given. c.) Surveyor #2 interviewed Resident #8 on 6/8/16 at 12:55 P.M: Resident #8 said he/she recalled their room being searched on 5/16/16 and that he/she hid the tablets of [MEDICATION NAME] in his/her prosthetic leg for when he/she had pain. Further interviews with the Administrator, DON and nurses regarding the treatment and services provided Resident #8 revealed the lack of treatment services to address the resident's substance abuse history prior to the incident; and, while monitoring services were implemented after the incident there remained an incomplete behavioral health program in place. During interviews on 6/8/16 with the Administrator, she stated further interventions put in place for Resident #8 after the [MEDICATION NAME] tablets were found in his/her room included: a.) Resident #8's Drug and Alcohol care plan was updated for nursing staff to perform oral checks; remind resident to participate in his/her exercise program and to seek support from the Administrator; the resident contracted with the Administrator and the Ombudsman in regards to substance use i.e., for Resident #8 to contact Administrator or Ombudsman if/when feeling the urge to use; and, that the Activities Director was actively involved in supporting the resident. (The Ombudsman during an interview on 6/10/16 said he would not have moved forward with a verbal contract with Resident #8.) b.) Surveyor #2 interviewed Nurse #1 at 1:05 P.M. on 6/8/16 and Unit Manager #2 at 1:10 P.M., on 6/18/16 who indicated no changes to the Resident's care plan or education was provided to staff in regards to Resident #8's underlying substance abuse history. c.) In addition, on 6/8/16 the Administrator said the facility utilizes a contracted psychiatric service to provide support to residents with a history of substance abuse and mental illness. A review of Resident #8's record indicated that the initial psychiatric assessment dated [DATE] noted the resident has a history of opiate and [MEDICAL CONDITION] and a treatment goal to maintain sobriety; however, while the record indicated the resident received multiple visits from the psychiatric services provider from 10/15/15 through 5/26/16, including the day of the incident when the resident was found with the [MEDICATION NAME], there was no documentation in any of the contracted psychiatric service notes to indicate that support, interventions or discussions regarding Resident #8's polysubstance abuse was reviewed with Resident #8. d.) During interviews on 6/7/16 and 6/8/16 with the Activities Coordinator, she said that she provides 1:1 visits to Resident #8 almost daily, (when able), and that Resident #8 attends the facility's Alcoholics Anonymous, (AA) meetings regularly. The Activities Coordinator said she has experience as a substance abuse counselor but is not a certified counselor and that this is not part of her job description at the facility; but rather, she volunteers these services. The facility failed to provide an effective treatment program and appropriate supervision for Resident #8 to address his/her substance abuse. 2. For Resident #23 the facility failed to implement an individualized treatment program for his/her substance abuse needs and provide appropriate supervision and prevent reoccurrence of substance abuse. Resident #23 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Review of the MDS, (Minimum Date Set), dated 2/27/16 indicated that he/she had a Brief Interview of Mental Status, (BIMS), score of 15/15, which reflects that he/she was cognitively intact. The MDS indicated that Resident #23 was independent with ambulation, and required supervision/set up for dressing and bathing. Review of the clinical record on 6/6/16 at 12:30PM., indicated that Resident #23 had care plans in place for the following problems/risks; Activities, Behavioral symptoms, Smoking/supervised, Activities of daily living/supervised, Diabetes, Potential for falls, Advanced Directives, Potential for skin breakdown, [MEDICAL CONDITION] medication use, and Nutritional status. The clinical record failed to have a care plan for known substance abuse. On 6/7/16 at 10:00 A.M. the DON gave Surveyor #1 a document labeled, Interdisciplinary Care Plan: Alcohol/Drug Abuse, for Resident #23. She said it was found in the administator's office. Review of the care plan document indicated preprinted approaches that included; Administer meds as ordered, Discourage visitors from bringing alcohol to resident, listen to resident with sympathy, do not deny the problem, observe after LOA ( leave of absence) for alcohol/drug use, observe for signs/symptoms of detox, and a hand written entry dated 4/14/16; re-educated on smoking policy, drug use and interactions, safety, and encouraged to go to AA ( alcoholic anonymous) meetings. The care plan failed to have individualized approaches to address Resident #23's specific needs related to his/her substance abuse. Surveyor #1 and Surveyor #2 interviewed the Director of Nursing, DON, and Administrator on 6/8/16 and requested a copy of the Facility drug and alcohol policy. The policy given to surveyors was dated 5/1/16. The administrator said the 5/1/16 policy was a revision, although this was not indicated on the policy. Surveyors requested a copy of the Facility's drug and alcohol policy prior to 5/1/16. No copy was given. Review of the clinical record on 6/6/16 indicated that the contracted psychiatric services provided counseling to Resident #23. Review of the progress notes from the contracted counselor on visits made 3/16/16, 3/21/16, and 3/28/16, failed to indicate that discussion or support around polysubstance abuse was addressed. Review of a progress note from the contracted psychiatric services dated 4/4/16 indicated that Resident #23 refused to be seen on that day. The clinical record failed to have any further progress notes by the contracted psychiatric services to address the Resident's known substance abuse or any further visits after 3 subsequent incidents of being suspected or positive for illicit drugs. Review of the clinical record on 6/6/16, indicated 3 occurrences of suspected or actual substance abuse for Resident #23. a. Review of a nurses note dated 4/14/16 indicated the following: at 2 P.M., pt (patient) observed to have tremors to upper extremities, slurred speech, decrease in balance, was slow to respond when questions were asked. Pt. admitted to smoking synthetic marijuana in the bathroom. Vital signs: BP 111/74, prior temp 98.2, FSBS (finger stick blood sugar) 216, no signs of hypo/[MEDICAL CONDITION] noted; Notified NP (nurse practioner) of pts condition, NP gave order to send pt to ER (emergency room ) for further evaluation. Review of a document on 6/6/16, from the ER dated 4/14/16 indicated that Resident #23's drug specimen inquiry, (or toxicology screen), report was positive for cocaine and THC, (the active ingredient in marijuana that makes you feel high). During interview with Unit Manager #3 on 6/7/16 at 1:30 P.M., she was asked about Resident #23 and what occurred on 4/14/16. She said it was a normal day for the resident until about 2:00 P.M., when he presented with mental status changes, decreased balance and slurred speech. She said his blood sugar was checked due to being a brittle diabetic and his/her blood sugars could run in the high 300's. She said that Resident #23 said he/she smoked synthetic marijuana. She further said an order was obtained to send the resident to the ER. She also said there was no obvious residue, and nothing was found in the room during a room search, and police were notified. When asked if an incident report was initiated she said she was not sure. When asked about facility policy around substance abuse she said some residents are put on 15 minute checks, monitored closely and make sure there are no medication interactions. Unit manager was asked what changed with Resident #23's care after he/she returned from the hospital, she said she could not remember. b. Review of clinical record on 6/6/16 indicated in a nursing progress note dated 4/19/16 that: Patient returned back from an appointment, he is unable to walk safely, is sleepy, and appears to be under the influence. NP updated and gave an order to send to ER for evaluation, ER nurse given report. Review of Nurses Note in the clinical record dated 4/20/16, 11-7 shift indicated the following: Resident returned from hospital at 1:30 A.M. clear, no finding of alcohol, cooperative and willing to try drug program. There was no mention in the note that a drug specimen inquiry was completed. The clincal record failed to have any further nursing progress notes to reflect that MD or NP notified of the resident's statement to try a drug program. c. Review of clinical record on 6/6/16 a nursing progress note dated 5/3/16 indicated the following: at 12:15 A.M., resident was found in the bathroom with another resident, patient was disoriented, room smelled like smoke, MD (medical doctor) notified and ordered to have resident transferred to ER for drug screen. Patient handed nurse a plastic bag with herbal like material and nurse handed plastic bag with NOS (not otherwise specified) contents to EMTs (Emergency Medical Technicians), Patient transferred to the ER. Review of clinical record on 6/6/16 a nursing progress note dated 5/3/16 indicated the following: Patient back on unit at about 6:30 A.M., appears lethargic and somnolent. A nurses note dated 5/3/16, written after previous 5/3/16 note indicated that Resident #23 left the facility AMA, (against medical advice). The note further indicated: NP aware, even though pt went AMA, pt was provided with medication, glucometer, insulin and insulin supplies. Pt was educated on importance of taking meds daily and to check blood sugars and to seek medical attention if needed, pt discharged with belongings. During interviews with the Social Worker on 6/7/16 at 10:05 A.M. and 4:15 she was asked about Resident #23. The social worker said she was familiar with the resident and aware that the resident was found in a bathroom with another resident and had an altered mental status, she further said the resident was sent to the ER and found to positive for substance abuse. When asked if she was aware of any other instances of illicit drug use, she said, I believe there were other times but I am not positive, or words to that effect. She said the resident was encouraged to go to AA and NA meetings offered at the facility. Surveyor #1 asked if a formal substance abuse assessment was completed for residents who are admitted to the facility, the Social Worker said the facility did not have a formal assessment for substance abuse. During interview with the Activity Director on 6/7/16 at 12:30PM., she said she was familiar with Resident #23. She said he/she was a smoker and she knew he/she struggled with addiction. She said she invited him/her to go to AA meetings and that he was attending regularly until about April when he stopped. The Activity Director said she did 1:1 support with the resident and attempted to call detox centers for him around 4/20/16, but he/she was denied acceptances. She said she was not aware of any previous reports that involved Resident #23 using non prescribed drugs before April 20, 2016. The Activity Director said she was aware that he/she was smoking synthetic marijuana in the bathroom with another resident in May. During further interview with Activity Director on 6/7/16 at 5:05 P.M., she said she volunteers her time running the AA and NA meetings at the facility, and although she has experience as a substance abuse counselor it is not part of her job description for the facility. During interview with the DON and the Administator on 6/8/16 at 11:32 A.M., the Administrator said that the staff worked closely with Resident #23 during his/her stay in the facility, that the resident met with the Activity Director, the Ombudsman, and that she also met with the resident. When asked by Surveyor #1 if she was a certified substance abuse counselor, the Administrator said she is not a certified substance abuse counselor. During interview, neither DON nor Administrator said they were aware that the contracted psychiatric health services failed to see the resident after the 4/14/16 incident when the resident had a positive toxicology screen. The Administrator also said there were concerns about drug activity in the building and after the 4/14/16 incident there was increased monitoring of suspicious residents or people that come into the facility, room searches as needed, they unzipped and checked all the mattresses in the facility and toilet bowl and tanks, conducted team meetings to discuss problems or incidents with department heads and staff, added smoke alarms to several bathrooms, search belongings and bags when residents return to the facility or when visitors bring in things, and also conducted a 30 minute training held at the facility on 1/28/16 on the use of [MEDICATION NAME], ( a medication used when an individual has an overdosed of drugs), and recognizing signs and symptoms of detoxing from drugs and alcohol. Although the facility implemented monitoring/reactive approaches to substance abuse, the facility failed to provide adequate formal substance abuse treatment to Resident #23, who had several incidents involving actual and suspected substance abuse.

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 Resident (#50) in a follow up sample of 15 residents. Findings include: 1. The facility failed to provide the necessary care and services for the prevention and treatment of [REDACTED]. Resident #50 was admitted to the nursing facility in March 2013, with [DIAGNOSES REDACTED]. The three page referral listed all medications that the Resident had been receiving and included [MEDICATION NAME] 600 milligrams three times daily, [MEDICATION NAME] 50 milligrams every six hours as needed (PRN) and [MEDICATION NAME] 5 milligrams every 6 hours PRN. A nurse's note, dated 3/22/13 documents that the nurse practitioner was notified of the Resident's admission and verified all medications (medications were verified from a list of discharge medications from the hospital and included [MEDICATION NAME]). There was no documentation to indicate that the [MEDICATION NAME] was to be discontinued. There were no signed physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The clinical record was reviewed on 4/1/13. Nurses' notes documented that the Resident had verbal outbursts. A Psychiatry note, dated 3/27/13 documents that the Resident has an anger tendency with triggers of pain, meal preference and people potentially entering his/her room with fear that they will steal. The note further documents that the Resident's pain is not optimized. Resident #50 was interviewed on 4/1/13 at 2:00 P.M. in regard to pain management (the Resident was not aware that he/she was not receiving the same medications as at the prior facility). Resident #50 stated that since being admitted to the facility he/she felt that his/her pain had gotten worse. Resident #50 stated that he/she had been given [MEDICATION NAME] PRN but that it did not work. When asked to rate his/her pain, on a scale of 1 to 10 (with one being the least amount of pain and 10 being excruciating pain), the Resident stated that his/her pain was at a level of 9. Unit Manager #1, when interviewed on 4/1/13, at 2:00 P.M., stated that the [MEDICATION NAME] had not been transcribed as part of the initial orders on admission, although the nurse practitioner had verified all of the medications, and that he would check with the attending physician to determine if he wanted the Resident to receive the [MEDICATION NAME]. The Physician came to the facility to review Resident #50's medications 4/1/13. When interviewed, the Physician stated that the Resident should have been on the [MEDICATION NAME] as it provided better pain control for the Resident and eliminated/reduced the use of narcotics. The Physician stated that when the Nurse Practitioner had verified all the medications that [MEDICATION NAME], having been on the discharge medication list should have been implemented and administered

Based on observation, staff interview and documentation review, the facility failed to establish and implement policies, procedures and protocols to identify the roles and function of staff responding to a medical emergency as evidenced by the staff ' s inability to respond to a medical emergency whereby one Resident (#32) was having a [MEDICAL CONDITION]. Resident #32 was admitted to the nursing facility in November 2012 with [DIAGNOSES REDACTED]. On 2/27/13, at 9:35 A.M., this Surveyor was the first floor nurses station, obtaining a report of Resident status with Unit Manager #1 who is a Licensed Practical Nurse. Someone called out " I need help. " Unit Manager #1 and this Surveyor entered the day room and observed the following: ? Resident #32 was in his/her wheelchair and was having a tonic/clonic [MEDICAL CONDITION]. ? The Activities Director was observed holding onto Resident #32 with her right arm hooked under Resident #32 ' s left arm. ? Unit Manger #1 observed Resident #32 seizing and left the room, returning to the nurses station. Unit Manager #1 proceeded to use the overhead paging system to announce " medical emergency in day room. " Unit Manger #1 stayed at the nurses' station gathering paperwork and proceeded to call 911. The nurses station is approximately 30 feet from the day room and the Unit Manager did not have visual access of the Resident during the time at the desk. ? The Resident continued to seize for 3 minutes and was sliding off of the wheelchair seat. This surveyor placed her left arm under and through the Resident 's right arm to prevent the Resident from falling out of the wheelchair as he/she was still seizing. ? The Activities Director was told by this Surveyor that the Resident needed to be lowered to the floor to ensure the Resident's safety. The Activities Director stated that the Resident was not going to fall. ? No medical/nursing staff responded to the day room for 3 ? minutes, at which point the Resident 's [MEDICAL CONDITION] had ended and the Resident was in a postictal state (still unresponsive and limp). ? C.N.A. #1 (Certified Nursing Assistant) and Nurse #2 arrived in the day room ? a minute after the [MEDICAL CONDITION] ended. Neither had brought the emergency cart. ? C.N.A. #1 was observed to grab the Resident ' s dungarees at the thigh level in an attempt to raise the Resident ' s legs to assist in lowering the Resident to the floor. This Surveyor stopped C.N.A. #1 as he/she was attempting an unsafe manner of transfer. ? The Staff Development Coordinator then brought the emergency cart and passed the cart to Nurse #2 (this was 4 ? minutes after the Resident had begun seizing and 1 ? minutes after the [MEDICAL CONDITION] had ended). The emergency cart was stored in a locked clean utility room requiring a number combination to access the room. ? Nurse #3, who arrived on the unit 5 minutes after the [MEDICAL CONDITION] had ended, was observed to obtain the Resident ' s pulse; however, no other vital signs were obtained. ? EMTs (Emergency Medical Technician) and the fire department arrived at the facility at 9:40 A.M. The Resident was transported to the hospital at 9:53 A.M. There were 2 nurses (Nurses #4 and 5) and 5 C.N.A.s on the unit during this medical emergency. However, none of the clinical staff on the unit had responded to the medical emergency. Interview on 2/27/13 at 10:00 A.M. with Nurses #4 and 5 and the 5 C.N.A..s revealed that none of the above 7 staff had heard the emergency page. Nurse #4 was interviewed further at 10:05 A.M. regarding how to respond to Resident #32 when seizing. Nurse #4 stated that he/she was to stay with the Resident, position the Resident to ensure he/she did not choke, take the Resident 's vital signs and call 911. Unit Manager #1 was interviewed on 2/27/13 at 2:30 P.M. Unit Manager #1 stated that when he/she announced the medical emergency, he/she was not sure who would respond. Unit Manager #1 was asked if someone was designated to bring the emergency cart when a medical emergency was called. Unit Manager #1 stated that no one was designated. Unit Manager #1 further stated that he/she had never had a medical emergency occur before and was unsure of how to respond. Unit Manager #1 stated that he/she had received no training on how to respond to a medical emergency. A Surveyor on a second floor nursing unit observed Nurse #2 running by the nurses ' station and stated " medical emergency ". The Surveyor and Unit Manager #2 who were sitting at the nurses ' station had not heard the overhead page of the medical emergency. Nurse #2 was interviewed on 2/27/13 at 3:00 P.M. Nurse #2 was asked if he/she were the designated person to respond to a medical emergency. Nurse #2 stated that he/she had heard the page and responded but that no one was specifically designated to respond from each unit. Nurse #2 was asked what his/her role was once he/she responded to the emergency. Nurse #2 stated that there was no specific role, just to be available to help, however, he/she had not been asked to help. Nurse #2 was asked if he/she had noted that upon arriving at the medical emergency that there was not an emergency cart. Nurse #2 stated that he/she had noticed that an emergency cart was not present, but thought that someone else would bring the cart. Nurse #2 stated that there were no clear guidelines of who was to respond to an emergency and what each person's role was. Nurse #2 stated that usually a team leader would tell each person what to do, however, he/she was unsure of who the team leader was in the medical emergency he/she had responded to. A Surveyor conducting medication pass observations heard a muffled page of the medical emergency. However, the nurse pouring medications stated he/she had not heard the page. The Surveyor went to Unit Manager #3 who was still at the nurses ' station and when asked, stated he/she had not heard the medical emergency page. The Activities Director was interviewed on 2/27/13 at 10:10 A.M. regarding the observed medical emergency and the Activities Director ' s response. The Activity Director stated that she was to keep the Resident safe, call for help and make sure the Resident did not whack his/her head or fall. The Survey team checked 3 of 3 units policy and procedure books as well as their emergency preparedness plan books. Neither book on any of the units contained any policy, procedure or protocol to address any type of medical emergency. Although there was a content list in the policy and procedure book, it did not contain any policy for medical emergencies. The emergency preparedness book did contain a page for various codes with an attached color (code blue being a medical emergency), however, there were no protocols or procedures regarding the codes (and the correct code of ' code blue ' had not been used by Unit Manager #1 when announcing the medical emergency). At 10:30 A.M., on 2/27/13, the Admission Coordinator produced a policy and procedure for [MEDICAL CONDITION] along with a policy and procedure manual content list with [MEDICAL CONDITION] Care handwritten in. The Admissions Coordinator stated " here is our policy for [MEDICAL CONDITION]. " Interview with the Administrator on 2/27/13 at 10:40 A.M. revealed that the policy presented to this Surveyor had not been in place at the time of the medical emergency. The Administrator further stated that there were no policies, procedures or protocols in place for any medical emergencies. There was no evidence that the facility had a systemic approach to dealing with medical emergencies. Ther was no team leader designated, no staff designated for securing necessary emergency equipment and no policies for staff to reference at the time of the medical emergency. Staff interviews validated that insevices for emergency response had not been conducted.

Based on observations, record review and staff and resident interview, the facility failed to provide appropriate treatment and services to restore the resident's ability to perform transfers and ambulate independently for 1 Resident (#16) in a follow up survey sample of 24. Findings include: For Resident #16, the facility failed to follow up with an orthopedic consult for a Resident who suffered a left quadricep muscle pull, which resulted in an avoidable decline in the Resident's ability to transfer and ambulate. Findings include: Resident #16 was admitted to the facility November 2010 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the Resident as alert and oriented and cognitively intact, and independent with all activities of daily living (ADLs). Review of the Resident's clinical record documented a nursing note, dated 1/30/13, indicated that at 10:45 A.M., while standing in the beauty parlor, the Resident's left knee buckled and he/she fell to the floor landing on his/her left side. The Resident stated that he/she was having pain on his/her left side, knee and hip. The Resident was sent to the emergency room for further evalution. The Resident returned with bilateral ace bandages. A Nurse Practitioner's note, dated 1/30/13, revealed that after the Resident's fall in the beauty parlor, he/she was unable to get up. The injuries noted were an abrasion to the right knee and a swollen left knee. A nursing note dated 1/31/13, revealed that the Resident expressed to the staff that he/she was having a phobia about standing up on his/her own. Review of the Resident's clinical record revealed a nursing note, dated 2/4/13, which documented that a call was made to an orthopedic physician for a follow-up, however, the orthopedic physician stated that they did not take the Resident's insurance. The facility then made a call to another orthopedic physician, and was awaiting a call back. A nursing note, dated 2/6/13, indicated that the Resident was seen by another orthopedic physician, who stated that he did not feel comfortable handling a resident his/her size. It was noted that the nurse practitioner was made aware, and that other bariatric programs in the area would be researched. A orthopedic physician's note, dated 2/6/13, noted that the resident was likely to have a torn left quadricep. It was noted that the Resident apparently had a similar injury on the right quadricep, which was operated on 2 years ago. The note further stated that the previous surgeon refuses to see the resident, per the Resident. The orthopedic physician's recommendation was to make a referral to a tertiary hospital in Boston. The physician reported that he did not feel capable of handling a patient his/her size, since the Resident would likely require surgery to repair the quadricep tendon. An Accident and Incident Report indicated that on 2/9/13 at 6:30 A.M., the Resident was attempting to self transfer to his/her wheelchair, and needed to be lowered to the floor by 3 staff persons. Also, since the Resident was not able to safely transfer to the wheelchair, the staff were to utilize the hoyer due to his/her recent change in mobility (this resident had previously been independent in transfers). On 2/18/13, a physician's note documented a referral was made to a Boston hospital, which refused to treat the Resident secondary to the type of medical insurance the Resident has, and that the facility needed to contact another known Boston hospital to arrange for an orthopedic follow-up. Review of the nursing notes revealed that from 2/18/13 to 2/28/13, the facility did not follow up on the Resident's physician's orders [REDACTED]. During the interview, on 2/28/13, at 9:30 A.M., Unit Manager #1 said that she had not followed up with the physician's orders [REDACTED]. at the time. However, a progress note, written on 2/19/13 by the Nurse Practitioner, also stated that a follow-up was to be pursued at the second Boston hospital. On 3/4/13, at 4:00 P.M., interview with the Resident revealed that he/she was fearful of ambulating for fear of falling again. The Resident stated that he/she was not happy with utilizing a bed pan for toileting, when prior to the fall the Resident reported he/she was able to toilet self. The Resident reported that the staff came to him/her on this day to report that there was an orthopedic follow-up scheduled on 3/7/13 at 11:00 A.M., which had not been scheduled prior to 3/4/13.

Based on observations, record review and staff and resident interview, the facility failed to provide appropriate treatment and services to restore the resident's ability to perform transfers and ambulate independently for 1 Resident (#16) in a follow up survey sample of 24. Findings include: For Resident #16, the facility failed to follow up with an orthopedic consult for a Resident who suffered a left quadricep muscle pull, which resulted in an avoidable decline in the Resident's ability to transfer and ambulate. Findings include: Resident #16 was admitted to the facility November 2010 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the Resident as alert and oriented and cognitively intact, and independent with all activities of daily living (ADLs). Review of the Resident's clinical record documented a nursing note, dated 1/30/13, indicated that at 10:45 A.M., while standing in the beauty parlor, the Resident's left knee buckled and he/she fell to the floor landing on his/her left side. The Resident stated that he/she was having pain on his/her left side, knee and hip. The Resident was sent to the emergency room for further evalution. The Resident returned with bilateral ace bandages. A Nurse Practitioner's note, dated 1/30/13, revealed that after the Resident's fall in the beauty parlor, he/she was unable to get up. The injuries noted were an abrasion to the right knee and a swollen left knee. A nursing note dated 1/31/13, revealed that the Resident expressed to the staff that he/she was having a phobia about standing up on his/her own. Review of the Resident's clinical record revealed a nursing note, dated 2/4/13, which documented that a call was made to an orthopedic physician for a follow-up, however, the orthopedic physician stated that they did not take the Resident's insurance. The facility then made a call to another orthopedic physician, and was awaiting a call back. A nursing note, dated 2/6/13, indicated that the Resident was seen by another orthopedic physician, who stated that he did not feel comfortable handling a resident his/her size. It was noted that the nurse practitioner was made aware, and that other bariatric programs in the area would be researched. A orthopedic physician's note, dated 2/6/13, noted that the resident was likely to have a torn left quadricep. It was noted that the Resident apparently had a similar injury on the right quadricep, which was operated on 2 years ago. The note further stated that the previous surgeon refuses to see the resident, per the Resident. The orthopedic physician's recommendation was to make a referral to a tertiary hospital in Boston. The physician reported that he did not feel capable of handling a patient his/her size, since the Resident would likely require surgery to repair the quadricep tendon. An Accident and Incident Report indicated that on 2/9/13 at 6:30 A.M., the Resident was attempting to self transfer to his/her wheelchair, and needed to be lowered to the floor by 3 staff persons. Also, since the Resident was not able to safely transfer to the wheelchair, the staff were to utilize the hoyer due to his/her recent change in mobility (this resident had previously been independent in transfers). On 2/18/13, a physician's note documented a referral was made to a Boston hospital, which refused to treat the Resident secondary to the type of medical insurance the Resident has, and that the facility needed to contact another known Boston hospital to arrange for an orthopedic follow-up. Review of the nursing notes revealed that from 2/18/13 to 2/28/13, the facility did not follow up on the Resident's physician's orders [REDACTED]. During the interview, on 2/28/13, at 9:30 A.M., Unit Manager #1 said that she had not followed up with the physician's orders [REDACTED]. at the time. However, a progress note, written on 2/19/13 by the Nurse Practitioner, also stated that a follow-up was to be pursued at the second Boston hospital. On 3/4/13, at 4:00 P.M., interview with the Resident revealed that he/she was fearful of ambulating for fear of falling again. The Resident stated that he/she was not happy with utilizing a bed pan for toileting, when prior to the fall the Resident reported he/she was able to toilet self. The Resident reported that the staff came to him/her on this day to report that there was an orthopedic follow-up scheduled on 3/7/13 at 11:00 A.M., which had not been scheduled prior to 3/4/13.

Based on documentation review and resident and staff interviews, the facility failed to provide only those specialized rehabilitative services ordered by a physician for two Residents (#15 and 19) in a sample of 31 residents. Findings include: 1. For Resident #15, the facility failed to ensure that a physician's order was obtained before utilizing a hot pack which resulted in first and second degree burns. During a group meeting, conducted on 12/11/12, Resident #15 stated that he/she had sustained a burn to the neck after utilizing a hot pack. Resident #15 was admitted to the nursing facility in July 2012, with [DIAGNOSES REDACTED]. Review of the medical record revealed that on 9/8/12, Resident #15 reported to a nurse that he/she had gone to physical therapy the day before and asked for a heating pad to the neck. Resident #15 reported that the neck felt like it was burning but thought it was from neck pain. Resident #15 reported that another resident had checked his/her neck and saw blisters. The nurse confirmed the presence of blisters and called the nurse practitioner who ordered [MEDICATION NAME] cream twice daily until healed. On 9/10/12, a physician's progress note documents "asked to evaluate patient with burn on neck after using a heating pad. Observation 6 inch x 4 inch area of first and second [MEDICAL CONDITION] central neck. One inch blisters at top of burn, few smaller blisters at lower part of burn." Review of the treatment sheet for September 2012, revealed that the [MEDICATION NAME] cream was used from 9/8/12 through 9/17/12 when the neck area is described as scabbed. Further review of the medical record revealed there was no physician's order for the hot pack. The Director of Rehabilitation was further interviewed on 12/15/12 at 2:40 P.M. stated that there was not a physician's order for the hot pack. 2. For Resident #19, the facility failed to obtain a physician's order to continue Occupational Therapy. Resident #19 was admitted to the nursing facility on 11/8/12 after an extended acute care hospital stay. On admission, an order was obtained for Occupational Therapy 5 times per week for 4 weeks (which would have ended on 12/8/12). Review of the clinical record on 12/20/12 as well as the Occupational Therapy billing log revealed that Resident #19 continued to receive Occupational Therapy from 12/8/12 through 12/18/12 without a physician's order. Unit Manager #1, when interviewed on 12/20/12 at 11:25 A.M., stated that a new order for continued Occupational Therapy services had not been obtained.

Not corrected from survey of 12/21/12 Based on observations, record review, and resident and staff interview, the facility failed to ensure that 1 Resident (#33) in a follow up survey sample of 24, was provided adequate supervision and effective interventions to prevent accidents. For Resident # 33, the facility failed to ensure that the Resident had effective safety devices/interventions in place to avoid a fall. Resident #33 was admitted to the facility in June 2012 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the Resident as alert and oriented and cognitively intact. The MDS identified the Resident as an extensive physical assist of 1 staff person for transfers, and all other activities of daily living. The Resident required supervision for mobility, and was continent of bowel and bladder. A nursing note, dated 2/23/13 (during the 11:00 P.M. to 7:00 A.M. shift), indicated that the Resident reported to staff that he/she had a fall at night. The Resident stated he/she was in the bathroom and unable to hold on to the bar, fell and hit his/her head on the sink The Resident had reported the incident in the morning around 8:00 A.M on 2/23/13. There was no noted injury from this fall. An interview on 2/27/13, during the initial entrance tour, Resident #33 stated that the facility had removed the toilet grab bars, which caused him/her to have a fall when transferring on to the toilet. Resident #33 stated that he/she told the facility that he/she had difficulty transferring on to the toilet due to not having grab bars. When the Surveyors were exiting the Resident's room, it was observed that the grab bars were still not on the toilet. On 3/4/13 at 3:30 P.M., the Maintenance Director said that he was told to make a list of all broken toilet grab bars that needed replaced. However, the Maintenance Director said that he threw that list away. He did state that he was told to replace all the broken ones and put new ones in bathrooms for the newly admitted Residents who required the device. The Maintenance Director stated that the Resident had a broken one, and it had been replaced, but did not document the date of the replacement. On 3//4/13 at 2:30 P.M., the surveyor went to the Resident's bathroom and observed a new toilet grab bar. On 3/4/13 at 3:55 P.M., the Surveyor requested to review the fall investigation. At the time of the follow-up exit, the Director of Nursing said that she could not find the Incident/Investigation report for the Resident's fall.

Based on record review, interviews, and observations the facility failed to provide medically related social services to 1 resident (#16) out of a sample of 31. Findings include: On 12/1012, state surveyor #1 and the federal surveyor were meeting residents in their rooms. Resident #16 said he/she was anxious due to being given a 30 day discharge notice. He/she stated that he/she was unaware of what the "charges" were and why he/she was being discharged . Review of the medical record on 12/10/12, indicated that the social service section had several notes. A quarterly note dated 1/23/12, documented that Resident #16 wanted to be discharged to the area, where he/she has family. A note dated 2/3/12, documented that allegations were made against Resident #16. It was alleged that he/she was selling a narcotic medication to other residents. The room was searched and no medications were found. Social Service note of 10/26/12, documented that there was a meeting on 10/26/12, with the Administrator, Social Worker #1, Resident #16 and another resident. The resident alleged that Resident #16 was cheeking his pills and selling them. He/she allegedly sells coffee to residents including those residents with a fluid restriction. The resident also said that when Resident #16 goes out with a family member he/she brings back marijuana and smokes it in the smoking area. The next note dated 10/29/12 documented that a meeting was held with Resident #16, the Administrator and the Social Worker #1. The note documented that the resident was being given a 30 day discharge notice secondary to reports that other residents have offered. The note further documents that he continues to violate the laws of the Commonwealth of Massachusetts and selling coffee. Discharge Notice documented that the resident was going to be transferred to a 24 hour shelter located in Boston. There was no assessment or documentation of the residents reaction to the discharge notice. The Discharge Notice gave two reasons for the discharge: The health and safety of individuals in the nursing facility would otherwise be endangered and "You continue to violate the facility rules and the laws of the Commonwealth of MA." The form noted that the reasons have to be documented in detail. The reasons were not documented in detail. On 12/10/12 at approximately 2:00 P.M., Surveyor #1 interviewed Resident #16. The resident stated he/she was upset because the facility was going to discharge him/her. Resident #16 stated that he/she did not know what the "charges" were and that no one would explain them to him/her. On 12/10/12 at 3:45 P.M. surveyor #1 met with the Administrator and the Social Service Director. The Consultant Social Worker joined the meeting. Surveyor #1 questioned them as to why specifically the resident had received a thirty discharge notice. They stated the allegations were selling coffee and cigarettes to residents. They stated other residents were making these allegations. They had no evidence of the resident being involved in this behavior. When they were asked what Law of the Commonwealth was being broken, they could not state it. The staff were asked what documenation they had regarding these allegations. They could not produce any. There was no evidence that the facility had provided medically related social services to the resident to deal with his/her concerns regarding the pending discharge. Surveyor #1 asked the staff what steps were taken to address these alleged behaviors, prior to giving the resident a discharge notice. They stated that they did not do any interventions. The Administrator stated changing the resident smoking status was a violation of the residents rights. After asking the staff if they had done any interventions, they acknowledged that they realized that they needed to do them. Subsequently, the facility initiated a behavior plan. There was no evidence that the facility had provided medically related social services for Resident #16 to deal with his/her anxiety regarding the pending discharge.

Based on record review and staff interview, the facility failed to ensure that services being provided met professional nursing standards of quality for 5 sampled residents (#12, #14, #17, #18, and #19) in a total sample of 31 residents. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." 1. For Resident #14, the facility failed to obtain a physician's order for a nutritional supplement which was recommended by the Registered Dietitian. Resident #14 was admitted to the facility 09/09 with [DIAGNOSES REDACTED]. The resident has also had significant weight loss over several months related to his complex medical issues. Review of the resident's medical record on 12/17/12 indicated a dietary recommendation, dated 10/17/12, for a sugar free mighty shake (a nutritional supplement) , 4 ounces by mouth once daily. Review of the resident's October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident returned from the hospitalization on [DATE]. The physician orders that were reinstated upon the resident's return to the hospital did not include the nutritional supplement, despite the Dietitian recommendation on 10/25/12. On 12/16/12 there was a new order for sugar free mighty shakes one by mouth daily (53 days later than the Registered Dietitian's recommendation). During interview on 12/17/12 at 3:00 P.M., Nurse Manager #1 said that although the Dietitian did recommend it on 10/25/12, she missed writing it with all the other orders that had come in on that day for that resident. The Nurse Manager's failure to follow through with the Registered Dietitian's recommendation, resulted in Resident #14 not receiving the nutritional supplement for 53 days. 2. For Resident #18, the facility failed to ensure that a physician's order was obtained before the resident performed urinary self catheterization. Resident #18 was admitted to the facility in 6/2012 with [DIAGNOSES REDACTED]. Review of the resident's clinical record on 12/12/12 indicated a bowel and bladder assessment tool had been completed on 6/6/12, which indicated that the resident has a [MEDICAL CONDITION] bladder and performs urinary self catherization. Review of the physician orders, dated December 2012, lacked a physician's order allowing the resident to self catheterize. During interview on 12/12/12 at 4 P.M., Nurse Manager #2 said that the resident had been self catheterizing at home for years and didn't realize that there wasn't a physician order in place for him/her to perform the self catheterization procedure. Please see F441. 3. For Resident #12, the facility failed to ensure a physician's order was obtained before allowing the resident to have psychiatric services. Resident #12 was admitted ,[DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident with a BIMS (Brief Interview of Mental Status) score of 14 indicating the resident was cognitively intact. He/She required assistance with dressing, bathing, transfer and was independent with ambulation. The resident also was coded in the behavior section for refusal of care. On 12/13/12 at 4:30 P.M., a review of a signed physician's order sheet for 12/12 indicated that there was no order for psychiatric services. Further review of the clinical record indicated that the resident had been seen by a psychiatrist on 12/13/12 for medication and behavioral review. During interview on 12/13/12 at 5:15 P.M, Nurse Manager #3 said he was unaware that there was no physician's order for psych services to see this resident and would look into it. 4. For Resident #17, the facility failed to ensure a physician's order was obtained before allowing the resident to have psychiatric services. Resident #17 was admitted ,[DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident with a BIMS (Brief Interview of Mental Status) score of 15 indicating the resident was cognitively intact. He/She was independent with dressing, bathing, transfer and was independent with ambulation. The resident's mood interview score coded an 18 which is indicative of mood issues. On 12/12/12 at 4:30 P.M., a review of a signed physician's order sheet for 12/12 indicated that there was no order for psychiatric services. Further review of the clinical record indicated the resident has been followed by the psychiatric nurse practioner as well as an social worker for one to one therapy during the month of November and December 2012. During interview on 12/12/12 at 4:45 P.M, Nurse Manager #2 said she thought the Resident had a physician's order, but upon review of the clinical record, confirmed there was no physician's order. She continued to say that "with the facility's old pharmacy, there was always a psych consult as needed order, but with the new pharmacy, the order for psych consult as needed was left off the physician order sheets". 5. For Resident #19, the facility failed to accurately reconcile hospital discharge orders resulting in the failure to address use of a [MEDICAL CONDITION] (continuous positive air pressure) machine for this resident with a [DIAGNOSES REDACTED]. Resident #19 was admitted to the nursing facility in November 2012, with [DIAGNOSES REDACTED]. During an interview with Resident #19 on 12/11/12 at 5:00 P.M., the Resident was asked about the use of a [MEDICAL CONDITION] machine that was in the Resident's room. Resident #19 stated that he/she was suppose to use the [MEDICAL CONDITION] machine, however, the machine needed to be re-calibrated and this had not been done in the 6 weeks since admission. Review of the hospital discharge summary, on 12/12/12 revealed that the Resident had used the [MEDICAL CONDITION] machine at the hospital and had been given nasal pads versus a face mask which the Resident tolerated without difficulty. Review of the admission orders [REDACTED]. Unit Manager #1, when interviewed on 12/12/12 at 9:45 A.M. said that she had missed the order for the [MEDICAL CONDITION] machine on admission. Further more, Unit Manager #1 stated that the Resident had refused use of the machine on 12/10/12 and 12/11/12 due to the machine needing re-calibration. Unit Manager #1 stated she did not know whom to notify to get the [MEDICAL CONDITION] machine re-calibrated.

Based on record review and staff interview, the facility failed to insure that services being provided met professional nursing standards of quality for reconciling re-admission orders [REDACTED]. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." 1a. For Resident #50, the facility failed to accurately reconcile hospital discharge orders resulting in the failure to transcribe and administer [MEDICATION NAME] (used to treat pain from diabetic [MEDICAL CONDITION]) for 10 days and 28 doses of the medication. Resident #50 was admitted to the nursing facility in March 2013, with [DIAGNOSES REDACTED]. The three page referral listed all medications that the Resident had been receiving and included [MEDICATION NAME] 600 milligrams three times daily. A nurse's note, dated 3/22/13 documents that the nurse practitioner was notified of the Resident's admission and verified all medications (medications were verified from a list of discharge medications from the hospital and included [MEDICATION NAME]). There was no documentation to indicate that the [MEDICATION NAME] was to be discontinued. There were no signed physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Unit Manager #1, when interviewed on 4/1/13, at 2:00 P.M., stated that the [MEDICATION NAME] had not been transcribed as part of the initial orders on admission, although the nurse practitioner had verified all of the medications, and that he would check with the attending physician to determine if he wanted the Resident to receive the [MEDICATION NAME]. The Physician came to the facility to review Resident #50's medications 4/1/13. When interviewed, the Physician stated that the Resident should have been on the [MEDICATION NAME] as it provided better pain control for the Resident and eliminated/reduced the use of narcotics. The Physician stated that when the Nurse Practitioner had verified all the medications that [MEDICATION NAME], having been on the discharge medication list should have been implemented and administered. Please see F309. 1b. For Resident #50, the facility failed to follow up on a psychiatry recommendation for an increase in [MEDICATION NAME] (an antidepressant/mood stabilizer). Resident #50 was admitted to the facility with [DIAGNOSES REDACTED]. The clinical record was reviewed on 4/1/13. Nurses' notes documented that the Resident had verbal outbursts, however, there was no documentation to indicate that any of the staff had talked with the Resident to determine the cause of the verbal outbursts. There were no interim care plans other than one for nutrition (10 days after admission). A Psychiatry note, dated 3/27/13 documents that the Resident has an anger tendency with triggers of pain, meal preference and people potentially entering his/her room with fear that they will steal. The note further documents that the Resident's pain is not optimized. The note also documents that the Resident is struggling to accept placement in long term care. The Psychiatrist recommended that the [MEDICATION NAME] be increased to 75 milligrams (from 50 milligrams) daily. Review of the Nurses' notes from 3/27/13 to 4/1/13 revealed that there was no documentation to indicate that the physician had been notified of Psychiatry's recommendation to increase the dose of [MEDICATION NAME]. Unit Manager #1 when interviewed on 4/1/13 at 2:00 P.M. stated that he was not aware of the recommendation to increase the dose of [MEDICATION NAME] and could not explain the lack of follow through with the attending physician. 2. For Resident #51, the facility failed to accurately edit monthly orders resulting in the omission of [MEDICATION NAME] (an antipsychotic medication) used to treat [MEDICAL CONDITION] which effected the Resident's ability to accept food, and [MEDICATION NAME] prescribed for [MEDICAL CONDITION]. Resident #51 had returned to the nursing facility on 3/29/13, after an in-patient psychiatric admission for [MEDICAL CONDITION] and hallucinations with paranoia, which resulted in Resident #50 refusing medications and food. The discharge summary from the hospital documented that the Resident had previously been taking [MEDICATION NAME] to treat [MEDICAL CONDITION] and hallucinations which was discontinued and [MEDICATION NAME] 0.5 milligrams twice daily had been added. The discharge summary stated that at the end of the Resident's hospital stay, the Resident had begun to take his/her medications and eat more food. [MEDICATION NAME] 25 milligrams at hour of sleep had also been added to the Resident's medications during the hospital admission. Review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s orders and add any medication changes received in between monthly orders), the [MEDICATION NAME] and [MEDICATION NAME] did not appear on the April 2013 physician's orders [REDACTED]. The Resident did not receive a scheduled 8:00 A.M. dose of the [MEDICATION NAME] on 4/1/13. When interviewed, Unit Manager #1 stated that a medication error report would be completed for the missed dose of [MEDICATION NAME]. Unit Manager #1 could not explain how the medications had been missed during the final edit of monthly orders.

Not corrected from survey of 12/21/12 Based on observations, record review, and resident and staff interview, the facility failed to ensure that 1 Resident (#33) in a follow up survey sample of 24, was provided adequate supervision and effective interventions to prevent accidents. For Resident # 33, the facility failed to ensure that the Resident had effective safety devices/interventions in place to avoid a fall. Resident #33 was admitted to the facility in June 2012 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the Resident as alert and oriented and cognitively intact. The MDS identified the Resident as an extensive physical assist of 1 staff person for transfers, and all other activities of daily living. The Resident required supervision for mobility, and was continent of bowel and bladder. A nursing note, dated 2/23/13 (during the 11:00 P.M. to 7:00 A.M. shift), indicated that the Resident reported to staff that he/she had a fall at night. The Resident stated he/she was in the bathroom and unable to hold on to the bar, fell and hit his/her head on the sink The Resident had reported the incident in the morning around 8:00 A.M on 2/23/13. There was no noted injury from this fall. An interview on 2/27/13, during the initial entrance tour, Resident #33 stated that the facility had removed the toilet grab bars, which caused him/her to have a fall when transferring on to the toilet. Resident #33 stated that he/she told the facility that he/she had difficulty transferring on to the toilet due to not having grab bars. When the Surveyors were exiting the Resident's room, it was observed that the grab bars were still not on the toilet. On 3/4/13 at 3:30 P.M., the Maintenance Director said that he was told to make a list of all broken toilet grab bars that needed replaced. However, the Maintenance Director said that he threw that list away. He did state that he was told to replace all the broken ones and put new ones in bathrooms for the newly admitted Residents who required the device. The Maintenance Director stated that the Resident had a broken one, and it had been replaced, but did not document the date of the replacement. On 3//4/13 at 2:30 P.M., the surveyor went to the Resident's bathroom and observed a new toilet grab bar. On 3/4/13 at 3:55 P.M., the Surveyor requested to review the fall investigation. At the time of the follow-up exit, the Director of Nursing said that she could not find the Incident/Investigation report for the Resident's fall.

Based on observation, record review, and resident and staff interview, the facility failed to ensure that 4 of 31 Residents (#4, 15, 21 and 26) in a total sample of 31, were provided adequate supervision and effective interventions to prevent accidents. The facility failed to implement a system to ensure adequate supervision of residents who smoke in regards to maintaining lighting equipment. The facility failed to manage full sharps containers located in shower rooms and resident bathrooms. The facility failed to ensure that surge protectors were used appropriately and failed to store combustible material in a safe manner. Findings include: 1. For Resident #15, the facility failed to ensure that a hot pack was appropriately utilized, resulting in first and second degree burns to the neck. During a group meeting, conducted on 12/11/12, Resident #15 stated that he/she had sustained a burn to the neck after utilizing a hot pack. Review of the medical record revealed that on 9/8/12, Resident #15 reported to a nurse that he/she had gone to physical therapy the day before and asked for a heating pad to the neck. Resident #15 reported that the neck felt like it was burning but thought it was from neck pain. Resident #15 reported that another resident had checked his/her neck and saw blisters. The nurse confirmed the presence of blisters and called the nurse practitioner who ordered Silvadene cream twice daily until healed. On 9/10/12, a physician's progress note documents "asked to evaluate patient with burn on neck after using a heating pad. Observation 6 inch x 4 inch area of first and second degree burns on central neck. One inch blisters at top of burn, few smaller blisters at lower part of burn." Review of the treatment sheet for September 2012, revealed that the Silvadene cream was used from 9/8/12 through 9/17/12 when the neck area is described as scabbed. Review of the Accident/Incident Report, dated 9/8/12, revealed that there was only a statement from the nurse whom the Resident reported the burn to. The Director of Rehabilitation was interviewed on 12/12/12, at 3:00 P.M. regarding the burn. The Director of Rehabilitation stated that a statement from the physical therapist who applied the hot pack had been taken and given to the Administrator (but was not attached to the Incident/Accident Report). A copy of the physical therapist statement was given to this surveyor and documents: "After removing the heat pack, I noticed tiny bubbles on neck which were about 1/16 of an inch in diameter. When I started to massage patient's shoulders and neck, top layer of dermis started to slough off. The skin underneath the layer that came off was of the same color. I thought that the bubbles were resultant from combination of sun burn and the heat I applied." Further review of the medical record revealed there was no physician's order for the hot pack. The Director of Rehabilitation was further interviewed on 12/15/12 at 2:40 P.M. The Director of Rehabilitation stated that the use of the hot pack was not appropriate as the resident had stated he/she had a sunburn and the physical therapist put the hot pack on anyway. The Director of Nurses was interviewed on 12/15/12 at 4:30 P.M. regarding the burn incident. The Director of Nurses stated that she had not reported the burn to the Department of Public Health as required. 2. The facility failed to empty full sharps containers in a shower room, used by multiple residents and in resident bathrooms. Observations during environmental tour on 12/10/12 revealed full sharps containers as follows: - Room 101 - full sharps container in resident bathroom. A razor was sticking out with the blade end exposed. The flap to close the container was wedged open by the razor, enabling anyone to reach in to the container which contained used needles. - Winthrop Unit shower room - full sharps container. A razor was sticking out with the blade end exposed. The flap to close the container was wedged open by the razor, enabling anyone to reach in to the container which contained used needles. - Room 116 - full sharps container with flap wedged open from volume of used needles. - Room 126 - full sharps container with flap wedged open from volume of used needles. - Room 207 - full sharps container with flap wedged open from volume of used needles. - Room 212 - full sharps container with flap wedged open from volume of used needles. The full sharps containers above were observed on 12/11/12, 12/13/12 and 12/14/12. On 12/14/12, the Administrator was instructed to have the full sharps containers removed from the nursing units. However, on 12/17/12 the sharps container in room 217 was observed to remain full and overflowing with used needles. Interview with the Administrator on 12/18/12 at 4:15 P.M., revealed that the Maintenance department would be responsible for daily checking of sharps containers going forward. 3. For Resident #21, the facility failed to ensure that lighting materials for cigarettes were turned into facility staff, even though staff knew or should have known the Resident was smoking in his/her room. During a tour of the facility grounds on 12/11/12 at 1:00 P.M. it was observed that one of the window frames had multiple circular black spots (30 or more) on the base of the vinyl window. The black spots were similar in size to a lit end of a cigarette. Resident #21 had been identified as having independent smoking privileges. Upon entering Resident #21's room, the bedside table drawer was observed to be full of full packs of cigarettes. The Resident does not have a room mate. The facility was asked for the policy for smoking on 12/11/12. The policy for independent smoking indicates that lighters are to be turned in at the reception desk after each use. The policy indicates that Residents are not allowed to keep or store matches, lighters or other combustible materials of any kind and are not permitted in resident's rooms or facility common areas. This policy was confirmed with the Administrator on 12/11/12. The Administrator was informed of the black marks outside of Resident #21's window and that surveyors believed the Resident was smoking in his/her room on 12/11/12. The Administrator left the room and upon returning stated that the Resident was unable to open his/her window and reach out as there were stops on the frame limiting the amount of space the window could be opened. On 12/12/12, the Adminstrator provided the survey team with a written statement that Resident #21 "was agitated that housekeepers were in his room and I (the Administrator) was talking about the importance of a thorough cleaning. I was informed by DPH that they found marks outside the window where cigarettes appeared to be put out. I asked the Resident if the Resident had been smoking in the room, the Resident stated only once when admitted . Resident assured Administrator that Resident has not smoked in room since that day." Review of the medical record indicated that Resident #21 had been assessed to be able to smoke safely and independently on 4/12/12. However, on 4/20/12, nurse's notes document that while conducting rounds, the 11-7 nurse noted that Resident #21's room smelled of smoke. The Resident denied smoking and was reminded of danger of smoking in room. The note documents that the Administrator was informed. Review of the Smoking Safety Assessment indicated that Resident #21 was re-assessed on 7/17/12 and 10/23/12 and continued to be able to smoke independently. The Administrator was instructed by the survey team on 12/14/12, to put a plan into place to ensure that Residents did not keep lighters or matches on their person when in the building. The Administrator stated that all residents were informed that lighters/matches must be turned in each time the resident re-entered the building and that this would be monitored over the weekend. An updated smoking policy, which included revocation of independent smoking privileges for violations of not turning in lighting material with a signature page for the Resident to sign was implemented. On 12/20/12 review of the Lighter Sign Out Sheets revealed that out of 13 Residents who were designated as smoking independently, 6 had not signed lighters in and out daily, including Resident #21 from 12/17/12 through 12/20/12. The Administrator was informed of the above failure to follow policy, including that Resident #21 (with concerns that he/she was smoking in his/her room) had only signed a lighter out once for the 4 days reviewed. The Administrator stated that he would investigate whether or not Resident #21 had a lighter in his/her possession. The Administrator returned to the survey team a short time later to report that Resident #21 was indeed found with a lighter on his/her possession in his/her room. The Administrator could not explain why the policy for lighters had not been monitored or enforced since being informed by the survey team that there was a belief that a resident was smoking in his/her room in the facility. 4. For Resident #4, the facility failed to provide adequate supervision and effective interventions to prevent falls. Resident #4 was admitted to the nursing facility with [DIAGNOSES REDACTED]. The Annual Minimum Data Set, dated dated [DATE], indicates that Resident #4 requires extensive assistance of one person for bed mobility and transfers. The Resident had range of motion limitations to bilateral lower extremities and has had two falls without injury. Review of the medical record revealed that on 8/21/12, the Resident's alarm sounded and the Resident was found on the floor. The Resident stated to staff that he/she had put him/herself on the floor so he/she could go to the hospital. A care plan, dated 9/17/12 is in place for Falls. Interventions include: - Call light within reach. - Assist patient during transfer. - Bed alarm. - Scoop mattress. A nurse's note, dated 9/22/12 documents that the Resident was found on the floor beside the bed. The Resident Incident/Accident Report indicates that the Resident stated that he/she rolled over in bed and slid down to the floor. The resident sustained [REDACTED]. There is no documentation that an alarm had sounded nor that an alarm was in place at the time of the fall. 5. The facility failed to ensure that surge protectors and extension cords were not used. An environmental tour was conducted on 12/10/12 at 3:00 P.M. and 12/11/12 at 10:00 A.M. and revealed that surge protectors were being used as extension cords. Observations include: - Room 101- a surge protector plugged into an electrical outlet behind Bed A, with no devices plugged into the surge protector. - Room 107- A surge protector plugged into an electrical outlet with 2 devices plugged into it. - Room 121 - Extension cord plugged into wall with no device plugged into extension cord. - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - Room 204 - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - Room 209 - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - Room 211 - A surge protector plugged into an electrical outlet with four devices plugged into the surge protector. - Room 213 - a surge protector plugged into an electrical outlet beside Bed A, with no devices plugged into the surge protector. - Room 218 - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - Room 227 - Extension cord plugged into electrical outlet with thre devices plugged into extension cord. - Room 238 - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - A second surge protector plugged into an electrical outlet with three devices plugged into the surge protector. - Room 240 - A surge protector plugged into an electrical outlet with three devices plugged into the surge protector. 6. The facility failed to store combustible materials in a safe manner. On the first day of survey 12/10/12 at 1:00 P.M., while conducting the environmental tour, a shed was observed from the window of room 117. The shed was half covered with a tarp. There were used and broken furniture around the shed as well as a stack of approximately 36 mattresses which were left open to the elements and 36 hospital beds under tarps. The Maintenance Director stated that that had bought the equipment in July 2012, from a nursing facility which was closing. The shed had a biohazard waste sticker attached to the front of the shed. The Maintenance Director confirmed that this was the area biohazardous material was stored. Inspection on 12/13/12 of the shed revealed that the shed was not used for only biohazard waste storage and that the shed was not protected from the elements or access by vermin. Located in the shed were 2 mattresses, rock salt, a snow blower, three mattress pads in plastic bags (ripped and torn), 4 propane gas tanks, books, manuals, intravenous supplies, bumper pads and 18 containers of charcoal lighter fluid. The back left corner of the shed was observed with the roof collapsing. A support beam had snapped and large nails were sticking out. The owner of the nursing facility was told to remove the charcoal lighter fluid immediately as it posed a significant fire hazard. Maintenance removed the box of lighter fluid and then placed it on a loading dock where staff were allowed to smoke. The charcoal lighting fluid remained on the back loading dock until 12/15/12. In addition, one of the bottles of charcoal lighting fluid was observed on a desk in the business office. The Administrator was directed to remove the charcoal lighter fluid from the loading dock/smoking area and to clean up the furniture and mattresses surrounding the shed. 7. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record was reviewed on 12/20/12. The fall risk assessment documented on 6/21/12, 10/8/12 and 10/15/12 that the resident was a high fall risk. Review of the treatment sheets indicated that the resident had a self releasing alarmed velcro seat belt, that had been ordered on [DATE]. The Quarterly MDS of 9/27/2012 indicated that the resident had severe dementia, needed extensive assistance in transfer and was totally dependent for wheelchair mobility. The Incident /Accident Report dated 10/14/12 indicated that the resident was in the day room at 10/14/12 at 3:15 P.M. when the fall occurred. The witness statement given by the staff directly involved indicated that the resident had a history of [REDACTED]. It was documented that the resident was "non compliant" with sitting in the wheelchair. It was also documented that Resident #26 had attempted to stand three times prior to the fall and was redirected without results. The report indicated that the activity personnel left the room to get help and when he/she returned the resident had fallen on the floor on his/her left side. There was no mention if the alarm sounded or not. The resident was assessed by nurse #3 and was found to have a left frontal hematoma and an abrasion to the left leg. Resident #26 was transferred to the hospital for an evaluation. The resident had a computed tomography scan (CT scan)of the head. The scan showed a frontal scalp hematoma but no acute intracranial bleed, mass, midline shift or fracture. A CT scan was done of the cervical spine which did not show any evidence of fracture or subluxation. On 10/16/12, the physical therapist (PT) did a fall screen. He/she noted that the resident has dementia and despite instructions not to get up continues to. The PT fall screen indicates that the resident has staff always present in the room to supervise him/her to prevent falls. The screen documented that the staff did leave the room and the resident immediately got up and fell . The facility failed to adequately supervise Resident #26 to prevent falls.