Every finding on record at Regalcare at Worcester

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required hemodialysis (a life-saving treatment that filters waste products and excess fluid when the kidneys stop working) three times a week for end stage renal disease (ESRD), the facility failed to ensure Resident #1 received the care and services consistent with his/her care plan, when Resident #1 missed a dialysis session because of a transportation issue and miscommunication with the dialysis center, he/she went four days without receiving dialysis and when he/she was transported to the dialysis center for treatment, he/she required Hospital transfer due to a change in status. Findings include: Review of the Facility's Policy, titled Care of Resident with End Stage Renal Disease, dated as revised 4/2022, indicated the following: -Residents with ESRD will be cared for according to currently recognized standards of care. -If a resident has been identified in need of hemodialysis, the resident will receive dialysis treatment from a Dialysis Facility. -Transportation to and from an off-site [dialysis treatment] location will be arranged by the nursing staff. Resident #1 was admitted to the facility in April 2025, diagnoses included ESRD with dependence on dialysis, Stage IV (full thickness tissue skin and tissue loss with exposed muscle, tendon, ligaments, cartilage or bone in the ulcer; slough and/or eschar/dead tissue may be visible) sacrum pressure injury, and Diabetes Mellitus. Review of Resident #1's Hospital Discharge Summary, dated 04/03/25, indicated he/she was to continue with hemodialysis every Monday, Wednesday, and Friday. Review of Resident #1's Admission Nursing Evaluation, dated 04/03/25, indicated Resident #1 received his/her most recent dialysis treatment on (Wednesday) 04/02/25. Review of Resident #1's Nursing Progress Note, dated (Friday) 04/04/25, indicated Nurse #1 received a call from Resident #1's Dialysis Center because he/she did not attend the dialysis treatment scheduled for that morning. The Note indicated that Resident #1 was re-scheduled to receive dialysis on (Saturday) 04/05/25. During a telephone interview on 05/07/25 at 10:08 A.M., the Dialysis Center's Clinical Manager said she notified the Facility on (Friday) 04/04/25 that there were no openings to accommodate Resident #1 until his/her next scheduled dialysis treatment on (Monday) 04/07/25. The Clinical Manager said she was confused when Resident #1 arrived at the Dialysis Center on (Saturday) 04/05/25 because there was no scheduled dialysis treatment for him/her that day. The Clinical Manager said when Resident #1 arrived at the Dialysis Center on (Monday) 04/07/25, he/she was unstable, confused, and lethargic, therefore, he/she was transferred to the Hospital ED for evaluation. Review of Resident #1's Nursing Progress Note, dated 04/05/25, indicated Resident #1 was transported to the Dialysis Center but they did not have an opening to accommodate Resident #1 and he/she was transported back to the facility [without having received dialysis treatment]. The Note indicated that a Nurse Practitioner was notified and advised that Resident #1 remain at the facility until his/her scheduled dialysis treatment on Monday (04/07/25). During a telephone interview on 05/06/25 at 9:13 A.M., the Facility's Admission Liaison said the Facility was aware of Resident #1's pending admission several days prior to him/her being admitted to the facility and that nursing was responsible for booking transportation to his/her dialysis treatments. During an interview on 05/06/25 at 3:15 P.M., the Assistant Director of Nurses said it was her understanding that Resident #1's family member booked his/her transportation for the scheduled dialysis treatments. During a telephone interview on 05/07/25 at 10:00 A.M., the Customer Service Representative at the Transportation Company said the first transportation booking for Resident #1 in April 2025 was for a pick up at the facility on (Saturday) 04/05/25. Review of Resident #1's Medication Administration Record (MAR) for the month of April 2025 indicated his/her physician's order to attend dialysis three days a week on Monday, Wednesday, Friday with a transport pick up time of 6:30 A.M., was not obtained by the nursing staff until 04/09/25 (several days after Resident #1's admission to the facility and two days after he/she was transferred to the Hospital ED). During a telephone interview on 05/08/25 at 10:32 A.M., the Director of Nurses (DON) said that it was her understanding that Resident #1's family had set up transportation for him/her to attend their dialysis treatments, but usually the Unit Managers booked transportation for the residents who required dialysis services. The DON said that Resident #1's physician's orders for dialysis should have been put in place at the time of his/her admission to the facility. The DON said that the whole admission process [for Resident #1] was a mess from the start.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission had specific physician's orders for treatment of his/her pressure injury, the facility failed to ensure that the treatment orders transcribed and provided by nursing were appropriate and adequate to treat his/her wound. Findings include: Review of the Facility's policy titled Pressure Ulcer/Injuries Overview, with a revision date of 03/2022, indicated the following: -Pressure Ulcer/Injury refers to localize damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Debridement methods may include a range of treatments such as the use of enzymatic dressings to surgical debridement in order to remove tissue or matter from a wound to promote healing. Resident #1 was admitted to the facility in April 2025, diagnoses included End Stage Renal Disease with dependence on dialysis (a life-saving treatment that filters waste products and excess fluid when the kidneys stop working), Stage IV (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the wound, slough and/or eschar/dead tissue may be visible) sacrum pressure injury, and diabetes mellitus. Review of Resident #1's Hospital Discharge Summary, dated 04/03/25, indicated he/she had a Stage IV sacral pressure injury and to continue wound care which consisted of Collagenase Topical (medication used to treat severe burns or pressure injuries in adults, helps to remove dead skin tissue and aid in wound healing) 250 units per gram ointment that was to be applied daily. Review of Resident #1's Admission Nursing Evaluation, dated 04/03/25 and signed by Nurse #5, indicated Resident #1 had a pressure injury on the coccyx [sacral area]. Review of Resident #1's Nursing Progress Note, dated 04/04/25 and written by Nurse #1, indicated he/she had a sacral wound which measured 4.4 centimeters (cm) x 8.5 cm, wash area with normal saline, pat dry, and apply dry protective dressing (DPD) until seen by the Physician. During a telephone interview on 05/06/25 at 12:50 P.M., Nurse #5 said he was the nurse on duty for the 3:00 P.M. through 11:00 P.M. shift on 04/03/25 and completed the Admission Nursing Evaluation for Resident #1. Nurse #5 said it was protocol to follow the wound treatment orders that were listed on the Hospital Discharge Summary. Nurse #5 said he was the only nurse on that night so he may not have entered Resident #1's wound treatment orders but that the next shift nurse could pick-up any orders that may have been missed. Review of Resident #1's Initial Admission History and Physical, dated 04/05/25 and signed by Physician #1, indicated Resident #1 had multiple wounds including a Stage IV sacral wound and the plan included wound care and pressure relief. During a telephone interviews on 05/06/25 at 12:15 P.M. and 05/07/25 at 11:40 A.M., Nurse #1 said she was Resident #1's nurse for the day shift (7:00 A.M. through 3:00 P.M.) on 04/04/25. Nurse #1 said she did not reference Resident #1's Hospital Discharge Summary when she notified Resident #1's provider to obtain wound care treatment orders. Nurse #1 said she did not remember what Resident #1's wound looked like but said the facility's protocol was to put a treatment order in place until the resident could be evaluated by the Facility's Wound Nurse Practitioner (NP). Review of Resident #1's Treatment Administration Record (TAR) for the month of April 2025, indicated Resident #1 received wound care to his/her sacrum which consisted of the following: normal saline wash and a DPD, which was applied daily from 04/05/25 through 04/07/25. During a telephone interview on 05/07/25 at 9:00 A.M., Physician #1 said he was in the facility on 04/05/25 to complete Resident #1's Initial History and Physical. Physician #1 said he did not visualize Resident #1's wound but knew that he/she had a quite advanced pressure injury. Physician #1 said he expected nursing staff to refer to the Hospital Discharge Summary when requesting wound care treatment orders and thought Resident #1 was receiving Collagenase to his/her [sacral] wound because that was what he/she received in the Hospital. Physician #1 said it was their fault that the correct treatment was not initiated. During a telephone interview on 05/08/25 at 10:32 A.M., the Director of Nurses (DON) said the facility's protocol was to follow the wound care treatment orders listed on the Hospital Discharge Summary until the resident could be seen by the facility's Wound Nurse Practitioner (NP). The DON said the Wound NP comes to the facility weekly but Resident #1 was transferred to the hospital before the Wound NP was able to assess his/her wound. The DON said Normal Saline with a DPD would not be the standard of care for the treatment of a Stage IV pressure injury and the wound treatment orders on Resident #1's Hospital Discharge Summary should have been implemented.

Based on observations, and interviews, the facility failed to maintain a safe and sanitary smoking environment for residents, staff, and visitors. Specifically, the facility failed to: -Ensure that proper signage was visible to designate resident smoking areas. -Ensure residents were smoking in the designated smoking areas and not on the facility sidewalks and driveways. -Ensure residents were safely disposing of cigarette materials/refuse in the designated receptacles to prevent the risk of starting a fire when cigarettes were thrown near shrubs, mulch and on the ground with other trash. Findings include: Review of the facility policy titled, Smoking, effective April 2017 Revised March 2022, indicated: -This facility shall establish and maintain safe resident smoking practices. -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers with self-closing cover devices are available in smoking areas. -Ashtrays are emptied only into designated receptacles. On 4/16/25 between 10:02 A.M. - 10:27 A.M., surveyor #1 observed the following: -Ten residents smoking on the sidewalk along the left side of the building. -Several chairs, a fire extinguisher and three covered cigarette receptacles were located in the sidewalk area. -Three residents were observed to be smoking in the circular driveway in front of the facility main entrance. -A No Smoking sign was observed on the right side of the lawn next to the facility main entrance. -The ground surrounding the front entrance was observed with copious amounts of cigarette butts thrown on the ground. -The cigarette butts and other smoking associated trash were observed along the sidewalk of the circular driveway, in the landscaped area in front of the covered porch around the shrubbery and mulch, and on the grass and sidewalk surrounding the chairs on the left side of the building where the ten residents were observed smoking. -Four residents in the designated smoking area were observed throwing their cigarettes on the ground when they were done smoking. -Three residents in the circular driveway were also observed throwing their cigarettes on the ground. -The Staff Aide supervising the resident smokers was not observed directing the residents to use the covered cigarette receptacles to dispose of their cigarettes. -No staff intervention was observed when the residents did not dispose of their cigarettes in the covered cigarette receptacles. During an interview at the time, the Administrator said the smoking area is regularly cleaned, but the residents are always out smoking, and it was difficult to keep up and keep the area clean. The Administrator said the residents should be using the cigarette receptacles to dispose of their cigarettes and the staff supervising smoking should be directing the residents to dispose of the cigarettes in the appropriate covered receptacles. On 4/16/25 between 10:29 A.M. - 10:37 A.M., surveyor #2 observed the following: -The covered porch area next to the main entrance of the facility had three chairs, a bench, a table and a fire extinguisher. -Multiple cigarette butts were observed on the lawn next to the facility main entrance and on the circular driveway. -One resident sitting in the designated smoking area which had 3 smoking receptacles and several chairs. -Cigarette butts were observed on the ground in the designated smoking area. -Residents were observed throwing cigarettes on the ground instead of disposing in the smoking receptacles. During an interview on 4/17/25 at 12:20 P.M., the Administrator said when there is inclement weather the residents smoke on the covered patio next to the facility main entrance. The Administrator said he considers both areas, the covered porch by the main entrance and the sidewalk area at the end of the driveway on the left side of the building, as designated smoking areas, and that was where the residents should be smoking. The Administrator said the No Smoking sign only pertains to the right side of the area by the main entrance. The Administrator said there was no signage to designate smoking areas because all the residents know where the smoking areas were located, and smoking designated area signs were not needed.

Based on interview and record review, the facility failed to provide privacy for residents during Resident Council meetings. Specifically, the facility failed to provide a private meeting space for Resident Council meetings where facility staff was not using the meeting space area as a conduit to other building areas during times when Resident Council meetings were in progress. Findings include: Review of the facility's Residents Rights located in the admission Packet, undated indicated: -You have the right to organize and participate in Resident groups in the facility. -You have the right to privacy in accommodations, in receiving personal and medical care and treatment, in written and telephone communications, in visits, and meetings with family and Resident groups. During the Resident Group meeting held on 4/16/25 at 11:00 A.M., the surveyor interviewed 15 residents who were in attendance: -10 of the 15 Residents in attendance said that the space provided by the facility was not private and that staff frequently cut through the space during their meetings to get to other units in the building. -The Resident Council President said that this was the first time in a long time that the group had had privacy during their meeting. The surveyor observed that the Resident Council group meeting space that was reserved by the facility staff was divided by a hallway running down the middle, with two sets of double doors that were closed on either end. During an interview on 4/16/25 at 1:54 P.M., the Activities Director (AD) said that she was responsible for helping the Residents organize the Resident Council meetings. The AD said that in 2024, the Resident Council meetings had been interrupted by staff walking through the hallway approximately four times. The AD also said that staff should not have been present at the Resident Council meetings because the Residents wanted their privacy, and privacy had not been respected.

Based on observations, and interviews, the facility failed to maintain a homelike environment on two units (Unit 2 and Unit 4) out of four resident units. Specifically, the facility failed to: -On Unit 2, maintain eight out of 22 resident rooms and the activity room in a safe, clean, comfortable and homelike environment. -On Unit 4, ensure that 19 out of 19 resident rooms were maintained in a safe, clean, comfortable and homelike environment. Findings include: Review of the facility policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment, not dated, indicated: -that the facility will provide a safe, clean, comfortable and homelike environment. On 4/15/25 from 2:49 P.M. to 3:08 P.M., on Unit 2, the following was observed in Resident Rooms and the Activity Room by Surveyor #1: room [ROOM NUMBER]- Gouges in the wall behind the headboard of one resident's bed. room [ROOM NUMBER]- The room nightlight was nonfunctional. room [ROOM NUMBER]- The bathroom door and both closet doors had large gouges, scrapes, and holes. room [ROOM NUMBER]- The closet door had a deep hole and the wall had gouges and scrapes. room [ROOM NUMBER]- The bathroom sink was clogged, the wall underneath the window had gouges, scrapes, and holes, and the heating vent was dented with the ends exposed and uncovered. room [ROOM NUMBER]- The wall had scrapes with missing paint behind the headboard of one resident's bed. room [ROOM NUMBER]- The wall had scrapes with missing paint behind the headboard of one bed. room [ROOM NUMBER]- The night light was missing a cover with the lightbulb and wiring exposed. Activity/Unit Dining Room- The wall had gouges and scrapes. On 4/15/25 from 3:10 P.M to 3:36 P.M., on Unit 4, the following was observed in Resident rooms by Surveyor #2: room [ROOM NUMBER]- Gouges in the wall, the wallpaper was torn, and one window had silver utility tape on the edges. Rooms 402, 403, 404, and 405 - had gouges in the wall behind one resident's bed. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed, torn wallpaper, and a lightbulb with an exposed lightbulb in the hallway outside of the room. room [ROOM NUMBER]- The wall behind the door had a hole from the door handle. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed and a hole in the plastic trim. room [ROOM NUMBER]- Gouges in the wall and the wallpaper was ripped behind one resident's bed. room [ROOM NUMBER]- The wall had a hole with an exposed wire, gouges in the wall behind one resident's bed, and the wallpaper was ripped. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed. room [ROOM NUMBER]- The wall had holes behind both resident's beds. room [ROOM NUMBER]- The wall behind the door had a hole from the door handle, and a missing electrical outlet cover. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed, the floor was missing a floor tile, and the wallpaper was ripped. room [ROOM NUMBER]- Gouges in the wall behind one resident's bed, the wall had a hole behind the bathroom door from the door handle, and the wallpaper was ripped. room [ROOM NUMBER]- The wall had holes behind both resident's beds. room [ROOM NUMBER]- The wall had scrapes behind both resident's beds and the wallpaper was ripped. room [ROOM NUMBER]- The wall had scrapes behind one resident's bed, the base board trim had a hole, and the wallpaper was ripped. During an interview on 4/16/25 at 9:11 A.M., with surveyor #1 and Unit Manager (UM) #1, UM #1 said she was the manager for both Units 2 and 4. UM #1 said when there are maintenance issues identified, she will document a maintenance request in the log book on the unit. UM #1 said any staff are able to put requests in the log book and that the Maintenance Director is responsive and rounds on the units. UM #1 showed surveyor #1 where the Maintenance log book is kept at the nurses stations. Surveyor #1 and UM #1 reviewed the log book and failed to find any maintenance requests for repairs to walls, doors, lights, or electrical outlets documented for Rooms 201, 203, 206, 207, 211, 216, 217, 218, or the Activity/Dining Room. During an interview on 4/16/25 at 9:40 A.M., with surveyor #1, the Administrator and the Director of Clinical Operations, the Administrator said that the Maintenance Director was newly promoted into the position and works with the Regional Maintenance Director for support in the role. The Director of Clinical Operations said the facility is hiring for a second maintenance department staff member and other staff to complete painting projects. On 4/16/25 at 10:58 A.M., surveyor #1, the Maintenance Director and the Director of Clinical Operations toured Unit 2 and reviewed Rooms 201, 203, 206, 207, 211, 216, 217, 218, and the Activity/Dining Room. The Maintenance Director said he was aware of the need for repair to the wall in room [ROOM NUMBER] but that materials needed to be ordered for the repair. The Maintenance Director said that nursing staff put maintenance requests in the log books on each unit and he will do rounds in the morning, midday, and at the end of each day to check the books. The Maintenance Director said if there were immediate or emergent needs, nursing staff can contact him directly and he is easily available. Surveyor #1, the Maintenance Director, and the Director of Clinical Operations reviewed the last 90 days of maintenance logs for Units 2 and 4 and failed to find any documented requests relative to the damaged areas observed in the resident rooms. On 4/16/25 at 11:00 A.M., surveyor #1 conducted a Resident Council Group with 14 residents in attendance, who resided on four out of four units. During an interview at the time, 12 of the 14 residents in attendance said there were issues with the facility environment and problems such as holes in the walls, broken heating vents, and bathrooms needing repairs. The residents expressed frustration that these issues continued, and nothing happens. During an interview on 4/17/25 at 1:05 P.M., with surveyor #1, the Administrator said that the current facility renovation and remodeling project was partially complete and included future plans to remodel Unit 2 and Unit 4. The Administrator further said there was no quality improvement (QI) project relative to repairs or improving the environment on Unit 2 and Unit 4 prior to the survey team entrance.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#48) out of a total sample of 25 residents, increasing the risk of contamination and the spread of infections within the facility. Specifically, for Resident #48, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact care to the Resident during ADLs (Activities of Daily Living: such as bathing, dressing, grooming, personal hygiene) when providing high contact care to the Resident. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), last revised September 2022, indicated the following: -Enhanced barrier precautions are infection prevention intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) in the facility. >The precautions involve gown and glove use during high contact care activities for residents known to be colonized or infected with an MDRO, as well as those with an increased risk of contracting an MDRO. -Use of Enhanced Barrier Precautions includes, but not limited to residents, with indwelling medical devices or wounds (regardless of MDRO colonization or infection status) . -Examples of indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies/ventilators. -Examples of high contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Resident #48 was admitted to the facility in March 2022 with diagnoses including Neuromuscular Dysfunction of Bladder and Cerebral Palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #48: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible 15. -has an indwelling catheter (Foley) in place. Review of Resident #48's April 2025 Physician's orders indicated: -Enhanced Barrier Precautions related to (r/t) Foley, every shift, initiated 1/4/25. Review of Resident #48's Plan of Care for Enhanced Barrier Precautions, initiated 1/18/23 and revised 2/7/25, indicated the Resident was on EBP for suprapubic catheter care. On 4/15/25 from 9:24 A.M. to 9:33 A.M., the surveyor observed the following: -Signage outside of Resident #48's room, attached to the room name plate, indicating Enhanced Barrier Precautions (EBP). The EBP sign indicated: >Perform hand hygiene before and after patient contact, contact with environment, and after removal of PPE (Personal Protective Equipment). >Wear gown and gloves prior to these activities: *During High Contact Care Activities: *Dressing *Bathing/Showering *Transferring *Providing hygiene *Changing linens *Changing briefs or assisting with toileting *Device Care or use of a device (i.e central lines, urinary catheters, feeding tubes, tracheostomies, ventilators). -Clear storage bin with PPE including gloves and clean disposable blue gowns outside of the room. -Black trash bin outside of the room. >9:24 A.M.: -Nurse #1 was observed standing at the medication cart across the hall from Resident #48's room. -Staff Development Coordinator (SDC) was observed standing in the hall near Resident #48's room and assisting staff collecting breakfast trays. -Certified Nurses Aide (CNA) #1 and CNA #2 were observed to don gloves, did not don gowns, and entered Resident #48's room with a mechanical lift and closed the door for privacy. >9:29 A.M.: -CNA #1 was observed to open the door to reposition the mechanical lift in the room and Resident #48 was observed lifted in the mechanical lift. -CNA #1 and CNA #2 were observed wearing gloves, but were not observed wearing gowns. >9:33 A.M.: -CNA #1 was observed exiting the Resident's room with the mechanical lift, removed her gloves, and disposed of the gloves in the black trash bin. During an interview on 4/15/25 at 9:33 A.M., CNA #1 said that she was not sure what the signage outside of Resident #48's room indicated, or to which resident in the room the signage applied. During an interview on 4/15/25 at 9:37 A.M., with Nurse #1 and the SDC, Nurse #1 said that Resident #48 was on EBP due to use of an indwelling catheter. The surveyor and the SDC reviewed the signage outside of Resident #48's room, and the SDC said the sign indicated that staff should wear a gown and gloves when providing care to the Resident. The SDC said that CNA #1 and CNA #2 should have worn gowns and gloves when providing care to Resident #48. During an interview on 4/15/25 at 10:20 A.M., Resident #48 was observed in bed and dressed for the day. The Resident said that he/she had a urinary catheter in place and that sometimes the urinary catheter did leak urine. During an interview on 4/17/25 at 9:52. A.M., the Infection Control Nurse/Assistant Director of Nursing (ADON) said that residents who have wounds, ostomies, catheters, or tracheostomies would be on EBP and the facility has signage outside of the resident rooms that require EBP. The ADON said that if any staff are unsure of the signage or which PPE to wear, they can ask the Unit Nurse. The ADON further said that CNA #1 was a recent hire in the past 90 days, had completed her orientation process, and that she should have been wearing a gown and gloves when providing care to Resident #48. The surveyor requested evidence of staff education to CNA #1 relative to infection control. Review of the Education Record for CNA #1 indicated the following: -Education on Hand Hygiene and PPE donning observation was completed on 1/29/25. -Education regarding Enhanced Barrier Precautions was completed on 2/5/25.

Based on record review, interview, and observation, the facility failed to provide routine dental services for one Resident (#29) out of a total sample of 25 residents. Specifically, for Resident #29, the facility failed to schedule a follow-up appointment for dental care in a timely manner which resulted in a delay in dental care and increased risk for oral pain and infection. Findings include: Review of the facility policy titled Dental Services, last revised January 2025, indicated: -Routine and 24-hour emergency dental services are provided to our residents through: >a contract agreement with a licensed dentist that comes to the facility monthly >referral to the resident's personal dentist >referral to community dentists >referral to other health care organizations that provide dental services -Selected dentists must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs -Social Services Representative will assist residents with appointments Resident #29 was admitted to the facility in March 2015 with diagnoses including Dementia and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #29: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible total score of 15. -reported frequent moderate pain [sic] within the last five days. Review of Resident #29's Medical Record indicated: -an activated Healthcare Proxy (HCP), effective 2/20/23. -the HCP signed a consent for Dental services, effective 2/20/23. Review of Resident #29's Dental Group Consultant Sheet dated 6/21/23, unsigned indicated: -Patient needs extractions will reschedule with proxy (HCP) permission. Review of Resident #29's Dental Group Consultant Sheet dated 8/31/23, signed by the Dental Hygienist indicated: -Patient was having trouble with pain during treatment. -Patient will need a deep clean. -Patient will need to see the Doctor for treatment plan for decay. During an interview on 4/15/25 at 8:49 A.M., Resident #29 said that his/her back tooth was sore and that he/she had seen the Dentist in the past, but had not seen the Dentist for a while. During an interview on 4/16/25 at 1:46 P.M., Unit Manager (UM) #1 said that Resident #29's dental care recommendations should have been followed up on and they were not. UM #1 also said that a dental appointment had been canceled, and had never been rescheduled but should have been.

Based on observation, record review, and interview, the facility failed to ensure that medications were secure and inaccessible to unauthorized persons, for one Resident (#91), out of a total sample of 25 residents. Specifically, for Resident #91, the facility failed to ensure that medications prepared for the Resident was handled in a safe and secure manner, when Nurse #3 left medications reconstituted in a cup of coffee, with Certified Nurses Aide (CNA) #4, and instructions that CNA #4 ensure the Resident consumed the coffee/ medications, and Nurse #3 did not remain with the Resident to ensure safe medication administration. Findings include: Review of the facility's policy titled Oral Medication Administration, effective April 2017 and last revised April 2022, indicated the following: -The purpose of this procedure is to provide guidelines for safe administration of oral medications. -Verify that there is a Physician's medication order for this procedure. -If the resident cannot hold his or her own medications, place the cup near the lips and gently introduce each medicine one at a time, followed by a sip of water. Do not rush the resident. -Remain with the resident until all medications have been taken. Resident #91 was admitted to the facility in March 2022, with diagnoses including Dementia, Major Depressive Disorder, Anxiety Disorder, Gastro-Esophageal Reflux Disease without Esophagitis, and Unspecified Blepharitis Unspecified Eye. Review of Resident #91's recent MDS assessment dated [DATE], indicated the Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. Review of Resident #91's April 2025 Physician's orders indicated the following: -Amlodipine Besylate Tablet 10 milligrams (mg), Give 1 tablet by mouth one time a day for hypertension (HTN), initiated 3/2/22. -Multivitamin Tablet (Multiple Vitamin), Give 1 tablet by mouth one time a day for supplement, initiated 3/2/22. -Pepcid Oral Tablet 20 mg (Famotidine), Give 1 tablet by mouth two times a day related to Gastroesophageal reflux disease without esophagitis, initiated 2/27/23. -Trazodone HCL Oral Tablet 50 mg (Trazodone HCL), Give 25 mg by mouth two times a day related to Major Depressive, Recurrent, Unspecified, give ½ tab in A.M. & 2:00 P.M., initiated 2/19/24. -Valproic Acid Solution 250 mg/5 milliliters (ml), Give 375 mg by mouth two times a day for Mood Disorders related to Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance [7.5 ml per dose equals 375 mg], initiated 3/19/25. -May crush allowable Meds, initiated 3/2/22. Review of Resident #91's 4/16/25, Medication Administration Record (MAR) indicated Nurse #3's initials that Amlodipine Besylate, Multivitamin, Pepcid, Trazodone, and Valproic Acid medications were administered to the Resident as ordered by the Physician. Review of Resident #91's Nursing Evaluation: Medication Reconciliation/Self-Admin [administration] of Meds, dated 3/31/25 indicated: -Resident wishes not to administer his/her own medications. -No documentation that Resident #91 was able to self-administer his/her scheduled medications prescribed by the Physician. On 4/16/25 at 8:21 A.M., the surveyor observed Nurse #3 enter the dining room on Unit 4. The surveyor observed Nurse #3 holding a small plastic medication cup containing a pink liquid, a clear pill crush bag containing a powered substance, and a spoon. The surveyor observed Nurse #3 approach Resident #91 who was seated in a wheelchair at the dining table. The surveyor also observed CNA #4 seated in a stationary chair at the table next to Resident #91. Nurse #3 was observed mixing the pink liquid substance and the powered substance into Resident #91's cup of coffee. The surveyor observed Nurse #3 instruct CNA #4 to ensure that Resident #91 drank the coffee because the cup of coffee contained Resident #91's medications. Nurse #3 was observed exiting the dining room and leaving the cup of coffee containing the medications unattended with CNA #4. During an interview on 4/16/25 at 8:23 A.M., CNA #4 said that Nurse #3 told the CNA that she mixed medications in Resident #91's cup of coffee and for CNA #4 to ensure that Resident #91 drank the coffee. During an interview on 4/16/25 at 8:24 A.M., Nurse #3 said that she reconstituted medication into Resident #91's cup of coffee and instructed CNA #4 to ensure that Resident #91 drank the coffee because the cup contained Resident's #91's morning scheduled medications. Nurse #3 said that she thought instructing CNA #4 to ensure that the Resident drank the coffee was okay. On 4/16/25 at 8:26 A.M., the surveyor observed Nurse #3 standing next to the medication cart at the nurses station and out of direct line of sight from Resident #91 who was seated in the dining room. The surveyor observed Resident #91 pick up the cup of coffee, bring it to his/her lips to drink. Nurse #3 was not observed to re-enter the dining room. During a follow-up interview on 4/16/25 at 8:32 A.M., CNA #4 said that Nurse #3 did not return to the dining room to remove the cup of coffee containing Resident #91's medication. CNA #4 said that the Resident consumed the coffee without Nurse #3 present. During an interview on 4/16/25 at 9:49 A.M., the Assistant Director of Nursing (ADON) said that residents have a Physician order to crush medications and to mix with the fluid of choice. The ADON said that Nurse #3 should have stayed with the Resident when she reconstituted the medications with the cup of coffee. The ADON said that Nurse #3 should have ensured that the Resident consumed the medication dose ordered by the Physician prior to exiting the dining room. The ADON said that the expectation for nursing staff during medication administration was to remain with residents to ensure that medications are administered as ordered. The ADON said the medications should not have been left with CNA's to be administered to Residents as CNA's were not identified as Licensed Nurses.

Based on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (providing nutrition directly into the stomach/intestines through a feeding tube), for one Resident (#114) out of a total sample of 25 residents. Specifically, for Resident #114, the facility failed to record the total amount of administered enteral feeding as ordered by the Physician, and perform weekly weight monitoring with the Resident experiencing a significant weight loss over a one-month period. Findings include: Review of the facility policy titled Weight Management last revised 4/2022, indicated: -Weights will be done weekly for the first four weeks and then monthly unless otherwise recommended by the Dietician or RN. -Weekly weights should be done on residents who are (identified) as high nutritional risk. -Weight change is defined as any unplanned weight gain or loss as follows: >+/- 5% weight change in one month >+/- 7.5% weight change in 3 months >+/- 10% weight change in 6 months Review of the facility policy titled Enteral Nutrition, last revised 4/2022, indicated: -The Registered Dietician completed the Nutrition Care Process to include: -calculations of estimated energy, protein and fluid requirements -recommendations as needed for alternative formulas, rates, or amounts of the formula or water to meet the resident's needs -monitoring of weight .tolerance to feeding and oral food/fluid intakes (if applicable) Resident #114 was admitted to the facility in March 2025, with diagnoses including Traumatic Brain Injury (TBI), Acute Respiratory Failure, Dysphagia, Gastrostomy Status (G-tube - a flexible tube inserted through the abdomen and stomach to deliver nutrition, fluids and medication directly to the stomach). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #114 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of a total possible score of 15. On 4/15/25 at 9:57 A.M., the surveyor observed Resident #114 lying in bed and enteral formula being administered via a feeding controller pump set at 75 milliliters/hour (ml/hr). Review of the active Physician orders dated 4/17/25, indicated: -NPO (nothing per os-nothing by mouth) diet, initiated 3/13/25 -Enteral feed order, Jevity 1.2 cal @75 ml/hr x 20 hours until 1500 ml total infused, down at 1300 hours (1:00 P.M.) and up at 1700 hours (5:00 P.M.), Document total amount of enteral feed infused every day shift, initiated 3/13/25 Review of Resident #114's Comprehensive Nutritional Evaluation dated 3/13/25, indicated: -recommendation to initiate weekly weight monitoring x 4 weeks. -goal to maintain weight within 5% of current body weight and experience no significant weight changes. Review of Resident #114's weight record indicated the following weights: -3/13/25: 148.9 pounds -4/7/25: 132.4 pounds -Further review of Resident #114's weight record failed to indicate that weekly weights were obtained for four weeks. Review of Resident #114's Nutrition/Dietary Progress Note dated 4/7/25, indicated the Resident experienced a significant weight loss of 11.1% over a one-month period. Review of Resident #114's March 2025 and April 2025 Medication Administration Record (MAR) failed to indicate documentation recording the total amount of enteral formula that was administered to the Resident during the day shift as ordered. During an interview on 4/17/25 at 9:15 A.M., the Dietician said that it is important to know exactly how much enteral formula Resident #114 received because the amount of enteral formula was specifically calculated based on the Resident's height, weight and nutritional requirements. The Dietician said that all newly admitted residents were placed on weekly weights for four weeks and then if the weights were stable, the resident was moved to monthly weight monitoring. The Dietician said that all weights were documented on the weight record in the electronic medical record. The surveyor and the Dietician reviewed Resident #114's weight record and the Dietician said that there was no evidence that weekly weight monitoring had been performed for the Resident, but should have been. The Dietician further said that the amount of enteral formula that had been administered to Resident #114 had not been documented as ordered but should have been documented.

Based on record reviews, and interviews, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #102, accurately code that the Resident used corrective lenses during the MDS observation period putting the Resident at risk for not receiving required vision care and services. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual version 1.19.1 dated October 2024, indicated the following: >Hearing, Speech and Vision: Document whether the resident is comatose, the resident's ability to hear, understand, and communicate with others and the resident's ability to see objects nearby in their environment. >Corrective Lenses: -Decreased ability to see can limit the enjoyment of everyday activities and can contribute to social isolation and mood and behavior disorders. -Many residents who do not have corrective lenses could benefit from them, and others have corrective lenses that are not sufficient. 1. Resident #102 was admitted to the facility in November 2023 with diagnoses including Chronic Systolic (Congestive) Heart Failure, Chronic Kidney Disease, Type 2 Diabetes Mellitus, and other Vascular Syndromes of Brain in Cerebrovascular Disease. Review of Resident #102's Optometry Evaluation, dated 10/8/24, indicated: -Resident was alert, oriented to person and place. -Resident has Cataract -Glasses Dispensed +2.25 Near [sic] Review of the MDS assessment dated [DATE], indicated Resident #102: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a possible 15 points. -had adequate vision and saw fine detail, such as regular print in newspapers/books. -did not use corrective lenses (contacts, glasses, or magnifying glass). During an interview on 4/15/25 at 9:28 A.M., Resident #102 said he/she wears eyeglasses. The surveyor observed two pairs of eyeglasses laying on the Resident's nightstand next to his/her bed. During an interview on 4/17/25 at 12:03 P.M., the Corporate MDS Nurse said that she was unaware that Resident #102 wears eyeglasses. The Corporate MDS Nurse said she would investigate, and get back to the surveyor. During a follow-up interview on 4/17/25 at 12:19 P.M., the Corporate MDS Nurse said that Resident #102 wears eyeglasses, and was not coded for corrective lenses in error on the MDS assessment dated [DATE]. The Corporate MDS Nurse said the MDS should be coded as corrective lenses used. Surveyor: [NAME], [NAME]

Based on interview and record review, the facility failed to provide care and services for an ileostomy (a surgically made opening that connects the lower end of the small intestine to the abdominal wall. Through the abdominal wall opening, or stoma, the lower intestine is stitched into place. A wafer [a dressing that surrounds the stoma] is applied to the surrounding skin and allows for a bag/pouch to be attached to collect stool) appliance per professional standards, for one Resident (#13) out of a total sample of 21 residents. Specifically, the facility staff did not change the ileostomy bag and appliance (baseplate [or wafer] where the bag/pouch attaches) as required. Findings include: Resident #13 was admitted to the facility in February 2020 with diagnoses including ileostomy and Schizoaffective Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. Review of the current Physician's orders indicated the following orders relative to ileostomy care: -May change ileostomy bag and appliance as needed. Order initiated 3/23/23 -Monitor ileostomy site every shift. Order initiated 2/5/2020. Recommended ileostomy care found at: https://my.clevelandclinic.org/health/treatments/22496-ostomy indicates: -dependent on the type of pouch system - will need to change the bag every three to seven days or some bags are designed to be changed daily. When changing the bag, be sure to: >Wipe away any mucous on the stoma. >Use warm water, mild soap and a washcloth to clean the skin around the stoma. (Avoid soaps with fragrances and oils.) >Rinse the skin well. >Dry the area completely. -In addition to keeping the stoma clean, be sure to examine it daily to ensure it looks normal. -If changes in the stoma size, color or shape, is noticed, notify the healthcare provider immediately. During an interview on 1/2/24 at 8:45 A.M., Resident #13 said that the Nurses took care of his/her ileostomy appliance. During an interview on 1/3/24 at 11:30 A.M., Nurse #4 said that the Certified Nurses Aides (CNAs) change the Resident's ileostomy appliance and empty the ileostomy bag. Nurse #4 said Resident #13's ileostomy appliance was changed two to three times per week. When the surveyor asked for documentation of the ileostomy appliance changes, Nurse #4 said she did not know where the ileostomy care was documented because she has never looked for the documentation of care. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2023, December 2023 and January 2024 indicated no documented evidence that Resident #13's ileostomy appliance had been changed. Review of the progress notes for November 2023, December 2023 and January 2024 indicated no evidence that Resident #13's ileostomy appliance had been changed. During an interview on 1/3/24 at 2:09 P.M., the Director of Nurses (DON) said that the CNAs were permitted to empty the ileostomy bag/ pouch but the CNAs were not permitted to change the ileostomy appliance. The DON said that a Nurse should change the ileostomy appliance and document the appliance change on the TAR and that the ileostomy appliance should be changed according to professional standards and on an as needed (PRN) basis. The DON also said that she was not sure how long an ileostomy appliance should stay in place according to professional standards. The surveyor and the DON reviewed the Resident's medical record and the DON said that there was no evidence that Resident #13's ileostomy appliance had been changed during November 2023, December 2023 and current date in January 2024. The DON said the ileostomy appliance should have been changed as required and the appliance change should have been documented.

Based on observation, interview, record and policy review, the facility failed to maintain appropriate infection control measures related to a wound dressing change for one Resident (#46) out of a total sample of 21 residents. Specifically, the facility staff failed to perform hand hygiene as required between glove changes during a wound dressing change for Resident #46, putting the resident at risk for contamination and infection of the wound. Findings include: Review of the facility policy titled Dressings, Dry/Clean, revised 3/2022, included: -pull glove over dressing and discard into plastic bag or receptacle -perform hand hygiene and apply new gloves -remove dirty gloves, perform hand hygiene, put clean gloves on Review of the facility policy titled Hand Hygiene, revised 4/2022, included: -This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub .or soap and water .after removing gloves -Hand hygiene is the final step after removing and disposing of personal protective equipment -The use of gloves does not replace hand washing/hand hygiene. -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections. Resident #46 was admitted to the facility in December 2020 with diagnoses including complications of a skin graft, and encounter for surgical after care following surgery on the skin and subcutaneous tissue of the left knee. Review of the January 2024 Physician's orders, order date 1/3/24 included: -Cleanse left knee open area with Wound Cleanser, pat dry. -Apply Alginate (gel-forming agent obtained from seaweed and used for wound healing) f/b (followed by) border DSG (dressing) daily and PRN (as needed) for soilage until resolved, every day shift. On 1/3/24 at 9:54 A.M., the surveyor observed Nurse #2 perform the dressing change procedure on Resident #46's left knee. During the procedure, Nurse #2 removed his soiled gloves two times and then re-applied clean gloves. The surveyor did not observe Nurse #2 performing hand hygiene between the changing of gloves for both glove change occurrences. During an interview on 1/3/24 at 10:06 A.M., Nurse #2 said that he did not perform hand hygiene in between glove changes but should have done so. Nurse #2 further said that he was aware that each time gloves are changed, hand hygiene should be performed.

Based on observation, interview, policy and record review, the facility failed to provide respiratory care services as ordered for one Resident (#29), out of one applicable resident, in a total sample of 21 residents. Specifically, the facility staff failed to change Resident #29's oxygen (O2) tubing weekly, as ordered by the Physician putting the Resident at risk for sinus and airway infections resulting from contaminated equipment. Findings include: Review of the facility's policy titled Oxygen Use; revised April 2022 indicated: -Verify that there is a Physician's order. -Review the Physician's orders or facility protocol for Oxygen administration. -Review the residents care plan to assess any special needs of the resident. Resident #29 was admitted to the facility in December 2021 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - lung disease that makes it difficult to breathe) and Shortness of Breath (SOB - difficult or labored breathing). Review of Resident #29's Physician's orders dated 9/25/23, included the following order: -change O2 tubing weekly on Sunday night, 11:00 P.M. - 7:00 A.M. shift. Review of Resident #29's Respiratory Care Plan initiated 9/25/23, indicated the Resident had difficulty breathing related to a diagnosis of COPD and to administer and monitor effectiveness of drugs affecting respiratory status. On 1/2/24 at 9:45 A.M., the surveyor observed Resident #29 in his/her room, lying in bed with eyes closed. The Resident was receiving Oxygen at a flow rate of 2 liters per minute (LPM - the amount of Oxygen delivered liter per minute) via a nasal cannula (pronged tube inserted into the nose). The surveyor observed that the O2 tubing connected to the oxygen concentrator (device that pulls air from the environment and filters into Oxygen for delivery to a patient) was dated 11/8/23. On 1/3/24 at 9:55 A.M., the surveyor observed Resident #29 lying in his/her bed. The Resident was receiving Oxygen at 2 LPM via a nasal cannula and the O2 tubing was observed to be dated 11/8/23. On 1/3/24 at 11:05 A.M., the surveyor and Nurse #1 observed Resident #29's oxygen equipment. During an interview at the time, Nurse #1 said the Resident's O2 tubing should have been changed weekly, but it had not been changed as required. During an interview on 1/3/23 at 11:45 A.M., Unit Manager (UM) #1 said Resident #29's O2 tubing was last changed on 11/8/23 and should have been changed weekly as ordered by the Physician but this was not done.

Based on interviews, record and policy review, the facility failed to arrange for services or care that accepted standards of quality dictate should have been provided for one Resident (#65) out of a total sample of 21 residents, to aid in treating Tardive Dyskinesia (TD - abnormal movements in the face, tongue, or other body parts that cannot be controlled). Specifically, for Resident #65, the facility staff failed to communicate Behavioral Health recommendations to the Physician so an increased dosage of the medication, Ingrezza (used to treat -TD) could be initiated to manage TD symptoms for the Resident. Findings include: Review of the facility policy, Abnormal Involuntary Movement (AIM), dated 4/2022 indicated the following: -A rating of 2 or higher on the AIMS scale is evidence of Tardive Dyskinesia (TD). Review of the facility policy, Physician Services and Discipline Recommendations dated 3/2022, indicated the following: -The attending Physician will determine the relevance of any recommended interventions from any discipline. -The Physician is not obligated to accept these recommendations if he or she has clinically valid reason for not doing so. Resident #65 was admitted to the facility in July 2021 with diagnoses including drug-induced Sub-acute Dyskinesia, Schizoaffective Disorder Bipolar type (a mental health disorder with a combination of Schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as Depression or mania), Major Depressive Disorder (MDD - depression that affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and Anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs). Review of the Resident's medical record indicated use of the following psychotropic (medication that affects mental activity, behavior, perception or mood) medications: -Escitalopram (class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), used to treat depression). -Trazodone (class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), used to treat depression). -Mirtazapine (class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), used to treat depression). -Ativan- (anti-anxiety medication that belongs to a class of drugs known as benzodiazepines [are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures]) -Buspirone- (class of medications called anxiolytics and used to treat anxiety disorders or the short-term treatment of symptoms of anxiety). Further review of the Resident's medical record indicated a current Physician's order for Ingrezza 60 milligram (mg), initiated 6/5/23, at bedtime related to drug induced Sub-acute Dyskinesia. Review of the Informed Consent Form dated 7/3/23, indicated Ingrezza with a dose of 80 mg/day, and was signed by the Health Care Proxy (HCP). Review of the AIMS scale, dated 11/27/23, indicated a score of 2. Review of the Behavioral Health Care Team's Certified Nurse Practitioner (CNP) progress note dated 12/14/23, indicated: -Resident #65 exhibits abnormal facial movements -Severity: Moderate -Recommendation to increase the Resident's Ingrezza dose to 80 mg daily. Review of the AIMS report, dated 12/14/23, with a score of 16, indicated mild symptoms for: -Facial and oral movements: >Muscles of Facial Expression >Lips and Perioral (around the mouth) Area >Jaw >Tongue -Global Judgement: >Severity of abnormal movements overall >Incapacitation due to abnormal movements >Patient's awareness of abnormal movements - Aware, mild distress (score of 2 [out of 5]) Review of the Care Plan Psychotropic Medication Use, dated 8/17/21, indicated the following: -Resident will be free from signs and symptoms of adverse consequences of psychotropic drug use through next review. -Consult Psychiatric services as needed -Monitor for effectiveness of psychotropic drug -Observe for any signs or symptoms of drug related consequences -Update Nurse Practitioner (NP)/Medical Doctor (MD) of any signs or symptoms Review of the Social Worker (SW) Progress Note dated 12/15/23, indicated Resident #65 was followed by Behavioral Health and was last seen on 12/14/23 with recommendations to adjust the Ingrezza dosage. During an interview on 1/3/24 at 2:52 P.M., SW #1 said that the facility had been unable to contact the Health Care Proxy (HCP) to sign the consent for the increased dose of Ingrezza to 80 mg. When the surveyor and SW #1 reviewed the current Ingrezza consent signed by the HCP, she said that she was not aware that the consent was signed for up to 80 mg of Ingrezza. SW #1 further said that she was not sure why the medication dosage increase was not initiated, as the Nursing Department would handle that. During an interview on 1/4/24 at 8:20 A.M., Unit Manager (UM) #1 said the Ingrezza 80 mg was not started due to the facility being unable to contact the Health Care Proxy (HCP) to have them sign the consent. When the surveyor reviewed the medical record with UM #1, she said that the consent was signed for Resident #65 to receive up to 80 mg daily of Ingrezza. UM #1 further said that she did not realize that the consent was for a dosage up to 80 mg. During a follow-up interview on 1/4/24 at 10:44 A.M., UM #1 said when the Behavioral Health Care Team makes a recommendation, she (UM #1) would reach out to the Physician to get a verbal order if the Physician agrees with the recommendation. UM #1 said that she had previously reached out to the Provider/ Physician regarding the increased medication dosage and was just waiting for the HCP consent to start the dosage increase. UM #1 said she could not provide documentation that the Physician was notified of the Behavioral Health Care Team recommendations or that the Physician order was given to increase the Ingrezza to 80 mg/day, as they were waiting for the consent to be signed by the HCP.

Based on interview and record review, the facility failed to provide coverage by a Registered Nurse (RN) for at least eight consecutive hours a day for seven days a week, as required. Specifically, the facilty was not able to provide evidence that a Registered Nurse (RN) was scheduled and worked for a minimum of eight hours on Saturday, 12/30/2023. Findings include: Review of the facility's daily nursing schedule provided by Administration to the surveyor, indicated for the period 12/1/23 to 12/31/23, that no RN had not been scheduled to work on Saturday 12/30/23. During an interview on 1/2/24 at 11:05 A.M., the Director of Nurses (DON) said that she had been experiencing difficulty with hiring RN's at the facility. During an interview on 1/2/23 at 11:16 A.M., the facility Scheduler said that there was no RN coverage provided by the facility on Saturday 12/30/23, as required.

Based on interview, record and policy review, the facility failed to ensure the resident's right to make healthcare decisions for one Resident (#8) out of a total sample of 21 residents. Specifically, the facility failed to obtain written informed consent prior to administering a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication, including providing education on the risks and benefits of proposed care related to the use of the medication. Findings Include: Review of the facility policy titled Psychotropic Medication, revised April 2022, indicated the following: -Purpose is to administer and monitor the effects of psychoactive (also known as psychotropic) medications when prescribed. -Guidelines include: <Obtaining a Physician's order and an appropriate diagnosis is required for all psychoactive medications. <An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for the administration of psychoactive medication. <The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychoactive medications. <The resident, and when indicated, the family or responsible person, will be included in this process prior to administration of the dose. Resident #8 was admitted to the facility in August 2021 with diagnoses including Schizoaffective Disorder with Bipolar type (a mental illness where the individual experiences stimuli that are not there, ideas that are not based in reality, as well as mood disorder with episodes of mania and sometimes Depression), Major Depressive Disorder (disorder characterized by persistently depressed mood and long term loss of pleasure or interest in life), and Generalized Anxiety Disorder (severe, ongoing anxiety that interferes with daily activities). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated: -Resident #8 had moderately impaired cognition as evidenced by Brief Interview for Mental Status (BIMS) score of 10 out of total of 15. -experienced mood symptoms of feeling depressed, having negative thoughts of self, and trouble concentrating. Review of the Psychiatric Services Note on 3/17/23, indicated Resident #8 was experiencing increased anxiety and behavioral disturbances, and recommended: -initiating Carbamazepine (a medication use to treat certain types of seizures and Bipolar Disorder) at 100 milligrams (mg) twice a day for 3 days -then increasing to Carbamazepine 200 mg twice a day for 4 days -then on Day 8 increase Carbamazepine to 400 mg twice a day Review of the Physician's Progress Note dated 3/21/23, indicated the Resident had low mood and Anxiety and was started on Carbamazepine as recommended by Psychiatric Services. Review of the March 2023 Physician's orders indicated: -Carbamazepine, give 100 mg by mouth two times a day for Anxiety for 3 days (initiated 3/21/23) -Carbamazepine, give 200 mg by mouth two times a day for Anxiety for 4 days (initiated 3/24/23) -Carbamazepine, give 400 mg by mouth two times a day for Anxiety (initiated 3/28/23) Review of January 2024 Physician's orders indicated: -Carbamazepine oral tablet, give 400 mg by mouth two times a day for Anxiety (initiated 3/28/23) Review of the March 2023 through December 2023, and January 2024 Medication Administration Records (MAR) indicated Resident #8 received the Carbamazepine medication as ordered, from 3/21/2023 through 1/3/2024. Review of the clinical record did not show evidence that a written Informed Consent for Psychotropic Administration for the use of Carbamazepine was obtained and signed by Resident #8 prior to administration of the medication. During an interview on 1/3/24 at 11:36 A.M., the surveyor and Unit Manager (UM) #1 reviewed the January 2024 Physician's orders and UM #1 said that Resident #8 started on Carbamazepine on 3/21/23 and the Physician orders read that it was prescribed for Anxiety. UM #1 said that an informed consent for the medication should have been obtained prior to the administration but was not obtained, as required.

Based on observation, interview and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in two out of the three nourishment kitchens. Specifically, the facility failed to properly label and date resident food items, discard perishable foods by the sell by date, and maintain a clean microwave to prevent contamination and the risk of food-borne infections. Findings include: Review of the facility policy for Food Brought into the Facility, dated [DATE], indicated: -perishable foods must be stored and identified with Resident's name, food item and use by date. -the nursing staff is responsible for discarding perishable foods on or before the use by date. On [DATE] at 9:12 A.M., the surveyor and the Food Service Director (FSD) observed the following: Nourishment Kitchen #2: -microwave with a black caked-on substance that was flaking off the edges of the appliance -two staff lunch bags (identified by the FSD) -one subway sandwich, partially exposed to air with no date in the refrigerator -an unlabeled and undated bag containing two used storage containers in the refrigerator Nourishment Kitchen #3: -one Resident's bag of sliced cheese with a sell-by date of [DATE] - four bags of resident (labeled) food in the freezer (dated [DATE]) with no use by date. - two staff lunch bags (identified by the FSD) During an interview on [DATE] at 9:17 A.M., the FSD said that all the Resident's food items should have been labeled and dated, that all the undated, unlabeled and expired items should have been thrown away, and they had not been as required. The FSD also said that the staff lunch bags and food belonging to staff should not be stored in the Resident's Nourishment Kitchen refrigerator.

Based on observation and interview the facility failed to ensure that its staff conducted COVID-19 antigen (a rapid test used to detect [CONDITION(S)] CoV-2 infection) testing in a manner consistent with current standards of practice. Specifically, the facility failed to ensure that its staff wore appropriate personal protective equipment (PPE), according to the Centers for Disease Control and Prevention (CDC) guidelines, while performing nasal swabbing of a visitor for COVID-19. Findings include: Review of the Centers for Disease Control Interim Guidelines for collecting and handling of Clinical Specimens for COVID-19 Testing, updated July 2022, indicated the following: For healthcare providers collecting specimens or working within six feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended PPE, which includes an N95 or higher - level respirator (or facemask if a respirator is not available), eye protection, gloves and a gown. Healthcare providers can minimize PPE use if patients collect their own specimens while maintaining at least 6 feet of separation. For example, the provider should wear a face mask, gloves and a gown. During an observation on 7/18/22 at 10:30 A.M , the surveyor observed the Receptionist in the facility lobby, standing less than six feet away from a visitor who was swabbing his/her nose for a COVID-19 test. The Receptionist who was wearing a surgical mask and no other PPE, was observed handling the used nasal testing swab, after the visitor had swabbed her nose, with ungloved hands. She was also observed handling the used testing device with ungloved hands prior to discarding the item. When interviewed, the Receptionist said that she was trained on how to do the COVID-19 testing and that she only wears a mask to do the testing. During an interview on 7/18/22 at 12:25 P.M., the SDC/ICP (Staff Development Coordinator/ Infection Control Preventionist) said she wears full PPE to perform the testing in her office as required. She also said that she expects the Receptionist to wear full PPE including eye protection, mask and gloves to perform COVID-19 testing for visitors.

Based on record review and interview, the facility failed to ensure staff informed residents, their representatives, and their families by 5:00 P.M. the next calendar day following the occurence of a single confirmed COVID-19 infection in the facility as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 cases among Residents and staff in Nursing Homes, Reference: QSO-20-29-NH dated May 6, 2020 indicated: (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . Review of the facility policy titled Coronavirus Prevention and Control dated 4/17 indicated: the Administrator is identified as the Emergency Response Communications Coordinator who is responsible for disseminating information to the staff, residents and family regarding information about the virus, the status of COVID-19 in the facility and the impact on facility operations . Resident # 52 was admitted to the facility in April 2022. Review of the Resident's clinical record showed evidence of a positive result for COVID-19 dated 5/27/22. Review of an email from the Administrator to the Residents, families, Guardians and Responsible parties dated June 1, 2022 indicated .inform you that two of our residents and staff tested positive for COVID-19 on 5/23/22 and 5/25/22 . During an interview on 6/02/2022 at 4:50 P.M. the Administrator said that she was responsible for notifications to the residents, families, and representatives regarding the status of any COVID infection in the facility. The Administrator said that she sends emails out with any notifications and usually send them out within 1 to 5 days after any new infection of COVID-19 was identified. The Administrator confirmed that the email sent on June 1, 2022 was the first notification sent out to the residents, families, Guardians and Responsible parties with information about a newly identified case of COVID-19 in the facility which she also confirmed was actually identified on 5/27/22. The Administrator confirmed that the notification was sent out at least four days after she was aware of the newly identified COVID-19 infection in the facility.

Based on record review and interview the facility failed to ensure that staff were tested for COVID-19, based on parameters for outbreak testing, for 2 staff members out of a total of 8 staff members sampled. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum reference #QSO-20-38-NH revised 3/10/2022, indicated: -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Resident # 52 was admitted to the facility in April 2022. Review of the Resident's clinical record showed evidence of a positive result for COVID-19 dated 5/27/22. Review of the time card for CNA #7 indicated that she worked at the facility on: -5/28/22 from 11:02 P.M. to 7:11 A.M. -5/30/22 from 3:00 P.M. to 10:51 P.M. Review of the COVID testing logs showed no evidence of any COVID testing for CNA #7 from 5/27/22 through 5/31/22 Review of the time card for CNA #8 indicated that she worked at the facility on: -5/28/22 from 6:51 A.M. to 3:00 P.M. -5/29/22 from 7:02 A.M. to 3:04 P.M. -5/30/22 from 7:05 A.M. to 2:57 P.M. Review of the COVID testing logs showed no evidence of any COVID testing for CNA #8 from 5/27/22 through 5/31/22 During an interview on 6/7/22 at 3:23 P.M. the Infection Control Preventionist (ICP) said that the facility was in outbreak testing from 5/27/22 through 5/31/22 and that the facility tested all staff members. The ICP said that a new case of COVID infection was identified on 5/27/22 and all staff were expected to be tested before they worked in the facility beginning 5/27/22. She said that the facility was following the most current guidelines from the federal government. The ICP was unable to provide evidence of COVID testing for CNA #7 or CNA #8 for the time period of 5/27/22 through 5/31/22. The ICP acknowledged that CNA #7 and CNA #8 did work at the facility between the dates of 5/27/22 and 5/31/22.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 maintained acceptable parameters of weight when he/she experienced a significant weight loss of fifteen pounds, (5.48 %) in a thirty day period, was not identified as having experienced significant weight loss and immediate interventions were not implemented. Findings Include: Review of the Facility Policy titled Weight Assessment and Intervention, dated as revised 2019, indicated the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents and indicated that the threshold for significant unplanned and undesired weight loss would be based on the following criteria (usual weight subtracted by actual weight, divided by actual weight, and then multiplied by 100): 1 month 5% weight loss significant, greater than 5% severe The Policy indicated that the Facility may elect to treat any unplanned, undesired weight change of three pounds or more from the previously recorded weight as a potential undesired weight change and any three pound weight change would result in a reweigh within twenty four hours. The Policy indicated that once a three pound weight change was confirmed, nursing would immediately notify the Physician and Dietitian of the weight change and documentation of the notification shall be entered into the resident's Medical Records. Resident #1 was admitted to the Facility in March 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weights and Vitals Summary, dated 09/01/21, indicated that Resident #1 weights were as follows: 03/01/21 - 273.6 pounds 03/02/21 - 273.6 pounds 03/23/21 - 271.8 pounds 04/05/21 - 258.6 pounds Based on the documented weight, this reflects a 15 pound (lb.) weight loss, (5.48%) during the above referenced time period. Review of the Nutrition Note, dated 05/17/21, indicated that Resident #1 experienced weight loss in the past month and that weekly weights were recommended. Review of the typed Statement signed by the Dietician, undated, indicated that Resident #1 experienced a weight loss of 13.2 pounds, 4.8%, in one month after admission. The Dietician's Statement indicated that Resident #1's admission weight was 273.6 pounds and dropped to 258.6 pounds. During an interview on 09/22/21 at 1:30 P.M., the Dietician said that Resident #1's weight loss on 04/05/21 was a 4.8% weight loss and was not considered significant. The Dietician said she is made aware of significant weight loss because the weights are flagged by the computer when a recorded weight equals a significant loss from the previous recorded weight. The Dietician said Resident #1 did not trigger for significant weight loss until 05/17/21. Although the Dietician said and her documentation indicated, Resident #1 did not experience a significant weight loss, based on Facility's documented weights of 273.6 and 258.6, Resident #1 actually lost a total of 15 pounds, which is 5.48%, and is therefore significant and severe, based on Facility Policy. During an interview on 09/23/21 at 9:49 A.M., Nurse Practitioner (NP) #1 said she expected to be notified if a resident had significant weight loss. During an interview on 09/28/21 at 12:03 P.M., Nurse Practitioner (NP) #2 said she did not recall being notified that Resident #1 experienced a significant weight loss of 15 pounds from 03/01/21 to 04/05/21. NP #2 said if she had been notified, she would have provided orders for interventions and written it in her progress notes. On 09/23/21, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 5/17/21, Resident #1 was assessed by the dietician and his/her NP and it was determined that his/her weights had been stable. B. On 05/28/21, the Facility completed an audit on all residents at risk or who experienced weight loss. The audit included documentation of Physician notification. C. On 6/01/21, the Facility re-educated nursing staff and the dietician regarding the Weight Assessment and Intervention Policy. D. A weekly audit will be completed by the DON/Designee to ensure weights were completed, documented, and reported to the dietician, weekly for 4 weeks, then monthly for two months to ensure weights were completed, documented, and reported to the dietician for any significant weight loss for intervention as needed. E. The results of the audits will be presented to QAPI for three months or as the committee determines compliance. F. The Administrator and/or designee is responsible for overall compliance.

Based on policy review, record review, observations and interviews, the facility failed to ensure its staff provided respiratory care consistent with professional standards for four sampled Residents (#282, #130, #78, and #99), out of the 29 sampled residents. Findings include: 1. For Resident #282, the facility staff failed to implement facility policy and ensure emergency respiratory equipment, including spare tracheotomy tubes of the correct size and type, were readily accessible at Resident #282's bedside according to Professional Standards of Care. Review of the facility policy titled, Tracheotomy Care, dated 2017, indicated a replacement tracheotomy tube must be available at the bedside at all times. Resident #282 was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #282's discharge paperwork from the acute care facility indicated Resident #282 had a [MEDICATION(S)] TTS Tracheotomy ([CONDITION(S)]) Tube Size 8, Cuffed. (A [MEDICATION(S)] TTS Tracheotomy tube has a water filled cuff which is inflated to maintain its position in the airway, and no inner cannula. An inner cannula is a tube within the tube that can be removed, cleaned of crusted secretions, and reinserted.) Review of April 2021 Physician's Orders for Resident #282 indicated the following: -[CONDITION(S)] Type: [MEDICATION(S)] size 8 (dated 4/13/21) -Same size and one smaller/type [CONDITION(S)], obturator, lubrication kit, and large syringe for cuff inflation at bedside at all times (dated 4/13/21) -If [CONDITION(S)] becomes dislodged, maintain patent airway and notify the physician immediately On 4/29/21 at 8:42 A.M., the surveyor observed Resident #282 while they were in their room. A portable oxygen (O2) cylinder and an Ambu bag (a device used to manually inflate a person's lungs) were observed in the far corner of the room with furniture (a large wooden chair and boxes) in front of it. No spare tracheotomy tubes were visible for use in an emergency at the bedside. During an interview on 4/29/21 at 9:31 A.M., Unit Manager (UM) #2 said that emergency equipment required in the rooms for residents with a tracheotomy include: -an O2 canister -an Ambu bag -A spare tracheotomy tubes: one larger and one smaller to use in an emergency. At the time of the interview, UM #2 was unable to locate the spare tracheotomy tubes and said that ultimately, it is the nurse's responsibility to make sure the emergency supplies are in place and this was not done, as required. On 5/03/21 at 8:02 A.M. and 9:12 A.M., the surveyor observed a spare oxygen canister, with Ambu bag, to be positioned directly across from Resident #282's foot of bed. There were two spare tracheotomy tubes hanging from a bag, on the wall, at the head of the Resident's bed; a [MEDICATION(S)] TTS 8.0 and a [MEDICATION(S)] D.I.C. (Disposable Inner Cannula) size 7.0. During an interview on 5/05/21 at 11:49 A.M., the Respiratory Therapist (RT) said the emergency equipment needed in the room is a dressing to occlude (stop or close up), the [CONDITION(S)] stoma (opening), an Ambu bag with mask, oxygen supply and two different size trachs: one of the actual size and type in the Resident's neck and another one size smaller of the same brand and type. The RT said it is important to know what the actual [CONDITION(S)] type is. At the time of the interview, the RT went to Resident #282's room to check the emergency equipment with the surveyor. The RT said the [MEDICATION(S)] D.I.C. is not the correct [CONDITION(S)] for the resident, a [MEDICATION(S)] TTS size 7 should be in the room, but was not, and said that all trachs are not interchangeable. During an interview on 5/06/21 at 10:25 A.M., UM#2 said tracheotomy tubes are not interchangeable and there should be one of the same size and type and one size smaller of the same type. UM#2 said the [MEDICATION(S)] size 7 was not the correct tube. She said she didn't notice that there were letters at the end of the [CONDITION(S)] name (DIC indicating a disposable inner cannula) that indicated there were differences in the [CONDITION(S)] tubes and she should have known. 2. For Resident #130, the facility staff failed to ensure its staff used the correct inner cannula for Resident 130's [CONDITION(S)] tube. Specifically, the facility failed to document a change in the [CONDITION(S)] status (issue with bleeding), failed to recognize and document a pattern of Resident behavior and develop interventions to prevent the occlusion of the [CONDITION(S)] tube, and failed to investigate an unplanned transfer related to an occluded airway. Resident #130 was admitted to the facility in March of 2021 with Acute Respiratory Failure. Review of the Physician Orders, dated April 2021, indicated the following: -Tracheotomy Type: Shiley #6 CFS (dated 3/29/21) (Shiley is the manufacturer of the tube) (size 6, CFS is an abbreviation indicating the [CONDITION(S)] tube has a fenestration or a hole, and a reusable inner cannula) -[CONDITION(S)] size 6 Shiley, Ambu bag, oxygen tank, suction canisters and suction catheters in the room at all times (dated 3/29/21) A review of the Admission Minimum Data Set (MDS) Assessment, dated 4/2/21, and subsequent MDS Assessment, dated 4/19/21, indicated Resident #130 did not have any behaviors related to rejecting care during the assessment periods. Review of Progress Notes did not indicate Resident #130 exhibited behaviors related to rejecting care. Review of the Tracheotomy Care Plan, initiated 3/29/21, did not indicate Resident #130 was rejecting care. Review of a progress note, dated 4/7/21, indicated at 12:42 P.M. the Respiratory Therapist (RT) was not able to suction the resident as the [CONDITION(S)] was occluded and the wrong inner cannula was in place. The note further indicated that the RT was unable to insert the correct inner cannula due to resistance. Resident #130 was not in respiratory distress and had an oxygen saturation of 97% (above 95% is considered to be within normal range), and was currently being sent out (to the emergency room ) for evaluation. Further review of the progress notes, indicated a late entry on 4/7/2021 at 3:12 P.M., stating that Resident #130's [CONDITION(S)] was occluded because he/she was noncompliant with wearing his/her [CONDITION(S)] mask (a mask that goes over the [CONDITION(S)] to deliver humidified oxygen) since admission. Review of the Hospital Discharge Summary Notes, dated 4/12/21 at 5:02 P.M., indicated Resident #130 was sent to Emergency Department (ED) by the facility related to a concern for [CONDITION(S)] obstruction. They had removed the inner cannula. Emergency Medical Services was able to suction some blood tinged mucous. The notes indicated that while in the ED, Resident #130 had slight desaturation (a lowering of the oxygen levels in his/her tissues) when he/she was moved, that resolved with suction. A Bedside Bronchoscopy (a procedure to look at the lower airway), conducted on 4/8/21, demonstrated mucosal abrasion of anterior trachea either from suction trauma or direct trauma from the tracheotomy tube, which was replaced by cuffed [MEDICATION(S)] 6.0. Resident #130 was decannulated (had the tracheotomy tube removed) on 4/9/21 and then was weaned to room air (transitioned over to ambient air as opposed to being administered concentrated oxygen). The primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/05/21 at 11:59 A.M., the RT said that on 4/7/21, she came in to see Resident #130 and the Resident was able to speak, which is abnormal, and indicated the [CONDITION(S)] was occluded. The RT said that Resident didn't appear to be in any distress. When she removed the [CONDITION(S)] mask (a mask that is positioned over the [CONDITION(S)] to deliver humidified oxygen), she noted that there was a different style inner cannula in the [CONDITION(S)]. She removed the wrong inner cannula, disinfected the correct inner cannula that had come with the [CONDITION(S)], and then attempted to insert it without success. She was told the Resident had been bleeding earlier that day, and assumed that was the cause of the occlusion of the [CONDITION(S)]. The RT said Resident #130 had a Shiley #6 with a reusable cannula that twisted and locked into place. The cannula that she discovered in the [CONDITION(S)] was disposable and had tabs on each side that had to be squeezed to insert and it did not fit Resident #130's [CONDITION(S)]. During an interview on 5/06/21 at 10:28 A.M., the Unit Manager (UM) #2 said that on 4/7/21, there was resistance noted upon suctioning, and the RT observed that there was the wrong inner cannula in the [CONDITION(S)] and sent Resident #130 out to the hospital. Resident #130 had a reusable inner cannula that twisted and locked into place. She said that the inner cannula that came with the resident's Shiley [CONDITION(S)] was reusable and the one that was sent as a back-up was disposable with a different kind of locking mechanism. During an interview on 5/06/21 at 12:43 P.M., the Director of Nurses (DON) said Resident #130 was sent out via 911 and the facility did not do an investigation every time a resident is sent out for an emergency evaluation. In a subsequent interview on the same day at 2:01 P.M., the DON, after viewing the progress notes for 4/7/21 regarding the incorrect inner cannula in place, said that having the wrong inner cannula in place was a concern, and an investigation should have been done. 3. For Resident #78, the facility staff failed to accurately document the use of oxygen and lung sound assessments, and failed to ensure the oxygen signage was visible outside the Resident's room. Review of the facility Oxygen Therapy Policy, dated 2017, indicated the following: - Place sign OXYGEN IN USE outside the room of the resident. - Record oxygen therapy on treatment record: rate of flow, concentration, and tolerance. - Chart pertinent observations. Resident #78 was admitted to the facility in April of 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) Assessment, dated 3/2/21, indicated the Resident received oxygen therapy while in the facility. On 4/28/21 at 11:03 A.M., the surveyor observed Resident #78 resting in bed, while receiving oxygen at 2 liters per minute (l/min) via a nasal cannula (NC). There was no oxygen signage located outside the Resident's room as per facility policy. On 4/29/21 at 9:30 A.M., the surveyor observed Resident #78 was resting in bed. The Resident was receiving oxygen at 2 l/min via an NC. There was no oxygen signage located outside the Resident's room as per facility policy. Review of a Physician Order, dated 1/30/20, indicated the following: -may apply oxygen at 2 liters via n/c as needed (PRN) for oxygen saturation (pox) below 90 % room air. Lung sounds: 1. Clear 2. Congested 3. Wheeze 4. Crackles 5. Diminished 6. Shortness of breath when lying flat. Assessment: 0: Stable 1: Dyspneic 2: Shortness of Breath (SOB) 3: Restless 4: Accessory Muscles The March 2021 and April 2021 Treatment Administration Records (TARs) were blank for the lung sounds assessments, pulse, respirations and oxygen saturation documentation. During an interview on 4/30/21 at 12:31 P.M., Nurse #5 said there was no documentation on the March 2021 and April 2021 TARs relative to lung sound assessments or the use of oxygen. She further said there was no signage outside the Resident's room to indicate oxygen was in use, as required. 4. For Resident #99, the facility's staff failed to ensure A.) Oxygen (O2) usage was monitored and documented in the Treatment Administration Record (TAR) and B.) Appropriate signage was posted to indicate the use of oxygen therapy. Resident #99 was admitted to the facility in December of 2018 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A.) On 4/28/2021 at 9:50 A.M., the surveyor observed Resident #99 lying in bed with O2 on via nasal cannula (NC). The O2 was set at 2 liters per minute (l/min) (O2 L is the rate at which O2 flows into the nostrils over a period of one minute). On 4/29/2021 at 8:26 A.M., the surveyor observed Resident #99 lying in bed with O2 on via NC. The O2 was set at 2 l/min. Review of Resident #99's Physicians Orders for April 2021, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #99's TAR for April 2021, did not indicate any documentation that Resident #99 utilized O2 during the month of April. During an interview on 05/03/2021 at 3:37 P.M., Unit Manager (UM) #1 said that the TAR for April 2021 did not show the resident had utilized O2 during the month of April. B.) On 5/03/2021 at 3:36 P.M., the surveyor observed Resident #99 lying in bed with oxygen on. Outside Resident #99's room, they surveyor did not observe any cautionary and safety signage indicating oxygen was utilized in the room. Review of the facility's policy titled Oxygen Therapy, dated 2017 indicated: 1. Place sign OXYGEN IN USE outside the room of the resident. During an interview on 5/03/2021 at 3:37 P.M., UM #1 said there was no cautionary signage outside the resident's room and there should be, per facility policy.

Based on document review, policy review, record review, observation and interview, the facility's staff failed to follow Professional Standards of Practice relative to 1.) Failing to follow a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) Failing to maintain accurate documentation relative to in-service information and attendance, 3.) Failing to ensure the Dietitian's recommendations and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) The facility staff failed to ensure fluid restrictions were maintained as per the Physicians Order for one sampled Resident (#10) out of a total sample of 29 residents. Findings include: Review of the Lippincott Nursing Procedures, Eighth Edition, Copyright 2019, indicated that for implementation of pressure injury care, including dressing changes, the procedure should be documented. If a pressure injury develops, note the changes in the condition or size of the pressure injury and elevations of skin temperature. Document when the physician was notified of pertinent observations of abnormalities, interventions performed, and the patient's response to the interventions. Review of the facility Pressure Ulcers\Skin Breakdown-Clinical Protocol Policy, dated 2017, indicated the following: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sores including location, stage, length, width and depth, pressure of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces, and e. All active diagnoses. 1.) Resident #78 was admitted to the facility in April of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) Assessment, dated 3/7/21, indicated Resident #78 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the clinical record indicated Resident #78 was observed to have reddened buttocks on 3/7/21, and a barrier cream was applied. Review of the Wound Physician Summary Consult Note, dated 3/12/21, indicated the resident's left buttock wound was evaluated and the Physician determined the wound to be a Stage 2 (a shallow open ulcer with a red/pink wound bed) pressure ulcer, and treatment orders were given. Review of the Wound Physician Summary Consult Note, dated 3/19/21, indicated the left buttock wound was evaluated and the Physician determined it to be a Stage 3 (an open area that has progressed through the two layers of skin and into the fatty tissue) pressure ulcer, and with treatment orders were given. Review of a Physician Order, dated 3/26/21, indicated the following treatment order: -cleanse the buttocks with normal saline, pat dry and apply Santyl (removes dead tissue from wounds so they can start to heal) to a 1.0 inch by 1.0 inch area of slough (necrotic tissue) and apply [MEDICATION(S)] (used to prevent and treat wound infections) to the other wound. Then cover the area with a dry protective dressing daily and as needed. Review of the Wound Physician Summary Consult Note, dated 4/23/21, indicated the pressure ulcer was debrided (removal of damaged tissue), and the treatment order recommendation was changed to the following: -cleanse the buttock wound with normal saline, pat dry and apply Silver Alginate (silver incorporated into the wound dressing to treat infected wounds and reduce wound microbial burden) to the wound bed and cover with a dry protective dressing daily. Review of the clinical record indicated that the change in the wound treatment recommendation, per the Wound Physician Summary Consult, was approved and ordered on 4/23/21 by the attending Physician, and was documented on the Interim physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the April 2021 Treatment Administration Record (TAR), indicated the wound treatment order, dated 3/26/21, had been discontinued on 4/23/21. Further review of the April 2021 TAR did not indicate the updated order from 4/23/21, and there was no documentation found to indicate a treatment to the wound was being done from 4/23/21 thru 4/30/21, as per the wound Physician recommendations. On 4/30/21 at 8:29 A.M., the surveyor observed Resident #78 in bed during breakfast, and the Occupational and Speech Therapists were observed providing therapy. During an interview 4/30/21 at 11:30 A.M., in regards to the treatment orders for Resident #78's wound, on Nurse #5 said she would apply Santyl to the resident's buttock wound during the dressing changes. When the surveyor further questioned Nurse #5, she said she knew it was Santyl from memory. She said she was not aware that the treatment order had been changed on 4/23/21. She further said she did not document on the TAR the dressing changes and the description of the skin integrity, as required. 2.) The facility failed to ensure respiratory therapy in-services for licensed staff were accurately documented, and documentation of respiratory therapy competencies. Review of the Respiratory In-service Attendance Log, dated 11/2/21, indicated 11 licensed staff signatures. During an interview on 5/7/21 at 2:15 P.M., the Respiratory Therapist (RT) said there were 9 licensed staff members that attended the 11/2/21 Respiratory Competency in-service. The RT showed the surveyor a copy of the original 11/2/20 attendance log that indicated there were 9 signatures. During an interview on 5/7/21 at 3:46 P.M., the Director of Nurses (DON) said the original in-service log did not match the facility's copy of the in-service log, as it should. She further said 2 licensed staff names were added, but they did not attend the in-service. Review of the Life Supply Respiratory Services (LSRS) In-Service log, titled [CONDITION(S)] ([CONDITION(S)]), Oxygen, PEP Therapy, [CONDITION(S)]/[CONDITION(S)], Respiratory Assessment, Nebs, and AirVo, dated 11/10/20, indicated 9 licensed staff members attended the in-service. During an interview on 5/7/21 at 2:15 P.M., the RT said there were 7 licensed staff members that attended the 11/10/20 in-service. The RT showed the surveyor a copy of the original 11/20/20 attendance log that indicated only trachs were in-serviced and not all the items listed on the log sheet. There were 7 signatures on the original log sheet. The RT said 7 licensed staff attended the in-service. During an interview on 5/7/21 at 3:46 P.M., the DON said the original log sheet did not match the facility's copy of the log sheet with the list of topics discussed, as it should. She further said the facility's copy had 2 licensed staff names added, but they did not attend the in-service. Review of the LSRS In-Service log, titled Fit Testing, [CONDITION(S)], O2, PEP, [CONDITION(S)], [CONDITION(S)], Respiratory Assessment, Nebs, AirVo, dated 11/23/20, indicated 25 staff members attended. During an interview on 5/7/21 at 2:15 P.M., the RT said that Fit Testing for N95 facemask's were done on that day and no other topics were in-serviced. The RT showed the surveyor a copy of the original log sheet that indicated Fit Testing was the only topic discussed that day. During an interview on 5/7/21 at 3:46 P.M., the DON said the topics documented on the original log sheet did not match the facility log sheet, as it should. The DON further said this was a problem. 3.) For Resident #127, the facility staff failed to ensure the Dietitian's (RD) recommendations and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #127 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/30/21 at 8:14 A.M., the surveyor observed Resident #127 standing at the doorway to his/her room. The surveyor observed that the resident was very thin in appearance and was unsteady on his/her feet. Review of the Admission Nutritional Assessment, dated 2/25/20, indicated Resident #127 was 136.0 lbs. one month ago and had experienced a significant weight loss prior to admission, and nutritional interventions were added to the plan of care. Review of the RD note, dated 11/25/20, indicated Resident #127 was consuming only 20% meals. The RD further indicated that fortified mashed potatoes were added to lunch and dinner trays. Review of the RD note, dated 12/4/20, indicated Resident #127 had an 8.1% significant weight loss over a 30 day period (significant = greater than or equal to 5% weight loss/gain). The RD indicated that Ensure puddings were added to the nutrition plan of care. Review of the eMAR (electronic Medication Administration Record) notes on 1/24/21, 1/25/21, 1/28/21, indicated the Ensure pudding were not available. Review of the April 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Regular Mechanical Soft Diet texture, Nectar Thick liquids, extra sauces/[NAME] with meals when available per meal option (initiated 4/2/21) -Ensure Plus 8 ounces (oz.) four times daily (initiated 12/4/20) -Magic Cup (thickened high calorie/high protein nutritional ice cream) three times daily with meals (initiated 11/25/20) On 5/5/21 at 11:53 A.M., the surveyor observed the tray line for lunch. The Food Service Director (FSD), who was serving the tray line, showed the surveyor items for resident service. The surveyor observed 1 pan of mashed potatoes positioned in the steam table. When the surveyor asked the FSD if there were fortified mashed potatoes available for service, he said that the facility does not do fortified mashed potatoes. He further said that that fortified pudding (Ensure pudding) are located on the nursing units and they are given from there. On 5/5/21 1:10 P.M., the surveyor observed the lunch meal. Resident #127 was observed seated in his/her room with the lunch tray positioned in front of him/her. The meal ticket containing the resident's name and diet prescription were located on the tray. Review of the meal ticket indicated the following were to be included in the meal tray for lunch under standing orders: -4 oz. Ensure pudding -1/2 cup of fortified mashed potatoes -2 oz. gravy -4 oz. of Magic Cup (fortified ice cream) The surveyor observed that the Ensure pudding and Magic Cup were not on Resident #127's meal tray, as care planned. The surveyor also observed that the mashed potatoes on the resident's meal tray were regular mashed potatoes and not fortified, as care planned. During an interview on 5/05/21 at 1:15 P.M., Nurse #7 (who was observing the contents and meal ticket for Resident #127) said that there was no Magic Cup or Ensure Pudding on the resident's meal tray. When the surveyor informed Nurse #7 that the mashed potatoes on Resident #127's lunch tray were regular, not fortified, Nurse #7 said that she had no idea that there were not fortified. She further said that she would encourage Resident #127 to eat them because she thought they were fortified. Nurse #7 said that the missing items are not located on the units, that the kitchen provides them (Magic Cup and the Ensure pudding). During an interview on 5/05/21 at 1:17 P.M., Nurse #6 said that the kitchen provides the Ensure puddings, Magic Cup and fortified food items. During an interview on 5/05/21 at 1:54 P.M., the RD said that she was not aware that the kitchen did not make fortified mashed potatoes. She further could not explain why the items prescribed on Resident #127's meal ticket were not provided, as care planned. During an interview on 5/05/21 at 2:25 P.M., the Director of Nursing said that the items listed on the resident's meal trays like Ensure pudding, Magic cup, and fortified foods, should be provided by the kitchen. 4.) For Resident #10, the facility failed to ensure fluid restrictions were maintained as per the Physicians Order. Review of the facility Encouraging and Restricting Fluids Policy, dated 2017, included: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in milliliters (ml). 4. Be supportive of the resident's fluid intake. Encourage the resident to follow specific instructions. 5. Encourage the resident's family and visitors to stay within the limits of his or her intake. 6. Substitute other liquids (ex. tea, broth, soda, gelatin, milk, ice cream, etcetera) as permitted by the resident's diet. 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. 8. Be sure intake and output record is maintained in the resident's room. Resident #10 was admitted to the facility in February of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, 2/1/21, indicated Resident #10 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of the medical record indicated Resident #10 went to [CONDITION(S)] (process of removing excess water and toxins from the blood in people whose kidneys no longer perform these functions naturally) three times weekly. Review of the medical record indicated Resident #10 was hospitalized on [DATE] through 2/19/21 for an acute exacerbation of Congestive Heart Failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) with reduced ejection fraction (how well the left and right side of the heart pumps blood with each heart beat). Review of the March 2021 Monthly Physician Orders, indicated a verbal order, dated 3/9/21, for a 1500 milliliters (ml) fluid restriction. Review of the March 2021, April 2021 and May 2021 Medication Administration Records (MAR) and Treatment Administration Records (TARs) did not indicate Resident #10 had been placed on fluid restriction. There were no areas on the MARs/TARs to indicate how much fluid the resident was able to receive or how much fluid the resident had consumed each shift. During an interview on 5/4/21 at 10:31 A.M., the dietitian (RD) said the dietitian at the [CONDITION(S)] facility would make recommendations for any type of fluid restrictions, and that information would be in the [CONDITION(S)] communication book. She further said she was not notified that Resident #10 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [CONDITION(S)] communication book did not contain any documentation to indicate Resident #10 was on a 1500 ml fluid restriction. During an interview on 5/4/21 at 11:04 A.M., Nurse #5 said she does not document in the medical record for Resident #10 fluid intake. She further said she was not aware that the resident had a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/4/21 at 1:35 P.M., Certified Nursing Assistant (CNA) #4 said she does not give Resident #10 more than 360 milliliters (ml) because the resident receives [CONDITION(S)] treatments. She said there is no information on the CNA care card indicating the resident is on fluid restriction. She said there is no documentation to indicate a fluid intake breakdown for each shift that Resident #10 can consume. She further said she was not aware of any daily tallies of Resident #10's fluid intake. On 5/5/21 at 12:16 A.M., the surveyor observed Resident #10 sitting in a wheelchair in his/her room consuming lunch. Review of the diet slip did not indicate the resident was on a fluid restriction.

Based on policy review, record review, observations and interviews, the facility's staff failed to ensure care/services were provided to prevent the development of a Pressure Injury for one sampled Resident (#78), and failed to provide appropriate treatment to aid in healing of a Pressure Injury for two sampled Residents (#129 and #46), out of a total of 29 sampled residents. Findings include: Review of the facility Pressure Ulcers\Skin Breakdown-Clinical Protocol Policy, dated 2017, included the following: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sores including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces, and e. All active diagnoses. Resident #78 was admitted to the facility in April of 2019 and was diagnosed with a stage 2 Pressure Injury on the left buttock on 3/12/21 and a deep tissue injury on the left heel on 3/17/21. Review of the Minimum Data Set (MDS) Assessment, dated 3/2/21, indicated Resident #78 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS) Assessment. A.) Review of the Weekly Skin Check Reports indicated that for 3/3/21 and 3/10/21 there were no skin concerns found. Review of a nursing progress note, dated 3/7/21, indicated that Resident #78's buttocks were pink and house barrier cream was applied. Further review of the progress notes did not indicate any documentation relative to the pink areas on the resident's buttocks until 3/12/21. Review of the March 2021 Treatment Administration Record (TAR), indicated an order (initiated on 4/22/19) to wash the resident's buttocks with soap and water, apply house antifungal cream then house barrier cream every shift, as needed (PRN), for redness. The order was not initialed as being administered in the month of March of 2021, and it was discontinued on 3/12/21. The Weekly Pressure Injury Report, dated 3/12/21, indicated Resident #78 now had a Stage 2 Pressure Injury (PI) (localized damage to the skin and/or underlying soft tissue. The wound bed is pink or red and may also present as intact or ruptured blister) to the left buttock. Review of a progress note, dated 3/12/21, indicated the Nurse Practitioner (NP) was notified of the Stage 2 PI on the left buttock and treatment orders were obtained. Review of the Initial Wound Physician Evaluation and Management Summary, dated 3/19/21, indicated Resident #78 was being seen for a Stage 3 wound to the left buttock and treatment orders were obtained. Review of the Wound Physician Evaluation and Management Summary, dated 3/26/21, indicated Resident #78 was being seen for the Stage 3 PI to the left buttock. Review of the Wound Physician Evaluation and Management Summary, dated 4/23/21, indicated the PI to the left buttock was debrided (the removal of damaged tissue or foreign objects from a wound), and a change in treatment orders were obtained. Review of a progress note, dated 4/25/21, indicated the left buttock wound developed an abscess with large amounts of purulent drainage (thick and milky discharge from a wound often indicating infection) noted. The Nurse Practitioner ordered warm compresses be applied and an antibiotic medication. B.) Review of the weekly skin check for Resident #78, dated 3/10/21, indicated no skin concerns were found. Review of a progress note, dated 3/17/21, indicated that during morning care, a red non-blanchable area (meaning that pressing on the area does not force blood out of the capillaries and make the skin [NAME] or white) was found on the left heel. The heel was elevated and skin prep was applied. There was no documentation to indicate the facility staff notified the resident's Physician of the new presence of a Deep Tissue Injury (DTI). Further review of the medical record, indicated a Weekly Pressure Injury Evaluation form was completed on 3/19/21, 2 days after the initial observation, for the DTI. During an interview on 4/30/21 at 1:07 P.M., Nurse #5 said there was no care plan in place relative to the DTI to the resident's left heel. 2. For Resident #129, the facility's staff failed to ensure the record reflected clear treatment orders for an existing pressure injury. Resident #129 was admitted to the facility in April of 2021 with a Stage 3 Pressure Injury (sore gets worse and extends into the tissue beneath the skin. Fat may show in the sore, but not muscle, tendon or bone) of the sacrum (the triangular bone at the base of the spine) and dementia. Review of the Admission Minimum Data Set (MDS) Assessment, dated 4/16/21, indicated Resident #129 had moderate cognitive impairment with a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS) and had a Stage 3 Pressure Injury present on admission. Review of Resident #129's care plans, dated 4/16/21, indicated the resident exhibited cognitive impairment, an alteration in skin integrity, had a chronic/progressive decline in intellectual functioning and had a temporary guardian in place due to his/her Dementia diagnosis. Further review of the Resident's care plans indicated that licensed staff were to conduct all treatments as ordered by the Physician. Review of the April 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] ointment 250 unit/gram (gm) to be applied to the pressure ulcer every day and evening shift, dated 4/24/21. The order also indicated the resident can apply the treatment without supervision -Wash coccyx wound with normal saline, pat dry, apply Santyl followed by calcium alginate then DPD (Dry Protective Dressing) daily on the evening shift, dated 4/12/21. On 4/28/21 at 9:11 A.M., the surveyor observed Resident #129 in his/her room. Dressing supplies, including a tube of Santyl ointment (a brand name of a prescription [MEDICATION(S)] ointment used to help heal skin ulcers by removing dead skin cells and tissue to speed up the healing process), was located in the bins on the windowsill of the resident's room. On 5/05/21 at 10:30 A.M., the surveyor observed the dressing change performed by Nurse #14. After the dressing change, while Nurse #14 was charting the dressing change in the electronic medical record, she said there was a notation, indicating that the resident could self-apply the Santyl treatment to his/her own wound. Nurse #14 further said that this was not happening. During an interview on 5/05/21 at 11:00 A.M., Nurse #14 said that Resident #129's main dressing change was on the evening shift, and that calcium alginate is part of the evening dressing change order. She said the resident does not apply Santyl ointment unsupervised to his/her wound as he/she cannot do it. She further said that there should not be two different wound treatment orders scheduled on the same shift. During an interview on 5/05/21 at 11:32 A.M., the Unit Manager (UM) #2 said that she doesn't know why there was an order indicating Resident #129 could self-apply a treatment to his/her sacral wound, as the order does not make sense. During a subsequent interview on 5/06/21 at 10:11 A.M., UM #2 said Resident #129 was incapable of doing his/her own treatment. The ointment (Santyl) should not have been on the windowsill in the Resident's room as it should have been locked in the treatment cart, as required. 3. For Resident #46, the facility staff failed to ensure a Physicians ordered air mattress was set at the appropriate setting to promote healing of a Stage 4 Pressure Injury. Resident #46 was admitted to the facility in August of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Alteration in Skin Integrity Care Plan, initiated 8/31/20, indicated Resident #46 had actual alteration in skin integrity related to a Stage 4 pressure ulcer. The plan of care included the following intervention: - Air mattress to bed, set dial at 140 lbs. mark (initiated on 9/8/20). On 4/29/21 at 8:42 A.M., the surveyor observed Resident #46 lying in bed. The surveyor observed the air mattress to be set at 350 pounds (lbs.). On 4/30/21 at 8:37 A.M., 12:40 P.M. and at 1:29 P.M., the surveyor observed Resident #46 lying in bed. The air mattress set was observed set to 350 lbs. Review of Resident #46's weight record, indicated the most recent weight obtained was 154.0 lbs. on 4/12/21. Review of the April 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the Resident's weight was 155.3 lbs. on 2/23/21. Review of the April 2021 Treatment Administration Record (TAR), indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the Resident's weight was 155.3 lbs. on 2/23/21. Further review of the TAR indicated the nursing staff signed off that the order was completed from 4/1/21 through 4/29/21. During an interview on 5/04/21 at 10:31 A.M., Nurse #6 said Resident #46 stays in bed due to his/her pressure ulcer. She said that she has not noticed any difference in the area for the last several months and that the Wound Physician comes to the facility weekly to assess it. Nurse #6 said that the TAR indicated Resident #46's weight and therefore the weight that the air mattress should be set at. When the surveyor reviewed the observations from 4/29/21 and 4/30/21, Nurse #6 said she would have to double check the orders and Resident's weight. She further said that the resident's air mattress should be set to what the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews and record and policy reviews, the facility staff failed to ensure care and services were provided relative to therapeutic nutritional interventions for one sampled Resident (#46), out of a total sample of 19 residents. Findings include: Review of the facility policy entitled Weight Assessment and Intervention, revised 2019, indicated the following: -interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for the residents -nursing staff will measure the resident weights on admission, the next day, and weekly for two weeks or as recommended or ordered thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter -the threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant; greater than 5% is severe b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe c. 6 months- 10% weight loss is significant; greater than 10% is severe -any 3 pound (lbs.) weight change will result in a reweigh within 24 hours. Once this 3 lbs. weight change has been confirmed, nursing will immediately notified the Physician and Dietitian (RD). Documentation of the notification shall be entered into the resident's medical record -the Physician and the (RD) are expected to respond within 24 hours of a resident's weight change notification -the RD will review all resident weights routinely but at least monthly -the Physician will be notified of unplanned, undesirable weight loss -care planning for undesired weight changes, weight loss or impaired nutrition will be an interdisciplinary effort -individualized care plans shall address the identified causes of the undesired weight change or weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment 1. For Resident #46, the facility failed to ensure weights were monitored as per the facility policy and failed to ensure a Nutritional intervention was provided as recommended by the Dietitian, resulting in the resident continuing to lose weight. The resident is not being assessed, per the facility policy relative to weight loss, and was not monitored weekly as per the policy and Dietician (RD) interview. The RD did not identify that the resident had significant weight loss Resident #46 was admitted to the facility in August of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A.) Review of Resident #46's weight record indicated the following weights were obtained since admission: -9/15/20: 199.7 lbs. -9/22/20: 191.8 lbs. -10/07/20: 182.0 lbs. -11/14/20: 179.2 lbs. -1/12/21: 165.0 lbs. -2/10/21: 158.4 lbs. -2/23/21: 155.3 lbs. -4/12/21: 154.0 lbs. -5/05/21: 149.0 lbs. Further review of the weight record indicated Resident #46 weights were not obtained in December 2020 or March 2021. Review of the RD assessment note, dated 9/21/20, indicated Resident #46 was 199.7 lbs., had a significant weight loss prior to admission (had lost 90 lbs. over 6 month period), had fair intake with meals and had nutritional interventions (protein powder) in place. The assessment indicated that a nutritional care plan was initiated. Review of the Nutrition Care Plan, initiated on 9/21/20, indicated Resident #46 had fair/varying meal intakes, significant weight loss, and a Stage 4 Pressure Ulcer. The care plan indicated that the resident may not eat enough to promote healing of the wound and included the following interventions: -provide diet as ordered, set up meals and encourage intakes and assist and/or feed resident as needed. -monitor and record meal intakes -offer finger foods as appropriate, sandwich with lunch -weights as per policy or as ordered -provide and serve supplements as ordered Review of the Quarterly Nutritional Assessment, dated 11/27/20, indicated Resident #46 was started on antibiotics for [CONDITION(S)] (infection of the bone) had fair intake with meals and had nutritional supplements in place. The weight obtained for this assessment was 179.2 lbs., and the RD indicated that there was no significant weight loss. The nutrition goals indicated were to continue with the current plan (which was not being implemented), improve skin and stabilize the Resident's weights. Review of the Resident #46's weight record indicated the last weight obtained was on 11/14/20 and at this time the resident experienced a 20.5 lbs. weight loss since admission (greater than 10% noted in 3 months, which is severe weight loss). Review of the Quarterly Nutritional Assessment, dated 2/26/21, indicated Resident #46 was 155.2 lbs. at the time of the assessment, had good-fair intake, and did experience significant weight loss of 5.8% over 1 month. The nutrition goal/plan indicated weight maintenance and addition of sandwiches to meals. On 4/30/21 at 12:53 P.M., the surveyor observed Resident #46 lying in bed and his/her lunch tray had been picked up. Resident #46 said that he/she received pureed chicken, vegetables, and some mashed potatoes with lunch. When the surveyor asked if he/she received the sandwich with the lunch tray, Resident #46 said No, I only get that once in a blue moon. Review of Resident #46 lunch ticket for 5/6/21, did not indicate for facility staff to provide a sandwich in addition to the meal. During an interview on 5/06/21 at 4:19 P.M., the Food Service Director (FSD) said that he was unaware that Resident #46 was supposed to get sandwiches with his/her lunch meal and will follow up with the Dietitian. He further said that when there is a recommendation from the Dietitian, it is put onto a communication slip and brought to the kitchen so that he can add it to the resident's meal tickets. Review of a Nutrition Note, dated 4/14/21, indicated Resident #46 has slowly lost weight since admission . The note did not indicate any additional nutritional interventions at the time, nor was there further assessment of the Resident's weight goals or plan. Review of the Resident's weights at the time of the 4/14/21 Nutrition Note, indicated the most recent weight obtained was 154.0 lbs. on 4/12/21, which indicated a 45.7 lbs. weight loss since admission, or 29.7% weight loss since admission. During an interview on 5/04/21 at 10:31 A.M., Nurse #6 said that resident weights are obtained monthly. If there is an issue (weight gain/loss), then the resident would be weighed more frequently. During an interview on 5/04/21 at 12:25 P.M., the Director of Nurses (DON) said that resident weights are obtained on admission, and then monthly, unless otherwise indicated. During an interview on 5/05/21 at 9:59 A.M., the RD said that she assesses Resident #46 quarterly (every 3 months) and that he/she is on monthly weights that are reviewed. She said the Resident had significant weight loss on admission, has also had significant weight loss since admission and would consider him/her high risk due to the pressure area and weight loss. The RD said that if a resident has significant weight loss, they would be put on weekly weights for 3-4 weeks and she would assess the weights more frequently, but this did not occur for Resident #46. She said she assess weights monthly for all residents and if a resident monthly weight is missed, she notifies the facility staff to obtain, and is not sure why this resident did not have weights obtained in December 2020 or March 2021 as he/she is not one to refuse to be weighed . Per the RD, intake will affect progress in wound healing. During an interview on 5/05/21 at 10:30 A.M., Resident #46 stated he/she had lost a significant amount of weight and continues to lose weight.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to implement adequate interventions to prevent abuse, when Nurse #1 purposely threw water on Resident #1, who was cognitively impaired. Although Resident #1 did not recall the abuse, a reasonable person would experience emotional upset from having water thrown in his/her face. Findings include: The Facility's policy, titled, Understanding the Health Care Provider's Role in Dealing with Abuse and Neglect, undated, indicated: -Physical abuse was defined as the use of physical force that may result in bodily injury, pain, or impairment, or controlling behavior through corporal punishment. -Signs of physical abuse include, Residents report of being mistreated and sudden changes in behavior. -Psychological abuse was defined as the infliction of pain or distress through verbal or non-verbal acts, including humiliation. Resident #1 was admitted to the Facility in (MONTH) 2014, [DIAGNOSES REDACTED]. The Annual Minimal Data Set (MDS) assessment, dated 7/16/18, indicated Resident #1 was cognitively impaired. The Care Plan, dated 8/1/18, indicated Resident #1 had a chronic decline in intellectual functioning characterized by deficit in memory, judgement, decision making, and thought process due to Dementia. The Description of Incident, undated, indicated that at approximately 4:00 P.M. on 10/3/18, Resident #1 had a cup of juice in his/her hand that belonged to another resident, and Nurse #1 attempted to take the cup of juice away from Resident #1. The Description indicated Resident #1 threw the cup of juice at Nurse #1. The Description indicated Nurse #1 then threw a full cup of water on Resident #1's face. The Surveyor interviewed Nurse #1 at 9:34 A.M. on 11/13/18. Nurse #1 said Resident #1 was known to pick up drinks that were unattended, and on 10/3/18 he noticed Resident #1 with a cup of juice that appeared contaminated. Nurse #1 said he asked Resident #1 to give him the cup of juice and offered a new cup of juice in exchange. Nurse #1 said Resident #1 ignored him and started to drink the juice, and when he reached for the cup again, Resident #1 threw the cup of juice in his face. Nurse #1 said he then grabbed a cup of water that was on the medication cart and threw it in Resident #1's face. The Surveyor interviewed Activities Aide #1 at 10:34 A.M. on 11/13/18. Activities Aide #1 said that at approximately 3:55 P.M. on 10/3/18, she was near the elevator and witnessed Resident #1 threw a cup of juice at Nurse #1, then Nurse #1 poured a cup of water, walked over to Resident #1, and threw the water in Resident #1's face. Activities Aide #1 said Resident #1's clothes and face were wet, and he/she stood quietly for a moment, then walked quietly toward his/her room. Activities Aide #1 said Resident #1 was the kind of person who would yell if he/she was upset, and seeing him/her stand there quietly was uncharacteristic and made her feel sad for Resident #1. The Surveyor interviewed the Director of Nurses at 8:49 A.M. on 11/13/18. The Director of Nurses said when she saw Resident #1 on 10/3/18 immediately after Nurse #1 threw water in his/her face, Resident #1 was visibly upset, and said He threw water on me! or words to that effect. The Surveyor interviewed the Administrator at 8:35 A.M. on 11/13/18. The Administrator said that at approximately 4:00 P.M. on 10/3/18, he had walked onto the unit and saw that Resident #1 was wet. The Administrator said Nurse #1 said Resident #1 threw juice at him, and at the time the Administrator was not told that Nurse #1 had thrown water at Resident #1. The Administrator said Resident #1 was upset. The Administrator said shortly after, Activities Aide #1 reported that Nurse #1 had thrown water at Resident #1's face. The Administrator said Nurse #1 said he wanted Resident #1 to know how it felt, or words to that effect.

Based on records reviewed and interviews, for 4 of 5 sampled residents with substance use disorders (Resident #4, Resident #7, Resident #8, and Resident #9), the facility failed to complete substance use assessments following allegations of alcohol and/or substance use; failed to ensure that the substance use assessments accurately documented the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status; and, failed to ensure initial substance use assessments were completed within 48 to 72 hours as required by Facility policy. - On 07/20/17, Resident #7 allegedly received one Klonopin (a benzodiazepine which requires a prescription, and is prohibited by Federal law to be transferred to any person other than for whom it was prescribed) tablet from Resident #4, which was not prescribed to Resident #4 or Resident #7. - On or about 07/22/17, Resident #8 was reported be in possession of Klonopin, which was not prescribed to him/her. - During the dates of survey, Surveyor #1 and Surveyor #2 received reports that Resident #9 was allegedly smoking marijuana on Facility property. - Resident #6 was allegedly provided Klonopin by Resident #4 on 07/20/17, and by Resident #8 on or about 07/22/17. Findings include: 1. The physician's orders [REDACTED].#4 was prescribed Klonopin. The Clinician Note, dated 07/20/17and signed by the Nurse Practitioner (NP), indicated that Resident #4 had altered mental status, agitated behavior, and an unsteady gait. The note indicated that per the Director of Nurses (DON) and the Administrator, pills consistent with Klonopin were found in Resident #4's room after a visitor the previous night. The Progress Note, dated 07/20/17 at 14:53, indicated that Resident #4 presented with altered mental status, and was found with multiple Klonopin in his/her possession that did not coincide with his/her current prescribed medications. The Hospital Emergency Department Record, dated 07/20/17, indicated that Resident #4 reported that he/she took Klonopin, but was unclear where he/she got it or how much he/she took. The record indicated that there was a concern for a benzodiazepine overdose when Resident #4 went out to the [MEDICATION NAME] (a medication used for the treatment of [REDACTED]. The Progress Note, dated 07/21/17 at 10:59, indicated that Resident #4 potentially received more non-prescribed medications from a visitor. The note indicated that a conversation was had with Resident #4 and the visitor regarding not bringing in items that were against policy, but did not indicate who initiated the conversation. The note indicated that Resident #4 gave the Director of Social Services and the DON consent for a room search, but then revoked consent once the search started. The Progress Note, dated 07/22/17 at 15:17, indicated that Resident #4 was alert and confused off and on all shift. The note indicated Resident #4 was noted to be staggering, and was found on the sidewalk and had to be assisted back into the Facility. The Progress Note, dated 07/22/17 at 23:26, indicated that Resident #4 was very sleepy that evening and was observed nodding off while smoking. The SBAR - Physician/NP/PA Communication Tool, dated 07/23/17, indicated that Resident #4 fell and sustained a 0.5 centimeter laceration over the left eyebrow. The tool indicated that there was a possibility of alcohol consumption, which Resident #4 denied. The Clinician Note, dated 07/24/17 and signed by the NP, indicated that Nurse #4 observed Resident #4 going to a liquor store and tobacco store sometime after 07/20/17, and afterwards appeared intoxicated with confusion and an unsteady gait. The Progress Note, dated 07/24/17 at 10:59, indicated that a resident purchased 4 pills from Resident #4, with the money to change hands later. The note from the Facility's mental health provider, dated 07/25/17, indicated that Resident #4 had a long history of drug abuse and relapse pattern, and acknowledged using drugs once several days ago in response to extreme stress he/she was experiencing. The Progress Note, dated 07/28/17 at 00:17 (12:17 A.M.), indicated that Resident #4 was observed inhaling from a device while in the bathroom, and refused to give the device to staff. There was no documentation at the time of survey that Resident #4's substance use was reassessed in response to the allegation that Resident #4 was ingesting and distributing Klonopin to other residents of the Facility, in response to his/her potential consumption of alcohol, or after he/she was observed inhaling from a device. - Resident #7 was admitted to the Facility in April 2017 with [DIAGNOSES REDACTED]. The Physician Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #7 was prescribed Klonopin. Surveyor #1 and #2 interviewed Resident #6 at 4:35 P.M. on 07/31/17. Resident #6 said that within the few weeks prior to the date of interview, he/she observed Resident #4 give Resident #7 a Klonopin pill during a staff supervised smoking time. Surveyor #1 and #2 interviewed the DON at 5:08 P.M. on 07/31/17. The DON said that on 07/20/17, Resident #6 witnessed Resident #4 give Resident #7 pills that were thought to be Klonopin. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 1:00 P.M. on 08/01/17. The Social Worker said he, the Administrator and the DON spoke with Resident #7 after receiving an allegation that Resident #7 had accepted medications from Resident #4. The Social Worker said Resident #7 denied the allegation, but then said he/she was his/her own person and so could put any substance in his/her body that he/she wanted. There was no documentation at the time of survey that Resident #7's substance use was reassessed in response to the allegation that he/she received Klonopin tablets from Resident #4. - Resident #8 was admitted to the Facility in March 2017 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#8 was prescribed Klonopin. The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified that Resident #8 was in possession of a bottle of Klonopin, and had provided two Klonopin tablets to another resident. The note indicated that Resident #8 denied any knowledge of the pills. Surveyor #1 and Surveyor #2 interviewed the DON and Administrator at 10:09 A.M. on 08/01/17. The DON said her understanding was that Resident #8 flushed Klonopin tablets down the toilet after finding them in his/her personal belongings. The DON said she did not verify that Resident #8 no longer had the Klonopin. There was no documentation at the time of survey that Resident #8's substance use was reassessed in response to the allegation that Resident #8 was in possession of and distributing Klonopin to persons within the Facility. 2. The Substance Abuse Policy, undated, indicated that social services would conduct an assessment of the resident within 48 to 72 hours of admission to identify risk and to put a plan of care into place. Surveyor #1 and Surveyor #2 interviewed the Director of Nurses (DON) at multiple times throughout the dates of survey. The DON said that the Substance Abuse Policy provided to the Surveyors was the Facility's current, active policy. - The Substance Use Assessment Tool, dated 02/24/17, was completed more than 72 hours after Resident #4's admission to the Facility. - The Substance Use Assessment Tool, dated 04/05/17, was completed more than 72 hours after Resident #8's admission to the Facility. - The Substance Use Assessment Tool, dated 07/10/17, was completed more than 72 hours after Resident #9's admission to the Facility.

Based on records reviewed and interviews, for 4 of 5 sampled residents with substance use disorders (Resident #4, Resident #7, Resident #8, and Resident #9), the facility failed to ensure that comprehensive care plans were developed or revised to accurately reflect the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. - On 07/20/17, Resident #7 allegedly received one Klonopin (a benzodiazepine which requires a prescription, and is prohibited by Federal law to be transferred to any person other than for whom it was prescribed) tablet from Resident #4, who also allegedly distributed Klonopin to other persons within the Facility. Neither Resident #4 nor Resident #7 had current physician orders [REDACTED]. - On or about 07/22/17, Resident #8 was allegedly in possession of Klonopin, as well as allegedly distributing the Klonopin to persons within the Facility. Resident #8 did not have a current physician order [REDACTED].>- During the dates of survey, Surveyor #1 and Surveyor #2 observed Resident #9 smoking during Facility designated smoking times. There was no documentation of a care plan related to Resident #9's smoking dated prior to 08/01/17, when Surveyor #1 and Surveyor #2 requested a list of all residents at the Facility who smoked. Findings include: 1. The Care Plan, initiated on the date of Resident #4's admission to the Facility and revised on 07/25/17, indicated that Resident #4 was at risk for relapse of substance use, history of drug dependence, ETOH (alcohol) use, learned response patterns for cultural factor, person/family values. At the time of survey, there were no new interventions documented after 05/19/17. The physician's orders [REDACTED].#4 was prescribed Klonopin. The Clinician Note, dated 07/20/17and signed by the Nurse Practitioner (NP), indicated that Resident #4 had altered mental status, agitated behavior, and an unsteady gait. The note indicated that per the Director of Nurses (DON) and the Administrator, pills consistent with Klonopin were found in Resident #4's room after a visitor the previous night. The Progress Note, dated 07/20/17 at 14:53, indicated that Resident #4 presented with altered mental status, and was found with multiple Klonopin in his/her possession that did not coincide with his/her current prescribed medications. The Hospital Emergency Department Record, dated 07/20/17, indicated that Resident #4 reported that he/she took Klonopin, but was unclear where he/she got it or how much he/she took. The record indicated that there was a concern for a benzodiazepine overdose when Resident #4 went out to the [MEDICATION NAME] (a medication used for the treatment of [REDACTED]. The Progress Note, dated 07/21/17 at 10:59, indicated that Resident #4 potentially received more non-prescribed medications from a visitor. The note indicated that a conversation was had with Resident #4 and the visitor regarding not bringing in items that were against policy, but did not indicate who initiated the conversation. The note indicated that Resident #4 gave the Director of Social Services and the DON consent for a room search, but then revoked consent once the search started. The Progress Note, dated 07/22/17 at 15:17, indicated that Resident #4 was alert and confused off and on all shift. The note indicated Resident #4 was noted to be staggering, and was found on the sidewalk and had to be assisted back into the Facility. The Progress Note, dated 07/22/17 at 23:26, indicated that Resident #4 was very sleepy that evening and was observed nodding off while smoking. The SBAR - Physician/NP/PA Communication Tool, dated 07/23/17, indicated that Resident #4 fell and sustained a 0.5 centimeter laceration over the left eyebrow. The tool indicated that there was a possibility of alcohol consumption, which Resident #4 denied. The Clinician Note, dated 07/24/17 and signed by the NP, indicated that Nurse #4 observed Resident #4 going to a liquor store and tobacco store sometime after 07/20/17, and afterwards appeared intoxicated with confusion and an unsteady gait. The Progress Note, dated 07/24/17 at 10:59, indicated that a resident purchased 4 pills from Resident #4, with the money to change hands later. The note from the Facility's mental health provider, dated 07/25/17, indicated that Resident #4 had a long history of drug abuse and relapse pattern, and acknowledged using drugs once several days ago in response to extreme stress he/she was experiencing. The Progress Note, dated 07/28/17 at 00:17, indicated that Resident #4 was observed inhaling from a device while in the bathroom, and refused to give the device to staff. There was no documentation at the time of survey that Resident #4's substance use care plan was updated to accurately reflect his/her alleged use and possession of a non-prescribed controlled substance, possible alcohol consumption, or use of an inhalant device in July 2017. - The Care Plan, initiated on 4/5/17 and revised on 7/22/17, indicated Resident #7 was at risk for relapse of substance relapse and has a history of drug dependence with a goal to maintain substance abuse free. At the time of survey, there were no new interventions documented after the care plan was initiated on 04/05/17. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 1:00 P.M. on 08/01/17. The Social Worker said he, the Administrator and the DON spoke with Resident #7 after receiving an allegation that Resident #7 had accepted medications from Resident #4. The Social Worker said Resident #7 denied the allegation, but then said he/she was his/her own person and so could put any substance in his/her body that he/she wanted, but he/she wouldn't do that. - The Care Plan, initiated 5 days after Resident #8's admission to the Facility and revised on 04/20/17, indicated that Resident #8 was for at risk for relapse of substance relapse, history of drug dependence. At the time of survey, there were no new interventions documented after the care plan was initiated. The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified that Resident #8 was in possession of a bottle of Klonopin, and had provided two Klonopin tablets to another resident. The note indicated that Resident #8 denied any knowledge of the pills. Surveyor #1 and Surveyor #2 interviewed the DON and Administrator at 10:09 A.M. on 08/01/17. The DON said her understanding was that Resident #8 flushed Klonopin tablets down the toilet after finding them in his/her personal belongings. The DON said she did not verify that Resident #8 no longer had the Klonopin. There was no documentation at the time of survey that Resident #8's substance use care plan was updated to accurately reflect his/her alleged possession and distribution of a non-prescribed controlled substance in July 2017. 2. The Facility Policy, titled Smoking Policy-Residents, revised 12/2011, indicated that a care plan would be developed and would note any smoking-related privileges, restrictions, and concerns. A List of Residents that Smoke, dated 08/01/17 and provided by the DON, indicated that Resident #7 and Resident #9 were smokers. - There was no documentation at the time of survey that a Smoking Care Plan was developed for Resident #7. - The Independent Safe Smoking Evaluation: Champion, dated 07/05/17, indicated that Resident #9 was a smoker. Surveyor #1 and Surveyor #2 observed Resident #9 at multiple times throughout the dates of survey, engaged in the Facility's supervised smoking group. There was no documentation at the time of survey that a Smoking Care Plan was developed for Resident #9 prior to 08/01/17.

Based on records reviewed, interviews, and observations, for 4 of 5 sampled residents with substance use disorder (Resident #4, Resident #7, Resident #8, and Resident #9) and one sampled resident without a substance use disorder (Resident #6), the facility failed to ensure each resident received a comprehensive medical and interdisciplinary evaluation to determine the severity of the issue, and develop treatment priorities. The Facility failed to determine each resident's immediate psychiatric and/or substance abuse care needs, evaluate their risks, and strengths; and, identify all appropriate [DIAGNOSES REDACTED]. The Facility failed to reassess residents to determine those residents at risk for relapse, and the level of supervision necessary. The Facility failed to ensure they could provide the level of services necessary to provide the least restrictive, but safe, level of care to residents with substance abuse/use disorders or addiction prior to admitting residents with this need. - On 07/20/17, Resident #6 and Resident #7 allegedly received one Klonopin (a benzodiazepine which requires a prescription, and is prohibited by Federal law to be transferred to any person other than for whom it was prescribed) tablet from Resident #4, who was reportedly also distributing Klonopin to other persons within the Facility. There were no physician's orders for the administration of Klonopin for Resident #4, Resident #6, or Resident #7. The Administrator, Director of Nurses (DON), Director of Social Services and Social Worker were aware of the alleged incident at the time of occurrence. There was no documentation in Resident #6's or Resident #7's clinical record at the time of survey that the attending physician and/or nurse practitioner (NP) were notified of the alleged incident. - On or about 07/22/17, Resident #8 was allegedly in possession of Klonopin, as well as distributing the Klonopin to persons within the Facility including Resident #6. Resident #8 did not have a current physician order for [REDACTED].#6's clinical record at the time of survey that the attending physician and/or NP were notified of the alleged incident, or that Resident #8's attending physician and/or NP was notified prior to 07/27/17. - On 07/25/17, Resident #4 allegedly gave Resident #6 additional Klonopin tablets. The Administrator, DON, Director of Social Services and Admission Coordinator said they were aware of the alleged incident at the time of occurrence. There was no documentation in Resident #6's clinical record at the time of survey that the attending physician and/or NP were notified of the alleged incident. - During the dates of survey, Surveyor #1 and Surveyor #2 received reports that Resident #9 was allegedly smoking marijuana on Facility property. The Director of Social Services said she was unaware of Resident #9's alleged substance abuse. Findings include: Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 12:18 P.M. on 08/01/17. The Director of Social Services said that at the time of the alleged events, there were no substance use services available at the Facility, and that the Facility's mental health provider did not currently have a representative certified to provide substance abuse services to any of the residents at the Facility. 1. Resident #7, Resident #8 and Resident #9 reported the desire to maintain sobriety. - The Care Plan, initiated on 04/05/17 and revised on 07/22/17, indicated that Resident #7 was at risk for relapse of substance relapse and has a history of drug dependence with a goal to maintain substance abuse free. - Surveyor #1 and Surveyor #2 interviewed the DON and Administrator at 10:09 A.M. on 08/01/17. The DON said Resident #8 told her that he/she wanted to maintain sobriety, and so would not have taken medication not prescribed to him/her. - The Progress Note, dated 08/01/17, indicated that Resident #9 was sober, and wanted to remain sober. The note indicated that Resident #9 did not want to return to his/her prior living situation, because according to him/her, there were too many active drinkers and substance abusers there. 2. There was no documentation at the time of survey that Resident #4's, Resident #6's, Resident #7's, or Resident #8's substance use was assessed or reassessed following reported incidents of use and/or possession of alcohol or Klonopin. The Physician's Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #4, Resident #6, Resident #7 or Resident #8 was prescribed Klonopin. - The note from the Facility's mental health provider, dated 07/25/17, indicated that Resident #4 had a long history of drug abuse and relapse pattern, and had acknowledged using drugs once several days ago in response to extreme stress he/she was experiencing. - Resident #6 said he/she reported receiving Klonopin from Resident #4 and Resident #8 because he/she had post-traumatic stress disorder ([MEDICAL CONDITION]) as a result of his/her parent being an addict and growing up with an addict. - Surveyor #1 and Surveyor #2 interviewed the Social Worker at 1:00 P.M. on 08/01/17. The Social Worker said he, the Administrator and the DON spoke with Resident #7 after receiving an allegation that Resident #7 accepted medications from Resident #4. The Social Worker said Resident #7 denied the allegation, but said he/she was his/her own person and so could put any substance in his/her body that he/she wanted, but he/she wouldn't do that. - The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified by another nurse that Resident #8 provided two Klonopin tablets to another resident, and that Resident #8 had a whole bottle of the tablets. The DON said she had not conducted an internal investigation into the allegation that Resident #8 distributed Klonopin to Resident #6 because her understanding was that Resident #8 flushed the Klonopin down the toilet after finding it in his/her personal belongings. The DON said she did not verify that Resident #8 no longer had the Klonopin because Resident #8 said he/she flushed the tablets. 3. There was no documentation at the time of survey that the substance abuse care plans for Resident #4, Resident #7, Resident #8, or Resident #9 were updated following the alleged incidents, to reflect the alleged incidents or to include any new interventions. - The substance use care plans for Resident #4 and Resident #8 did not include the residents' drug(s) of choice. 4. There was no documentation at the time of survey that Facility staff was aware of Resident #9's reported marijuana use on Facility property. The Physician's Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #9 was prescribed or ordered medical marijuana. The Substance Use Assessment Tool, dated 07/10/17, indicated that Resident #9 had a hostory of marijuana use. The Director of Social Services said she was not aware that Resident #9 was reportedly in possession of and smoking marijuana. 5. There was no documentation at the time of survey that Resident #4, Resident #6, Resident #7, Resident #8, or Resident #9 were evaluated by, or offered substance abuse services following reported incidents of use and/or possession of alcohol, Klonopin, or marijuana.

Based on records reviewed, observations and interviews, for 4 of 5 sampled residents with substance use disorder (Resident #4, Resident #7, Resident #8 and Resident #9) and one of four sampled residents without substance use disorder (Resident #6), the facility failed to provide adequate supervision in response to reports of Resident #4's ingestion and distribution and/or sale of non-prescribed controlled substances within the Facility, and were also unaware of an alleged incident in which Resident #8 allegedly supplied the same non-prescribed controlled substance to three persons at the Facility, or of Resident #9's alleged marijuana use. The Facility also failed to provide adequate supervision to address concerns that a specific male visitor was supplying, at minimum, Resident #4 with a non-prescribed controlled substance; failed to provide adequate supervision to address reports that a second male visitor was supplying various residents with cigarettes and/or alcohol; failed to verify the destruction of a non-prescribed controlled substance by Resident #8; failed to reassess the involved residents' substance use habits; failed to implement interventions to reduce or eliminate the risk of additional incidents of non-prescribed controlled substance distribution or ingestion within the Facility, including updating relevant care plans; and, failed to protect other residents from the potential intentional or accidental ingestion of a non-prescribed controlled substance. - On 07/20/17, Resident #4 allegedly distributed Klonopin (a benzodiazepine which requires a prescription, and is prohibited by Federal law to be transferred to any person other than for whom it was prescribed) tablets to Resident #6 and Resident #7. The Administrator, Director of Nurses (DON), Director of Social Services, and Social Worker said they were aware of the alleged incident at the time of occurrence. - On or about 07/22/17, Resident #8 was allegedly in possession of Klonopin, as well as allegedly distributing the Klonopin to persons within the Facility. The DON and the Director of Social Services said they were aware of the alleged incident. - On 07/25/17, Resident #4 allegedly distributed additional Klonopin to Resident #6. The Administrator, DON, Director of Social Services, and Admissions Coordinator said they were aware of the alleged incident at the time of occurrence. - During the dates of survey, Surveyor #1 and Surveyor #2 received reports that Resident #9 was allegedly smoking marijuana on Facility property. The Director of Social Services said she was unaware of Resident #9's alleged substance use. - On at least two occasions, a physical description of the alleged drug dealer who was suspected of providing the Klonopin to Resident #4 was given to Facility staff and/or law enforcement, and attempts were made to alert Facility staff to the presence of said person when they were in the Facility. - There was no documentation at the time of survey that substance use reassessments were completed on Resident #4, Resident #7 and Resident #8. - There was no documentation at the time of survey that substance use care plans for Resident #4, Resident #7 and Resident #8 were revised and included interventions to reduce or eliminate the risk of additional incidents of non-prescribed controlled substance distribution or ingestion. - On 08/01/17, a back exterior door of the Facility, which staff said was supposed to be secured, was observed unsecured. On 08/08/17, the same door was observed unsecured for more than 8 hours; and, at 6:59 A.M. when Surveyor #2 and Surveyor #3 entered the Facility, the front doors that the Administrator said were supposed to be closed and locked between the hours of 7:00 P.M. and 8:00 A.M., were observed propped open and/or unlocked. Findings include: The Accidents/Incidents policy, revised 09/2016, indicated that regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and appropriate documentation completed on the shift that the accident or incident occurred; the resident's physician shall be notified; the charge nurse and/or the department director or supervisor must document the incident and conduct an immediate investigation of the accident or incident; immediate measures/interventions must be put into place to provide for resident protection; and, an investigation folder must be maintained for each accident/incident, which must contain pertinent documentation surrounding the event and witness statements. Surveyor #1 and Surveyor #2 interviewed the DON at multiple times throughout the dates of survey. The DON said Resident #4 and Resident #8 attended two separate methadone (a medication used for the treatment of [REDACTED]. The DON said that Resident #4 and Resident #8 were transported to the clinics via a chair car, and were not accompanied by Facility staff. The DON said the chair car would drop the resident off, and then return to pick the resident back up once the appointment was completed. - Resident #4 was admitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #4 was cognitively intact and required supervision with ambulation. The physician's orders [REDACTED].#4 was prescribed Klonopin. The Clinician Note, dated 07/20/17 and signed by the NP, indicated that per the DON and the Administrator, pills consistent with Klonopin were found in Resident #4's room after he/she had a visitor the previous night. The note indicated that Resident #4 had altered mental status, agitated behavior, and an unsteady gait. The Progress Note, dated 07/20/17 at 14:53, indicated that Resident #4 presented with altered mental status, and was found with multiple Klonopin in his/her possession that did not coincide with his/her current prescribed medications. The Hospital Emergency Department Record, dated 07/20/17, indicated that Resident #4 reported that he/she took Klonopin, but was unclear where he/she got it or how much he/she took. The record indicated that there was a concern for a benzodiazepine overdose when Resident #4 went out to the methadone clinic. The Progress Note, dated 07/21/17 at 10:59, indicated that Resident #4 had potentially received more non-prescribed medications from a visitor. The note indicated that the Director of Social Services informed the Administrator and DON, and a conversation was had with Resident #4 and the visitor regarding not bringing in items that were against Facility policy. The Progress Note, dated 07/21/17 at 22:06, indicated that at 8:45 P.M. while doing hourly checks, a Certified Nurse Aide (CNA) observed Resident #4 in the bathroom with 2 green boxes and a vapor implement. The note indicated that Resident #4 would not let staff near the items. The Progress Note, dated 07/22/17 at 15:17, indicated that Resident #4 was alert and confused off and on all shift. The note indicated Resident #4 was noted to be staggering, and was found on the sidewalk and had to be assisted back into the Facility. The Progress Note, dated 07/22/17 at 23:26, indicated that Resident #4 was very sleepy that evening and was observed nodding off while smoking. The SBAR - Physician/NP/PA Communication Tool, dated 07/23/17, indicated that at approximately 8:00 A.M., Resident #4 fell and sustained a 0.5 centimeter laceration over the left eyebrow. The tool indicated that there was a possibility of alcohol consumption, which Resident #4 denied. The Suspicion of Impairment Assessment Tool Revised, dated 07/23/17 at 11:51, indicated that there was a suspicion that Resident #4 was impaired. The Progress Note, dated 07/23/17 at 11:56, indicated that Resident #4 was alert with periods of confused conversation, but denied any drug or alcohol use. The Clinician Note, dated 07/24/17, indicated that e-cigarette solution was also found in Resident #4's room on 07/20/17. The note indicated that Nurse #4 observed Resident #4 going to a liquor store and a tobacco store sometime after he/she returned from the hospital, and afterwards appeared intoxicated with confusion and an unsteady gait. The Progress Note, dated 07/24/17 at 10:59, indicated that a resident purchased four pills from Resident #4. The note indicated that the DON and Administrator were notified, and the police were called. The note indicated that Resident #4 was placed on 1:1 observation. The Police Report, dated 07/26/17, indicated that the police received a call from the Facility on 07/25/17. The report indicated that Resident #4 admitted to purchasing approximately 20 Klonopin tablets from a man named James, who visited the Facility on certain days. The report indicated that when asked if he/she gave any of the Klonopin tablets to Resident #6 or any other resident, Resident #4 replied that he/she had not sold pills to anyone. The report indicated that the officer was able to obtain a physical description of the man believed to be supplying Resident #4 with the Klonopin tablets. The note from the Facility's mental health provider, dated 07/25/17, indicated that Resident #4 had a long history of drug abuse and relapse pattern, and acknowledged using drugs several days ago in response to extreme stress he/she was experiencing. The Clinician Note, dated 07/27/17, indicated that Resident #4 had altered mental status the prior day and was found with more non-prescribed medication/pills in his/her room. The note also indicated that Resident #4 was caught selling Klonopin to other residents and the police were contacted, and that Resident #4 refused urine drug testing. The Progress Note, dated 07/28/17 at 00:17, indicated that while Resident #4 was on 1:1 supervision, he/she inhaled from a device while in the bathroom, and refused to give the device to staff. Surveyor #1 and Surveyor #2 interviewed Resident #4 at 4:20 P.M. on 07/31/17. Resident #4 said that on a date he/she could not remember, he/she bought 4 or 5 tablets of either Klonopin or Valium (an anti-anxiety and sedative medication) from a male visitor. Resident #4 denied giving or selling any of the tablets to anyone. Surveyor #1 and Surveyor #2 interviewed the Director of Social Services at 12:18 P.M. on 08/01/17. The Director of Social Services said that prior to these events, Resident #4 often left the Facility and its surrounding grounds, and often did not sign out when he/she left the Facility, so staff were not always aware of where he/she was or who he/she was with. The Director of Social Services said she spoke with Resident #4 about that, as the busyness of the surrounding areas and the close proximity of a methadone clinic made her concerned for his/her safety. Surveyor #1 and Surveyor #2 interviewed the Admissions Coordinator at 10:55 A.M. on 08/01/17. The Admissions Coordinator said that prior to these events, Resident #4 moved freely within and outside of the Facility. - Resident #6 was readmitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #6 was cognitively intact. The Physician Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #6 was prescribed Klonopin. There was no documentation in Resident #6's clinical record at the time of survey regarding the alleged incidents that occurred on 07/20/17, on or about 07/22/17, and on 07/25/17, or that Resident #6's physician and/or NP were notified of the alleged events. - Resident #7 was admitted to the Facility in April 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #7 was cognitively intact. The Physician Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #7 was prescribed Klonopin. There was no documentation in Resident #7's clinical record at the time of survey regarding the alleged incident that occurred on 07/20/17, or that Resident #7's physician and/or NP were notified of the alleged events. - Resident #8 was admitted to the Facility in March 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #8 was cognitively intact and could ambulate independently. The physician's orders [REDACTED].#8 was prescribed Klonopin. The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified by another nurse that Resident #8 had a bottle of Klonopin tablets, and had provided two of the tablets to another resident. The note indicated that Resident #8 denied any knowledge of the pills. The note did not indicate what happened to the bottle of Klonopin tablets, or whether Resident #8's physician and/or NP were notified of the alleged incident. The Progress Note, dated 07/23/17, indicated that Resident #8 denied giving another resident medication, or having medication on his/her person or in his/her room. The Clinician Note, dated 07/27/17, indicated that Resident #8 was reportedly found with Klonopin tablets not prescribed to him/her. - Resident #9 was admitted to the Facility in July 2017 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#9 was prescribed or ordered medical marijuana. The Substance Use Assessment Tool, dated 07/10/17, indicated that Resident #9 had a history of [REDACTED]. The Director of Social Services said that at the time of the alleged events, there were no substance use services available at the Facility. 1. Surveyor #1 and Surveyor #2 requested to review the Facility's internal investigations into the reported incidents involving Resident #4, Resident #6 and Resident #7 at multiple times on 07/31/17 and 08/01/17. The DON said the internal investigations into the two separate alleged incidents were not completed. When asked why the investigations were not completed more than 10 days after the first alleged incident, the DON said, they just aren't, or words to that effect. The DON said she had not conducted interviews regarding the alleged incidents because the investigations were not completed. The DON said she had one written statement from 07/25/17, from the Admissions Coordinator. - The DON said that on 07/20/17, it was reported to her that Resident #6 had witnessed Resident #4 give Resident #7 pills that were thought to be Klonopin. The DON said she spoke to Resident #4, Resident #6 and Resident #7 about the alleged incident, but could not provide any documentation of the interviews at the time of survey. The DON said no other residents were interviewed, and said she did not interview anyone else. Surveyor #1 and Surveyor #2 interviewed Resident #4 at 4:20 P.M. on 07/31/17. Resident #4 said that on a date he/she could not remember, he/she bought four or five tablets of either Klonopin or Valium (an anti-anxiety and sedative medication) from a male visitor. Resident #4 denied giving or selling any of the tablets to anyone. Surveyor #1 and #2 interviewed Resident #6 at 4:35 P.M. on 7/31/17. Resident #6 said he/she observed Resident #4 give Resident #7 a Klonopin pill during a staff supervised smoking time. Resident #6 said he/she asked Resident #4 if he/she could have some pills, and said Resident #4 retrieved four Klonopin tablets from the bedside drawer in his/her room and gave them to Resident #6. Resident #6 said he/she took the pills and immediately went to a staff member to report the incident and to give them the pills, but could not recall who the staff member was. Resident #6 said he/she reported the distribution of the Klonopin because he/she had PTSD related to his/her parent having been an addict and growing up with an addict, and that was why he/she had never ingested any alcohol or drugs. Resident #6 said he/she repeatedly reported similar events to Facility staff because it triggered his/her PTSD, but no one ever did anything about it. Resident #6 said he/she even attempted to point out to Facility staff the visitor named Jimmy, who he/she believed was supplying the Klonopin to Resident #4, but said he/she did not believe anything ever came of that either. Resident #6 said he/she was not interviewed by anyone regarding this alleged event. The Director of Social Services said that on 07/20/17, she received a report that Resident #4 had distributed Klonopin tablets to Resident #6 and Resident #7. The Director of Social Services said she notified the Administrator and DON of the alleged incident. The Director of Social Services said she, the Administrator and the DON conducted a search of Resident #4's room, and 12 pills identified as Klonopin were found wrapped up in a coffee shop receipt dated 07/19/17 in Resident #4's bedside table. The Director of Social Services said an unidentifiable orange pill was also located in Resident #4's bedside table at the time of the room search. The Director of Social Services said that at the time, Resident #4 had increased difficulty responding to questions, was unable to form complete thoughts, and was very lethargic. The Director of Social Services said Resident #4 was placed under 1:1 observation until he/she could be transported to the hospital for evaluation due to the change in his/her mental status. Surveyor #1 and Surveyor #2 interviewed the Administrator at 1:45 P.M. on 08/01/17. The Administrator said that on 07/26/17, he was notified by the Director of Social Services that Resident #6 witnessed Resident #4 offer other residents medication. The Administrator said he, the Director of Social Services and the DON conducted a search of Resident #4's room, where approximately 12 Klonopin tablets were located. The Administrator said that at the time, Resident #4 was struggling to form sentences and was sleepy, and was sent to the hospital for evaluation. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 1:00 P.M. on 08/01/17. The Social Worker said he, the Administrator and the DON spoke with Resident #7 after receiving an allegation that Resident #7 accepted medications from Resident #4. The Social Worker said Resident #7 denied the allegation, but then said he/she was his/her own person and so could put any substance in his/her body that he/she wanted. The Social Worker said Resident #7 offered to take a drug test, but said that no screen was conducted, nor were Resident #7's room and belongings searched, because he/she denied the allegation. - Surveyor #1 and Surveyor #2 interviewed the Admissions Coordinator at 10:55 A.M. on 08/01/17. The Admissions Coordinator said that on 07/25/17, she received a report that Resident #4 had given Resident #6 four Klonopin tablets with the expectation of being paid for them later. The Admissions Coordinator said Resident #6 gave her the four Klonopin tablets, and she then notified the Administrator and gave the tablets to him. The Director of Social Services said that on 07/25/17, she was notified that Resident #4 had allegedly given Resident #6 additional tablets of Klonopin. The Administrator said that on the Monday or Tuesday after finding the Klonopin tablets in Resident #4's belongings (07/31/17 or 08/01/17), the Admissions Coordinator gave him tablets that allegedly had been given to Resident #6 by Resident #4. The Administrator said the police department was notified. The Police Report, dated 07/26/17, indicated that the police received a call from the Facility on 07/25/17. The report indicated that an officer responded on 07/26/17, and the Administrator reported that Resident #4 gave Resident #6 three Klonopin tablets. The report indicated that Resident #4 admitted to purchasing approximately 20 Klonopin tablets from a man named James, and when asked if he/she had given tablets to anyone, Resident #4 denied selling the pills. - The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified by another nurse that Resident #8 had a bottle of Klonopin tablets, and had provided two of the tablets to another resident. The note indicated that Resident #8 denied any knowledge of the pills. The note did not indicate what happened to the bottle of Klonopin tablets, or whether Resident #8's physician and/or NP were notified of the alleged incident. The Progress Note, dated 07/23/17, indicated that Resident #8 denied giving another resident medication, or having medication on his/her person or in his/her room. The Clinician Note, dated 07/27/17 and signed by the NP, indicated that Resident #8 was reportedly found with Klonopin tablets not prescribed to him/her. Resident #6 said he/she asked Resident #8 for Klonopin pills, and Resident #8 gave him/her two Klonopin pills. Resident #6 said he/she immediately went to a staff member to report the incident and to give them the pills. Resident #6 said Resident #8 said he/she met his/her dealer and obtained the Klonopin pills when he/she was at the methadone clinic. Resident #6 said that a few days after the incident, Resident #8 said he/she had given out Klonopin pills to three people, including Resident #6. Resident #6 said Resident #8 did not identify who the other two people were that he/she gave Klonopin tablets to. Resident #6 said he/she was not interviewed by anyone regarding this alleged event. The Director of Social Services said she and the DON were aware of the allegation that Resident #8 had non-prescribed medications in his/her possession. Surveyor #1 and Surveyor #2 interviewed the DON and Administrator at 10:09 A.M. on 08/01/17. The DON said she had not conducted an internal investigation into the allegation that Resident #8 distributed Klonopin to Resident #6 because her understanding was that Resident #8 flushed the Klonopin down the toilet after finding it in his/her personal belongings. The DON said she did not verify that Resident #8 no longer had the Klonopin because Resident #8 said he/she flushed the tablets. 2. The Director of Social Services said that on 07/25/17, she was notified that the man who sold the Klonopin tablets to Resident #4 was in the Facility. The Director of Social Services said she notified the Administrator, who went down and spoke with a male visitor in Resident #4's room, requesting that the visitor not provide Resident #4 with substances that he/she should not have. Resident #6 said that Resident #4 got the Klonopin tablets from a man who plays Resident #4's nephew Jimmy. The Admissions Coordinator said Resident #4 allegedly received the Klonopin tablets from a drug dealer named Jimmy, who was reportedly in the Facility on 07/25/17. The Admissions Coordinator said Resident #6 provided her with a basic physical description of the man at the time, but she did not see Jimmy herself and so could not identify him. The Police Report, dated 07/26/17, indicated that a police officer received a physical description of the man believed to be supplying Resident #4 with the Klonopin tablets, who was also identified as having the name James. 3. The DON said she received two sets of tablets that were reportedly given to Resident #6 by Resident #4, and both sets of tablets were identified as Klonopin. The DON said the first set of Klonopin tablets was destroyed by herself and the Director of Social Services by placing them into sharps container (a special container designed for the safe disposal of used sharp medical equipment such as needles). The DON said the second set of Klonopin tablets was handed over to the police department. The DON said she did not document the destruction of the first set of Klonopin tablets, or her possession of either set of Klonopin tablets. The Director of Social Services said she and the DON disposed of the Klonopin tablets in a sharps container. The DON said her understanding was that Resident #8 had found the Klonopin in his/her personal belongings, and had flushed the tablets down the toilet. The DON said she did not verify that Resident #8 no longer had the Klonopin because Resident #8 said he/she flushed the tablets. 4. Resident #6 and the Administrator said Resident #6's room and belongings were never searched in response to the reported allegations that he/she received Klonopin from Resident #4. The DON said that even though she had received reports that Resident #6 and Resident #7 received Klonopin tablets from Resident #4 and/or Resident #8, the only room search conducted was of Resident #4's room. The DON said Resident #7's room and belongings were not searched because he/she denied receiving Klonopin tablets from Resident #4, and Resident #8's room and belongings were not searched because he/she reported flushing the Klonopin tablets down the toilet. The Director of Social Services said she knew one search had been conducted of Resident #4's room, but did not know if room searches were conducted of Resident #6's, Resident #7's, or Resident #8's rooms. The Director of Social Services said Resident #4 initially consented to a second search of his/her room, but then revoked consent when she approached the bedside table where the Klonopin tablets were found on 07/20/17. The Social Worker said no room search or personal belongings check was conducted in response to the allegation that Resident #7 had accepted medications from Resident #4. 5. There was no documentation at the time of survey that Resident #4's, Resident #7's, or Resident #8's substance use was reassessed following reported incidents of use and or possession of alcohol or Klonopin. 6. Although substance abuse care plans were in place for Resident #4, Resident #7 and Resident #8 at the time of the alleged incidents, there was no documentation at the time of survey that the care plans were updated to reflect the alleged incidents, or that new interventions were added. 7. The Admissions Coordinator said she was not aware of any video surveillance cameras on Facility property. The Admissions Coordinator said that all of the Facility exit doors, except for the front door, were alarmed and required a code to enter. The Admissions Coordinator said all exterior doors should be closed at all times, because they were alarmed, but then observed that a visible exterior door into one of the Facility's parking lots from near the kitchen area was not closed properly. The Admissions Coordinator identified the door as one which opened near the Facility's kitchen At the time of the Admissions Coordinator's observation, Surveyor #1 and Surveyor #2 also observed that the exterior door was not properly closed. On 08/08/17 at 7:19 A.M., Surveyor #2 and Surveyor #3 observed that the same door was unsecured. - At12:49 P.M., the DON confirmed that the door remained unsecured, and said it should have been closed and locked. The DON said she would have someone close the door. - At 1:54 P.M., Surveyor #2 and Surveyor #3 observed a Facility staff person, later identified as a maintenance person by the DON, working on the armature and latch portion of the door. - At 3:42 P.M., Surveyor #2 observed the maintenance person close the door, and tug on the handle from the outside to ensure that the door latched. However, the maintenance person was observed opening the door from the outside, without the use of a key. - Surveyor #1 and Surveyor #2 interviewed the Administrator at 1:45 P.M. on 08/01/17. The Administrator said that most of the Facility's exterior doors were locked and/or alarmed. The Administrator said the front doors of the Facility were unlocked during the day, but were locked at approximately 7:00 P.M., and unlocked at approximately 8:00 A.M. the following morning. At 11:50 A.M. on 08/08/17, Surveyor #2 and Surveyor #3 confirmed with the Administrator that the front doors were locked at approximately 7:00 P.M., and unlocked at approximately 8:00 A.M. the following morning. At 6:59 A.M. on 08/08/17, Surveyor #2 and Surveyor #3 observed that the outermost front door was propped open with a small brownish-grey oblong shaped item, and the inner front door was unlocked and unalarmed.

Based on records reviewed and interviews, the Facility failed to ensure that the Medical Director was consulted to provide clinical guidance for the development, implementation and evaluation of resident care policies and procedures for substance use disorders. The Facility also failed to ensure the Medical Director's collaboration to help the Facility assess and address potential clinical concerns as they pertained to residents with histories of substance use disorders. Findings include: The Policy titled, Substance Use Disorders, undated, indicated the Medical Director and ED/DNS (Executive Director/Director of Nursing Services) will meet weekly to discuss the current list of patients at risk and any new processes. Surveyor #2 and Surveyor #3 interviewed the Director of Nursing Services (DON) at 12:50 P.M. on 08/08/17. The DON said the Facility's Policy, Substance Use Disorders, undated, was the Facility's most current and only policy pertaining to substance use disorders. The DON said the Facility did not consult the Medical Director for the development, implementation and evaluation of resident care policies and procedures for substance use disorders. The DON said the Facility was not meeting, and had not met, weekly with the Medical Director to discuss patients at risk for substance use disorder relapse and any new processes. The DON said that this was not consistent with the Facility's Substance Use Disorders policy. Surveyor #2 and Surveyor #3 interviewed the Medical Director at 2:15 P.M. on 08/08/17. The Medical Director said he was aware the Facility had a large population of residents whose past medical histories included [DIAGNOSES REDACTED]. The Medical Director said that when the Facility began admitting residents with substance use disorders, he expressed concern due to the close proximity of a [MEDICATION NAME] clinic (a medication used for the treatment of [REDACTED]. The Medical Director said he had not been consulted by the Facility on the development, implementation and evaluation of resident care policies and procedures for substance use disorders. The Medical Director said he had not seen, read or reviewed the Facility's Substance Use Disorder Policy, undated, prior to the interview on 08/08/2017. The Medical Director said he did not participate in and was not aware of any weekly rounds conducted by the Facility to discuss patients at risk for substance use disorder relapse and any new processes.

Based on records reviewed and interviews, for 5 of 9 sampled residents (Resident #4, Resident #6, Resident #7, Resident #8 and Resident #9), the facility failed to investigate reports of the ingestion, and distribution and/or sale of non-prescribed controlled substances within the Facility. Because the Facility failed to conduct thorough investigations into two alleged incidents of Resident #4 supplying Klonopin (a benzodiazepine which requires a prescription, and is prohibited by Federal law to be transferred to any person other than for whom it was prescribed) to Resident #6 and Resident #7, staff were unaware of a third alleged incident in which Resident #8 supplied Klonopin to three persons at the Facility, or of Resident #9's reported marijuana use. This prevented the Facility from determining the scope of the availability and types of substances within the Facility; the persons involved in the provision of said substances, whether they be other residents, staff, or visitors; where and how the substances were obtained; failed to prevent access to substances which posed a hazard to residents with impaired cognition; and, any areas within Facility or on its surrounding grounds where the substances might be kept, in an effort to provide residents with an environment consistent with expressed wishes to maintain sobriety. - On 07/20/17, Resident #4 allegedly gave Resident #6 and Resident #7 Klonopin tablets. The Administrator, Director of Nurses (DON), Director of Social Services and Social Worker were aware of the alleged incident at the time of occurrence. There was no documentation in Resident #6's or Resident #7's clinical record at the time of survey that the attending physician and/or nurse practitioner (NP) was notified of the alleged incident. The Facility did not immediately conduct an investigation to determine the scope of the issue, resulting in a second incident five days later. - On 07/25/17, Resident #4 allegedly gave Resident #6 additional Klonopin tablets. The Administrator, DON, Director of Social Services and Admission Coordinator said they were aware of the alleged incident at the time of occurrence. There was no documentation in Resident #6's clinical record at the time of survey that the attending physician and/or NP was notified of the alleged incident. - During the dates of survey, the Surveyors received information that Resident #8 allegedly gave Resident #6 Klonopin tablets on or about 07/22/17. The DON and the Director of Social Services said they were aware of the alleged incident. There was no documentation in Resident #6's clinical record at the time of survey that the attending physician was notified of the alleged incident, or that Resident #8's attending physician and/or NP was notified prior to 07/27/17. - During the dates of survey, the Surveyors received a report that Resident #9 smoked marijuana on Facility property. The Director of Social Services said she was unaware of the alleged substance use. Findings include: During a tour of the Facility on 07/28/17, Surveyor #1 observed that Unit 3 was a secured unit, which required a keypad code to access. The Daily Census report, dated 07/28/17, indicated that Resident #4 and Resident #6 resided on Unit 3. 1. Resident #6 was readmitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #6 was cognitively intact. The Physician Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #6 was prescribed Klonopin. Surveyor #1 and #2 interviewed Resident #6 at 4:35 P.M. on 07/31/17. Resident #6 said Resident #4 provided him/her with four Klonopin tablets retrieved from the bedside dresser drawer in Resident #4's room. Resident #6 said he/she took the pills and immediately went to a staff member to report the incident and to give them the pills, but could not recall who the staff member was. Resident #6 said he/she reported the distribution of the Klonopin because he/she had [MEDICAL CONDITION] related to his/her parent having been an addict and growing up with an addict, and that was why he/she had never ingested any alcohol or drugs. Resident #6 said he/she repeatedly reported similar events to Facility staff because it triggered his/her [MEDICAL CONDITION], but no one ever did anything about it. Resident #6 said he/she even attempted to point out to Facility staff the visitor named Jimmy, who he/she believed was supplying the Klonopin to Resident #4, but said he/she did not believe anything ever came of that either. Resident #6 said there was also an incident in which Resident #8 gave him/her two Klonopin tablets. Resident #6 said he/she immediately reported it to a staff member, and handed over those tablets as well. Resident #6 said that a few days after the incident, Resident #8 asked Resident #6 if he/she had written a letter about receiving the Klonopin pills because Resident #8 had only given out the Klonopin pills to 3 people, and Resident #6 was one of them. Resident #6 said Resident #8 did not tell him/her who the other two people were that received the Klonopin. Resident #6 said he/she was not interviewed by Facility staff regarding the alleged incidents with Resident #4 or Resident #8. Surveyor #1 and Surveyor #2 interviewed the DON at multiple times on 07/31/17 and 08/01/17. The DON said she had not interviewed Resident #6 regarding the alleged incidents. There was no documentation at the time of survey that Resident #6's reports of the alleged distribution and/or sale of Klonopin within the Facility were addressed, which caused Resident #6 emotional distress related to his/her [DIAGNOSES REDACTED]. 2. Resident #4 was admitted to the Facility in February 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #4 was cognitively intact and required supervision with ambulation. The physician's orders [REDACTED].#4 was prescribed Klonopin. The Clinician Note, dated 07/20/17 and signed by the NP, indicated that per the DON and the Administrator, pills consistent with Klonopin were found in Resident #4's room after he/she had a visitor the previous night. The note indicated that Resident #4 had altered mental status, agitated behavior, and an unsteady gait. There was no indication that the Facility attempted to obtain information from the visitor, inform local law enforcement, re-evaluate Resident #4's level of supervision, or need for visitors to be supervised in response to the incident. The Progress Note, dated 07/20/17 at 14:53, indicated that Resident #4 presented with altered mental status, and was found with multiple Klonopin in his/her possession that did not coincide with his/her current prescribed medications. The Hospital Emergency Department Record, dated 07/20/17, indicated that Resident #4 reported that he/she took Klonopin, but was unclear where he/she got it or how much he/she took. The record indicated that there was a concern for a benzodiazepine overdose when Resident #4 went out to the [MEDICATION NAME] clinic. The Progress Note, dated 07/21/17 at 10:59, indicated that Resident #4 had potentially received more non-prescribed medications from a visitor. The note indicated that the Director of Social Services informed the Administrator and DON, and a conversation was had with Resident #4 and the visitor regarding not bringing in items that were against Facility policy. There was no indication that efforts were made to supervise the visitor, restrict visitation, call local law enforcement, or notify Resident #4's attending physician and/or NP in response to the incident. The Progress Note, dated 07/21/17 at 22:06, indicated that at 8:45 P.M. while doing hourly checks, a Certified Nurse Aide (CNA) observed Resident #4 in the bathroom with 2 green boxes and a vapor implement. The note indicated that Resident #4 would not let staff near the items. The Progress Note, dated 07/22/17 at 15:17, indicated that Resident #4 was alert and confused off and on all shift. The note indicated Resident #4 was noted to be staggering, and was found on the sidewalk and had to be assisted back into the Facility. The note indicated that the nursing supervisor was notified. The Progress Note, dated 07/22/17 at 23:26, indicated that Resident #4 was very sleepy that evening and was observed nodding off while smoking. There was no indication that the attending physician and/or NP were notified of the observed and documented changes in Resident #4's condition on 07/21/17 and 07/22/17, or that Resident #4's level of supervision was re-assessed. The SBAR - Physician/NP/PA Communication Tool, dated 07/23/17, indicated that at approximately 8:00 A.M., Resident #4 fell and sustained a 0.5 centimeter laceration over the left eyebrow. The tool indicated that there was a possibility of alcohol consumption, which Resident #4 denied. The Suspicion of Impairment Assessment Tool Revised, dated 07/23/17 at 11:51, indicated that there was a suspicion that Resident #4 was impaired. The Progress Note, dated 07/23/17 at 11:56, indicated that Resident #4 was alert with periods of confused conversation, but denied any drug or alcohol use. The Clinician Note, dated 07/24/17, indicated that e-cigarette solution was also found in Resident #4's room on 07/20/17. The note indicated that Nurse #4 observed Resident #4 going to a liquor store and a tobacco store sometime after he/she returned from the hospital, and afterwards appeared intoxicated with confusion and an unsteady gait. The Progress Note, dated 07/24/17 at 10:59, indicated that a resident purchased four pills from Resident #4. The note indicated that the DON and Administrator were notified, and the police were called. The note indicated that Resident #4 was placed on 1:1 observation. The date of the progress note conflicts with subsequent documentation and interviews that indicated the alleged incident occurred and that local law enforcement were notified on 07/25/17. The Police Report, dated 07/26/17, indicated that the police received a call from the Facility on 07/25/17. The report indicated that Resident #4 admitted to purchasing approximately 20 Klonopin tablets from a man named James, who visited the Facility on certain days. The report indicated that when asked if he/she gave any of the Klonopin tablets to Resident #6 or any other resident, Resident #4 replied that he/she had not sold pills to anyone. The report indicated that the officer was able to obtain a physical description of the man believed to be supplying Resident #4 with the Klonopin tablets. The note from the Facility's mental health provider, dated 07/25/17, indicated that Resident #4 had a long history of drug abuse and relapse pattern, and acknowledged using drugs several days ago in response to extreme stress he/she was experiencing. The Clinician Note, dated 07/27/17, indicated that Resident #4 had altered mental status the prior day and was found with more non-prescribed medication/pills in his/her room. The note also indicated that Resident #4 was caught selling Klonopin to other residents and the police were contacted, and that Resident #4 refused urine drug testing. The Progress Note, dated 07/28/17 at 00:17, indicated that while Resident #4 was on 1:1 supervision, he/she inhaled from a device while in the bathroom, and refused to give the device to staff. Surveyor #1 and Surveyor #2 interviewed Resident #4 at 4:20 P.M. on 07/31/17. Resident #4 said that on a date he/she could not remember, he/she bought four or five tablets of either Klonopin or [MEDICATION NAME] (an anti-anxiety and sedative medication) from a male visitor. Resident #4 denied giving or selling any of the tablets to anyone. There was no documentation at the time of survey that Resident #4's desire to achieve or maintain sobriety was assessed, that his/her substance use was reassessed after episodes of presumed impairment, or that interventions were revised or implemented to ensure Resident #4 did not ingest, distribute or sell non-prescribed controlled substances. There was no indication that efforts were made to ensure the visitor in question was restricted from entering the Facility, or supervised during visits. 3. Resident #8 was admitted to the Facility in March 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated that Resident #8 was cognitively intact. The physician's orders [REDACTED].#8 was prescribed Klonopin. The Progress Note, dated 07/22/17, indicated that Nurse #3 was notified by another nurse that Resident #8 had a bottle of Klonopin tablets, and had provided two of the tablets to another resident. The note indicated that Resident #8 denied any knowledge of the pills. The note did not indicate what happened to the bottle of Klonopin tablets, or whether Resident #8's physician and/or NP were notified of the alleged incident. The Progress Note, dated 07/23/17, indicated that Resident #8 denied giving another resident medication, or having medication on his/her person or in his/her room. Surveyor #1 and Surveyor #2 interviewed the DON and Administrator at 10:09 A.M. on 08/01/17. The DON said she had not conducted an internal investigation into the allegation that Resident #8 distributed Klonopin to Resident #6 because her understanding was that Resident #8 flushed the Klonopin down the toilet after finding it in his/her personal belongings. The DON said she did not verify that Resident #8 no longer had the Klonopin because Resident #8 said he/she flushed the tablets. The DON said Resident #8 told her that he/she wanted to maintain sobriety, and so would not have taken medication not prescribed to him/her. The Clinician Note, dated 07/27/17 and signed by the NP, indicated that Resident #8 was reportedly found with Klonopin tablets not prescribed to him/her. There was no documentation at the time of survey that the Facility verified the destruction of the Klonopin in Resident #8's possession, in an effort to assist his/her wishes to remain sober, or that the attending physician and/or NP was notified until 5 days after the alleged incident. 4. Resident #7 was admitted to the Facility in April 2017 with [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident #7 was cognitively intact. The Physician Orders, dated 07/01/17 through 07/31/17, did not indicate that Resident #7 was prescribed Klonopin. The Substance Use Assessment Tool, dated 04/05/17, indicated that Resident #7 had evidence of psychological dependence on substances, and unpredictable control over use of substances. The Care Plan, initiated on 04/05/17 and revised on 07/22/17, indicated Resident #7 was at risk for relapse and had a history of [REDACTED]. Resident #6 said he/she witnessed Resident #4 give Resident #7 a Klonopin pill during a staff supervised smoking time. Surveyor #1 and Surveyor #2 interviewed the Social Worker at 1:00 P.M. on 08/01/17. The Social Worker said he, the Administrator and the DON spoke with Resident #7 after receiving an allegation that Resident #7 accepted medications from Resident #4. The Social Worker said Resident #7 denied the allegation, but then said he/she was his/her own person and so could put any substance in his/her body that he/she wanted. The Social Worker said Resident #7 offered to take a drug test, but said that no screen was conducted, nor were Resident #7's room and belongings searched, because he/she denied the allegation. 5. Resident #6 said he/she observed Resident #9 smoking marijuana on Facility grounds, as had other residents and Facility staff. Resident #6 said he/she did not bother reporting the observations, as prior reported incidents of residents using substances at the Facility had been ignored.

Based on record review and interviews, for 1 of 3 sampled residents (Resident #1), the Facility failed to safely assist Resident #1, who had a [DIAGNOSES REDACTED]. Findings include: The Facility Policy titled Progressive Ambulation, (dated 9/1/14), indicated if a resident can walk safely with assistance, stand behind the resident, place one hand under the resident's axilla (under arm) and the other hand around the resident's waist, holding on to gait belt. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) assessment, dated 6/27/16, indicated Resident #1 had severe cognitive impairment and required the assistance of one staff member with ambulation. A Fall Risk Evaluation dated 7/1/16 indicated Resident #1 was at moderate risk for falls and he/she exhibited loss of balance while standing. A Care Plan dated 7/1/16 indicated Resident #1 was at risk for injuries related to a history of falls and directed staff to monitor use of adaptive devices such as his/her walker. A Nurse's Progress note, late entry dated 7/30/16 and timed at 7:40 P.M., indicated Resident #1 was ambulating with a walker assisted by a Certified Nurse's Aide (CNA) and fell when the CNA attempted to move another resident out of the way. Resident #1's Physician was notified and an order was obtained for an x-ray of Resident #1's right shoulder, elbow and forearm. Certified Nurse Aide (CNA) #1 was interviewed on 10/20/16 at 9:35 A.M. CNA #1 said that on 7/30/16 at approximately 6:00 P.M. she put a gait belt on Resident #1 and started to walk with him/her out of the dining room. CNA #1 said another resident, who was seated in a wheel chair, was in front of the doorway, and she left Resident #1 standing by himself/herself while she went to help move the other resident away from the doorway. CNA #1 said Resident #1 lost his/her balance and fell . This was inconsistent with Facility policy titled Progressive Ambulation and Resident #1's Plan of Care. The Director of Nursing (DON) was interviewed on 10/19/16 at 8:12 A.M. The DON said because Resident #1 required assistance with ambulation, CNA #1 should have kept her hands on Resident #1 while ambulating with him/her and CNA #1 should have seated Resident #1 in a chair if she needed to help another resident move out of the way. A Nurse's Progress Note, dated 7/30/16 and timed at 7:40 P.M., indicated that a physician's orders [REDACTED].#1 to the emergency room for evaluation. The Hospital emergency room Physician's Report, dated 7/31/16 and timed at 2:42 A.M., indicated Resident #1 was discharged from the hospital back to the Facility with a [DIAGNOSES REDACTED].#1's arm was immobilized with a sling.

Based on record reviews, observations and interviews, the facility failed to provide services in accordance to the resident's written plan of care for 4 residents (#1, #9, #12 and #14) in a total sample of 24. Findings include: 1. For Resident #9, the facility failed to follow the physician's orders [REDACTED]. According to the facility's policy on Pressure Ulcer Prevention Measures, dated 1/22/09, it states under #2,"All resident's skin is inspected at least weekly by a licensed nurse." Resident #9 was admitted to the facility in 9/2014 with the following pertinent diagnoses; status [REDACTED]. a. Review of the physician's orders [REDACTED]. Review of the 11/2014 through 12/2014, treatment sheets, care plans and care card, indicated the physician's orders [REDACTED]. Review of the Physical Therapy Treatment Encounter Note of 11/17/14 indicated that the Physical Therapy Assistant (PTA) noticed pressure like ulcers on the lateroposterior left calf. Nursing was made aware of these new areas. The PTA said that the multi-podus boot was probably the cause of the pressure like ulcers. The Surveyor observed on 12/12/14 at 10:55 A.M., with Nurse #1, that this Resident had 4 unstagable pressure ulcers on the left and right posterior calves. During an interview with the Unit Manager (UM) #2 on 12/12/14 at 10:15 A.M., the Surveyor asked, where was the physician's orders [REDACTED].? UM #2 said that, the physician's orders [REDACTED]. She said that she took off that order and she did not document it anywhere (for nursing to follow) because she thought that Rehabilitation would monitor the skin under the multi-podus boot for breakdown. During an interview with the Certified Nursing Assistant (CNA) #1 (the CNA taking care of this Resident) on 12/12/14 at 2:10 P.M., the Surveyor asked, "Do the CNAs check the skin under the multi-podus splints and braces for skin breakdown?" She said, "No, the Nurses do that." During an interview with Nurse #1 (the Nurse taking care of this Resident) on 12/12/14 at 2:15 P.M., the Surveyor asked, "Do the Nurses check the skin under the multi-podus splints and braces for skin breakdown?" He said that the CNAs check the skin with direct care in the morning with dressing, and at night when the splints come off. He said, "It is the CNAs responsibility. The Nurses do weekly skin checks." During an interview with the Assistant Director of Nurses (ADON) on 12/12/14 at 2:30 P.M., the Surveyor said, "I did not see where the physician's orders [REDACTED]." The Surveyor asked, "Where should the nursing staff have transcribed and documented that physician's orders [REDACTED].?" The ADON said, "The Doctors order of 11/5/14 should have gone onto the treatment sheet or onto the (CNA) care card." The Surveyor asked, "Did the physician's orders [REDACTED].?" She said, "No, it didn't." b. Review of the Skin Integrity care plan of 9/2014 had the following pertinent interventions: - Treat existing alterations as ordered and assess weekly. - Assist resident with every 2 hours repositioning with an assist of 2. - Specialty Air mattress for the bed. Review of the medical record indicated that weekly skin checks were not done for October and November 2014 as per the care plan and their policies. The Pressure Ulcer and Skin Care Management Policy revised 1/22/09 indicates that " a licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin alterations: a. at admission or readmission to the facility, b. weekly on all residents, and....." The Pressure Ulcer Preventive Measures Policy revised 1/22/09 indicates that "...... 2. All residents' skin is inspected at least weekly by a licensed nurse....." Review of the medical record indicated that this Resident developed bilateral facility acquired pressure ulcers of the posterior calves on 11/17/14. During an interview and review of the weekly skin checks with the ADON on 12/12/14 at 2:30 P.M., she stated that there were no weekly skin checks on the treatment sheets for October and November 2014 as per their care plan. Please refer to F314. 2. For Resident #1, the facility failed to follow the resident's plan of care relative to the use of alarms and 1 to 1 (1:1) supervision. Resident #1 was admitted to the facility in 7/2014 with [DIAGNOSES REDACTED]. Review of the resident's care plans for falls, date initiated 7/8/14, indicated the resident had a potential for injury related to history of falls, unsteady gait, decreased/poor safety awareness, psych meds, cardiovascular meds, diuretic meds, periods of agitation/combativeness, rising without assist and new environment. Interventions included: -pressure alarm in bed and chair, -1:1 supervision at night (dated 8/10/14), -Continue 1:1 supervision, 7:00 A.M.-3:00 P.M./3:00 P.M.-11:00 P.M. (8/15/14), (1:1 supervision was discontinued 11/28/14), -Velcro alarm seat belt (12/3/14). Review of the Initial Minimum Data Set (MDS) Assessment, dated 7/14/14, indicated the resident had some difficulty with cognitive skills in daily decision making (in new situations only), was an extensive assist with transfers, ambulation, dressing and toilet use. Review of the Unusual Event Report, dated 8/9/14, indicated the resident had an unwitnessed fall in the hallway at 1:00 P.M. The resident was found sitting on floor and said he/she had tripped on sandals. The report indicated the safety devices were not used in accordance to the care plan at the time of the fall. The report indicated the new interventions included; a rehabilitation screen and send out to the hospital (section 12-involuntary psychiatric evaluation). Review of the Unusual Event Report, dated 8/10/14, indicated the resident had an unwitnessed fall in his/her room at 1:20 A.M. The resident was heard calling for help and was found sitting on the floor facing the side of the bathroom. The report indicated the safety devices were not in use according to the care plan at the time of the fall. The report indicated the intervention was to apply a pressure alarm. this intervention was initiated on the care plan for falls dated 7/8/14. Review of the Unusual Event Report, dated 8/15/14, indicated the resident had an unwitnessed fall in his/her room at 2:45 A.M. The resident was found sitting on the floor at the doorway. The report indicated the safety devices were not in use according to the care plan at the time of the fall and was on 1:1 at the time of the incident. The report indicated the new interventions were to do neurological checks and a rehabilitation screen. Review of the Unusual Event Report, dated 9/26/14, indicated the resident had an unwitnessed fall in his/her room at 2:15 P.M. The resident was found sitting on the floor. Prior to the fall the report indicated the resident had been sitting in a wheel chair. The report indicated the safety devices were in use according to the care plan at the time of the fall, however the resident had turned off the alarm. The report indicated the new interventions were to do neurological checks and a rehabilitation screen. The resident was observed on 12/11/14 at 12:30 P.M., sitting in a wheel chair in a small dining room on the unit. The resident was dressed, had on shoes and had an over the bed side table directly in front of him. A Certified Nurses Assistant was sitting in a chair in front of him. The resident was observed on 12/12/14 at 9:55 A.M., sitting in a wheel chair in a small dining room on the unit. The resident was dressed, had on shoes and had the Velcro seat belt across his/her lap. A staff member was in the unit dining room, to the resident's left side. During an interview on 12/12/14 at 10:35 A.M., Unit Manager (UM) #1 said she was unsure why the safety alarms were not in place for the falls of 8/9/14, 8/10/14 and 8/15/14 and the 1:1 supervision was not in place for the falls of 8/15/14 and 9/26/14. She said they should have been in place per the resident's plan of care for falls. Please refer to to F323 3. For Resident #12, the facility failed to follow the resident's plan of care to prevent falls. Resident #12 was admitted to the facility 2/2014 with [DIAGNOSES REDACTED]. Review of the Initial MDS Assessment, dated 3/3/14, indicated the resident had cognitive impairment and required assistance for transfers and ambulation. Review of the resident's care plan for falls, initiated 3/7/14, indicated the resident had the potential for injury due to a history of falls, an unsteady gait, and was very impulsive. A preventative intervention implemented was for the resident to have non-skid strips next to bed. Review of an Unusual Event Report, dated 5/27/14, indicated that at 9:00 P.M. a staff member was assisting the resident back to bed after toileting. The resident, all of a sudden, bent down to move his/her shoes and fell . The resident said he/she had lost her balance. The report did not indicate that non-skid strips were next to the bed. Review of an Unusual Event Report, dated 8/9/14, indicated an unwitnessed fall at 11:25 P.M. The resident tried to get up unassisted to go to the bathroom and slid down from the bed. The report did not indicated that non-skid strips were next to the bed. On 12/12/14 at 10:30 A.M., UM #3 accompanied the surveyor to the resident's room, she agreed there were no non-skid strips on either side of the resident's bed. She said the intervention for non-skid strips was in place prior to the resident's falls. Please refer to F323, Example #2 4. For Resident #14, the facility failed to follow the resident's plan of care to prevent falls. Resident #14 was admitted to the facility 8/2013 with [DIAGNOSES REDACTED]. Review of the Care Plan for falls, re-written on 5/14/14, indicated an intervention for non-skid strips to the right side of the bed. Review of the resident's Quarterly MDS Assessment, dated 8/8/14, indicate the resident required physical assistance for ambulating, transfers and toileting. The surveyor and UM #3 observed the resident's room on 12/12/14 at 1:30 P.M. She agreed there were no non-skid strips to either side of the resident's bed.

Based on record review, observation and interview, the facility failed to ensure that necessary care and services were provided relative to the prevention of facility acquired pressure ulcers for 1 of 2 applicable residents (#9) out of a total sample of 24 residents. Findings include: For Resident #9, the facility failed to monitor the Resident after a multi-podus boot was applied to the left foot, resulting in deep tissue trauma and progressing to an unstagable pressure ulcer (a full thickness tissue loss covered with dead tissue). There was a 4 day delay in reporting this pressure sore to the Physician and obtaining a treatment. In addition, a facility acquired unstagable pressure ulcer developed on the right calf. There was a 20 day delay in reporting this pressure sore to the Physician and obtaining a treatment. Resident #9 was admitted to the facility in 9/2014 with the following pertinent diagnoses; status [REDACTED]. Review of the facility's policy on Pressure Ulcer and Skin Care Management, dated 1/22/09, it states: "A Resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrated that they are unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. (Under #2.) "Residents determined to be at high risk for pressure ulcers will be considered for preventive measures and an appropriate care plan will be implemented. 3. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin alterations; a. at admission or readmission to the facility b. weekly on all residents... 4. The licensed nurse documents that the body check was completed on the resident's treatment administration record. If a new ulcer ... is noted, the nurse assesses the wound and documents the assessment on the Weekly Wound Assessment form." Under documentation, it states: "1. On the treatment administration record, document completion of the weekly body check for the presence of new pressure ulcers... According to the facility's policy on Pressure Ulcer Prevention Measures, dated 1/22/09, it states under #2,"All resident's skin is inspected at least weekly by a licensed nurse." 2. On the treatment administration record, also document treatments for skin alterations identified, as ordered by the physician." Review of the Admission Skin Assessment of 9/16/14 indicated that this Resident had no pressure sores, but had [MEDICAL CONDITION] of the left foot. Review of a Norton Plus Pressure Ulcer Scale dated 9/17/14 indicated that the resident scored 10. (Score of 10 or less equals High Risk for Pressure Ulcers). Review of the Admission Minimum Data Set (MDS) Assessment completed on 9/23/14 indicated that the resident had short term memory impaired, long term memory was intact, was independent with decision making ability, was nonambulatory, was totally dependent with bed mobility, dressing and personal hygiene and required an assist of two, and was not transferred to a wheelchair, chair or to a standing position. The resident was at risk for developing pressure ulcers, and had no pressure ulcers. Review of the pertinent admission physician's orders [REDACTED]. Review of the Skin Integrity care plan of 9/2014 had the following pertinent interventions: - Treat existing alterations as ordered and assess weekly. Encourage adequate nutritional intake and monitor nutritional status. - Notify the physician if skin condition worsens. - Assist resident with every 2 hours repositioning with an assist of 2. - Specialty Air mattress for the bed. a. Review of the physician's orders [REDACTED]. Review of the 11/2014 through 12/2014, treatment sheets, care plans and care card, indicated the physician's orders [REDACTED]. Although the multi-podus boot was applied to the left foot. Review of the Physical Therapy Treatment Encounter Note of 11/5/14, indicated that the left multi-podus boot was given to the Resident and the Charge Nurse was notified. The multi-podus boot was to be used for the Resident to decrease the risk for contracture and skin breakdown, secondary to the Resident having left foot drop. Review of the Physical Therapy Treatment Encounter Note of 11/17/14 indicated that the Physical Therapy Assistant (PTA) noticed (new) pressure like ulcers on the lateroposterior left calf. Nursing was made aware of these new areas. The PTA thought the multi-podus boot was probably the cause of the pressure like ulcers. Review of the Weekly Wound Sheets, Nurse's notes indicated there was no documentation of the left calf pressure ulcers on 11/17/14, 11/18/14, 11/19/14, 11/20/14, and 11/21/14. Review of the Nurse's notes and physician's orders [REDACTED]. Review of the investigation of 11/21/14 at 10:00 A.M. indicated that this Resident had bilateral lower extremity braces resulting in the lower extremity development of darkened areas, deep tissue trauma. There were 3 pressure ulcers on the left leg under depth of all three it was documented with question marks (?). Their measurements on the investigation were as follows: - The 1st area was 1.5 centimeters (cm) in length by 0.5 cm in width. - The 2nd area was 1.5 cm in length by 0.9 cm in width. - The 3rd area was 2.5 cm in length by 1.4 cm in width. Review of the verbal physician's orders [REDACTED]. Review of a Nurse's note on 11/22/14 stated, "New Rx (treatment) for LLE (left lower extremity) area 11/21/14 MD (Medical Doctor)." The Weekly Wound Assessment of 12/3/14 indicated that the Resident had unstagable pressure ulcers due to necrotic tissue on the left calf with the date of onset as 11/21/14 (incorrect date of onset, it was 11/17/14). There were 3 pressure ulcers on the left leg, with no depth, The measurements were as follows: - The 1st area was 1 cm in length by 0.5 cm in width. - The 2nd area was 1.5 cm in length by 0.9 cm in width. - The 3rd area was 2.2 cm in length by 1.1 cm in width. The wound beds were described as a black/brown eschar. The wound edges were slightly red. In comparison from last assessment (the date of the investigation 11/21/14), the pressure ulcers were described as better. Review of the Physician's notes of 12/8/14 indicated that the bilateral lower extremity wounds had increased redness and consider starting an antibiotic. The Weekly Wound Assessment of 12/10/14 indicated that the Resident continued to have unstagable pressure ulcers due to necrotic tissue on the left calf with no depth. The measurements were as follows: - The 1st area was 1 cm in length by 0.8 cm in width. - The 2nd area was 1.5 cm in length by 1 cm in width. - The 3rd area was 2.5 cm in length by 1 cm in width. The wound beds were described as a black/brown eschar. The wound edges were slightly red. In comparison from last assessment (the date of the previous assessment on 12/3/14), the pressure ulcer were described as better. b. Review of the medical record indicated in 11/2014 there was no documentation that the Physician was notified of (new) right calf pressure sore (found on 11/21/14) or that a treatment was obtained. Review of the investigation of 11/21/14 at 10:00 A.M. indicated that this Resident had bilateral lower extremity braces resulting in the lower extremity development of darkened areas, deep tissue trauma. The right leg measurements were as follows: - 1.5 cm in length by 0.4 cm in width, a question mark was written for the depth. Review of the medical record indicated in 11/2014 there was no documentation that the Physician was notified of the right calf pressure sore or that a treatment was obtained. The Weekly Wound Assessment of 12/3/14 indicated that the Resident had an unstagable pressure ulcer due to necrotic tissue on the right lower leg (calf area). The date of onset was 11/21/14. The measurements were as as follows: The area was 1.4 cm in length by 0.4 cm in width. The wound bed was described as a black/brown eschar. In comparison from last assessment (the date of the investigation 11/21/14), the pressure ulcer was described as better (even though it had increased in size). Review of the Physician's notes of 12/8/14 indicated that the bilateral lower extremity wounds had increased redness and consider starting an antibiotic. The Weekly Wound Assessment of 12/10/14 indicated that the Resident had an unstagable pressure ulcer due to necrotic tissue on the right lower leg (calf area). The measurements were as follows: The area was 1.0 cm in length by 1.0 cm in width. The wound bed was described as a black/brown eschar. In comparison from last assessment (the date of the previous assessment on 12/3/14), it was described as better (even though it had increased in size). The Surveyor observed a dressing change on 12/12/14 at 10:55 A.M., with Nurse #1. The surveyor observed that this Resident had unstagable pressure ulcers on the right and left calves. The periwound area of the left calf was significantly red. During the dressing changes of left calf, the 3 pressure sore measurements were as follows: -The 1st area to the end of the 3rd area was approximately 8 cm. -The 1st area was 2.2 cm in length by 1 cm width and 0.3 millimeters in depth. (This had increased in size from the previous measurement.) -The 2nd area was 2 cm in length by 1 cm in width and no depth. It had an eschar base. (This had increased in size from the previous measurement). -The 3rd area was 1.1 cm in length by 0.5 cm in width and no depth. It had an eschar base. (This one had decreased in size from the previous measurement.) -The pressure ulcer on the right calf was 1.3 cm in length by 1 cm in width, with no depth. It had an eschar base. (This was mostly unchanged.) During an interview with Physical Therapy Assistant (PTA) #1 on 12/12/14 at 9:22 A.M. (in the Rehabilitation Department) and at 12:00 noon (at this Resident's bedside), the PTA said that she was the person who had found the left lower leg pressure ulcers and said the multi-podus boot probably caused it. She said, "The left leg brace/immobilizer was not new, the multi-podus boot was new." The Surveyor asked the PTA to demonstrate with the multi-podus boot how this boot could cause the left calf pressure sore. She showed the Surveyor how the plastic inside this boot (the plastic support edge), if not aligned properly or checked frequently could cause pressure ulcers consistent with the pattern and location of this Resident's pressure ulcer. The Surveyor asked the PTA, "Who checks the skin under the multi-podus boot or brace to prevent skin breakdown?" She said, "the CNAs (Certified Nursing Assistants) and Nursing." During an interview with the Unit Manager (UM) #2 on 12/12/14 at 10:15 A.M., the Surveyor asked, where was the physician's orders [REDACTED].? UM #2 said that, the physician's orders [REDACTED]. She said that she took off that order and she did not document it anywhere (for nursing to follow) because she thought that Rehabilitation would monitor the skin under the multi-podus boot for breakdown. During an interview with the Certified Nursing Assistant (CNA) #1 (the CNA taking care of this Resident) on 12/12/14 at 2:10 P.M., the Surveyor asked, "Do the CNAs check the skin under the multi-podus splints and braces for skin breakdown?" She said, "No, the Nurses do that." During an interview with Nurse #1 (the Nurse taking care of this Resident) on 12/12/14 at 2:15 P.M., the Surveyor asked, "Do the Nurses check the skin under the multi-podus splints and braces for skin breakdown?" He said that the CNAs check the skin with direct care in the morning with dressing, and at night when the splints come off. He said, "It is the CNAs' responsibility. The Nurses do weekly skin checks." During an interview and review of the weekly skin checks and Weekly Wound Assessment Sheets with the Assistant Director of Nurses (ADON) on 12/12/14 at 2:30 P.M., the Surveyor indicated that there were no weekly skin checks for October and November 2014 as per the care plan and their policy. The Surveyor said, "There were no documented measurements of the left calf pressure sores on the Weekly Wound Assessment Sheets for November." The ADON said, "The first documented measurements of the left calf pressure sores were 11/21/14 on the incident report when it was brought to my attention, and I did an incident report." The Surveyor said, "I did not see where the physician's orders [REDACTED]." The Surveyor asked, "Where should the nursing staff have transcribed and documented the physician's orders [REDACTED].?" The ADON said, "The doctors order of 11/5/14 should have gone onto the treatment sheet or onto the (CNA) care card." The Surveyor asked, "Did the physician's orders [REDACTED].?" She said, "No, it didn't." The Surveyor asked, "How did this Resident develop a pressure ulcer on the right posterior calf?" The ADON said, "From the brace." The Surveyor said, "Both the brace and the multi-podus boot were ordered to be on the left leg, not the right leg, prior to the pressure sore developing (on 11/17/14). Did the staff put the multi-podus boot or brace on the wrong leg (the right lower leg)?" She said, "I don't know what happened, it could be from the heel pro mat (a small pressure relieving mattress) that was added to the foot of the bed." During an interview with the Unit Manager on 12/15/14 at 8:45 A.M., the Surveyor said, "I did not see where the Physician was notified of the right calf pressure sore or that a treatment was obtained? She said, "No, I did not know about the right (referring to the right pressure ulcer) until 12/11/14 (20 days after the pressure ulcer developed). I only obtained an order for [REDACTED].

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to immediately notify the Physician of Resident #1's pain and poor response to the pain medication. On 5/23/14, at 12:00 A.M., Resident #1, who had [MEDICAL CONDITION], had symptoms of pain and the nurse gave Resident #1 Tylenol (non-narcotic pain medication). Although the pain flow sheet indicated after one hour, there was no change in Resident #1's level of pain, the nurse did not notify the Physician. On 5/25/14, Resident #1 complained of pain, was medicated with [MEDICATION NAME], but the medication was not effective, and the nurse did not contact the Physician regarding the ineffective pain management. Findings include: The Hospital transfer summary, dated 5/20/14, indicated Resident #1 had stage IV [MEDICAL CONDITION] with liver and bone metastasis (a more advanced form [MEDICAL CONDITION], which has spread from its original origin to a distant location within the body) and received palliative treatment. The initial nursing assessment, dated 5/22/14, indicated Resident #1 had no cognitive issues. The comprehensive pain assessment, dated 5/22/14, indicated Resident #1 frequently had pain during the previous five days. The comprehensive pain assessment indicated the pain made it difficult for Resident #1 to sleep at night and the pain limited his/her day-to-day activities during the past five days. The comprehensive assessment indicated Resident #1's worst pain during the previous five days was an 8, on a scale of 0 to 10. The physician order, dated 5/22/14, included: Tylenol 640 milligrams (mg) every 4 hours as needed (prn) for pain. The pain flow sheet indicated that on 5/23/14, at 12:00 A.M., Resident #1 had vocal complaints of pain and protective body movements or postures that indicated pain. The pain flow sheet indicated the nurse gave Resident #1 Tylenol 650 mg for abdominal and arm pain for a pain rating of 7 (on a scale of one to 10 with 10 being the worst pain). The pain flow sheet indicated after one hour, there was no change in Resident #1's level of pain. There was no documentation to indicate the nurse notified a Physician of Resident #1's complaint of pain or that the Tylenol was not effective in managing Resident #1's pain. The Change in Condition Policy, dated 9/1/04, indicated the facility was to consult with the physician when there was a significant change in the resident's physical, mental, psychosocial status or a need to alter a treatment significantly. The Pain Assessment and Management Policy indicated the nurse was to notify the physician if the resident experienced breakthrough pain that was unrelieved by prn pain medications. The Surveyor interviewed Nurse #1 at 12:35 P.M. on 7/21/14. Nurse #1 said Resident #1 received minimal effect from the 12:00 A.M. dose of Tylenol. Nurse #1 said the unit was busy and she could not recall if assessed Resident #1's pain at 4:00 A.M., when Resident #1 could have additional Tylenol. Nurse #1 said in error, she did not notify the Physician/Nurse Practitioner regarding Resident #1's continued pain and need for a stronger pain medication. Nurse #1 said on 5/23/14, Resident #1 did not receive effective pain management from the prescribed Tylenol. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 7:15 A.M. on 7/21/14. The ADON said Nurse #1 did not notify the Physician that Resident #1 did not receive effective pain management from Tylenol and obtain pain medication to manage Resident #1's pain. The ADON said Nurse #1 did not follow the Change in Condition Policy. The pain flow sheet, dated 5/25/14, indicated Resident #1 had abdominal pain with a pain rating of 8 and received [MEDICATION NAME] 5/325 mg at 1:30 A.M. The pain flow sheet indicated that after one hour there was no change in Resident #1's pain. The MAR, dated 5/25/14, indicated the nurse gave Resident #1 [MEDICATION NAME] 5/325 mg at 1:30 A.M. for a pain rating of 8. The MAR indicated [REDACTED].M. for a pain rating of 7. The nurse's note, dated 5/25/14 indicated Resident #1 had a pain rating of 8 and the nurse gave Resident #1 [MEDICATION NAME] 5/325 mg at 1:30 A.M. and 5:30 A.M. with some effect. There was no documentation to indicate the nurse notified the Physician regarding Resident #1's ineffective pain management from [MEDICATION NAME] during the night shift on 5/25/14. The ADON said the night nurse did not notify the Physician regarding Resident #1's continued pain and did not follow the Facility's Change in Condition Policy. The day shift nurse's note, dated 5/25/14, indicated that at 7:30 A.M., Resident #1 moaned, groaned, and screamed in pain and had a pain rating of 8 out of 10. The nurse's note indicated Resident #1 complained of head, neck, abdominal, back, and leg pain. The nurse's note indicated Resident #1 received pain medication recently during the night shift and therefore, the nurse did not give any pain medication Resident #1. The nurse's note indicated the nurse notified the Nurse Practitioner who ordered additional fluids and laboratory blood work. The note indicated Family Member #1 called an ambulance and had Resident #1 transferred to the emergency department for an evaluation.

Based on record review and interviews for one of three sampled residents (Resident #1), whose [DIAGNOSES REDACTED].#1 received effective pain management; and the Facility failed to ensure Resident #1's pain was assessed in accordance with the Facility's policy. - On 5/23/14, at 12:00 A.M., Resident #1 had symptoms of pain, the nurse gave Resident #1 Tylenol; and the pain flow sheet indicated there was no change in Resident #1's level of pain, but the nurse did not notify the Physician, and the nurse did not continue to assess Resident #1's pain, or give Resident #1 Tylenol at 4:00 A.M., per the physician orders. - On 5/23/14, there was no documentation to indicate the nurse assessed Resident #1 for pain during the day shift. On 5/23/14, during physical therapy, Resident #1 had pain, but there was no indication staff responded to Resident #1's complaints. - On 5/25/14, during the night, the nurse administered Resident #1 [MEDICATION NAME] (pain medication), but the medication was not effective, but the nurse did not inform the Physician. Findings include: Resident #1's list of medications used at home, prior to his/her hospitalization included the narcotic pain medication, [MEDICATION NAME] 5/325 milligrams (mg) four times a day as needed (PRN). The Hospital transfer summary, dated 5/20/14, indicated Resident #1 had stage IV [MEDICAL CONDITION] with liver and bone metastasis and received palliative treatment. The Hospital discharge summary, dated 5/20/14, indicated that although Resident #1 recevied [MEDICATION NAME] at home, the use of [MEDICATION NAME] was not clarified at the time of discharge to the Facility. The summary indicated the medication was not included as a medicaton, which was discontinued during the hospitalizaition, but also did not include [MEDICATION NAME] as a medication Resident #1 was to continue to receive at the time of trasnfer to the Facility. The Hospital medication tracking sheet, dated 5/22/14, indicated Resident #1 had an order for [REDACTED].#1's last dose of [MEDICATION NAME] at the Hospital was on 5/19/14. The admission orders [REDACTED]. The initial admission nursing assessment, dated 5/22/14, indicated Resident #1 had no cognitive issues. The comprehensive pain assessment, dated 5/22/14, was completed by the Unit Manager, and indicated Resident #1 frequently had pain during the past five days. The comprehensive pain assessment indicated Resident #1 reported the pain made it difficult for Resident #1 to sleep at night and limited his/her day-to-day activities during the five days prior to 5/22/14. The comprehensive assessment indicated Resident #1's worst pain during the five days (prior to the completion of the assessment) was an 8, on a scale of 0 to 10 (0 being no pain and 10 being the worst pain). The evening shift nurse's note, dated 5/22/14, indicated the nursing staff documented Resident #1 had no pain. The Surveyor interviewed Nurse #2 at 5:00 P.M. on 7/21/14. Nurse #2 said on 5/22/14, the Unit Manager did not discuss Resident #1's pain assessment with her and she was not aware Resident #1 received [MEDICATION NAME] at home prior to his/her hospitalization and in the Hospital. The pain flow sheet indicated that on 5/23/14, at 12:00 A.M., the nurse assessed Resident #1's pain and Resident #1 complained of pain verbally and had protective body movements or postures, which indicated Resident #1 had symptoms of untreated pain. The pain flow sheet indicated the nurse gave Resident #1 Tylenol 650 mg for abdominal and arm pain for a pain rating of 7. The pain flow sheet indicated after one hour, there was no change in Resident #1's pain. The nurse's note, dated 5/23/13 at 1:00 A.M., indicated Resident #1 had a pain score of 7, complained of pain daily, and Resident #1, "had only (acetominophen) for pain." The note indicated Resident #1 was administered the Tylenol at 12:15 A.M., with only "fair" effect. There was no documentation to indicate the nurse notified a Physician regarding Resident #1's complaint of pain or that the Tylenol was not effective in managing Resident #1's pain; and no changes were made in the plan of care in response to Resident #1's untreated pain. The night shift nurse's note, dated 5/23/14, indicated Resident #1 received only fair effect from the Tylenol and slept intermittently. The Surveyor interviewed Nurse #1 at 12:35 P.M. on 7/21/14. Nurse #1 said she worked on Resident #1's unit 6 times each month during the night shift. Nurse #1 said Resident #1's unit was very busy and she was the only nurse on the unit. Nurse #1 said she had difficulty completing the necessary care and treatments required by the residents. Nurse #1 said on 5/22/14 into 5/23/14, Resident #1 did not receive effective pain management from Tylenol. Nurse #1 said in error, she did not notify the Physician/Nurse Practitioner regarding Resident #1's continued pain and need for a stronger pain medication. The Pain Assessment and Management Policy, dated 3/26/09, indicated that each resident had the right to expect a prompt, effective response to reports of pain. The Policy indicated the nurse was to notify the physician if the resident experienced breakthrough pain that was unrelieved by prn pain medications. The physical therapy evaluation and plan of treatment, dated 5/23/14, indicated that initially Resident #1 had no pain. The physical therapy evaluation indicated later during therapy, Resident #1 had left lower extremity pain and was not able to elaborate regarding the pain. The Surveyor interviewed Physical Therapist #1 at 10:55 A.M. on 7/21/14. Physical Therapist #1 said on 5/23/14, she completed Resident #1's physical therapy evaluation and Resident #1 had pain during the evaluation. Physical Therapist #1 said she always reported resident complaints of pain to the assigned nurse. The physician order, dated 5/23/14, at 11:00 A.M., included changes were made in Resident #1's pain management plan of care to include: [MEDICATION NAME] 5/500, one tablet from emergency kit and [MEDICATION NAME] 5/325, one tablet every 4 to 6 hours prn pain. The nurse assigned to care for Resident #1 during the day shift on 5/23/14 was not available for interview with the Surveyor. There was no documentation to indicate the day shift nurse was aware of Resident #1's complaints of pain during physical therapy. There was no documentation that indicated the day nurse assessed Resident #1's pain during the day shift on 5/23/14. There was no documentation that the day nurse transcribed the [MEDICATION NAME] orders or obtained the [MEDICATION NAME] from the Pharmacy or emergency supply. The Pain Assessment and Management Policy indicated the nurse was to document an ongoing assessment of a resident's pain/pain management on the pain flow sheet. The Surveyor interviewed the Assistant Director of Nurses (ADON) at 7:15 A.M. on 7/21/14. The ADON said the day nurse (who worked during the day shift on 5/23/14) did not address Resident #1's pain during physical therapy. The ADON said there was no indicatation the day nurse assessed Resident #1's pain and offered pain medication to Resident #1. The ADON said the day nurse did not transcribe the [MEDICATION NAME] orders onto the medication records or order [MEDICATION NAME] from the Pharmacy. The ADON said the day nurse did not follow the Facility Pain Assessment and Management Policy. The evening shift nurse's note, dated 5/23/14, indicated Resident #1 had no pain. There was no documentation to indicate the nurse faxed the one time order for [MEDICATION NAME] 5/500 mg to the Pharmacy to obtain an authorization number to open the emergency kit if Resident #1 required pain medication prior to the delivery of the prn [MEDICATION NAME] to the Facility. There was no documentation to indicated the nurse transferred the one time [MEDICATION NAME] order onto the Medication Administration Record [REDACTED] The Surveyor interviewed Nursing Supervisor #1 at 10:45 A.M. on 7/21/14. Nursing Supervisor #1 said Resident #1 did not have the [MEDICATION NAME] available for administration between 5/23/14, at 11:00 A.M. and 5/24/14, at 12:09 A.M., because the prescription for the medication was not sent to the pharmacy. Nursing Supervisor #1 said she ordered [MEDICATION NAME] from the Pharmacy during the evening shift on 5/24/14. The Surveyor interviewed Nurse #2, who was assigned to Resident #1 during the evening shift. Nurse #2 said she was not aware Resident #1 had a one time order for [MEDICATION NAME] that could be removed from the emergency kit with Pharmacy authorization. The ADON said the nurse did not obtain authorization from the Pharmacy to allow the nurse to use one dose of [MEDICATION NAME] from the emergency kit for Resident #1 if needed. The ADON said the nurse did not note the one time [MEDICATION NAME] order on the Medication Administration Record [REDACTED]. The ADON said if Resident #1 required pain medication, prior to the delivery of [MEDICATION NAME], he/she would have had a delay in getting the [MEDICATION NAME]. The night shift nurse's note, dated 5/24/14, indicated Resident #1 had no complaints of pain. The Medication Administration Record [REDACTED].M. for a pain rating of 6 out of 10 with good effect. The evening shift nurse's note, dated 5/24/14, indicated Resident #1 had no pain. The pain flow sheet, dated 5/25/14, indicated Resident #1 had abdominal pain with a pain rating of 8 and received [MEDICATION NAME] 5/325 mg at 1:30 A.M. The pain flow sheet indicated that after one hour there was no change in Resident #1's pain. The MAR indicated [REDACTED].M. for a pain rating of 7. The nurse's note, dated 5/25/14 indicated Resident #1 had a pain rating of 8 and the nurse gave Resident #1 [MEDICATION NAME] 5/325 mg at 1:30 A.M. and 5:30 A.M. with some effect. There was no documentation on the pain flow sheet regarding the administration of [MEDICATION NAME] to Resident #1 at 5:30 A.M., and Resident #1's response to the [MEDICATION NAME]. There was no documentation that indicated the nurse notified the Physician that the [MEDICATION NAME] was ineffective in treating Resident #1's pain during the night shift on 5/25/14. The Surveyor interviewed Nurse #3 at 12:15 P.M. on 7/21/14. Nurse #3 said Resident #1 reported feeling better after getting the 1:30 A.M. pain medication, but this was not consistent with the documentation completed at the time of the assessment. Nurse #3 said she could not recall Resident #1's pain rating after the 1:30 A.M. and 5:30 A.M. pain medication. The ADON said Nurse #3 did not follow the Pain Assessment and Management Policy. The day shift nurse's note, dated 5/25/14, indicated that at 7:30 A.M., Resident #1 moaned, groaned, and screamed in pain and had a pain rating of 8 out of 10. The nurse's note indicated Resident #1 complained of head, neck, abdominal, back, and leg pain. The nurse's note indicated Resident #1 received pain medication recently during the night shift and therefore, the nurse did not give pain medication Resident #1. The nurse's note indicated the nurse notified the Nurse Practitioner, who gave an order for [REDACTED].#1 called the emergency medical service and the emergency medical technicians transferred Resident #1 to the Emergency Department (ED).

Based on interviews and record review for four of four residents (Resident #4, Resident #5, Resident #6, and Resident #7, who were prescribed pain medication, the Facility failed to ensure the nursing staff consistently documented the date and time they administered pain medication; consistently assessed the resident's level of pain before and after pain medication administration; and failed to ensure staff consistently documented those assessments onto the Pain flow Sheet, per Facility policy. Findings include: The Policy/Procedure titled Medication Pass Guidelines, released 9/1/04, indicated the nurse initialed and recorded the time he/she administered medication onto the Medication Administration Record (MAR). The Facility practice was for the nursing staff to document the times they administered as needed medications on the back of the MAR. The Policy/Procedure titled Pain Assessment & Management, revised 3/26/09, indicated the nurse documented the identification and description of pain onto the Pain Flow Sheet. The Pain Flow Sheet included areas to document the location of the pain, the pain intensity (numeric scale of 0-10 with zero representing no pain and 10 representing the worse possible pain), the medication and non-medication intervention, and the level of pain after intervention(better, same, worse). The In-Service Attendance Sheet, dated from 7/23/14 to 8/15/14, indicated the Assistant Director of Nurses educated the nursing staff regarding the Pain Management Policy and the Pain Flow Sheet. 1) The Hospital Transfer Summary, dated 8/27/14, indicated Resident #4 presented to the Hospital and [DIAGNOSES REDACTED]. The Face Sheet indicated the Facility staff admitted Resident #4 in August, 2014 for continued care. The Admission Nursing Assessment, dated 8/28/14, indicated Resident #4 was alert and oriented to person, time, and place. The Comprehensive Pain Assessment, dated 8/28/14, indicated Resident #4 occasionally experienced pain in his/her back and lower extremities. The MAR for September 2014 included Tylenol (non-narcotic [MEDICATION NAME]) 1000 milligrams (mg) three times daily, [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg every 4 hours as needed for mild pain, and [MEDICATION NAME] 10 mg every 4 hours as needed for moderate to severe pain. The Narcotic Book, Page 179, dated from 9/6/14 to 9/17/14, indicated Resident #4 received [MEDICATION NAME] on 5 occasions during that period of time. The MAR, dated from 9/6/14 to 9/17/14, indicated the nursing staff initialed they administered [MEDICATION NAME] on two occasions, which was not consistent with the Narcotic Book. The front and back of the MAR did not include the times the nursing staff administered [MEDICATION NAME] to Resident #4. The Pain Flow Sheet for September 2014 indicated the nursing staff assessed Resident #4 's level of pain before and after the nurses administered pain medication, on two occasions. There was no assessment of Resident #$4's level of pain or response to medications administered on 9/6/14, 9/14/14, and 9/16/14. 2) The Face Sheet indicated the Facility staff admitted Resident #5 on August 2014, and [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 8/2714, indicated Resident #5 was alert and oriented to person, time and place. The Comprehensive Pain Assessment, dated 8/27/14, indicated Resident #5 denied pain. The Physician order [REDACTED]. The MAR for September 2014 indicated at 12:00 A.M. on 9/12/14, Resident #5 requested and received Tylenol 650 mg for pain. The MAR did not indicate the location of Resident #5's pain. The Pain Flow Sheet for September 2014 indicated the nursing staff did not assess Resident #5 s level of pain before and after administration of Tylenol. The Nursing Progress Note and the MAR, dated 9/15/14, indicated Resident #1 complained of right hand pain rated 10/10, and received Tylenol 650 mg with good effect. The Physician Orders, dated 9/16/14, included a right hand x-ray (negative for acute injury), ice packs, and [MEDICATION NAME]. At 8:20 A.M. on 9/18/14, the Surveyor toured the Long Term Care Unit and spoke with Resident #5 who reported he/she experienced right wrist pain. The Surveyor interviewed Nurse #5 at 8:30 A.M. on 9/18/14. Nurse #5 said Resident #5 received Tylenol earlier, the physician was in the Facility, and she notified the physician of Resident #5's continued complaints of right wrist pain. The MAR and the Pain Flow Sheet did not indicate Resident #5 received Tylenol as reported by Nurse #5. The Surveyor interviewed Unit Manager #1 at 9:50 A.M. on 9/18/14. Unit Manager#1 said per the shift report, at 6:00 A.M. Resident #5 received Tylenol 650 mg. The nursing staff failed to consistently document on the MAR each time they administered Tylenol to Resident #5. The nursing staff failed to consistently assess Resident #5's level of pain pre and post administration of Tylenol. 3) The Face Sheet indicated the Facility staff admitted Resident #6 in September 2014 with a [DIAGNOSES REDACTED]. The Initial Nursing Assessment, dated 9/8/14, indicated Resident #6 was alert and oriented to person, time, and place. The Comprehensive Pain Assessment, dated 9/8/14, indicated Resident #6 frequently experienced pain rated as 8/10 and managed the pain with Tylenol and [MEDICATION NAME]. The Physician Orders, dated 9/8/14, included: Tylenol 650 mg every 4 hours as needed for pain and [MEDICATION NAME] 10 mg every 6 hours as needed for pain. The Narcotic Book, Page 39, dated from 9/9/14 to 9/18/14, indicated Resident #6 received [MEDICATION NAME] a total of 28 times. The MAR, dated from 9/9/14 to 9/18/14, indicated the nursing staff initialed the MAR to indicate Resident #6 received [MEDICATION NAME] a total of 22 times. The Pain Flow Sheet and MAR, dated from 9/9/14 to 9/18/14, indicated the nursing staff did not document an assessment of Resident #6's pain before and after pain medication was administered, a total of 10 out of 28 times Resident #6 received [MEDICATION NAME]. 4) The Hospital Discharge Instructions indicated Resident #7 had [MEDICAL CONDITION] with metastasis to the brain and spine. The Face Sheet indicated the Facility staff admitted Resident #7 in September 2014. The Initial Nursing Assessment, dated 9/4/14, indicated Resident #7 was alert and oriented to person, time and place. The Comprehensive Pain Assessment, dated 9/4/14, indicated Resident #7 reported he/she experienced pain rated 6/10 over the 5 days before 9/4/14. The Physician Orders, dated 9/4/14, included: Tylenol 650 mg as needed every 4 hours for pain, scheduled [MEDICATION NAME] (narcotic pain medication) three times daily for pain, and [MEDICATION NAME] 45 mg every 3 hours as needed for pain (prn). The Narcotic Book, Page 31, dated from 9/5/14 to 9/17/14, indicated Resident #7 received [MEDICATION NAME] 45 mg, a total of 14 times. The September 2014 MAR indicated the nurses administered [MEDICATION NAME] 6 times to Resident #7, which was not consistent with the Narcotic Book entries. The Pain Flow Sheet, dated from 9/5/14 to 9/17/14, indicated the nursing staff assessed Resident #7's level of pain a total of 4 of the 14 times, before and after the nurses administered prn [MEDICATION NAME], which was not consistent with the Narcotic Book and the Facility policy.