Every finding on record at Poet's Seat Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to ensure that the Provider was contacted regarding a significant change in condition relative to a medication and/or the need to alter treatment for one Resident (#13) out of a total sample of 16 residents. Specifically, for Resident #13, the facility failed to notify the Provider (Physician/Nurse Practitioner [NP]/ Physician Assistant [PA]) when the Resident's scheduled Oxycodone (short-acting opioid medication used to treat moderate to severe pain) was unavailable to be administered, resulting in increased pain and psychosocial upset for the Resident. Findings include: Review of the facility policy titled Medication Orders dated 2006 and revised in January 2018, indicated but was not limited to the following: -Controlled Substance Prescriptions: >The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not, or will not be available. Resident #13 was admitted to the facility in July 2024, with diagnoses including dorsalgia (back pain), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain), low back pain, other chronic pain, and polyneuropathy (disease affecting peripheral nerves resulting in various symptoms including pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #13: -scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident was cognitively intact. -was prescribed a scheduled pain medication regimen. -had presence of pain almost constantly, which frequently affected his/her sleep. -pain interfered with day-to-day activities frequently. -pain intensity was a seven out of 10. During an interview on 5/23/25 at 10:00 A.M., Resident #13 said he/she had issues getting his/her scheduled Oxycodone. Resident #13 said it had been an issue several times that the Oxycodone pain medication was not always available. Resident #13 said that he/she had gone anywhere from 12 to 18 hours without the pain medication at times. At this time, the Resident began to cry and said when he/she went without the scheduled Oxycodone medication, he/she experienced an increase in pain. Resident #13 said no alternate options to manage his/her pain were discussed or offered to him/her at the times when the Oxycodone medication was not available to be administered. Resident #13 said that he/she did not know whether the Nurses had called the Provider or whether the Provider had recommended alternative medication or treatment for pain management at the times when the scheduled Oxycodone was not available to be administered. During an interview on 5/27/25 at 11:55 A.M., Resident #13's Advocate said the concern related to the unavailability of Oxycodone started on 7/31/24. Resident #13's Advocate provided nine dates that he/she documented between 7/31/24 and 4/13/25 on which the Oxycodone was not available to the Resident. Review of Resident #13's Physician orders between 7/29/24 and 12/31/24 indicated the following: -Oxycodone HCl oral tablet 10 milligrams (mg). Give 1 tablet by mouth every 4 hours for pain. Start date 7/29/24, end date 10/18/24. -Oxycodone HCl oral tablet 5 mg. Give 1 tablet by mouth every 12 hours as needed (PRN) for pain. Start date 7/29/24, end date 8/10/24. -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 10/19/24, end date 12/3/24. -Oxycodone HCl oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed (PRN) for moderate pain AND give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 12/3/24, end date 12/24/24. -Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every 4 hours for pain. Start date 12/24/24. -Acetaminophen (analgesic [pain-relieving] medication) tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain do not exceed 3 grams of Acetaminophen in 24 hours. Start date 7/29/24. -Monitor for pain every shift using standard pain scale 0-10 (tool used to assess pain intensity, where zero indicates no pain, and 10 indicates the worst pain imaginable) every shift for Pain Monitoring. Start date 7/29/24, end date 9/7/24. Review of Resident #13's Medication Administration Record (MAR) dated July 2024, and the correlating Controlled Substance Log indicated the following: -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 7/31/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 7/31/24: -At 12:00 A.M. (Resident reported pain level: zero out of 10) -At 4:00 A.M. (Resident reported a pain level of 10 out of 10) -At 8:00 A.M. (Resident reported a pain level of 10 out of 10) -Review of the medical record failed to indicate that the Provider was notified that the Oxycodone medication was unavailable or that any alternative medication or that non-pharmacological intervention was offered to the Resident. -The first dose of Oxycodone medication was administered to the Resident on 7/31/24 at 10:00 A.M. (14 hours after the last administered dose). Review of Resident #13's MAR dated November 2024 and the correlating Controlled Substance Log indicated the following: -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 P.M. on 11/13/24, and 12:00 A.M. and 4:00 A.M. on 11/14/24, due to the medication not being available. >Resident #13's pain scale was documented as follows on 11/13/24 and 11/14/24: -At 8:00 P.M. on 11/13/24 (Resident reported a pain level of zero out of 10) -At 12:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10) -At 4:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10) -At 8:00 A.M. on 11/14/24 (Resident reported a pain level of 10 out of 10) -Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that non-pharmacological intervention was offered to the Resident. -The first dose of Oxycodone medication was administered to the Resident on 11/14/24 at 9:15 A.M. (17 hours after the last administered dose). Review of Resident #13's MAR dated December 2024 and the correlating Controlled Substance Logs indicated the following: -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 A.M. on 12/24/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 12/24/24: -At 8:00 A.M. (Resident reported a pain level of eight out of 10) -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). was not administered at 12:00 P.M. on 12/24/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 12/24/24: -At 12:00 P.M. (Resident reported a pain level of nine out of 10) -Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that non-pharmacological intervention was offered to the Resident. -The first dose of Oxycodone medication was administered to the Resident on 12/24/24 at 4:00 P.M. since the first missed dose at 8:00 A.M. (10 hours after the last administered dose). During an interview on 5/27/25 at 11:51 A.M., Nurse Practitioner (NP) #1 said when a medication was not available to administer as ordered the Nurse should notify the Provider. NP #1 said the Provider can then give an order to hold if appropriate or can provide an order to administer an alternative medication from the emergency supply. NP #1 said she was not aware of a chronic issue regarding the unavailability of Resident #13's prescribed Oxycodone. During an interview on 5/28/25 at 10:35 A.M., the DON said if a scheduled pain medication was not available for administration, the resident should be assessed for pain and asked whether they wanted to wait for the ordered medication to be delivered from the pharmacy or whether they wanted the Nurse to contact the Provider to request an alternative medication. During an interview on 5/28/25 at 11:06 A.M., by the Physician said he did not know if he was notified of Resident #13's scheduled Oxycodone being unavailable. The Physician said that the facility should be notifying the Provider when a medication was not available for administration, and the Nurse should inform the Provider of similar medication that is available on-hand that may be administered alternatively. The Physician said if multiple doses in a row of a scheduled short-acting pain medication were not administered to a resident, he would expect the resident to have increased pain. During an interview on 5/28/25 at 1:10 P.M., Resident #13 said that most of the time, his/her pain level was between a seven and nine out of 10. Resident #13 said when he/she swells it really hurt, and sometimes he/she curled up in a little ball. Resident #13 said he/she was hurting all the time, and that his/her body was in pain from his/her head to his/her feet, that was why he/she needed pain medication every four hours. Resident #13 said it took at least one hour for any pain medication administered to bring down his/her pain level. Please Refer to F697.

Based on observations, interviews, and record reviews, the facility failed to ensure that pain management was provided in accordance with the individual goals for care and preferences for one Resident (#13) out of a total sample of 16 residents. Specifically, for Resident #13, the facility failed to administer scheduled Oxycodone (short-acting opioid medication used to treat moderate to severe pain) medication as ordered by the Physician, and failed to provide any other pain relieving measures, resulting in an increase in physical pain and psychological upset for the Resident. Findings include: Review of the facility policy titled Administering Medications version 2.1, dated 2001 and revised April 2019, indicated but was not limited to the following: -Policy Statement: >Medications are administered in a safe and timely manner, and as prescribed. >Medications are administered in accordance with prescriber orders, including any required time frame. >Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . Review of the facility policy titled Pain-Clinical Protocol version 2.2, dated 2001 and revised October 2022, indicated but was not limited to the following: -Assessment and Recognition: <The physician and staff will identify individuals who have pain or who are at risk for having pain. <The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -Treatment/Management: <With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment . -The physician will order .medication interventions to address the individual's pain. Review of the facility policy titled Medication Orders, dated 2006 and revised January 2018, indicated but was not limited to the following: -Controlled Substance Prescriptions: >The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not, or will not be available. Resident #13 was admitted to the facility in July 2024, with diagnoses including dorsalgia (back pain), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain), low back pain, other chronic pain, and polyneuropathy (disease affecting peripheral nerves resulting in various symptoms including pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #13: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 15 out of a possible score of 15. -was prescribed a scheduled pain medication regimen. -had presence of pain almost constantly, which frequently affected his/her sleep. -pain interfered with day-to-day activities frequently. -pain intensity was a seven out of 10. During an interview on 5/23/25 at 10:00 A.M., Resident #13 said he/she had issues getting his/her scheduled Oxycodone medication. Resident #13 said it had been an issue that the pain medication was not always available several times. Resident #13 said that he/she had gone anywhere from 12 to 18 hours without the pain medication at times. At this time, the Resident began to cry and said that when he/she went without the scheduled Oxycodone medication, he/she experienced an increase in pain. Resident #13 said no alternate options to manage his/her pain were discussed or offered to him/her at the times when the Oxycodone medication was not available to be administered. Resident #13 also said he/she wanted to receive the Oxycodone medication as prescribed and did not want to experience any more missed doses. During an interview on 5/27/25 at 11:55 A.M., Resident #13's Advocate said the concern related to the unavailability of Oxycodone medication started on 7/31/24. The Resident's Advocate provided nine dates that he/she documented between 7/31/24 and 4/13/25 on which the Oxycodone medication was not available to the Resident. The Resident's Advocate said he/she had attended care plan meetings and had discussed the concern regarding the unavailability of Oxycodone medication with nursing staff. The Resident's Advocate said the most recent care plan meeting during which the concern was discussed was on 2/11/25. The Resident's Advocate said the facility did not state what actions were going to be taken to address the concern regarding the availability of the Resident's Oxycodone medication. Review of Resident #13's current active Care Plans failed to indicate any care plans relative to pain management. Review of Resident #13's Physician Orders between 7/29/24 and 12/31/24 indicated the following: -Oxycodone HCl oral tablet 10 milligrams (mg). Give 1 tablet by mouth every 4 hours for pain. Start date 7/29/24, End date 10/18/24. -Oxycodone HCl oral tablet 5 mg. Give 1 tablet by mouth every 12 hours as needed (PRN) for pain. Start date 7/29/24, End date 8/10/24. -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 10/19/24, End date 12/3/24. -Oxycodone HCl oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed (PRN) for moderate pain AND give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 12/3/24, End date 12/24/24. -Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every 4 hours for pain. Start date 12/24/24. -Acetaminophen tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed (PRN) for pain. Do not exceed 3 grams of Acetaminophen in 24 hours. Start date 7/29/24. -Monitor for pain every shift using standard pain scale 0-10 (commonly used tool to assess pain intensity, where zero indicates no pain, and 10 indicates the worst pain imaginable) every shift for pain monitoring. Start date 7/29/24, End date 9/7/24. -Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24. Review of Resident #13's Medication Administration Record (MAR) dated July 2024 and the correlating Controlled Substance Log indicated the following: -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 7/31/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 7/31/24: -At 12:00 A.M. (Resident reported pain level: zero out of 10) -at 4:00 A.M. (Resident reported a pain level of 10 out of 10) -at 8:00 A.M. (Resident reported a pain level of 10 out of 10) -Review of the medical record failed to indicate that the Provider was notified that the Oxycodone medication was unavailable to administer to Resident #13, or that any non-pharmacological intervention was offered. -The first dose of Oxycodone medication was administered to the Resident on 7/31/24 at 10:00 A.M. (14 hours since the last administered dose). Review of Resident #13's MAR dated September 2024, correlating Controlled Substance Logs, On-call Provider Log, and Nursing Notes indicated the following: -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 8:00 P.M. on 9/20/24, and 12:00 A.M., and 4:00 A.M. on 9/21/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 9/20/24 and 9/21/24: -At 8:00 P.M. on 9/20/24 (Resident reported a pain level of eight out of 10) -At 12:00 A.M. on 9/21/24 (Resident reported a pain level of 10 out of 10) -At 4:00 A.M. on 9/21/24 (Resident reported a pain level of 10 out of 10) -The facility staff contacted the on-call Provider on 9/20/24 at 10:38 P.M., regarding the need to obtain a new prescription of Oxycodone. The medical record documentation failed to indicate that a discussion occurred with the Provider regarding the Resident's pain assessment or the unavailability of the Resident's scheduled Oxycodone medication at the time the Provider was contacted. -A Nursing Note written on 9/21/24 at 3:30 A.M., indicated that the on-call Provider was to contact the pharmacy to provide an order to obtain the Oxycodone medication from the pyxis (machine that is utilized to dispense an emergency supply of medication). The Nursing documentation failed to indicate that the facility accessed the pyxis at that time and administered the scheduled Oxycodone medication to the Resident. -The first dose of Oxycodone medication was administered to the Resident on 9/21/24 at 9:40 A.M. (17 hours since the last administered dose). Review of Resident #13's MAR dated October 2024, correlating Controlled Substance Logs, and Nursing Notes indicated the following: -The Resident's supply of Oxycodone was exhausted at 8:15 P.M. on 10/17/24. -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 10/18/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 10/18/24: -At 12:00 A.M. (Resident reported a pain level of two out of 10) -At 4:00 A.M. (Resident reported a pain level of five out of 10) -At 8:00 A.M. (Resident reported a pain level of 10 out of 10) -A Nursing Note written on 10/18/24 at 4:44 A.M., indicated the on-call Provider was contacted at that time for a new Oxycodone prescription and pyxis access. (Five hours since the Resident's missed dose of scheduled Oxycodone) -The first dose of Oxycodone medication was administered to the Resident on 10/18/24, and documented for the 8:00 A.M. dose (12 hours since the last administered dose). Review of Resident #13's MAR dated November 2024, and the correlating Controlled Substance Log indicated the following: -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 P.M. on 11/13/24, and 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 11/14/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 11/13/24 and 11/14/24: -At 8:00 P.M. on 11/13/24 (Resident reported a pain level of zero out of 10) -At 12:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10) -At 4:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10) -At 8:00 A.M. on 11/14/24 (Resident reported a pain level of 10 out of 10) -Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that any non-pharmacological intervention was offered to the Resident. -Acetaminophen 650 mg was administered as needed (PRN) on 11/14/24 at 8:08 A.M. -The first dose of Oxycodone medication was administered to the Resident on 11/14/24 at 9:15 A.M. (17 hours since the last administered dose.) -The Resident reported a pain level of three out of 10 on 11/14/24 at 12:58 P.M. Review of Resident #13's MAR dated December 2024, and the correlating Controlled Substance Logs indicated the following: -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 A.M. on 12/24/24 due to the medication not being available. -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). was not administered at 12:00 P.M. on 12/24/24 due to the medication not being available. >Resident #13's pain scale was documented as follows on 12/24/24: -At 8:00 A.M. on 12/24/24 (Resident reported a pain level of eight out of 10) -At 12:00 P.M. on 12/24/24 (Resident reported a pain level of nine out of 10) -The Resident was offered Acetaminophen as needed (PRN) on 12/24/24 at 10:42 A.M., and declined. -Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that any non-pharmacological intervention was offered to the Resident. -The first dose of Oxycodone medication was administered to the Resident on 12/24/24 at 4:00 P.M. since the first missed dose at 8:00 A.M. (10 hours since the last administered dose.) During an interview on 5/27/25 at 11:51 A.M., Nurse Practitioner (NP) #1 said when a medication was not available to administer as ordered the Nurse should notify the Provider. NP #1 said the Provider can then give an order to hold if appropriate or can provide an order to administer an alternative medication from the emergency supply. NP #1 said she was not aware of a chronic issue regarding the unavailability of Resident #13's prescribed Oxycodone medication. NP #1 said nursing staff informed NP #1 when the Resident was admitted to the facility that the Resident's pain management interventions were not effective. NP #1 said she discussed with the Resident the option to be prescribed long-acting Oxycodone, but the Resident declined the long-acting Oxycodone order and stated that his/her stomach could not tolerate this medication. NP #1 said the Resident is very particular about what medications he/she wanted and at what time he/she wanted to take the prescribed medications. During an interview on 5/27/25 at 4:30 P.M., the Director of Nursing (DON) said she was not aware of any times that Resident #13 did not have Oxycodone medication available for administration. The DON further said she also found that residents' medications were not always re-ordered timely. During an interview on 5/28/25 at 9:10 A.M., the DON said the expectation is that medications are re-ordered by licensed nursing staff when the medication reached the red line (indicates medication level is running low and should be re-ordered) on the blister pack to allow the pharmacy time to refill the medication so that residents' medications were available to administer as ordered. During an interview on 5/28/25 at 10:35 A.M., the DON said if a scheduled pain medication was not available for administration, the resident should be assessed for pain and asked whether they wanted to wait for the ordered medication to be delivered from the pharmacy or whether they wanted the Nurse to contact the Provider to request an alternative medication. During an interview on 5/28/25 at 11:06 A.M., the Physician said that the facility should be notifying the Provider when a medication was not available for administration. The Physician also said if multiple doses in a row of a scheduled short-acting pain medication were not administered to a resident, he would expect the resident to have increased pain. During an interview on 5/28/25 at 1:10 P.M., Resident #13 said that most of the time, his/her pain level was between a seven and nine out of 10. Resident #13 said when he/she swells it really hurt, and sometimes he/she curled up in a little ball. Resident #13 said he/she was hurting all the time, and that his/her body was in pain from his/her head to his/her feet, that was why he/she needed medication every four hours. Resident #13 said it depended on which Nurse cared for him/her as to whether he/she would be offered as needed pain medications. Resident #13 said it took at least one hour for any pain medication being administered to bring down his/her pain level. Please Refer to F842.

Based on observations, record reviews, and interviews, the facility failed to ensure one Resident (#32) out of a total sample of 14 residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #32's wheelchair brakes were unlocked while seated in a wheelchair, in front of a counter, restricting his/her ability to move freely when the Resident had a history of attempting to stand up from a seated position. Findings include: Review of the facility policy titled Use of Restraints, revised 4/2017, indicated the following: -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjusted to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted: >Placing a resident in a chair that prevents the resident from rising. >Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. Resident #32 was admitted to the facility in February 2023, with diagnoses including syncope and collapse and Dementia with behavioral disturbances. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -Resident's behavior (rejection of care or wandering) had worsened since the prior assessment conducted 9/11/24. -No impairment for upper extremity range of motion. -No impairment for lower extremity range of motion. -Required substantial/maximal assistance to sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). -Required substantial/maximal assistance to walk 10 feet. -was dependent to wheel 50 feet with two turns while in the wheelchair Review of Resident #32's Fall Care Plan, initiated on 2/24/23, indicated the following interventions: -If Resident is awake, keep him/her in the area of staff for safe monitoring, secondary [sic] if he/she is not tired he/she will attempt to get up independently, updated on 7/14/24. Review of a Nurses' Note dated 4/3/25, indicated Resident #32 continued to stand up and required frequent direction to sit in his/her chair. Review of a Nurses Note dated 4/6/25, indicated in part: - .staff redirecting the Resident from standing up in his/her wheelchair - .Resident attempted to stand up from the wheelchair seven times. -Monitored for safety because he/she would not sit still. Review of the Physical Restraint assessment dated [DATE], indicated Resident #32: -had a history of being impulsive and impaired safety awareness due to significant cognitive deficits and agitation. On 5/27/25 the surveyor observed the following at 1:22 P.M., 2:18 P.M., 2:57 P.M., 3:03 P.M., 3:12 P.M., 3:26 P.M., 3:30 P.M., and 3:37 P.M.: -Resident #32 to be sleeping in his/her wheelchair located next to the nurses station, with both feet flat on the floor and pushed up to a counter with his/her upper body approximately six inches away from the counters' edge, and the Resident's legs under the counter. -The wheelchair had anti-tippers (a safety accessory attached to the frame of the wheelchair, typically near the rear wheels that extend outward, designed to prevent the wheelchair from tipping backward). -The wheelchair had an anti-rollback (a safety accessory attached to the wheelchair to prevent wheelchair users from rolling backwards in any situation) devices installed. -The wheelchair brakes were engaged, restricting the Resident's mobility and ability to move him/herself away from the counter or to move freely. During an interview on 5/27/25 at 3:03 P.M., with Certified Nurses Aide (CNA) #3 and CNA #2, CNA #3 said she thought Resident #32 might be able to lock and unlock the brakes depending on the day but she was not sure. CNA #3 said the Resident preferred to be seated at the counter and if he/she was not seated there, the Resident would become confused and try to get up from the wheelchair. CNA #3 said when the Resident was anxious or attempted to get up from the wheelchair, the staff would take him/her for a walk or to the bathroom. CNA #3 said Resident # 32's daughter came in for lunch today and sat with the Resident during lunch. CNA #3 said staff had brought the Resident to the bathroom after lunch, placed him/her back at the counter in the hallway near the nurses station where he/she fell asleep shortly after. CNA #3 said if the staff were to put him/her to bed, the Resident would climb out, so CNA #3 felt it was safer for the Resident to be situated where he/she was (at the counter). When the surveyor asked about the wheelchair brakes being engaged, CNA #3 said the brakes should not be on, that the Resident had anti-tippers, and an anti-rollback device on the chair and with his/her energy level today, the Resident would not be able to unlock the brakes him/herself or free him/herself from his/her current position. CNA #2 said she thought the Resident's daughter may have placed the Resident in that position and must have put his/her brakes on when she left. The surveyor observed at the end of the interviews on 5/27/25 at 3:12 P.M., that neither CNA #3 nor CNA #2, unlocked the Resident's wheelchair brakes, leaving Resident #32 pushed up to the nurses station counter with the wheelchair brakes engaged, restricting the Resident to this position and unable to move freely. On 5/27/25 at 3:12 P.M., the surveyor observed a staff member rubbing Resident #32's back. Resident #32 awoke and began to engage with the staff. The staff member provided a baby doll with clothing and a baby doll seat, which the Resident began to engage with. The staff member walked away from the Resident, and the wheelchair brakes remained engaged. During an interview on 5/27/25 at 3:37 P.M., the Director of Nursing (DON) said that the Resident preferred to be seated at the counter. The DON said in the Resident's current position, he/she would not be able to independently move him/herself but should be able to. The DON unlocked the wheelchair brakes and said the brakes should not be locked, as the Resident had the anti-rollback wheels and the anti-tippers in place to prevent the wheelchair from tipping backwards or rolling away if he/she should stand up. The DON said the Resident does attempt to stand routinely and felt that the staff most likely thought they were doing the right thing in terms of safety. The DON further said that the Resident's current position with locked brakes did restrict the Resident's movement and the brakes should not have been engaged while the Resident was placed at the counter.

Based on observations, interviews, and record reviews, the facility failed to adequately assess the urinary status for one Resident (#12) of three applicable residents, out a total sample of 16 residents, when the Resident was admitted to the facility with an indwelling urinary catheter. Specifically, the facility failed to: -Identify the Resident's indwelling urinary catheter specifications, including size of catheter, type of catheter and size of balloon. -Obtain instructions from the Physician timely to ensure proper care for the Resident's indwelling urinary catheter, putting the Resident at risk for delays in urinary catheter care and urinary catheter associated complications. Findings include: Review of the facility's policy titled Output, Measuring and Recording, dated 2001 and revised October 2010, indicated the following: -The purpose was to accurately determine the amount of urine that a resident excretes in a 24-hour period. -The following information should be recorded . in the resident's medical record: >The date and time the resident's urine output was measured and recorded. >The amount (in mls [milliliters]) of output. Review of the facility's policy titled Catheter Care, Urinary, dated 2001 and revised August 2022, indicated the following: -The purpose was to prevent urinary catheter associated complications. -Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Review of the Lippincott Manual of Nursing Practice - 12th Edition (2025) Unit VI - Renal, Genitourinary, and Reproductive Health, Chapter 17. Renal and Urinary Disorders Unit VI - Renal, Genitourinary, and Reproductive Health - TDS Health indicated the following: -Oliguira (small volume of urine) is indicated by urinary output of 50 - 500 mls in a 24-hour period. -Oliguria may result from Acute Renal Failure, Chronic Kidney Disease (Stage V), shock, dehydration, fluid and electrolyte imbalance, or obstruction. -Report decrease in output. Resident #12 was admitted to the facility in July 2024, with diagnoses including retention of urine and obstructive and reflux uropathy. Review of Resident #12's Hospital Discharge/Transfer note, dated July 2024, indicated the following: -The Resident had a chronic indwelling Foley catheter. -The Resident was treated for urinary tract infection (UTI). Review of Resident #12's Nursing Admission Summary Note, dated July 2024, indicated the following: -The Resident arrived at the facility at approximately 4:30 P.M. -The Resident was alert and oriented. -The Resident arrived with a (urinary) catheter. -The (urinary) catheter was chronic and would remain in place. -The on-call Provider was notified when the Resident arrived at the facility and verified medications. Further review of the Admission Summary Note failed to indicate specifications for the Resident's indwelling urinary catheter. Review of Resident #12's Nursing Admission Evaluation, dated July 2024, indicated the following: -The Resident was incontinent of urine. -The Resident had burning, pain, or discomfort with urination. -The Resident had recurrent UTIs. -The Resident's urine was very cloudy or purulent (containing pus). -The Resident was admitted with a Foley (also referred to as an indwelling urinary catheter) catheter. -The Foley catheter size/type was unknown. Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated Resident #12: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -was dependent for toilet hygiene. -did not have an indwelling urinary catheter. Review of Resident #12's Care Plan Report indicated the following: -The Resident was totally dependent for toileting (7/6/24). -The Resident had a Foley catheter (7/6/24) >Check for tubing kinks each shift per policy. >Maintain Enhanced Barrier Precautions (EBP). >Monitor and document output as per facility policy. >Observe for/document pain/discomfort due to catheter. >The Resident will be/remain free from catheter-related trauma through next review date (revised 7/28/24). Review of Resident #12's Initial Encounter Summary Provider Progress Note, dated 7/9/24, indicated the following: -The Resident had a chronic indwelling Foley catheter. -The Resident had been treated in the hospital for a UTI. -The Resident continued on treatment for UTI with an antibiotic medication, end date of 7/12/24. -The Resident had chronic retention of urine. Review of Resident #12's July 2024 Physician orders failed to indicate any orders relative to care of the Resident's indwelling urinary catheter. Review of Resident #12's Nursing Note, written by Nurse #3 on 7/18/24 at 2:37 P.M., indicated the following: -The Resident's output was around 100 cc (cubic centimeters- measurement of volume where one cc is equal to one milliliter) each shift for the last two days (less than 500 mls for each of two consecutive 24-hour periods). -On-call Provider contacted and requested order for flush (irrigation). -Waiting for response. Review of Resident #12's clinical record failed to include: -any evidence that an order to flush the Resident's indwelling urinary catheter had been obtained. -any evidence that instructions had been obtained relative to the Resident's urine output of approximately 100 cc per shift. -any evidence the Resident's urinary output was routinely monitored. Further review of Resident #12's clinical record indicated the following instructions for care of the Resident's indwelling urinary catheter were not obtained until 8/7/24 (more than one month after admission to the facility): -Catheter leg strap or catheter secure device in place every shift. -Change Foley every three months and as needed . -Empty Foley catheter bag every shift. -Foley catheter care every shift for urinary elimination. -Foley catheter size 18 F (French: catheter sizing), balloon size 30 ml. -May irrigate or flush catheter with 60 cc of (normal saline) as needed >Resistance (was there resistance?) >Return (+ or -) >Sediment (was there sediment?) >Color (describe color of return) On 5/22/25 at 8:37 A.M., the surveyor observed the following: -Resident #12 was lying in bed. -The Resident's urinary catheter tubing was visible, extending out from under the Resident's blankets and led to a collection bag that was positioned below the level of the Resident's bladder and covered by a privacy bag. -Clear yellow urine was observed moving through the tube into the collection bag. During an interview on 5/28/25 at 10:05 A.M., Resident #12 said shortly after he/she was admitted to the facility, his/her catheter was not draining properly. Resident #12 said that staff at the facility cleaned the catheter to get it to drain. When the surveyor asked how staff cleaned the catheter, the Resident said the staff used a tube of something and pushed it in. Resident #12 further said after staff cleaned the catheter, the catheter drained properly. During an interview on 5/28/25 at 9:10 A.M., the Director of Nursing (DON) said when Resident #12 was admitted to the facility with an indwelling urinary catheter, the admitting Nurse should have assessed the Resident's catheter in order to identify the type and size of catheter that was in place. The DON said the following orders should have been requested from the Physician and should have been entered into the Resident's electronic health record (EHR) for catheter care and services: -the type and size of the catheter. -the balloon size for the catheter. -frequency for catheter care to be provided. -catheter change frequency. -an as needed (PRN) order to include instructions, including flushing and changing the catheter, to address catheter associated complications. The DON also said that residents with chronic indwelling urinary catheters would not always be monitored for fluid intake and would be routinely monitored for urinary output. The DON said monitoring urinary output was important to ensure the Resident's catheter was functioning properly. During a follow-up interview on 5/28/25 at 10:15 A.M., the DON also said when Resident #12 had 100 cc of urine output, it would indicate a potential complication with the Foley catheter and should have been assessed and reported to the Provider right away to avoid complications such as catheter tube kinking or urine obstruction. The DON said there were no orders in place for care of Resident #12's indwelling urinary catheter when the reduced urine output was identified, and she was unable to identify the intervention provided to address the Resident's low urine output. The DON also said waiting two days to address low urinary catheter output was concerning and that staff should have assessed Resident #12's urinary catheter status sooner and obtained instructions timely to address the low urine output. During an interview on 5/28/25 at 3:33 P.M., Nurse #3 said she could not remember the exact date, but she had worked at the facility with Resident #12 when the Resident experienced reduced urine output for a period of two days. Nurse #3 said she contacted the on-call Provider and that she could not recall whether the on-call Provider had returned her call. Nurse #3 said she could not recall what she did to resolve the Resident's reduced urine output, and that if the on-call Provider had provided instructions, Nurse #3 would have included the instructions in a Progress Note and Physician order in the Resident's clinical record.

Based on observations, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented, for one Resident (#13) out of a total sample of 16 residents, resulting in an inaccurate depiction of both pain medication administered and the Resident's pain status, and having the potential to affect the Resident's treatment plan. Specifically, for Resident #13, the facility failed to: 1. Document the administration status of scheduled doses of Oxycodone (short-acting opioid medication used to treat moderate to severe pain) in the Resident's Medication Administration Records (MAR) on 8/7/24, 11/13/24, and 11/21/24. 2. Accurately document the Resident's pain level for one assessment of pain on 5/27/25. Findings include: Review of the facility policy titled Administering Medications version 2.1, dated 2001 and revised in April 2019, indicated but was not limited to the following: -Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility policy titled Pain-Clinical Protocol version 2.2, dated 2001 and revised in October 2022, indicated but was not limited to the following: -Assessment and Recognition: - .Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. -Treatment/Management: -With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment . -The physician will order .medication interventions to address the individual's pain. Resident #13 was admitted to the facility in July 2024, with diagnoses including dorsalgia (back pain), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain), low back pain, other chronic pain, and polyneuropathy (disease affecting peripheral nerves resulting in various symptoms including pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #13: -scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating the Resident was cognitively intact. -was prescribed a scheduled pain medication regimen. -had presence of pain almost constantly, which frequently effected his/her sleep. -pain interfered with day-to-day activities frequently. -pain intensity was a seven out of 10 on the standard pain scale 0-10 (commonly used tool to assess pain intensity, where zero indicates no pain, and 10 indicates the worst pain imaginable) Review of Resident #13's Physician Orders between 7/29/24 and 5/28/25 indicated but was not limited to the following: -Oxycodone HCl oral tablet 5 mg. Give 1 tablet by mouth every 12 hours as needed for pain. Start date 7/29/24, End date 8/10/24. -Oxycodone HCl oral tablet 10 milligrams (mg). Give 1 tablet by mouth every 4 hours for pain. Start date 7/29/24, End date 10/18/24. -Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 10/19/24, End date 12/3/24. -Oxycodone HCl oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed for moderate pain AND give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 12/3/24, End date 12/24/24. -Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every 4 hours for pain. Start date 12/24/24. -Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24, End date 9/7/24. -Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24. 1. Review of Resident #13's August 2024 and November 2024 MARs, and the correlating Controlled Substance Log and Nursing Notes indicated the following: -8/7/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 4:00 A.M. -The Controlled Substance Log indicated that Oxycodone 10 mg was administered to the Resident at 4:55 A.M. on 8/7/24. -11/13/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 8:00 P.M. -11/21/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 4:00 A.M. -The Controlled Substance Logs indicated that Oxycodone 10 mg was administered to the Resident at 5:35 A.M. on 11/21/24. -Documentation of Nursing Notes failed to indicate the status of administration of the 8:00 P.M. dose of Oxycodone on 11/13/24 and the 4:00 A.M. dose of Oxycodone on 11/21/24. During an interview on 5/28/25 at 8:15 A.M., with the Administrator and the Director of Nursing (DON), the Administrator said the 4:00 A.M. dose on 8/7/24 and the 4:00 A.M. dose on 11/21/24 were not documented in the MARs, and were documented in the Controlled Substance Logs. The Administrator said she was unable to verify whether the 8:00 P.M. dose on 11/13/24 had been administered to the Resident as ordered by the Physician. The DON said when a medication is documented in the Controlled Substance Log, it should be reflected as having been administered in the MAR. 2. On 5/27/25 at 12:09 P.M. surveyor #1 and surveyor #2 observed Nurse #2 administer the 12:00 P.M. dose of scheduled Oxycodone medication to Resident #13. Nurse #2 asked the Resident whether he/she had pain, and the Resident said that he/she did have pain. Nurse #2 was not observed to ask the Resident a pain level according to the standard pain scale (0-10) as ordered. Review of Resident #13's May 2025 MAR, indicated documentation the Resident's pain score was zero out of 10 for the 12:00 P.M. dose of scheduled Oxycodone on 5/27/25. During an interview on 5/28/25 at 7:22 A.M., Nurse #2 said she recalled providing Resident #13 his/her 12:00 P.M. dose of Oxycodone on 5/27/25. Nurse #2 said she recalled the Resident saying at that time that there is always something hurting him/her. Nurse #2 reviewed the May 2025 MAR and said that she documented a zero out of 10 for the Resident's pain at that time. Nurse #2 said she could have asked the Resident what his/her pain score was on the standard pain scale 0-10. Nurse #2 said she should have asked the Resident about his/her pain level but did not ask. Nurse #2 said that it is important to document an accurate pain score because the Provider needs to know the effectiveness of the treatment plan.

Based on observation, interviews, and record reviews, the facility failed to accurately assess the urinary status on one comprehensive Minimum Data Set (MDS) Assessment for one Resident (#12) of three applicable residents, out of a total sample of 16 residents. Specifically, the facility failed to accurately code the Resident's comprehensive MDS Assessment to indicate that the Resident had an indwelling urinary catheter when the Resident was admitted to the facility with a chronic indwelling urinary catheter, putting the Resident at risk of not receiving urinary catheter care as required. Findings include: Resident #12 was admitted to the facility in July 2024, with diagnoses including retention of urine and obstructive and reflux uropathy. Review of Resident #12's Hospital Discharge/Transfer note, dated July 2024, indicated the following: -The Resident had a chronic indwelling Foley catheter. -The Resident was treated for urinary tract infection (UTI). Review of Resident #12's Admission Summary Note, dated July 2024, indicated the following: -The Resident arrived at the facility with a catheter. -The catheter was chronic and would remain in place. Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated Resident #12: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -was dependent for toilet hygiene. -did not have an indwelling urinary catheter. On 5/22/25 at 8:37 A.M., the surveyor observed the following: -Resident #12 was lying in bed. -The Resident's urinary catheter tubing was visible, extending out from under the Resident's blankets and led to a collection bag that was covered by a privacy bag. -Clear yellow urine was observed moving through the urinary catheter tubing into the collection bag. During an interview at the time, Resident #12 said that he/she had an indwelling urinary catheter which had been in place since prior to being admitted to the facility. During an interview on 5/23/25 at 1:30 P.M., the MDS Nurse said she reviewed Resident #12's clinical record and the Resident was admitted to the facility with an indwelling urinary catheter. The MDS Nurse said the indwelling urinary catheter was in place at the time of the comprehensive MDS Assessment, dated 7/10/24. The MDS Nurse said that the MDS was inaccurately coded. The MDS Nurse also said the MDS Assessment should have been coded to indicate the Resident had an indwelling urinary catheter. Please Refer to F690.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1), who was severely cognitively impaired and had a history of disrobing in public and intrusive wandering, and (Resident #2) who was severely cognitively impaired and had a history of inappropriate touching, the Facility failed to ensure they developed and implemented a Comprehensive Plan of Care that identified goals, interventions and outcomes related to Resident #1 and Resident #2's behaviors. Findings include: Review of the Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated 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. The Policy indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Review of the Facility Policy titled Wandering and Elopements, dated as revised March 2019, indicated if identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/25/24, indicated that on 09/23/24 at approximately 3:45 A.M., Nurse #1 found Resident #1 in Resident #2's bed with his/her pull-up brief around his/her ankles. The Report indicated Resident #2 was standing facing the bed with his/her pants and underwear down around his/her ankles. The Report indicated no physical contact was witnessed between Resident #1 and Resident #2. A) Resident #1 was admitted to the Facility in March of 2022, diagnoses included dementia, insomnia and anxiety. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/03/24, indicated Resident #1 was severely cognitively impaired with a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact.) The Assessment also indicated Resident #1 ambulated with supervision or touch assistance from staff, and he/she exhibited wandering, physical, verbal and other behaviors 4 to 6 days per week, during the assessment period. Review of Resident #1's Behavior Care Plan, reviewed and renewed with Quarterly MDS completed 07/03/24, indicated he/she exhibited intrusive behavior such as entering other resident rooms. Further review indicated there was no documentation to support that any of Resident #1's care plans addressed goals or interventions specific to his/her intrusive wandering or disrobing in public behaviors. Review of Resident #1's Care Card (Certified Nurse Aide reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), undated, indicated Resident #1 required supervision when ambulating on and off the unit. Review of Resident #1's Behavioral Health Note, dated 07/26/24, indicated that nursing reported that he/she had increased behaviors, including (but not limited to) pacing, wandering and disrobing in public. The Note indicated that the Behavioral Health Provider observed Resident #1 disrobing in public during the evaluation. Review of Resident #1's Behavioral Health Note, dated 08/02/24, indicated that the Social Worker reported he/she had been physically aggressive, disrobing in public, exit seeking, anxious, pacing, wandering and screaming with disruptive sounds and repetitive motions. During an interview on 10/03/24 at 1:20 P.M., Nurse #2 said Resident #1 wandered between both the North and South units and often wandered in and out of other resident rooms. During an interview on 10/04/24 at 8:20 A.M., CNA #2 said that Resident #1 frequently wandered on both units during the 11:00 P.M. to 7:00 A.M. shift when he/she could not sleep. CNA #2 said that Resident #1 sometimes disrobed or pulled off his/her urine-soaked incontinent brief at night. During a telephone interview on 10/09/24 at 2:38 P.M., the Director of Nurses (DON) said Resident #1 wandered in and out of all areas of the facility, including other resident's rooms. The DON said she was not aware that Resident #1's Care Plan did not address his/her intrusive wandering and disrobing behaviors. B) Resident #2 was admitted to the Facility in March of 2022, diagnoses included dementia with other behavioral disturbance, and other symptoms and signs involving cognitive functions and awareness. Review of a Facility Investigation Summary, undated, indicated that on 07/25/24 at around 10:45 A.M., Resident #2 was found in another resident's room, and he/she was observed with his/her hand on the incontinent brief of a resident (of the opposite sex) who was in bed. Review of Resident #2's Physician Progress Note, dated 07/29/24, indicated Resident #2 was referred to the physician for inappropriate contact with a resident (of the opposite sex). During an interview on 10/03/24 at 9:30 A.M., the Physician said he was aware of the incident on 07/25/24 when Resident #2 inappropriately touched another resident. The Physician said that Resident #2 had dementia, was very confused, and had the physical ability to roam. The Physician said Resident #2's inappropriate behaviors were related to his/her dementia and would be better managed with staff interventions, like redirection and supervision, rather than pharmacological interventions. During a telephone interview on 10/08/24 at 3:55 P.M., the Behavioral Health Provider said that Resident #2 required supervision from staff due to a history of behaviors including intrusive wandering and inappropriate touching, and said staff needed to ensure they knew his/her whereabouts. Review of Resident #2's Medical Record indicated there was no documentation to support that any of Resident #2's care plans addressed goals or interventions specific to his/her behavior of inappropriately touching other residents. Review of Resident #2's Care Card, undated, indicated Resident #1 required supervision when ambulating on and off the unit. Review of Resident #2's Quarterly Minimum Data Set Assessment, dated 08/07/24, indicated Resident #1 was severely cognitively impaired with a score of 5 out of 15 on the Brief Interview for Mental Status. The Assessment also indicated Resident #1 ambulated with supervision or touch assistance from staff. During a telephone interview on 10/09/24 at 2:38 P.M., the Director of Nurses (DON) said that she was not aware that Resident #2 did not have interventions on his/her care plan to address his/her history of inappropriate touching.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1, who was known to intrusively wander and disrobed in public areas, and Resident #2 who was known to exhibit inappropriate behaviors to residents of the opposite sex), the Facility failed to ensure Resident #1 and Resident #2 were provided with an adequate level of staff supervision in effort to reduce the potential for a resident to resident altercation. Findings include: Review of the Facility Policy titled Wandering and Elopements, dated as revised March 2019, indicated the Facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Policy also indicated if identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/25/24, indicated that on 09/23/24 at approximately 3:45 A.M., Nurse #1 found Resident #1 in Resident #2's bed with his/her pull-up brief around his/her ankles. The Report indicated Resident #2 was standing facing the bed with his/her pants and underwear around his/her ankles. The Report indicated no physical contact, between Resident #1 and Resident #2, was witnessed. A) Resident #1 was admitted to the Facility in March of 2022, diagnoses included dementia, insomnia and anxiety. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/03/24, indicated Resident #1 was severely cognitively impaired with a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact.) The Assessment also indicated Resident #1 ambulated with supervision or touch assistance from staff, and he/she exhibited wandering, physical, verbal and other behaviors 4 to 6 days per week, during the assessment period. Review of Resident #1's Behavior Care Plan, reviewed and renewed with Quarterly MDS completed 07/03/24, indicated he/she exhibited intrusive behavior such as entering other resident rooms. Review of Resident #1's Care Card (Certified Nurse Aide reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), undated, indicated Resident #1 required supervision when ambulating on and off the unit. B) Resident #2 was admitted to the Facility in March of 2022, diagnoses included dementia with other behavioral disturbance, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #2's Quarterly MDS Assessment, dated 08/07/24, indicated Resident #1 was severely cognitively impaired with a score of 5 out of 15 on the BIMS. The Assessment also indicated Resident #1 ambulated with supervision or touch assistance from staff. Review of Resident #2's Care Card, undated, indicated Resident #1 required supervision when ambulating on and off the unit. Review of a Facility Investigation Summary, undated, indicated that on 07/25/24 at around 10:45 A.M., Resident #2 was found in another resident's room, and he/she was observed with his/her hand on the incontinent brief of a resident (of the opposite sex) who was in bed. During an interview on 10/03/24 at 9:30 A.M., the Physician said he was aware of the incident on 07/25/24 when Resident #2 inappropriately touched another resident. The Physician said that Resident #2 had dementia, was very confused, and said he/she had the physical ability to roam. The Physician said Resident #2's inappropriate behaviors were related to his/her dementia and would be better managed through staff interventions, like redirection and supervision, than through pharmacological interventions. During a telephone interview on 10/08/24 at 3:55 P.M., the Behavioral Health Provider said that Resident #2 required supervision from staff due to a history of behaviors including intrusive wandering and inappropriate touching, and said staff needed to ensure they knew his/her whereabouts. During a telephone interview on 10/04/24 at 8:20 A.M., Certified Nurse Aide (CNA) #2 said that when she worked the overnight shift on 09/21/24, she observed Resident #1 sitting in a chair outside the doorway to his/her room and Resident #2 was rubbing his/her back. CNA #2 said she separated and redirected Resident #1 and Resident #2 and communicated her observation with the CNAs on the next (7:00 A.M. to 3:00 P.M.) shift. CNA #2 said that Resident #1 often wandered on both units during the overnight shift when he/she could not sleep. During a telephone interview on 10/04/24 at 11:22 A.M., Nurse #1 said that she worked on 09/22/24 from 3:00 P.M. into 09/23/24 until 7:00 A.M., on the North Unit. Nurse #1 said that during the evening, while she was passing medications, she observed three separate times, Resident #1 wander in and out of Resident #2's room in response to his/her request or invitation, for him/her (Resident #1) to come into his/her (Resident #2's) room. Nurse #1 said she was unable to hear, if anything, what Resident #2 said to Resident #1. Nurse #1 said that she had never observed Resident #2 call Resident #1 into his/her room before, and said she felt his/her (Resident #2) behavior seemed a bit off that evening. Nurse #1 said that although she did not communicate her concern to other staff members, she said that she had planned to watch him/her (Resident #2) closely. Nurse #1 said it was common for Resident #1 to wander between both units during the evening and overnight shifts. During a telephone interview on 10/04/24 at 8:06 A.M., Certified Nurse Aide (CNA) #1 said he last saw Resident #1 wandering on the unit at approximately 2:45 A.M. on 09/23/24. CNA #1 said he supervised Resident #1 to ensure he/she did not wander into any resident rooms, until he had to assist Resident #1's roommate. CNA #1 said that while he assisted Resident #1's roommate, sometime after 3:00 A.M. (exact time unknown), he observed that Resident #1 was not in his/her bed. CNA #1 said he was in Resident #1's room longer than expected because he had to address a clogged toilet in the bathroom. CNA #1 said that when he exited Resident #1's room, sometime before 3:45 A.M., he became concerned because he did not see Resident #1 in the hallway. CNA #1 said he alerted Nurse #1 that he was unsure of Resident #1's whereabouts, and said he went to check the dining room and the South Unit. CNA #1 said that when he arrived on the South Unit, he heard Nurse #1 call out for assistance. Nurse #1 said that she took a break sometime after 3:30 A.M., at the nurses' station across from Resident #2's room. Nurse #1 said she had only been at the nurses' station for a few minutes when CNA #1 asked if she had seen Resident #1. Nurse #1 said she last saw Resident #1 at approximately 2:00 A.M., sitting in a chair by the nurses' station. Nurse #1 said that she checked Resident #1's room and he/she was not in bed. Nurse #1 said the next room she checked was Resident #2's room, at approximately 3:45 A.M. and found Resident #1 lying in Resident #2's bed. Nurse #1 said that from the doorway of Resident #2's room, she saw him/her standing next to his/her bed with his/her back facing the door. Nurse #1 said Resident #2's jeans and underwear were down around his/her ankles and the lower half of his/her buttocks were exposed below the hem of his/her T-shirt. Nurse #1 said Resident #1 was lying on his/her back, in Resident #2's bed, his/her bedtime garment was lifted up, his/her incontinent brief was wet and pulled down to his/her left ankle, and Resident #1's private area was slightly exposed. CNA #2 said that just before 3:45 A.M. on 09/23/24, CNA #1 asked if she had seen Resident #1. CNA #2 said she then heard Nurse #1 call out for assistance, so she and CNA #1 immediately responded. CNA #2 said that when she got to the North Unit, she found Nurse #1 in Resident #2's room, which was located across from the nurses' station. CNA #2 said that as she entered Resident #2's room, she observed that Resident #1 was lying flat on his/her back on Resident #2's bed, and his/her incontinent brief, which was saturated with urine was pulled down to his/her ankles, but that his/her (Resident #1's) private area was not exposed. CNA #2 said Resident #2 was sitting in a chair next to his/her bed, he/she was fully clothed, and he/she did not appear disheveled. Nurse #1 said that on 09/23/24, CNA #1 was the only staff member that worked with her during the overnight shift on the North Unit. Nurse #1 said one CNA and one nurse were scheduled to float between both units (North ans South) during the overnight shift, but that neither she or and #1 had worked on the South Unit leading up to the incident. Nurse #1 said that prior to the incident, she last saw Resident #2 at midnight in his/her room. CNA #1 said he assisted Resident #1 with his/her incontinent brief at 1:00 A.M. and said he last saw him/her around 2:45 A.M., wandering in the hallway. CNA #2 said she did not see Resident #1 on 09/23/24, prior to the incident. During a telephone interview on 10/09/24 at 2:38 P.M., the Director of Nurses (DON) said that both Resident #1 and Resident #2 required supervision by staff due to their behaviors. During an interview on 10/03/24 at 2:50 P.M., the Administrator reviewed the staffing for 09/22/24 and said the 63-bed facility had two nursing units that were staffed for the overnight shift with one nurse and one CNA assigned to each nursing unit (I Nurse and 1 CNA on North, then 1 Nurse and 1 CNA on South) and that an additional nurse and CNA were scheduled to float between both units. The Administrator said it was the responsibility of staff to provide supervision to residents that wandered, especially those that wandered into other resident rooms.

Based on observation, interview, and policy review, the facility failed to ensure that food served to the residents was prepared in accordance with professional standards for food service and safety. Specifically, the facility staff failed to ensure that the microwave, ovens, food mixer, and ice machine equipment in the facility's main kitchen was maintained in a clean and sanitary manner, to prevent contamination and the risk of foodborne illnesses. Findings include: Review of the facility's Kitchen Sanitation and Infection Control policy, undated, included but was not limited to: -The Dietary Manager (Food Service Director) is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department. -The Dietary Manager and Consultant Dietitian will develop a cleaning schedule . -A clean department is essential for good sanitation. The department includes equipment, materials that are used, floors, walls . Review of the facility's Cleaning and Sanitizing Dietary Areas and Equipment, undated, included but was not limited to: -All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. -Procedure for cleaning food mixers: .be sure to wash splash up areas. -Sanitation of ice machine: The ice machine shall be sanitized twice monthly. During an inspection of the main kitchen on 3/7/24 between 7:40 A.M. and 7:50 A.M., the surveyor observed the following: >Microwave Oven: Interior door and interior top of microwave covered with dried-on, splattered food particles. >Two side-by-side ovens: -The interior of the oven on the left side contained multiple large pieces and areas of black and gray debris. The oven door was coated with baked on food residue. -The interior of the oven on the right side contained multiple crumbled pieces of aluminum foil and baked on black residue. The oven door was coated with baked on food residue. The exterior bottom panel covering the pilot light switch for both ovens was missing, revealing exposed copper wire and springs and the entire length of the missing panel was covered with a black/orange substance and strings of dust hanging off the edges of the panel. >Commercial Food Mixer: The hub where the mixer attachment connects (facing the mixing bowl) was covered with a sticky, brownish/black/orange substance, which when touched caused particles to drop into the mixing bowl. During an interview on 3/7/24 at 7:50 A.M., the Food Service Director (FSD) said he was not sure when both ovens and he microwave oven were last cleaned. The FSD said he thought the [NAME] mixer was recently cleaned. The FSD said he did not have a cleaning/maintenance schedule for the kitchen, and to his knowledge, there were no facility policies related to kitchen cleaning and sanitation. During an observation and interview on 3/7/24 at 1:05 P.M., Dietary Staff #1 said the staff did not have a cleaning schedule or checklist of items to clean in the kitchen and that staff just cleaned areas of the kitchen if they noticed the areas needed cleaning. The surveyor and Dietary Staff #1 observed both oven interiors and Dietary Staff #1 said both ovens were overdue for a cleaning. When the surveyor and Dietary Staff #1 observed the exposed bottom panel for both ovens, Dietary Staff #1 said the exposed area was where the pilot light was located, that there used to be a cover over the whole area, and was unsure where the panel cover went. Dietary Staff #1 said the whole bottom panel area was very dirty and needed to be cleaned. During an observation with Dietary Staff #1 and Dietary Staff #2, of the ice machine that was in use for the facility residents and located outside the kitchen door in the main service hallway, the surveyor observed a long piece of plastic attached to the interior top of the ice machine, hanging over the ice when the lid to the ice machine was opened. The surveyor also observed approximately a foot long area that contained a brownish/orange, wet substance with vertical streaks and the substance dripping down into the ice. Dietary Staff #1 said it did not appear that the ice machine had been cleaned in a long time. Dietary Staff #2 said judging from the cleaning log sheet attached to the side of the ice machine, it was last cleaned on 12/10/23 and appeared to have been on a monthly cleaning schedule. Dietary Staff #1 said the Director of Maintenance was responsible for cleaning the ice machine. During an interview on 3/7/24 at 1:42 P.M., the Director of Maintenance said he was the staff person responsible for cleaning the ice machine monthly and he was not sure when he last cleaned it, maybe the beginning of January. The Director of Maintenance further said that he did not know what the dark, wet substance in the ice machine was, that the substance appeared to be dripping into the ice, and the ice machine needed to be cleaned because this could make the residents sick. During an interview on 3/8/24 at 2:45 P.M., the FSD provided a cleaning checklist to the surveyor, however the FSD said the cleaning checklist was not being utilized.

Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) and/or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) were issued for two Residents (#12 and #36) out of a total sample of three residents. Specifically, the facility failed to issue: 1. A NOMNC notice and a SNF ABN notice to Resident #12. 2. A SNF ABN notice to Resident #36. NOMNC notice is issued to a resident who is receiving benefits under Medicare Part A when all covered services end. A resident must be told in advance when changes will occur in their bills, and the facility must fully inform the resident of service-related changes and appeal rights. SNF ABN notice is issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days. The SNF ABN provides information to beneficiaries so they can decide if they wish to continue receiving skilled services that may not be paid for by Medicare and the beneficiary assumes financial responsibility. Findings include: 1. Resident #12 was admitted to the facility in January 2024. Review of the SNF Beneficiary Protection Notification Review, completed by the facility indicated Resident #12 came off (Medicare benefits ended) his/her Medicare benefit on 3/4/24. No NOMNC or SNF ABN notice corresponding with the Resident coming off his/her Medicare benefit on 3/4/24 was provided to the surveyor to review. 2. Resident #36 was admitted to the facility in November 2023. Review of the SNF Beneficiary Protection Notification Review completed by the facility indicated Resident #36 came off his/her Medicare benefit on 12/4/23. No SNF ABN notice corresponding with the Resident coming off his/her Medicare benefit on 12/4/23 was provided to the surveyor to review. During an interview on 3/6/24 at 2:55 P.M., the Business Office Manager (BOM) said no NOMNC was issued for Resident #12 when he/she came off his/her Medicare benefit on 3/4/24 and one should have been issued at least two days prior to the Resident's last covered day on Medicare. The BOM further said Resident #12 and Resident #36 remained in the facility after their Medicare benefits ended and a SNF ABN was not issued to either Resident. The BOM said a SNF ABN should have been issued to both Residents when their Medicare benefit ended and it was determined they would remain the facility.

Based on observation, interview, record and policy review, the facility failed to provide an environment that was free of accidents and hazards for two Residents (#10 and #46) out of a total sample of 15 residents. Specifically, the facility staff failed to: 1. For Resident #10, ensure a fall event was investigated and interventions were implemented to prevent further falls for a Resident who was identified as being at risk of falling. 2. For Resident #46, provide maintenance and testing of a wander guard device (a device worn by the Resident, usually in a bracelet form, which alarms when the Resident attempts to leave a secure area of the facility) for a Resident who was identified as being at risk for elopement. Findings include: 1. Review of the facility policy titled Falls-Clinical Protocol, revised March 2018, indicated the following: -The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events etc. -For an individual who has fallen, the staff and Practitioner will begin to try and identify possible causes within 24 hours of the fall. Resident #10 was admitted to the facility in October 2020, with diagnoses including Fracture of the Right Femur (large bone in the thigh), history of Falls, and Hemiparesis (partial paralysis of one side of the body that can affect arms, legs and facial muscles). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #10 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15. Review of the clinical record progress notes for Resident #10 indicated: -On 2/13/24 at 9:41 P.M., the Resident sustained an unwitnessed fall and hit his/her face on a bedside table and was sent to the hospital. The Resident returned to the facility on [DATE] at 1:00 A.M., with a large right sided facial bruise. -On 2/19/24 at 4:40 A.M., the Resident was found sleeping on the floor next to his/her bed. The Resident remained in the facility. -On 2/29/24 at 2:00 A.M., the Resident was found on the floor, with a bump on head his/her head. The Resident was sent to the hospital. The Resident returned to the facility on [DATE] at 11:45 A.M. -On 3/1/24 at 7:28 A.M., the Resident sustained a witnessed fall while ambulating in the hallway without assistance. The Resident remained in the facility. Review of the fall investigation reports, provided by the facility and pertaining to Resident #10, indicated no evidence that the unwitnessed fall event that occurred on 2/29/24 had been investigated by the facility staff. Review of the Resident's current care plan relative to Falls initiated 4/20/22, and last revised 3/8/24, indicated no evidence the care plan was updated to include additional interventions for falls safety, to prevent the Resident from falling, were implemented after the Resident sustained an unwitnessed fall on 2/29/24. During an interview on 3/11/24 at 10:52 A.M., the Director of Nurses (DON) said that there was no investigation report pertaining to Resident #10's unwitnessed fall that occurred on 2/29/24. The DON said that there was confusion as to whether the fall on 2/29/24 was the same fall that was reported for 3/1/24. The DON said the facility should have investigated the fall that occurred on 2/29/24, and interventions should have been implemented as required. 2. Review of the facility policy titled Wandering and Elopements, revised March 2019, indicated the following: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #46 was admitted to the facility in March 2022 with diagnoses of Vascular Dementia (Dementia associated with disease in the blood vessels of the brain) and Psychotic Disturbances (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). Review of the MDS assessment dated [DATE] indicated Resident #46 was severely cognitively impaired as evidenced by a BIMS score of three out of a total score of 15. On 3/6/24 at 10:46 A.M., the surveyor observed a wander guard device that was placed on the Resident's right ankle. On 3/6/24 at 3:44 P.M., the surveyor observed Resident #46 ambulating up and down the hallway on the North Unit. The surveyor also observed that the Resident did not require assistance of a device to ambulate, and the Resident had a wander guard device on his/her right ankle. Review of the Nursing Progress Notes in the clinical record, dated 1/5/24, indicated Resident #46 had attempted to leave the facility and the facility staff placed a wander guard device on the Resident after speaking to the Resident's Healthcare Proxy (HCP -the person chosen as the healthcare decision maker when the individual is unable to do so for themself). Further review of the Nursing Progress Notes in the clinical record indicated no evidence that the facility staff had provided scheduled maintenance and testing for the Resident's wander guard device. Review of the March 2024 Physician orders indicated no order for scheduled maintenance and testing for the Resident's wander guard device to ensure proper functioning of the device. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2024, February 2024 and March 2024 indicated no evidence that the facility staff had provided scheduled maintenance and testing for Resident #46's wander guard device. Review of the current care plan, initiated 8/21/23, indicated Resident #46 wanders aimlessly and an intervention was initiated 1/5/24, for the placement of a wander guard device. Further review of the care plan did not indicate an intervention for scheduled maintenance and testing for the wander guard device to ensure proper functioning of the device in preventing accidental elopement from the facility by the Resident. During an interview on 3/11/24 at 8:05 A.M., the DON said that Resident #46 had a wander guard device placed in January 2024 after he/she attempted to leave the facility. The DON said the wander guard devices come with very expensive batteries and sometimes the batteries last a long time and sometimes they do not last a long time. The DON said that the night Nurses used a special tool to test the wander guard every night to make sure the device was functioning properly; and the Nurses documented wander guard maintenance and testing on the Resident's MAR or TAR. The surveyor and the DON reviewed Resident #46's MAR and TAR, and the DON said that there was no documentation regarding the maintenance and testing of the wander guard device. During an interview on 3/11/24 at 11:26 A.M., the Assistant Director of Nurses (ADON) said that the nursing staff were supposed to test wander guard devices every day and document on the MAR and that there was no documented evidence for the maintenance and testing of Resident #46's wander guard device. The ADON further said that the wander guard device had not been maintained and tested as required but the device should have been maintained and tested .

Based on interview, observation, and record review, the facility failed to ensure that the breakfast meal was served at a palatable temperature on one Unit (South Unit) out of two units observed. Specifically, the facility staff failed to: -address Resident Council concerns pertaining to meal temperatures. -ensure that breakfast meals on the South Unit were served to the residents at a palatable and appetizing temperature as indicated by test tray tasting completed for breakfast on South Unit. Findings include: During the initial survey resident interviews conducted on 3/6/23 the following information was provided by residents of the South Unit regarding meal temperatures: -Breakfast oatmeal was often cold. -Plates used to keep food warm were not warm so the meals did not stay warm and were cold when received. -The breakfast meal was cold at least once a week. Review of the 12/14/23 Resident Council Meeting Minutes indicated the Residents had a concern that food is cold upon delivery to their rooms. Review of the Activities Communication Sheet (form that provides follow-up to concerns raised in Resident Council), dated 12/15/23, indicated: -the Food Service Director (FSD), provided logs of the initial temperature of the food from the kitchen to show that food left the kitchen at a hot temperature. -no further follow-up was done to indicate that the FSD had assessed the food once it arrived to the Units. On 3/7/24, the surveyor requested a test tray for breakfast on the South Unit. On 3/7/24 at 8:03 A.M., the surveyor observed the South Unit breakfast meal carts arrived on the Unit. On 3/7/24 from 8:06 A.M. through 8:21 A.M., staff on the South Unit passed breakfast trays to Residents in their rooms. On 3/7/24 at 8:21 A.M., the test tray came off the breakfast meal cart and Nurse #1 assisted the surveyor with taste testing and obtaining temperatures of the meal. The following temperatures were obtained and observations were made: -Scrambled Egg: 88 degrees Fahrenheit (F) - Nurse #1 said the eggs were cool to the taste, the surveyor observed the eggs were cool to the taste -Shredded Potatoes: 82 degrees F - Nurse #1 said the shredded potatoes were cool to taste, the surveyor observed the shredded potatoes to be cool to the taste -Oatmeal: 100 degrees F - Nurse #1 said the oatmeal was warm to the taste, the surveyor observed the oatmeal to be warm to the taste During an interview immediately following the test tray tasting, Nurse #1 said she was unsure what temperature food should be when it comes up to the unit. During an interview on 3/7/24 at 12:20 P.M., the surveyor discussed with the FSD, the test tray tasting results for breakfast on the North and South Units and lunch on the South Unit, with findings that the breakfast meal on the South Unit did not meet temperatures that were appetizing and palatable. The FSD said food should come up to the units between 130 -135 degrees F and should be hot to the taste. During a follow-up interview on 3/8/24 at 2:45 P.M., the FSD said he had not conducted any test tray audits recently and the last time test tray audits had been conducted was quite some time ago (the FSD did not provide a time frame of when the last test tray audits were completed). During an interview on 3/11/24 at 12:34 P.M., the Administrator said she was unable to locate any follow-up action or test tray audits that the FSD had completed pertaining to the concerns regarding cold food raised from the 12/14/23 Resident Council Meeting. The Administrator said she would speak with the FSD. The facility did not provide any evidence by end of the survey, that test tray audits or any other action had been done in response to the concerns brought to the facility's attention from the 12/14/23 Resident Council Meeting.

Based on interview, policy, and record review, the facility failed to implement smoking policies as required for one Resident (#49) out of one applicable Resident, out of a total sample of 15 residents, and also failed to ensure that the Resident smoking area was maintained in a safe, clean and sanitary manner. Specifically, the facility staff failed to: 1. For Resident #49, ensure that smoking assessments and Resident Agreement for safe smoking habits were completed quarterly as required. 2. Establish a cleaning schedule to empty the cigarette disposal receptacles timely and replace a missing cigarette disposal receptable cover to prevent accidental fires and/or burns and unsafe disposal of cigarette butts on the ground in the smoking area. Findings include: 1. Resident #49 was admitted to the facility in September 2022 with diagnoses of nicotine dependence and Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow and breathing problems). Review of the facility policy titled Smoking Policy and Resident Agreement, undated, indicated the following: -A smoking assessment will be completed upon admission, quarterly, when a resident chooses to change their smoking decision, and when it is warranted. Review of the document titled Smoking, provided to the survey team on 3/6/24, as part of the survey entrance indicated Resident #49 was an independent smoker. Review of the Smoking Policy and Resident Agreement, signed by the Resident on 11/23/22 indicated he/she agreed to the facilities policies and procedures surrounding smoking. Review of Resident #49's medical record indicated his/her smoking abilities and habits had been assessed on the Nursing Evaluation .(Admit, Readmit, Quarterly, Change of Condition (COC)-Version (V) 5 only twice in the last year on 9/25/23 and 3/6/24. During an interview on 3/6/24 at 1:46 P.M., Nurse #2 said she was unsure how often residents who smoked should be evaluated for safe smoking habits. During an interview on 3/7/24 at 10:42 A.M., Nurse #3 said she was unsure how often residents who smoked should be evaluated for safe smoking habits. During an interview on 3/7/24 at 11:54 A.M., the Director of Nursing (DON) said residents who smoke should be evaluated quarterly for safe smoking habits. The DON said she had reviewed Resident #49's record and he/she had only been evaluated two times over the past year (from March 2023 until March 2024) on 9/25/23 and 3/6/24, and he/she should have been evaluated quarterly (four times a year) per the facility policy. 2. During an observation on 3/7/24 at 11:12 A.M., the surveyor observed the facility's outdoor smoking area to be littered with cigarette butts which were thrown and scattered on the ground in the smoking area. The surveyor also observed that the cigarette disposal receptacle cover in the smoking area was missing, and the receptable was filled to the brim with cigarette butts. During an observation and interview on 3/7/24 at 11:21 A.M., the surveyor and the Director of Nurses (DON) observed the smoking area. The DON said it did not appear that the smoking area had been cleaned recently. The DON said the cigarette disposal receptacle should not be full and there should be no cigarette butts scattered all around on the ground. The DON further said Maintenance should be maintaining the cleanliness of the area and making sure the cigarette disposal receptable was emptied regularly. During an interview on 3/7/24 at 1:46 P.M., the Maintenance Director said the Housekeeping Department should be cleaning the smoking area regularly but there was no set schedule for cleaning the smoking area. The Maintenance Director further said he had observed the smoking area and that it had not been cleaned in some time and there were cigarette butts scattered on the ground. The Maintenance Director said the cigarette disposal receptacle should have been covered and also should have been emptied regularly.

Based on observation, interview, and record review, the facility failed to follow infection control guidance to prevent the spread of COVID-19 on two units (North and South), out of a total of two units. Findings include: Review of the Department of Public Heath (DPH) memo titled When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, Appendix A (Personal Protective Equipment Used When Providing Care to Residents in Long Term Care), dated May 10, 2023, indicated the following: -For COVID-19-positive residents: Recommended Staff PPE: Full PPE upon room entry to include fit-tested N95 respirator or alternative, and Face Shield/Goggles. Gown and Gloves if there is any contact with potentially infectious material. Gown and gloves must be changed between residents. Review of the facility's policy titled Coronavirus Disease (COVID -19) - Using Personal Protective Equipment, dated September 2021, indicated when personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 (COVID -19) infection adhere to standard precautions and use NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection. 1. On 8/28/23 at 9:05 A.M., the surveyor observed Nurse #1 enter a room located on the North Unit without donning (putting on) the required PPE. An isolation sign on the door outside of the room indicated the following: Staff and Providers must: -Clean hands when entering and exiting -Wear a gown, N95 Respirator, eye protection, and gloves During an interview immediately following the observation, Nurse #1 said that she was providing care for the resident in the room that recently had COVID-19 but tested negative as of that morning. Nurse #1 said the other resident in the room remained positive. She said that she did not wear the full PPE that was recommended on the signage outside of the room as she was not providing care for the resident who was COVID-19 positive. During an interview on 8/28/23 at 10:00 A.M., the Director of Nursing (DON) said that the staff are expected to wear full PPE when entering a COVID-19 positive room even if they were only providing care for the resident who was negative. The DON said when entering a room that is on Isolation, full PPE should be worn. 42741 2. On 8/28/23 at 8:14 A.M., the surveyor observed Nurse #2 enter a room located on the South Unit with an isolation sign on the outside of the door indicating the following: Staff and Providers must: -Wear a gown, N95 respirator, eye protection, and gloves. The surveyor observed Nurse #2 to be wearing a gown, gloves, eye protection, and a surgical mask, not an N95 mask. During an interview immediately following the observation, Nurse #2 said both residents in the room were positive for COVID-19 and she should have changed out her surgical mask for an N95 mask prior to entering the room.

Based on interviews and record review, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#3), out of a total sample of five residents. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, revised March 2022, indicated the following: -Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessment of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.htlm for educational materials.) Provision of such education is documented in the resident's medical record. -Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23, indicated the following: For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last pneumococcal vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . Resident #3 was admitted to the facility in July 2023 and was over the age of 65. Review of the Immunization Section in the Electronic Medical Record (EMR) indicated the Resident had received the PCV13 on 2/23/16 and the PPSV23 on 2/18/11. Review of the Resident's Pneumococcal Vaccine Informed Consent indicated he/she was only educated on and given the opportunity to accept or decline the PCV13 and PPSV23, which he/she already had been administered prior to admission to the facility. Further review of the Resident's medical record indicated no documented evidence the Resident was provided education, assessed for eligibility, and/or offered the PCV20, as recommended by the CDC. During an interview on 8/28/23 at 10:54 A.M., the Assistant Director of Nursing (ADON) said upon admission, all new Residents are asked to complete the Pneumococcal Vaccine Information Consent and their Pneumococcal Vaccine status would be checked in the Massachusetts Immunization Information System (MIIS). The ADON further said she was unsure which Pneumococcal Vaccinations should be offered to a Resident at admission for them to be considered up to date. During an interview on 8/28/23 at 11:08 A.M., the Director of Nursing (DON) said he thought Resident #3 was up to date on his/her Pneumococcal Vaccinations since he/she had the PCV13 and the PPSV23, but that he was unsure if the Resident was actually up to date. The DON further said there was no documentation to show that the Resident had been educated on, assessed for eligibility or offered the PCV20 at the time of admission, as required.

Based on observation, interview and record review, the facility failed to ensure its staff provide behavioral health care and services for one Resident (#26), out of 17 sampled residents. Specifically, the facility staff failed to follow up on behavioral health recommendations for the Resident who was experiencing symptoms of depression. Findings include: Resident #26 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 8/25/22, indicated a Behavioral Interview for Mental Status (BIMS) score of 13 out of 15, indicating he/she was cognitively intact. Review of a Nurses Progress Note, dated 9/29/22, indicated the following in part: -the Resident did not eat dinner or the snacks that were offered -he/she was crying incessantly and was unable to be redirected -PRN (as needed) [MEDICATION(S)] (antianxiety medication) was given with very little affect -PRN [MEDICATION(S)] (medication for pain) -the Resident continued to cry Review of the Psychiatric Evaluation and Consultation Note, with a service date of 9/29/22, indicated that the chief complaint for the Resident encounter was for agitation, not sleeping and crying. Further recommendations were made, in part; for depression and anxiety, and it was recommended to start [MEDICATION(S)] (antidepressant) 25 milligrams by mouth once a day. Review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurses Progress Note, dated 10/16/22, indicated the Resident was very anxious and crying and that he/she wanted to go home. During an observation and interview on 10/26/22 at 8:43 A.M., Resident #26 was observed to be fully clothed and was laying in bed, covered by blankets. Two untouched drinks and a banana were on the bed side table. The Resident greeted the surveyor however was very sleepy. When asked if he/she had breakfast, the Resident said that he/she was not hungry. The Resident then closed his/her eyes to indicate he/she was done talking. On 10/31/22 at 11:03 A.M. the surveyor observed Resident #26 to be sleeping in bed. The Resident did not wake when surveyor said hello. During an interview on 10/31/22 at 1:54 P.M., Certified Nursing Assistant (CNA) #6 said the Resident had been declining recently and that he/she used to come out more during the day. During an observation and interview on 10/31/22 at 2:55 P.M., the surveyor observed the Resident lying in bed, covered by blankets. The room was dark and there was no television (TV) or music on. The Resident said that he/she didn't feel normal today and that maybe tomorrow would be better. He/she further said some days are just like that and that the next day, hopefully will be a little better. The Resident continued to say that he/she was sleepy and did not have an appetite. When asked if he/she would be participating in the Halloween festivities that the facility was having today, he/she said that he/she was not interested in celebrating. The surveyor noted a mood change in the Resident when he/she began talking about horses and traveling. When asked if he/she enjoyed watching TV or listening to music he/she said that he/she did not care much for TV but liked classical music. The surveyor did not observe a TV or radio to be available in the room for the Resident. During an interview on 11/01/22 at 10:10 A.M., the Director of Nursing (DON) said that the behavioral health clinician would provide both himself and/or the Administrator a copy of the encounter notes from a resident visit, as well as put one in the Physician's binder. Next, the Physician would let the facility know in person, whether to make the recommended changes made by the behavioral health team. The DON additionally said that the facility staff would receive a list the day the behavioral health team was in the facility, with any recommendations that were made so that they would able to act on them accordingly. At that time, the surveyor requested evidence that the facility received and/or acknowledged the recommendations that were made for Resident #26 by the behavioral health team on 9/29/22. During an interview on 11/02/22 at 10:47 A.M., the Clinical Reimbursement Nurse said that there was no documented evidence that the facility staff or Physician followed up on the behavioral health recommendations for Resident #26. During an interview on 11/02/22 at 2:35 P.M., the DON said that the recommendations for Resident #26 made by the behavioral health team should have been followed up on and were not.

Based on interviews, observations and policy review, the facility failed to ensure its residents knew how to file a grievance (complaint or concern). Findings include: Review of the facility policy titled Resident and Family Concerns and Grievances Policy and Procedure, dated 2020, indicated the following: -Residents or their family members, guardians, or representative may voice a grievance to the facility staff in person, by telephone, or via written communication -The facility will notify residents, individually or through postings in prominent locations through the facility, of the right to file a grievance On 10/27/22 at 2:00 P.M., the surveyor conducted a resident group meeting with nine residents. When asked if they were aware of how to file a grievance, all nine residents stated they were unaware of where to find the grievance form, who to ask to obtain one or what the process was to file a grievance. During an interview on 10/31/22 at 7:49 A.M., the Administrator said that she was the grievance official. She said that often she will receive a complaint from a staff member on behalf of a resident, write up the grievance, check in with the appropriate manager or staff forwarding the complaint and start an investigation. She further said that she follows up with the resident to better understand the concern and then again to review the solution/resolution. Additionally, she said that the grievance forms were kept at the reception area for residents or family. The Administrator provided the grievance binder that had a total of five completed grievances dated from 9/27/21 through 9/6/22. She said they did not have many grievances in the binder because they did not have many submitted. On 10/31/22 at 8:00 A.M., the Surveyor did not observe grievance forms to be readily available near the receptionist area or near the main entrance area of the facility. During an interview on 10/31/22 at 11:11 A.M., the Receptionist said that she was unsure where the grievance forms were kept. During a follow-up interview on 10/31/22 at 1:47 P.M., the Receptionist said that the grievance forms were located in a folder behind her desk. She further said that she was unaware they were there because no one had ever asked her for one before.

Based on interview and record review, the facility failed to ensure its staff developed baseline care plans within 48 hours of admission and/or that the baseline care plans were provided to four Residents (#3, #29, #32 and #39) or their Representatives (if applicable), out of a total sample of 17 residents. Findings include: Review of the facility policy titled Baseline Care Plans, revised December 2016, indicated a baseline plan of care to meet the resident's immediate needs will be developed within forty eight hours of admission. The Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs . 1. Resident #3 was admitted to the facility in February 2022. Review of the clinical record indicated no documented evidence that a baseline care plan for Resident #3 was developed within 48 hours of admission, as required. Review of the Resident's current interdisciplinary care plans indicated they were initiated in October 2022 (8 months later). Further review of the care plans indicated no documented evidence of Activities of Daily Living (ADLs) and mobility needs. Review of the Care Card did not indicate the Resident's mobility and ADL needs. The Surveyor requested evidence of Resident #3's baseline care plan on 11/02/22 at 10:56 A.M. On 11/02/22 at 11:37 A.M., the Clinical Reimbursement Nurse said that he was unable to find documented evidence that a baseline care plan was developed for Resident #3 until October 2022 (8 months later). 2. Resident #29 was admitted to the facility in February 2022. Review of the clinical record indicated no documented evidence that a baseline care plan was developed for Resident #29 within 48 hours of admission, as required. Review of the Resident's current interdisciplinary care plans indicated they were initiated in May 2022 (3 months later), including his/her ADL and mobility needs. On 11/02/22 at 8:34 A.M., the surveyor requested evidence of Resident #29's baseline care plan from the Director of Nurses (DON). During an interview on 11/02/22 at 9:33 A.M., the Clinical Reimbursement Nurse said that there was no evidence that the baseline care plan was developed within 48 hours, as required. 3. For Resident #39 the facility staff failed to develop a baseline care plan relative to positioning, mobility, and/or level of assistance required during ADLs. Resident #39 was admitted to the facility in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical record review indicated a nursing assessment had been completed upon admission and identified the following: -One side stronger than another -Right foot press weak -Range of motion functional limitations of left upper and lower extremities -Contracture of left upper extremity Further review of the record indicated no evidence that a baseline care plan had been developed upon admission to address how to provide care for areas noted during the initial nursing assessment. A clinical record review indicated the following care plans and interventions had been developed seven days after admission: -Obtain physical therapy consult -Turn and reposition every two hours -Assist with all ADL needs. Encourage the Resident to participate as able -Maintain body in functional alignment when at rest -Perform a contracture assessment During an interview on 11/01/22 at 1:41 P.M., the DON said that when a resident was admitted to the facility, the staff complete an initial nursing assessment, at which point they would check specific care plans that should be completed. By selecting specific care plans they will then be prompted to complete a comprehensive care plan which are considered to be the baseline care plans. During an interview on 11/02/22 at 2:01 P.M., the Clinical Reimbursement Nurse said that an ADL care plan whether baseline or comprehensive should have been developed within 24-48 hours upon admission. The ADL care plan was developed seven days after the Resident's admission and should have been developed sooner, as required. 4. Resident #32 was admitted in September 2022. Review of the clinical record did not provide evidence a baseline care plan was written that included the minimum information necessary to properly care the Resident, nor was there evidence that the Resident and/or the Resident's Representative was provided with a summary of the baseline care plan. During an interview on 11/2/22 at 4:15 P.M. the DON said he was not able to provide evidence that the Resident and/or the Residents Representative was provided with a baseline care plan summary, as required.

Based on observation, interview and record review, the facility failed to ensure its staff reviewed and revised the plan of care for six Residents (#2, #3, #15, #28, #32, and #48), out of a total of 17 residents sampled. Findings include: 1. Resident #2 was admitted to the facility in April 2020. Review of the medical record indicated that Minimum Data Set (MDS) Assessments were completed for the Resident on the following dates: 3/18/21, 6/10/21, 9/2/21, 11/5/21, 5/5/22, and 7/28/22. Further review of the medical record did not include any evidence that the care plan was reviewed by the interdisciplinary team after each assessment. On 11/02/22 at 2:39 P.M., the Clinical Reimbursement Nurse said there was no evidence there were any interdisciplinary care conferences were held, as required. 2. Resident #28 was admitted to the facility in April 2022. Review of the medical record indicated MDS Assessments were completed on the following dates: 5/2/22, 6/11/22, and 9/8/22. Further review of the medical record did not include any evidence that the care plan was reviewed by the interdisciplinary team after each assessment. On 11/01/22 at 4:25 P.M., the Director of Nursing (DON) said there have been issues with care plan reviews and care plan meetings and there was no documentation that the care plan was reviewed after each assessment, as required. 3. Resident #48 was admitted to the facility in October, 2020. Review of the medical record indicated that MDS Assessments were completed on the following dates: 4/7/22, 6/30/22 and 9/22/22. Further review of the medical record did not include any evidence that the care plan was reviewed by the interdisciplinary team after April 2022. On 11/2/22 at 11:31 A.M., the Social Worker (SW #1) said interdisciplinary care conferences are timed with the MDS Assessments and there was no evidence the Resident's care plan was reviewed by the interdisciplinary team after April 2022. On 11/2/22 at 1:31 P.M., SW #1 said she was out of town when the Resident's quarterly interdisciplinary care conference was scheduled on 10/6/22 and there was no evidence in the medical record that the care plan review occurred, as scheduled. She further said she was not working in the facility when the Resident should have had his/her care plan reviewed after the 6/30/22 Assessment and could not speak to whether the care plan was reviewed at that time. On 11/02/22 at 2:39 P.M., the the Clinical Reimbursement Nurse said there was no evidence there were any interdisciplinary care conferences after April 2022, as required. 4. Resident #32 was admitted in September 2022. Review of the MDS Assessment, dated 9/14/22, indicated the Resident required extensive assistance of one care giver for bed mobility, locomotion, dressing, toilet use, hygiene, and bathing, required extensive assist of two care givers for transfers, required set-up for eating, and used a wheelchair for mobility. Review of the Activities of Daily Living (ADL) Care Plan, initiated 9/7/22, indicated the Resident had an ADL self-care deficit with a goal to improve current level of function by next review, with a target date of 9/27/22. The Resident care plan did not indicate any interventions for how care was to be provided or what level of assistance the Resident required. During an interview on 11/1/22 at 4:15 P.M., the DON said interventions should be documented on the ADL Care Plan, these interventions reviewed at the care plan meeting, and it appeared that this had not been done, as required. 5. For Resident #3, the facility failed to ensure staff conducted routine care plan meetings with the Resident and/or Resident Representative, as required. Resident #3 was admitted to the facility in February 2022. During an interview on 10/26/22 at 11:45 A.M., Resident #3 said he/she had received notices about care plan meetings that were scheduled, but they never occurred, or if they did, he/she was not a part of them. Review of the clinical record indicated no documented evidence that a care plan meeting for Resident #3 was held prior to October 2022. On 11/02/22 at 10:56 A.M., the surveyor requested evidence that scheduled care plan meetings were held for Resident #3 from the Clinical Reimbursement Nurse. During an interview on 11/02/22 at 11:37 A.M., the Clinical Reimburse Nurse said that he reviewed Resident #3's clinical record and could not find evidence that care plan meetings were conducted quarterly as required. He further said that he found evidence that one meeting occurred on 10/26/22, but that was all he could find.

Based on interview and record review, the facility failed to ensure one Resident (#3) was free from significant medication errors, out of a total of 17 sampled residents. Findings include: Resident #3 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -obtain vital signs every shift -[MEDICATION(S)] (medication used to treat high blood pressure) 10 milligram (mg) tablet, give orally every 6 hours as needed (PRN) for high BP; systolic (pressure in the arteries when the heart beats) BP greater than (>) 160 and/or diastolic (pressure in the arteries when the heart rests) BP > 100 Review of the 10/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -10/15/22 on the day shift: 163/80 -10/15/22 on the night shift: 173/80 -10/16/22 on the evening shift: 196/80 -10/17/22 on the day shift: 162/80 -10/19/22 on the evening shift: 217/113 -10/19/22 on the night shift: 217/113 -10/28/22 on the day shift: 176/74 Further review of the 10/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and was effective. There was no indication that [MEDICATION(S)] was administered on the other dates/times that the Resident's BP was elevated. During an interview and review of the 10/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., the Director of Nurses (DON) said that [MEDICATION(S)] should have been administered on 10/15/22, 10/16/22, 10/17/22 and on 10/28/22 but there was no indication that it was. He said the missed doses of [MEDICATION(S)] were medication omissions, were considered medication errors and the Physician would need to be notified. The DON further said that the by not administering the BP medication as ordered, the Resident would continue to have elevated BP levels and would be at risk for a stroke.

Based on record review and interview for 1 of 3 sampled Residents (Resident #1), the Facility failed to notify the physician of the Resident's mouth pain, and failed to promptly notify the Physician of the Resident's decreased oral intake for 8 days. Findings include: Resident #1 was admitted to the Facility for rehabilitation following a [MEDICAL CONDITIONS] on 4/22/15, which resulted in dysphasia, [MEDICAL CONDITION] and right arm weakness; additional [DIAGNOSES REDACTED]. 1. Reesident #1's Physician's Physical examination and progress note of 5/6/15, indicated there were no positive findings on Physical Examination and the Resident was comfortable. Review of the Nurses' Notes documentation indicated Resident #1 had new onset mouth pain as follows; - The Nurse's Note, dated 5/15/15 during the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #1 had signs and symptoms of mouth pain. - The Nurse's Note, dated 5/21/15 during the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 stated, I can't stand it, pointing to his/her throat and mouth. - The Nurse's Note, dated 5/26/15 during the 7:00 A.M. to 3:00 P.M. shift, indicated that Resident #1 was very upset and was yelling and crying, and continued to have mouth pain. - The Nurse's Note, dated 5/26/15 during the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 had signs and symptoms of mouth pain. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 8/13/15. Nurse #1 was asked about Resident #1's mouth pain referring to the Nurse's Note on 5/15/15. Nurse #1 said Resident #1 started pinching at his/her mouth and telling staff to take the food back. Nurse #1 said she did not perform a mouth exam. Nurse #1 said the Facility Physician was not informed of Resident #1's mouth pain. Nurse #1 said that staff thought a dental consult was needed and the request was faxed to the physician. The Surveyor interviewed Nurse #2 at 4:00 P.M. on 8/13/15 and reviewed Nurse #2's Note of 5/15/15. Nurse #2 said she was unclear where the Resident's mouth pain was, and that there was blood in the corner of Resident #1's mouth. Nurse #2 said that she did not notify the physician; however, a referral was made to the Dental Clinic. The Surveyor interviewed the Director of Nursing (DON) at 4:30 P.M. on 8/13/15. The DON said the attending Physician was not notified of the Resident #1's mouth pain. 2. Review of Resident #1's oral intake indicated his/her intake had been progressively decreasing, and the physician was not been notified in a timely manner. Review of the Meal Sheets indicated that from 5/1/15 to 5/4/15, this Resident's baseline meal intake percentage was approximately 25% to 50%, and was 75% only on 3 occasions. Review of the Meal Sheets indicated Resident #1's intake progressively decreased from 5/11/15 to 5/18/15 as follows: On 5/11/15 breakfast was 50%, lunch and dinner were documented as a bite. On 5/12/15 breakfast was documented as 25%, and dinner was documented as 50%. On 5/13/15 breakfast was documented as refused and dinner was documented as 25%. On 5/14/15 breakfast was documented as 20%, lunch was documented as refused and dinner was documented as bites. On 5/15/15 breakfast was documented as 20%, lunch was documented as refused and dinner was documented as bites. On 5/16/15 breakfast was documented as 25%, lunch was documented as 50% and dinner was documented 25%. On 5/17/15 breakfast, lunch and dinner were documented as bites. On 5/18/15 breakfast and lunch were documented as bites, and dinner was documented as 25%. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 8/13/15. Nurse #1 said the Physician was not notified about Resident #1's decreased oral intake until 5/19/15 (a delay of 8 days).

Based on record review and interviews, for 1 of 3 sampled Residents (Resident #1), the Facility failed to ensure Resident #1 received effective pain management. Resident #1 continued to have mouth pain which could impact Resident #1's ability to eat. he nurses did not consistently document Resident #1's response to the pain medication. Findings include: The Facility policy on Pain Management, (undated), indicated, Whenever the results of a pain assessment reveal that a resident's pain is not under control, the attending physician .should be notified. Resident #1's Admission Minimum Data Set (MDS) assessment, dated 5/1/15, indicated Resident #1 had unclear speech, was sometimes understood and had severely impaired vision. The MDS indicated Resident #1 had impaired short and long term memory and daily decision making was severely impaired. The MDS indicated Resident #1 refused care 4 to 6 days in the past 7 days and Resient #1 received scheduled pain medication in the past 5 days. The Nurse's Note, dated 5/15/15 during the 7:00 A.M. to 3:00 P.M. shift, indicated Nurse #2 wrote that Resident #1 had signs and symptoms of mouth pain. Resident #1's Medication Administration Record [REDACTED]. There was no documentation of the pain medication's effectiveness. Resident #1's Nurse's Note, dated 5/21/15 during the 3:00 P.M. to 11:00 P.M. shift, indicated that Resident #1 stated, I can't stand it, pointing to his/her throat and mouth; and [MEDICATION NAME] was given with positive effect. Resident #1's Nurse's Note, dated 5/26/15 during the 7:00 A.M. to 3:00 P.M. shift, indicated Resident #1 was very upset and yelling and crying. The Note indicated Resident #1 continued to have mouth pain, and it is very hard to have the Resident take medications or drink anything. There was no evidence that a pain medication was given to Resident #1 or that the physician was notified. Resident #1's Nurse's Note, dated 5/26/15 during the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 had increased anxiety on all shifts and was yelling. The Note indicated [MEDICATION NAME] (a pain medication) was given for the signs and symptoms of mouth pain. There was no documentation of the pain medication's effectiveness. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 8/13/15, and Nurse #2 at 4:00 P.M. on 8/13/15. Although both Nurse #1 and Nurse #2 said they aware of Resident #1's mouth pain, the physician was not notified and the efficacy of the pain medication was not documented. Nurse #1 stated that even though Resident #1 was given [MEDICATION NAME] for breakthrough pain, the cause of the mouth pain was never determined and treated by the physician. Nurse #1 had requested a dental consult instead.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the certified nurse aides (CNAs) and nurses were aware Resident #1 was to complete oral hygiene while seated due to his/her poor balance and recent fracture of the right arm. On 4/12/14, Resident #1 stood independently at the sink in the bathroom with a staff member present, brushed his/her teeth, and fell backward to the floor after the staff member stepped away from Resident #1. Resident #1 sustained a three fractured vertebra (bones in the spine) as a result of the fall. Findings include: The admission record indicated that the staff admitted Resident #1 to the Facility in March 2014 and his/her [DIAGNOSES REDACTED].#1 had a long time use of the steroid medication, and Prednisone (side effect osteoporosis). The plan of care related to falls, dated 3/17/14, included: quad cane for ambulation and gait belt and assist with personal care. The Activity of Daily Living/Rehabilitation Potential Care Area Assessment (CAA) report, dated 3/27/14 indicated that Resident #1 had decreased strength, shortness of breath with exertion, and was non weight bearing with his/her right arm related to a fracture. The Fall CAA report, dated 3/27/14, indicated that Resident #1 required limited to extensive assistance with all areas of personal care. The Fall CAA report indicated that Resident #1 had increased pain in the lower extremities, decreased strength, decreased balance, and shortness of breath with exertion. The Admission Minimum Data Set (MDS), completed on 3/27/14, indicated that Resident #1 had no cognitive issues and required staff assistance for ambulation, personal care, and hygiene. The MDS assessment indicated that Resident #1 had a fall prior to his/her admission to the Facility and had impairment of one of his/her upper extremities. The Admission Care Card, used by the certified nurse aides (CNAs) for information regarding their residents indicated that Resident #1 required staff assistance for activities of daily living. The Care Card did not indicate that Resident #1 was to be seated during personal care and hygiene The occupational therapy notes, dated from 4/8/14 to 4/11/14, indicated that Resident #1 completed activities of daily living at the toilet level with minimal staff assistance. The Surveyor interviewed Physical Therapist #1 at 11:52 A.M. on 5/7/14. The Surveyor interviewed the Occupational Therapist at 12:05 P.M. on 5/7/14. Physical Therapist #1 and the Occupational Therapist said Resident #1 could not functionally use his/her right hand and required a quad cane or staff assistance to balance safely. Physical Therapist #1 and the Occupational Therapist said Resident #1 was not able to use his/her right hand for balancing. The Occupational Therapist and Physical Therapist #1 said Resident #1 had muscle spasms in his/her legs. The Occupational Therapist said Resident #1 sat when completing personal care, such as bathing and brushing his/her teeth. The Surveyor interviewed Nurse #1 at 2:45 P.M. on 5/6/14. The Surveyor interviewed Nurse #2 at 4:25 P.M. on 5/6/14. The Surveyor interviewed CNA #2 at 3:50 P.M. on 5/7/14. Nurse #1 and Nurse #2 said the rehabilitation staff did not always include their plan of care on the nursing kardex (used by direct care staff to know a resident's care needs) or plan of care. CNA #2 said sometimes the amount of assistance required by a resident was not listed on the care card. Nurse #1 said she was not aware that Resident #1 had balance issues. Nurse #2 said she was not aware that Resident #1 had issues with his/her legs. The Surveyor interviewed CNA #1 at 2:20 P.M. on 5/7/14. The Surveyor interviewed CNA #6 at 1:55 P.M. on 5/7/14. Nurse #1, Nurse #2, and CNA #1 said they were not aware that Resident #1 was to brush his/her teeth while sitting. Nurse #1, Nurse #2, CNA #1, CNA #2, and CNA #6 said Resident #1's care card did not indicate that Resident #1 was unsafe to stand at the sink and was to complete all personal care and hygiene while seated. Physical Therapist #1 and the Occupational Therapist said standing at the sink without staff support was not a safe activity for Resident #1. The Occupational Therapist said she did not include the information regarding Resident #1's need to be seated during oral hygiene in Resident #1's plan of care and did not notify the nurses and CNAs. The Surveyor interviewed Resident #1 at 10:15 A.M. on 5/6/14. Resident #1 said his/her dominant hand was the right hand. Resident #1 said he/she was not able to use his/her right hand. Resident #1 said on 4/12/14, CNA #1 assisted him/her with personal care on the toilet seat. Resident #1 said afterward, CNA #1 asked him/her if he/she wanted to brush his/her teeth at the sink in the bathroom, and he/she said words to the effect of, "okay." Resident #1 said prior to 4/1/214, he/she brushed his/her teeth while sitting in a chair. Resident #1 said she was not able to hold onto the sink for support with his/her right hand. Resident #1 said he/she began brushing his/her teeth with his/her left hand and was standing independently at the sink. Resident #1 said CNA #1 stood on his/her left side. Resident #1 said someone spoke to CNA #1 and she went to the doorway in the bathroom. Resident #1 said immediately afterward, he/she fell backward and hit his/her back on the tub. CNA #1's written statement, dated 4/15/14 and interview with CNA #1 indicated that on 4/12/14, Resident #1 completed personal care in the bathroom. CNA #1 said she planned to have Resident #1 brush his/her teeth while seated on the toilet. CNA #1 said she asked Resident #1 if he/she wanted to brush his/her teeth and Resident #1 asked if he/she could brush his/her teeth while standing at the sink. CNA #1 said she did not apply a gait belt while assisting Resident #1 to stand or while Resident #1 stood at the sink. CNA #1 said Resident #1 appeared stable and had no balance issues. CNA #1 said she placed toothpaste on the toothbrush and handed the toothbrush to Resident #1. CNA #1 said she stood on the left side of Resident #1. CNA #1 said she heard CNA #2 ask her a question. CNA #1 said she turned and moved a few steps to the entrance to the bathroom and spoke with CNA #2. CNA #1 said although she was within an arms reach of Resident #1, she was not directly observing Resident #1. CNA #1 said within seconds of speaking with CNA #2, she heard Resident #1 gasp. CNA #1 said she turned and observed Resident #1 fall backward and hit his/her back on the tub. CNA #1 said she was not aware that Resident #1 was not safe to stand at the sink without assistance to brush his/her teeth. The nurse's note, dated 4/12/14, indicated that Resident #1 sat on his/her buttock in the bathroom and moved his/her extremities, except his/her right arm. The nurse's note indicated that Resident #1 complained of back discomfort and had a red area on the back. The Emergency Department Radiology report, dated 4/13/14, indicated that Resident #1 had a left fractures of three lumbar vertebra. The Surveyor interviewed the Director of Nurses (DON) at 7:00 A.M. on 5/6/14. The DON said the rehabilitation staff did not always ensure that a plan of care was placed on the care card timely. The DON said there was insufficient information regarding how Resident #1 was to complete personal care in the care card. The DON said CNA #1 did not have a gait belt on Resident #1 per the Facility Policy. The DON said CNA #1 assisted Resident #1 to stand at the sink to brush his/her teeth, which was not a safe activity for Resident #1.

Based on record review and interviews, the facility failed for 3 of 5 residents (#1, #2, and #5) to follow standards of practice when administering medications and reconciling a narcotic count. The facility failed to complete an incident report at the time the medication error was discovered. The facility failed to adequately monitor a nurse, who made a significant medication error, with subsequent medication passes. The nurse made two additional errors on the following two days. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." According to Lippincott's Nursing Center.Com 2008, nurses must: -Administer the right medication to the right patient. -Must check the medication label and order. -Must double check that the right dose is given at the right time. Practice Standards CNO revised 2008 Medication states: -Verify allergies and sensitivities. -Ensure the client receives appropriate monitoring during and after administering the medication administration. 1. For Resident #1, the facility administered [MEDICATION NAME], a medication the resident was allergic to. The resident experienced a decrease in respiratory status, a decreased pulse rate and experienced changes in mental status. The resident required [MEDICATION NAME] to reverse the effects of the [MEDICATION NAME]. The resident experienced nausea, sweating and a rapid pulse after administration of the [MEDICATION NAME]. Resident #1 was admitted to the facility in 8/2013 with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the resident's initial Minimum Data Set (MDS) Assessment of 8/27/13 indicated the resident was cognitively intact, with a score of 15/15 on the Brief Interview of Mental Status (BIMS) exam. The resident required limited assistance of one for transfers, locomotion, dressing and toileting. The resident was continent of bowel and bladder. Review of the resident's 9/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurses' notes from 9/10/13 to 9/29/13 indicated the resident's oxygen saturation levels (the amount of oxygen circulating in the blood) were monitored every shift and remained between 91% to 98% (Normal for a person without the [DIAGNOSES REDACTED]. Review of the nurse's note of 9/30/13 at 9:30 A.M., indicated the resident received [MEDICATION NAME] 0.5 milligrams, as ordered by the physician, for complaints of anxiety. Oxygen saturations were noted to be 95 to 96 % on 0.5 liters of oxygen. Review of the nurse's note of 9/30/13, at 3:30 P.M., indicated the resident was sleepy and arousable. Review of the 9/30/13 nurse's note of 4:00 P.M., indicated the resident was "very hard to arouse with a pulse of 44 beats per minute." The oxygen saturation was noted to be 66% (low even for a resident with [MEDICAL CONDITION] disease). The oxygen was increased to 2 liters. The note indicated the resident responded with a one word response at 5:30 P.M., the pulse was 42 beats per minute and the oxygen saturation was 76% (low for this resident). This note indicates the resident's pulse and oxygen saturations were monitored during the shift. Oxygen saturation levels were 78% at 10:30 P.M. This note indicates the resident was unsteady on his/her feet when toileted with assistance from two staff. This note indicates all medications scheduled for 4:00 P.M. and 8:00 P.M., were held due to lethargy. Review of the nurse's note of 10/1/13 at 8:00 A.M., indicated the resident was very sleepy on the night shift with oxygen saturations of 86% to 91% on 2 liters of oxygen. Review of the nurse's note of 10/1/13 at 10:25 A.M. indicated the residents oxygen saturations were low (between 84-85%). The physician was notified and an order was obtained for [MEDICATION NAME] (a medication used to reverse the side effects of the [MEDICATION NAME]) 0.4 milligrams intramuscularly. Review of the Medication Error Report of 9/30/13 indicated the resident was administered [MEDICATION NAME], extended release 60 milligrams instead of [MEDICATION NAME] 0.5 milligrams. This report did not refer to the resident's allergy to [MEDICATION NAME]. During interview on 10/10/13 at 12:00 P.M., Nurse #1 said that he/she administered [MEDICATION NAME] 60 milligrams Extended Release in error to Resident #1 on 9/30/13 at 10:00 A.M.. Nurse #1 said the error was not discovered until the Narcotic count was completed on 9/30/13 at 3:30 P.M. with Nurse #2. Nurse #1 said that the he/she signed the [MEDICATION NAME] 0.5 out of the Narcotic book at 10:00 A.M., but administered the [MEDICATION NAME] in error. Nurse #1 said the incident report was completed on 9/30/13 at 3:30 P.M., and she notified the MD of the medication error on 9/30/13 at 3:30 P.M. and left the building between 4:00 P.M. and 4:30 P.M. Nurse #1 said the incident report lacked any reference to the resident having an allergy to [MEDICATION NAME] and the fax to the physician did not include the [MEDICATION NAME] allergy. Nurse #1 said that she did not follow the standard of practice for giving medications as she did not compare the medication card and the MAR indicated [REDACTED]. Nurse #1 said that she did not follow the standard of practice for making sure the resident was not allergic to the medication being administered. Nurse #1 said that although the MAR indicated [REDACTED]. Nurse #1 said that consequently the resident was not monitored for an allergic reaction (such as hives, redness, and swelling). Nurse #1 said "the [MEDICATION NAME] and [MEDICATION NAME] look alike and were located next to one another in the medication drawer". During interview on 10/10/13 at 12:00 P.M., Nurse #1 said that she made two additional medication errors after the error on 9/30/13. These errors involved [MEDICATION NAME] and Klonopin and were made on 10/1/13 and 10/2/13. Nurse #1 said that the medication errors were made because she did not compare the medication card to the MAR (per standard of practice and facility policy). Nurse #1 said that despite making 3 medication errors from 9/30/13 to 10/2/13, she continued to pass medications on 10/3/13. Nurse #1 said that she had not had a medication pass observation completed with the Staff Education Nurse after the 3 errors were made. During interview on 10/10/13 at 1:20 P.M., Nurse #5 said that she was the Staff Education Nurse for the facility. Nurse #5 said that she was aware of the 3 medication errors made by Nurse #1 from 9/30/13 to 10/2/13, which involved two errors in [MEDICATION NAME] administration and one error in Klonopin administration. Nurse #5 said that on 10/4/13 she reviewed the Medication Pass Audit with Nurse #1. Nurse #5 said that she scored the Medication Pass Audit as having an error rate of 0%. However, Nurse #5 said that she did not actually do a medication pass observation of Nurse #1. Nurse #5 said that the error rate of 0% was based on what Nurse #1 told her, not on what she observed. According to the score calculation instructions listed on the Medication Pass Audit, the score was to be calculated by observing a medication pass. During interview on 10/10/13 at 3:10 P.M., the Director of Nurses (DON) said that she was aware of the three medication errors involving [MEDICATION NAME] and Klonopin made by Nurse #1 from 9/30/13 to 10/2/13. The DON said that the Medication Pass Audit tool was a tool used to observe a medication pass. She said she was not aware that Nurse #1 was not provided with a Medication Pass Audit observation after the 3 medication errors occurred. The DON said that Nurse #1 had continued passing medications on 10/2/13 and 10/3/13 despite the three medication errors. The DON also said that Nurse #1 had not received an employee evaluation since 2005. The DON said that the facility's policy was to generally evaluate employees' performance on an annual basis. 2. For Resident #2, the facility failed to document the administration of Klonopin and then falsified the Narcotic book to reconcile the count. Resident #2 was admitted to the facility in 9/2012 with [DIAGNOSES REDACTED]. Review of the resident's 9/2013 MAR indicated [REDACTED].M. and 9:00 P.M. Review of the Narcotic Book (page 95) indicated on 9/13/13 a notation that Klonopin 1 milligram was wasted (thrown away and signed as such by three nurses). However, review of the 9/13/13 MAR for Resident #2 indicated that the resident was given Klonopin as ordered at 9:00 A.M. and 9:00 P.M. Review of the Narcotic Count on 9/13/13 between the 3:00 P.M. to 11:00 P.M. and the 11:00 P.M., to 7:00 shift, indicated the count for the Klonopin was listed as correct at 16. The Narcotic Count on 9/14/13 between the 11:00 P.M. to 7:00 A.M. shifts listed the count for the Klonopin as being correct at 16. However, the Narcotic Count on 9/14/13 between the day and evening shift was incorrect. The count was documented as having 15 tablets remaining in count but only 14 tablets were present on 9/14/13 at 3:00 P.M. During interview on 10/15/13 at 10:45 A.M., the DON said she was aware that a Klonopin had been recorded as wasted on page 95 on the Narcotic Book at 3:00 P.M. on 9/14/13. However, the DON was not aware that the count had been recorded as correct on 9/13/13 at 11:00 P.M. and on 9/14/13 at 7:00 A.M., but in fact one Klonopin tablet was missing at these counts as well. The DON said that this indicated the nurses may not have been doing count or not doing count correctly. During interview on 10/15/13 at 2:00 P.M., Nurse #3, on duty on 9/14/13 7:00 A.M. to 3:00 P.M., said that she did not do count according to standards of practice on 9/14/13 at 7:00 A.M. as she did not look at the medication card to determine how many tablets of Klonopin remained. Nurse #3 said that she falsified page 95 of the Narcotic book to make it appear as if a Klonopin tablet was wasted. Nurse #3 said no Klonopin tablet was wasted. During interview on 10/15/13 at 2:30 P.M., Nurse #7, the 3:00 P.M. to 11:00 P.M. nurse on 9/14/13, said that when she did the count with Nurse #3 the count was short one tablet. Nurse #7 said that she and Nurse #3 decided to sign page 95 in the narcotic book stating that they had wasted (thrown away) the Klonopin. Nurse #7 said that she was aware that there was no Klonopin tablet to waste. 3. For Resident #5, the Facility failed to follow the standard of practice for medication administration errors. Although Nurse #1 discovered the medication error, she did not complete an incident report at the time the error was discovered. Resident #5 was admitted to the Facility in 9/2013 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the 10/2013, Routine Medication Record, indicated that Resident #5 did not receive the scheduled dose [MEDICATION NAME] on 10/2/13 at 9:00 A.M. There was no documentation of the reason for the omission of the dose of [MEDICATION NAME]. Review of the nurse's notes of 10/2/13 indicated no documentation regarding the omitted dose of [MEDICATION NAME]. Review of the Medication Errors and Drug Reactions Policy indicated: "Report all medication errors and drug reactions immediately to the attending physician, Director of Nursing Service, and Administrator." Review of the Medication Error Report of 10/2/13 indicated that the medication error occurred at 9:00 A.M., the Director of Nursing was notified on 10/2/13 with no time noted, and the physician was notified by fax at 10:00 P.M. There was no indication that the Administrator was notified. The report was signed as completed on 10/2/13, during the 3:00 P.M.-11:00 P.M. shift, by Nurse #2. Nurse #1 was requested to fill out a Medication Error Report by Nurse #2, and neglected to do so. The report was filled out by Nurse #2. During a discussion with Nurse #1 on 10/15/13 at 9:50 A.M., Nurse #1 said 10/2/13 was a busy day, and she did not know why she did not administer the scheduled dose of [MEDICATION NAME] to Resident #5. Nurse #1 further stated that she did not fill out a medication error report regarding the omission of the [MEDICATION NAME] prior to leaving, as requested, by Nurse #2.

Based on record review and interviews, the facility failed for 3 of 5 residents (#1, #3, and #5) to insure the residents were free from significant medication errors. Findings include: 1. For Resident #1, the facility administered [MEDICATION NAME] Extended Release 60 milligrams by mouth. The resident did not have an order for [REDACTED]. The resident required [MEDICATION NAME] to reverse the effects of the [MEDICATION NAME]. Following the administration of [MEDICATION NAME], the resident experienced a rapid pulse rate, nausea and sweating. Resident #1 was admitted to the facility in 8/2013 with [DIAGNOSES REDACTED]. Review of the resident's initial Minimum Data Set (MDS) Assessment of 8/27/13 indicated the resident was cognitively intact with a score of 15/15 on the Brief Interview of Mental Status (BIMS) exam. The resident required limited assistance of 1 for transfers, locomotion, dressing and toileting. The resident was continent of bowel and bladder. Review of the admission orders [REDACTED]. Review of the resident's 9/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurses' notes from 9/10/13 to 9/29/13 indicated the resident's oxygen saturation levels (the amount of oxygen circulating in the blood) were monitored every shift and remained between 91% to 98% (Normal for a person without the [DIAGNOSES REDACTED]. Review of the nurse's note of 9/30/13 at 9:30 A.M., indicated the resident received [MEDICATION NAME] 0.5 milligrams as ordered by the physician, for complaints of anxiety. Oxygen saturations were noted to be 95 to 96 % on 0.5 liters of oxygen. Review of the nurse's note of 9/30/13 at 3:30 P.M., indicated the resident was sleepy and arousable. Review of the 9/30/13 nurse's note at 4:00 P.M., indicated the resident was "very hard to arouse with a pulse of 44 beats per minute". The oxygen saturation was noted to be 66% (low even for a resident with [MEDICAL CONDITION] disease). The oxygen was increased to 2 liters. The note indicated the resident responded with a one word response at 5:30 P.M., the pulse was 42 beats per minute and the oxygen saturation was 76% (low for this resident). This note indicates the resident's pulse and oxygen saturations were monitored during the shift. Oxygen saturation levels were 78% at 10:30 P.M. This note indicates the resident was unsteady on his/her feet when toileted with two staff. All medications scheduled for 4:00 P.M., and 8:00 P.M., were held due to lethargy. Review of the nurse's note of 10/1/13 (time 8:00 A.M.), indicates the resident was very sleepy on the night shift with oxygen saturations of 86% to 91% on 2 liters of oxygen. Review of the nurse's note of 10/1/13 at 10:25 A.M. indicated the residents oxygen saturations were low 84-85%. The physician was notified and an order was obtained for [MEDICATION NAME] (a medication used to reverse the side effects of the [MEDICATION NAME]) 0.4 milligrams intramuscularly. Following the administration of [MEDICATION NAME], the resident experienced nausea, sweating, and [MEDICAL CONDITION] Review of the Medication Error Report (of 9/30/13) indicated the resident was administered [MEDICATION NAME], extended release 60 milligrams instead of [MEDICATION NAME] 0.5 milligrams. During interview on 10/10/13 at 12:00 P.M., Nurse #1 said that he/she administered [MEDICATION NAME] 60 milligrams Extended Release in error to Resident #1 (9/30/13 at 10:00 A.M.) During interview on 10/10/13 at 3:10 P.M., the DON said that she was aware of the [MEDICATION NAME] error made by Nurse #1 on 9/30/13. The DON said that the resident required [MEDICATION NAME] after the administration of [MEDICATION NAME]. 2. Resident #3 was admitted to the facility in 7/2011. Review of the signed Physician order [REDACTED]. (milligrams) 1 tablet by mouth every other day. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 1 tablet by mouth every day and not every other day, as ordered by the physician. During interview with the Director of Nursing on 10/10/13 at 2:35 P.M., she said she was aware of the [MEDICATION NAME] errors, between 3/1/13 and 3/13/13, made by multiple nurses. 3. For Resident #5, the Facility failed to provide a scheduled dose of [MEDICATION NAME] (narcotic pain medication). Resident #5 was admitted to the Facility in 9/2013 with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the 10/2013, Routine Medication Record, indicated that Resident #5 did not receive the scheduled dose [MEDICATION NAME] on 10/2/13 at 9:00 A.M. Review of the Medication Error Report of 10/2/13 indicated that the medication error occurred at 9:00 A.M. During a discussion with Nurse #1 on 10/15/13 at 9:50 A.M., Nurse #1 said that 10/2/13 was a busy day and she did not know why she did not administer the scheduled dose of [MEDICATION NAME] to Resident #5.