Every finding on record at Oak Knoll Rehabilitation and Healthcare Center

Based on observation, and interview, the facility failed to adhere to infection control and prevention standards related to multi-resident medical equipment use for one Unit (Sub Acute) out of two units observed, to mitigate the development and transmission of communicable diseases and infections. Specifically, the facility failed to:1. ensure that facility staff cleaned and disinfected a blood glucose monitor (BGM - device used to measure the amount of glucose [sugar] in the blood) between multi-resident use after Nurse #2 used the BGM to obtain finger stick blood sugar (FSBS) levels on two residents and before storing the BGM device in the medication cart with clean equipment.2. ensure the facility staff cleaned and disinfected a wrist blood pressure cuff (machine used to check blood pressure) between multi-resident use when Nurse #2 used the wrist blood pressure cuff to obtain blood pressure readings on three residents, placed the wrist blood pressure cuff in her pocket after use on the three residents, and placed the contaminated device on the surface of the medication administration cart after exiting the three residents rooms. Findings include: Review of the facility policy titled: Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, indicated the following: -Reusable items are cleaned and disinfected or sterilized between residents. -Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. -Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. Review of the facility policy titled: Blood Sampling- Capillary (Finger Sticks), revised September 2014, indicated the following: -The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. -Equipment and supplies: Alcohol pledgets. Disinfected blood glucose meter (glucometer) with sterile lancet; or singly resident use spring-loaded device (e.g., Pen let) or automatic or safety type lancet. Disposable lancet. Personal protective equipment (e.g. gloves) Sharps Container. Approved EPA registered disinfectant for cleaning of sampling device. -General guidelines: - Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between residents uses. -Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. On 2/11/26, during a medication administration observation, the surveyor observed the following: -At 7:45 A.M., Nurse #2 performed a blood pressure measurement on a resident on Enhanced Barrier Precautions (EBP - mandates the use of gowns and gloves during high-contact resident care, such as dressing, bathing, or changing linens to reduce the transmission of multidrug-resistant organisms) in his/her room with a wrist blood pressure cuff. Nurse #2 placed the wrist blood pressure cuff in her pocket after obtaining the blood pressure reading from the resident and failed to clean or disinfect the wrist blood pressure cuff after use. Nurse #2 exited the resident's room and removed the wrist blood pressure cuff from her pocket, placed the wrist blood pressure cuff on top of her medication administration cart and documented the resident's blood pressure reading. -At 7:49 A.M., Nurse #2 obtained a blood glucose level on a resident, using a BGM. The surveyor observed Nurse #2 place the BGM back in the basket containing the BGM supplies without cleaning or disinfecting the equipment and then place the basket on top of the medication administration cart and document the resident's blood glucose reading. - At 7:56 A.M., Nurse #2 obtained a blood pressure reading on a second resident in his/her room with the wrist blood pressure cuff and placed the wrist blood pressure cuff in her pocket after obtaining the blood pressure reading from the second resident. Nurse #2 was not observed cleaning or disinfecting the wrist blood pressure cuff after use on the second resident. Nurse #2 exited the second resident's room and removed the wrist blood pressure cuff from her pocket, placed the wrist blood pressure cuff on top of her medication administration cart and documented the second resident's blood pressure reading. - At 8:11 A.M., Nurse #2 obtained a blood pressure reading on a third resident in his/her room with the wrist blood pressure cuff and placed the wrist blood pressure cuff in her pocket after obtaining the blood pressure reading from the resident without cleaning or disinfecting the equipment before or after use on the third resident. Nurse #2 then obtained a blood glucose reading with the BGM on the same resident and failed to clean and disinfect the BGM prior to use. The surveyor observed Nurse #2 place the BGM back in the basket containing the BGM supplies, exited the resident's room and removed the wrist blood pressure cuff from her pocket, placed the wrist blood pressure cuff and the basket containing the BGM on top of her medication administration cart, and documented the blood pressure reading and the blood glucose reading. Nurse #2 was not observed to clean or disinfect the BGM and the wrist blood pressure cuff after multi-resident use. During an interview on 2/11/26 at 8:41 A.M., Nurse #2 said she forgot to clean the BGM and the wrist blood pressure machine after each resident use. Nurse #2 said she should have disinfected the BGM and the wrist blood pressure cuff after each resident use, but she did not. During an interview on 2/11/26 at 8:47 A.M., Unit Manager (UM) #2 said the facility used germicidal bleach wipes to disinfect the BGM after each resident use. UM #2 said Nurse #2 should have cleaned the wrist blood pressure cuff after each resident use. UM #2 further said Nurse #2 should have disinfected the BGM with the facility approved disinfecting wipes.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing), was identified to be at increased risk for aspiration, with multiple choking episodes which required the nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), and for whom Speech Therapy had recommended the need for direct supervision by nursing staff while eating, the Facility failed to ensure they provided an adequate level of staff supervision for Resident #1 in an effort to maintain a safe environment, when on 5/02/25, he/she choked again on his/her meal, and although nursing staff performed the Heimlich Maneuver, Resident #1 died. Findings include: Review of the Facility's policy, titled Accidents and Incidents, with a revision date of April 2024 included the following: -It is the policy of the Facility to provide a safe and healthful work environment. -Definition of an incident: Any event occurring by chance or arising from unknown cause which is not consistent with the desired operation of the facility or the care of the resident. -The following data, as it may apply, must be obtained: Corrective action taken. Resident #1 was admitted to the facility in July 2013, diagnoses included dysphagia, dementia, and right-side hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral vascular accident (CVA/stroke). Review of Resident #1's Documentation of Resident Incapacity Pursuant to the Massachusetts Health Care Proxy Law, indicated Resident #1 lacked the capacity to make, or to communicate, health care decisions and his/her HCP was invoked indefinitely, as of 05/09/24, due to moderate dementia. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) assessment, dated 05/06/24, indicated he/she scored a 12 out of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests a resident is cognitively intact), required staff supervision for eating, and was on a mechanically altered diet. Review of Resident #1's Incident Investigation, dated 07/09/24, indicated Resident #1 had a choking episode during supper and nursing staff performed the Heimlich Maneuver with success. The Investigation indicated Resident #1's diet was downgraded from diced to ground and a Speech Language Pathologist (SLP) screen was submitted. Review of Resident #1's SLP Progress Note, dated 07/10/24, indicated the SLP attempted to evaluate Resident #1 and he/she refused the evaluation. Review of Resident #1's Physician's Order Report, dated August 2024, included an order for ground diet with thin liquids at all meals, along with a lip plate and adaptive cup. Review of Resident #1's Incident Investigation, dated 08/09/24, indicated Resident #1, who was seated near the Nurses Station, choked during supper and nursing staff performed the Heimlich Maneuver which caused him/her to expel large pieces of unchewed meat and bread. Further review of the Investigation indicated Resident #1 was re-educated to take small bites with small sips to alternate between, and that Resident #1 continued to be non-compliant with nursing education. Review of Resident #1's SLP Evaluation, dated 08/15/24, indicated Resident #1 reported knowingly overstuffing his/her oral cavity, and swallowing food without fully masticating (chewing) the bolus which led to the choking events. The Evaluation indicated that the SLP recommended a Modified Barium Swallow Study (a special x-ray to evaluate how well a person swallows) but Resident #1's Health Care Agent declined. Further review of the Evaluation indicated the SLP recommended that Resident #1 continue with current diet of ground solids and thin liquids and that he/she needed direct supervision with PO [anything by mouth], and he/she required the following swallow strategies/supervision: -Direct supervision with PO -Upright positioning -Slow rate of eating -Small bites -Aspiration Precautions -Safe swallow strategies Review of Resident #1's Dysphagia Care Plan indicated no additional interventions were added after the SLP evaluation dated 08/15/24, despite the recommendation from the SLP for him/her to receive direct supervision from staff with po [intake]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 10/25/24, indicated he/she scored an 8 out of 15 on his/her BIMS, was on a mechanically altered diet, and required supervision at meals. Review of Resident #1's Nursing Progress Note, dated 11/25/24 and signed by Nurse #3, indicated Resident #1 choked on food during his/her evening meal and nursing staff performed abdominal thrusts. The Note indicated Resident #1 had a large mouthful of cheese from pizza which was cleared from his/her mouth and throat. The Note indicated that Resident #1 allowed staff to cut his/her food following the choking episode. Review of Resident #1's Incident Investigation, unsigned and dated 11/25/24, indicated Resident #1 choked during supper and nursing staff performed abdominal thrusts with good effect. The Investigation indicated Resident #1's invoked Health Care Agent was notified and refused for Resident #1's diet to be downgraded. During a telephone interview on 06/04/25 at 8:24 A.M., Nurse #3 said she was on duty for the 3:00 P.M. through 11:00 P.M. (evening) shift on 11/25/24. Nurse #3 said Resident #1 always ate his/her meals at the Nurses Station. Nurse #3 said Resident #1 ate a piece of pizza for the evening meal and choked on a large piece of cheese. Nurse #3 said she had to perform abdominal thrusts to help clear Resident #1's mouth and airway. Nurse #3 said Resident #1 was at a very high risk for choking and that we all knew the sound Resident #1 made when he/she was choking. Nurse #3 said staff was always within earshot of Resident #1 during mealtimes, but that no one staff member was assigned to stay with Resident #1 while he/she was eating to provide direct supervision. Review of Resident #1's Incident Investigation, dated 12/18/24 and signed by Nurse #2, indicated Resident #1 was seated at the Nurses' Station and eating his/her meal when Nurse #2 heard Resident #1 cough. The Investigation indicated Nurse #2 assessed Resident #1 and noted that he/she was choking on a piece of broccoli, was unable to talk and Nurse #2 initiated the Heimlich Maneuver with good effect. During an interview on 06/03/25 at 3:20 P.M., which included a review of his written statement, Nurse #2 said he was on duty during the evening shift on 12/18/24, and was at the Nurses Station when he heard Resident #1's voice changing and he knew he/she was choking. Nurse #2 said he performed the Heimlich Maneuver and Resident #1 coughed out a full piece of broccoli. Nurse #2 said that a referral for Resident #1 to have an evaluation by SLP should have been done, but that he did not put one in, and said that he had already done his part. Nurse #2 said Unit Manager #1 should have followed up on the need for a SLP referral. Review of Resident #1's medical record indicated that although he/she experienced two additional incidents of choking on food after his/her 8/15/24 SLP Evaluation, which required nursing staff to perform the Heimlich Maneuver, there was no documentation to support that nursing staff provided direct supervision during meals as recommended by SLP Therapy. Review of Resident #1's Physician's Orders, for the month of May 2025, included an order for a ground diet with thin liquids at all meals, along with a divided plate and adaptive cup. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/02/25, indicated Resident #1 was observed by a staff member to be eating lunch at the Nurses Station when the staff member noticed that Resident #1's lips were blue. The staff member summoned help from nearby nursing staff. That nursing staff initiated the Heimlich Maneuver with assistance from Emergency Medical Technician's (EMTs ) who were in the facility for a different resident, and that Resident #1 lost consciousness and died at the facility. During an interview on 06/03/25 at 2:09 P.M., which included review of her written statement, Nurse #1 said she was on duty on 05/02/25 during the 7:00 A.M. through 3:00 P.M. (day shift). Nurse #1 said she was standing at her medication cart on one side of the Nurses Station around 12:00 P.M., Resident #1 was seated near the Nurses Station, and two staff members were on the other side of the Nurses Station talking to each other when one of them called out that Resident #1 appeared to be choking. Nurse #1 said that Nurse #4 initiated the Heimlich Maneuver on Resident #1 and green mush was coming out of his/her mouth. Nurse #1 said EMTs were on the unit for a different resident and assisted nursing staff with bringing Resident #1 to his/her room to continue with abdominal thrusts and back blows, but said the interventions were unsuccessful. Nurse #1 said that Resident #1 always sat at the Nurses Station during mealtimes and that Resident #1 often needed to be reminded by staff to slow down and chew his/her food. Nurse #1 said there was no specific staff person or formal assignment for a staff member to provide supervision for Resident #1. Nurse #1 said whoever was at the Nurses Station would supervise him/her. The Surveyor was unable to interview Nurse #4, as he did not respond to the Department of Public Health's telephone or letter requests for an interview. During an interview on 06/03/25 at 1:18 P.M., which included review of her written statement, Certified Nurse Aide (CNA) #1 said she was on duty during the day shift on 05/02/25. CNA #1 said that Resident #1 often ate too fast and choked all the time, that it was normal for him/her. During an interview on 06/03/25 at 1:37 P.M., which included review of her written statement, CNA #2 said she was on duty during the day shift on 05/02/25. CNA #2 said Resident #1 ate his/her meals at the Nurses Station and there was no one specifically assigned to supervise Resident #1 because we are just all around. During a telephone interview on 06/05/24 at 8:16 A.M., CNA #3 said she was on duty during the day shift on 05/02/25. CNA #3 said Resident #1 was able to feed him/herself and eat his/her meals at the Nurses Station. CNA #3 said she was passing meal trays to residents in their rooms when she heard staff calling for help. During a telephone interview on 06/06/25 at 8:01 A.M., CNA #4 said she was on duty during the day shift on 05/02/25. CNA #4 said Resident #1 ate his/her meals at the Nurses Station and she did not think anyone was specifically assigned to supervise him/her while he/she was eating. Although staff said Resident #1 was seated during meals in front of the nursing station so they could watch him/her, staff said they were also passing out meal trays, administering medications or performing other tasks, and that there was no staff member specifically assigned to sit with and directly supervise him/her while eating. During an interview on 06/03/25 at 3:05 P.M., which included a review of her written statement, Unit Manager #1 said she was on duty during the day shift on 05/02/25. Unit Manager #1 said she was in her office when she heard a nurse calling for help. Unit Manager #1 said she came out of her office and saw Resident #1 seated at the Nurses Station and Nurse #4 performing abdominal thrusts on him/her. Unit Manager #1 said she performed back blows on Resident #1, and he/she coughed up chewed up pieces of broccoli and phlegm. Unit Manager #1 said they brought Resident #1 to his/her room where she (Unit Manager #1) and Nurse #4 continued with the Heimlich Maneuver. Unit Manager #1 said Resident #1 became unresponsive, EMTs were already at the Facility and confirmed that Resident #1 was in asystole (complete absence of a heartbeat) and Resident #1 was pronounced dead. Unit Manager #1 said Resident #1 refused to slow down when he/she ate and would stuff his/her mouth with food. Unit Manager #1 said Resident #1 and his/her family were educated about the importance of adhering to his/her diet, but that she did not document the education. Unit Manager #1 said the education was mostly verbal or over the phone. Unit Manager #1 said that the Unit Secretary or the Nurses on duty were expected to provide supervision for residents who ate their meals at the nurses station, but that there was no specific staff person assigned to provide the supervision. Unit Manager #1 said when a resident choked, they would put in a request for a SLP evaluation. Unit Manager #1 said when nursing staff called her to report a choking incident, she would remind them to put in a request for a SLP evaluation. Unit Manager #1 said once a resident was evaluated by an SLP, the recommendations from the evaluation were written and given to her. Unit Manager #1 said she was unable to provide any additional documentation for the surveyor during the survey related to the SLP Therapy Evaluation from 8/15/24, that recommended Resident #1 needed direct supervision from staff during PO (intake). During an interview on 06/03/25 at 2:40 P.M., the Rehabilitation Director said that residents were often referred to SLP for an evaluation due to choking or coughing episodes. The Rehabilitation Director said when he received a request for a resident to be evaluated due to choking, he made those requests a priority. The Rehabilitation Director said he was unable to provide any documentation to support that any additional SLP screens and/or evaluations were requested by the nursing staff for Resident #1 after the SLP evaluation that was completed on 08/15/24. During a telephone interview on 06/04/25 at 3:51 P.M., Speech Language Pathologist (SLP) #2 said he had worked with Resident #1 off and on over the years. SLP #2 said that he had observed Resident #1 several times, that due to his/her cognitive deficits and right-hand tremor, he/she had difficulty eating and did not always understand what he/she should be doing. SLP #2 said that when SLP makes a recommendation for direct supervision, it means that the resident requires a staff member to always be present with the resident during the entire time while eating and even if a resident was able to physically feed him/herself, they may need constant cueing for safety. During a telephone interview on 06/04/25 at 8:33 A.M., the Registered Dietician (RD) said Resident #1 ate his/her meals seated at the Nurses Station and said she considered that to be distant supervision. RD #1 said direct supervision meant a staff member who was certified in Cardiopulmonary Resuscitation (CPR) always had their eyes on a resident and did not walk away or have any other tasks to do during mealtimes. During a telephone interview on 06/04/25 at 1:24 P.M., the Director of Nurses (DON) said that it was her expectation that a referral to SLP would have been done after Resident #1's choking incidents on both 11/25/24 and 12/18/24. The DON said she was unable to find documentation to support that, but said it was facility protocol to refer a resident to SLP following any episodes of choking. The DON said that the SLP was the one to determine what level of supervision was required at mealtimes. The DON reviewed the SLP evaluation completed on 08/15/24 which included a recommendation from SLP for Resident #1 to have direct supervision when having anything by mouth. The DON said after Resident #1 had choking choking incidents on 11/25/24 and 12/18/24, he/she continued to receive distant supervision by staff at the Nurses Station when eating. The DON said that if Resident #1 required direct supervision, per the 8/15/24 SLP recommendation, that it meant that a staff member would be required to sit with him/her during mealtimes.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing) with several episodes of choking which required nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), the Facility failed to ensure his/her Dysphagia Care Plan was reviewed and/or revised related to effectiveness of interventions, when he/she remained on the same diet but continued to experience choking episodes and despite recommendations from Speech Therapy to implement a new intervention for direct supervision by staff during all meals, he/she was only supervised from a distance by staff. On 5/02/25, Resident #1 choked on his/her meal and died. Findings include: Review of the Facility's policy, titled Comprehensive Person-Centered Care Plans, with a revision date of March 2022, included the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #1 was admitted to the facility in July 2013, diagnoses included dysphagia, dementia, and right-side hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral vascular accident (CVA/stroke). Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) assessment, dated 05/06/24, indicated he/she scored a 12 out of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderate cognitive impairment, and 13-15 suggests a resident is cognitively intact), required staff supervision for eating, and was on a mechanically altered diet. Review of Resident #1's Incident Investigation, dated 07/09/24, indicated Resident #1 had a choking episode during supper and nursing staff performed the Heimlich Maneuver with success. The Investigation indicated Resident #1's diet was downgraded from diced to ground and a request for a Speech Language Pathologist (SLP) screen was submitted. Review of Resident #1's Dysphagia Care Plan, reviewed and renewed with the Significant Change in Status MDS assessment, indicated the following interventions were initiated on 07/09/24: *Problem: [The Resident] is at risk for aspiration secondary to dysphagia following CVA. *Interventions included: -Instruct [the Resident] to eat in an upright position, to eat slowly, and to chew and bite thoroughly, -Encourage him/her to eat meals in highly visible areas, -Encourage him/her to take small bites followed by small sips, -Alternate liquids and solids, -Monitor for difficulty swallowing, holding food in mouth, -Monitor for coughing, shortness of breath, choking, labored respiration and or lung congestion. -Refer to SLP as indicated Review of Resident #1's Incident Investigation, dated 08/09/24, indicated Resident #1, who was seated near the Nurses Station, choked during supper and nursing staff performed the Heimlich Maneuver which caused him/her to expel large pieces of unchewed meat and bread. Further review of the Investigation indicated Resident #1 was re-educated to take small bites with small sips and alternate between, Resident #1 continued to be non-compliant with nursing education. Review of Resident #1's Dysphagia Care Plan indicated the following intervention was added on 08/09/24: -Re-educate/Encourage [the Resident] to take small bites alternating with small sips. Offer assistance /cut items such as bread into bite size pieces. Review of Resident #1's SLP Evaluation, dated 08/15/24, indicated Resident #1 reported knowingly overstuffing his/her oral cavity, and swallowing food without fully masticating (chewing) the bolus which led to the choking events. The Evaluation indicated that the SLP recommended a Modified Barium Swallow Study (a special x-ray to evaluate how well a person swallows) but Resident #1's Health Care Agent declined. Further review of the Evaluation indicated the SLP recommended that Resident #1 continue with his/her current diet of ground solids and thin liquids, the need for direct supervision by staff with PO [anything by mouth] and required the following swallow strategies/supervision: -Direct supervision with PO -Upright positioning -Slow rate of eating -Small bites -Aspiration Precautions -Safe swallow strategies Review of Resident #1's Dysphagia Care Plan indicated no additional interventions were added after the SLP Evaluation was conducted on 08/15/24, despite the recommendation from the SLP that Resident #1 needed direct supervision with po [intake]. Review of Resident #1's Nursing Progress Note, dated 11/25/24, indicated Resident #1 choked on food during his/her evening meal and nursing staff performed abdominal thrusts. The Note indicated Resident #1 had a large mouthful of cheese from pizza which was cleared from his/her mouth and throat. Review of Resident #1's Dysphagia Care Plan, indicated no revisions or additional interventions, including specifically the need for direct supervision by staff during meals per SLP, were entered following Resident #1's episode of choking on 11/25/24. Review of Resident #1's Incident Investigation, dated 12/18/24, indicated Resident #1 was seated at the Nurses' Station eating his/her meal when Nurse #2 heard Resident #1 cough. Nurse #2 assessed Resident #1 and noted that he/she was choking on a piece of broccoli, was unable to talk, and she initiated the Heimlich Maneuver with good effect. Review of Resident #1's Dysphagia Care Plan indicated no revisions, or additional interventions, including specifically the need for direct supervision by staff during meals per SLP, were entered following Resident #1's episode of choking on 12/18/24. During an interview on 06/03/25 at 3:05 P.M., Unit Manager #1 said when a resident choked, they would put in a request for a SLP evaluation. Unit Manager #1 said once a resident was evaluated by an SLP, the recommendations from the evaluation were written and given to her. Unit Manager #1 said Resident #1 and his/her family had been educated about the importance of adhering to his/her diet, but that she had not documented the education. Unit Manager #1 said the education she provided was mostly verbal or over the phone. Unit Manager #1 said she was unable to provide any additional documentation regarding Resident #1's SLP Evaluation conducted on 8/15/24, and was unable to offer an explanation as to why the recommendation for the addition of an intervention for nursing to provide direct supervision during meals was never added to the care plan or implemented. During a telephone interview on 06/04/25 at 8:24 A.M., Nurse #3 said Resident #1 always ate his/her meals at the Nurses Station. Nurse #3 said Resident #1 was at a very high risk for choking and that we all knew the sound Resident #1 made when he/she was choking. Nurse #3 said staff was always within earshot of Resident #1 during mealtimes, but that no one staff member was assigned to stay with Resident #1 while he/she was eating to provide direct supervision. Further review of Resident #1's medical record indicated there was no documentation to support that nursing made any additional referrals to Speech for Resident #1 for additional SLP evaluations following his/her choking episodes on 11/25/24 and 12/18/24, or that SLP's recommendation for direct supervision during meals was added to his/her Dysphagia Care Plan as an intervention. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/02/25, which included the Facility Investigation indicated Resident #1 was observed by a staff member to be eating lunch at the Nurses Station when the staff member noticed that Resident #1's lips were blue. The staff member summoned help from nearby nursing staff, who initiated the Heimlich Maneuver with assistance from Emergency Medical Technician's (EMTs), who were in the facility for a different resident, but Resident #1 lost consciousness and died at the facility. During a telephone interview on 06/04/25 at 1:24 P.M., the Director of Nurses (DON) said after Resident #1's SLP Evaluation on 8/15/24, the recommendation for direct supervision by staff during meals was not added to his/her care plan as an intervention. The DON also said, despite Resident #1 continuing to experience choking episodes while eating meals, there were no new interventions added and no changes were made to Resident #1's Dysphagia Care Plan.

Based on record review, interview, and policy review, the facility failed to ensure that one Resident (#84), out of a total sample of 23 residents, was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility failed to ensure that appropriate monitoring for adverse consequences and side effects of antipsychotic medications using the Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale used to measure involuntary movements of the face, mouth, trunk, or limbs known as Tardive Dyskinesia (TD) in a resident taking antipsychotic medications) was completed timely in accordance with standards of practice. Findings include: Review of the facility policy titled Guidelines for Completing AIMS Testing, revised 10/2019, indicated: -All residents receiving antipsychotics (neuroleptics) will have an AIMS test completed prior to initiation of the medication and at least every six (6) months thereafter to monitor for movement disorder. -The AIMS aids in early detection of tardive dyskinesia as well as provides a method for ongoing surveillance. -In the absence of psychiatric services, the AIMS test will be completed by an authorized member of the nursing staff or the Nurse Practitioner. Review of the National Library of Medicine (NLM), dated 5/25/23, reviewed at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10292174/ indicated but was not limited to: -The Abnormal Involuntary Movement Scale (AIMS) is administered every three to six months to monitor the patient for the development of TD (tardive dyskinesia - a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs). In elderly patients, however, TD can develop after as little as one month. Resident #84 was admitted to the facility in November 2021, with diagnoses including Alzheimer's disease (a progressive disease that destroy memory, thinking, and behavior), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), Restlessness (a feeling of discomfort that arises when a person is unable to relax or make progress), Agitation (a state of extreme arousal that can cause a person to feel tense, irritable, and unable to relax) and Insomnia (sleep disorder with trouble falling and/or staying asleep). Review of the Minimum Data Set (MDS) Assessment, dated 9/27/24, indicated Resident #84: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of a total of 15. -received an antipsychotic (psychotropic medication primarily used to manage psychosis [including delusions, hallucinations, paranoia or disordered thought]) and the antipsychotic was administered on a routine basis. Review of Resident #84's Care Plan last reviewed/revised on 10/23/24 included care planning to complete an AIMS test every six months and as needed (PRN). Review of Resident #84's October 2024 Physician's orders included: -Seroquel (Quetiapine - an antipsychotic medication used to treat agitation and anxiety) tablet (tab) 50 milligrams (mg), amount (amt) to be administered 1 tab = 50 mg, oral (by mouth). Special Instructions: For agitation, Give med (medication) during dinner time. At bedtime: 7:00 P.M., initiated 1/17/24, discontinued 10/11/24. -Seroquel (Quetiapine) tablet 25 mg, amt: 25 mg, oral. Special Instructions: For agitation, give med during dinner time. At bedtime: 8:00 P.M., initiated 10/11/24, discontinued 10/28/24. -Seroquel (quetiapine) tablet 50 mg, amt: 50 mg, oral. Special instructions: For agitation, give med during dinner time. At bedtime, 8:00 P.M., initiated 10/28/24, order active. Review of the October 2024 Medication Administration Record (MAR) for Resident #84 indicated that the Resident received the Seroquel medication as ordered. Review of Resident #84's clinical record did not indicate that an AIMS assessment was completed within the last six months. During an interview on 10/30/24 at 1:23 P.M., Unit Manager (UM) #2 said that the last time an AIMS assessment was completed for Resident #84 was on 1/31/24. UM #2 said that nursing should be checking on due dates for AIMS assessments. During an interview on 10/30/24 at 2:18 P.M., the Director of Nursing (DON) said AIMS assessments should be completed every six months for all residents receiving antipsychotic medications.

Based on interview, record and policy review, the facility failed to ensure that professional standards of practice relative to dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) care and services for one Resident (#32), of two applicable residents reviewed for dialysis, out of a total sample of 23 Residents. Specifically, for Resident #32, the facility failed to: 1. Monitor and assess the Physician's ordered fluid restriction to ensure adequate fluid intake. 2. Provide food items prior to dialysis as indicated in the plan of care and per the Resident's preferences. Findings include: Review of facility policy titled Guidelines for Initiating, Maintaining, and Removing Residents from Intake & Output Recording, dated 1/2016, indicated the following: -It is the policy of this facility to monitor the intake and output of residents as needed based on the resident's clinical condition and physician orders. -Conditions for which a resident must be put on I & O (intake and output) include the following: Dialysis and Fluid Restriction. -I & O monitoring will be communicated to all levels of staff. Review of the facility policy titled Fluid Restrictions, dated 2/12/24, indicated the following: -11:00 P.M. to 7:00 A.M. Nurse will transcribe the 24-hour totals to the Monthly I & O Record. -Any discrepancies or incomplete recordings will be reported to the Charge Nurse at this time. Review of the facility policy titled Nursing Management of Residents Requiring Dialysis, dated 1/8/19, indicated the following: -Notify Culinary Services of any need for meals to be sent with the Resident, day and time. Resident #32 was admitted to the facility in June 2022, with diagnoses including End Stage Renal Disease (ESRD - a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a kidney transplant to maintain life) on Hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately), Hypotension (low blood pressure) of Hemodialysis, and Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels). Review of the Minimum Data Set (MDS) Assessment, dated 9/6/24, indicated that Resident #32: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out 15 -utilized a wheelchair -required set-up assistance from staff for eating and oral hygiene -received Hemodialysis during the assessment period Review of the October 2024 Physician's orders indicated the following: -the Resident has dialysis at the [dialysis clinic] at 7:00 A.M. Leaves the facility at 6:00 A.M., returns after 10:30 A.M. on Monday, Wednesday, Friday, initiated 6/7/23 -Fluid Restriction 1500 milliliters (ml) per day, initiated 7/27/23 Review of the Registered Dietician (RD) Progress Note, dated 9/6/24, indicated Resident #32 was on a 1500 ml Fluid Restriction. Review of the Nutritional Status Care Plan, dated 9/6/24, included the following interventions: -Resident was to be sent to dialysis center with half sandwich or peanut butter crackers and 4 ounces (oz) of juice. -Maintain Fluid Restriction of 1500 ml. During an interview on 10/29/24 at 12:47 P.M., Resident #32 said he/she did not eat anything at dialysis and would like to have something to eat. Resident #32 said he/she would accept food from the facility staff if they offered and was hungry while at dialysis. Resident #32 said the facility staff did not offer any food/snacks prior to him/her leaving for dialysis and his/her family had provided crackers for him/her to eat. During an interview on 10/29/24 at 1:04 P.M., Certified Nurses Aide (CNA) #1 said Resident #32 had been on a fluid restriction in the past but was unsure if the fluid restriction was still in place. The surveyor and CNA #1 reviewed the Care Assist Tool (electronic documentation that included specific information about the Resident) which indicated the Resident's diet, and CNA #1 said the Care Assist Tool did not indicate that the Resident was on a fluid restriction. CNA #1 said that since the fluid restriction was not indicated on the Care Assist Tool, Resident #32 must no longer be on fluid restriction. During an interview on 10/30/24 at 6:50 A.M., Nurse #5 (who worked the 11:00 A.M. to 7:00 P.M. shift), said Resident #32 was sometimes provided with crackers and coffee prior to leaving for dialysis. Nurse #5 further said Resident #32 was on a fluid restriction and the dietary department sent a portion of the amount of fluids (750 ml) with the Resident's meal trays and that Nursing staff provided the remainder of the fluids (750 ml). Nurse #5 said the CNAs should be documenting the fluid intake provided with meals and the Nurses would document the total amount of fluids provided from the nursing staff and from meals on each shift. Nurse #5 said the 11:00 P.M. to 7:00 A.M. Nurse was responsible for totaling the 24-hour fluid amount totals and documenting the fluid amounts on the Medication Administration Record (MAR). The surveyor requested to review the 24-hour fluid intake amounts with Nurse #5 at this time, and Nurse #5 said she was unable to find the 24-hour fluid intake totals in the MAR and requested assistance from Unit Manager (UM) #1. The surveyor, Nurse #5 and UM #1 tried to review Resident #32's fluid intake amounts as documented by the CNAs and were unable to find amounts of fluids provided daily for Resident #32. Both Nurse #5 and UM #1 said it would be important to find this information in the MAR so that abnormalities could be reported to the Physician or Nurse Practitioner (NP) in order to maintain proper fluid balance for any Resident on fluid restriction. During an interview on 10/30/24 at 7:09 A.M., the Food Service Director (FSD) said the dietary staff save Resident #32's breakfast tray in the kitchen until he/she returns from dialysis. The FSD further said the nursing staff were responsible for making sure Resident #32 received something to eat at 5:00 A.M. because the kitchen was not open at that time. The FSD said dietary staff stock the kitchenettes on the nursing units with foods like juice, yogurt, jelly, cereal, and bread that could be provided to the Resident before he/she went to dialysis. The FSD further said Resident #32's diet slip indicated he/she was on a 1500 ml Fluid Restriction. The FSD said the dietary department provided one-half of the 1500 ml (750 ml) of the fluid restriction, and the nursing department provided the other half, and were responsible for totaling the Resident's 24-hour fluid intake amounts. During an interview on 10/30/24 at 9:15 A.M., Nurse #1 and UM #1 said they were unsure why the CNA Care Assist Tool documentation was not indicating fluids amounts for Resident #32. Nurse #1 and UM #1 both said the 1500 ml Fluid Restriction was not on the Resident's Care Card (specific information about the Resident's care) for Resident #32 or under Diet in the Care Assist Tool, and that this was how the CNA's find the information on how to take care of the Resident. During an interview on 10/30/24 at 9:19 A.M., CNA #4 said that he/she referred to the Residents Care Card and Care Assist Tool for how to appropriately care for a Resident. During an interview on 10/30/24 at 9:43 A.M., UM #1 provided the surveyor with the October 2024 MAR for Resident #32, which indicated the total 24-hour Intake and Output documentation for fluids for the past 30 days. UM #1 said that the fluid amounts totals on the MAR for Resident #32 did not fall within the normal range, and staff had not maintained accurate monitoring of his/her fluid intake. UM #1 said inaccurate monitoring of the Resident's fluid intake could put the Resident at risk for fluid overload or dehydration. Review of the October 2024 Medication Administration Record (MAR) indicated Total 24-hour Intake and Output for Resident #32 from 10/01/24 through 10/30/24 indicted the following: -15 days that the Resident's fluid intake was below 1000 ml. -8 days that the 24-hour fluid intake totals were not documented. -2 days that the 24-hour fluid totals were over 1500 ml. During an interview on 10/30/24 at 10:15 A.M., Resident #32 said he/she did not have any food or drink from staff this morning prior to dialysis and ate a few crackers which were provided from his/her family before leaving. Resident #32 said he/she was uncomfortable, was very hungry and wanted to eat his/her breakfast. UM #1 was observed to ask the Resident if he/she would like to be changed or repositioned and Resident #32 said he/she needed to eat breakfast because he/she was diabetic. During an interview on 10/30/24 at 3:06 P.M., the RD said the facility staff save Resident #32's breakfast tray and it was provided to him/her when he/she returned from dialysis. The RD said snacks were available in the unit kitchenette that the nursing staff could provide to Resident #32. The RD said she was unsure if the Resident was provided with any food/fluids prior to leaving for dialysis. The RD further said Resident #32 has had hypoglycemic (low blood sugar) episodes in the past and that the dialysis center had suggested the facility send the Resident to dialysis with peanut butter crackers. The RD said she was not sure if staff have asked Resident #32 what his/her preferences were in regards to receiving breakfast or snacks prior to his/her dialysis treatments. The RD said that the Resident was on a fluid restriction and that the nursing staff were responsible for tracking the 24-hour fluid totals for accurate fluid restriction/fluid intake monitoring. The RD further said best practice would be for the Nurses to report abnormal fluid intakes which included fluid intake less than 1000 ml and greater than 2000 ml to the Medical Doctor to avoid any complications related to potential dehydration or fluid overload.

Based on observation, interview, policy and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#87 and #24), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #87, routinely maintain the oxygen concentrator (a device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturers guidelines, placing Resident #87 at risk for equipment malfunction, impaired oxygen delivery and contamination. 2. For Resident #24, ensure that the Resident had an active Physician's order for nebulizer (delivery device used to administer medication in the form of an aerosol that is inhaled into the lungs) equipment care, handling, and storage, to prevent contamination and the spread of infections. Findings include: Review of the facility policy titled Oxygen and Respiratory Equipment Management, dated September 2009, revised February 2019, indicated the following: -It is the policy of this facility to provide consistent care of all oxygen and respiratory equipment in accordance with recognized infection control practices. -After obtaining a Physician order to initiate oxygen therapy, the Nurse will initiate oxygen therapy on a treatment sheet (documentation location where Nurses record delivery of oxygen and care of oxygen equipment for residents) including all required elements (monitoring and equipment care). -after a Physician order is received for hand held nebulizer treatment, the Nurse will: <obtain tubing, face mask and plastic bag. Write date on sticker. <add handheld nebulizer to treatment sheet. <tubing and mask are changed weekly on 11-7 shift. <the handheld nebulizer is to be rinsed, air dried and replaced in the appropriate (storage) bag after each use. Review of the New Life Elite Oxygen Concentrator Service Manual, undated, retrieved at https://files.caireinc.com/MN105-1-E.pdf indicated: -To ensure accurate output and efficient operation of the oxygen concentrator, the user must clean the gross particle filter weekly, as described below: >Remove the dirty air intake particle filter from the back of the unit, and install the clean filter stored in the pocket on the back of the unit. >Wash the dirty filter in warm soapy water and rinse. >Use a soft absorbent towel to remove excess water. >Place the clean air intake gross particle filter in the pocket on the back of the unit. 1. Resident #87 was admitted to the Facility in January 2022, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs that leads to respiratory problems including difficulty breathing, shortness of breath and wheezing) and Chronic Respiratory Failure (a condition that occurs when the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, identified with symptoms of trouble breathing and fatigue). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #87: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of a total score of 15. -was receiving Oxygen therapy. Review of Resident #87's October 2024 Physician's orders included: -Oxygen at 2 Liters Per Minute (LPM - the flow rate of oxygen) via Nasal Cannula (NC - a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) continuous (non-stop), effective 1/8/23. -Rinse (oxygen concentrator) filter on Sunday night shift (11:00 P.M.-7:00 A.M.), effective 10/1/24 Review of Resident #87's current Comprehensive Care Plan, indicated: -Oxygen in use to promote comfort and optimize lung expansion, start date 11/22/22. >Administer Oxygen as ordered by Physician, effective 11/22/22. >Rinse oxygen concentrator filter weekly, effective 11/22/22. -Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, fungi or aspiration [when food or liquid is accidentally inhaled into airways and lungs] and characterized by severe cough with phlegm, fever, chills and difficulty breathing), effective 9/29/24 >Keep room cool and free from irritants such as dust, effective 9/29/24. Review of Resident #87's October 2024 Treatment Administration Record (TAR) indicated that the oxygen concentrator filter had been cleaned on 10/27/24 as evidenced by the Nurse's signature of completion on the TAR. On 10/28/24 at 10:38 A.M., the surveyor observed Resident #87 lying in bed with Oxygen set at 2 LPM via NC from a New Life Elite oxygen concentrator located at the bedside. The surveyor observed the air intake gross particle filter on the back of the concentrator unit was covered in a thick layer of gray dust. During an observation and interview on 10/29/24 at 7:22 A.M., the surveyor and Unit Manager (UM) #2 observed Resident #87 lying in bed with Oxygen set at 2 LPM via NC from a New Life Elite oxygen concentrator and the air intake gross particle filter was covered in a thick layer of gray dust. UM #2 said the air intake gross particle filter should be cleaned weekly by the night shift Nurse on Sundays. UM #2 said that the oxygen concentrator filter was covered in thick gray dust and was not cleaned on Sunday as indicated had been done on the Resident's TAR. UM #2 said that air intake gross particle filters should be cleaned so that dirty air does not get inhaled by the Resident and to ensure accurate output of clean (filtered) air to the Resident. During a follow-up interview on 10/29/24 at 7:46 A.M., UM #2 said the New Life Elite oxygen concentrator user manual indicated that the air intake gross particle filters should be cleaned weekly because when the air intake gross particle filter is not cleaned weekly, the dirty filter could impact the oxygen concentrator function and impair oxygen flow to the Resident. UM #2 further said that impaired Oxygen flow could be dangerous for Resident #87 because the Resident might not get the correct Oxygen flow. 51571 2. Resident #24 was admitted to the facility in August 2024, with diagnoses including Pneumonia, Acute Respiratory Failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide from the body, with difficulty attaining normal blood oxygen levels), and Orthopnea (discomfort with breathing while lying flat/supine). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated that the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of the Resident #24's October 2024 Physician's orders included the following: -Acetylcysteine (mucolytic - breaks down or dissolves mucus) solution; 100 milligrams (mg)/milliliters (ml) (10%); amount to administer (amt): 1 dose = 4 mls; inhalation. Special instructions: Shortness Of Breath (SOB)/wheeze, three times a day PRN (as needed), initiated 8/16/24, order active. -Albuterol Sulfate (bronchodilator - relaxes the airway muscles and open the airways) solution for nebulization. 2.5 mg/3 ml (0.083%); amt: 1 vial inhalation. Special instructions: for Bronchospasm, four times a day PRN, initiated 10/10/24, order active. -The Physician's orders did not include any orders for the care and maintenance of the nebulizer equipment or any special instructions for cleaning the nebulizer equipment after Acetylcysteine medication administration. Review of Resident #24's October 2024 Medication Administration Record (MAR) indicated the following medications were administered PRN as ordered: -Albuterol Sulfate solution for nebulization was administered once daily on: 10/12/24, 10/18/24, 10/22/24, and 10/24/24. -Acetylcysteine Solution for nebulization was administered once daily on: 10/5/24, 10/14/24, 10/16/24, 10/21/24, and 10/25/24. Review of the article, Acetylcysteine (inhalation route), reviewed at: https://www.mayoclinic.org/drugs-supplements/acetylcysteine-inhalation-route/description/drg - 20061456 indicated the following: -side effects: >patients using a face mask for inhalation of Acetylcysteine: the mask may leave a stickiness on your face This (stickiness) can be removed with water. >when you use Acetylcysteine, you may notice that the medicine has an unpleasant odor at first. However, this smell will go away soon after you use the medicine On 10/28/24 at 11:31 A.M. and 4:39 P.M., the surveyor observed Resident #24 lying in bed watching television, and the nebulizer equipment and tubing were laying on the Resident's nightstand table. The surveyor observed the nebulizer tubing and face mask were laying directly on the nightstand and touching the wood surface. The surveyor did not observe an equipment storage bag or date label on the nebulizer equipment. On 10/29/24 at 8:39 A.M., the surveyor observed Resident #24 lying in bed and the nebulizer equipment and tubing were laying on the nightstand table. The surveyor observed there was no equipment storage bag or date label on the nebulizer equipment. During an interview at the time, Resident #24 said that he/she have used the nebulizer equipment when he/she needed it, but the nebulizer equipment had never been changed. The Resident said he/she last used the nebulizer equipment a few days ago. Resident #24 further said that he/she had a nebulizer device at home and changed the home nebulizer equipment and tubing every few days. During an interview and observation on 10/30/24 at 12:46 P.M., Nurse #3 said the nebulizer equipment and tubing was changed once a week on Sunday by the night shift Nurse. Nurse #3 examined Resident #24's nebulizer equipment and tubing and said that there was a date written in marker which indicated 10/5. Nurse #3 said that the Resident's nebulizer equipment should have been changed on 10/28/24 and stored in a plastic bag but this had not been done. Nurse #3 said all nebulizer equipment and tubing are changed weekly, labeled and dated, and stored in a clean plastic bag when not in use. During an interview on 10/30/24 at 1:37 P.M., the Director of Nursing (DON) said nebulizer equipment should be changed once a week on Sunday by the night shift Nurse. The DON also said the nebulizer equipment changes should be recorded on the Treatment Administration Record (TAR). The DON said that there should have been an order from the Physician for nebulizer equipment maintenance but there was none.

Based on observation, interview, record review and policy review, the facility failed to provide treatments in accordance with professional standards of practice for one Resident (#78) out of a total sample of 23 residents. Specifically, the facility failed to implement and perform care and treatment consistent with the Physician orders and professional standards of practice for a Resident with Diabetes Type II (DM II- a chronic medical condition where the body cannot effectively use insulin [hormone that regulates blood glucose/sugar] or produce enough insulin and has trouble controlling blood sugar levels), placing the Resident at risk for side effects of hyperglycemia (high blood sugar). Findings include: Review of the National Library of Medicine document titled, Management of Diabetes and Hyperglycemia in hospitalized Patients, dated October 2024, https://www.ncbi.nlm.nih.gov/books/NBK279093/ indicated: -hyperglycemia . is defined as blood glucose greater than 140 mg/dL (milligrams per deciliter) -for non-critically ill individuals, a glycemic goal of 100-180 mg/dL is recommended -there is a strong association between those with hyperglycemia and poor clinical outcomes such as mortality, infections and hospital complications. Review of the American Diabetes Association Treatment and Care target ranges for blood sugar testing, undated, https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar indicated: -before a meal: 80-130 mg/dL -1-2 hours after beginning of the meal: less than 180 mg/dL Review of the facility policy for Blood Glucose (sugar) Monitoring System, last revised January 2024 indicated: -to determine the capillary (small blood vessel) blood glucose levels for regulation of subcutaneous (under the skin) Insulin administration in accordance with Physician's orders. -for screening of asymptomatic or suspected hypoglycemia (low blood sugar) or hyperglycemia. -the Physician's order will include: >the frequency of testing >interventions >parameters (numerical or another measurable factor) Resident #78 was admitted to the facility in June 2022, with diagnoses including Diabetes Type II and hypoglycemia. Review of Resident #78's Nutrition Care Plan, last revised 8/7/24, indicated: -the goal is to maintain blood sugars between 80-180 mg/dL -an intervention to provide Insulin (hormone medication used to regulate blood sugar levels) and Finger Stick Blood Sugar (FSBS) as ordered -monitor for signs and symptoms of hypoglycemia and hyperglycemia Review of Resident #78's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of total 15. -was diagnosed with Diabetes Mellitus and received Insulin injections. Review of Resident #78's October 2024 Physician's orders indicated: -Finger Stick Blood Sugar (FSBS) 4 times a day (before meals and at hour of sleep) -Special Instruction: **Follow facility protocol for fasting blood sugar less than 60 mg/dL. -Report HI (high) reading to MD (Medical Doctor)/NP (Nurse Practitioner)** start date of 4/28/23. -Novolog FlexPen (fast acting Insulin injection) U-100 Insulin Pen; 100 unit/mL (Units/Milliliters) (3 mL); amount 10 Units subcutaneous with meals: 8 A.M., 12 P.M., 5 P.M., start date of 12/29/23 Review of Resident #78's Vitals Report indicated high blood sugar levels on the following dates: -9/10/24: 500 mg/dL -9/23/24: 504 mg/dL -10/1/24: 532 mg/dL -10/2/24: 411 mg/dL -10/4/24: 492 mg/dL -10/5/24: 541 mg/dL -10/7/24: 452 mg/dL -10/9/24: 439 mg/dL -10/29/24: 422 mg/dL Review of Resident #78's Nursing Progress Notes indicated that nursing staff did not notify the Physician or Nurse Practitioner (NP) regarding the Resident's high blood glucose levels on any of the dates listed when the Resident's FSBS results were high. During an interview on 10/30/24 at 3:01 P.M., the Director of Nursing (DON) said that Resident #78 did not have any parameters for what high blood sugar levels were since his/her admission to the facility. The DON also said that although the Physician's orders indicated to follow facility policy for blood sugar, the facility did not have a policy for hyperglycemia and there was no evidence that the Physician and/or Nurse Practitioner (NP) were notified of the elevated blood sugars in the Nursing Progress Notes. During a follow-up interview on 10/30/24 at 3:29 P.M., the DON said that she expects the nursing staff to notify the Physician or NP if the Resident's blood sugar levels are over 450 mg/dL and the nursing staff did not. During an interview on 10/30/24 at 3:45 P.M., Resident #78's Physician said that he did not put in the current order for high blood sugar levels and that the order should have documented the numerical value for contacting the Physician. The Physician also said that he was not contacted for Resident #78's elevated blood sugar levels but that his NP may have been contacted. Further review of the medical record did not indicate that the NP was contacted regarding the high blood sugar levels resulted for Resident #78 on: 9/10/24, 9/23/24, 10/1/24, 10/2/24, 10/4/24, 10/5/24, 10/7/24, 10/9/24, and 10/29/24. During an interview on 10/30/24 at 4:29 P.M., Resident #78 said that he/she had been experiencing high blood sugars which makes him/her feel uncomfortable. Resident #78 also said that when the high blood sugars occurs, his/her mouth becomes dry, breath smells sweet, and he/she urinate a lot. Resident #78 said that a year ago he/she had been sent out to the hospital when his/her blood sugar went up to 500 mg/dL.

Based on interview, and record review, the facility failed to notify the State Mental Health Authority for a Resident Review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#98), out of a total sample of 23 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness [SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #98 received emergency mental health interventions and was transferred to the hospital for a psychiatric evaluation. Findings include: Resident #98 was admitted to the facility in May 2024, with diagnoses including Severe Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation, Adjustment Disorder (a disorder characterized by a group of symptoms such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after a stressful life event) with Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), and Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy). Review of Resident #98's clinical record included the following: -Nursing Progress Note, dated 8/17/24, which indicated the Resident punched a Certified Nurses Aide (CNA) in the face during care and when the CNA attempted to get away, the Resident grabbed the CNA's hand so hard it left a reddened area with scratches. A subsequent Nursing Note indicated Section 12 (Section 12 (a): allows for an individual to be brought against his or her will to a hospital for evaluation. Section 12 (b): allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent) paperwork was received and the Resident was sent to the hospital for a psychiatric evaluation. -Nursing Progress Note, dated 8/30/24, indicated the Resident was readmitted to the facility after being transferred to the hospital for a psychiatric evaluation. -no documented evidence that a PASRR Level II screen for Resident Review was completed after Resident #98 had a change/decline in his/her condition requiring psychiatric evaluation/treatment at the hospital. During an interview on 10/30/24 at 11:34 A.M., Social Worker (SW) #1 said she would have to review the Resident's paperwork after he/she was readmitted back to the facility after the Section 12 hospitalization to determine if a PASRR Level II screen would be required. During a follow-up interview on 10/30/24 at 2:31 P.M., SW #1 said the PASRR Level II review was not submitted after Resident #98's hospitalization for psychiatric evaluation. SW #1 said she was going to submit the request for the Resident's Level II review today.

Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for one Resident (#85), out of a total sample of 23 residents. Findings include: Resident #85 was admitted to the facility in April 2023, with diagnoses including Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy) and Psychotic Disorder (serious mental disorders characterized by a disconnection from reality which results in strange behaviors often accompanied by disturbances of thought [excessive suspiciousness, guilt] and perception [hearing voices, seeing things, feeling things] with hallucinations [an experience involving the apparent perception of something not present]). Review of the PASRR Level I Screening, dated 4/19/23, indicated the Level I (initial pre-screening completed prior to admission to a Nursing Facility) Screen was completed after the Resident was admitted to the facility. During an interview on 10/30/24 at 3:55 P.M., Social Worker (SW) #1 said the PASRR Level I Screen should be completed prior to the Resident's admission to the facility. During a follow-up interview on 10/30/24 at 4:08 P.M., the surveyor and SW #1 reviewed Resident #85's PASRR Level I Screening and SW #1 said it was completed after the Resident's admission and should have been completed prior to his/her admission to the facility.

Based on record review and interview the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after the completion date for 17 Residents (#4, #43, #57, #90, #95, #102, #103, #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118) out of a total sample of 23 residents. Specifically, the facility failed to ensure that: 1) Comprehensive MDS assessments for Resident's #4, #43, #57, #90, #95, #102, #103 were not submitted late with submission dates more than 14 days after the completion date. 2) Non comprehensive MDS assessments for Residents #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118 were not submitted late with submission dates more than 14 days after the completion date. Findings include: Review of The Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual dated October 2024, indicated: -Comprehensive assessments (Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessments include the completion of both the MDS Assessment and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required) must be transmitted (Assessment Transmission refers to the electronic transmission of submission files to the Internet Quality Improvement and Evaluation System (iQIES)), not later than 14 calendar days after completion of the care plan. -Further review of the RAI manual indicated that non comprehensive MDS assessments (OBRA-required non-comprehensive MDS assessments include a select number of MDS items, but not completion of the CAA process and care planning.) must be transmitted to IQIES no later than 14 calendar days after the MDS completion date. Review of the Facility's MDS 3.0 Final Validation Report indicated: -Comprehensive MDS assessments for Resident's #4, #43, #57, #90, #95, #102, #103 were submitted late with submission dates more than 14 days after the completion date. -Non comprehensive MDS assessments for residents #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118 were submitted late with submission dates more than 14 days after the completion date. During an interview on 10/30/24 at 1:39 P.M., the Corporate MDS Coordinator said the facility uses the RAI manual to determine the dates for completion and submission of the facility's MDS assessments. The Corporate MDS Coordinator said the facility's regular MDS Coordinator is out on leave and the Corporate MDS Coordinator is responsible for the oversight of completion and submission of the facility's MDS assessments, while the regular facility MDS Coordinator is out on leave. The Corporate MDS Coordinator said the MDS assessments for the 17 Residents reviewed were submitted late per RAI manual standards. The Corporate MDS Coordinator said she was in the process of getting the MDS assessments up to date.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#98), was free from physical restraints, out of a total sample of 23 residents. Specifically, for Resident #98, the facility failed to: -appropriately assess and re-assess the use and need of wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) as a restraint that was being used in the place of an ordered scoop mattress (a mattress with raised edges on all four sides to prevent accidental rolling out of bed). -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of wedge cushions while the Resident was in bed to prevent him/her from exiting the bed, increasing the potential risk of accidental falls and injury. Findings include: Review of the facility policy titled Guidelines for the Use of a Restraint, revised 11/2016, indicated it was the policy of the facility to provide care and services to assist each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has a medical symptom that warrants the use of restraints. The policy also included the following: -every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience . -when the use of restraints is indicated, the facility will use the least restrictive alternative for the least amount of time and document ongoing evaluation of the need for the restraints. -physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -physical restraints may include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays that the resident cannot remove easily. -also included as restraints are facility practices that meet the definition of a restraint, such as: >using the side rails that keep a resident from voluntarily getting out of bed; >tucking in or using velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted >placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out of the bed -removes easily means that the manual method, device, material, or equipment can be removed intentionally by the same manner as it was applied by the staff (e.g., side rails are put down, not climbed over) considering the resident's physical condition and ability to accomplish the objective . -convenience is defined as any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by a facility and not in the resident's best interest. -freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control -before initiating any device that has a potential to act as a restraint, the facility will conduct a comprehensive assessment utilizing the Restraint/Positioning Assessment form -the assessment should include: -resident diagnoses and prior medical history -problem for which restraint use is being considered -falls history -behaviors -physical functioning status -evaluate the risks and benefits of ALL options -the order must be specific to: -the type of restraint to be used -time limitations for the use of the restraint -the diagnosis and specific medical symptoms to warrant the restraint -the frequency of observing and assessing the resident -the periodic removal/release of the restraint -in order to be fully informed, the facility will explain to the resident or resident representative, in terms specific to the resident's condition: -the specific medical symptoms/conditions that would require the use of the restraints -how the use of the restraint would treat the medical symptoms and assist the resident in attaining his/her highest level of physical/psychological well-being -the risks and benefits of restraint use -After reviewing the terms of the restraint use and being given the opportunity to discuss the risks, benefits and alternatives, the resident or, in the case of a resident who is incapable of making a decision, the legal surrogate or resident representative will give their permission by signing the Consent to the Use of Restraints form. Resident #98 was admitted to the facility in May 2024, with diagnoses including Severe Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation, Adjustment Disorder (a disorder characterized by a group of symptoms such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after a stressful life event) with Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations) and muscle weakness. Review of the Minimum Data Set (MDS) Assessment, dated 8/2/24, indicated Resident #98: -had a Brief Interview of Mental Status (BIMS) score of 1 out of 15. -had other behaviors that occurred towards others (hitting, physical, throwing things, disruptive sounds). -was dependent on staff for activities of daily living (ADLs: basic skills you need to perform daily life activities, such as bathing, dressing, and eating) and had two or more falls since the previous assessment. Review of Resident #98's clinical record indicated: -Sustained a fall 5/10/24 out of his/her wheelchair in the dining room, and sustained falls on 6/1/24 and 6/13/24 out of his/her bed. -Falls Care Plan, initiated 5/7/24, included the following intervention: >scoop mattress (mattress with raised edges on the bottom and/or top and a space in the middle to allow access in/out of the bed which assists a resident to define the edges of the bed) while in bed (initiated 6/6/24). Review of the Restraint/Positioning Assessment, completed on 9/9/24, indicated the following: -the problem/diagnosis for which the restraint or positioning device was being considered: falls out of bed -Resident was severely cognitively impaired -had agitation and history of falls -had left upper extremity range of motion impairments -was dependent on staff for ADLs, transfers and mobility -type of restraint/positioning device being considered: scoop mattress in order to prevent self-injury while in bed -the summary of the explanation for the use of the scoop mattress included the following: Resident tries to get out of bed, has a history of falls and the mattress is used to prevent him/her from falling out of bed. Review of the October 2024 Physician's orders included the following: -activate Health Care Proxy (HCP: designated person who makes medical decisions when a person was unable), initiated 5/3/24 -fall precautions, initiated 6/4/24 -may utilize bilateral half side rails for medical necessity ., initiated 6/14/24 -scoop mattress at all times while in bed. Check every shift for placement, initiated 9/9/24 On 10/29/24 at 8:21 A.M., the surveyor observed the Resident was awake and lying upright in bed. The surveyor observed the head of the bed was elevated, bilateral side rails were in place and wedge cushions (shaped like V-shaped wedges, assist with posture, alignment and comfort during long sitting) were positioned adjacent to the side rails on both sides of the bed, at the same height as the side rails and extended from the Resident's hips to knees/lower legs. The surveyor observed there was no space between the side rails and the wedge cushions and a facility staff member was seated next to the Resident and assisting him/her with the breakfast meal. On 10/29/24 at 10:35 A.M., the surveyor observed Resident #98 lying in a low positioned bed. The surveyor observed the Resident was dressed in a hospital gown, bilateral side rails were in place, and wedge cushions were positioned adjacent to the side rails on both sides of the bed. The surveyor observed the wedge cushions were the same height as the side rails and were positioned under the fitted bottom sheet of the bed. The surveyor observed there was no space between the side rails and the wedge cushions, the Resident's eyes were open, and he/she waved at the surveyor. On 10/29/24 at 12:57 P.M., the Resident was observed dressed and seated in a specialized wheelchair in the dining room after lunch. On 10/29/24 at 2:17 P.M., the surveyor observed Resident #98 was awake and lying in a low positioned (in a lower position closer to the floor) bed with the head of the bed slightly elevated. Bilateral side rails were observed in place and wedge cushions positioned adjacent to the side rails on both sides of the bed, and under the fitted bottom sheet. The surveyor observed there was no space between the side rails and the wedge cushions. On 10/29/24 at 3:12 P.M., the surveyor and Certified Nurses Aide (CNA) #3 observed Resident #98 was awake and lying in a low positioned bed. the surveyor observed the bilateral side rails were in the up position, and wedge cushions were positioned on both sides of the Resident's lower extremities adjacent to the side rails and were under the fitted bottom sheet. During an interview at the time, CNA #3 said the wedge cushions were put under the bottom sheet of the bed and were in place to prevent the Resident from falling out of bed. CNA #3 said the Resident would try to get out of bed and would fall. On 10/29/24 at 3:23 P.M., the surveyor and Nurse #1 observed the Resident, and Nurse #1 said the Resident had previous falls and the wedge cushions were placed under the fitted bottom sheet on both sides to prevent him/her from getting out of bed and falling. Nurse #1 further said the mattress was not a scoop mattress and was not sure why a scoop mattress was not in place. Nurse #1 said the Resident would be unable to remove the wedge cushions that were placed under the bottom sheet. On 10/29/24 at 3:31 P.M., the surveyor and Unit Manager (UM) #1 observed Resident #98 and UM #1 said the Resident had previous falls out of the bed and the wedge cushions were put into place to prevent him/her from exiting the bed. UM #1 said the wedge cushions would be considered a restraint and an evaluation was completed. UM #1 said that she had considered the use of the wedge cushions the same as a scoop mattress. The surveyor relayed observation of the placement of the wedge cushions which were adjacent to the bilateral side rails and allowed no space between their use and the side rails, and that the wedge cushions were positioned under the fitted bottom sheet. UM #1 said the wedge cushions were placed that way to prevent the Resident from exiting the bed due his/her numerous falls. UM #1 said the Resident would be unable to remove the wedge cushions and because the wedge cushions were used, an assessment would need to be completed, and the Resident's Representative would be notified. UM #1 said she was not sure if consent was obtained for the use of the wedge cushions or if the risks/benefits of the intervention were reviewed with the Resident's Representative. During an interview on 10/29/24 at 3:59 P.M., the Director of Nursing (DON) said she looked at Resident #98's bed. The DON said what was currently in place was not a scoop mattress but were wedge cushions that were placed on both sides of the Resident. The DON said there was no space for the Resident to exit the bed because the wedge cushions were positioned under the fitted bottom sheet. The DON said the wedge cushions were the same height as the side rails that were also in place and that she would consider the wedge cushions use a restraint. The DON said if the wedge cushions were to be used, the Resident's Representative would need to be educated on their use, consent would have to be obtained, a Physician's order for their use would need to be in place, and the use as a restraint would need to be reviewed periodically.

Based on record review, policy review, and interview, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#94) out of a total sample of 23 residents. Specifically, for Resident #94, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #94's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). Findings include: Review of the facility policy for Advance Directives, last revised February 2022, indicated: -capacity to make health care decisions is the ability to understand and appreciate the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision. -In Massachusetts, the determination of a patient's lack of capacity must be made by a Physician in writing before a health care proxy can be put into effect. -health care decision made by an agent under the healthcare proxy is a decision which . is consistent with any limitations in the healthcare proxy and is consistent with responsible medical practice. Resident #94 was admitted to the facility in May 2024, with diagnoses including Dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident #94's clinical record revealed: -a MOLST form signed on 2/5/23 by Resident #94's HCP prior to the Resident's admission to the facility. -a HCP activation form dated 5/4/24 after the MOLST form had been signed by the HCP. -no evidence that the MOLST form had been re-addressed with Resident #94's HCP after their facility admission and before the surveyor brought t it to the attention of the facility. During an interview on 10/29/24 at 9:50 A.M., Social Worker (SW) #2 said that the MOLST form was not valid as it had been signed by the HCP before the Resident had been deemed incapacitated by his/her Physician. SW #2 also said that a new MOLST form should have been completed upon the Resident's admission to the facility and it was not.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent contamination and stop the spread of infections for one Resident (#54), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #54, perform appropriate hand washing/hygiene for five opportunities, during a wound care procedure which increased the Resident's risk for wound contamination and infection. 2. For Resident #54, Adhere to Enhanced Barrier Precautions (EBP: infection control guidelines that use Personal Protective Equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]) during medication and fluid administration through a gastrostomy tube (G-tube: a tube surgically inserted through the abdominal wall and into the stomach to provide nutrition, fluids and medications by bypassing the mouth and esophagus). Findings include: Review of the facility policy titled Handwashing, dated June 2012 with revision date of January 2016, indicated the following: -It is the policy of this facility to follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene .and reduce the risk of healthcare associated infections. Review of the Centers for Disease Control and Prevention Guidelines for Core Infection Prevention and Control Practices in All Settings indicated the following: >Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient. -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. -Before moving from work on a soiled body site to a clean body site on the same patient. -After touching a patient or the patient's immediate environment. -After contact with blood, body fluids or contaminated surfaces. -Immediately after glove removal. Review of the Centers for Disease Control Hand Hygiene in Healthcare Settings Glove Use indicated the following: -Gloves are not a substitute for hand hygiene. -If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. -Perform hand hygiene immediately after removing gloves. -Change gloves and perform hand hygiene during patient care, if gloves become damaged, or visibly soiled with blood or body fluids following a task. -Change gloves and perform Hand hygiene when moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. -Never wear the same pair of gloves in the care of more than one patient. -Carefully remove gloves to prevent hand contamination. Review of the facility policy titled Personal Protective Equipment (PPE- protective gear which includes gloves, masks, gowns and eyewear to prevent the spread of infection), dated June 2021 revised September 2021 indicated: -Gloves >Perform hand hygiene after removing gloves. >Gloves do not replace hand hygiene. Resident #54 was admitted to the facility in October 2019, with diagnoses including Stage Four Pressure ulcer (full thickness loss of skin with extensive destruction/damage to muscle, bone or supporting structures such as tendon or joint capsule) of the sacral (bony structure located at the base of the spine) area and Neuromuscular Dysfunction of the Bladder (a condition where the nerves and muscles of the bladder do not work together well and can cause problems with the emptying of the bladder), dysphagia (difficulty swallowing), Cerebrovascular Accident (CVA: when blood flow to a part of the brain is stopped either by a blockage or a rupture of a blood vessel) and presence of gastrostomy tube (feeding tube). Review of the Minimum Data Set (MDS) Assessment, dated 9/13/24, indicated Resident #54: >was severely cognitively impaired as evidenced by staff interview. >had an indwelling urinary catheter (soft flexible tube that drains urine from the bladder). >was dependent for Activities of Daily Living (ADLs-the basic self-care needs including washing, dressing, and getting in and out of bed or chair). >had a feeding tube which provided greater than 51 percent (%) calorie needs and greater than 501 milliliters (mls) of fluids daily. Review of Resident #54's Comprehensive Person-Centered Care Plan indicated: >Pressure ulcer on the sacrum (large flat bone in the lower part of the spine), effective October 2020 >Feeding tube, effective March 2021 >Indwelling catheter, effective July 2022 1. Review of Resident #54's October 2024 Physician's orders indicated: >Stage 4 Pressure wound of the sacrum- wash with Normal Saline (NS- nine grams of salt per one liter of water solution) and pat dry. -Apply Santyl (a prescription ointment used remove dead tissue from wound beds) followed by Alginate Calcium (a fibrous dressing that absorbs wound drainage) followed by super absorbent gelling fiber with silicone border (an absorbent cover dressing that gels when exposed to liquids and has soft flexible edges made from silicone). -change three times a week. >Foley Catheter (a soft, flexible tube inserted to the bladder to drain urine) 16 French (5.3 millimeter tube) with 10 milliliter (ml) balloon (a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body) to continuous drainage. On 10/30/24 at 11:50 A.M., the surveyor observed Nurse #4 and the Infection Preventionist (IP) Nurse provide the following wound care for Resident #54's sacral wound: -Nurse #4 and the IP performed hand hygiene and donned (put on) disposable gowns and gloves. -Nurse #4 and the IP then positioned the Resident into a side lying position in the bed. -Nurse #4 dragged Resident #54's urinary drainage bag (a collection bag attached to the indwelling Foley Catheter to collect urine), that was lying directly on the floor, across the floor and placed the urinary drainage bag on top of the Residents fitted sheet. -Nurse #4 removed the old sacral dressing from Resident #54 with the same gloves on that were used to pick up the urinary drainage bag from the floor and placed the old dressing into a trash bag. -Nurse #4 then removed her gloves and placed them in the trash bag. -Nurse #4 put on new gloves without performing hand hygiene first. -Nurse #4 cleansed the Resident's wound using NS with gauze and patted the area dry. -Nurse #4 removed her gloves and placed them in the trash bag. -Nurse #4 put on new gloves without performing hand hygiene first. -Nurse #4 then measured the Resident's wound which was 2 cm (centimeters) x 2 cm x 0.3 cm. -Nurse #4 removed her gloves and placed them in the trash bag. -Nurse #4 put on new gloves without performing hand hygiene first and applied Santyl to the wound bed, followed by Alginate Calcium. -Nurse # 4 removed her gloves and washed her hands in the bathroom sink. -Nurse #4 put on new gloves and covered the Alginate Calcium with super absorbent gelling fiber with silicone border. -Nurse #4 removed her gloves and put them in the trash bag. -Nurse #4 then reached into her pocket without performing hand hygiene first, retrieved a marker pen and initialed the outer dressing which was on the Resident's sacrum. During an interview on 10/30/24 at 12:18 P.M., Nurse #4 said that she had dragged the urinary drainage bag across the floor and put it on top of the Resident's fitted sheet prior to the dressing change so the urinary drainage bag would not pull on the Resident. Nurse #4 said she knew that the urinary drainage bag should not have been placed on the bed because it was dirty from being on the floor and could spread germs. Nurse #4 said that she sometimes brings a bottle of hand sanitizer into the room when she performs wound care. Nurse #4 said should have used hand sanitizer each time she removed her gloves while providing wound care for Resident #54, but she did not. Nurse #4 said that hand cleansing was important for the prevention of infection when providing wound care. During an interview on 10/30/24 at 12:18 P.M., the IP said she was aware that Nurse #4 had not performed hand hygiene after removing soiled gloves and before putting on new gloves several times during the dressing change but did not say anything to correct Nurse #4, but she should have. The IP said hands should be cleaned every time gloves are removed to prevent the spread of infection. 37400 2. Review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, indicated that it was the policy that all staff providing high-contact resident care activities will implement EBP for residents with any of the following: >infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. >wound and/or indwelling medical device even if the resident is not known to be infected or colonized with a MDRO >high contact resident care activities are defined as to be .device care or use such as .feeding tubes . >indwelling medical devices include .feeding tubes . >a sign indicating the need for EBP will be placed conspicuously to alert staff before approaching the resident for care >a receptacle with necessary PPE will be placed in or near the room for easy accessibility Review of the October 2024 Physician's orders indicated the following: -NPO (nil per os or nothing by mouth), initiated 7/24/21 -flush G-tube with minimum of 15 ml water pre/post medication administration four times daily, initiated 3/4/22 -check G-tube placement before feeding and prior to medication administration every shift ., initiated 12/29/21 -water flushes 400 ml every 4 hours per Medical Doctor (MD) via G-tube, initiated 4/13/24 -may combine all liquid/medications via G-tube, initiated 3/16/23 -may crush medications per guidelines, initiated 4/6/21 -maintain EBP every shift ., initiated 12/5/22 On 10/30/24 at 9:54 A.M., the surveyor observed Nurse #2 administer medications via Resident #54's G-tube and the following was observed: -EBP signage was posted outside of the Resident's room and indicated for everyone to cleanse hands before entering and when leaving the room, wear gloves and a gown for high contact resident care activities including device care . feeding tubes -a compartment containing different sizes of gloves and gowns was hanging on the outside of the Resident's door -Nurse #2, who was outside of the Resident's room at the medication cart, crushed the medication, put it in a disposable cup and mixed it with warm water. -Nurse #2 donned (put on) gloves and entered the Resident's room with the cup of medication and water. Nurse #2 did not don a gown as required. -Nurse #2 used her gloved hands to move the Resident's blanket and hospital gown to expose the G-tube. -Nurse #2 opened a piston syringe packet, uncapped the G-tube and checked the residual (the volume of fluid or food remaining in the stomach during enteral nutritional feedings) using the piston syringe. -Nurse #2 then utilized the syringe connected to the G-tube, flushed the tube with 15 mls of water via gravity, then poured the cup containing the crushed medication and water into the syringe. -After administering the medication, Nurse #4 flushed the G-tube with 400 mls of water, replaced the cap on the end of the G-tube, disposed of the empty medication cup, doffed her gloves and exited the Resident's room. During an interview immediately following the observation, Nurse #2 said the Resident was on EBP precautions. Nurse #2 said a gown and gloves should be worn when providing direct care to the Resident. Nurse #2 said accessing his/her G-tube to administer medications was considered direct care. Nurse #2 said in addition to wearing the gloves, she should have worn a gown, but she did not.

Based on observation and interview, the facility failed to maintain professional standards relative to food storage and sanitation in one of three nourishment kitchens. Findings include: Review of the facility's Nourishment policy dated January 2016, indicated the following: -Dietary is responsible for monitoring and recording the temperatures of both the refrigerator and freezer of the nourishment refrigerators. -All non-nourishment food will be discarded immediately Review of the 2022 United States Food and Drug Administration Food Code indicated the following: *Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. *Time/Temperature control for safety, cold holding: -Except during preparation, cooking, or cooling, or when time is used as the public health control, food shall be maintained at 5 Celsius (41 Fahrenheit) or less. During an observation of the first floor nourishment kitchen on 8/24/23 at 8:38 A.M., the following concerns were observed: -The internal refrigerator thermometer read 58 degrees Fahrenheit (F), and beverage/food items felt warm to the touch. -On top of the refrigerator, a half full bag of flavored coffee grounds with no Resident's name or date when opened, was stored. -In a cabinet above the refrigerator there were two boxes of cereals. One box was half-full, undated and was left open to the air. One box was two-thirds full, undated and was left open to the air. Neither box was labeled with a Resident's name. -In a cabinet below the microwave, a divided storage container held packets of salt, pepper, sugar, and sugar substitute. The container was dirty with condiment debris. During a second observation of the first floor nourishment kitchen on 8/25/23 at 10:50 A.M., the following concerns were observed: -The internal refrigerator thermometer read 52 degrees F. -The two cereal boxes remained stored in the same cabinet, were still open to the air, undated. and had no Resident's name on them. -The bag of coffee grounds remained stored on top of the refrigerator. It was not lableed with a Resident's name and was undated. -The condiment storage container remained dirty with food debris. During a third tour of the first floor nourishment kitchen, along with the Food Service Director (FSD), the Registered Dietitian (RD) and the surveyor, on 8/25/23 at 11:45 A.M., the following concerns were observed: -The internal refrigerator temperature read 50 degrees F. At this time, the FSD said the temperature was too high. -The bag of ground coffee remained on top of the refrigerator, unlabeled and undated. -Both boxes of cereal remained stored in the cabinet, open to the air, undated and had no Resident's name on them. Additionally, a large container of ground coffee was stored in the same cabinet next to the cereal, was undated when opened and had no Resident's name on it. -The condiment container remained with dirty food debris. During an interview on 8/25/23 at 11:50 A.M., the FSD said the boxes of cereal and containers of ground coffee were not items provided by the kitchen. She said that if they were for a Resident, they should have contained a Resident's name and date when brought in and/or opened. She said food should not be stored open to the air. She said she was unsure when the last time the condiment container had been cleaned and it should not have been dirty with food debris.

Based on observations, policy reviews and interviews, the facility failed to adhere to Infection Control policies/practices during a COVID-19 outbreak. Specifically the facility staff failed to: 1) utilize the appropriate precaution signs on one out of three units during an outbreak of COVID-19 infection. 2) use appropriate personal protective equipment (PPE) by staff in a manner that would minimize the spread of COVID-19 infection during an active outbreak for one Resident (#96) out of four applicable residents, out of a sample of 21 residents. 3) to ensure staff were tested for COVID-19 as required when the facility was experiencing an outbreak of COVID-19 infections. Findings include: Review of the facility policy titled, COVID-19 Control Plan, revised 5/14/23, indicated the following: *Residents in whom a diagnosis of COVID-19 is suspected or confirmed will be separated from non-infected residents. The following measures will be implemented: -An Isolation Precautions sign will be placed on the door and necessary personal protective equipment (PPE) will be utilized immediately. -Eye protection, gown, and gloves will also be worn per precaution guidelines. Review of the Massachusetts Department of Public Health (MA DPH) Memorandum titled Comprehensive PPE Guidance, dated 5/5/23, included the following PPE requirements for staff when caring for patients with suspected or confirmed COVID-19: -DPH recommends that a fit-tested N95 filtering face-piece respirator or alternative and eye protection be used when caring for patients with suspected or confirmed COVID-19. If there is any contact with potentially infectious material, an isolation gown and gloves should also be used. -Respirators: Proper use of respiratory protection by health care personnel (HCP) requires a comprehensive program (including medical clearance, training, and fit testing) that complies with the Occupational Safety and Health Administration (OSHA)'s Respiratory Protection Standard. -N95 respirators should always be discarded after doffing (removal), such as when leaving a patient room . -Eye Protection: Disposable eye protection should be discarded when it is removed for any reason; it should not be reused. Reusable eye protection should be cleaned and disinfected when visibly soiled and after removal/doffing. -Isolation Gowns: Gowns should be disposed of or laundered after each patient encounter. -Gloves: Gloves should be worn when there is any contact with potentially infectious material. HCP should perform hand hygiene prior to donning (putting on) and after doffing gloves. Review of the facility's Enhanced Barrier Precaution sign, undated, indicated the following procedure: *Everyone must: -clean their hands, including before entering and when leaving the room. -wear gloves and a gown for the following high contact activities: -Dressing-bathing/showering -Transferring -Changing linens -Providing hygiene -Changing briefs or assisted[sic] with toileting -Device care of use: central line, urinary catheter, feeding tube, tracheostomy -Wound care: any skin opening requiring a dressing. Review of the facility's Quarantine Droplet/Contact Precaution sign, undated, indicated the following: *Everyone must: -clean hands when entering and exiting -Wear the following PPE: -gown -N95 respirator -eye protection -gloves 1) Upon entrance to the facility on [DATE], there was a sign on the main reception desk stating that there were currently five COVID-19 positive cases on the Rehabilitation unit. During the initial pool process on the Rehabilitation Unit, on 8/22/23 there were no quarantine droplet/contact precaution signs noted to be hanging outside of any resident rooms. Enhanced Barrier signs were noted on the doors of the following rooms of COVID-19 positive residents: -203 -209 -212 -216 2) Resident #96 was admitted to the facility in May 2023 with diagnoses including: bladder cancer. Review of the clinical record indicated Resident #96 tested positive for COVID-19 infection on 8/16/23. On 8/22/23 at 8:27 A.M., the surveyor observed enhanced barrier signage outside of the Resident's room. The Resident was observed inside of the room, was not wearing a mask and was actively coughing. During an interview on 8/22/23 at 2:16 P.M., Unit Manager (UM) #1 said that the COVID-19 outbreak started the previous week. She further said that they are using enhanced barrier precaution signs to identify PPE for COVID-19 positive residents. UM #1 reviewed the enhanced barrier sign and said that it does not say to wear goggles or eye protections but that the staff should be wearing it when caring for COVID-19 positive residents. During an observation on 8/22/23 at 2:25 P.M., UM #1 was observed updating the enhanced barrier precautions signs to droplet/contact precautions signs outside of the COVID-19 positive rooms. On 8/24/23 at 10:56 A.M., the surveyor observed Nurse #1 and CNA #1 had entered Resident #96 room with no eye protection. On 8/24/23 at 11:28 A.M., the surveyor observed Nurse #1 exiting Resident #96's room wearing only an N95 mask and no eye protection. On 8/24/23 at 11:32 A.M., the surveyor observed Nurse #1 enter Resident #96's room with only an N95 mask and no other PPE as required. Signs for enhanced barrier precautions and droplet/contact precautions signs were posted outside of Resident #96's door. On 8/24/23 at 11:34 A.M., the surveyor observed CNA #1 enter Resident #96's room with no eye protection. During an interview on 8/24/23 at 11:45 A.M., Nurse #1 said that for COVID-19 positive residents, staff will use a gown, gloves, and an N95 mask. She further said that sometimes depending on the wound care being provided, she will use a face shield or eye protection. Nurse #1 said that as of yesterday Resident #96 was still testing positive for COVID-19 and that she should have worn an eye shield and she did not, because the Resident is Covid positive. During an interview on 8/24/23 at 11:48 A.M., CNA #1 said that the PPE for COVID-19 positive residents is an N95 mask, gloves and a gown. He further said that staff do not have to wear eye protection when taking care of COVID-19 positive residents. During an interview on 8/24/23 at 1:04 P.M., the Infection control Nurse said that for COVID-19 positive residents, staff are expected to use a gown, gloves, face shield and N95 mask for droplet/contact precautions. 44337 3) Review of the facility policy titled COVID-19 Control Plan last revised 5/14/23 indicated the following: - The facility will perform all COVID-19 testing in accordance with DPH (Massachusetts Department of Public Health). Review of the Massachusetts Department of Public Health Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents dated May 10, 2023 indicated the following: -Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH Epidemiologist directs otherwise. During an interview on 8/24/23 at 12:57 P.M., the IC (Infection Control) Nurse said that the first case of COVID-19 infection for the current outbreak was identified in a resident on the subacute unit on 8/14/23. She said all the residents and staff on the subacute unit were tested immediately and two more residents tested positive. She said that the residents on the subacute unit are being tested every other day and all facility staff are required to test every other day prior to reporting to their work area. Review of the time card punch documentation for CNA #2 provided by the facility indicated CNA #2 worked in the facility on 8/15, 8/16, 8/20, 8/21, 8/23 and 8/24. Review of the COVID-19 staff testing logs provided by the facility showed no evidence that CNA #2 had been tested for COVID-19, every other day, between 8/15 and 8/24 as required. Review of the time card punch documentation for Laundry Personnel #1 provided by the facility indicated Laundry Personnel #1 worked in the facility on 8/13, 8/15, 8/16, 8/17, 8/18, 8/22, 8/23, and 8/24. Review of the COVID-19 staff testing logs provided by the facility showed evidence that Laundry Personnell #1 was tested for COVID-19 on 8/15 and 8/22 but showed no evidence that Laundry Personnel #1 had been tested every other day as required. Review of the time card punch documentation for Nurse #5 provided by the facility indicated Nurse #5 worked in the facility on 8/14, 8/16, 8/17, 8/19, 8/20, 8/21, 8/23 and 8/24. Review of the COVID-19 staff testing logs provided by the facility showed evidence that Nurse #5 was tested for COVID-19 on 8/20 but showed no evidence that Nurse #5 had been tested every other day as required. During an interview and staff COVID-19 testing log review on 8/28/23 at 11:34 A.M., the IC Nurse said that CNA #2 had not been tested for COVID-19 during the outbreak and Laundry Personnel #1 had only been tested two times during the outbreak. She said Nurse #5 had only been tested on e time for COVID-19 during the outbreak. She said that all facility staff should have been tested every other day as part of the COVID-19 infection outbreak but they had not been tested as required.

Based on interview and record review, the facility failed to ensure a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) was submitted for one Resident (#48) out of a total sample of 21 residents. Specifically, for Resident #48, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Resident #48 was admitted to the facility in November 2022 with diagnoses including Wernicke's Encephalopathy (a neurological disorder often associated with chronic alcoholism). Review of Resident #48's Level I PASRR screen dated 11/29/22, indicated that he/she had a history of alcohol abuse and did not meet criteria for Serious Mental Illness, therefore a Level II PASRR evaluation was not needed. Review of the Behavioral Health Group note dated 8/2/23, indicated the following: -The Resident was anxious with concerns for depression and agitation. -His/her speech was excessive and repetitive, often had trouble completing thoughts. -He/she would benefit from an increase in Zoloft (an anti-depressant medication) for depression/anxiety. -Diagnosis of Major Depression Disorder and Adjustment Disorder with Anxiety. Further review of the clinical record did not indicate that the PASRR Level I evaluation had been updated and resubmitted as required, after it had been identified that the Resident had a diagnosis of mental illness and had limitations in major life activities related to interpersonal functioning. During an interview on 8/28/23 at 3:44 P.M., Social Worker (SW) #1 said that a PASRR Level II screen request should have been submitted to the Department of Mental Health PASRR office and had not been, as required.

Based on observation, record review and interview, the facility failed to assess one Resident (#70), out of a total sample of 21 residents, for self-administration of medications. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Resident #70 while at the Dialysis Clinic. Findings include: Review of the facility policy titled, Self-Administration of Medications, revised 3/2022, included but was not limited the following: -Residents who desire to self-administer medications may do so if the interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility. -If the resident desires to self-administer medication, an assessment is conducted by the IDT of the resident's cognitive, physical and visual ability to carry out this responsibility. -The IDT determines the resident's ability to self- administer medications by means of a skills assessment. -The results of the IDT assessment are recorded on the self-administration of medications in the resident's medical record. A periodic reassessment (at least annually and with significant change in status) of the resident's ability to continue self-administration should be conducted. -If the resident demonstrates the ability to safely self-administer medications, a Physician's order for self-administration is obtained and placed in the resident's medical record. -Self-administration teaching must be documented on the resident education form. A resident specific care plan must also be completed. -Nursing staff is responsible for recording self-administrated doses on the medication administration record (MAR). Review of the facility policy titled, Dialysis Treatment, Care and Transport of Residents Requiring, revised 1/8/2019, indicated the following: -The facility shall communicate with the designated dialysis center to identify the schedule of services for the resident. -The facility will initiate a communication book to accompany the resident to scheduled dialysis appointments. -The assigned Nurse will administer required medications and or treatments prior to the resident leaving the facility, as ordered. -Pertinent medication information will be recorded in this book by both the facility and the dialysis center staff to ensure continuity of care for the resident. -Upon return from dialysis treatment the Nurse will review the communication book for pertinent information, observations or recommendations. -The Nurse will contact the Physician, as needed, based on the information received from the dialysis center. -The Nurse will update the care plan as needed, based on the information received from the dialysis center and Physician orders. Resident #70 was admitted to the facility in July 2023 with diagnoses including: end stage renal disease (ESRD - a condition where the kidneys have lost most of their function) and was receiving dialysis treatment. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #70 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and was receiving dialysis while in the facility. Review of the August 2023 Physician's orders included the following: -Send Midodrine (a medication used for low blood pressure) - 7.5 milligram (mg) tablet the 2:00 P.M. dose with patient to dialysis. Once a day on Monday, Wednesday and Friday at 9:00 A.M. -Midodrine 7.5 mg three times a day, 6:00 A.M., 2:00 P.M., and 10:00 P.M., hold for systolic blood pressure (SBP-is the highest arterial blood pressure of a cardiac cycle) greater than 160. Review of Resident #70's dialysis communication book on 8/23/23 at 3:35 P.M., the surveyor observed that it contained a plastic pouch with three small, round, white pills. The outside of the pouch was labeled with Resident #70's name and Midodrine 7.5 mg 2pm. Review of the August 2023 Medication Administration Record (MAR) indicated that Resident #70, took Midodrine with him/her to dialysis and the medication was not signed off by the Nurse as being administered. Review of Resident #70's care plan, Resident wishes to self-administer medication dated 8/16/23, indicated the following: -Assess resident for ability to safely self-administer medication. -Complete resident competency for each medication to be self-administered. -Complete self-administration of meds observation in electronic medical record (EMR). -Document resident education. -Monitor for compliance with medication administration schedule. -Monitor for continued ability to self-administer medication. -Obtain Physician's order for self-administration of medication. -Record medication administration on the electronic medical administration record (EMR). On 8/23/23 at 3:41 P.M., Unit Manager (UM) #1 reviewed the medical record with the surveyor. She said that there was no determination as required by the IDT that Resident #70 had the ability to self-administer medication. She further said that there was no self-administration of medication assessment completed, per policy. UM #1 also said that she was not sure why the Resident did not take the medication while at dialysis because there was no communication received from the dialysis center. Upon further review of the medical record UM#1 said that she was unable to provide documentation from the medical record or from the dialysis communication book about blood pressures and parameters for Resident #70 for the dialysis treatment on 8/23/23. During an interview on 8/23/23 at 4:45 P.M., UM #1 said that she called the Dialysis center, and they said that Resident #70 may have forgotten to take the Midodrine today. UM #1 further said that the medication should not have been left in the dialysis book and they (staff) should be communicating before and after every dialysis treatment.

Based on record review and interview, the facility failed to include one Resident (#21) and/or their Resident Representative in the care planning process out of a total sample of 21 residents. Specifically, the facility staff was unable to provide evidence that Resident #21, and/or their Resident Representative had been invited to, and/or were included in care plan meetings as required. Findings include: Review of the facility policy titled Interdisciplinary Care Planning revised 1/2022, included: -The care planning process provides the resident and their representative with information on the plan for delivery of care and services and a means to remain actively engaged. -Responsible parties are notified by phone or mail in advance of the meeting which is scheduled based on the Medicare/MDS (MDS - Minimum Data Set) review. -The resident is invited to attend the scheduled meeting or the meeting can be held at the bedside if elected to do so by this resident. -The plan includes .involving residents and their representative in the planning process. Resident #21 was admitted to the facility in June 2022 with diagnoses including unspecified Dementia, unspecified psychosis, and Anxiety Disorder. Review of the Resident's clinical record showed evidence of a Health Care Proxy (HCP- an appointed individual to legally make medical decisions on a person's behalf if he/she became unable to do so) form dated 4/1/2019, but there was no evidence that the HCP was ever invoked (made active). Review of the Resident's clinical record showed evidence that MDS Assessments were completed on the following dates: -10/30/22 -3/3/23 -6/2/23 Review of the Resident's Care Plan Meeting Attendance sheets dated 12/16/22, 3/10/23, and 6/8/23, indicated that the only meeting participants were the Social Worker and the Unit Manager. There was no evidence that the Resident and/or their Representative were invited to, or participated in the care plan meeting process. Review of the Resident's clinical record did not provide any evidence that the Resident and/or their Representative were invited to, or participated in any care plan meetings. During an interview on 8/28/23 at 1:30 P.M., Social Worker (SW) #1 said that the residents' care plan meetings occur quarterly along with MDS assessment reviews. She said that she invites the resident if their HCP is not invoked, and if the HCP was invoked she invites the resident's representative. SW #1 said that she thought that Resident #21's HCP was invoked. SW #1 said she could not recall inviting the Resident to a care plan meeting, and said that she must have invited the Resident's Representative instead. SW#1 said that after reviewing the Resident's record she could not find any evidence that the HCP was ever invoked. She said that she was unable to provide evidence that the Resident or the Resident's Representative had been invited to, or participated in the care plan meeting process for the last three quarterly meetings. SW #1 said that the Resident should have been included in the care planning process but was not.

Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan for one Resident (#35), out of a total sample of 21 Residents. Specifically, for Patient #35, the facility staff failed to implement a care plan with interventions related to a re-occurring health problem that resulted in required hospitalization s. Findings include: Review of the facility Interdisciplinary Care Planning policy dated January 2022, indicated the following: -The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services with a person-centered approach. The plan is continually reevaluated and modified to ensure the resident's needs are met. Resident #35 was admitted to the facility in August 2014 with diagnoses including Angiodysplasia (a bleeding disorder in which one or more blood vessels in the gastrointestinal tract become dilated or stretched beyond their normal size) of the colon with hemorrhage (bleeding) and Gastro-Esophageal Reflux Disease (GERD-a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the clinical record indicated the Resident had been hospitalized from 12/24/22 through 12/29/22 due to rectal bleeding. Review of the clinical record indicated the Resident was re-hospitalized on [DATE]. A progress note dated 7/29/23, indicated the Resident was readmitted to the facility from the hospital, where he/she had been medically treated for rectal bleeding. Review of Resident #35's care plans and Physician's orders did not indicate any interventions to monitor for signs and symptoms of rectal bleeding. During an interview on 8/24/23 at 10:25 A.M., after reviewing Resident #35's clinical record, Unit Manager (UM) #2 said there was not a care plan developed and implemented relative to the rectal bleeding. UM #2 said there were no interventions in place for the Resident's gastrointestinal issues but there should have been.

Based on record review and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for two Residents (#8, and #102), out of a total sample of 21 Residents. Specifically: 1. For Resident #8, the facility staff failed to ensure the correct medication dose was documented on the Informed Consent for the use of an antidepressant (medicine used to treat clinical depression) medication. 2. For Resident #108, the facility staff failed to ensure the Resident was: a) was given the right to be informed of the risk and benefits of the use of an antipsychotic (medication which are to treat psychosis) medication. b) an Informed Consent was signed by the Resident or the Resident's Representative/Health Care Proxy (HCP) for the use of an antianxiety (medication that help reduce the symptoms of anxiety, such as panic attacks or extreme fear and worry) medication. Findings include: Review of the facility's Psychotropic Medication Management and Informed Consent policy, dated October 2019, indicated the following: -Prior to initiating the first dose of a psychotropic medication, an Informed Consent will be signed by the competent resident, invoked HCP, Guardian, or court appointed [NAME] Guardian (court appointed legal guardian), as appropriate. -The prescriber will discuss with the resident or the resident's legal representative the purpose of the medication as well as the risks and benefits. -The Informed Consent shall include at a minimum: a) The purpose of the administering the drug, b) The prescribed dosage, and c) Any known effect or side effect. -A new Informed Consent document is required for each psychoactive medication being prescribed. -A new Informed Consent is required each time a new or renewed prescription falls outside the dosage range to which the resident or the resident's representative previously consented, or once a year, whichever is shorter. Review of Guidelines for the Administration of Antipsychotic Medications policy, dated October 2019, indicated the following: -Prior to initiating the first dose of an antipsychotic medication, an Informed Consent will be signed by the competent resident, invoked HCP, or court appointed [NAME] Guardian. -The prescriber will discuss with the resident or the resident's legal representative, the purpose of the medication as well as the risks and benefits. 1. Resident #8 was admitted to the facility in August 2020 with diagnoses of Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and Cognitive Communication Deficit. Review of the Documentation of Resident Incapacity form dated 1/14/21, indicated Resident #8's HCP had been invoked. Review of a Physician's order dated 9/5/21, indicated: Citalopram (Celexa-an antidepressant medication) 40 milligrams (mg) once a day. Review of the Informed Consent for Psychotropic Administration Form for Celexa dated 10/6/22, indicated a dose of 20 mg or less, and it was signed by the HCP. Review of a Minimum Data Set (MDS) Assessment, with an assessment reference date of 12/30/22, indicated the Resident had severe cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS), had active diagnoses of Anxiety and Depression, and had been administered an antidepressant during the previous seven days. Review of a Behavioral Health Group note dated 7/17/23, indicated a primary diagnosis of major depressive disorder, recurrent and mild, and that Celexa 40 mg was being administered daily. Review of the July 2023 Medication Administration Record (MAR) indicated Resident #8 was administered 40 mg of Celexa once daily from 7/1/23 through 7/31/23. Review of the August [DATE], indicated Resident #8 was administered 40 mg of Celexa once daily from 8/1/23 through 8/24/23. During an interview on 8/24/23 at 3:01 P.M., after reviewing Resident #8's clinical record, Unit Manager (UM) #2 said the Informed Consent signed by the HCP did not indicate the correct dose of Celexa being administered. She said the HCP had not been informed of the correct dose, or of the choice of an alternative dose before the medication was administered. 2. Resident #102 was admitted to the facility in July 2023 with diagnoses including unspecified Severe Dementia with agitation. a) Review of a MDS Assessment, with an assessment reference date of 7/26/23, indicated the Resident had severe cognitive impairment as evidenced by a score of 00 out of 15 on the BIMS, had an active diagnosis of Dementia, and had been administered an antipsychotic medication in the previous five days. Review of a Physician's order dated 7/21/23, indicated: Aripiprazole (Abilify-an antipsychotic medication that works by helping to restore the balance of certain natural chemicals in the brain) 5 mg once a day. Review of the clinical record indicated a signed Informed Consent for the use of Abilify was obtained on 7/21/23. Further review of the Informed Consent form indicated the consent was signed by someone who was not the Resident. Review of the July 2023 MAR indicated Abilify was administered daily as ordered, from 7/22/23 through 7/30/23 (the MAR provided to the surveyor did not include 7/31/23's medication administration). Review of the Documentation of Resident Incapacity form indicated the HCP was invoked on 8/1/23. During an interview on 8/25/23 at 3:32 P.M., the Director of Nurses (DON) said the HCP should not have signed the consent for the administration of Abilify because the HCP had not been invoked until 8/1/23. b) Review of a Physician's order dated 7/27/23, indicated: Lorazepam (Ativan-antianxiety medication) 0.25 mg once a day at bedtime, and 0.25 mg once a day as needed (PRN). Review of the July 2023 MAR indicated Ativan was administered once daily at bedtime from 7/27/23 through 7/30/23, and no additional PRN doses were administered. Review of the clinical record indicated no signed Informed Consent for the administration of Ativan. During an interview on 8/25/23 at 3:32 P.M., the DON said that there should have been an Informed Consent for the use of Ativan before it was administered.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the facility failed to provide adequate supervision and prevent Resident #1 from a fall on 02/01/17. Resident #1 sustained a laceration to his/her forehead, was transferred to the hospital for evaluation, and received sutures to his/her forehead to close the laceration. Resident #1 was admitted to the hospital for observation. Findings include: The Resident Face Sheet, dateless, indicated Resident #1's [DIAGNOSES REDACTED]. The Facility Policy, titled Falls Management Program, revised date 01/2016, indicated to implement interventions including adequate supervision, consistent with the resident's needs, goals, plan of care, and current standards of practice in order to reduce risk of accidents. The At Risk for Falls/Injury Care Plan, initiated 04/2009, last updated unknown, indicated Resident #1 was at risk for falls related to poor safety awareness and dementia. The Care Plan indicated Resident #1 was to have a sensor alarm and tab alarm in his/her wheelchair. The Care Plan did not indicate Resident #1 required to be supervised as a fall prevention intervention. The Morse Fall Scale, dated 12/16/16, indicated Resident #1's score was 65, indicated high fall risk (score 51-100 indicates a high fall risk). The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, and was total dependence of 2 staff members for transfers. The Activities of Daily Living Care Plan, initiated 04/2009, last updated unknown, indicated Resident #1 was total dependence of 2 assists with a mechanical lift. A Rehabilitation Screen Request, dated 1/23/17, indicated Resident #1 had a new onset of leaning forward in his/her wheelchair. The Certified Nursing Assistant (CNA) Daily Activities of Daily Living (ADL) Flowsheet, dated February 2017, indicated Resident #1 was total dependent of 2 staff members for transfers and positioning. The Facility Incident Report, dated 2/1/17, indicated Resident #1 had a fall in the dayroom and sustained lacerations to his/her forehead and was transferred to the hospital for evaluation. The Physician's Interim Telephone Order, dated 2/1/17, indicated to transfer Resident #1 to the hospital for evaluation. The Nursing Progress Notes, dated 2/1/17, indicated Resident #1 was transferred to the hospital after a fall and admitted to the hospital for observation. The Surveyor interviewed the Director of Environmental Services at 4:16 P.M. on 4/7/17. The Director of Environmental Services said he heard an alarm sounding, walked into the dayroom and found Resident #1 on the floor and immediately called for help. The Director of Environmental Services said there were no staff members in the dayroom. The Surveyor interviewed the Activities Director at 3:49 P.M. on 4/7/17. The Activities Director said she was in the dayroom and left the dayroom to go to throw something's away and to get new items to restock the activity cart. The Activities Director said when she returned to the dayroom Resident #1 was on the floor and staff was assisting him/her. The Surveyor interviewed the Director of Nurses (DON) at 2:27 P.M. on 4/7/17. The DON said staff members are to supervise residents in the dayroom. The DON said when Resident #1 fell , no staff members were in the dayroom at the time of the fall and there should have been. The Hospital History and Physical, dated 2/1/17, indicated Resident #1 had an unwitnessed fall and sustained a large hematoma (collection of blood) and laceration to his/her forehead and required sutures to close the laceration and was admitted to the hospital. During tour of the Facility, on 4/7/17 at 8:47 A.M., the Surveyor observed the Long Term Care Unit 1 day room, with residents in the room and no staff members present. The Surveyor interviewed Nurse #1 at 8:47 A.M. on 4/7/17. Nurse #1 said a staff member should be in the day room supervising the residents and no staff members were present.

Based on interview and record review, for one of three sampled Residents (Resident #1), the Facility failed to ensure that Resident #1 remained free from restraints used for discipline or convenience, and not required to treat the Resident's medical symptoms as directed in the Facility's Guidelines for use of a Restraint. CNA #1 restrained Resident #1's hands by wrapping them in pillow cases and securing the pillow cases with tape twice during the 3:00 P.M. to 11:00 P.M. shift on 11/6/14. Nurse #1 saw Resident #1's hands wrapped in something white at 5:00 P.M. on 11/6/14, but did not intervene. CNA #1 did not remove the restraint at 11:00 P.M. and, although CNA #3, CNA #4 and Nurse #2 cared for Resident #1 during the 11:00 P.M. to 7:00 A.M. shift, the restraint was not noticed or removed until staff arrived for the 7:00 A.M. to 3:00 P.M. shift on 11/7/14. Findings include: Resident #1's [DIAGNOSES REDACTED]. Resident #1's physician orders [REDACTED]. The Facility Internal Investigation, dated 11/7/14, indicated that during rounds around 7:00 A.M., staff members found Resident #1 in bed with his/her hands wrapped in pillow cases and secured loosely with paper tape. The Surveyor interviewed CNA #1 at 3:30 P.M. on 11/25/14. CNA #1 said that on 11/6/14 in the afternoon, he wrapped pillowcases around Resident #1's hands and wrists and secured the pillowcases with paper tape. CNA #1 said he applied the pillow cases because Resident #1 tried to scratch him when he cared for him/her. CNA #1 said that he removed the pillow cases when Resident #1 was at dinner, and reapplied the pillow cases when he put Resident #1 to bed. CNA #1 said that he did not think the pillow cases were considered a restraint. The Surveyor interviewed Nurse #1 at 10:30 A.M. on 12/5/14. Nurse #1 said that she applied a topical gel to the skin on Resident #1's wrist around 5:00 P.M. on 11/6/14. Nurse #1 said she saw that Resident #1's hands and wrists were wrapped in something white. Nurse #1 said that it was as if Resident #1's hand and arm were inside of a pillowcase, but she did not see how the pillowcase was secured to stay in place. Nurse #1 said she assumed the wrap was a new treatment because she had heard in report that Resident #1 scratched caregivers. Nurse #1 did not intervene to remove the pillowcases or report what she observed to anyone. The Schedule indicated Nurse #2, CNA #3 and CNA #4 were assigned to Resident #1's unit during the 11:00 P.M. to 7:00 A.M. shift which started on 11/6/14 and ended on 11/7/14. The Surveyor interviewed CNA #3 at 10:00 A.M. on 12/5/14. The Surveyor interviewed CNA #4 at 6:30 A.M. on 12/10/14. CNA #3 and CNA #4 said that they provided incontinence care to Resident #1 twice, together during the 11:00 P.M. to 7:00 A.M. shift which started on 11/6/14 and ended on 11/7/14. CNA #3 and CNA #4 said that although they turned on the light in Resident #1's room and pulled his/her covers down completely in order to complete his/her incontinence care, they did not notice Resident #1's hands wrapped in pillowcases and taped. The Surveyor interviewed Nurse #2 at 11:30 A.M. on 12/5/15. Nurse #2 said that she checked Resident #1's respiration rate a few times during the 11:00 P.M. to 7:00 A.M. shift which started on 11/6/14 and ended on 11/7/14. Nurse #2 said that she stood at Resident #1's bedside and counted his/her respirations, but did not draw back Resident #1's blankets. Nurse #2 said she never saw Resident #1's hands and was not aware that his/her hands were restrained within pillowcases beneath the bed sheets.

Based on interview and record review, for one of three sampled Residents (Resident #1), the Facility failed implement its Abuse Prevention Policy by identifying, correcting and intervening a situation in which abuse or mistreatment is more likely to occur, such as with residents with a history of aggressive behavior. Resident #1's nursing progress notes and behavioral records, dated from August to November 2014, indicated Resident #1's had aggression toward staff members, which included scratching staff, during care 7 times. The Facility failed to develop and implement a plan to address the behavior symptoms and, on 11/7/14, Certified Nurse Aide (CNA) #1 wrapped pillow cases around Resident #1's hands and secured the pillow cases with tape in order to prevent Resident #1 from scratching him during care. Findings include: The Facility Abuse Policy, most recently revised December 2010, was reviewed and indicated the Facility identified, corrected and intervened in situations in which abuse is more likely to occur, including an analysis of the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict, such as residents with a history of aggressive behavior. Resident #1's [DIAGNOSES REDACTED]. Resident #1's physician orders [REDACTED]. The Surveyor reviewed Resident #1's Nurse Progress Notes from 8/27/14 to 11/10/14 and Resident #1's Behavior Monitoring Sheets for November 2014 which indicated Resident #1 scratched others seven times. Resident #1's care plan concerns were reviewed. A care concern, initiated 11/30/13, identified that Resident #1's behavior was altered due to dementia, anxiety, agitation and depression and he/she used [MEDICAL CONDITION] medications. The goals per Resident #1's care plan were reduced risk for injury from falls, decreased frequency and duration of unacceptable behaviors and use of the least restrictive and most effective [MEDICAL CONDITION] medications with minimal to no side effects. The care plan approaches included: monitoring for non-compliance with care, combativeness, increased agitation and anxiety; calm, quiet approach; quiet area with reduced noise and stimulation; allowance of time for Resident # to express thoughts and feelings; one to one redirection and positive feedback; activity participation; resident and family education; notification of the physician of changes; medications as ordered, and, monitoring the effectiveness of medications. Although the care plan concern was reviewed 10/17/14 and 11/3/14 to document medication changes, no other interventions were identified. The care plan concern did not specifically identify Resident #1's behavior of scratching staff members or specify interventions. The Surveyor reviewed Resident #1's CNA Care Card which did not include any information about Resident #1's behavioral symptoms or interventions to address his/her behavioral symptoms. The Surveyor interviewed CNA #2 at 2:00 P.M. on 11/25/14. CNA #2 said Resident #1 frequently scratched staff during personal care. The Facility Internal Investigation, dated 11/7/14, indicated that during rounds around 7:00 A.M., staff members found Resident #1 in bed with his/her hands wrapped in pillow cases and secured loosely with paper tape. The Surveyor interviewed CNA #1 at 3:30 P.M. on 11/25/14. CNA #1 said that on 11/6/14 in the afternoon, he wrapped pillowcases around Resident #1's hands and wrists and secured the pillowcases with paper tape. CNA #1 said he applied the pillow cases because Resident #1 tried to scratch him when he care for him/her. CNA #1 said he had the experienced of being scratched when he care for Resident #1 during other shifts and he heard other CNAs talking about Resident #1's scratching behavior. CNA #1 said that he removed the pillow cases when Resident #1 at dinner, and re-applied the pillow cases when he put Resident #1 to bed. CNA #1 said he forgot to remove the pillow the cases at 11:00 P.M. when his shift ended. The Surveyor interviewed Nurse #1 at 10:30 A.M. on 12/5/14. Nurse #1 said that she applied a topical gel medication to the skin on Resident #1's wrist around 5:00 P.M. on 11/6/14. Nurse #1 said she saw that Resident #1's hands and wrists were wrapped in something white. Nurse #1 said that it was like Resident #1's hand and arm was inside of a pillowcase, but she did not see how the pillowcase was secured to stay in place. Nurse #1 said she assumed the wrap was a new treatment because she had heard in report that Resident #1 scratched caregivers. Nurse #1 did not take any actions to investigate whether this was a prescribed treatment or intervene to remove the pillow cases. As a result, Resident #1 was found by staff the following morning with his/her hands inside pillow cases, which were secured with tape.

Based on record review, observation, staff and Resident interviews, the facility failed to ensure that one sampled Resident (#4) receive proper care and treatment to prevent one pressure sore from developing in a total sample of 24 For Resident #4, the facility failed to consistently provide pressure relief from a knee immobilizer and subsequently the Resident developed a new pressure area. The findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident had a surgical incision on the right thigh that was 32 centimeters long and had 49 staples in place. The Admission Minimum Data Set (MDS), with an assessment reference date of 6/15/11, coded the Residents' BIMS (brief interview for mental status) as a 15, which indicates the Resident is cognitively intact. The Resident was continent of bowel and bladder and was working with physical and occupational therapy. The Resident came with discharge instructions from the acute care setting for a knee immobilizer at all times. The facility did not obtain an order to remove and reapply the immobilizer with care. During an interview with the Director Of Nursing (DON) on 6/30/11 at 8:45 A.M. it was relayed to the surveyor it is a usual nursing measure to obtain a order to remove and reapply the knee immobilizer with care, each shift. The Resident received a bed bath by the nursing assistants daily in which the right leg immobilizer remained in place. The right leg immobilizer would be un-strapped by the nurses so that the incision on the right thigh could be inspected. The immobilizer would be readjusted, and then refastened. Interview with the physical therapist on 6/30/11 at 8:45 A.M. revealed the immobilizer was frequently sliding down on the Resident's leg and had to be readjusted due to the shape and length of the Resident's leg in proportion to the immobilizer. The physical therapist frequently inspected the Resident's skin, and indicated no reddened area was noted on the right outer ankle. The physical therapist did not document the Resident's skin integrity in the physical therapy notes. Record review also revealed a treatment administration record for 6/11 (TAR) to apply TEDS Stockings (Elastic stockings) to bilateral legs, on in A.M., off at hour of sleep. Review of the treatment administration record documented the resident as having the TEDS on. Interview with Resident on 6/29/11 at 8:45 A.M. revealed the Resident never had the TEDS applied, although the TAR documentation by the nursing staff indicated the TEDS were applied and removed from 6/6/11 through 6/28/11. Interview with the occupational therapist (OT) on 6/30/11 at 8:45 A.M. revealed on 6/21/11 the immobilizer was removed for the first time because a shower was given to the Resident. The OT stated no pressure area was noted on the Resident's right outer ankle at that time. Nursing note dated 6/23/11, 4:14 P.M. documents "Patient noted to have Linear area to right outer aspect of ankle with open center. Some yellow slough, scant amt. of drg. 3.0 x 0.5 cm. tender to touch See new orders" Interview with the Resident at 7:30 A.M.on 6/30/11 revealed the knee immobilizer never entirely came off except for that one day in the shower on 6/21/11. Per the Resident, the nursing assistants never "touched" the immobilizer and the nurses would readjust it and slide it up because it was frequently sliding down over the ankle. The Resident states she had complained of pain in the right ankle area on June 23 rd and that's how the area was discovered. This was confirmed per documentation on the TAR which read, "Pt c/o disc. to right outer ankle. Noted to have 3.0 x 0.5 area with yellow slough center, scant amt. of drainage. Pt. wear immobilizer at all times." The Resident stated the immobilizer was constantly sliding down and was frequently being readjusted. (The immobilizer was to be in place from the top of the groin area to approximately 4-6 inches above the ankle). Interview with the DON at 10:00 A.M. on 6/30/11 confirmed the facility failed to consistently provide pressure relief from a knee immobilizer and subsequently the Resident developed a new pressure area. After surveyor inquiry, the physical therapist contacted the orthopedist to inquire about a shorter leg immobilizer, the knee immobilizer was padded with lambs wool to provide extra protection to prevent further pressure/friction to the right outer ankle area and the nursing staff obtained an order for [REDACTED].

Based on record review and staff interview the Facility failed to ensure for one of three sampled residents (Resident #1), that safe temperature protocols were in place for re-heating liquids in the microwave to prevent burns, and on 10/22/10 Resident #1 sustained first degree burns (superficial burn in which damage was limited to the outer layer of the skin and was characterized by redness) surrounded by second degree burns (burns in which damage extends through the outermost layer of the skin and into the next layer of skin) on Resident #1's bilateral inner thighs when Resident #1 spilled hot tea on Resident #1's lap that had been re-heated in the microwave. Findings included: Resident #1 was admitted to the Facility July, 2010, and had a [DIAGNOSES REDACTED]. The Occupational Therapist (OT) was interviewed at 1:00 P.M. on 9/7/10. The OT said, and the occupational therapy assessment, dated 8/9/10, indicated Resident #1 was able to eat and drink independently. Resident #1 was interviewed at 11:40 A.M. on 9/7/10. Resident #1 said this Resident took a few sips of the tea, the tea was hot the way Resident #1 liked it; Resident #1 thought Resident #1 may have fallen asleep while seated in the wheelchair because Resident #1 was tired, and Resident #1 accidentally knocked over the tea. Resident #1 said Resident #1 had not reported the incident at that time because Resident #1 believed no injury had occurred. Resident #1 refused to identify the cna that re-heated the tea because the cna provided very good care. Certified Nurse Assistant (CNA) #1 was interviewed at 2:00 P.M. on 9/7/10. CNA #1 said this cna was assigned to Resident #1's personal care needs during the evening shift on 8/22/10. CNA #1 said Resident #1 was set up with clean linen and a basin of water following the evening meal and Resident #1 independently completed evening personal care. CNA #1 said Resident #1 had no complaints of discomfort and had not reported that Resident #1 had spilled the tea. CNA #2 was interviewed at 3:30 P.M. on 9/8/10. CNA #3 was interviewed at 3:00 P.M. on 9/7/10. CNA #4 was interviewed at 12:00 P.M. on 9/7/10. CNA #2, CNA #3 and CNA #4 said they were assigned to Resident #1's unit during the evening shift on 8/22/10. CNA #1, CNA #2, CNA #3, and CNA #4 said they had not previously been requested to re-heat liquids in the microwave. CNA #1, CNA #2, CNA #3, and CNA #4 denied that they had re-heated Resident #1's tea. The Evening Shift Nurse was interviewed at 3:55 P.M. on 9/7/10. The Evening Shift Nurse said this nurse was assigned to Resident #1's nursing care needs during the evening shift on 8/22/10. The Evening Shift Nurse, CNA #1, CNA #2, CNA #3, and CNA #4 said Resident #1 voiced no concerns, routinely wore knee length pants, and had not reported that the tea had been spilled. CNA #1 said Resident #1 had an uneventful evening on 8/22/10, was assisted with a transfer into bed, voiced no complaints, and was left resting comfortably in bed with a call bell within reach. The Night Shift Nurse was interviewed at 6:50 A.M. on 9/8/10. The Night Shift Nurse said the Night Shift Nurse was assigned to Resident #1's nursing care needs during the night shift (11:00 P.M. on 8/22/10 to 7:00 A.M. on 8/23/10). The Night Shift Nurse said Resident #1 slept well and had not reported that the tea had been spilled during the previous shift. The Day Shift Nurse was interviewed at 4:00 P.M. on 9/7/10. The Day Shift Nurse said the day Shift Nurse was assigned to Resident #1's nursing care needs during the day shift on 8/23/10. The Day Shift Nurse said Resident #1 had an uneventful day, wore knee length pants, and had not reported that the tea had been spilled on the previous day. CNA #1 said this cna was assigned to Resident #1's personal care needs during the evening shift on 8/23/10. CNA #1 said Resident #1 reported at 10:45 P.M. on 8/23/10 that Resident #1 had spilled hot tea on Resident #1's lap during the dinner meal on 8/22/10. CNA #1 said the Evening Shift Nursing Supervisor was notified and Resident #1 was transferred to bed for an evaluation. The Evening Shift Nursing Supervisor was interviewed 9/7/10 at 3:40 PM. The Evening Shift Nursing Supervisor said the Evening Shift Nursing Supervisor was assigned as the Charge Nurse on Resident #1's unit during the evening shift on 8/23/10. The Evening Shift Nursing Supervisor said, and the evening shift nurse's note, dated 8/23/10 at 10:45 P.M., indicated Resident #1 reported that Resident #1's thighs were burning because Resident #1 had spilled tea on Resident #1's lap during the dinner meal on 8/22/10. The Evening Shift Nursing Supervisor said, and the evening shift nurse's note indicated the Physician was notified that Resident #1 had first and second degree burns on the right inner thigh that measured 13 centimeters (cm) by 13 cm.; burns on the left inner thigh that measured 13 cm by 10.5 cm, and treatments were done as ordered. The Evening Shift Nursing Supervisor said an investigation was initiated. The Physician Telephone Orders, dated 8/23/10, included: cleanse Resident #1's bilateral inner thighs with normal saline and wrap with loose gauze until Silvadene (treatment of [REDACTED]. The treatment record, dated 8/24/10, indicated the Silvadene cream arrived and the recommended treatment was initiated. The Unit Manager was interviewed at 9:00 A.M. on 9/7/10. The Unit Manager said Resident #1 was able to eat and drink liquids independently.The Unit Manager said Resident #1 had no previous incidents of spilling hot liquid and prior to the incident there was no safety protocol for re-heating liquids in the microwave. The Nurse Practitioner's progress notes, between 8/26/10 and 8/30/10, indicated that Resident #1 accidentally dropped hot tea on Resident #1's lap and sustained second degree burns surrounded by first degree burns on Resident #1's bilateral thighs and recommended continuing the same treatment until healed.