Every finding on record at Premier Healthcare at Harrington House

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had reported to nursing at breakfast time and again at lunch time, that he/she was unable to grasp his/her utensil which was a change for him/her, the Facility failed to ensure nursing notified his/her Physician and Health Care Proxy (Family Member #1) in a timely manner of his/her change in condition. Resident #1 was subsequently transferred to the Hospital Emergency Department (ED) around dinner time for evaluation of his/her complaints and was admitted .Findings include:Review of the Facility Policy titled Notification of Changes, dated as last revised 10/2025, indicated to promptly inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident's representative when there is a change requiring notification.The Policy indicated the Facility must consult with the resident's physician and notify the resident's legal representative when there is a significant change in the resident's physical, mental or psychosocial condition and circumstances that require a need to alter treatment.Resident #1 was admitted to the Facility in March 2024, diagnoses include paraplegia (partial or complete paralysis of the lower half of the body), diabetes mellitus, a chronic stage four (IV) pressure injury, obstructive uropathy with a chronic indwelling catheter (flexible tube inserted into the bladder to drain urine) in place, and a history of bilateral Deep Vein Thrombosis (DVT's).Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE], indicated that his/her Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating he/she was cognitively intact (13-15 indicates cognitively intact, 8-12 indicates moderately impaired cognition, and 0-7 indicates severe cognitive impairment).During an interview on 07/01/26 at 1:49 P.M., Resident #1 said on 05/11/26 right after breakfast he/she informed his/her nurse (later identified as Nurse #1), that he/she was unable to hold any utensils in his/her right hand. Resident #1 said Nurse #1 asked him/her to squeeze both of his/her hand, Resident #1 said he/she did. Resident #1 said at lunchtime he/she had to ask for a sandwich because he/she still could not grasp and hold his/her utensils and was unable to eat the lunchtime meal that had been served because it required utensils.Resident #1 said after returning from lunch another nurse and the head nurse (later identified as the Unit Manager and the Director of Nurses), came to him/her room and asked him/her to squeeze his/her hands as well as some other things to evaluate him/her.Resident #1 said he/she heard the Director of Nurses (DON) say they were going to do a telehealth appointment with his/her provider, however Resident #1 said that did not happen.Resident #1 said his/her daughter (Family Member #1, Health Care Proxy, HCP) came in to visit at suppertime, and he/she informed her that he/she had been having difficulty since breakfast grasping his/her utensils. Resident #1 said as soon as his/her daughter looked at him/her, she thought he/she was having a stroke, the evening nurse (later identified as Nurse #2) then called the Physician, Emergency Medical Services (EMS) and then he/she was sent out to the Hospital.During a telephone interview on 06/30/26 at 2:12 P.M., Family Member #1 said on 05/11/26, she had gone to visit her parents (Resident #1 and roommate are married) and said when she walked into their room, she was not looking directly at Resident #1 because he/she was watching television and his/her face was not visible.Family Member #1 said Resident #1 informed her he/she was having trouble all day grasping items and that he/she said he/she had reported it right after breakfast and then again after lunch to his/her nurse. Family Member #1 said, prior to arriving at the facility around dinnertime to visit with Resident #1, she had not been notified by nursing that he/she had reported earlier that day that he/she was not able to hold his/her utensils.Family Member #1 said she looked at Resident #1's face and noticed he/she had right sided facial drooping and knew something was wrong. Family Member #1 said Nurse #2 assessed Resident #1 right away, called the Physician, EMS, and Resident #1 was transferred to the ED.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had suffered an acute Cerebral Vascular Accident (CVA) with right upper extremity weakness and right facial droop with associated dysarthria (difficulty with articulation).During a telephone interview on 07/01/26 at 2:10 P.M., Nurse #1 said on 05/11/26 Resident #1 reported to him that he/she was unable to grasp his/her utensils during breakfast. Nurse #1 said Resident #1 could eat independently after being set-up and said not being able to grasp his/her utensil was a change from his/her baseline.Nurse #1 said he assessed Resident #1, asked him/her to squeeze both hands (equal strength noted) and said he told Resident #1 he would have occupational therapy evaluate him/her for the potential need for weighted utensils.Nurse #1 said later that afternoon, another staff member asked him to assess Resident #1 again, specifically checking his/her face for right facial drooping. Nurse #1 said he asked Resident #1 to smile and said the left side of his/her face went up however the right side did not go up when he/she smiled.Nurse #1 said that he had not called the Physician after his first evaluation because he felt Resident #1's hand grasps were equal. Nurse #1 said after the second assessment, he felt since Resident #1's face was asymmetrical (opposite side do not match) to begin with, and he could not tell if his/her inability to fully smile was new or his/her baseline.Nurse #1 said he should have notified Resident #1's physician and Family Member #1 (HCP) upon the discovery of a significant change in his/her baseline condition.During an in-person interview on 07/01/26, the Unit Manager said on 05/11/26, after breakfast, Resident #1 informed her he/she was unable to use his/her motorize electric wheelchair because his/her right hand was feeling funky and he/she could not grasp the joystick (controls motion and movement of wheelchair). The Unit Manager said she observed Resident # 1 not being able to engage his/her motorize wheelchair because of his/her right-hand weakness and he/she needed to have his/her wheelchair pushed manually by staff.The Unit Manager said she informed Nurse #1 of her discussion with Resident #1 and asked Nurse #1 to assess him/her. The Unit Manager said she also informed the Director of Nurses (DON) and asked her to assess Resident #1 as well.The Unit Manager said if she had been Resident #1's nurse, she would have assessed him/her herself and notified his/her physician and Family Member #1 (HCP) of the changes.During a telephone interview on 07/02/26, Resident #1's Nurse Practitioner (NP) said after his/her second report of right-hand weakness and any concern about facial drooping, nursing staff should have called to inform the providers of Resident #1's changes. The NP said something was clearly going on with him/her and said she would have had nursing send Resident #1 to the ED at that time. During an interview on 07/01/26 at 3:38 P.M., The Director of Nurse (DON) said on 05/11/26, sometime after lunch, she was asked to assess Resident #1 by the Unit Manager because he/she had reported that he was unable to independently use his/her motorize electric wheelchair.The DON said that she reported her assessment of Resident #1 to the Unit Manger and said perhaps they could do a telehealth visit with his/her provider.The DON said that she was not aware Resident #1 had reported he/she was unable to use his/her right-hand during breakfast due to being unable to grasp the utensils.The DON said if she had been aware of Resident #1's initial complaint of not being able to hold the utensils, reported to Nurse #1, she would have asked if he (Nurse #1) had informed the physician of the resident's change.The DON said it is the Facility's expectation that nursing must notify the residents physician and responsible party of changes in status in a timely manner.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#7), out of a total sample of 18 residents, was offered devices (hearing aids or amplifier) to assist with communication.Findings include:Resident #7 was admitted to the facility in June 2025 with diagnoses of dementia and hearing loss. Review of the care plans indicated Resident #7 had impaired communication related to hearing loss. Review of the Resident Evaluation (a facility assessment), dated 3/5/26, indicated Resident #7 had a hearing impairment and no hearing aids. During an attempted interview on 4/26/26 at 8:45 A.M., Resident #7 could not hear the surveyor and pointed to his/her ears. The surveyor inquired loudly if the Resident had hearing aids and pointed to the ears, the Resident responded, I'd love to have something for my ears. I saw a doctor, but then nothing happened. During an interview on 4/26/26 at 11:30 A.M., the Family Member for Resident #7 said the Resident had three sets of hearing aids when admitted to the facility and the family had sent an amplifier (a box for someone to speak into which connects to headphones the Resident wears to amplify the voice). He said the staff should be using the hearing aids or the amplifier. Review of the medical record included a list of items Resident #7 had including clothing, glasses, hearing aid, charger for hearing aid, phone and phone charger. Review of the progress notes indicated the following:7/13/25: Hearing aids at bed side.12/22/25: Resident very hard of hearing and on observation ear seems to be blocked with wax. Resident oriented to self and repeats questions due to inability to hear. Physician contacted for ear drops.12/23/25: Care plan meeting held and the family inquired if they could send a hearing amplifier. Further review of the orders, care plans, and progress notes had no mention of Resident #7 being assisted with hearing aids or amplifier use or their effectiveness. Review of the consultant Audiology Group progress note, dated 1/16/26, indicated Resident #7 needed wax removed from both ears, there was a speech discrimination related to profound hearing loss and Resident #7 would like to try hearing aids and impressions could be taken once wax was removed. Review of the medical record indicated Resident #7 saw an Otolaryngologist (physician specialized in hearing loss) on 3/19/26. Review of the visit summary indicated bilateral wax (cerumen) impaction was removed. On 4/27/26 at 10:02 A.M., the surveyor observed an amplifier on the nightstand in the room of Resident #7. On 4/27/26 at 10:07 A.M., the surveyor observed Resident #7 seated in the hallway as Activity Assistant #1 approached. The Activity Assistant provided Resident #7 with a cup of coffee, told the Resident the coffee was hot and asked if the Resident would like to add ice. When the Resident did not respond the Activity Assistant asked louder and demonstrated with her hand adding something to the coffee while saying the word ice. The Resident responded, No, I like it black. On 4/27/26 at 1:01 P.M., the surveyor observed another resident attempt to talk to Resident #7 and become more animated as Resident #7 did not respond. Resident #7 yelled what do you want and pointed to his/her ears. On 4/27/26 at 1:10 P.M., the surveyor observed Resident #7 tell Unit Manager #2 that he/she had to go to the bathroom. The Unit Manager responds, Give me a minute and I'll help you and Resident #7 pointed to his/her ears. On 4/27/26 at 1:42 P.M., Activity Assistant #1 attempted to engage Resident #7 in a conversation about animals and repeated herself three times. Resident #7 responded huh and pointed to his/her ears. During an interview on 4/27/26 at 1:47 P.M., Activity Assistant #1 said Resident #7 did have trouble hearing and would point to their ears to indicate they could not hear you. She said she was not sure if the Resident had heard her this morning asking about ice in the coffee. She said she was not sure if Resident #7 had hearing aids or any other devices and it would be better to ask one of the Certified Nursing Assistants (CNA). During an interview on 4/27/26 at 2:15 P.M., CNA #1 said Resident #7 was hard of hearing and she had to speak loud to the Resident. She said Resident #7 did have hearing aids, but she was not sure why they were not used. She said he/she did not use any other devices. During an interview on 4/27/26 at 4:09 P.M., Nurse #1 said she was familiar with Resident #7 and worked on the unit regularly. She said the Resident was hard of hearing and she believed the Resident previously had hearing aids but she did not know where they were. She said she was not putting in the hearing aids or taking them out. During an interview on 4/28/26 at 8:20 A.M., Unit Manager #2 said Resident #7 previously had hearing aids but refused to wear them. She said she did not think the hearing aids were at the facility any longer. She said there was no documentation to indicate the hearing aids had been tried or refused by the Resident. She said the Resident did have an amplifier and the Resident used it sometimes. She said all staff should be attempting to use the amplifier with the Resident. She said no one had attempted to use the hearing aids after the wax was removed on 3/19/26, one month prior because the Unit Manager did not know if there were hearing aids in the facility for the Resident. During an interview on 4/28/26 at 11:54 A.M., Unit Manager #2 said she had found hearing aids in Resident #7's room. She said no, staff had not been trying to provide them to the Resident because the Unit Manager did not know they were there and had thought the Resident only had an amplifier.

Based on interview and record review, the facility failed to ensure an antibiotic was effective in treating the identified bacteria after the culture and sensitivity (C&S) report indicated high level of resistance and failed to notify physician of ongoing urinary tract symptoms for one Resident (#33), out of a total sample of 18 residents. Findings include: Review of facility's policy titled Antibiotic Stewardship Program., dated 5/20/25, indicated but was not limited to the following:-It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.-The program includes antibiotic use protocols and system to monitor antibiotic use.Monitoring antibiotic use.:-Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., Antibiotic timeout).-Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48 to 72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on findings. Resident #33 was admitted to the facility in October 2025 with diagnoses which included cerebral vascular infarction (stroke), generalized weakness, and morbid obesity. Review of the Minimum Data Set (MDS) assessment, dated 4/21/26, indicated Resident #33 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident was cognitively intact. During an interview on 4/26/26 at 8:30 A.M., Resident #33 said he/she was on antibiotics because of another urinary tract infection (UTI). During an interview on 4/27/26 at 1:18 P.M., Resident #33 said he/she still has strong burning with urination. Resident #33 said this past weekend he/she told the overnight nurse (Nurse #6) he/she was having pain in the urethra area, abdominal cramping, flank pain, and he/she had to ask for pain medication. Resident #33 said if it does not get better he/she will have to go to the hospital because he/she only has one kidney and must be careful with UTIs. Review of Resident #33's Lab Results Report, dated 4/22/26, indicated but was not limited to the following:Abnormal results:-Appearance: Turbid -White blood cell: 3+-Protein:2+ -Occult Blood: 2 +Microscopic was indicated and was performed:-WBC: >30-RBC: >30Bacteria: ManyUrine Culture, Urology Workup: Final report abnormal:Proteus mirabilis/penneri 25,000-50,000 cfu's.Antimicrobial Susceptibility:-Trimethoprim/sulfa (Macrobid) Resistant >=320 Review of Resident #33's Physician Note completed by Physician #1, dated 4/20/26, indicated but was not limited to the following:-Chief complaint/Nature of presenting problem: Patient seen for acute visit for evaluation of dysuria and urinary urgency, as well as follow up of recent lower extremity swelling and duplex ultrasound.-Over the past several days, patient has reported persistent dysuria and urinary urgency, consistent with his/her prior UTI symptoms. Urinalysis (UA) from 4/19/26 notable for Turbid urine, 3+ leukocyte esterase, >30 white blood cells (WBC), >30 red blood cells (RBC), and many bacteria. -Preliminary urine culture growing Proteus mirabilis (25-50 thousand colony forming unit per milliliter (CFU/ml). Despite borderline colony count, patient remains clinically symptomatic.-Urinary tract infection; Urinalysis strongly suggestive of infection. -Plan: Start Bactrim DS twice a day (BID) times 7 days. Encourage hydration. Monitor symptoms closely. Follow final culture and sensitivities and adjust antibiotics if needed. -Monitor for fever or worsening symptoms. Review of Physician's Orders indicated:-4/20/26 Bactrim DS (antibiotic) oral tablet 800-160 milligram (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth two times a day for dysuria (pain, discomfort, or burning with urination), UTI until 4/26/26.-4/28/26 Cefpodoxime Proxetil (antibiotic) oral Tablet 100 mg, give one tablet by mouth two times a day for UTI for seven days. Review of Medication Administration Record (MAR) indicated Resident #33 completed the course of antibiotic Bactrim 800-160 mg, receiving 14 doses from 4/20/26 through 4/26/26. Review of Resident #33's current Care Plan indicated but was not limited to the following:1. Incontinence: Resident has a potential for complications associated with bowel and urinary incontinence, dated 10/24/25.-Report any changes in bladder or bowel status to nurse such as: Low urine output, foul smelling urine, discolored urine, pain, bladder dissension, frequency, urgency, date initiated 10/24/25.-Report change in bladder status to physician, date initiated 10/24/25.2. The resident is at risk for infection Related to: History of recurrent UTIs-prophylactic treatment in place pending urinalysis and culture results, Date initiated 4/28/26.-Monitor for worsening symptoms of infection and notify the physician, Date initiated 4/28/26. Review of Resident #33's Nursing Notes indicated the following:1. 4/20/26 at 2:41 P.M., Resident #33 evaluated for infection this date related to new antibiotics orders placed by Physician #1. Resident #33 recently complained of dysuria, pain in urinating and frequency. Urinary analysis with culture and culture and sensitivity (UA/CS) completed with no new findings noted. -Resident #33 does not meet meagers (sic) criteria for antibiotic use at this time. -Physician #1 aware continue antibiotic therapy with Bactrim DS 800-160 BID a day, times five days. Note written by Unit Manager #1.2. 4/24/26 at 7:29 A.M., Patient did complain of pain during shift, also discomfort with urinating, advised he/she has a UTI and is on antibiotic treatment, urine in brief is yellow with strong odor, no blood noted, patient does not have any pain to the flank or back area when assessed. Patient did not want to go to the emergency room for further evaluation and stated if it gets worse he/she will let the nurse know. Written by Nurse #6.3. 4/27/26 at 1:38 P.M., Resident reported to this nurse of continuing burning while urinating and right flank and lower abdominal cramping. Upon assessment, there was no redness or irritation in the perineal area, no distension noted. No signs of trauma noted at this time. Resident has completed recent antibiotic therapy for UTI, message left for Physician #1 with Resident's concerns and nurse finding. Note written by Nurse #4.-4/27/26 at 1:47 P.M., Physician #1 consulted regarding urinary symptoms new orders received to repeat urinalysis and urine culture with sensitivity. Resident in agreement at this time. Note written by Nurse #4.During an interview on 4/27/26 at 1:25 P.M., Nurse #4 said he works four days a week and he is aware Resident #33 had a UA/CS which was not positive with less than 100,000 (cfu), but Resident #33 was started on antibiotics because of his/her symptoms of dysuria. Nurse #4 said there was never a CS because the urine was negative. Nurse #4 said he was not aware Resident #33 still had symptoms. During an interview on 4/27/26 at 1:25 P.M., with Nurse #4 present, Resident #33 said he/she had burning with urination this morning and pain over the weekend with urination. Resident #33 asked Nurse #4 if he/she was still on an antibiotic. Nurse #4 said no, you finished it last night. Resident #33 said then maybe he/she should go to the hospital for IV antibiotics because he/she can't take a chance with one kidney. Nurse #4 said the Nurse Practitioner is coming in tomorrow, we will wait and see what she says. During a telephonic interview on 4/27/26 at 1:42 P.M., Lab Contractor Manager (LCM) #1 said Resident #33's urinalysis was collected on 4/17/26 and the final report was sent 4/22/26. LCM #1 said Bactrim was not sensitive to bacteria and said it was most resistant, meaning it was resistance to the bacteria organism at the highest number of 320 (Antibiotic was not sensitive to Proteus mirabilis). During a telephonic interview on 4/27/26 at 1:51 P.M., Physician (MD) #1 said the urine results initially came back and she was not sure if Resident #33 was infected or colonized with bacteria but started Resident #33 on antibiotics because of his/her symptoms. MD #1 said she was not aware of the C&S results until today, the facility did not call her and she admits she should have looked at them herself. MD #1 said she was looking at the C&S now and the bacteria was not susceptible to Bactrim. MD #1 said she was not aware Resident #33 had ongoing urinary tract symptoms of burning with urination, or symptoms over the weekend. MD #1 said she would probably start Resident #33 on a stronger antibiotic knowing the antibiotic he/she was on was not effective and the Resident is still having symptoms. During an interview on 4/28/26 at 10:19 A.M., Resident # 33 said he/she still has burning with urination, and they just started him/her on a new antibiotic twice a day for seven days. During an interview on 4/28/26 at 3:14 P.M., Unit Manager (UM) #1 said once the lab returns the culture and sensitivity (CS) report, the nurse calls the doctor to notify them of the results and writes a nursing note. UM #1 was not aware Resident #33 had complaints of urinary pain over the weekend. UM #1 said the nurse should have notified the doctor of the persisting symptoms. During an interview on 4/28/26 at 3:10 P.M., the Director of Nursing (DON) said she is now aware of an issue with an antibiotic for Resident #33. The DON said when lab results come back in the building the nurse should call and fax the results to the physician for review. The DON said in this case the lab report indicated Physician #1 reviewed the lab results on 4/22/26 at 5:00 P.M. and didn't make any changes. The DON said it was out of her scope of practice to call and confirm the doctor wants to continue the medication even if it wasn't sensitive. The DON said she was not aware that Physician #1 had said to the surveyor she was aware of the culture and sensitivity report and the new lab system was hard to see the results. The DON said she was aware of the nursing note over the weekend which indicated Resident #33 was still having urinary tract pain overnight. The DON said she was not aware of the physician being notified of the continued symptoms. During an interview on 4/28/26 at 3:56 P.M., Nurse #6 said she was not aware the antibiotic Resident #33 was on was not sensitive to the bacteria on the C&S report. Nurse #6 said she just thought Resident #33 was already on an antibiotic and she told the Resident to push fluids and offered to send the Resident to the hospital, but he/she declined. Nurse #6 said she would normally notify the doctor and pass it on in report, but she can't remember if she did. Nurse #6 said she just got in report that Resident #33 is on a new antibiotic. Refer to F881

Based on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of two nurses observed during the medication pass made three errors out of 31 opportunities, resulting in a medication error rate of 9.68%. Those errors impacted two Residents (#68 and #32). Specifically:a. For Resident #68, the nurse administered the wrong aspirin and failed to administer a lidocaine patch (local anesthetic for pain management) as ordered; andb. For Resident #32, the nurse administered the wrong aspirin. Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to the following:Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers. Review of the facility's policy titled Medication Administration, dated as last revised 5/2025, indicated but was not limited to the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection-Review medication administration record (MAR) to identify medication to be administered.-Compare medication source with MAR to verify medication name, form, dose, route and time.-Administer medication as ordered.-Sign MAR after administered. a. Resident #68 was admitted to the facility in October 2025 with diagnoses including hypertensive retinopathy (damage to the retina due to hypertension) and chronic pain. On 4/27/26 at 8:31 A.M., the surveyor observed Nurse #3 prepare and administer Resident #68's scheduled 9:30 A.M., medications which included:- Enteric Coated (EC) Aspirin 81milligrams (mg) tablet, one tablet. Review of the Physician's Orders indicated but were not limited to the following:-Aspirin 81 Oral Tablet Chewable 81mg give one tablet by mouth one-time a day related to hypertensive retinopathy (revised 4/6/26).-Lidocaine External Patch 4% apply to back topically one time a day for chronic pain and remove per schedule (revised 4/6/26).Nurse #3 failed to administer the correct form of aspirin.Nurse #3 failed to administer the lidocaine patch. Review of the MAR indicated but was not limited to the following:-Aspirin 81mg oral tablet Chewable was signed off as administered.-Lidocaine External Patch 4% was signed off as administered. During an interview on 4/27/26 at 3:10 P.M., Family Member #1 observed Resident #68's lower back and said there is no patch in place. He/she said the Resident usually has a patch on his/her lower back and does not today.During an interview on 4/27/26 at 3:21 P.M., Nurse #3 said she administered the lidocaine patch to Resident #68 later in the day. She said she does not remember the exact time; however, she documented it when she administered it. Nurse #3 said she does not know why she gave EC aspirin instead of chewable aspirin. She said they are not the same medication.Review of the Medication Administration Audit Report for Resident #68 indicated but was not limited to the following:-Aspirin 81mg oral tablet Chewable administered on 4/27/26 at 8:37 A.M.-Lidocaine External Patch 4% administered on 4/27/26 at 8:31 A.M. b. Resident #32 was admitted to the facility in November 2015 with diagnoses which include hypertension and hyperlipidemia (high cholesterol).On 4/27/26 at 9:06 A.M., the surveyor observed Nurse #2 prepare and administer Resident #32's scheduled morning medications which included:- EC Aspirin 81mg tablet, one tablet.Nurse #2 failed to administer the correct form of aspirin. Review of the Physician's Orders indicated but were not limited to the following:-Aspirin Tablet Chewable 81mg Give one tablet by mouth one time a day for reduce cardiac event (revised 3/18/26). Review of the MAR indicated but was not limited to the following:-Aspirin Tablet Chewable 81mg was signed off as administered. During an interview on 4/27/26 at 2:23 P.M., Nurse #2 said the dose of the aspirin is the same, it was only the kind of aspirin that was different. She said she will notify her supervisor of the error. During an interview on 4/28/26 at 1:34 P.M., the Director of Nursing (DON) said her expectations are for all medications to be administered as ordered by the physician. She said EC aspirin and chewable aspirin are different medications. DON said the lidocaine patch should have been administered to the Resident when documented as given.

Based on observations, interviews, and document review, the facility failed to ensure medications with a shortened expiration date were properly labeled once opened, in one of two medication carts observed. Findings include:Review of the facility's policy titled Medication Storage, dated 05/2025, indicated but was not limited to:-Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the facility's policy titled [Medication Management Company Name], Medications with Shortened Expiration Dates, dated 2025, indicated but was not limited to:-Once these products are opened, they must be used within a specific timeframe to avoid reduced stability and sterility and potentially, reduced efficacy. These medications should be labeled in such a way that the Beyond Use Date is securely attached to a part of the package and will not be discarded. Beyond use dating can be found in the product's package insert under the How Supplied/Storage and Handling section.-Clinical education provided by [Medication Management Company Name]'s LTC pharmacy divisions, Remedi and ProCare [sic].-Injectable Diabetes Medications - Insulins:a. Brand Name: Novolog mix 70/30; Stability, in Use, Room Temperature: Vial 28 days;b. Brand Name: Lantus; Stability, in Use, Room Temperature: Vial 28 days. On 4/26/26 at 10:10 A.M., the surveyor and Nurse #5 inspected the medication cart on Unit 200 Hall A and observed the following:-one partially used vial of Novolog insulin labeled with a resident name with no opened or discard date;-one partially used vial of Lantus insulin with no resident name and no opened or discard date. During an interview on 4/26/26 at 10:10 A.M., Nurse #5 said opened insulin vials should be labeled with the open date and discard date and there was a chart in the medication storage room that indicated the timeframes for medications with shortened expiration dates. Nurse #5 said the Novolog and Lantus insulin vials had a shortened expiration date of 28 days once opened. During an interview on 4/26/26 at 10:40 A.M., Unit Manager #2 said insulin vials should be labeled with the date they were opened and the discard date. During an interview on 4/28/26 at 12:25 P.M., the Director of Nursing said the Novolog and Lantus have shortened expiration dates and should have been labeled with the open and discard date upon opening.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to follow proper hand hygiene protocols while administering medications for two Residents (#5 and #68), out of three residents observed during medication administration.Findings include:Review of the facility's policy titled Hand Hygiene, dated as revised 9/2025, indicated but was not limited to the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.-If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the hand hygiene table- before preparing or handling medications. Review of the facility's policy titled Medication Administration, dated as last revised 5/2025, indicated but was not limited to the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection-Wash hands prior to administering medication per facility protocol and product. On 4/27/26 at 8:31 A.M., the surveyor observed Nurse # 3 approach her medication cart and began taking medications out of the cart and placing them in a clear plastic medication cup. Nurse #3 did not perform hand hygiene prior to prepping the medications. She poured a cup of water and brought the medications and the water into Resident #68's room and administered the medications to Resident #68. Nurse #3 then entered the Resident's bathroom and took a piece of toilet paper off the toilet paper roll and returned to her medication cart in the hallway. She placed the piece of toilet paper on top of her medication cart, opened the top drawer, removed a bottle of eye drops and donned (put on) gloves. Nurse #3 did not perform hand hygiene after administering the medications or prior to donning gloves. Nurse #3 took the piece of toilet paper and the bottle of eye drops, entered Resident #68's room and administered the eye drops to Resident #68. Nurse #3 handed the Resident the piece of toilet paper. Resident #68 dabbed her eyes with the piece of toilet paper. On 4/27/26 at 8:43 A.M., the surveyor observed Nurse #3 begin taking medications out of the cart and placing them in a clear plastic medication cup. Nurse #3 did not perform hand hygiene prior to prepping the medications. She placed a scoop of applesauce on top of the medications and poured a cup of water and brought the medications and the water into Resident #5's room. Nurse #3 administered the medications to the Resident. During an interview on 4/27/26 at 8:54 A.M., Nurse #3 said she thought she completed hand hygiene prior to giving medications and must have forgotten. She said she needed to put on gloves to administer eye drops and should have done hand hygiene prior to putting them on. Nurse #3 said she usually uses the hand sanitizer on her medication cart or the pump on the wall and does not know why she did not do it. During an interview on 4/28/26 at 1:34 P.M., the Director of Nursing (DON) said her expectations are for hand hygiene to be completed prior to preparing medications and donning gloves. The DON said the nurse should have given the Resident a tissue that was not taken out of the bathroom off the exposed toilet paper roll to reduce the risk of cross-contamination.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Specifically, the facility failed to ensure:1. Resident #33 received an antibiotic that was effective in treating an infection following a culture and sensitivity; and2. Resident #27's antibiotic use was reviewed for appropriateness for continued use following a culture with no growth of bacteria identified. Findings include:Review of the facility's policy titled Antibiotic Stewardship Program, revised May 2025, indicated the following:-the purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotics-the Director of Nursing uses their influence as nurse leaders to help ensure antibiotics are prescribed only when appropriate-monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g. antibiotic time-out).-nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings Review of the facility's policy titled Infection Surveillance, revised May 2025, indicated the Registered Nurses (RN) and Licensed Practical Nurses (LPN) participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff. Examples of notification of triggers include, but are not limited to microbiology test results show drug resistance. 1.Resident #33 was admitted to the facility in October 2025. Review of the medical record indicated Resident #33 was tested for a urinary tract infection (UTI) on 4/17/26 related to painful urination. Review of the Physician Progress Note, dated 4/20/26, indicated based on the urinalysis and symptoms Resident #33 was started on an antibiotic of Bactrim DS (double strength) 800-160 mg (milligrams) twice per day for seven days. Review of the culture and sensitivity, dated 4/22/26, indicated the antibiotic Bactrim DS was not effective in treating Resident #33's infection. During an interview on 4/27/26 at 1:51 P.M., Physician #1 said when the initial urine results came back, she initiated an antibiotic (4/20/26) for Resident #33 based on reported symptoms and was unsure if the Resident was infected or colonized with bacteria. She said she was not aware of the results of the culture and sensitivity until the surveyor inquiry and was reviewing them on this day. She said the facility had not called her to let her know the bacteria was resistant to Bactrim DS. She said the antibiotic Resident #33 was receiving was not effective. During an interview on 4/28/26 at 11:14 A.M., the Director of Nurses (DON) said she was the infection preventionist. She said the process for suspected UTIs was for the nursing staff to complete an infection assessment and inform the physicians of the results of the assessment. She said if a resident presents with symptoms the physician will wait for laboratory results prior to starting an antibiotic. She said the laboratory (lab) results are reviewed and addressed with the physician following the culture and sensitivity. The DON reviewed the culture and sensitivity for Resident #33 and said the infection was resistant to Bactrim DS (making the antibiotic ineffective). She said for Resident #33 she can see in the lab electronic system that the physician looked at the culture and sensitivity results on 4/22/26. She said the facility did not contact the physician to review the continued use of the antibiotic because it was the physician's responsibility to check the lab results and was outside of her nursing scope of practice to review this with the physician. The DON said the practice for a 48-72-hour timeout occurred prior to the antibiotic starting. 2. Resident #27 was admitted to the facility in January 2026 with a diagnosis of chronic kidney disease with a nephrostomy tube (tube to drain urine). Review of the nursing progress notes indicated on 3/4/26 Resident #27 presented with increased confusion with hallucinations. The physician was notified and lab work was ordered including a urinalysis. The physician ordered the antibiotic Levaquin 250 mg for seven days. The nursing progress notes indicated that although the urinalysis results did not support the use of antibiotics, the physician would like to continue the use based on blood work and urinalysis. Review of Resident #27's urine culture, dated 3/5/26, indicated there was no growth of a bacteria. The laboratory work failed to indicate the culture was reviewed by the physician. Review of the nursing progress notes and assessments failed to indicate the culture results with no growth were reviewed with the physician for re-evaluation of the antibiotic. During an interview on 4/28/26 at 11:20 A.M., the DON said there was no documentation to indicate the antibiotic for Resident #27 was reviewed by the physician following the culture results of no growth. She said the facility did not contact the physician to review the continued use of the antibiotic because it was the physician's responsibility to check the lab results and was outside of her nursing scope of practice to review this with the physician. During an interview on 4/28/26 at 2:03 P.M., Unit Manager #1 said the process was for the nursing staff to notify the physicians following the culture and sensitivity for review of appropriate antibiotics. Unit Manager #1 said she was not aware of what an antibiotic time out was. During an interview on 4/28/26 at 2:15 P.M., Unit Manager #2 said the process was for the nursing staff to call to alert the physicians of culture and sensitivity results in order to see if changes should be made.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they reported an allegation of abuse to the Department of Public Health (DPH) within two hours, as required. On 06/15/25, Resident #1 was observed with an injury of unknown origin and were also made aware of an allegation of physical abuse related to the injury, the Facility did not report the incident to DPH, until 06/17/25, 48 hours after the injury had been identified.Findings include:Review of the Facility Policy titled Abuse, Neglect, and Exploitation, dated as last revised 03/2025, indicated that the Facility is to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Policy indicated that possible indicators of abuse, include, but are not limited to:-Resident, staff or family report of abuse;-Physical marks such as bruises or patterned appearances;-Physical injury of a resident of unknown source; and-Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. The Policy further indicated that reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g. law enforcement when applicable) within specific time frames: -Immediate, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or-Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury.Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/17/25, indicated that on 06/17/25, a Police Officer arrived at the Facility to speak to the Director of Nurses (DON) and Administrator regarding a recent incident involving Resident #1, a suspected fall with injury The Report indicated that the police officer informed the Facility that the Health Care Agent (HCA) of Resident #1 was alleging that the injury (laceration) had been intentionally inflicted.During a telephone interview on 07/22/25 at 2:22 P.M., Resident #1's HCA said that she had received a phone call from a nurse at the Facility on the morning of 06/15/25, informing her that Resident #1 had a fall and sustained a wound to his/her forehead.The HCA said she asked the Nurse how he/she could have possibly fallen because Resident #1 was immobile and unable to move by him/herself. The HCA said after she asked the Nurse that question, the Nurse changed the story and said that they found him/her with a wound on his/her forehead.The HCA said that once she arrived at the Hospital Emergency Department (ED) and saw the wound, thought it could not have been from a fall and said she thought the wound was inflicted intentionally.Resident #1 was admitted to the Facility in 10/2022, diagnoses include, but not limited to, dementia, adult failure to thrive, anxiety, and depression.Review of Resident #1's Document of Resident Incapacity Form dated 10/26/22, indicated his/her Health Care Proxy (HCP) had been activated.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 03/27/25, indicated he/she required extensive to total assistance of one to two staff members with all Activities of Daily Living (ADL's).Review of Resident #1's Facility Incident Report, dated 06/15/25, indicated at 7:15 A.M., Nurse #1 was called into Resident #1's room by Certified Nurse Aide (CNA #3), and that Resident #1 was sitting in his/her wheelchair, dressed and ready for the day. The Report indicated that Resident #1 had an open area to his/her forehead that was bleeding, he/she complained of pain in his/her index and middle finger of his/her right hand, and Nurse #1 saw a small spot of blood on the floor next to the bed.The Report further indicated Resident #1 was transferred back to his/her bed, a dressing was applied to his/her forehead, and Resident #1 was transferred to the ED for treatment and evaluation. During a telephone interview on 07/24/25 at 10:18 A.M., CNA #2 said that when she got to work on the morning of 06/15/25, she went into Resident #1's room to get him/her up for breakfast, dressed him/her in bed and then transferred him/her into his/her wheelchair.CNA #2 said that she noticed some (what looked like) dry blood underneath his/her fingernails, said she did not see where it was coming from and thought Resident #1 must have scratched him/herself. CNA #2 said that she then called for CNA #3 to come into his/her room.CNA #2 said that when CNA #3 came into his/her room she had noticed the cut on Resident #1's forehead and called for Nurse #1.During a telephone interview on 07/28/25 at 9:50 A.M., Nurse #1 said that on 06/15/25 at approximately 7:18 A.M., CNA #3 called out to her to go to Resident #1's room. Nurse #1 said that she went into his/her room, and she saw a wound on Resident #1's forehead and asked why CNA #2 had gotten him/her out of bed instead of calling for her first.Nurse #1 said she asked Resident #1 what happened and that Resident #1 said that they tussled me and beat me, I think they broke my finger. Nurse #1 said that after she assessed Resident #1, he/she was put back to bed and was then transferred to the ED for evaluation.Nurse #1 said that when Emergency Medical Services (EMS) arrived she told them she did not know what happened and that the CNA reported to her that Resident #1 was found in his/her bed. Nurse #1 said that at approximately 8:00 A.M., she called the Assistant Director of Nurses (ADON, the manager on call) to inform her of the situation.During an interview on 07/23/25 at 12:45 P.M., the ADON said that on 06/15/25 at approximately 8:03 A.M., she received a call from Nurse #1 explaining the incident involving Resident #1.The ADON said that Nurse #1 reported that Resident #1 was found by CNA #2 in bed, with an injury of unknown origin and when Nurse #1 saw him/her, he/she was sitting up in his/her wheelchair and no one had reported to have found Resident #1 on the floor. The ADON said that the staff was unable to give her a clear answer as to what happened that may have caused the injury.The ADON said that she then called the Director of Nurses (DON) and Administrator to inform them of the incident. The ADON said that it was reported to her as a possible unwitnessed fall, however, she told the Administrator and DON that she had some concerns that the incident/injury was not related to a fall. The ADON said that she called Resident #1's HCA around 3:00 P.M., and the HCA told her that based on the look of the wound, that she (HCA) did not think it was from a fall, but felt that the injury had been inflicted intentionally.The ADON said she immediately called the DON to report what Resident #1's HCA had said and told the DON, she felt it was clearly an injury of unknown origin and should be reported as such.The ADON said that the DON told her that the injury/incident was being treated as an unwitnessed fall and they would continue to investigate.During an interview on 07/23/25 at 4:00 P.M., the Director of Nurse (DON) said that on 6/15/25, the ADON called to report an incident that had occurred with Resident #1. The DON said that it had been reported to him as an unwitnessed fall. The DON said that the ADON did tell him that Resident #1's HCA reported to her that she thought the injury had been intentionally inflicted and said it did not dawn on him at that time to report the event to DPH.The DON said that on Monday 06/16/25, when he began investigating and things were not making sense to him, because no one had reported Resident #1 ever being found on the floor. The DON said that he was about to report the event to DPH when the Local Police arrived and informed them of an allegation of suspected abuse on Resident #1.The DON said that it is the Facility's expectation that all alleged allegations of abuse, including injuries of unknown origin, be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was found on the floor on 07/19/25 after an unwitnessed fall, the Facility failed to ensure he/she was provided care and treatment that met professional standards of nursing practice related to initial and ongoing assessments, and physician notification. Findings include:Review of the Facility Policy titled Accidents and Incidents, dated as last revised 09/2024, indicated that an Accident refers to any unexpected or unintentional incident, which may result in injury and an Incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. The Policy further indicated; -Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so;-The Supervisor will be notified of the accident/incident;-The Nurse will contact the resident's practitioner to inform them if the accident/incident, report any injuries or other findings, and obtain orders, if indicated; and-The Resident's Family or representative will be notified of the accident/incident and any orders obtained. Review of the Facility Form titled Incident and Accident Checklist, undated, indicated that the Checklist is to be completed for each incident and accident and signed off as complete by the DON and Administrator supporting that through a thorough and complete investigation has been completed. The Checklist further indicated that the bold items on the checklist are to be performed by the staff nurses and initiated at the time of the incident/accident, the bold items included; -Notify the Physician;-Obtain statements/interviews from staff, collected for each staff member regardless if directly involved;-Skin Check;-Pain Assessment;-Fall Assessment; and-Neurological signs for all unwitnessed falls. Resident #2 was admitted to the Facility in 10/2022 diagnoses include vascular dementia, adult failure to thrive, diabetes mellitus, and anemia. Review of Resident #2's Document of Resident Incapacity Form dated 08/03/22, indicated his/her Health Care Proxy (HCP) had been activated.Review of Resident #2's Facility Incident Report, dated 07/19/25, indicated that he/she was found on the floor and he/she was unable to state what had happened. Review of Resident #2's Nurse Progress Note, dated 07/19/25, written by Nurse #2, indicated that she heard a resident crying out for help, she went into Resident #2's room and found him/her on the floor. During an interview on 07/24/25 at 8:53 A.M., Nurse #2 said the day she received her orientation for the Facility, her preceptor told her that if she were to find Resident #2 on the floor, not to worry about it and that he/she does it all the time. Nurse #2 said that on 07/19/25 at approximately 9:30 P.M., she heard a resident calling out for help, went into Resident #2's room and found him/her on the floor mat beside his/her bed. Nurse #2 said she called two Certified Nurse Aides (CNA's)'s for assistance and attempted to transfer him/her back into bed, but they were unable to do so manually. Nurse #2 said she left the room to get a mechanical lift.Nurse #2 said that when she returned to Resident #2 room, the CNA's had cleaned and changed Resident #2 because he/she had been incontinent. Nurse #2 said that she did not assess Resident #2 until after he/she was transferred up off the floor and put back into bed.Review of Resident #2's medical record, there was no documentation to support that Nurse #2;-Notified his/her physician that he/she was found on the floor;-Completed a physical assessment prior to having him/her moved off the floor; -Completed a new Fall Risk Assessment; and-Initiated neurological signs, per facility policy.During a telephone interview on 07/28/25 at 11:08 A.M., the Nurse Supervisor said that she was not aware that on 07/19/25, Resident #2 had been found on the floor. The Supervisor said that when a resident is found on the floor or has an unwitnessed event the nurse must assess the resident before moving them, notify the physician, HCA, complete a fall, skin, and pain assessment and initiate neurological checks.During an interview on 07/23/25 at 4:00 P.M., the Director of Nurses (DON) said that he was not aware Nurse #2 had not followed the facility Fall Protocol until after the event occurred. The DON said that it is the Facility's expectation that if a resident has an unwitnessed fall the nurse must first assess the resident for injury, obtain vital signs, ensure the resident's safety and once the resident is assessed and may be safely moved, the nurse may then move the resident.The DON said that the nurse must initiate the Fall Protocol, including notification to the Physician, HCA, initiate neurological signs, and complete the appropriate follow-up assessments.

Based on observation, interview, and document review, the facility failed for one Resident (#77), out of a sample of 18 residents, to ensure the Resident received consistent care and treatment to prevent the further deterioration of a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel that went from dime sized and intact on 3/29/25 to quarter sized and open with drainage on 4/3/25. Findings include: Review of the facility's policy titled Pressure Injury Prevention and Management, dated as reviewed 10/2024, indicated but was not limited to the following: - the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury DEFINITIONS: Pressure Ulcer/Injury: refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device Avoidable: means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and other risk factors, define and implement interventions that are consistent with resident needs, resident goals and professional standards of practice; monitor and evaluate the impact of the interventions as appropriate. POLICY EXPLANATION AND COMPLIANCE GUIDELINES: - the facility will establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate - Licensed nurses will conduct a pressure injury risk assessment, the assessment will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include: impaired/decreased mobility and functional ability; co-morbid conditions; drugs that may affect healing; impaired blood flow; refusal of care of treatments; cognitive impairment; exposure of skin to incontinence (loss of control of bowels or bladder); under nutrition, malnutrition, or hydration deficits; the presence of previously healed pressure injuries - Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. - Assessments of pressure injuries will be performed by a Licensed nurse, and documented; the staging of pressure injuries will be clearly documented to ensure correct coding on the Minimum Data Set (MDS) INTERVENTIONS FOR PREVENTION AND TO PROMOTE HEALING: - after completing a thorough assessment, the interdisciplinary team (IDT) shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions - interventions will be based on specific factors and identified risks including: nutritional factors, wound staging, assessment, impaired mobility, moisture management, and wound characteristics - evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present, which could include but are not limited to: redistribution of pressure (such as repositioning, pressure relieving mattress, protecting or offloading heels, etc.) - the goals and preferences of the resident and/or authorized representative will be included in the plan of care - interventions will be documented in the care plan and communicated to all relevant staff; compliance with interventions will be documented in the weekly summary charting MONITORING: - the unit manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risk, progression towards healing, and compliance at least weekly and document a summary of findings in the medical record - the attending physician will be notified of the presence of a new pressure injury upon identification; the progress towards healing, or lack of healing and any complications as needed - a focused incident review will be performed on each pressure injury that develops in the facility and reported in the monthly facility Quality Assurance (QA) committee meeting MODIFICATIONS OF INTERVENTIONS: - any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner - interventions on a resident's care plan will be modified as needed Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, for Resident #77 indicated but was not limited to the following: - Section C: Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the Resident was cognitively intact - Section GG: Exhibited functional limitation in range of motion with impairment on the bilateral (both sides) lower extremities and was dependent with care for toileting, bathing, lower body dressing, putting on and taking off footwear, rolling from left to right on the bed, moving from sitting to lying, lying to sitting, sitting to standing, and transferring from bed to chair - Section M: At risk of developing a pressure ulcer/injury, does not have one or more unhealed pressure ulcers/injuries Review of the Norton Scale for predicting risk of pressure ulcers for Resident #77 indicated a score of high risk (less than 10 in accordance with the assessment key) on 1/16/25, 1/23/25, and 1/30/25. Review of the medical record indicated Resident #77 had developed a DTI to his/her right heel that was first observed by staff on 2/2/25 and was first evaluated by the wound physician on 2/4/25. The wound physician last evaluated the Resident's wound on 2/11/25 and documented the area as Pressure, unstageable, and intact skin with purple/maroon discoloration measuring: 1.5 centimeters (cm) long by (x) 1.5cm wide. The plan was for pressure off-loading booties and follow up with wound physician in 2 weeks or sooner if needed. On 2/26/25 the wound physician group had not seen the Resident but signed off from the case related to the termination of the facility contract. The Resident had not had their right heel wound evaluated by a wound consultant, a Physician, Nurse practitioner or any Licensed nurse in the facility for wound measurements and progress towards healing of the wound since the last visit on 2/11/25. During an interview on 4/1/25 at 10:53 A.M., Resident #77 said he/she had a wound on their right foot. The Resident said he/she used to have booties but does not know what happened to them. During an interview with observation on 4/1/25 at 12:21 P.M., Family Member #1 said he visits Resident #77 daily and the Resident is dependent on the staff for all care and positioning. He said the Resident still had the wound on his/her right heel and there are booties that are usually up on the shelf in the room and not on the Resident. Family Member #1 and the Resident showed the surveyor the area on the Resident's right heel which was dark red to maroon in color and intact without any signs of drainage. Review of the current orders for Resident #77, as of 4/1/25, indicated but were not limited to the following: - Booties/heel protectors on at all times as tolerated, every shift (2/4/25) - Wound Care: Unstageable DTI of right heel. Cleanse with NS or wound cleanser, apply skin prep to wound surface, leave open to air (LOTA). Place heel in bootie every day shift (2/4/25) - Wound MD consult as indicated (1/8/25) During an interview on 4/1/25 at 12:53 P.M., Resident #77 and Family Member #1 said the nurse had just been in the room to do the treatment to the Resident's right heel. The surveyor observed the offloading booties were not in place. The Resident said he/she does not refuse the use of the booties and doesn't know where they are. Family Member #1 said the booties have been up on the shelf in the Resident's room for quite some time and they were not aware of why the booties were no longer used on the Resident even though the Resident still had the area to their right heel. During an interview on 4/1/25 at 1:27 P.M., Nurse #7 observed the Resident in his/her room with the surveyor and Family Member #1. He said he provided the wound treatment of cleansing and skin prep to the Resident's right heel area approximately 45 minutes prior. He said the Resident is supposed to wear booties to offload his/her heels and the Certified Nursing Assistants (CNA) are supposed to put them on the Resident. He doesn't know why they do not put them on the Resident. He said the heels should be offloaded to prevent further issues with pressure but they are not. He said he did not attempt to place the offloading booties on the Resident at the time of the treatment being provided and was not observed to offer or attempt to place the booties on the Resident prior to leaving the room. Throughout the survey the surveyor made the following observations of Resident #77: - 4/1/25: In bed, on his/her back, without offloading boots in place or any type of offloading provided to keep the Resident's heel off the bed at 10:05 A.M., 10:53 A.M., 12:21 P.M., 12:53 P.M., and 4:23 P.M. - 4/2/25: bed, on his/her back, without offloading boots in place or any type of offloading provided to keep the Resident's heel off the bed at 6:52 A.M., 7:41 A.M., 7:54 A.M., 8:42 A.M., 10:11 A.M. During an interview on 4/1/25 at 4:26 P.M., CNA #1 said she knows the Resident but was unaware that the Resident had an area on his/her right heel and required booties to be worn to offload their heels. During an interview on 4/1/25 at 4:28 P.M., CNA #2 said she knows the Resident well and the Resident is dependent on care including repositioning in the bed and she was not aware that the Resident was supposed to wear offloading booties at all times and if the CNAs do not know, this is likely the reason the Resident is not wearing them. During an interview on 4/2/25 at 7:54 A.M., CNA #3 said she knows the Resident well and used to take care of him/her all the time. She said the Resident is dependent on staff for all care and had an area on his/her right heel and was supposed to be wearing booties at all times. She said she does not know why the Resident is no longer wearing the booties. Review of the current care plans for Resident #77 failed to indicate a care plan was developed for the right heel DTI. Review of the Nursing progress notes for Resident #77 indicated on 3/29/25 that the wound remained on the right heel and was intact, red and dime sized. Further review of the nursing progress notes failed to consistently reflect information on the known right heel wound that was being treated throughout the months of February and March 2025. Review of the Physician and NP progress notes for Resident #77 indicated but were not limited to the following: - 2/6/25: Resident seen by a wound specialist on 2/4/25, an unstageable DTI on the right heel; wound orders put in place, unable to visualize wound. High risk for skin breakdown and poor wound healing. Assessment: L 89.616 (diagnosis code for Pressure-induced deep tissue damage of right heel); followed by facility wound specialist, wound care orders are in place. At risk for poor wound healing and further skin breakdown due to limited mobility. - 2/11/25: Unable to visualize the right heel wound. High risk for skin breakdown and poor wound healing. Followed by facility wound specialist. - 2/20/25: Skin normal color and turgor, unable to visualize the right heel wound; high risk for skin breakdown and poor wound healing. - 2/25/25: DTI of the right heel continues to have intact skin with purple discoloration. High risk for skin breakdown and poor wound healing, continue skin prep. During an interview with observation on 4/2/25 at 10:11 A.M., the surveyor and Unit Manager (UM) #1 observed the Resident in bed, lying on his/her back with their feet resting on the bed, not offloaded with their ordered booties. UM #1 said the Resident would be at risk for pressure to his/her heels, especially with the head of their bed elevated, and the heels should be offloaded but were not. Nurse #7 entered the room and confirmed the Resident had a DTI on his/her right heel and was supposed to have their heels offloaded with the ordered booties, which were available in the room, but not placed on the Resident. During an interview on 4/2/25 at 10:12 A.M., UM #1 said she was not aware that the Resident still had a wound on their right heel and had thought the wound had resolved and therefore the Resident was not seen during wound rounds the day prior. She reviewed the record and said the order was still in place for skin prep and offloading booties to the Resident at all times for the right heel DTI and the Resident should have had the offloading booties on and did not. She said even though the nurses are signing off the TAR indicating the booties are in place to the Resident, based on her observation and the surveyor's observations this was not occurring as it should be and the TAR was inaccurate; the nurses are just signing off the orders. She said the record indicated the Resident was first observed to have an area to his/her right heel on 2/2/25 and was seen by the consultant wound physician for initial evaluation on 2/4/25. She said when the wound to the right heel was identified, a resident centered care plan should have been developed and implemented to help heal and prevent any further deterioration of the area but at this time there still was no care plan in place for the care or treatment of the Resident's right heel DTI. She said she could not find any evidence that a Licensed nurse completed a pressure wound evaluation or that a physician or NP had evaluated the Resident's wound since the consultant wound physicians had stopped coming to the facility in February. She said the Resident may have been missed in error and that is why his/her wound was unknown to the wound team and not managed and monitored as it should have been. During an interview on 4/3/25 at 10:14 A.M., the Director of Nurses (DON) said there was not a care plan developed or implemented for the care and treatment of Resident #77's right heel pressure area and there should have been. He reviewed the CNA care Kardex and said the Kardex does not reflect the need for offloading booties to be on the Resident at all times and that is likely why some of the CNAs were unaware of the need for the booties. During an interview on 4/3/25 at 10:26 A.M., the DON said the Resident appeared to have developed a deep tissue pressure injury to his/her right heel that was first identified on 2/2/25 and was evaluated by the consultant wound physician on 2/5/25. He said there was no documentation in the record that he could find that the right heel wound had resolved, or that the Resident had been evaluated by the Licensed nurses using the pressure ulcer evaluation tool or any physician or NP after the consultant wound physician stopped coming to the facility. He was made aware of the surveyor's observations of the Resident not having their offloading booties in place, even after the surveyor spoke to staff about the missing booties, and said the order was active and signed off on the TAR and the staff should have ensured the MD orders were followed and the offloading booties were in place as ordered. During an interview on 4/3/25 at 12:29 P.M., Regional Nurse #1 provided the surveyor with an assessment of the Resident's right heel wound, dated 4/3/25, that indicated the wound was approximately quarter sized (larger than 1.5 cm x 1.5 cm), open and had an area of drainage with the physician being contacted for new orders. She said she is aware that these changes to the wound indicate further deterioration of the area had occurred since the last observation of the area by the staff on 3/29/25 and the surveyor on 4/1/25. During an interview on 4/3/25 at 3:38 P.M., NP #1 said she cares for Resident #77 regularly and knows him/her well. She said back in February she was notified that the Resident had developed a DTI to the right heel and the Resident was being seen by the consultant wound care physician for the management of their pressure injury to the right heel. She said once the wound developed the orders for offloading for this Resident should be followed consistently to prevent any further deterioration of the area and failing to use the offloading booties as ordered would be a contributing factor to the pressure area further deteriorating. She said she spoke with the facility today and was made aware that the pressure area on the right heel had deteriorated and was now open with drainage and larger in size. She said she was not aware that the Resident still had the wound to his/her right heel and assumed it had resolved since there was no indication in the record that the Resident was still being seen by a wound physician for management or any documentation that spoke to the evaluation or progress of the wound and that is why she had not seen and evaluated the wound herself. She said she believed that the Resident's case was missed when the wound consultant left the facility at the end of February and the new wound care physician team began and that was likely why the Resident did not receive consistent evaluation, care and management of the area since 2/11/25.

Based on interview and review of the Health Care Facility Reporting (HCFS-State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator and Director of Nursing (DON) occurred. Findings include: During the entrance conference interview on 3/31/25 at 8:59 A.M., the Administrator said she was the facility's new Administrator, effective 3/10/25, and the facility had a new Director of Nursing (DON), effective 3/15/25. The Administrator said the changes were not reflected in HCFRS yet but were in process and would provide documentation of such to the surveyor. Review of the HCFRS indicated the last reported change in the facility's Administrator was 12/6/24 and the last reported change in the facility's DON was 5/23/24 but no changes were indicated that the Administrator and DON were no longer working at the facility. Further review of the HCFRS failed to indicate the State Agency was notified when the change took place for the current Administrator on 3/10/25 and DON on 3/15/25. During an interview on 3/31/25 at 3:10 P.M., the Administrator provided the surveyor with an email, dated 3/31/25, that indicated she did not have access to HCFRS yet, but the current DON did. During an interview on 3/31/25 at 4:15 P.M., the Administrator and DON said the previous company (prior to 3/1/25) said they would put the changes in HCFRS for them, but they did not. They said there were staff still working in the facility from the previous company that had access to HCFRS for reporting, but they did not report it either. They said it was their responsibility to ensure that it was done and said when there's a change in Administrator or DON it should be reported in HCFRS, but it wasn't. During an interview on 4/2/25 at 3:19 P.M., Regional Nurse #1 said the changes in Administrator and DON should have been reported in HCFRS prior to their start or immediately after.

Based on records reviewed and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; 3. For Resident #41, ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection; 4. For Resident #49, ensure respiratory equipment including oxygen and nebulizer tubing was properly stored in a clean and sanitary manner to decrease the risk of potential contamination and infection; 5. For Resident #73, ensure the proper care and storage of the Resident's continuous positive airway pressure (CPAP-helps treat sleep apnea) machine; and 6. For Resident #77, ensure nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing was stored in a sanitary manner. Findings include: 1. Review of the facility's policy titled Infection Surveillance, last revised September 2024, indicated but was not limited to: - A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. The purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections. - Infection surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data. - The Facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread. - The facility will communicate staff and/or prescribing practitioner's information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. - Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. - All residents and infections will be tracked. On 3/31/25 at 3:27 P.M., the surveyor requested to see the facility's completed surveillance logs for December 2024, January 2025, and February 2025. During an interview on 3/31/25 at 4:31 P.M., Support Staff #2 said the facility did not have access to December 2024, January 2025, and February 2025 completed surveillance logs and was working on getting them. During an interview on 4/1/25 at 12:53 P.M., Support Staff #2 said the facility was not able to provide any surveillance logs prior to March 1, 2025, to the survey team. During an interview on 4/2/25 at 1:08 P.M., the Director of Nursing (DON) and Support Staff #2 said there were no surveillance logs that the facility could provide to the survey team. 2. Review of Centers for Medicare & Medicaid Services (CMS) Memorandum titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease, revised July 2018, indicated but was not limited to the following: - In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least [AGE] years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Review of the facility's policy titled Legionella Water Management Program, dated November 2017, indicated but was not limited to: -Policy: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. -Guideline: - As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. - The water management team will consist of at least the following personnel: - Infection Preventionist - Administrator - Medical Director - Director of maintenance - Other members as assigned by the Administrator -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionella Disease. -The water management program used by our facility is based on applicable federal and state regulations. The water management program may include the following elements: - A description and diagram of the water system in the facility is available upon request; - The Identification of area in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria; Review of the facility's Water Management Plan, dated 11/5/24, indicated but was not limited to: - Medical Director signature -Blank - Water enters the basement on the property - Hot water is distributed to plumbing fixtures in the basement - Areas where Legionella could grow and spread: - Fountains - Hydrotherapy During an interview on 4/1/25 at 4:44 P.M., the Director of Maintenance (DOM) said the Medical Director had never been part of the Water Management team. The DOM said the facility was built on a slab and did not have a basement. The DOM said the facility did not have any hydrotherapy and the only fountains in the facility were water fountains which were capped off and shut off over five years ago. The DOM said the water management plan was not specific to the facility and did not accurately represent the facility. During an interview on 4/2/25 at 1:08 P.M., the DON and Support Staff #2 said the Facility's water plan was not specific to the facility but should have been. 3. Review of the facility's policy titled Care and Treatment of Feeding Tubes, last revised September 2024, indicated but was not limited to: - Direction for staff on how to provide the following care will be provided: - Use of infection control precautions and related techniques to minimize the risk of contamination. Review of the facility's policy titled Flushing a Feeding Tube, last revised October 2024, indicated but was not limited to: - Change the 60 ml catheter tip syringe used every 24 hours or as needed. - Store in a bag or container. Resident #41 was admitted to the facility in October 2022 with diagnoses including cerebral infarction and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident #11 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Further review of Resident #41's MDS indicated he/she had a feeding tube and received 51% or more of their total calories from the feeding tube. Review of Resident #41's current Physician's Orders indicated but was not limited to: - Enteral feed Jevity 1.5 Calorie, administer 54 milliliters (ml)/hour (hr) for a total of 20 hours with 150 ml of free water flushes every 4 hours for total of 1080 ml of formula daily, dated 11/8/2024 a. On the following dates and times, the surveyor observed dried splatters of a thick, tacky, tan colored substance on Resident #41's tube feeding pump, pole, the floor underneath the pump, the bedrail of his/her bed, and on their privacy curtain: - 3/31/25 at 8:58 A.M., - 3/31/25 at 10:18 A.M., - 3/31/25 at 12:06 P.M., - 3/31/25 at 2:30 P.M., - 3/31/25 at 4:43 P.M., - 4/1/25 at 7:10 A.M., - 4/1/25 at 10:01 A.M., - 4/1/25 at 10:21 A.M., - 4/1/25 at 11:57 A.M., and - 4/2/25 at 8:31 A.M. During an interview on 4/2/25 at 8:31 A.M., Nurse #5 and the surveyor observed the dried splatters of the thick, tacky, tan colored substance on Resident #41's tube feeding pump, pole, floor underneath the pump, the bedrail of his/her bed, and on their privacy curtain. Nurse #5 said it was the nurse's responsibility to wipe up any tube feeding formula they had spilled or dripped. Nurse #5 said housekeeping was responsible for cleaning the floor and cleaning the privacy curtain. During an interview on 4/2/25 at 8:38 A.M., Unit Manager (UM) #1 said the expectation was for all feeding tube equipment and the surrounding area to be kept in a clean and sanitary manner to promote healthy infection control practices. UM #1 said that whoever spilled the formula should have wiped down the spilled formula and notified housekeeping to clean and replace the privacy curtain. During an interview on 4/2/25 at 4:02 P.M., the DON said that the expectation was for all feeding tube equipment and the surrounding area to be kept in a clean and sanitary manner to promote healthy infection control practices. b. On 3/31/25, the surveyor observed Resident #41's piston syringe lying uncovered dated 3/29/25 on his/her dresser: - 8:58 A.M., - 10:18 A.M., - 12:06 P.M., - 2:30 P.M., - 4:43 P.M. On 4/1/25 at 8:26 A.M. and 10:01 A.M., the surveyor observed Resident #41's piston syringe lying uncovered, dated 3/29/25, on a towel his/her overbed table. On 4/1/25 at 10:21 A.M., the surveyor observed Nurse #8 administering Resident #41's medications using the piston syringe, dated 3/29/25. Nurse #8 said she used the syringe from Resident #41's overbed table because she could not find a new syringe and she needed to hang his/her tube feeding. Nurse #8 said she should not have used the piston syringe from Resident #41's overbed table because it was not stored in a clean manner and was outdated. Nurse #8 said piston syringes should be replaced daily and stored in a bag. On 4/1/25 at 3:23 P.M., Regional Nurse #1 said piston syringes should be changed daily and stored in a sealed bag. Regional Nurse #1 said piston syringes should not be stored out of a sealed bag when not in use. 48362 4. Review of the facility's policy titled Oxygen Administration, dated last revised 9/2024, indicated but was not limited to the following: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered plans, and the resident's goals and preferences. - Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include a.) Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated; d.) If applicable, change nebulizer tubing and delivery devices weekly and as needed if it becomes soiled or contaminated; e.) Keep delivery devices covered in plastic bag when not in use. - Cleaning and care of equipment shall be in accordance with facility policies for such equipment. Review of the facility's policy titled Nebulizer Therapy, dated last revised 9/2024, indicated but was not limited to the following: - It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. - Care of Equipment: 1.) Clean after each use; 2.) Wash hands before handling equipment; 3.) Disassemble parts after every treatment; 4.) Rinse the nebulizer cup and mouthpiece with sterile or distilled water; 5.) Shake off excess water; 6.) Air dry on an absorbent towel; 7.) Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag; 8.) Change the nebulizer tubing every seventy-two hours or per facility policy; 9.) Periodically disinfect unit per manufacturer's recommendations. Resident #49 was admitted to the facility in January 2024 with diagnoses including pulmonary fibrosis and emphysema. Review of Resident #49's MDS assessment, dated 12/26/24, indicated he/she was cognitively intact as evidenced by a BIMS of 15 out of 15. Furthermore, the MDS assessment indicated he/she required assistance from staff for activities of daily living. Review of Resident #49's Physician's Orders indicated but was not limited to the following: - 3/27/25: May apply O2 (oxygen) at 1-3 L (liters) via NC (nasal cannula) to maintain saturation 94% of above; if saturation is 94 or above on O2, turn O2 down/off every shift - 3/26/25: Oxygen 1L per minute via NC and titrate to keep saturation above 93%. - 3/26/25: Duoneb Solution 0.5-2.5 3MG (milligrams)/3mL (milliliters); 3mL inhale orally via nebulizer every 8 hours as needed for SOB (shortness of breath). Review of Resident #49's March and April Medication Administration Records (MAR) indicated he/she received the Duoneb Solution treatment on 3/26/25. During an observation with interview on 3/31/25 at 2:46 P.M., the surveyor observed Resident #49 resting in bed; an oxygen concentrator was on and set to 2L of oxygen. Nasal cannula tubing was attached to the concentrator. The nasal cannula tubing was observed to be on the ground on the left side of the bed and the tubing was not dated. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. Resident #49 said he/she was recently diagnosed with pneumonia and was requiring nebulizer treatments and oxygen. Resident #49 said none of the oxygen equipment, including nasal cannula tubing and nebulizer mask/tubing, had been changed since he/she started using the equipment. On 4/1/25 at 10:55 A.M., the surveyor observed Resident #49 resting in bed with nasal cannula tubing donned (on). The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing was exposed to the environment, was not dated, and was not covered with a plastic bag. On 4/1/25 at 4:11 P.M., the surveyor observed Resident #49 asleep in bed without nasal cannula tubing donned. The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated and was found resting across Resident #49's lap exposed to the environment. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. On 4/2/25 at 7:49 A.M., the surveyor observed Resident #49 resting in bed without nasal cannula tubing donned. The oxygen concentrator was set to 2L. The nasal cannula tubing was not dated and was found resting across Resident #49's lap exposed to the environment. A nebulizer mask and tubing were noted to be resting on the nightstand next to Resident #49's bed. The nebulizer mask and tubing were exposed to the environment, was not dated, and was not covered with a plastic bag. Review of Resident #49's medical record failed to indicate any documentation indicating that the oxygen tubing and/or nebulizer mask/tubing was changed. During an interview on 4/2/25 at 8:16 A.M., Nurse #1 said oxygen equipment is changed weekly at the facility or if it is soiled. Nurse #1 said when nebulizer or oxygen equipment is not in use it should be stored in a bag. Nurse #1 said tubing should be dated to indicate the last time it was changed. During an interview on 4/2/25 at 11:07 A.M., the Assistant Director of Nursing (ADON) said all oxygen equipment, including nebulizer equipment, should be stored in a bag when it is not in use. The ADON said oxygen and nebulizer tubing should be dated to indicate when it was last changed. The ADON and the surveyor reviewed the observations made during the survey process. The ADON said all items needed to be changed as they were potentially contaminated. The ADON said the items should have been stored properly when not in use. During an interview on 4/2/25 at 11:32 A.M., the DON said all oxygen equipment should be stored in a bag when not in use and should not be left on the ground or on a nightstand exposed to the environment. The DON said tubing should be dated to indicate to the staff how recently it was changed. The DON said Resident #49's oxygen and nebulizer equipment was not stored appropriately. 43935 5. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the MDS assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of the current Physician's Orders for Resident #77 indicated but were not limited to the following: - Albuterol sulfate inhalation nebulizer solution (2.5 milligrams / 3 milliliters) 0.083% inhale one application orally via nebulizer every 12 hours, as needed (PRN) for shortness of breath (SOB) (1/8/25) Throughout the survey the surveyor made the following observations: 4/1/25: nebulizer mask and tubing on the bedside table touching other items on the table, exposed to environmental debris and germs in the environment, not stored in a plastic bag at 10:05 A.M., 10:52 A.M., 12:21 P.M. and 1:23 P.M. During an interview on 4/1/25 at 12:21 P.M., Family Member #2 and the Resident said they were unsure of the last time the Resident had received a nebulizer treatment. Family Member #2 said the nebulizer mask and tubing had been left on top of the bedside table and stored there consistently. During an interview on 4/1/25 at 1:23 P.M., Nurse #7 observed the nebulizer tubing and mask with the surveyor. He said the nebulizer tubing and mask were not supposed to be stored that way and the equipment was dirty and would need to be replaced. He said the Resident is on nebulizer treatments PRN and he had not provided a treatment to the Resident recently. During an interview on 4/2/25 at 10:09 A.M., the Unit Manager said nebulizer tubing and mask or mouthpiece equipment is to be cleaned after each use and then stored in a plastic bag to protect it from germs. She said it does not appear that the process was followed in this instance and the Resident's nebulizer mask and tubing should have been stored in a sanitary manner. During an interview on 4/3/25 at 10:14 A.M., the DON said the process for storing nebulizer tubing and mask or mouthpiece is to clean it after each treatment and store it in a bag once it is dried for infection control reasons. He said that process was not followed for Resident #77 based on the surveyor's observations. 42742 6. Review of Lippincott Nursing Procedures. Eighth edition. [Philadelphia: Wolters Kluwer, (2019)] indicted but was not limited to the following: Continuous Positive Airway Pressure (CPAP) Use Administering CPAP: -When the treatment is over-in the morning or on discontinuation of the order-turn off the pressure generator and remove the headgear and appliance from the patient. -Clean and disinfect the equipment and store it properly. Resident #73 was admitted to the facility in December 2024 with diagnoses including sleep apnea (sleep disorder in which breathing repeatedly stops and starts). During an observation with interview on 4/1/25 at 10:40 A.M. and 2:06 P.M., the surveyor observed Resident #73 sitting up in bed. A CPAP machine was stored on top of the Resident's side table. The face mask and tubing were observed attached to the machine and resting on top of the side table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a protective bag when not in use by the Resident. Resident #73 said he/she used the machine for sleep apnea. Review of current Physician's Orders indicated the following: -CPAP @10 cm (centimeters of water pressure) H2O inspiration; 5 cmH2O expiration, on at HS (before sleep at bedtime), off in AM, at bedtime for sleep apnea, 12/26/24 During an observation with interview on 4/1/25 at 2:49 P.M., the surveyor and Unit Manager (UM) entered the Resident's room and observed a CPAP machine stored on top of the Resident's side table. The face mask and tubing were observed attached to the machine and resting on top of the side table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a plastic bag when not in use by the Resident. The UM said the mask and tubing should have been stored in a protective bag when not in use secondary to the potential for infection control concerns related to the danger of exposure to contaminants. On 4/2/25 at 6:58 A.M., the surveyor observed Resident #73 sitting up in bed. A CPAP machine was stored on top of the Resident's overbed tray table. The face mask and tubing were observed attached to the machine and resting on top of the tray table potentially exposed to environmental contaminants. The face mask and tubing were not stored in a protective bag when not in use by the Resident. During an interview on 4/2/25 at 3:13 P.M., the DON and Regional Nurse #1 said the Resident uses a CPAP machine for sleep apnea every night. They said the mask and tubing should be stored in a bag when not in use to avoid potential contamination.

Based on record review and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Findings include: Review of the facility's Antibiotic Stewardship Program policy, undated, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. On 3/31/25 at 3:27 P.M., the surveyor requested to see the facility's antibiotic use for December 2024, January 2025, and February 2025. During an interview on 3/31/25 at 4:31 P.M., Support Staff #2 said the facility did not have access to December 2024, January 2025, and February 2025 antibiotic use records. Support Staff #2 said the facility was working on getting the completed antibiotic use records for the facility. During an interview on 4/1/25 at 8:20 A.M., Support Staff #2 said the facility was still working on obtaining the facility's antibiotic use for December 2024, January 2025, and February 2025. During an interview on 4/1/25 at 11:03 A.M., Support Staff #2 said there was someone on their way to the facility with some files which may contain the completed records for antibiotic use. During an interview on 4/2/25 at 1:08 P.M., the Director of Nursing and Support Staff #2 said they were not able to provide any documentation of the facility's antibiotic use prior to March 1, 2025, to the survey team.

Based on observations, interviews, and records reviewed, for four Residents (#41, #63, #5 and #10) of 18 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #41, a. to ensure feeding tube formula was administered per physician's orders, and b. to ensure a dietary consult was obtained as ordered by the Physician; 2. For Resident #63, to ensure a physician's order was obtained prior to sending him/her to the hospital; 3. For Resident #5, to ensure the air mattress was set according to physician's orders and accurately documented in the medical record; and 4. For Resident #10, a. to ensure medication was administered as ordered; b. to ensure the air mattress was set according to physician's orders and accurately documented in the medical record. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Review of the facility's policy titled Care and Treatment of Feeding Tubes, last revised September 2024, indicated but was not limited to: - It is the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. - Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Resident #41 was admitted to the facility in October 2022 with diagnoses including cerebral infarction and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident #11 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Further review of Resident #41's MDS indicated he/she had a feeding tube and received 51% or more of their total calories from the feeding tube. Review of Resident #41's Physician's Orders indicated but was not limited to: - Enteral feed Jevity 1.5 Calorie, administer 54 milliliters (ml)/hour (hr) for a total of 20 hours with 150 ml of free water flushes every 4 hours for total of 1080 ml of formula daily, dated 11/8/2024 a. On 3/31/25 at 8:54 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie running. On 4/1/25 at 7:10 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie running. On 4/1/25 at 8:26 A.M., the surveyor observed Resident #41 in bed with Jevity 1.5 Calorie off and not running. On 4/1/25 at 10:21 A.M., the surveyor observed Nurse #8 administer medications to Resident #41 and start Jevity 1.5 Calorie. During an interview on 4/1/25 at 10:21 A.M., Nurse #8 said she was starting Resident #41's tube feed because it was supposed to start at 10:00 A.M. Nurse #8 said the tube feed was supposed to be off for four hours and was due to be restarted at 10:00 A.M. During an interview on 4/2/25 at 6:57 A.M., Nurse #6 said she had worked the 11:00 P.M. to 7:00 A.M. shift from 3/30/25 to 3/31/25. Nurse #6 said Resident #41's tube feed was supposed to be turned off at 6:00 A.M. and remain off until 10:00 A.M. Nurse #6 said Resident #41's tube feed was supposed to run for only 20 hours a day. Nurse #6 said she must have forgotten to turn off Resident #41's tube feed on 3/31/25 at 6 A.M., but she should have shut it off per physician's orders. During an interview on 4/2/25 at 8:31 A.M., Nurse #5 said Resident #41 received Jevity 1.5 Calorie via gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) for 20 hours a day. Nurse #5 said the tube feed is turned off at 6:00 A.M. every morning and is turned back on at 10:00 A.M. Nurse #5 said she thought the tube feed was turned off at 6:00 A.M. on 3/31/25 but she could not be sure because it is the responsibility of the 11:00 P.M. to 7:00 A.M. shift nurse to turn it off. Nurse #41 said she did not recall if she had started Resident #41's tube feed at 10:00 A.M. on 3/31/25. During an interview on 4/2/25 at 2:19 P.M., the Unit Manager (UM) said Resident #41 had an order for Jevity 1.5 Calorie for 20 hours a day, start at 10:00 A.M. and turn off at 6:00 A.M. The UM said all nurses must follow physician's orders and turn the Jevity 1.5 Calorie off at 6:00 A.M. and restart it at 10:00 A.M. as ordered. During an interview on 4/2/25 at 4:02 P.M., the Director of Nursing (DON) said his expectation was for all staff to follow physician's orders for feeding tubes. b. Review of Resident #41's Physician's Orders indicated but was not limited to: - Dietitian Consult related to weight gain, dated 3/11/25 Review of Resident #41's weights indicated but was not limited to: 3/31/25 212.0 pounds 3/17/25 211.0 pounds 3/10/25 211.0 pounds 3/10/25 211.0 pounds 3/3/25 210.5 pounds 2/5/25 202.0 pounds Further review of Resident #41's medical record failed to indicate a Dietitian Consult had been obtained on 3/11/25 or after. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 reviewed Resident #41's medical record and said a Dietitian consult was ordered for Resident #41 due to his/her weight gain. Nurse #5 said if a consultation was conducted by the Dietitian, it would have been documented in a note. Nurse #5 said she did not see a note from the Dietitian. During an interview on 4/2/25 at 2:19 P.M., the UM said Dietitian consultations were documented either in a note or in a dietary assessment. The UM reviewed Resident #41's medical record and said she did not see a Dietitian note or dietary assessment in Resident #41's chart on 3/11/25 or after that. During a telephonic interview on 4/3/25 at 2:11 P.M., the Regional Registered Dietitian said the facility had a Registered Dietitian and she would conduct the dietary consults. The Regional Registered Dietician reviewed Resident #41's medical record and said she could not see that a Dietitian Consultation was conducted as ordered by the physician. During an interview on 4/2/25 at 4:02 P.M., the DON said his expectation was for all staff to follow physician's orders for a Dietary Consult and the dietary consult to be completed within a week. A call was placed to the facility's Registered Dietitian on 4/2/25 at 11:47 A.M. and on 4/3/25 at 7:48 A.M. with no call back. 2. Review of the facility's policy titled Transfer and Discharge (including AMA), last revised September 2024, indicated but was not limited to: - Emergency Transfer/Discharge- initiated by the facility for medical reasons to an acute care setting such as a hospital, for immediate safety and welfare of a resident. - Obtain physician's orders for emergency transfer or discharge. Resident #63 was admitted to the facility in February 2023 with diagnoses including dementia and chronic kidney disease. Review of the MDS assessment, dated 1/31/25, indicated Resident #63 had a severe cognitive deficit as evidenced by a BIMS score of 6 out of 15. Review of Resident #63's medical record indicated he/she was transferred to the hospital on 10/23/24 and 12/10/24 for a change in condition. Further review of the medical record failed to indicate an order was obtained prior to transferring Resident #63 to the hospital on 10/23/24 and 12/10/24. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 said prior to transferring a resident to the hospital they must obtain an order from the physician or physician's extender. Nurse #5 said the order must then be transcribed in the resident's medical record. During an interview on 4/2/25 at 2:19 P.M., the UM said prior to transferring a resident to the hospital they must obtain an order from the physician or physician's extender. The UM said the order must then be transcribed in the resident's medical record. The UM reviewed Resident #63's medical record and said she did not see an order to the transfer Resident #63 to the hospital on 10/23/24 and 12/10/24 but he/she should have had an order. During an interview on 4/2/25 at 4:02 P.M., the DON reviewed Resident #63's medical record and said he did not see an order to transfer Resident #63 to the hospital on 10/23/24 and 12/10/24 but he/she should have had an order. The DON said all residents must have an order to be transferred to the hospital. 34145 3. Resident #5 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive, rheumatoid arthritis, and a stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to his/her coccyx and a stage 2 pressure ulcer to his/her right lateral dorsal foot. Review of the MDS assessment, dated 2/27/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, was at risk for developing pressure ulcers and had a pressure reducing device in bed. Review of Physician's Orders indicated but was not limited to: -Air mattress set at 100, check function and setting every shift for skin integrity (3/26/25) On 3/31/25 at 9:06 A.M., 11:37 A.M., 12:18 P.M. and 2:45 P.M., the surveyor observed Resident #5 sitting upright in bed. An air mattress was in place and set between 320 pounds (lbs.) and 400 lbs. On 4/1/25 at 7:01 A.M., the surveyor observed Resident #5 lying in bed sleeping. An air mattress was in place and set between 320 lbs. and 400 lbs. Review of the April 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) indicated nursing staff signed off that the air mattress was in place and set to 100 lbs. on all shifts on 3/31/25 during the time of the surveyor's observations of it set between 320 lbs. and 400 lbs. During an interview on 4/1/25 at 2:28 P.M., the DON said that although sometimes air mattress settings can be changed by mistake, such as if the dial is moved when staff change bed linens, nursing staff are to check the setting every shift to ensure it is set according to physician's orders. He said Resident #5's air mattress should be set to 100 lbs. according to physician's orders. 4. Resident #10 was admitted to the facility in September 2023 and had diagnoses including protein calorie malnutrition and weakness. Review of the MDS assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced by a BIMS score of 7 out of 15, was at risk for developing pressure ulcers, had a pressure reducing device in bed and received anticoagulant medication on a daily basis. Review of Physician's Orders indicated but was not limited to: -Eliquis (anticoagulant-blood thinner) 2.5 mg twice a day (7/9/24) -Pressure redistribution mattress, setting 180, check function and setting every shift (3/26/25) a. On 3/31/25 at 9:00 A.M., the surveyor observed Resident #10 lying in bed awake. A clear plastic medication cup with a round yellow pill inside was on the overbed table next to the Resident's bed. The Resident said he/she does not take medications independently and did not know what the pill was. Review of the medical record failed to indicate Resident #10 was assessed to self-administer any medications. On 3/31/25 at 9:39 A.M., the surveyor observed Resident #10 sitting upright in bed awake. Nurse #3 was at the Resident's bedside adjusting his/her oxygen tubing. A clear plastic medication cup with a round yellow pill inside was on the overbed table next to the Resident's bed. Nurse #3 then left the Resident's bedside and began to walk toward the door. The surveyor called the Nurse back to the Resident's bedside and showed him the pill in the medication cup. He said the pill was levothyroxine (thyroid hormone) and should have been administered at 6:00 A.M. The nurse said the night nurses sometimes leave medications for residents to take on their own when they shouldn't. Further review of the medical record indicated Resident #10 did not have a physician's order for levothyroxine. During a subsequent interview on 3/31/25 at 2:22 P.M., Nurse #3 said the medication left at Resident #10's bedside this morning was Eliquis 2.5 mg and not levothyroxine as he indicated to the surveyor previously. He said the Resident is not prescribed levothyroxine, but receives Eliquis at 9:00 A.M. and 9:00 P.M. He said he worked a double shift on 3/30/25 (7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M.) and was the only nurse to administer the Eliquis. He could not explain how the medication was left at the bedside. The nurse said after the surveyor brought the pill at the bedside to his attention, he discarded it. Nurse #3 said he did not inform the Resident's physician or nursing supervisor that a dose of Eliquis was found at the bedside and not administered. Review of the April 2025 Medication Administration Record indicated Nurse #3 signed off that Resident #10 was administered Eliquis 2.5 mg on 3/30/25 at 9:00 A.M. and 9:00 P.M. and 3/31/25 at 9:00 A.M. b. On 3/31/25 at 9:00 A.M. and 9:39 A.M., the surveyor observed Resident #10 sitting upright in bed. An air mattress was in place and set at 150 lbs. On 4/1/25 at 8:31 A.M., 1:59 P.M. and 2:20 P.M., the surveyor observed Resident #10 lying in bed asleep. An air mattress was in place and set at 150 lbs. Review of March and April 2025 MAR/TARs indicated nursing staff signed off that the air mattress was in place and set to 180 lbs. on 3/31/25 and 4/1/25 during the time of the surveyor's observations of it set at 150 lbs. During an interview on 4/1/25 at 2:28 P.M., the Director of Nursing (DON) said that although sometimes air mattress settings can be changed by mistake, such as if the dial is moved when staff change bed linens, nursing staff are to check the settings every shift to ensure it is set according to physician's orders. He said Resident #10's air mattress should be set to 180 lbs. according to physician's orders. The DON said that he was not notified that Resident #10's dose of Eliquis was left at the bedside and not administered. He said the physician should have been notified of the missed dose of Eliquis so he could determine if any blood work or monitoring is necessary.

Based on observation, interview and record review the facility failed to develop, implement and individualize comprehensive care plans for four Residents (#10, #29, #12, and #73), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #10, a comprehensive care plan was developed to address the use of Quetiapine Fumarate (Seroquel-antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #29, a comprehensive care plan was developed to address the use of Risperdal (antipsychotic medication) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan to address the Resident's smoking status as well as his/her smoking preferences; and 4. For Resident #73, to ensure a comprehensive care plan was developed and implemented to address the Resident's use of a continuous positive airway pressure (CPAP-helps treat sleep apnea) machine. Findings include: Review of the facility's policy titled Comprehensive Care Plans, last revised 9/2024, indicated but was not limited to: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe, at a minimum, the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. -The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. -The objectives will be utilized to monitor the resident's progress. -Alterative interventions will be documented, as needed. 1. Resident #10 was admitted to the facility in September 2023 and had diagnoses including bipolar disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15, and received antipsychotic medication on a daily basis. Review of the medical record indicated a physician's order for Quetiapine Fumarate 25 milligrams (mg) at bedtime for bipolar disorder (2/1/24). Review of January 2025 through April 2025 Medication Administration Records (MAR) indicated Quetiapine was administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: - Focus: Resident uses antipsychotic medications related to Bipolar (initiated: 9/28/23). - Interventions: Administer medication per physician's orders. Observe for side effects and effectiveness each shift, report any negative signs/symptoms (s/sx) to physician (initiated 9/28/23). -Goal: Will be free from discomfort or adverse reactions related to antipsychotic medication through the review date (initiated 9/28/23; target date: 3/17/25). The care plan developed for the use of Quetiapine failed to identify Resident specific targeted signs/symptoms of bipolar disorder, non-pharmacological interventions and measurable goals of treatment to meet the Resident's needs. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said nursing staff are responsible for care plan development for psychotropic medications. She said Resident #10's care plans should include identification of all psychotropic medications administered with resident specific behaviors, signs/symptoms for their use as well as resident specific, non-pharmacological interventions and measurable goals but do not. 2. Resident #29 was admitted to the facility in October 2022 and had diagnoses including disorders of psychological development, anxiety disorder, and dementia, unspecified severity with anxiety. Review of the MDS assessment, dated 2/13/25, indicated Resident #29 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15, and received psychotropic medication on a daily basis. Review of the medical record indicated a physician's orders for: -Depakote (antiseizure medication used to treat mood) 125 mg, give two tablets two times a day for mood (2/11/25). -Risperdal 0.5 mg one time a day for impulsivity, intrusiveness, self-injurious behaviors (SIB) (3/20/25) -Risperdal 0.5 mg one time a day for disinhibition and behavior management (3/20/25) -Sertraline HCI (antidepressant) 100 mg in the morning related to anxiety disorder (12/26/24) -Sertraline HCI 25 mg in the morning related to anxiety disorder (2/14/25) -Trazodone HCI (antidepressant) 50 mg at bedtime for insomnia (2/14/25) Review of December 2024 through April 2025 MARs indicated the psychotropic medications were administered as ordered by the physician. Review of comprehensive care plans included but was not limited to: -Focus: Resident uses antidepressant medication (Trazodone) related to insomnia, depression (10/8/22) -Interventions: Administer antidepressant medications as ordered by the physician. Monitor/document side effects and effectiveness every shift (10/8/22); Follow-up with psych/physician as needed (12/7/23) -Goal: Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (10/8/22) The care plan for the use of Trazodone failed to include non-pharmacological interventions and measurable goals of treatment. Further review of comprehensive care plans failed to indicate care plans had been developed for the use of Depakote, Sertraline and Risperdal that identified Resident specific targeted behaviors, Resident-specific interventions, including non-pharmacological approaches, and measurable goals of treatment to meet the Resident's needs. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said nursing staff are responsible for care plan development for psychotropic medications. She said Resident #29's care plans should include identification of all psychotropic medications administered with resident specific behaviors, signs/symptoms for their use as well as resident specific, non-pharmacological interventions and measurable goals but do not. 48362 3. Review of the facility's policy titled Smoking Policy -Residents, dated as revised 3/2024, indicated but was not limited to: - This facility shall establish and maintain safe resident smoking practices. - Smoking is permitted in designated resident smoking areas located outside of the facility. - Smoking is not allowed inside the facility under any circumstances. - The resident will be evaluated upon admission and/or when a resident chooses to smoke, to determine the resident's ability to smoke safely. - A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) as determined by staff. - Any smoking-related concerns will be noted in the resident care plan. Resident #12 was admitted to the facility in January 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, and peripheral vascular disease. Review of Resident #12's MDS assessment, dated 3/7/25, indicated he/she had moderate cognitive impairment as evidenced by a BIMS score of 9 out of 15. Furthermore, the MDS assessment indicated Resident #12 required assistance from staff for activities of daily living. Review of the list of smokers provided by the facility upon entrance indicated Resident #12 was a smoker residing in the facility. During an interview on 3/31/25 at 9:00 A.M., Resident #12 said he/she is a smoker and goes out several times a day during the facility's allotted smoking hours with the supervision of staff to smoke. Review of Resident #12's Smoking Evaluation, dated 12/9/24, indicated but was not limited to the following: - Protective Smoking Equipment: Not Applicable (NA). - Resident is an independent smoker. - Resident is independent with lighting cigarette. Review of Resident #12's Smoking Evaluation, dated 2/6/25, indicated but was not limited to the following: - Protective Smoking Equipment: not indicated. - Resident is safe to smoke with supervision without protective smoking equipment. - Resident is safe to light own cigarette with staff supervision. Review of Resident #12's comprehensive care plans failed to indicate a smoking care plan was developed or implemented. During an interview on 4/2/25 at 8:17 A.M., Nurse #1 said Resident #12 does go out during the allotted smoking times when he/she desires. Nurse #1 said Resident #12's smoking equipment, including cigarettes and lighters, are kept at the receptionist's desk in a locked box. During an interview on 4/2/25 at 8:50 A.M., Receptionist #1 said Resident #12 does participate in smoking during the scheduled timeframes. Receptionist #1 said all smoking equipment is kept in a locked box at the reception desk and he generally takes the residents who smoke out during the allotted times. Receptionist #1 said Resident #12 does require a protective apron during smoking times but is otherwise just supervised when he/she is smoking. During an interview on 4/2/25 at 11:15 A.M., Social Worker (SW) #1 said Resident #12 did not smoke when he/she was initially admitted to the facility but expressed interest in December. SW #1 said an initial assessment for Resident #12 smoking status was completed at that time. SW #1 said she was not sure how often nursing repeated the assessments but believed they would be completed with any change in condition. SW #1 said there was a period of time recently when Resident #12 did not go out to smoke at all but recently started to go out again throughout the day when he/she desired. SW #1 said she would expect there to be a care plan related to Resident #12 smoking status. During an interview on 4/2/25 at 11:36 A.M., the Director of Nursing (DON) said the expectation was for any resident in the facility who smoked to have a care plan related to their smoking status. The DON said the care plan should reflect any changes in the resident's smoking status. 42742 4. Resident #73 was admitted to the facility in December 2024 with diagnoses including sleep apnea (sleep disorder in which breathing repeatedly stops and starts). Review of current Physician's Orders indicated the following: -CPAP @10 cm (centimeters of water pressure) H2O inspiration; 5 cm H2O expiration, on at HS (before sleep at bedtime), off in AM, at bedtime for sleep apnea, 12/26/24 During an observation with interview on 4/1/25 at 10:40 A.M., the surveyor observed a CPAP machine stored on top of the Resident's side table. Resident #73 said he/she used the machine for sleep apnea. Review of the medical record failed to indicate that an interdisciplinary comprehensive care plan was developed with measurable objectives and timeframes to address the Resident's use of the CPAP machine related to his/her diagnosis of sleep apnea. During an interview on 4/2/25 at 9:56 A.M., the surveyor reviewed the medical record with the Unit Manager who said there was no care plan for the Resident's use of the CPAP machine. During an interview on 4/2/25 at 3:13 P.M., the surveyor reviewed the medical record with the DON and Regional Nurse #1 who said the Resident used the CPAP machine for sleep apnea every night. Regional Nurse #1 said the Resident should have been care planned for the use of the CPAP equipment but wasn't. The DON said the focus, measurable goals and interventions would have been listed in the care plan for it. Regional Nurse #1 said she would expect it to have been completed but it wasn't.

Based on document review and interview, the facility failed to ensure monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for two Residents (#60 and #10), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Ensure a recommendation from June 2024 left by the consultant pharmacist for Resident #60 to potentially reduce their medication load of Famotidine (a medication that decreases the amount of acid the stomach produces) from twice a day to once a day; and 2. For Resident #10, to ensure the August, September and October 2024 consultant pharmacist recommendations were acted upon timely to clarify the need for two as needed orders for Duoneb (inhalation solution to help open the airways in the lungs). Findings include: Review of the facility's policy titled Medication Regimen Review, undated, indicated but was not limited to the following: - the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist and includes a review of the medical record - the MRR is an evaluation with the goal to promote positive outcomes and minimize adverse consequences and potential risks associated with medications - the pharmacist will document, either manually or electronically, that each MRR was completed and document either no irregularity or the nature of any identified irregularities - written communications from the pharmacist will be a permanent part of the medical record - staff shall act upon all recommendations according to procedures for addressing MRR irregularities 1. Resident #60 was admitted to the facility in February 2024 with diagnoses including: adult failure to thrive, abscess of the pharynx, and dysphagia (inability to swallow well). Review of the medical record indicated a full MRR was completed by the consultant pharmacist in June 2024 and to see report for irregularities and/or recommendations. The record failed to indicate what those irregularities were or that they were addressed by a physician. Review of the MRR from June 2024 was a recommendation left to the prescriber and indicated the following: Resident has received Famotidine 20 milligrams (mg) twice daily since admission for gastroesophageal reflux disease (GERD). Would it be appropriate to consider reducing Famotidine dose to 20mg every night (QHS) as maintenance therapy? The physician response section was not completed by the physician, instead the Director of Nurses (DON) contacted the attending and completed the bottom of the form indicating disagree, but failed to indicate a rationale for the disagreement, and dated the recommendation as addressed on 4/1/25, 8 months after the recommendation was placed. During an interview on 4/2/25 at 12:25 P.M., the Director of Nursing (DON) said once the facility located the MRR recommendation yesterday, he contacted the Nurse Practitioner (NP) about Resident #60's recommendation from June 2024. He said he asked the NP if they ever had awareness of this recommendation in the past and they told him they couldn't recall it. He said he informed them of the recommendation and the NP at this time decided to decline the change and maintain the current orders of Famotidine 20mg twice daily until the Resident could be re-evaluated. He said he did not have a rationale for the declined recommendation and just signed it as completed on 4/1/25. He said the process for MRR being addressed is that they are completed by the NP or physician timely, which he considers to be within one month of the original recommendation being placed and that when a recommendation is declined a rationale is documented in the medical record. He said this process does not appear to have been in place or effective since Resident #60's June MRR recommendation was not addressed for eight months after it was placed. 34145 2. Resident #10 was admitted to the facility in September 2023 and had diagnoses including chronic obstructive pulmonary disease (COPD-lung disease causing restricted airflow and breathing problems). Review of the medical record indicated Pharmacy Consultant Notes, dated 8/14/24, 9/9/24 and 10/8/24 which indicated that recommendations were made and to see the Consultant Pharmacist report for the recommendations. Further review of the entire medical record failed to indicate consultant pharmacy recommendations dated 8/14/24, 9/9/24, and 10/8/24. During an interview on 4/2/25 at 10:35 A.M., the DON said the previous owners of the facility had all of the pharmacy recommendations in their computer system. He said after the survey team requested to review pharmacy recommendations yesterday, they had to call the previous owners and requested the past year of pharmacy recommendations. He said the 8/14/24, 9/9/24 and 10/8/24 pharmacy recommendations were addressed by Resident #10's Nurse Practitioner yesterday, 4/1/25 (more than 230 days since the first recommendation).

Based on record review and interview, the facility failed to ensure for two Residents (#79 and #73), out of a total sample of 18 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed: 1. For Resident #79, to ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medications; and 2. For Resident #73, to: a) ensure as needed (PRN) use of clonazepam (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN trazodone, and b) ensure signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of antidepressant and antianxiety medications. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, revised September 2024, indicated but was not limited to the following: Policy: -Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 4. The indications for use of any psychotropic drug will be documented in the medical record and include non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentations that are initiated after admission. 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it's appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 12. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 1. Resident #79 was admitted to the facility in March 2025 and had diagnoses including sleep disorder, anoxic (complete lack of oxygen) brain damage, encephalopathy (brain disease that alters brain function or structure), and extrapyramidal and movement disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/10/25, indicated Resident #79 received antianxiety and antidepressant medications and exhibited mood symptoms. The MDS indicated the Resident did not exhibit any behavioral symptoms. Review of current Physician's Orders indicated the following psychotropic medications: -trazodone HCL oral tablet 50 milligrams (mg) (trazodone HCL), give 0.5mg tablet via PEG-tube every 8 hours as needed (prn) for anxiety for 14 days, then re-eval, 3/18/25 -sertraline HCL oral concentrate 20 mg/milliliters (ml), give 1.3 ml via PEG-Tube in the morning for anxiety, 3/4/25 Review of the March 2025 Medication Administration Record (MAR) indicated the following uses of PRN trazodone and sertraline: -administered PRN trazodone on 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/29/25, 3/30/25 -administered sertraline as ordered Further review of the medical record failed to indicate that staff monitored the Resident for significant side effects related to the use of the antidepressant and antianxiety medications as required. During an interview on 4/1/25 at 3:11 P.M., the surveyor reviewed the medical record with the Unit Manager (UM) who said there was no order for monitoring of side effects for the use of the medications. During an interview on 4/2/25 at 2:41 P.M., the Director of Nursing (DON) and Regional Nurse #1 said the Resident should have been monitored for side effects specific to the use of the medications but there's no order for it. The DON said staff need to be sure the Resident is not experiencing any symptoms to determine if a dose adjustment is needed and for effectiveness. 2a. Resident #73 was admitted to the facility in December 2024 and had diagnoses including diabetes mellitus type 2, complete paraplegia, anxiety, and depression. Review of the MDS assessment, dated 12/23/24, indicated the Resident received antidepressant and antianxiety medications daily and exhibited mood symptoms. The MDS indicated the Resident did not exhibit any behavioral symptoms. Review of current Physician's Orders indicated the following psychotropic medications: -clonazepam oral tablet 0.5 mg, give 1 tablet by mouth as needed for anxiety, 0.5 mg PO (by mouth) TID (three times a day) PRN (as needed) for anxiety, 2/20/25 (no stop date) -duloxetine (antidepressant) HCL oral capsule delayed release particles 60 mg, give 60 mg by mouth one time a day for depression, 12/17/24 -trazodone HCL oral tablet 50 mg, give 1 tablet by mouth at bedtime for insomnia, 12/20/24 -Wellbutrin SR oral tablet extended release 12-hour 150 mg (bupropion HCL), give 1 tablet by mouth two times a day for mood, 12/18/24, Further review of physician's orders failed to indicate a limited duration (i.e., 14 days) for the PRN clonazepam or documentation of a clinical rationale in the medical record for the medication to be extended beyond 14 days including an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN clonazepam. Review of the December 2024 through March 2025 MAR indicated the following: -administered PRN clonazepam on 2/20/25, 2/21/25, 2/23/25, 2/28/25, 3/1/25 through 36/25, 3/8/25, 3/9/25, 3/12/25 through 3/15/25, 3/18/25, 3/22/25, 3/24/25 through 3/26/25, 3/20/25, and 3/31/25 -administered medications as ordered b. Further review of the medical record failed to indicate that staff monitored the Resident for significant side effects related to the use of the antidepressant and antianxiety medications as required. During an interview on 4/2/24 at 10:26 A.M., Family Member #6, who was interpreting for Resident #73, said the Resident gets very anxious every day, gets panic attacks, cries, and feels sad sometimes. During an interview on 4/2/25 at 1:43 P.M., the Unit Manager (UM) said the Resident takes clonazepam as needed for anxiety and also takes duloxetine, Wellbutrin, and trazodone. She said there was no stop date for the PRN clonazepam or re-eval and added it this day after surveyor intervention. She said there should have been an end date of 14 days and a note to re-evaluate after 14 days. She said the order duration was indefinite but shouldn't have been. The UM said there should have been a documented clinical rationale to continue the PRN medication but there wasn't. The surveyor reviewed physician's notes with the UM who said there wasn't a clinical rationale to extend its use. The UM said side effects for clonazepam, duloxetine, trazodone, and Wellbutrin should be monitored and there should be a coordinated order to do this but there wasn't. She said there's an order template that lists the side effects for each class of psychotropic medications. During an interview on 4/2/25 at 3:03 P.M., the DON and Regional Nurse #1 said the PRN clonazepam did not have a stop date on it or to re-evaluate and did not have a clinical rationale by the provider documented but should have. They said the 2/20/25 PRN order was open ended and if it was to be extended then there would be a lengthy note as to why the medication needed to be extended and for how long. The DON said there was no order for side effect monitoring either but there should have been.

Based on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise their rights for two Residents (#77 and #5), out of a total sample of 18 residents. Specifically, the facility failed to ensure that for: 1. Resident #77, the legal guardian was provided information upon admission to sign or verbally consent to treatment at the facility and sign or consent verbally for a wound consultant; and 2. Resident #5, the Health Care Proxy (HCP: health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was provided information upon admission to sign or verbally consent to treatment at the facility including for the use of bilateral side rails. Findings include: 1. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission and since November 2024, naming Family Member #2 his/her legal guardian. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said Family Member #2 helps the Resident make treatment decisions. During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said at the time of Resident #77's admission to the facility he was the legal guardian and remained the legal guardian until 2/11/25. He said he felt the facility did not communicate well with him during this time and consents, including a consent to treat and a wound consultant consent, were not provided to him or discussed with him for him to provide informed consent for the Resident's treatment. Review of the medical record for Resident #77 failed to indicate a Consent to admission and treat or a wound consultant consent was obtained and those documents were blank in the record. During an interview on 4/2/25 at 12:26 P.M., Nurse #7 reviewed the medical record and said it did not appear that any consents had been signed for the Resident at the time of admission. He said upon admission if the residents are not their own person the staff will try to contact the healthcare proxy or guardians to let them know there are consents that require signature. The consents remain in the record unsigned until that person comes in to sign them, and staff documents that they are pending signature. Review of the admission note for Resident #77 indicated signed/verbal consents: tbd (to be determined). During an interview on 4/2/25 at 1:02 P.M., the Social Worker said the consents upon admission were not signed or sent to the legal guardian to the best of her knowledge, but she is not responsible for getting those signed. The Social Worker said they remain unsigned at this time. During an interview on 4/2/25 at 2:16 P.M., the Unit Manager said she could not find any evidence that the consent to treat by a wound consultant was provided to the Resident's legal guardian or that the facility had those signed consents in the paper or electronic records. During an interview on 4/2/25 at 2:49 P.M., Consulting Staff #3 said there is no policy to obtain consents to treat or wound consultant consents, but the expectation is that upon admission they would be completed by the nurse on duty. She said even if the legally responsible party were out of state the staff could fax the consents to them or temporarily obtain verbal consent until the form could be provided for a signature. She said the staff should be following the standard of practice and regulation for obtaining informed consent for any treatment. During an interview on 4/3/25 at 10:09 A.M., the Director of Nurses (DON) said the expectation would be that the legal guardian had provided informed consent for both admission consent to treat and wound consultants and there was no evidence in the medical record that had occurred. 34145 2. Resident #5 was admitted to the facility in June 2024 with diagnoses including adult failure to thrive and rheumatoid arthritis. Review of the MDS assessment, dated 2/27/25, indicated Resident #5 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and had an activated HCP. On 3/31/25 at 9:06 A.M., 4/1/25 at 7:01 A.M. and 4/2/25 at 9:39 A.M., the surveyor observed Resident #5 lying in bed sleeping; bilateral side rails were raised and in use. Review of the medical record indicated a physician's order, dated 7/17/24, for 1/2 lower side rails for movement and mobility. Review of July 2024 through April 2025 Medication/Treatment Administration Records (MAR/TAR) indicated 1/2 lower side rails were in place as ordered by the physician. Further review of the medical record indicated a side rail consent form, signed by Resident #5's HCP on 3/29/25. The form indicated that consent must be obtained prior to placing the side rails on the bed. The consent form included lines for the Resident's name, date of discussion with staff, date last reviewed by the facility that were blank. During an interview on 4/1/25 at 2:28 P.M., the DON said that nursing staff were supposed to provide information to residents and their representatives about the risks and benefits of side rails use and complete the consent form. During an interview on 4/1/25 at 3:20 P.M., Resident #5's HCP said that he was called by the facility a few weeks ago and told that he needed to sign admission paperwork because it was not done when the Resident was originally admitted in July 2024. He said he came into the facility on [DATE] and signed a stack of paperwork that was given to him and was not sure what they were. He said there was no nurse available to go over the paperwork with him, so he just signed it all. He said no one reviewed the risks and benefits for the use of side rails with him. During an interview on 4/2/25 at 10:05 A.M., the Social Worker said during a random medical record audit, she found that no admission consents were signed when Resident #5 was admitted in July 2024. She said she called the Resident's HCP and asked him to come in and sign admission paperwork. During an interview on 4/2/25 at 12:20 P.M., Unit Manager #1 said that Resident#5's HCP should have been provided admission paperwork including information about the risks and benefits of side rail use and signed the consent form before the siderails were put into place but was not.

Based on document review and interview, the facility failed to ensure the legally responsible representatives were notified of changes in a resident's condition for two Residents (#77 and #44), out of a total sample of 18 residents. Specifically, the facility failed to: 1. Inform the legal guardian of Resident #77 of the development of a facility acquired deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin often appearing as a deep bruise) to the right heel on 2/2/25 or of the physician evaluation of the area on 2/4/25; and 2. Notify the Health Care Proxy (HCP) of Resident #44 of a significant weight loss. Findings include: Review of the facility's policy titled Notification of Changes, dated as reviewed/revised 10/2024, indicated but was not limited to the following: The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. DEFINITION: Clinical complications: examples - development of pressure injury Need to alter treatment significantly: commence a new form of treatment to deal with a problem COMPLIANCE GUIDELINES: The facility must inform the resident, consult with the resident's physician and/or notify the family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: - a significant change in the resident's condition, such as deterioration in health, mental or psychosocial status; this may include clinical complications - circumstances that require a need to alter treatment; this may include: new treatment Additional considerations: - Resident incapable of making decisions: the representative would make any decisions that have to be made 1. Resident #77 was admitted to the facility in January 2025 and had diagnoses including: unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set (MDS) assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission until 2/11/25, naming Family Member #2 his/her legal guardian. Review of the medical record indicated Resident #77 had developed a DTI on his/her right heel, first identified on 2/2/25 and evaluated by the wound physician on 2/26/25 at which time new orders were received. The record failed to indicate the Resident's legal guardian at the time, Family Member #2, was notified of the development of the pressure ulcer or any treatments necessary. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said Family Member #2 was the legal guardian at the time the wound on the right heel developed and is the person that assists with treatment decisions for the Resident. During an interview on 4/1/25 at 1:27 P.M., Nurse #7 said when there is any change in condition, including the development of a wound, the Nurse would notify the physician or Nurse Practitioner (NP), the resident, and their HCP or legal guardian. He said he does not know if Family Member #2, who was the legal guardian for Resident #77 was notified at the time the right heel wound was identified. During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said he was the legal guardian for Resident #77 from November 2024 until 2/11/25. He said he was not notified about the Resident developing a DTI pressure wound on their heel and was unaware any treatments or wound physicians were involved in the Resident's care. He said the facility did not communicate well with him, even when he was the legal court ordered guardian. During an interview on 4/2/25 at 10:21 A.M., the Unit Manager reviewed the medical record for Resident #77 and said she could not find any documentation or evidence that Family Member #2, who was the legal guardian at the time the right heel wound developed, was notified that the wound had developed or that the Resident was evaluated by a wound specialist and new treatment orders were received. She said since the guardianship was still valid and active at the time of the wound developing Family Member #2 should have been notified and it appears they were not. During an interview on 4/3/25 at 10:09 A.M., the Director of Nurses (DON) reviewed the medical record of Resident #77 and said there was no documentation to indicate Family Member #2, who was the legal guardian at the time, had been notified that the Resident had developed a wound on his/her right heel and he should have been in accordance with the policy and standard. 48695 2. Resident #44 was admitted to the facility in October 2022 with diagnoses including dysphagia (difficulty swallowing). Review of the MDS assessment, dated 1/17/25, indicated Resident #44 had a severe cognitive deficit as evidenced by a BIMS score of 4 out of 15. Further review of Resident #44's MDS indicated he/she had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and his/her HCP was activated. Review of Resident #44's weight change note, dated 1/8/25, indicated but was not limited to: - On 1/6/25 Resident #44 weighed 108.8 pounds. On 10/2/24, Resident #44 weighed 124 pounds which is a weight loss of 15 pounds in the past 3 months, 12.2% considered significant. - NP/MD aware of weight trends. Further review of Resident #44's medical record failed to indicate his/her HCP was notified of his/her significant weight loss. During a telephonic interview on 4/2/25 at 10:29 A.M., Resident #44's HCP said they were not aware of Resident #44's weight loss. During an interview on 4/2/25 at 12:14 P.M., Nurse #5 said if a resident had a change in condition the facility must notify the Physician or NP and their Responsible Party/HCP if activated and document it in a nurse's note. Nurse #5 and surveyor reviewed Resident #44's medical record. Nurse #5 said she could not find any evidence of Resident #44's HCP being notified of their weight loss. During an interview on 4/2/25 at 2:19 P.M., the Unit Manager (UM) said if a resident had a change of condition their HCP or Guardian must be notified of the change and the notification must be documented in the resident's medical record. The UM and the surveyor reviewed Resident #44's medical record. The UM said Resident #44 had a significant weight loss in January 2025 and she could not find any documentation of his/her HCP being notified of the weight loss. The UM said Resident #44's HCP should have been notified of their weight loss but was not. During an interview on 4/2/25 at 4:02 P.M., the Director of Nursing (DON) and the surveyor reviewed Resident #44 medical record. The DON said he did not see any evidence of Resident #44's HCP being notified of their weight loss. The DON said Resident #44's HCP should have been notified of their weight loss but was not.

Based on document review and interview, the facility failed for one Resident (#77), out of a total sample of 18 residents, to involve the Resident's legal guardian in the baseline care plan process and offer or provide them with a copy of the baseline care plan summary. Findings include: Review of the facility's policy titled Baseline Care Plans, dated as reviewed/revised: 9/2024, indicated but was not limited to the following: - a baseline care plan will be developed within 48 hours of a resident's admission - a written summary of the baseline care plan shall be provided to the resident and representative in a language they can understand; the summary shall include the initial goals of care, summary of the resident's medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility - the person providing the written summary of the baseline care plan shall obtain a signature from the resident/representative to verify the summary was provided and make a copy for the medical record - if the summary was provided by telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident representative Resident #77 was admitted to the facility in January 2025 and had diagnoses including: Unspecified intracranial injury, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, and abnormal posture. Review of the Minimum Data Set assessment, dated 1/14/25, indicated Resident #77 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 Further review of the medical record indicated Resident #77 had a court ordered temporary guardian in place at the time of admission until 2/11/25, naming Family Member #2 his/her legal guardian. During an interview on 4/1/25 at 12:27 P.M., Resident #77 and Family Member #1 said they do not recall having any meetings regarding a care plan or what services the facility planned on offering the Resident, nor have they been offered or received any documents that summarize the care and plan for the Resident's stay. They said Family Member #2 was the legal guardian at that time and is the person that assists with treatment decisions for the Resident. Review of the medical record for Resident #77 failed to indicate a baseline care plan meeting was provided or summary was created within the first 72 hours of the Resident's stay at the facility. Further review indicated the facility did have an initial care plan meeting on 1/30/25, but the legal guardian was not in attendance, nor was the Resident, and a copy of the care plans was not documented as being offered (this question was left blank). During an interview on 4/1/25 at 4:53 P.M., Family Member #2 said he was the Resident's legal guardian from November 2024 until 2/11/25. He said the facility did not communicate well with him. He said he was not involved in any care plan meeting, or offered to be, nor was he offered a copy or summary of the baseline care plan summary. He said this involvement and these documents would certainly have been beneficial for him to have better insight into the care and services the facility was providing to Resident #77 since he lives out of state. Review of the progress notes for Resident #77 failed to indicate a discussion was had with Family Member #2 (the legal guardian at the time of admission) regarding the Resident's initial goals of care, summary of the resident's medications and dietary instructions, any services or treatments to be administered by the facility and personnel acting on behalf of the facility or a baseline care plan was mailed to or offered to Family Member #2. During an interview on 4/2/25 at 10:07 A.M., the Unit Manager reviewed the Resident's medical record and said she could not find any evidence or documentation that Resident #77's legal guardian was involved or offered a care plan summary or a copy of the baseline care plans as he should have been. She said the process for baseline care plans does not appear to have been followed. During an interview on 4/2/25 at 1:42 P.M., the Social Worker said she had a brief talk with Family Member #2 at the time of admission when she was doing her evaluation of the Resident. She said to the best of her knowledge Family Member #2 was not offered or mailed a copy of the baseline care plans and was not involved in the initial care plan meeting.

Based on record review and interview, for one of three sampled residents (Resident #2), the Facility failed to ensure that Resident #2, who was treated for [REDACTED]. The Director of Nurses (DON) said Resident #2 had nine falls in about two weeks because Resident #2 fell before staff responded to the bed alarm. Physician #1 said Resident #2 had his/her ninth and last fall on [DATE], sustained a bruise and hematoma above the right eye, was found unresponsive on [DATE], and died in the Hospital due to a subdural hematoma from one of the falls at the Facility. Findings include: The Hospital Discharge Summary, dated [DATE], indicated that Resident #2 was admitted to the Hospital after being found at home on the floor with multiple different age bruises throughout his/her body and was treated for [REDACTED]. The Hospital Discharge Summary indicated that Resident #2 was stabilized and transferred to the Facility for continued care and recommendations included: Vicodin one tablet every four hours as needed (PRN) for pain, Klonopin 0.5 milligram (mg) three times daily (TID) as needed for anxiety, and Lovenox (anticoagulant medication to prevent a stroke) 30 mg. subcutaneously (SC) two times daily (BID) The Hospital Discharge Summary indicated that Resident #2's [DIAGNOSES REDACTED]. The Patient Nursing Evaluation Form indicated that Resident #2 was admitted to the facility on October, 2011. The admission physician orders, dated [DATE], included Vicodin one tablet every four hours PRN for pain, Klonopin 0.5 mg TID PRN for anxiety, and Lovenox 30 mg. SC BID. The admission evening shift nurse's note, dated [DATE], indicated that Resident #2 was admitted from the hospital following treatment for [REDACTED]. The admission evening shift nurse's note indicated that Resident #2 was provided a bed alarm and floor mats as safety precautions. The admission plan of care, dated [DATE], indicated that Resident #2 was at high risk for falls due to a history of falls and a brain bleed that resulted in left sided weakness. The plan of care interventions included: a bed in the lowest position, reminding him/her to request assistance for transfers, call light within reach, provide a wheelchair for mobility, keep area free of clutter, bed alarm, and floor mats. The night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]) nurse's note, indicated Physician #1 was notified that Resident #2 had a fall, was unable to stand after the fall, and complained of pain all over. The nurse's note indicated that vital signs were within normal limits (WNL), and new orders were obtained from the physician to transfer Resident #2 to the Hospital for an evaluation. The Director of Nurses (DON) was interviewed at 7:40 A.M. on [DATE] and at 7:15 A.M. on [DATE]. The DON said she was hired after Resident #2 had died but was able to review the clinical record and the previous DON's internal investigations. The DON said Resident #2's first fall occurred at 1:50 A.M. on [DATE]. The Facility's ([DATE]) internal investigation report (report), indicated that Resident #2's bed alarm was activated, mats were on the floor, the bed was in the lowest position, and the call light was within reach prior to the fall. The report indicated that Resident #2 transferred out of bed without assistance, landed on the floor mat next to the bed at 1:50 A.M. on [DATE]. The report indicated that Resident #2 was unable to explain why he/she was getting out of bed. The report indicated Physician #1 was notified that Resident #2 had a bruise on his/her upper chest area after the fall and Physician #1 gave new orders to transfer Resident #2 to the Hospital for evaluation. The Hospital head and cervical spine CAT (computed axial tomography) Scan reports, dated [DATE], indicated no evidence of intracranial hemorrhage or fracture. The Hospital Emergency Department (ED) report, dated [DATE], indicated that Resident #2, returned to the facility on the same day with recommendations to return if a problem developed. The fall risk assessment, dated [DATE], indicated that Resident #2 was at high risk for falls due to disorientation, prior falls, incontinence, poor vision, balance problem while standing or walking, decreased muscular coordination, the effects of medications, and predisposing conditions. The DON said no new interventions were added to Resident #2's plan of care following his/her first fall out of bed. The DON said Resident #2's second fall out of bed occurred at 5:30 P.M. on [DATE]. The Facility's ([DATE]) internal investigation report (report) indicated that Resident #2's bed alarm was activated, mats were on the floor, and the bed was in the lowest position prior to the fall. The report indicated that Resident #2 said he/she fell out of bed while reaching for an unidentified object and landed on the floor mat next to the bed at 5:30 P.M. on [DATE]. The report indicated that Resident #2 had no apparent injury and Physician #1 was notified. The DON said no new interventions were added to Resident #2's plan of care following his/her second fall out of bed. The DON said Resident #2's third fall out of bed occurred at 7:45 A.M. on [DATE]. The Facility's ([DATE]) internal investigation report (report) indicated that Resident #2's bed alarm was activated, mats were on the floor, the bed was in the lowest position, and the call light was within reach prior to the fall. The report indicated that Resident #2 transferred out of bed without assistance, landed half on the floor mat next to the bed and half on the floor at 7:45 A.M. on [DATE]. The report indicated that Resident # 2 was unable to explain why he/she was getting out of bed. The repot indicated that Physician #1 was notified and gave a new order for electrical stimulation to the lower back for chronic pain management. The DON said no new interventions were added to Resident #2's plan of care following his/her third fall out of bed. The DON said Resident #2's fourth fall out of bed occurred at 7:30 A.M. on [DATE]. The Facility's ([DATE]) internal investigation report (report) indicated that Resident #2's bed alarm was activated, mats were on the floor, the bed was in the lowest position, and the call light was within reach prior to the fall. The report indicated that Resident #2 said she fell out of bed while trying to get out of bed to use the bathroom, landed on the floor mat next to the bed at 7:30 A.M. on [DATE], had no apparent injury, and was transferred back to bed. The report indicated that Physician #1 was notified and no new orders were given on [DATE]. The report indicated that Physician #1 ordered a urine test on [DATE] to rule out a urinary tract infection. The DON said no new interventions were added to Resident #2's plan of care following his/her fourth fall out of bed and the urine test was negative for an infection. The DON said Resident #2's fifth fall out of bed occurred at 7:30 P.M. on [DATE]. The DON said she could not find a Facility internal investigation report following Resident #2's fifth fall out of bed. Unit Manager #2 was interviewed at 8:00 A.M. on [DATE] and at 2:30 P.M. on [DATE]. Unit Manager #2 said she was assigned to supervise Resident #2's unit during the evening shift on [DATE]. Unit Manager #2 said she recalled responding to Resident #2's bed alarm sounding and found Resident #2 lying on the floor mat. Unit Manager #2 was unable to explain why he/she attempted to get out of bed; his/her bed was in the lowest position, and his/her call light was within reach. Unit Manager #2 said she recalled completing an internal investigation report and gave it to the previous DON. Unit Manager #2 said Resident #2's neurological signs remained within normal limits and Physician #1 was notified of the fall. Unit Manager #2 said Resident #2 had no apparent injuries and no new orders were given except to discontinue neurological signs unless a significant change was noted. The evening shift nurse's note, dated [DATE], indicated Physician #1 was notified that Resident #2 was found on the mat next to the bed with no apparent injury and new orders were obtained to discontinue neurological signs unless a significant change was noted. The evening shift nurse's note indicated Resident #2's family was notified and requested not to be notified regarding every roll out of bed onto the floor mat unless an injury occurred. The DON said no new interventions were added to Resident #2's fall plan of care following his/her fifth fall out of bed. The DON said Resident #2's sixth fall out of bed occurred at 2:30 A.M. on [DATE]. The Facility's ([DATE]) internal investigation report (report)indicated that Resident #2's bed alarm was activated, mats were on the floor, the bed was in the lowest position, and the call light was within reach prior to the fall. The report indicated that on [DATE] at 2:30 A.M. Resident #2 transferred out of bed without assistance, landed partially on the floor mat next to the bed, his/her head was on the floor (off the mat), one leg was on the bed, and the other leg was on the floor. The report indicated that resident #2 was unable to explain why he/she was getting out of bed. The report indicated that Physician #1 was notified of the fall. The DON said no new interventions were added to Resident #2's fall plan of care following his/her sixth fall out of bed. Physician #1's progress note, dated [DATE], indicated that Resident #2 had multiple falls at the Facility; he/she continued to have no judgment regarding her physical abilities and had no signs of a cerebral bleed. The progress note indicated that recommendations included long term care and the same plan of care. The DON said Resident #2's seventh fall out of bed occurred at about 7:00 A.M. on [DATE]. The DON said she could not find an internal investigation report following the seventh fall out of bed. Nurse #3 was interviewed at 2:45 P.M. on [DATE]. Nurse #3 said she completed an event report that was given to the previous DON. Nurse #3 said she responded to a bed alarm and found Resident #2 lying on his/her left side on the floor mat next to the bed with old bruising around the left eye and no other injury noted. Nurse #3 said she notified Physician #1 of the fall and that Resident #2 complained of a headache The day shift nurse's note, dated [DATE], indicated Physician #1 was notified that Resident #2 was found lying on his/her left side on the floor mat next to the bed with old bruising around the left eye and no other injury noted. The nurse's note indicated that Resident #2 complained of a headache, and received Vicodin one tablet for the headache. The DON said no new interventions were added to Resident #2's fall plan of care following his/her seventh fall out of bed. The DON said Resident #2's eighth fall out of bed occurred at about 5:00 A.M. on [DATE]. The DON said she could not find the Facility's internal investigation report following the eighth fall out of bed. Unit Manager #1 was interviewed at 8:45 A.M. on [DATE]. Unit Manager #1 said she was assigned to Resident #2's nursing care needs during the night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]). Unit Manager #1 said staff responded to Resident #2's bed alarm and she found Resident #2 lying on his/floor mat with no apparent injury. Unit Manager #1 said a message was left for Physician #1 that Resident #2 sustained a fall out of bed with no apparent injuries. Unit Manager #1 said Physician #1 gave no new orders. Unit Manager #1 said the event report was left for the previous DON. The night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]) nurse's note, indicated that Resident #2 was given Vicodin at 1:30 A.M. for a headache with good effect, The nurse's note indicated that Resident #2's vital signs and neurological signs remained within normal limits. The night shift nurse's note indicated that staff responded to Resident #2's bed alarm at 5:00 A.M. and found Resident #2 lying on the floor and he/she was unable to explain why he/she attempted to get out of bed. The nurse's note indicated that Resident #2 was assessed and had no apparent injury The DON said Resident #2's fall plan of care was updated on [DATE] following the eighth fall out of bed. Resident #2's care plan for falls, updated [DATE], indicated that Resident #2 was provided bed bolsters. The DON said Resident #2's ninth fall out of bed occurred at about 4:00 P.M. on [DATE]. The ([DATE]) internal investigation report (report) indicated that Resident #2's bed alarm was activated, mats were on the floor, the bed was in the lowest position, bed bolsters were in place, and the call light was within reach prior to the fall. The report indicated that Resident #2 said he/she fell out of bed while reaching for an unidentified object, was found on his/her knees and then fell on the right side of his/her on [DATE] at 4:00 P.M. The report indicated that Resident #2 sustained a bruise above his/her right eye. The report indicated that Physician #1 was notified of the fall and that Resident #2 sustained a bruise above the right eye. The evening shift nurse's note, dated [DATE], indicated that Resident #2's bed alarm sounded, he/she was found on the floor lying on his/her right side, Physician #1 was notified of the fall and that Resident #2 sustained a bruise and hematoma above the right eye, neurological signs and vital signs remained stable, and Physician #1 gave no new orders Unit Manager #2 said she was assigned to supervise Resident #2's unit during the evening shift on [DATE]. Unit Manager #2 said she recalled responding to Resident #2's bed alarm, found Resident #2 lying on the floor mat on his/her right side, said he/she was attempting to reach an unidentified object, his/her bed was in the lowest position, and her call light was within reach. Unit Manager #2 said Resident #2's neurological signs remained within normal limits and Physician #1 was notified of the fall, new bruise and hematoma above the right eye. Unit Manager #2 said Physician #1 gave no new orders other than monitoring Resident #2. The DON said no new interventions were added to Resident #2's fall plan of care following his/her ninth fall out of bed. The night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]) nurse's note, indicated that Resident #2's vital signs and neurological signs remained stable; he/she was given Vicodin one tablet and Klonopin one tablet at 4:00 A.M. for generalized body discomfort with a good effect. The Surveyor interviewed Nurse #4 at 3:15 P.M. on [DATE]. Nurse #4 said she was assigned to Resident #2's nursing care needs during the night shift (11:00 P.M. on [DATE] to 7:00 A.M. on [DATE]). Nurse #4 said Resident #2 acted like his/her usual self that included restlessness and complaints of generalized discomfort. Nurse #4 said she medicated Resident #2 for generalized discomfort and restlessness with a good effect. Nurse #4 said she monitored Resident #2's vital signs and neurological signs and they remained stable when checked during morning rounds about 6:30 A.M. Nurse #4 said Resident #2 rested comfortably during morning shift rounds with no signs of distress. The day shift nurse's note, dated [DATE], indicated that Resident #2 was transferred to the Hospital via a 911 call due to a sudden change in status at about 8:00 A.M. that included labored and rapid breathing of greater than 40 breaths per minute, a rapid pulse rate of greater than 150 beats per minute, an elevated temperature of 100.4 degrees Fahrenheit, he/she was unresponsive, and his/her pupils were unequal. The day shift nurse's note indicated Physician #1 and the family were notified. The Surveyor interviewed Physician #1 at 9:30 AM on [DATE] and at 12:30 P.M. on [DATE]. Physician #1 said he was very familiar with Resident #2's medical care needs because he had cared for him her in the community, as well as, in the Facility. Physician #1 said Resident #2 was admitted for long term care following brain surgery, continued the anticoagulant medication Lovenox to prevent a stroke that placed him/her at greater risk for bleeding. Physician #1 said he was notified of each fall and staff reported that Resident #2's vital signs and neurological signs remained stable until the morning of [DATE]. Physician #1 said Resident #2 was admitted to the hospital with [REDACTED].#2 died from a subdural hematoma most likely due to one of his/her many falls at the Facility. The DON said she reviewed the internal investigations and believed Resident #2's many falls were not prevented because Resident #2 had fallen out of bed before staff responded to the bed alarms that had sounded and the care plan was not updated until after the eighth fall. Resident #2's Certificate of Vital Record (death certificate), issued [DATE], indicated that the immediate cause of Resident #2's death was a subdural hematoma due to blunt force impact (fall).