Every finding on record at Mountain View Community

Based on interview and record review, it was determined that the facility failed to protect the personal privacy of a resident for 1 of 1 residents reviewed for abuse in a final sample of 21 residents (Resident identifier is #77). Findings include:Interview on 9/2/25 with the complainant revealed that on 8/28/25 a post was made on social media which revealed that a resident was being transferred from the facility to a local hospital. The post mentioned a resident's daughter's name and that Resident #77 had pain and a spinal issue. Someone sent the complainant the post on social media because they had identified that the post referred to the complainant's mother.Interview on 9/23/25 at approximately 11:15 a.m. with Staff G (Quality Director) revealed that Staff H (Social Service Director) informed Staff G on 9/15/25 that there had been a comment posted on a social media platform about Resident #77's transfer to the hospital. Interview on 9/23/25 at approximately 1:00 p.m. with Staff F (Health Information Manager) confirmed that on 8/28/25 he/she commented on a social media platform about Resident #77's transfer to the hospital. Staff F revealed they were counseled by administration about not sharing information on social media on 9/15/25. Review on 9/23/25 at approximately 10:30 a.m. of the facility's social media policy titled Social Media Policy revised on 6/29/23 revealed .H. Employees must take proper care not to purposely or inadvertently disclose any information that is confidential or sensitive.

Based on interview and record review, it was determined that the facility failed to meet professional standards of care for 1 of 1 resident reviewed for pain management in a final sample of 21 residents (Resident identifier is #4).Findings include:Review on 9/25/25 of [NAME] and [NAME], Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Elsevier, 2021. Page 610-Medication Administration Right Indication .is considering the seventh right of medication administration .Review on 9/23/2025 of Resident #4 physician orders revealed an order dated 4/21/25 for Oxycodone 5 milligrams (mg), Give 1 tablet by mouth every 4 hours as needed for moderate-severe pain.Review on 9/23/25 of Resident #4's August 2025 Medication Administration Record (MAR) revealed on 8/12 Resident #4 received Oxycodone for a pain level of 0. Review of September 2025 MAR revealed Resident #4 received Oxycodone on 9/1 for a pain level of 0; on 9/2, 9/4, and 9/5 for a pain level of 4; on 9/6 for pain level of 3; on 9/12, 9/16, 9/19, 9/21, and 9/22 for pain level of 4.Review on 9/24/25 of facility policy titled Pain Assessment and Management revised 2024 revealed .General Information: 3. Assessment scales .Mild 1-4; Moderate 5-6; Severe 7-10 .Interview on 9/24/2025 at approximately 11:30 a.m. with Staff E (Unit Manager) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from use for 1 of 2 medication carts observed. (Resident identifier is #97).Findings include:Observation on 9/23/2025 at approximately 9:00 a.m. of the Mount [NAME] medication cart with Staff A (Medication Nursing Assistant) revealed Resident #97's Tramadol 50 mg (milligrams) medication card with a pharmacy expiration date of 7/30/25.Review on 9/23/25 of the narcotic administration book revealed he/she had received one Tramadol on 8/4/25.Interview on 9/23/25 at approximately 9:00 a.m. with Staff A confirmed the above medication was administered to Resident #97 on 8/3/25, and it had expired on 7/30/25.

Based on interview and record review, it was determined that the facility failed to ensure residents receiving antipsychotic medications had appropriately identified behaviors for the continued use of antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications in a final survey sample of 20 residents. (Resident identifiers are #61 and #86). Findings include: Review on 9/12/24 of the facility's policy titled, Medication - Psychoactive, last revised 1/31/20, revealed: .1. The attending physician or consulting psychiatrist will do a comprehensive assessment of a resident according to OBRA requirements for dose reduction. Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless contraindicated, in an effort to discontinue these drugs. A progress note documenting the decision with supporting rationale shall be written by the physician. 2. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .6. The medication administration nurse/ LN [Licensed Nurse] will be responsible for documenting frequency of targeted behaviors and side effects of antipsychotic, hypnotic and anxiolytics medications, on the psychoactive flow record . Review on 9/12/24 of the facility's policy titled, Behavior Monitoring, initiated 8/8/18, revealed: .It is the policy to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psycho-social well being. Behaviors monitoring and documentation will be appropriate to allow the healthcare provider the ability to target acceptable behaviors and provide the necessary behavioral health care and services. Procedure: 1. Behavior Monitoring Flowsheets/notes are completed for all residents presenting behaviors. Documentation is to be completed by a Licensed Nurse. All other staff should report behaviors immediately to the Licensed Nurse . Resident #86 Review on 9/12/24 of Resident #86's physician orders revealed the following order: Seroquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg [milligram] by mouth at bedtime for psychosis, with a start date of 2/8/24. Further review on 9/12/24 of Resident #86's medical record revealed there were no identified target behaviors or psychotic symptoms monitored to support the use of an antipsychotic medication. Resident #86 was not receiving psychiatric services. Resident #86 did not have a care plan for behavior monitoring or any non pharmological interventions. Interview on 9/12/24 at approximately 11:30 a.m. with Staff A (Nurse Practitioner) and Staff B (Director of Nursing) confirmed the above findings. Resident #61 Observation on 9/10/24 at approximately 9:30 a.m. of Resident #61 revealed them to be in bed with eyes closed, not responding to verbal stimuli and with bilateral hand contractures. Review on 9/10/24 of Resident #61's physician orders revealed an order for Abilify 2mg once a day for unspecified psychosis that was started on 12/6/21. Review on 9/11/24 of Resident #61's medical record revealed the last documented behavior was on 8/22/22. Further review of Resident #61's medical record revealed that there was no care plans for behavior monitoring or any non pharmological interventions. Review on 9/11/24 of Resident #61's Psychiatry notes for January and April 2024 revealed no active behaviors. Further review of Resident #61's psychiatry notes revealed a note dated 4/15/24 that stated Gradual Dose Reduction (GDR) clinically contraindicated for one year as decrease in these medications can worsen patient's clinical condition. Interview on 9/12/24 at approximately 9:00 a.m. with Staff C (Licensed Practical Nurse) revealed Resident #61 was on end of life care, was unable to stand and was dependant on staff for all activities of daily living. Staff C stated they were unaware of any current or recent behaviors for Resident #61. Interview on 9/12/24 at approximately 9:21 a.m. with Staff B confirmed the last known or documented behavior for Resident #61 was 8/22/22. 28881

Based on interview and record review, it was determined that the facility failed to ensure that residents' as needed (PRN) orders for an anti-psychotic drug were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluated the resident for appropriateness of that medication for 1 of 6 residents reviewed for unnecessary medications (Resident identifier is #10). Findings include: Review on 8/24/23 of Resident #10's written physician's order, dated 8/2/23, revealed an order to resume Risperdal (anti-psychotic) 0.5 milligram (mg) by mouth two times a day as needed for hallucinations with an order date of 8/2/23 and start date of 8/3/23. Further review of the PRN Risperdal 0.5 mg order revealed no duration date of 14 days. Review on 8/24/23 of Resident #10's medical record revealed no documentation that the attending physician or prescribing practitioner evaluated Resident #10 for appropriateness of the Risperdal medication 14 days after the start date (8/3/23), which was 8/17/23. Review on 8/24/23 of Resident #10's August 2023 Electronic Medication Administration Record (EMAR) revealed a physician order for Risperdal 0.5 mg by mouth two times a day PRN with a start date of 8/3/23 and no duration date of 14 days. Further review revealed that Resident #10 received one dose of the PRN Risperdal 0.5 mg on 8/24/23. Interview on 8/24/23 at 1:00 p.m. with Staff D (Director of Nursing) confirmed the above findings. Review on 8/24/23 of the facility's policy titled, Medication- Psychoactive, revision date of 1/31/20, revealed .PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication .

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards and manufacturer's instructions for administering medications for 1 out of 28 medication administrations observed (Resident Identifier is #5). Findings include: Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. [NAME], 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 . Observation on 8/23/23 at 9:05 a.m. with Staff A (Medication Nursing Assistant) during medication administration for Resident #5 revealed that Staff A mixed 1 tablespoon of Metamucil 28.3 percent (%) with water in a 7-ounce plastic cup then administered to Resident #5. Review on 8/23/23 of Resident #5's August 2023 Electronic Medication Administration Record revealed a current order for Metamucil powder 28.3% give 1 tablespoon by mouth two times a day for constipation with a start date of 3/3/23. Further review of the order revealed that there were no instructions of how many ounces to use when mixing the Metamucil powder. Review on 8/23/23 of the Metamucil manufacturer's instruction revealed to mix one rounded teaspoon of product with 8 ounces of fluid. Interview on 8/23/23 at 9:14 a.m. with Staff A confirmed the above findings. Staff A stated that he/she would mix the Metamucil powder with water. Staff A does not know how much water to mix with the Metamucil powder.

Based on interview and record review, it was determined that the facility failed to follow the return to work guidelines for health care personnel who were positive for COVID-19 illness from working in the facility. 1 of 13 staff reviewed for COVID-19 infection returned to work the day after they tested positive for COVID-19. 12 of 13 staff reviewed for COVID-19 infection returned to work on day 4 or later. This failure increased the likelihood of exposure to pathogens for the facility's census of 87 residents, staff, and visitors (Staff identifiers are A, M, N, O, P, W, Q, R, S, G, T, U, and V). Findings include: Review on 4/10/23 of the facility COVID-19 line list of positive staff and the March 2023 and April 2023 nursing schedules revealed the following: Staff A (Registered Nurse (RN)) tested positive for COVID-19 on 3/14/23 and returned to work on 3/20/23 (Day 6); Staff M (RN) tested positive for COVID-19 on 3/17/23 and returned to work on 3/24/23 (Day 7); Staff N (Licensed Nursing Assistant (LNA)) tested positive for COVID-19 on 3/28/23 and returned to work on 4/2/23 (Day 5); Staff O (LNA) tested positive for COVID-19 on 3/28/23 and returned to work on 4/4/23 (Day 7); Staff P (LNA) tested positive for COVID-19 on 3/28/23 and returned to work on 4/5/23 (Day 8); Staff W (Activities Aide) tested positive for COVID-19 on 3/28/23 and returned to work on 4/3/23 (Day 6); Staff Q (Licensed Practical Nurse (LPN)) tested positive for COVID-19 on 3/29/23 and returned to work on 4/5/23 (Day 7); Staff R (Medication Nursing Assistant (MNA)) tested positive for COVID-19 on 3/29/23 and returned to work on 4/4/23 (Day 6); Staff S (LPN) tested positive for COVID-19 on 3/29/23 and returned to work on 4/4/23 (Day 6); Staff G (LNA) tested positive for COVID-19 on 3/30/23 and returned to work on 4/5/23 (Day 6); Staff T (LNA) tested positive for COVID-19 on 3/30/23 and returned to work on 3/31/23 (Day 1); Staff U (LNA) tested positive for COVID-19 on 4/1/23 and returned to work on 4/5/23 (Day 4); Staff V (LNA/Activities Aide) tested positive for COVID-19 on 4/1/23 and returned to work on 4/6/23 (Day 5). Interview on 4/7/23 at approximately 10:00 a.m. with Staff A (RN) revealed that he/she had COVID-19 on 3/12/23 and had returned to work on 3/20/23. Staff A also revealed that he/she tested negative either on 4/3/23 or 4/5/23. Interview on 4/7/23 at approximately 12:30 p.m. with Staff B (Infection Preventionist) confirmed that Staff A returned to work on Day 6 after they tested positive for COVID-19. Staff B stated the facility was using contingency staffing guidance at that time. Staff B stated they were following the return to work criteria for contingency staffing during the recent COVID-19 outbreak due to staff being out sick. Interview on 4/10/23 at approximately 11:30 a.m. with Staff B confirmed that Staff T tested positive for COVID-19 on 3/30/23 and was working on the 11 p.m. to 7 a.m. shift performing direct resident care on 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/5/23, 4/6/23 and 4/7/23. Staff B stated that at the time the facility was following the crisis staffing guidelines. Interview on 4/10/23 at approximately 1:30 p.m. with Staff X (Administrator) revealed that the process for changing to contingency or crisis staffing is done between the Infection Preventionist, Director of Nursing and the Administrator. Staff X stated that they were aware that Staff T was positive for COVID-19 and working while positive as they were informed that they had no other options due to low staffing and no one to replace Staff T. Staff X stated that if the facility cannot cover an open shift and staffing is needed they would utilize the MDS [Minimum Data Set] Nurse, Infection Preventionist and then the Director of Nursing to cover the shift as a last resort. Further interview with Staff X confirmed that no nurse managers were scheduled for the 6 days above that Staff T worked while COVID-19 positive and confirmed that 5 of those days they had more than minimal staffing to allow for Staff T to have the time off. Interview on 4/10/23 via phone call at approximately 2:30 p.m. with Staff Y (Director of Nursing) revealed that he/she did not realize that Staff T worked all 5 days after testing positive for COVID-19. Staff Y also revealed that the process for changing to contingency or crisis staffing is done by the Infection Preventionist, but should be completed by all of the management team. Review on 4/10/23 of the Centers for Disease Control (CDC) Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposed to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen. If symptoms recur (e.g. [for example], rebound) these HCP should be restricted from work and follow recommended practices to prevent transmission to others (e.g., use of well-fitting source control) until they again meet the healthcare criteria below to return to work unless an alternative diagnosis is identified. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 4/10/23 of the CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated September 23, 2022, . Key Points . CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency strategies followed by crisis strategies are provide to augment conventional strategies and are meant to be considered and implemented sequentially (i.e.[that is], implementing conventional strategies followed by contingency strategies followed by crisis strategies. Introduction . CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency, followed by crisis capacity strategies, augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing contingency strategies before crisis strategies) . Allowing HCP with SARS-CoV-2 infection to return to work before meeting the conventional criteria could result in healthcare-associated SARS-CoV-2 transmission. Healthcare facilities (in collaboration with risk management) should inform patients and HCP when the facility is utilizing these strategies, specify the changes in practice that should be expected, and describe the actions that will be taken to protect patients and HCP from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are requested to work to fulfill staffing needs. As part of conventional strategies, it is recommended that healthcare facilities: Ensure any COVID-19 vaccine requirements for HCP are followed, and where none are applicable, encourage HCP to remain up to date with all recommended COVID-19 vaccine doses. Understand their normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances. Understand the local epistemology of COVID-19-related indicators (e.g., community transmission levels). Communicate with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed . When staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use contingency capacity strategies to plan and prepare for mitigating this problem. These include: Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities. Cancel all non-essential procedures and visits. Shift HCP who work in these areas to support other patient care activities in the facility. Facilities will need to ensure these HCP have received appropriate orientation and training to work in these areas that are new to them. Attempt to address social factors that might prevent HCP from reporting to work, such as need for transportation or housing that allows for physical distancing, particularly if HCP live with individuals with underlying medical conditions or older adults. Consider that these social factors disproportionately affect persons from some racial and ethnic groups, who are also disproportionally affected by COVID-19 (e.g., African Americans, Hispanics and Latinos, and American Indians and Alaska Natives). Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP. As appropriate, request that HCP postpone elective time off from work. However, there should be consideration for the mental health benefits of time off and that care-taking responsibilities may differ substantially among staff. Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection. Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: At least 5 days have passed since symptoms first appeared (day 0), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative nucleic acid amplification test (NAAT) or a series of 2 negative antigen tests taken 48 hours apart*. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: At least 5 days have passed since the date of their first positive viral test (day 0) . Review on 4/10/23 of the facility's policy titled A Staffing in Emergencies updated 4/15/22, revealed . Most of our staff work 8 hr [hour] shifts. If we got in to an emergency situation, we could switch to 12 hour shifts 3 days on and 3 days off .With administrators approval incentive can be offered for staff to work extra .There may be times when we need to use discretion and weigh the benefits and risks of a staff member entering the building and performing their department tasks. Departments with staff shortages: If a department has 50% [percent] of their staff out because of illness related to the pandemic we will use the contingency category for work restrictions from the CDC .

Based on interview and record review, it was determined that the facility failed to notify resident representatives and families of those residing in the facility by 5:00 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection for 8 out of 14 days reviewed from 3/14/23 to 4/5/23 when there were newly identified positive COVID-19 cases. Findings include: Review on 3/7/23 of the facility's COVID-19 line list revealed that the facility had positive COVID-19 rapid test results on the following dates: 3/14/23 (1 staff); 3/17/23 (1 staff); 3/20/23 (1 staff); 3/25/23 (1 resident residing on Mount [NAME]); 3/27/23 (1 resident residing on Mount [NAME]); 3/28/23 (6 staff); 3/29/23 (4 staff, 4 residents residing on Mount [NAME] North); 3/30/23 (1 staff); 3/31/23 (3 staff, 1 resident Mount [NAME]); 4/1/23 (2 staff); 4/2/23 (1 staff, 1 resident residing on Mount [NAME]); 4/3/23 (1 staff); 4/4/23 (2 staff); 4/5/23 (1 resident residing on Mount [NAME]). Interview on 4/7/23 at approximately 10:00 a.m. with Staff B (Infection Preventionist) revealed that the facility uses social media updates, emails, and phone calls to notify individuals that do not have access to the social media or email and that if a call is made it is noted in the resident chart. Review on 4/7/23 of all social media posts and emails provided by the facility that were utilized to notify residents representatives and families revealed the following: Social media updates were done on 3/27/23, 3/28/23, 3/29/23, 3/31/23, 4/3/23, and 4/5/23 and only discussed residents that were identified as positive; Email notifications were done on 3/27/23, 3/28/23, 3/29/23, 3/31/23, 4/3/23 and 4/6/23. Review on 4/7/23 of March 2023 and April 1-7, 2023 progress notes revealed: -Resident #1 residing on Mount [NAME], Durable Power of Attorney for Healthcare (DPOA-HC) (not activated), no documentation of notifications; -Resident #2 residing on Mount [NAME], DPOA-HC activated, documented notification on 3/27/23; -Resident #3 residing on Green Mountain, DPOA-HC not activated, no documentation of notifications; -Resident #4 residing on Green Mountain, DPOA-HC activated, no documentation of notifications; -Resident #5 residing on Mount [NAME], with a Guardian, documentation of notification on 4/3/23 and 4/6/23; -Resident #6 residing on Mount [NAME], DPOA-HC not activated, no documentation of notifications; -Resident #7 residing on Mount Chocurua, DPOA-HC not activated, no documentation of notifications; -Resident #8 residing on Mount Chocurua, DPOA-HC not activated, no documentation of notifications. Interview on 4/7/23 at approximately 2:30 p.m. with Staff B confirmed the above information and that the facility did not notify residents, representatives and families throughout the facility of all resident and staff COVID-19 positives identified. Staff B stated that the facility was only notifying the resident and/or representatives for only the residents that resided on the unit where a positive COVID-19 resident was identified.

Based on interview and record review, it was determined that the facility failed to adhere to physician ordered medication parameters for 1of 1 resident reviewed for parameters in a final sample of 24 Residents. (Resident identifier is #5.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 9/8/22 at approximately 11:50 a.m. of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure < [less than] 90 heart rate < 55 related to Essential (Primary) Hypertension. Start date 6/12/22. Review on 9/8/22 of Resident #5's MAR (Medication Administration Record) for June, July, August, and September revealed that Resident #5's blood pressure was documented on the MAR prior to administrating medication, however there was no documentation of Resident #5's heart rate being taken at the time the medication was administered at 8:00 p.m. for all dates in June, July, August, and September. Interview on 9/8/22 with Staff E (Director of Nursing) revealed that Resident #5's heart rate is taken on day shift and documented in the EMR (electronic medical record) in the section labeled Weights and Vitals Summary and not documented on the MAR with the blood pressure prior to administering medication. Staff E also confirmed that Resident #5's heart rate is taken on the day shift, several hours prior to the medication being administered at 8:00 p.m.

Based on interview and record review it was determined that the facility failed to ensure that suspected violations of allegations involving abuse were thoroughly investigated to ensure that the residents were free from abuse and neglect for 2 of 7 residents reviewed for alleged abuse and neglect in a final sample of 24 residents. (Resident identifiers are # 38 and #49.) Findings include: Resident #38 Review on 9/8/22 at approximately 9:30 a.m. of Resident #38's medical record revealed a nursing note dated 7/10/22 which documents that Resident #38 reached out to remove a peer's arm from the armrest of a chair; when peer stated Don't you touch me, you can get in trouble for touching another resident at which time Resident #38 put up both fists in a threatening manner. Review on 9/8/22 at approximately 10:00 a.m. of Resident #38's medical record revealed a nursing note dated 7/21/22 which documents that Resident #38 yelled at a peer in the dining room after breakfast You better stop yelling or they will come over and slap you in the face. Staff intervened and Resident #38 yelled out at another peer get out of here, get out of here while waving fist. Interview on 9/8/22 with Staff G (Unit Manager) on Green Mountain Unit revealed that resident to resident altercations are only reportable to the Ombudsman and the State if it is physical abuse. Interview on 9/8/22 with Staff E (Director of Nursing) revealed that Staff E did not consider Resident #38's altercations on 7/10/22 and 7/21/22 reportable, and did not require investigation. Interview on 9/8/22 with Staff A (Administrator/Abuse Coordinator) confirmed that Resident #38's altercations on 7/10/22 and 7/21/22 had not been reported or investigated. Resident #49 Findings include: Interview on 9/07/22 at 10:37 a.m. with Resident #49 (BIMS 15/15) revealed that the resident was reporting that there was a staff member that was not very nice. Resident #49 described the staff member as witchy-poo and that they do swear but not at him/her. Resident #49 declined to give anymore information and had not reported this information to anyone else. Resident #49 would not elaborate on the details around the word nice. Interview on 9/7/22 at 11:30 a.m. with Staff A (Administrator) was informed of Resident #49s comments Staff A was not aware of any complaints or issues with Resident #49 but would look into it. Record review on 9/07/22 at 12:30 p.m. of Resident #49's medical record revealed a documented note from Staff F (Social Services) on 09/07/22 with Resident #49 regarding the above concerns. Resident #49's note indicated that he/she does not need anyone's help with it and can handle this on his/her own and that the staff member was rude to her on more than one occasion. No further notes or elaboration on the word rude were documented. Interview on 9/9/22 at 11:00 a.m. with Staff A regarding the above investigation, Staff A was unable to provide evidence of an investigation. Review on 9/9/22 of facility policy titled Freedom from Abuse, Neglect, and Exploitation, revised on 10/20/20, revealed the following .3. An immediate inquiry must be made by the staff member in charge. All staff assigned to the unit, or location in the area where the alleged incident occurred, must complete a written statement as to their knowledge of the incident .4. Findings of the initial inquiry are to be reported to the Administrator, DON, or designees immediacy .6. At the Administrator's direction, a three member investigative team shall interview the resident (if able), witnesses and alleged perpetrator. All finds will be accurately documented and given to the ADM [Administrator], DON, or designee .

Based on interview and record review, it was determined that the facility failed to ensure that suspected violations of allegations of abuse were reported to the State Survey Agency within 24 hours for 2 of 7 residents reviewed for abuse in a final sample of 24 residents. (Resident identifiers are #38 and #49.) Findings include: Resident #38 Review on 9/8/22 at approximately 9:30 a.m. of Resident #38's medical record revealed a nursing note dated 7/10/22 which documented that Resident #38 reached out to remove a peer's arm from the armrest of a chair; when peer stated Don't you touch me, you can get in trouble for touching another resident at which time Resident #38 put up both fists in a threatening manner. Review on 9/8/22 at approximately 10:00 a.m. of Resident #38's medical record revealed a nursing note dated 7/21/22 which documented that Resident #38 yelled at a peer in the dining room after breakfast You better stop yelling or they will come over and slap you in the face. Staff intervened and Resident #38 yelled out at another peer get out of here, get out of here while waving fist. Interview on 9/8/22 with Staff E (Director of Nursing) revealed that Staff E did not consider Resident #38's altercations on 7/10/22 and 7/21/22 reportable, and did not require investigation. Interview on 9/8/22 with Staff A (Administrator/Abuse Coordinator) confirmed that Resident #38's altercations on 7/10/22 and 7/21/22 had not been reported or investigated. Resident #49 Interview on 9/07/22 at 10:37 a.m. with Resident #49 (BIMS 15/15) revealed that Resident #49 was reporting that there was a staff member that was not being nice to he/she. Resident #49 described the staff member as witchy-poo and that they do swear but not at him/her. Resident #49 has not reported this to any staff member and would not elaborate on details regarding them not being nice. Interview on 9/7/22 at 11:30 a.m. with Staff A (Administrator) Staff A was not aware of any complaints or issues with Resident #49 but would look into it. Record review on 9/07/22 at 12:30 p.m. of Resident #49's medical record revealed a documented note from Staff F (Social Services) on 09/07/22 with Resident #49 regarding the above concerns. Resident #49's note indicated that he/she does not need anyone's help with it and can handle this on her own and that the staff member was rude to her on more than one occasion. Interview on 9/9/22 at 11:00 a.m. with Staff A revealed that the above investigation was not completed and a copy was not available. Review on 9/9/22 of facility policy titled Freedom from Abuse, Neglect, and Exploitation, revised on 10/20/20, revealed .All staff will immediately report any suspected abuse to their supervisor of charge nurse. This includes, but is not limited to, resident injuries or other symptoms of abuse/neglect, report from resident or witness of verbal, sexual, physical abuse, involuntary seclusion, mental/emotional abuse, neglect and misappropriation of property . Review on 9/9/22 of the facility policy titled Freedom from Abuse, Neglect and Exploitation revised on 10/20/20 revealed .At the Administrators's direction, a three member investigative team shall interview the resident (if able), witnesses and alleged perpetrator. All findings will be accurately documented and given to the ADM (administrator) , DON (director of nurses), or designee. This report will be filed with the Administrator and confidentially stored. Reporting: 1. The Administrator, DON, or designee must report allegations of abuse to the resident's representative and Ombudsman immediately with in 2 hours if there is and injury and 24 hours without injury. The facility's complete investigation must be forwarded to the NH Long Term Ombudsman's with in 72 hours of the alleged incident

Based on interview and record review, it was determined that the facility failed to maintain a grievance log for a period of no less than 3 years. Findings include: Interview on 9/8/22 at approximately 9:11 a.m. with Staff A (Administrator) revealed that grievances are addressed at the time the grievance is reported to the facility. Staff A confirmed that there was no documented grievance log to track and/or trend complaints/grievances investigated by the facility for a period of no less than 3 years.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure proper storage of expired medications for 1 medication room out of 2 medication rooms observed. Findings include: Observation on 7/13/21 at 10:10 a.m. in the Mt. [NAME] medication room with Staff D (Medication Nursing Assistant) revealed a [MEDICATION(S)] medication with expiration date of 3/2021 which was stored with 5 unexpired [MEDICATION(S)] medications. Further observation revealed that Resident #19's [MEDICATION(S)] medication with a use by date of 7/12/21 stored with the unexpired insulin medication. Interview on 7/13/21 at approximately 10:15 a.m. with Staff D confirmed the above findings. Review on 7/14/21 of the facility's policy titled, Storage Medication, dated 11/17, revealed .Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without closures are immediately remove from stock

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols for 2 resident out of 6 residents reviewed for infections. (Resident identifiers are #11 and #38.) Findings include: Review on 7/19/21 of the CDC (Center for Disease Control and Prevention) and SHEA (Society of Health and Epidemiology of America) position paper titled, Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, October 2012, retrieved from: https://www.jstor.org/stable/pdf/10.1086/ 3.pdf, revealed that .Guiding Principles The criteria that define infections for surveillance purposes were selected to increase the likelihood that the events captured by application of the definitions are true infections . .Definitions for Constitutional Criteria in Residents of Long-Term Care Facilities (LTCFs) . A. Fever 1. Single oral temperature > [greater than] 37.8 degrees C [Celsius] (110 degrees F [Fahrenheit]) OR 2. Repeated oral temperatures >37.2 C (99 F)or rectal temperatures >37.5 C (99.5 F) OR 3. Single temperature >1.1 C (2 F) over baseline from any site (oral, tympanic, axillary) B. Leukocytosis 1. Neutrophilia(114,000 leukocytes/mm3) OR 2. Left shift(>6% bands or > 1,500 bands/mm3) C. Acute change in mental status from baseline (all criteria must be present .) 1. Acute onset 2. Fluctuating course 3. Inattention AND 4. Either disorganized thinking or altered level of consciousness D. Acute functional decline 1. A new 3-point increase in total activities of daily living (ADL) score (range 0-28) from baseline, based on the following 7 ADL items, each scored from 0(independent) to 4( total dependence) a. Bed mobility b. Transfer c. Locomotion within LTCF d. Dressing e. Toilet use f. Personal hygiene g. Eating . Confusion Assessment Method Criteria Acute onset Evidence of acute change in resident ' s mental status from baseline Fluctuating Behavior fluctuating(e.g coming and going or changing in severity during the assessment) Inattention Resident has difficulty focusing attention(e.g unable to keep track of discussion or easily distracted) Disorganized thinking Resident ' s thinking is in coherent (e.g rambling conversation, unclear flow of ideas, unpredictable switches in subject) Altered level of consciousness Resident ' s level of consciousness is described as different from baseline (e.g hyper alert, sleepy, drowsy, difficult to arouse,nonresponsive) . .Surveillance Definitions for Urinary Tract Infections (UTIs) . .Criteria . A. For residents without an indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign or symptom subcriteria a. Acute dysuria or acute pain, swelling,or tenderness of the testes, epididymis, or prostate b. Fever or leukocytosis .and at least 1 of the following localizing urinary tract subcriteria i. Acute costovertebralangle pain or tenderness ii. Suprapubic pain iii. Gross hematuria iv.New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract subcriteria i. Suprapubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv.New or marked increase in urgency iv.New or marked increase in frequency . .UTI should be diagnosed when there are localizing [CONDITION(S)] signs and symptoms and a positive urine culture result. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In the absence of a clear alternate source of infection,fever or rigors with a positive urine culture result in the noncatheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source . .2. One of the following microbiologic subcriteria a. At least 105 cfu/mL of no more than 2 species of microorganisms in a voided urine sample b. At least 102 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter . .Surveillance Definitions for Skin, Soft Tissue, and Mucosal Infections . .Criteria . A. [CONDITION(S)], soft tissue, or wound infection (at least 1 of the following criteria must be present) 1. Pus present at a wound, skin, or soft tissue site 2. New or increasing presence of at least 4 of the following sign or symptom subcriteria a. Heat at the affected site b. Redness at the affected site c. Swelling at the affected site d. Tenderness or pain at the affected site e. Serous drainage at the affected site f. One constitutional criterion Review on 7/19/21 of facility's policy titled, Antibiotic Stewardship dated 7/25/19, revealed that .Action a. Facility may consider protocols to address: i. Improving the evaluation and communication of clinical signs and symptoms when resident is first suspected of having an infection. ii. Optimizing the use of diagnostic testing. iii. An antibiotic review process, also known as antibiotic time-out (ATO) for all antibiotic prescribed in the facility. ATOs prompt clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. A- TO can be considered a stop order of an antibiotic when diagnostic test results or symptoms of resident do not support the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #11 Review on 7/14/21 of Resident #11's nurse's notes revealed that on 4/26/21, Resident #11 had frequent urination with incontinence and Resident #11 spoke to the nurse to ask physician for a UA (urinalysis) order. On 4/27/21, Resident #11 had no complaints of pain, itching and frequent urination. On 4/28/21 there was a new order for UA and [MEDICATION(S)] (antibiotic) for 7 days. Review also revealed that UA was collected and that urine was clear. Review on 7/15/21 of Resident #11's April 2021 EMAR (Electronic Medication Administration Record) revealed that Resident #11 received [MEDICATION(S)] on 4/29/21 and 4/30/21. Interview on 7/14/21 at approximately 1:00 p.m. with Staff C (Infection Preventionist) confirmed the above findings. Staff C stated that Resident #11 did not meet criteria for antibiotic use related to urinary tract infection (UTI). Staff C also stated that antibiotics for UTI's should be prescribed after receiving the results of urinalysis, culture and sensitivity. Staff C also stated that they use the McGeer's criteria for their antibiotic use protocol Review on 7/15/21 of Resident #11's urinalysis report dated 4/30/21 revealed that urine was yellow, clear, negative for [MEDICATION(S)], negative for leukocytes, no bacteria seen and no urine culture indicated. Interview on 7/15/21 at approximately 10:00 a.m. with Staff B (Assistant Director of Nursing) confirmed the above findings on 7/15/21. Resident #38 Review on 7/14/21 of Resident #38's infection control reporting form dated 2/23/21 revealed that Resident was prescribed [MEDICATION(S)] from 2/18/21 to 2/25/21. Review also revealed that there were no urine culture done. Interview on 7/14/21 at approximately 1:00 p.m. with Staff C confirmed the above findings on Resident #38. Staff C stated that Resident #38 did not meet criteria for antibiotic use as there was no urine culture done. Staff C also stated that in order to meet criteria for antibiotic use, Resident #38 should have at least 1 of the following sign and symptom subcriteria (i.e. dysuria) and 1 of the following microbiologic subcriteria which would need a urine culture. Review on 7/15/21 of Resident #38's MD (Doctor of Medicine) progress note dated 2/18/21 revealed that Resident #38 was complaining of dysuria (difficulty or painful urination) and vaginal itching. Further review revealed that MD questioned UTI versus [MEDICATION(S)] infection and MD will treat Resident #38 with [MEDICATION(S)] and [MEDICATION(S)] cream. Review on 7/15/21 of Resident #38's written physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that there were no urine culture ordered. Review on 7/15/21 of Resident #38's February 2021 EMAR revealed that Resident #38 received [MEDICATION(S)] for 7 days. Review on 7/15/21 of Resident #38's nursing notes revealed that there were no antibiotic time outs discussed with physician. Review on 7/14/21 of Resident #38's infection control reporting form dated 7/12/21 revealed that Resident #38 was prescribed [MEDICATION(S)] (antibiotic) from 7/12/21 to 7/18/21. Further review revealed documentation that Resident #38 did not meet criteria for antibiotic use related to skin, soft tissues and mucosal infection. Further review revealed that in order to meet criteria the resident has to have one of the following: pus at a wound or 4 signs and symptoms of a subcriteria. Review also revealed that Resident #38 only had 2 signs and symptoms of the subcriteria which were heat and redness at the affected site. Review on 7/14/21 of Resident #38's nurse's notes revealed that Resident #38's had right lower extremities redness and warm to touch. Review also revealed that Resident #38 denies pain right lower leg on 7/11/21. Interview on 7/14/21 at approximately 1:00 p.m. with Staff C confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to follow physician's order regarding weights for 1 resident out of 6 residents reviewed for nutrition out of a final sample of 21 residents. (Resident identifier is #20.) Findings include: Resident #20 Review on 7/13/21 of Resident 20's June 2021 and July 2021 Treatment Administration Records (TAR) revealed the following orders and weights: June 2021 TAR Weight 3x (times) per week-if +(plus)3 pounds overnight, or 5 pounds in 1 week to change to daily, and notify [pronoun omitted and telephone number] one time a day related to HEART FAILURE, UNSPECIFIED, per [pronoun omitted] to be done at 0600 prior to having anything to eat or drink., Start Date 2/9/21. Resident #20's weight on June 5th was 252.4 pounds, on June 6th weight was 255.7 pounds. This was a 3.3 pound weight gain in 24 hours. Resident #20's weight on June 10th was 248.6 pounds, on June 11th weight was 252.0 pounds. This was a 3.4 pound weight gain in 24 hours. July 2021 Weight 3x per week-if +3 pounds overnight, or 5 pounds in 1 week to change to daily, and notify [pronoun omitted and telephone number] one time a day related to HEART FAILURE, UNSPECIFIED, per [pronoun omitted] to be done at 0600 prior to having anything to eat or drink, Start Date 2/9/21. Resident #20's weight on July 6th was 254.4 pounds, on July 7th weight was 258.6 pounds This was a 4.2 pound weight gain in 24 hours. Interview on 7/15/21 at approximately 9:45 a.m. with Staff A (Unit Manager) revealed that Resident #20's weights are obtained on the 11-7 shift and there is no documentation of the physician being notified when there was a weight gain of greater than 3 pound in 24 hours. Review on 7/15/21 of the facility policy titled, Weight Loss or Gain, Revision date 12/7/20 revealed: Policy Residents will be weighed regularly to ensure adequate nutrition and hydration. Significant weight changes will be evaluated. Procedure 1. All residents are weighed as ordered by the physician 3. Charge nurses are responsible for recording weights on the TAR and comparing new weight and with the old weight. When a weight differs by three or more pounds from the last weight obtained, a re-weigh is needed using the same scale. If the re-weigh is a gain or loss of more than 3 pounds, the charge nurse is to notify the physician Review on 7/15/21 of the facility policy titled, Physician Order, Revision date 5/21/19 revealed: Procedure .4. Nursing to follow all physician orders as prescribed

Based on record review, interview and review of the facility policy and procedure it was determined that the facility failed to ensure that the medical record was accurate for 1 resident in a survey sample of 24 residents. (Resident identifier is #32.) Findings include: Resident #32. Review on 11/8/18 of the facility policy and procedure titled Cardiopulmonary Resuscitation dated 12/07/2016 revealed the following; Policy: Cardiopulmonary resuscitation will be initiated on all residents who have a respiratory or [MEDICAL CONDITION] unless contraindicated with a DNR (Do Not Resuscitate) order written by a physician. Procedure: . d. DNR will be noted on the MAR (Medication Administration Record). Review on 11/8/18 of the facility policy and procedure titled Physician Transcription dated 4/15/15 revealed the following: Procedure: . Monthly Physician Order Sheets 1) Pharmacy provides new 4 part Physician Order Sheets every month . 2) Two 11-7 staff licensed nurses check these entries and make necessary corrections . 4) The MAR indicated [REDACTED]. Review on 11/7/18 of the medical record for Resident #32 revealed a PORTABLE DO NOT ATTEMPT RESUSCITATION .ORDER signed and dated by the physician on 8/8/18. Further review of Resident #32's Medication Administration Record [REDACTED]. Review on 11/7/18 of the MAR for Resident #32 dated 11/1/18 showed the code status as FULL CODE with a line through it and hand written in the letters DNR (Do Not Resuscitate). Review on 11/7/18 of the signed Physician Orders for Resident #32 dated 9/1/18 revealed Resident #32's code status as FULL CODE. Interview on 11/7/`18 at approximately 10:30 a.m. with Staff D (Licensed Practical Nurse) confirmed that Resident #32 is a DNR as of 8/8/18 and that the 8/1, 9/1, 10/1 MAR's and the signed physician orders for 9/1/18 were not correct and accurate for Resident #32. That the 8/1/18 MAR indicated [REDACTED]. Interview on 11/7/18 at approximately 1:30 p.m. with Staff A (Director of Nursing) after review of the above listed MAR's, DNR order and Physician Orders for Resident #32 revealed Staff A confirmed that Resident #32 was a DNR as of 8/8/18 and that these documents listed were incorrect and not accurate. Staff A confirmed at this time that the 11/1/18 MAR for Resident #32 with the crossed out Full Code should have been initialed and dated by the person changing the code status from Full Code to DNR.

Based on record review and interview it was determined that the facility failed to develop a coordinated Plan of Care for 4 of 4 resident's receiving Hospice services in a survey sample of 24 residents. (Resident identifiers are #12, #22, #40 and #59.) Findings include: Record review on 11/7/18 for Resident's #12, #22, #40 and #59 revealed that the facility failed to show a coordinated Plan of Care as evidenced by not including or documenting the Hospice goals and interventions in order to ensure that facility staff is providing consistent care when Hospice staff are not scheduled in the facility. The Hospice care plans did not establish which services will be provided to each individual resident. Interview on 11/7/18 at 1:30 p.m. with Staff A (DON) and Staff B (LPN) including review of Resident #12's, Resident #22's, and Resident #40's care plans revealed and confirmed that the Hospice Care Plans are not individualized with established services for each resident and are from the library, facility's computerized base care plan. Interview on 11/7/18 at 11:30 p.m. with Staff C, (ADON) icluding review of Resident #59's care plan revealed and confirmed that the goals and interventions were not listed for specific Hospice disciplines and frequencies rendering care to Resident #59.

Based on record review and interview, it was determined that the facility failed to develop and implement a timely plan of action to correct the recent issues they have had with residents spilling hot tea on 2 out of 4 nursing units. (Resident identifiers are #1 and #2.) Findings include: Review on 4/18/18 of the facility's Unusual Incident-Resident Injury, dated 3/29/18, revealed that on 3/19/18, Resident #1 spilled hot tea on their lap (left hip and thigh area.) .The hot water for tea was found to be taken directly from the 'Hot Water' spout from the coffee maker. It was determined that the water from the spout was at a temperature that was hotter than desired at serving . Review on 4/18/18 of emails written between Staff C (Food Service Supervisor) and the representative from the company that managed the facility's coffee makers revealed an email, dated 3/26/18, which was 7 days after the incident, that read .I have a question about the coffee machines. The nurses are stating that the water is too hot for residents to drink, we had an injury report from over the weekend and they asked if it can be turned down. I thought it might have to be set at a specific temp to brew the coffee properly. It is currently set for 200 degrees on all machines . The response email, dated 3/26/18 read Proper temp is 195. Please call (phone number) to have service come out to lower all [MEDICATION NAME] . Review on 4/18/18 of the Work Order from the equipment company, revealed that the hot water spouts were taken out of service and no longer active on 3/30/18. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed that from 3/19/18 until 3/30/18, the hot water spouts were still available to residents and staff. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 3/19/18, also had an action plan that stated A plan was put in place to brew hot water thru (sic) the coffee system and placed in carafe for serving. This would allow for time to cool prior to serving Resident #2 Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18, Resident #2 spilled a cup of hot tea on their stomach, which resulted in redness and then blisters. Interview on 4/18/18 at approximately 10:00 a.m. with Staff A revealed that the investigation into the incident that occurred to Resident #2 revealed that the LNA who had served tea to Resident #2 on 4/10/18 failed to use the carafe, as written in the action plan dated 3/19/18, and instead used a microwave to completely prepare the tea. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18 when Resident #2 spilt a cup of hot tea on their stomach, which resulted in redness and then blisters, they reported that they had used a paper cup with no handle and that they didn't have a good grip on the cup. Interview on 4/18/18 at approximately 1:30 with Staff E (Administrator) revealed that Staff E was still in the process of deciding on new cups to be used for hot beverages for the residents. Staff E also confirmed that Resident #2 had not been evaluated by Therapy to determine the appropriate cup for Resident #2 to use. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A confirmed that nothing had been put in place, such as education regarding microwaving, since the incident with Resident #2 occurred on 4/10/18. Staff A also confirmed that there is not a definite plan in place to prevent hot water spills and burn injuries to residents. It will be discussed at the next QAPI meeting, but that will not be held until 4/24/18.

Based on record review and interview, it was determined that the facility failed to prevent an accident, resulting in a burn injury for 1 resident in a survey sample of 3 residents. (Resident identifiers are #1 and #2 .) Findings include: Review on 4/18/18 of the facility's Unusual Incident-Resident Injury, dated 3/27/18, revealed that on 3/19/18, Resident #1 spilled hot tea on their lap (left hip and thigh area.) .The hot water for tea was found to be taken directly from the 'Hot Water' spout from the coffee maker. It was determined that the water from the spout was at a temperature that was hotter than desired at serving. A plan was put in place to brew hot water thru (sic) the coffee system and placed (sic) in carafe for serving. This would allow for time to cool prior to serving at breakfast. Carafes have been purchased for all units in the facility and a procedure was developed. All employees were notified of the new procedure. Review on 4/18/18 of the facility's Incident with Injury-Final Report, dated 4/11/18, revealed that on 4/10/18, Resident #2 spilled a cup of hot tea their stomach, which resulted in redness and then blisters. Review also revealed that .Due to a previous incident, the hot water has been shut off to the spouts from the coffee pots due to the lack of ability to regulate the temperature. At meal time hot water is now served from a carafe on each unit allowing the water temperature to cool . Interview on 4/18/18 at approximately 10:00 a.m. with Staff A (Director of Nursing) revealed that the investigation into the incident with Resident #2 revealed that the LNA who had served tea to Resident #2 used a microwave to heat the water. Review on 4/18/18 of the statement written by Staff B (Licensed Nursing Assistant,) who had served the tea to Resident #2 on 4/10/18, confirmed that Staff B had prepared the tea in the microwave, instead of brewing the water in the coffee maker and putting it in a carafe. Interview on 4/18/18 at approximately 1:00 p.m. with Staff A confirmed that Staff B should not have prepared the tea in the microwave, as they do not use thermometers and would not be able to tell how hot the water was. All staff were educated on the new procedure and Staff B should have followed the procedure that had been developed after the incident with Resident #1, which was brewing hot water through the coffee system.

Based on record review and interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifier is #7.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary Review on 9/5/17 of Resident #7's Physician's Telephone Orders dated 8/3/17 revealed a telephone order that read Try reinsert foley cath (catheter) 16# (size) 10 ml (milliliters) coude tip (tip designed for easier insertion) . Review on 9/5/17 of Resident #7's physician progress notes [REDACTED].they had a difficult time re-inserting and ended up with a #16 Coude placed .Otherwise, with the [MEDICAL CONDITION] ([MEDICAL CONDITION],) will continue with Coude in the future . Review on 9/5/17 of Resident #7's Physician order [REDACTED].#14-10 ML Balloon per protocol PRN (as needed) (Silicone Foley) Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/27/17 that read .Changed cath to a 100% Silicone 14 FR (French) - 10 cc(cubic centimeter) . There was no documentation of a coude tip. Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/26/17 that read .Foley cath removed - as unable to flush - #14 FR - 10 cc inserted . There was no documentation of a coude tip. Review on 9/5/17 of Resident #7's Problem Oriented - Progress Notes revealed a note written on 8/20/17 that read .Foley cath (symbol, meaning change, omitted) #14 - 10 ml . There was no documentation of a coude tip. Interview on 9/5/17 at approximately 2:00 a.m. with Staff A (Registered Nurse) confirmed that Resident #7 had a #14 FR catheter in place. Staff A also confirmed that there was a discrepancy in Resident #7's urinary catheter orders.