Every finding on record at Merrimack County Nursing Home

Based on observation, interview and record review the facility failed to determine that it is clinically appropriate to self-administer medications for 2 of 3 residents reviewed for choices in a final sample of 35 residents. (Resident identifiers are #115 and #227.)Findings include: Resident #115 Observation on 3/23/26 at approximately 9:35 a.m. of Resident #115 revealed a plastic bag with a box containing eye drops on his/her bedside table. Further observation revealed that the medication was Ketotifen Fumarate Ophthalmic Solution 0.035%, prescription provided by the facility, with an open date of 1/26/26. Interview on 3/23/26 at approximately 9:40 a.m. with Resident #115 revealed that he/she would self-administer their eye drops. Review on 3/24/26 of Resident #115's Minimum Data Set revealed that Resident #115 had a Brief Interview of Mental Status score of 15/15 indicating cognitively intact. Review on 3/24/26 of Resident #115's medical record revealed no documentation of a self-administration assessment or order for the resident to self-administer their eye drops. Interview on 3/24/26 at approximately 11:47 a.m. with Staff J (Licensed Practical Nurse (LPN)) revealed that the Resident #115 did not have a self-administration assessment or order to self-administer his/her medications. Interview on 3/24/26 at approximately 12:01 p.m. with Staff H (Unit Manager) confirmed the above findings. Resident #227 Observation on 3/24/26 at approximately 8:30 a.m. in Resident #227's room revealed Resident #227 was in bed with his/her eyes closed. Further observation revealed a medicine cup with multiple pills/capsules in it on his/her bedside table. There was no staff present. Interview on 3/24/26 at approximately 8:35 a.m. with Staff C (LPN) revealed he/she left Resident #227's morning medications at his/her bedside. Further interview revealed Resident #227 did not have a physician's order or an assessment to self-administer medication. Review on 3/24/26 of Resident #227's March 2026's Medication Administration Record revealed the following morning medications that were left at bedside: Furosemide 40 mg (milligrams), Levetiracetam 500 mg, Metformin HCL (Hyrdrochloride) ER (extended release) 500mg (2 tablets), Metoprolol Tartrate 25 mg (1/2 tablet), Multivitamin with minerals, Omeprazole Magnesium Capsule DR (delayed release) 20.6 mg, Potassium Chloride ER 10 meq (milliequivalents), Sertraline HCL 100 mg, Synthroid 125 mcg (micrograms), and Apixaban 5 mg. Review on 3/24/26 of Resident #227's medical record confirmed there was no physician's order or assessment to self-administer medication. Interview on 3/24/26 at approximately 1:30 p.m. with Staff F (Assistant Director of Nursing) confirmed Resident #227 did not have a physician's order or assessment to self administer medication. Review on 3/25/26 of the facility's policy Self administration of medications Effective date May 2018 revealed, A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.D. The results of the interdisciplinary team assessment of resident skills and determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized self- administration, the label contains a notation that it may be self- administered. E. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication is conducted. Review on 3/26/26 of the facility's policy Medication times Original Date: March, 2017 revealed, 9. A resident can request self-administration of medications with provider approval and written order.

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation to the SSA (State Survey Agency) for 2 of 2 residents reviewed for abuse in a final sample of 35 residents. (Resident identifiers are #3 and #145.)Findings include:Resident #3Review on 3/24/26 of Resident #3's Nursing Progress Notes, dated 1/18/26, revealed the following, LNA [Licensed Nursing Assistant] reported to nurse that resident pushed another resident after grabbing [pronoun omitted] by the chest while shouting to 'get out'. Other resident found on the floor against the wall slouched. Other resident was able to get up with assistance from a staff member. Message left for guardian. Nursing supervisor notified. Will start 15 minute safety checks.Review on 3/24/26 of Resident #3's Social Services Progress Notes, dated 1/23/26, revealed the following: High Risk Meeting Note, . Discussion of recent res-to-res [resident to resident] altercation where [name omitted] pushed another resident who wandered in [pronoun omitted] room.Resident #145Review on 3/24/26 of Resident #145's Nursing Progress Note, dated 1/8/26, revealed the following, Alerted by floor nurse of potential altercation involving 2 residents. Camera footage was reviewed, and it was observed that there was physical contact between [name omitted] and another resident [name omitted]. [name omitted] was observed grabbing at [name omitted]. [name omitted] sustained a bruise to his/her wrist. The primary nurse was instructed to complete incident report. Notification sent to administration .Review on 3/24/26 of the facility policy titled, Abuse And Neglect Policy, Revision Dated 2/13/26, revealed, 10. All allegations of abuse or neglect, including all reportable resident to resident incidents, will be reported immediately (immediately shall be defined as within 2 hours) An internal investigation will be forwarded within 5 working days to the office of the Long Term Care Ombudsman for investigation.Interview on 3/24/26 at approximately 12:15 p.m. with Staff F (Assistant Director of Nursing) revealed that the above resident to resident incidents were not reported to the SSA.

Based on interview, and record review, it was determined that the facility failed to revise a care plan for 1 of 2 residents reviewed for falls in a final sample of 35 residents (Resident identifier is #178).Findings include:Review on 3/25/26 of Resident #178's medical record revealed he/she had a fall on 12/24/25.Review on 3/25/26 of Resident #178's fall summary report revealed that a new intervention to be added to Resident #178's care plan was for staff to offer residents to keep curtain open between the sides of the room with the exception of cares per resident choice.Review on 3/25/26 of Resident #5's care plan titled, at risk for falls, revealed that the care plan was not updated with the above intervention after Resident #178's fall on 12/24/25.Interview on 3/25/26 at 8:30 a.m. with Staff O (Unit Manager) confirmed the above findings.Review on 3/25/26 of the facility policy titled, Fall/Accident Management Program, revised 12/2024, revealed: .3. IDT fall meeting will occur weekly after a fall and will include discussion of possible causes of the fall and development of new fall prevention interventions. Resident care plan will be updated accordingly.

Based on record review, observations, and interviews, the facility failed to ensure that medications were administered in accordance professional standards for 1 of 3 residents reviewed for closed records and for 2 of 3 residents observed during medication administration. (Resident's identifiers are #287, #16, and #296.)Findings include: Resident #287 [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614, .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 3/24/26 of Resident #287's February Medication Administration Record (MAR) revealed the following orders for Morphine Sulfate Concentrate 20 mg/mL(milligram/milliliter), active from 2/5/26 through 2/9/26: Moderate pain/dyspnea: Give 0.5 mL orally every 30 minutes as needed for breakthrough moderate pain or dyspnea with respiratory rate 26–28. May give PO/SL (by mouth/sublingual). Severe pain/dyspnea: Give 1 mL orally every 30 minutes as needed for breakthrough severe pain or dyspnea with respiratory rate >29. May give PO/SL. Review on 3/24/26 of Resident #287's February MAR documentation showed the following administration of morphine was administered outside the ordered parameters: On 2/7/26 at 12:47 p.m., 1 mL of morphine was administered, the respiratory rate was documented as 22, and no pain level was recorded. On 2/7/26 at 8:58 p.m., 1 mL of morphine was administrated, the respiratory rate was documented as 18, and pain level was documented as zero. on 2/8/26 at 4:00 a.m.50 mL of morphine was administrated, the respiratory rate was documented as 22, and pain level was documented as 3. Interview on 03/24/26 at 2:29 PM, with Staff R (physician) confirmed that the medication was administered outside the ordered parameters. Resident #16 Review of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the preferred method for administering medications through a gastrostomy tube (G-tube) is by gravity via a syringe bolus rather than manually pushing the medication with the plunger (Boullata, 2019; A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force, 2009). The gravity bolus technique involves removing the syringe plunger, connecting the barrel to the G-tube, and allowing medications to drip in naturally under the influence of gravity (A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force, 2009; Boullata, 2019). This approach is recommended to reduce clogging risk, minimize gastrointestinal discomfort, and better regulate flow rate. The push method is acceptable only when gravity administration is impractical, but it must be performed slowly and carefully to avoid undue pressure, reflux, or tube blockage (Boullata, 2019; A.S.P.E.N. Enteral Nutrition Practice Recommendations Task Force, 2009). Observation on 3/23/26 at approximately 9:15 a.m. of Staff A (Licensed Practical Nurse) administering Resident #16's medications via (by way of) Gastrostomy Tube revealed Staff A pushed the following medications: Senna Liquid 5 mls (milliliters), Oxybutnin Chloride 5 milligrams, Hyfiber liquid 30 mls, Amlodipine 5 mg, Acidophillus capsule, Tizanidine 2 mg, Amoxicillin 10 mls. Staff A pushed a 15 ml flush of sterile water before and after each medication that was administered (8 pushed flushes). Interview on 3/23/26 at approximately 9:30 a.m. with Staff A confirmed the above findings. Review on 3/25/26 of the facility policy titled, Enteral Nutritional Therapy, dated 3/2024, revealed, Medication Administration through a Feeding Tube . 3. Use a piston syringe . to deliver medication via (by way of) gravity, through feeding tube adapter. Resident #296 Observation on 3/24/26 at approximately 8:30 a.m. of Staff D (Registered Nurse) administering a Breyna inhaler to Resident #296 revealed that Staff D did not offer Resident #296 to rinse his/her mouth after the inhaler was administered. Interview on 3/24/26 at approximately 8:30 a.m. with Staff D confirmed the above findings. Review on 3/25/26 of the Breyna inhaler manufacturer's instructions, dated 9/2020, revealed, After inhalation, the patient should rinse the mouth with water without swallowing. Review on 3/25/26 of the facility policy titled, Specific Medication Administration Procedures (IIB8. Oral Inhalation Administration, dated May 2018, revealed, . Q. For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup.

Based on observation, interview and record review the facility failed to provide special eating utensils for 1 of 3 residents reviewed for activities of daily living in a final sample of 35 Residents. Findings include:Review on 3/23/26 of Resident #91's meal ticket located on his/her breakfast tray revealed that he/she should use a divided plate, foam on spoon, non-slip mat and sip cups. Observation on 3/23/26 at approximately 8:52 a.m. revealed Resident #91 eating his/her breakfast in bed. Resident #91 was observed to using a standard utensil, standard plate, and no non-slip mat as part of Resident #91's meal set up. Further observation revealed that Resident #91 had multiple crumbs from his/her muffin and eggs on their clothing protector.Interview on 3/23/26 at approximately 9 a.m. with Resident #91 revealed that he/she had not had foam on spoon, divided plate, or a non-slip mat in a long time and the foam on the spoon made it easier for him/her to feed themselves. Observation on 3/23/26 at approximately 12:16 p.m. revealed Resident #91 was in the dining room for lunch. Resident #91 was using a standard spoon. His/her plate was placed directly on the linen tablecloth with no non-slip mat. Resident #91 attempted to eat yellow beans with the standard spoon and dropped them on his/her clothing protector. Interview on 3/24/26 at approximately 12:38 p.m. with Staff I (Licensed Practical Nurse) revealed that Resident #91's lunch tray contained a sandwich, crustless blueberry streusel, two bowls of soup, and two beverages in sippy cups. There were no foam on spoon or non-slip mat.Observation on 3/23/26 at approximately 12:45 p.m. revealed Resident #91 eating lunch in his/her bed. Resident #91 was using a standard spoon and spilled his/her soup.Interview on 3/24/26 at approximately 1:06 with Staff H (3 North Unit Manager) revealed that Resident #91 had a care plan to utilize adaptive eating devices when eating: built up utensils, sip cup, lip plate, and non-slip mat. Interview on 3/24/26 at approximately 2:18 p.m. with Staff F (Assistant Director of Nursing) revealed that the facility did not have a policy for the use of adaptive equipment.

Based on interview and record review, the facility failed to provided specialized rehabilitation evaluation for 1 of 1 residents reviewed for rehabilitation and restorative services in a final sample of 35 residents. (Resident identifier is #196.)Findings Include:Interview on 3/24/26 at approximately 8:48 a.m. with Resident #196 revealed that he/she was ambulatory when he/she entered the facility in 2023 and has had a decline and is now unable to ambulate. Resident #196 further revealed that he/she would like to work with rehab to be able to walk again. Review on 3/24/26 of Resident #196's Plan of Care note dated 1/15/26 revealed . Per request of [Name omitted], now that [pronoun omitted] is off hospice [pronoun omitted] would like to work with PT [Physical Therapy] again. A referral has been made.Interview on 3/24/26 at approximately 2:08 p.m. with Staff H (Unit Manager) revealed a rehabilitation (rehab) screen request, dated 1/6/26. Further Staff H revealed that he/she emailed the request to the rehabilitation department. Interview on 3/24/26 at approximately 3:00 p.m. with Staff M (Rehabilitation Director) revealed that a rehabilitation screen was not completed for Resident #196. Review on 3/25/26 of the facility's policy titled, Rehabilitation Screen, dated 9/2016, revealed, Any resident requiring a rehabilitation screen will be seen within seven days of submitted request 2. A non-urgent rehabilitation screen can be requested by email to the rehab department.

Based on interview and record review, the facility failed to ensure that a Significant Change in Status Minimum Data Set (MDS) assessment was completed timely by the 14th calendar day of a resident being admitted to or discharged from hospice services for 6 of 8 residents reviewed for resident assessment in a final sample of 35 residents (Resident Identifiers are #43, #128, #173, #196, #221, and #279).Findings include:Resident #43 Review on 3/24/26 of Resident #43's Hospice Certification of Terminal Illness revealed that Resident #43 was admitted to hospice care on 12/4/25. Review on 3/24/26 of Resident #43's Significant Change in Status MDS with an Assessment Reference Date (ARD) of 12/12/25 revealed it was signed as completed on 12/23/25 by Staff G (MDS Coordinator), five days late. Resident #128 Review on 3/24/26 of Resident #128's Hospice Certification of Terminal Illness revealed that Resident #128 was admitted to hospice care on 11/8/25. Review on 3/24/26 of Resident #128's Significant Change in Status MDS with an ARD of 11/14/25 revealed it was signed as completed on 11/24/25 by Staff G, two days late. Resident #173 Review on 3/24/26 of Resident #173's Hospice Certification of Terminal Illness revealed that Resident #173 was admitted to hospice care on 12/8/25. Review on 3/24/26 of Resident #173's Significant Change in Status MDS with an ARD of 12/19/25 revealed it was signed as completed on 1/2/26 by Staff G, eleven days late. Resident #221 Review on 3/24/26 of Resident #221's Hospice Certification of Terminal Illness form revealed that Resident #221 was admitted to hospice care on 1/31/26 Review on 3/24/26 of Resident #221's Significant Change in Status MDS with an ARD of 2/6/26 revealed it was signed as completed on 2/19/26 by Staff G, 6 days late. Resident #279 Review on 3/24/26 of Resident #279's Hospice Certification of Terminal Illness revealed that Resident #279 was admitted to hospice care on 1/2/26. Review on 3/24/26 of Resident #279's Significant Change in Status MDS with an ARD of 1/9/26 revealed it was signed as completed on 1/23/26 by Staff G, seven days late. Interview on 3/25/26 at 1:44 p.m. with Staff G confirmed that MDS assessment for Residents #43, #128, #173, #221, and #279 were completed late. Resident #196 Review on 3/24/26 of Resident #196's Hospice Discharge Summary revealed that Resident #196 was discharged from hospice care on 12/31/25. Review on 3/24/26 of Resident #43's Significant Change in Status MDS with an Assessment Reference Date of 1/9/26 revealed it was signed as completed on 1/23/26 by Staff G, nine days late. Interview on 3/24/26 at approximately 2:49 p.m. with Staff G confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure expired medications were removed from stock and multidose vials were labeled with an open/expiration date for 3 out of 4 medication rooms and 1 out of 7 medication carts observed (Resident identifiers are #31, #33, #36, #112, #126, and #152). Findings include: Observation on 2/26/25 at approximately 8:15 a.m. with Staff B (Registered Nurse) of Young Adult/Hospice medication room revealed a bottle of Omeprazole suspension for Resident #152 with an expiration date of 2/15/25 in the medication refrigerator. Interview on 2/26/25 at approximately 8:20 a.m. with Staff B confirmed the above findings. Review on 2/26/25 of Resident #152's medical record revealed an order for Omeprazole Oral Suspension 2mg (milligrams)/ML (milliliter) Give 10 ml via G-tube in the morning, with a start date of 1/26/24. Review on 2/26/25 of Resident #152's Medication Administration Record (MAR) revealed that Resident #152 received Omeprazole on 2/26/25. Observation on 2/26/25 at approximately 8:40 a.m. with Staff C (Registered Nurse) of the 3rd floor medication room revealed one bottle of Synthroid 25 mcg (microgram) tablets for Resident #126 with a pharmacy expiration date of 12/25/24. Review on 2/26/25 of Resident #126's medical record revealed and order for Synthroid 25 mcg give 0.5 tablet by mouth one time of day with a start date of 7/19/23. Interview on 2/26/25 at approximately 8:45 a.m. with Staff C revealed that the Resident #126 was not receiving medication from the above bottle but that it had not been removed from available stock in the medication room. Observation on 2/27/25 at approximately 9:00 a.m. with Staff F (Registered Nurse) of the 4 South medication room revealed 3 bottles of Lipitor for Resident #112 with use by dates of 6/28/24, 9/18/24, and 3/22/24. Observation further revealed two unopened bottles of house stock Geri Mox with expiration dates of 11/24. Interview on 2/27/25 at approximately 9:10 a.m. with Staff F confirmed that Resident #112 was no longer on the above medication however it had not been removed from available stock in the medication room. Observation on 2/26/25 of 3400 Medication Cart with Staff D (Licensed Practical Nurse) at approximately 9:30 a.m. revealed 3 open bottles of Refresh Tears for Resident #31, #33, and #36 with no open date or open expiration date. Interview on 2/26/25 at approximately 9:35 a.m. with Staff D confirmed the above findings. Review on 2/26/25 of Resident #31's medical record revealed and order for Artificial Tears Ophthalmic Solution 1.4% instill one drop in both eyes three times per day with a start date of 12/21/24. Review on 2/26/27 of Resident #33's medical record revealed and order for Artificial Tears 1% drops solution instill one drop in both eyes two times per day with a start date of 8/17/22. Review on 2/26/25 of Resident #36's medical record revealed an order for Refresh Tears solution instill one drop in both eyes in the morning with a start date of 12/31/22. Review on 2/27/25 of manufacturers' instructions for Refresh Tears, Revised: 6/2022, revealed . Other Information Discard 90 days after opening . Review on 2/27/25 of facility policy titled, Medication Storage In the Facility, dated May 2018, revealed . Expiration Dating (Beyond-use dating) . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .

Based on observation, interview, and record review, it was determined that the facility failed to follow policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for indwelling catheters in a final sample of 35 residents (Resident Identifier is #225). Findings include: Review on 2/26/25 of Resident #225's physician orders revealed an order for suprapubic catheter, dated 5/28/24. Observation on 2/26/25 at approximately 10:10 a.m. of Resident #225's room revealed that Resident #225 that there was no signage at door for EBP or available Personal Protective Equipment (PPE) for use. Interview on 2/27/25 at approximately 2:30 p.m. with Staff G (Infection Preventionist) confirmed that Resident #225 was not on EBP. Interview on 2/28/25 at approximately 11:15 a.m. with Staff H (Licensed Nursing Assistant) revealed that Staff H had not followed EBP during care for Resident #225. Interview on 2/28/25 at approximately 11:17 a.m. with Staff I (Licensed Practical Nurse) confirmed that Resident #225 had a catheter. Review on 2/28/25 of Facility policy titled Enhanced Barrier Precautions, dated 7/2024, revealed .Policy Interpretation and Implementation .Requirements for EBP .1. Enhanced barrier precautions will be applied to facility residents with the following criteria: .c) Who have an indwelling medical device. (Devices include urinary catheters, .)

Based on record review and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 residents in a final sample of 35 residents (Resident Identifiers are #9, #27, #103 and #157). Findings include: Resident #9 Review on 2/27/25 of Resident #9's quarterly MDS with an Assessment Reference Date (ARD) of 1/29/25 revealed under item N0300 Injections and item N0350 Insulin were both coded 7 indicating that Resident #9 had received insulin injections during the last 7 days. Review on 2/27/25 of Resident #9's January 2025 Medication Administration Record and physician's orders revealed that there were no physician orders noted for insulin and no injections were documented as being administered. Interview on 2/27/25 at 1:48 p.m. with Staff A (Reimbursement Coordinator) revealed that Resident #9 was not receiving insulin in January 2025 and confirmed that the MDS was coded incorrectly. 43408 Resident #27 Review on 2/27/25 of Resident #27's Quarterly MDS, ARD of 12/11/24, revealed the following: Section O0110K1b (Special Treatments, Procedures and Programs) was coded for having Hospice while a resident; Section M1040 A. (Skin Conditions) was coded for having an infection of the foot; Section M1040 B was coded for having a diabetic ulcer. Review on 2/27/25 of Resident #27's medical record for December 2024 revealed no Hospice orders. Further review of Resident #27's medical record revealed no documentation of any Diabetic ulcers or foot infections. Interview on 2/28/25 at approximately 11:05 a.m. with Staff A confirmed that Resident #27 did not have Hospice services in place, did not have a foot infection, and did not have a diabetic ulcer during the look back period of the above MDS. Resident #103 Review on 2/27/25 of Resident #103's Quarterly MDS, ARD of 12/17/24, revealed that section N0415 E (Anticoagulant Medications) was coded as taking an anticoagulant medications. Review on 2/27/25 of Resident #103's medical record for December 2024 revealed no anticoagulant medications were ordered or given. Interview on 2/28/25 at approximately 11:05 a.m. with Staff A confirmed the above information and that Resident #103's Quarterly MDS, ARD 12/17/24, was not coded correctly. 49819 Resident #157 Review on 2/27/25 of Resident #157 most recent MDS, ARD 11/29/24, revealed section N0415 E (Anticoagulant Medications) was coded as taking an anticoagulant medication. Review on 2/27/25 of Resident #157 physician orders revealed no orders for an anticoagulant medication during the 7 day look back period. Further review revealed that Resident #157 was on Plavix (antiplatelet medication). Interview on 2/27/25 at approximately 1:50 p.m. with Staff A confirmed above findings.

Based on interview and record review, it was determined that the facility failed to ensure that residents received adequate supervision, during and after a fire alarm, which resulted in a resident eloping and a delay in locating the resident in which the resident was held at the hospital for observation and treatment for hypothermia for 1 of 3 resident reviewed for elopement in a final sample of 39 residents (Resident Identifier #99). Findings include: Interview on 3/19/24 at approximately 11:00 a.m. with Staff D (Administrator) revealed that on 3/13/24, the fire alarm sounded at 12:50 a.m. due to smoke coming from a resident room. The fire alarm sounded and the locking mechanism of the locked doors disengaged which led to all exit doors being unlocked. Staff D stated that during a review of the video recordings, Resident #99 was seen exiting the 2200 Unit via the stairwell exit door at 1:00 a.m. and exiting the facility at approximately 1:15 a.m. Staff D also stated that the fire alarm was cleared at approximately 1:30 a.m. and that a resident census check was not done by the staff at 2200 unit. Interview with Staff D also revealed that at approximately 4:00 a.m. staff at 2200 Unit found that Resident #99 was missing, the nurse supervisor was notified and a code green indicating a missing resident was initiated at approximately 4:25 a.m. Staff D stated that Resident #99 was found outside the facility at approximately 5:20 a.m. and Resident #99 was sent to the hospital for evaluation. Further interview with Staff D also revealed that on 3/13/24 they began their investigation of Resident #99's elopement, they updated the facility's fire procedure and elopement policy, initiated staff education on the updated policies and procedures, and planned for mock drills which will be reviewed and monitored in Quality Assurance. Interview on 3/19/24 at 12:11 p.m. with Staff F (Licensed Nurse Assistant (LNA)) revealed that he/she did not do a resident census check after the fire alarm was cleared on 3/13/24 at the 2200 Unit. Interview on 3/19/24 at 12:26 p.m. with Staff E (LNA) revealed that he/she did not do a resident census check at the 2200 Unit after the fire alarm was cleared on 3/13/24. Review on 3/19/24 of Resident #99's hospital records, dated 3/13/24, revealed Chief Complaint Hypothermia .Assessment/Plan 1. Hypothermia .there was a fire drill .and after (pronoun omitted) was unable to be located by staff. (Pronoun omitted) was found 4 to 5 hours later on the property but in a ditch. (Pronoun omitted) was only in a short-sleeved shirt and like [sic] cotton pants. (Pronoun omitted) was hypothermic and so (pronoun omitted) was transferred to the hospital. In the ER [emergency room ] (pronoun omitted) was placed on a Bair Hugger [a temperature managing system used to maintain core body temperature]. Initial Temperature at time of arrival was 33.5 C [degrees Celsius] . 33.5 C is equivalent to 92.3 degrees Fahrenheit (F). Review of Hypothermia retrieved on 3/19/24 from https://www.mayoclinic.org/diseases-conditions/hypothermia/symptoms-causes/syc-20352682 revealed the following: Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F . Left untreated, hypothermia can lead to complete failure of your heart and respiratory system and eventually to death. Review on 3/19/24 of the facility's policy, titled Fire Procedures, revised date of 3/13/24, revealed Nurses .4. After the all clear the nurse will print a unit census and a safety check will be completed and documented . Review on 3/19/24 of the facility's policy titled Elopement (Missing Resident), revised date of 3/13/24, revealed .Should an employee discover that a resident is missing from the facility, the employee should: .b.Fire alarm Procedure: When the fire alarm sounds all Secure Care locked doors automatically release. Staff should be assigned to monitor theses doors. (as stated in the Emergency Operation Plan Fire Procedures book) d. Immediately after the all clear a census check should be completed and documented to verify safety of residents on all units . Review on 3/19/24 of the facility's in-service staff education sheet on the facility's updated fire procedure and elopement policy revealed that it was completed between 3/13/24 through 3/15/24. Review on 3/19/24 of the facility's sign-in sheet for Code Red (fire procedure) mock drill revealed that it was completed on 3/19/24.

Based on observation, interview, and policy review, it was determined that the facility failed to maintain infection control practices in regards to wound dressing changes for 1 out of 1 resident observed during wound dressing changes (Resident Identifier #20). Findings include: Review on 3/22/24 of the Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings retrieved from https://www.cdc.gov/handhygiene/providers/index.html read, in part, .Introduction to Hand Hygiene . Why Practice Hand Hygiene? Cleaning your hands reduces the spread of potentially deadly germs .use an alcohol-based hand sanitizer . before moving from work on a soiled body site to a clean body site on the same patient . After contact with blood, body fluids, or contaminated surfaces .Glove Use .Change gloves and perform hand hygiene during patient care, if . gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient . Observation on 3/19/24 at approximately 10:30 a.m. of Staff A (Registered Nurse) performing the dressing change on Resident #20's surgical site (his/her right posterior hip) revealed that Staff A removed the old dressing, cleansed the wound, prepped the clean dressing, and attempted to apply the clean dressing to the wound without changing his/her gloves or performing hand hygiene. Interview on 3/19/24 at approximately 10:40 a.m. with Staff A confirmed that he/she did not remove gloves or perform hand hygiene between removing the old dressing and applying a new dressing. Interview on 3/21/24 at approximately 1:25 p.m. with Staff C (Director of Nursing) revealed it is the facility's policy to change gloves and perform hand hygiene after removing the old dressing and before applying the new dressing. Interview on 3/21/24 at approximately 1:25 p.m. with Staff B (Infection Preventionist) confirmed it is the facility's policy to change gloves and perform hand hygiene after removing the old dressing [soiled/contaminated body site] and before applying the new dressing [clean body site]. Review on 3/22/24 of the facility's policy titled Hand Hygiene dated 12/2017 revealed .1. Hand Hygiene must be performed: .Before donning gloves and after removing gloves . When moving from a contaminated body site to a clean body site.

Based on interview and record review, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, except if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days he/she would document their rational and indicate the duration for the PRN order, for 3 of 5 residents reviewed for psychotropic medication side effects in a final sample of 39 residents (Resident identifiers are #31, #177, and #205). Findings include: Resident #31 Review on 3/1/23 of Resident# 31's active physician orders revealed an order for Ativan [anti-anxiety] 0.5 milligram (mg), give 1 tablet sublingually every 4 hours as needed for mild anxiety with a start date of 1/18/23 and no duration or end date. Further review of Resident #31's active physician orders also revealed an order for Ativan 0.5 mg, give 2 tablets sublingually every 4 hours as needed for moderate to severe anxiety with start date of 1/18/23 and no duration or end date. Review on 3/2/23 of Resident #31's January 2023 and February 2023 Electronic Medication Administration Record (EMAR) revealed that Resident #31 did not receive any doses of the Ativan PRN with start date of 1/18/23. Review on 3/2/23 of Resident #31's provider notes and psychiatry consult notes revealed no documentation of duration or end date of the PRN Ativan 0.5 mg order and no documentation of rationale for extending the PRN Ativan order for more than 14 days. Interview on 3/2/23 at 2:40 p.m. with Staff A (Registered Nurse) confirmed the above findings. Resident #205 Review on 3/1/23 of Resident #205's active physician orders revealed an order for Lorazepam [anti-anxiety] 0.5 mg, give 1 tablet by mouth every 4 hours as needed for anxiety and review within 14 days with a start date of 1/25/23 and no duration or end date. Review on 3/2/23 of Resident #205's January 2023 and February 2023 EMAR revealed that Resident #205 received a dose of the PRN Ativan 0.5 mg on 1/26/23, 1/27/23, 2/1/23, 2/9/23, 2/10/23, 2/19/23, 2/26/23, 2/27/23, and 2/28/23. Review on 3/2/23 of Resident #205's provider notes and psychiatry consult notes revealed no documentation that the PRN Ativan was reviewed within 14 days from the order start date of 1/25/23, which would be approximately on 2/8/23 and 2/28/23. Further review of Resident #205's provider notes and psychiatry consult notes revealed no documentation of duration or end date for the PRN Ativan order and no documentation of rationale for extending the PRN Ativan order for more than 14 days. Interview on 3/2/23 at 2:43 p.m. with Staff B (Registered Nurse) confirmed the above findings for Resident #205. 38218 Resident #177 Review on 2/28/23 of Resident #177's February 2023 Medication Administration Record (MAR) revealed the following order: Lorazepam oral tablet 0.5 mg, give 1 tablet by mouth every 4 hours as need for anxiety or restlessness, start date 1/31/23. Interview on 3/1/23 at approximately 1:40 p.m. with Staff D (Assistant Director of Nurses) confirmed the above order for Lorazepam did not have a stop date for use.

Based on observation, interview, and record review it was determined that the facility failed to ensure 2 of 4 medication rooms had temperatures recorded for refrigerators containing influenza vaccinations and insulin pens. Additionally, there was an expired insulin vial available for use in 1 of 6 medication carts (Resident identifiers are #25 and #96). Findings include: Young Adult / Hospice Unit Medication Room: Observation on [DATE] at approximately 8:45 a.m. of the Young Adult / Hospice Unit medication room refrigerator with Staff B (Registered Nurse) revealed a box of Fluzone High-Dose influenza vaccine and one Basaglar Kwikpen 100 units per milliliter (u/ml) insulin for Resident #25. Review on [DATE] at approximately 8:45 a.m. of the facility's form titled, Merrimack County Nursing Med Room Refrigerator Temperature Readings revealed no temperature recordings on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review on [DATE] at approximately 8:45 a.m. of the facility's form titled Merrimack County Nursing Med Room Refrigerator Temperature Readings further revealed recorded medication refrigerator temperatures out of temperature range 36 degrees ( ) Fahrenheit (F) to 46 F with no recorded resolutions on the following dates: [DATE] (30 F), [DATE] (34 F), [DATE] (32 F), [DATE] (31 F), [DATE] (31 F), [DATE] (34 F), and [DATE] (33 F). 3-South Medication Room: Observation on [DATE] at approximately 9:00 a.m. of the 3-South Unit medication room with Staff F (Licensed Practical Nurse) revealed 2 unopened Trulicity 0.75 milligrams (mg) per 0.5 milliliter (ml) insulin pens for Resident #96 and 7 Fluzone High-Dose influenza vaccination syringes. Review on [DATE] at approximately 8:45 a.m. of the facility's form titled, Merrimack County Nursing Med Room Refrigerator Temperature Readings revealed no temperature recordings on the following dates: [DATE], [DATE], and [DATE]. Review on [DATE] of manufacturer specifications for Fluzone High-Dose, Basaglar Kwikpen 100u/ml insulin, and Trulicity 0.75mg/0.5ml insulin pen revealed to store unopened items refrigerated between 36 F to 46 F. Interview on [DATE] at approximately 10:50 a.m. with Staff D (Director of Nursing) confirmed the above findings. Review on [DATE] of Fluzone High-Dose manufacturer specifications stated: 16.2 Storage and Handling - Store Fluzone High-Dose Quadrivalent refrigerated at 2 C [Celsius] to 8 C (35 to 46 F). DO NOT FREEZE. Discard if vaccine has been frozen. Review on [DATE] of Basaglar Kwikpen 100u/ml insulin manufacturer specifications stated: Store unused Pens in the refrigerator at 36 F to 46 F (2 C to 8 C) Review on [DATE] of Trulicity solution for injection in pre-filled pen manufacturer specifications stated: Store in refrigerator (2 C to 8 C). Do not freeze. Review on [DATE] of the facility's policy titled Medication Room Refrigerator, origination date [DATE] stated: 1. The acceptable temperature range will be 36 F to 46 F (2 C to 8 C) 4. ,d+[DATE] Nurse will record the temperature daily on the monitoring sheet 3-South Medication Cart: Observation on [DATE] at approximately 7:45 a.m. during medication administration revealed that Staff G (Licensed Practical Nurse) was ready to administer expired Lantus insulin to Resident #96. The opened Lantus 100 u/ml insulin vial obtained from the 3-South medication cart was expired, with a recorded open date of [DATE] and a recorded expiration date of [DATE]. At the time of the observation Staff G confirmed the finding. Review on [DATE] of Lantus Manufacturer Specifications stated: The LANTUS vials you are using should be thrown away after 28 days, even if it still has insulin left in it. Review on [DATE] of the facility's policy titled Storage of Medications, with revision date of ,d+[DATE] stated: 6. The nurse will check the expiration date of each medication before administering it. 7. No expired medication will be administered to a resident.

Based on interview, and record review it was determined that the facility failed to ensure that the Paid Feeding Assistants (PFA) provided dining assistance only for residents who did not have complicated feeding problems for 1 of 3 residents who were fed by PFAs (Resident identifier is #30). Findings include: Review on 2/28/23 at approximately 11:00 a.m. of the facility's list titled Resident's who have been approved for assistance with the trained assistant revealed that Resident #30 was on this list. Review on 3/2/23 at approximately 9:00 a.m. of Resident #30's medical diagnosis list revealed that Resident #30 had a diagnosis of dysphagia. Review on 3/2/23 at approximately 9:00 a.m. of Resident #30's physician's orders revealed an order for pureed texture for dysphagia, no straws allowed, single sips via cup only. Review on 3/2/23 at approximately 9:00 a.m. of Resident #30's speech therapy discharge summary dated 12/14/22 revealed that Resident #30 was discharged from speech therapy with recommendations for puree diet with thin liquids (single sips via cup, straws not allowed.) Interventions included focused education and training for Resident #30 and caregivers in safe swallow strategies in order to reduce risks for aspiration and reduce s/sx [signs/symptoms] of dysphagia. Resident #30 is nonspeaking, unable to follow commands, and totally dependent for feeding. Review on 3/2/23 at approximately 9:00 a.m. of Resident #30's nutrition assessment dated [DATE] revealed that Resident #30 is on a pureed diet with nectar thick liquids and is dependent with feeding for most meals. Review on 3/2/23 at approximately 9:15 a.m. of Resident #30's care plan revealed a focus for swallowing .Resident #30 is at risk for impaired swallowing secondary to advanced age and dementia. Care plan interventions include . monitor for chewing and/or swallowing difficulty, including oral spillage, coughing, choking, wet vocal quality, watery nose/eyes while eating, pocketing food/fluids in cheeks. Further review of Resident #30's swallowing care plan revealed that on 1/25/23 Staff K (Registered Dietitian) canceled the care plan intervention that deemed Resident #30 appropriate to participate in the feeding assistant program. Interview on 3/2/23 at approximately 10:11 a.m. with Staff H (Unit Manager) confirmed that Resident #30 was assisted at meals by PFAs identified as Staff I (Hairdresser) and Staff J (Assistant Food Service Manager). Interview on 3/2/23 at approximately 10:53 a.m. with Staff J confirmed that he/she had completed the PFA training approximately 2 months ago and that Staff J does assist Resident #30 with feeding at mealtimes. Staff J also stated that the nurse on the unit, or the Unit Manager was responsible for assigning PFAs to residents who require assistance. Interview on 3/2/23 at approximately 11:13 a.m. with Staff I confirmed that he/she had completed the PFA training approximately 2 months ago and that Staff I does assist Resident #30 with feeding at mealtimes. Staff I also stated that the nurse on the unit, or the Unit Manager is responsible for assigning PFAs to residents who require assistance. Review of the facility's policy titled Paid Feeding Assistant Training Program dated 11/2022 under section Resident Selection item #2 Residents who have complicated eating problems, such as but not limited to difficulty swallowing, recurrent lung aspirations or who receive nutrition through parenteral or enteral means will not be eligible and item #3 .Appropriateness will be reflected in resident's comprehensive care plan.

Based on interview, record review, policy review, and Centers for Disease Control (CDC) COVID-19 testing guidance it was determined that the facility failed to test 1 of 4 residents reviewed for COVID-19 testing (Resident identifier is #10). Findings include: Review on 2/28/23 of Resident #10's medical record revealed the following nursing notes and COVID-19 assessments: 1/19/23 COVID-19 assessment: . Lung Sounds clr [clear] Cough No .Headache No . 1/20/23 COVID-19 assessment: . Lung Sounds clr/dim [clear/diminished] Cough Yes, intermittent cough dry and at baseline .Headache No . 1/21/23 COVID-19 assessment: . Cough Yes, loose nonproductive .Headache Yes, Resident says comes and goes past week . 1/22/23 COVID-19 assessment: none documented in medical record 1/23/23 4:05 a.m. a PRN [as needed] dose of Guaifenesin ER [extended release] 12 hour 600mg [milligrams] was administered for loose non productive cough. 1/23/23 5:33 a.m. Slept poorly during the night. HOB [head of bed] slightly elevated. Nasal congestion with clear nasal drainage noted. Resident c/o [complaint of] headache at 0130 [1:30 a.m.]. Stated It's not a migraine. LS [lung sounds] clear throughout. Occasional loose nonproductive cough. 0400 [4:00 a.m.] I think I got it. Mucinex DM [dextrethorphan] offered and accepted for cough. Temp 97.7 [degrees]. O2 sat [oxygen saturation] 97% [percent] room air. Updated on morning testing for unit. 1/23/23 8:35 a.m. Resident tested positive for COVID-19 this morning during the unit response testing . Interview on 3/2/23 at approximately 11:30 a.m. with Staff E (Infection Preventionist) confirmed that Resident #10 was not tested for COVID-19 until 1/23/23 at 8:22 a.m. Staff E revealed that he/she would expect residents to be tested as soon as the resident develops any symptoms. Review on 3/2/23 of the facility policy titled, BinaxNOW COVID-19 Ag [antigen] testing, dated December 9, 2020 revealed: . 3. Residents suspected of a potential COVID infection will be tested after onset of symptoms, or suspected exposure event. Review on 3/2/23 of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/27/22 .Perform SARS-CoV-2 Viral Testing Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible.

Based on observation and interview, it was determined that the facility failed to ensure that kitchen utensils were stored in a sanitary environement for food service safety in 6 out of 6 kitchenettes observed. Findings include: Standard: Review on 4/6/22 of the U.S. FDA (Food Drug and Administration) Food Code (2017), retrieved from: https://www.fda.gov/media/ 2/download, revealed [page 152-153] .Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in ¶ (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under ¶ (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted . 4 North Kitchenette Observation on 4/6/22 at approximately 9:08 a.m. with Staff K (Food Service Director) in the 4 North Kitchenette revealed 1 kitchen knife and 1 green-colored bread knife with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles and food debris in between the microwave and cabinet which the kitchen knife and bread knife were in contact with. Interview on 4/6/22 at approximately 9:08 a.m. with Staff K revealed the above findings in the 4 North Kitchenette. Staff K stated that knives should not be stored in between the microwave and the cabinet. Staff K also stated that kitchen staff managed the unit kitchenettes. 4 South Kitchenette Observation on 4/6/22 at approximately 9:14 a.m. with Staff K (Food Service Director) in the 4 South Kitchenette revealed 3 kitchen knives with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles in between the microwave and cabinet which the kitchen knives were in contact with. Interview on 4/6/22 at approximately 9:14 a.m. with Staff K revealed the above findings in the 4 South Kitchenette. 3 South Kitchenette Observation on 4/6/22 at approximately 9:22 a.m. with Staff K (Food Service Director) in the 3 South Kitchenette revealed 3 kitchen knives with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles in between the microwave and cabinet which the kitchen knives were in contact with. Interview on 4/6/22 at approximately 9:22 a.m. with Staff K revealed the above findings in the 3 South Kitchenette. 3 North Kitchenette Observation on 4/6/22 at approximately 9:14 a.m. with Staff K (Food Service Director) in the 3 North Kitchenette revealed 3 kitchen knives with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles in between the microwave and cabinet which the kitchen knives were in contact with. Interview on 4/6/22 at approximately 9:14 a.m. with Staff K revealed the above findings in the 3 North Kitchenette. Young adult/Hospice unit Kitchenette Observation on 4/6/22 at approximately 9:35 a.m. with Staff K (Food Service Director) in the Young adult/Hospice unit Kitchenette revealed 2 kitchen knives with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles in between the microwave and cabinet which the kitchen knives were in contact with. Interview on 4/6/22 at approximately 9:35 a.m. with Staff K revealed the above findings in the Young adult/Hospice unit Kitchenette. Dementia unit Kitchenette Observation on 4/6/22 at approximately 9:46 a.m. with Staff K (Food Service Director) in the Dementia unit Kitchenette revealed 4 kitchen knives with no covers were stored in between the microwave and the cabinet. Further observation revealed accumulated dust particles in between the microwave and cabinet which the kitchen knives were in contact with. Interview on 4/6/22 at approximately 9:46 a.m. with Staff K revealed the above findings in the Dementia unit Kitchenette.

Based on interview, record review, policy review and CDC (Centers for Disease Control) Long term care guidance it was determined that the facility failed to test 2 symptomatic residents for COVID-19 out of 3 residents reviewed for symptoms in a survey sample of 36 residents reviewed. (Resident identifiers are #88, and #111.) Findings include: Resident #88 Review on 4/7/22 of Resident #88's medical record revealed the following Nurse Progress Note, dated 3/28/22: At 1930 LNA (Licensed Nursing Assistant) reported that resident was throwing up; upon entering the room found resident in [pronoun omitted] bed laying on [pronoun omitted] right side with a basin in front of [pronoun omitted] with a small amount of liquid emesis with small food particles; resident stated that it all happened all of a sudden; resident stated that [pronoun omitted] still felt sick; . Review on 4/7/22 of Resident #88's medical record revealed that there was no documentation of Resident #88 being tested for COVID-19 on 4/7/22. Resident #111 Review on 4/7/22 of Resident #111's medical record revealed the following Nurse Progress Note, dated 4/2/22: Resident c/o (complained of) sore throat this shift, . Review on 4/7/22 of Resident #111's medical record revealed that there was no documentation of Resident #111 being tested for COVID-19 on 4/2/22. Interview on 4/8/22 at approximately 2:30 p.m. with Staff F, Infection Preventionist confirmed that Resident #88 and Resident #111 were not tested for COVID-19 after a symptom was identified and the residents identified were not placed on precautions after having a symptom of COVID-19. Staff F revealed that a resident with a solo symptom or a symptom one time would not be tested for COVID-19. Review on 4/8/22 of the facility policy titled, Binax NOW COVID-19 Testing, Origination Date, December 9, 2020 revealed: .2. Residents suspected of COVID infections will be tested after symptom onset, or suspected exposure event. Symptoms may include fever, sneezing, cough, sore throat, shortness of breath, absence of taste or smell, muscle aches, chills, severe fatigue, nausea, vomiting or diarrhea. Symptomatic residents who test negative will remain on assigned unit and may be placed under precautions if symptoms are significant. Review on 4/9/22 of the CDC's, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing homes, updates as of 2/2/22 revealed: .Testing .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible .

Based on interview and record review, the facility failed to ensure that the facility's bowel protocol was followed for 2 of 4 residents reviewed for constipation in a final sample size of 36 residents. (Resident identifiers are #30 and #63.) Findings include: Review on 4/8/22 of facility policy titled Bowel Management Program initiated 12/05, revealed .d) if a resident has not had a bowel movement by the evening of day 2, the resident should receive bowel management medication as ordered by the physican. e) Bowel management treatment should progress from the least invasive intervention to the more invasive intervention, i.e. Day 2 MOM, Day 3 Suppository .g) if there are no results after all ordered interventions have been attempted, a gastrointestinal assessment will be performed by the nurse and the physican will be notified . Review on 4/8/22 of the facility's Bowel Management Guidelines for Nurses, provided by Staff E, revealed the following algorithm; Day 2 no BM 3-11 shift, offer [MEDICATION(S)] (and circle refusal on MAR if declines); Day 3 no BM 11-7 shift, offer suppository per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 Review on 4/7/22 at 9:36 a.m. of Resident #63's medical record revealed a nurses note date 4/6/22 written at 10:12 p.m. that stated resident is x 8 days no BM [bowel movement], received PRN [as needed] MOM [milk of magnesia] results pending. Abdomen is soft and non-distended . Further review of Resident #63's progress notes revealed a nurse's note dated 4/6/22 written at 2:35 p.m. revealed .Resident is a day 8 according to the bowel list .currently smearing however due to [pronoun omitted] rib fractures, [pronoun omitted] is hesitant to push. Review on 4/7/22 at approximately 1:30 p.m. of Resident #63's LNA (licensed nursing assistant) documentation of bowel movements revealed the following entries: 3/29/22 size medium 3/30/22 hospital Review on 4/7/22 at 2:12 p.m. of Resident #63's Medical record revealed a comprehensive nursing assessment dated [DATE] that documents last BM 3/31/22. Further review of Resident #63's medical record revealed they were readmitted from the hospital on 4/1/22. Review on 4/7/22 at approximately 2:15 p.m. of Resident #63's April 2022 MAR (Medication Administration Record) revealed Resident # 63 was administered MOM at the following times: 4/4/22 2:57 a.m. 4/5/22 7:01 a.m. 4/6/22 10:12 p.m. Further review of the April 2022 MAR revealed Resident #63 was administered a Dulcolax suppository on 4/6/22 at 4:34 a.m. Interview on 4/7/22 at approximately 2:33 p.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #63's last known bowel movement was before his readmission on 4/1/22. Staff A stated that Resident #63 should have had the bowel protocol initiated after 2 days of no BM. Resident #30 Review on 4/6/22 of Resident #30's nursing progress notes revealed that the resident had an enema administered on 3/24/22 due to not having a bowel movement since 3/17/22. Review on 4/8/22 of Resident #30's Significant Change MDS Minimum Data Set, dated dated dated [DATE] revealed that the resident had short and long term memory deficits with severely impaired decision making, required extensive assistance of 2 people for toileting, was always incontinent of bowel and was checked for having constipation. Review on 4/8/22 of Resident #30's LNA documentation of bowel movements revealed the following entries: -3/17/22 a loose bowel movement -3/2722 a soft bowel movement. There were no other bowel movements documented between 3/18/22 to 3/26/22 (nine days). Review on 4/8/22 of Resident #30's nursing progress notes revealed the following: - On 3/24/22 at 10:53 p.m. the following note; Last charted BM [bowel movement] was on 3/17/22; hyper bowel sounds in all four quadrant; abdomen nondistended; updated supervisor; new order received: Fleet enema rectally daily prn [as needed] for constipation. At [9:30 p.m.] resident was given fleet enema with no results at this time; supervisor updated. -On 3/25/22 at 10:39 p.m. the following note; .Resident continue to be a day seven (sic) without BM; .APRN [Advanced Practice Registered Nurse] was updated. [New order] [MEDICATION(S)] 17.6 grams . Per LNA resident did not have a BM on this 3-11 shift . -On 3/26/22 at 11:25 p.m. the following note; Bowel assessment performed, [abdomen] flat, not distended. Review on 4/8/22 of Resident #30's March 2022 MAR revealed the following; -Senna 8.6 mg (milligrams) tablet. Give one tablet by mouth daily for constipation as needed was administered on 3/20/22, 3/22/22, 3/25/22 and 3/26/22. -[MEDICATION(S)] 10 mg suppository. Give one suppository per rectum daily as needed for constipation was adminstered on 3/24/22 and 3/27/22. -Fleet enema insert one dose rectally daily as needed for constipation was administered on 3/24/22. -[MEDICATION(S)] powder 17.6 gram give now by mouth was administered on 3/25/22. Review on 4/8/22 of Resident #30's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/08/22 at 1:38 p.m. with Staff E (Unit Manager) confirmed that Resident #30's had no documented bowel movement between 3/18/22 and 3/26/22. Staff E confirmed that the facility's bowel management protocol was not followed. Staff E stated that the Bowel Management Guidelines for Nurses should have been followed.

Based on record review, policy review, and interview, it was determined that the facility failed to inform the resident's Durable Power of Attorney (DPOA) of the risks of treatment from antipsychotic medications for 1 out of 5 residents reviewed for unnecessary medications. (Resident identifier is #33.) Findings Include: Review on 4/7/22 of Resident #33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 2.5 mg (milligram) PO [by mouth] in PM [evening]. Review on 4/7/22 of Resident # 33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 4/8/22 of Resident #33's medical record revealed there was no documented consent from Resident #33's DPOA for [MEDICATION(S)] 2.5mg, ordered on 11/2/21. Interview on 4/8/22 at 1:20 p.m. with Staff C (Registered Nurse) confirmed that there was no documentation of consent obtained prior to [MEDICATION(S)] being administered. Interview on 4/8/22 at 2:25 p.m. with Staff D (Licensed Practical Nurse) revealed that antipsychotics medications are not to be administered prior to obtaining consenf from a resident or resident's DPOA. Review on 4/8/22 of the facility policy titled, Monitoring and Documenting of Antipsychotic and [CONDITION(S)] Medication, Date 12/2017 revealed: Policy Statement To promote or maintain the resident's highest practicable mental, physical, and psychosocial well being while utilizing the lowest effective dose of antipsychotic and [CONDITION(S)] medications Dementia .8. The legal representative will be educated on the medication's side effects and consent to threat form must be completed. Consent must be given prior to the start of treatment.

Based on record review and interview, it was determined that the facility failed to provide an environment that was free of accidents with the use of assistive devices for 1 of 1 resident who fell and sustained injury in the standard survey sample of 35 residents. (Resident identifier is #210.) Findings include: Interview on 3/20/18 at 10:10 a.m. with Resident #210 revealed that they had a fall a couple of months ago. Resident #210 stated that during that day of the accident Resident #210 asked house keeping to clean the bathroom since it was dirty. Resident #210 said that evening they needed to use the bathroom so Resident #210 used the call bell and Staff E (Licensed nursing assistant) came to transfer Resident #210 onto the toilet seat, then left to get lotion for his/her shoulders and arms. Resident #210 stated as soon as I sat down on to the raised toilet seat it began to wobble and the raised toilet seat fell off the toilet throwing me to the ground. Review of Resident Incident Report dated 11/13/17 reveals: 2005 (8:05 p.m.) Responded to emergency bell in Resident's bathroom, upon arrival, Resident on floor on R (right) side, raised toilet seat on floor behind Resident's buttocks, ., LNA in attendance. Upon assessment, Resident with hematoma R head behind ear, skin tear on R jaw, c/o (complaining of) pain R shoulder and extreme pain R hip .Hematoma R side of head behind ear, skin tear R jaw line, R shoulder and hip pain (unable to move RLE (right lower extremity)). Review of the Hospital records titled history and physical examination [REDACTED].The patient although very physically frail, mostly in a wheelchair, but able to transfer with a walker and use the commode with a walker, is cognitively intact. (Resident #210) says that this evening (Resident #210) was on an elevated toilet seat, when (Resident #210) shifted in the toilet seat, slipped off the toilet, throwing (Resident #210) to the ground. Review of the hospital records titled INTERIM SUMMARY REPORT with a discharge date d of 11/24/17 reveals under ACTIVE [DIAGNOSES REDACTED]. Also within the notes it states The patient does need to have her cervical collar continued to be used for the next 2-3 months. There was some concern about inadequate p.o. (by mouth) intake due to this collar. Upon evaluation, it was felt that (Resident #210) may benefit from a PEG. This is in place. (Resident #210) is currently on bolus feedings. Review of the manufacture's instruction for the 2-in-1 locking Raised Toilet Seat . under installation instructions under number (5) reveals Check for secure fit routinely before using product . Also under a section of the instruction manual it states CAUTION 1) Always be sure that the seat is correctly and securely locked in place before using. 2) Be sure that the adjustment knob in front of the seat is tight at all times, thus securing the seat to the toilet bowl. After reading these instruction Staff A (Director of Nurses) when asked if LNA staff are trained prior to transferring resident to check for stability of the raised toilet seat prior to transferring and Staff A stated No This same question was asked of Staff D (Assistant director of nursing) who also said No. Interview on 3/22/18 at 10:45 a.m. with Staff A was asked if the Staff B (house keeper) who cleaned Resident #210's bathroom (confirmed by facility staff) that day could be interviewed, Staff A stated they were no longer employed and could not be interviewed. Staff A was then asked since Staff B is no longer employed at the facility could a house keeping staff from another unit that has raised toilet seats be asked what they would do to clean the raised toilets. Interview on 3/22/18 at 10:50 a.m. with Staff A on unit 3B revealed that there were multiple raised toilet lifts. Staff C (house keeper) and Staff A were asked if when cleaning a resident's bathroom with a raised toilet seat and you see there is feces on the seat what would you do? Staff C stated they would remove the seat and wash the toilet, Staff C went on to say if it were a bubble raised toilet which is the one Resident # 210 was using which was confirmed by Staff A they would remove the device and put it back on when done cleaning the toilet. Interview on 3/22/18 at 11:05 a.m. with Staff F (Director of Quality Improvement) revealed that the raised toilet seat that was used by Resident #210 at the time of the accident was tested the next day to see if the equipment was broken. Staff F stated they locked it on the toilet and moved there body forward, backward, and side to side while sitting on the toilet seat and no mater how hard they tried they could not get the raised toilet seat to come off the toilet. Interview on 3/23/18 at 10 a.m. with Staff A and Staff F confirmed that the facility did a compete audit of all resident bathrooms and this type of raised toilet chair has been removed and replaced with a 4 legged free standing type of raised toilet seat taking away the potential for this to reoccur.

Based on record review, review of the facility's incident report, the facility's surveillance video of the Special Care Unit common area and staff interview it was determined that the facility failed to ensure that a resident has the right to be free from abuse for 1 resident resulting in the resident becoming increasingly aggressive and physically abusive toward a staff member. (Resident identifier #2) Findings include: Review of Resident #2's medical record on 9/15/10 reveals that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's mini mental score on 7/30/10 reveals a score of 2 indicating severe cognitive impairment. Review of Resident #2's care plan reveals a focus area initiated 8/11/10 of alteration in behaviors: wandering, instances of physical aggression and abuse with an intervention that indicates if displays resistiveness, walk away and re-approach in 10-15 minutes. Review with Staff A, Administrator of the facility's surveillance video for 9/7/10 at 7:17 p.m. of the 2nd floor SCU (Special Care Unit) common area revealed Staff D, LNA (Licensed Nurses Assistant) approached Resident #2 who displayed resistance by attempting to push away Staff D. Another resident is observed walking nearby in the area of altercation with other residents seated at tables in the common area. Staff D does not walk away or attempt to re-approach Resident #2 later but continues the interaction with Resident #2 in which Staff D is observed placing hands on Resident #2's arm and attempting to pull Resident #2 towards Resident #2's room. Resident #2 is observed attempting to free arm from Staff D's hands when Staff D releases Resident #2's arm and Staff D then placed both hands onto Resident #2's back and pushes Resident #2 into the room. Resident #2 is then observed to have turned around and now facing Staff D Resident #2 grabs Staff D by both forearms, Staff D is observed attempting to break free of Resident #2's grasp and then Resident #2 pushes Staff D away from the doorway with Staff D landing onto the floor in the hallway. Interview on 9/15/10 with Staff A, Administrator and Staff B, DNS (Director of Nurses), indicated that Staff D, LNA did not follow Resident #2's care plan and that Staff D had unprivileged contact and rough handling utilizing physical interventions of pushing and pulling Resident #2. Resident #2's behavior escalated as a result with Resident #2 becoming physically abusive toward Staff D resulting in Staff D receiving injury.

Based on record review, review of the facility's incident report, the facility's surveillance video of the Special Care Unit common area and staff interview the facility failed to ensure that a resident has a right to refuse care for 1 resident in an investigation survey. (Resident identifier is #2.) Findings include: Review of Resident #2's medical record on 9/15/10 reveals that Resident #2 has Alzheimer's with behavioral disturbance, hearing loss and vision impairment. Resident #2 has much cognitive loss and may not comprehend words spoken. Review of Resident #2's care plan reveals a focus area initiated 8/11/10 of alternation in behaviors: wandering, instances of physical aggression and abuse with an intervention that indicates if displays resistiveness, walk away and re-approach in 10-15 minutes. Review with Staff A, Administrator of the facility's surveillance video for 9/7/10 at 7:17 p.m. of the 2nd floor SCU (Special Care Unit) common area revealed Staff D, LNA (Licensed Nurses Assistant) approached Resident #2 who displayed resistance by attempting to push away Staff D. Staff D does not walk away or attempt to re-approach later but continues the interaction with Resident #2 in which Staff D is observed placing hands on Resident #2's arm and attempting to pull Resident #2 towards Resident #2's room. Resident #2 is observed attempting to free arm from Staff D's hands when Staff D releases Resident #2's arm and Staff D then placed both hands onto Resident #2's back and pushes Resident #2 into the room. Interview on 9/15/10 with Staff A, Administrator and Staff B, DNS (Director of Nurses), indicated that Staff D, LNA did not follow Resident #2's care plan and that Staff D had unprivileged contact and rough handling utilizing physical interventions of pushing and pulling Resident #2.