Every finding on record at Reservoir Center for Health & Rehabilitation, The

Based on records reviewed, interviews, and observations, the facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility.Specifically, the facility failed to develop and implement an effective performance improvement plan to address the non-operational heating units on three out of four Resident Sitting Rooms, utilized for Resident meals. Findings include:Review of the Facility's policy for QAPI Program, last revised October 2024 indicated:-Our facility provides services across the continuum of care. These services have an impact on the clinical care and quality of life for residents living in our community.-All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services.>Our QAPI plan includes the policies and procedures used to:-Identify and use data to monitor our performance.-Establish goals and thresholds for our performance measurement.-Utilize resident, staff and family input.-Identify and prioritize problems and opportunities for improvement.-Systematically analyze underlying causes of systematic problems and adverse events.-Develop corrective action or performance improvement activities. Review of the July 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:- Administrator: PTAC (Packaged Terminal Air Conditioners- self-contained heating and cooling systems typically installed through an exterior wall) units - new contract signed to repair units in addition to purchased ones. Current Measurement/Target: 100% operational units. Actions/Interventions: Signed contract with vendor, continue to order as needed and replace all units across facility including 1-2 backups while prioritizing resident rooms. 4 PTAC units picked up on 7/8/25, 4 units picked up on 7/22/25. Target Date: Winter 2025. Responsible Party: LNHA (Licensed Nursing Home Administrator) and Maintenance. Follow up: Blank Review of the August 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:- Administrator: PTAC units being 100% operational in all resident areas. Current Measurement/Target: 100% operational units. Actions/Interventions: Signed contract with vendor repair units. Continue to order as needed and replace all units across facility including 1-2 as backups. Target Date: Winter 2025. Responsible Party: LNHA and Maintenance. Follow up: Blank Review of the September 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:- Administrator: PTAC continue to work with new vendor. Current Measurement/Target: 100% operational units. Actions/Interventions: Signed contract with vendor repair units. Continue to order as needed and replace all units across facility including 1-2 as backups. 4 PTAC units picked up on 7/8/25, 4 units picked up on 7/22/25. Target Date: Winter 2025. Responsible Party: LNHA and Maintenance. Follow up: Blank Review of the October 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:-no documented evidence recorded on PTAC units or progress. Review of the November 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:- Administrator: PTAC units picked up for repair and new (ones) ordered. Current Measurement/Target: 100% operational units. Actions/Interventions: Signed contract with vendor repair units. Continue to order as needed and replace all units across facility including 1-2 as backups while prioritizing resident rooms. 4 PTAC units picked up on 7/8/25, 4 units picked up on 7/22/25. Target Date: Winter 2025. Responsible Party: LNHA and Maintenance. Follow up: Two ordered 10/31/25. Review of the facility's Interfacility Request for Repairs or Alterations Logbook for 2025 indicated that staff had reported that various heating units in the Residents rooms and common areas on the First and Second Floors of the facility had stopped working on:-10/12/25-10/21/25-11/11/25-11/13/25 Review of the December 2025 QAPI Meeting Minutes indicated the following information was submitted from the Department Heads:- Administrator: no information. Current Measurement/Target: 100% operational units. Actions/Interventions: ordering 2 more this month. Ensure all occupied resident rooms have functioning units is priority. Target Date: Blank. Responsible Party: LNHA and Maintenance. Follow up: Blank. Review of the QAPI program from July 2025 to present failed to indicate that the facility had addressed the lack of heat in the resident Sitting Rooms, until the surveyor brought it to the facility's attention. On 1/12/26 at 8:34 A.M., the surveyor observed that the air temperature in the East Two Unit Sitting Room was cold. There were two heating units observed in the room which were not operating and cold to the touch, with one observed to be in a state of disrepair, and missing knobs, with the base board fallen off and on the floor with towels placed underneath. There was no thermostat in the Sitting Room and the surveyor could feel wind blowing from the outside of the building through one of the heating units. During an interview on 1/12/26 at 8:37 A.M., and 8:49 A.M., two Unit residents said they could not eat meals in the sitting room in the East Two Unit Sitting Room because the temperature was too cold in the room. During an interview on 1/12/26 at 8:50 A.M., Nurse #2 said that the heat on the East Two Unit Sitting Room had not been working for months and that it had been preventing the residents on the unit from being able to eat or socialize in there as often as they would like to. Nurse #2 also said that the other Sitting Room on the [NAME] Two Unit was cold, which results in most residents eating their meals in their bedrooms. On 1/12/26 at 8:56 A.M., the surveyor and the Maintenance Director made environmental rounds using the Maintenance Director's handheld thermostat device, and the following temperatures were observed:-East Two Sitting Room: 66.9 degrees-West Two Sitting Room: 68 degrees -West One Sitting Room: 69 degreesDuring an interview at the time, the Maintenance Director said that the heating units in the Sitting Rooms on East Two, [NAME] Two and [NAME] One have been broken for months and that the temperatures in each room should be at least above 71 degrees. He also said that he could feel the wind blowing through one of the broken heating units on East Two and that the Sitting Room felt cold. The Maintenance Director said that he had not been monitoring the temperatures in the Sitting Rooms or completing any audits regarding the broken heating units. During an interview on 1/12/26 at 12:55 P.M., the Administrator said that they have been trying to get the broken heating units repaired but they have been waiting on parts to arrive for them to be installed. During an interview on 1/13/26 at 10:19 A.M., the Administrator said that the QAPI program only addressed the heating concerns in the residents rooms, as this was a priority and did not address the heating concerns in the resident Sitting Rooms.

Based on observations, record review, and interviews, the facility failed to provide residents with a homelike environment on three out of four Resident Units (East Two, [NAME] One, and [NAME] Two) and for one Resident (#71) out of total sample of 28 Residents. Specifically, 1. the facility failed to provide Residents #41 and #69 and other residents with appropriate and comfortable air temperature levels during Resident meals in the Sitting Rooms on the East Two, [NAME] One, and [NAME] Two resident Units. 2. the facility failed to ensure safe and sanitary side rail pads for Resident #71's bed, placing the Resident at the risk of injury and contamination. Findings include: Review of the facility policy titled Environmental Rounds, dated 6/2023, included but was not limited to: Each center will have an effective process for identification of .risks in the resident environment. >Rounds will be conducted monthly by the Infection Prevention Committee and appropriate department heads. >Areas identified as non-compliant will be evaluated by the committee to identify specific hazards and risks and to develop targeted interventions to reduce potential for adverse events. Review of the facility policy titled Administration - Residents' [NAME] of Rights Policy, last revised February 2024 indicated that Residents have the right to treat their living quarters as their home and subject to rules designed to protect the privacy, health and safety of the other residents of the facility. 1. Review of the facility's Interfacility Request for Repairs or Alterations Logbook for 2025 indicated that staff had reported that various heating units in the resident's rooms and common areas on the First and Second Floors of the facility had stopped working on: -10/12/25 -10/21/25 -11/11/25 -11/13/25 On 1/12/26 at 8:34 A.M., the surveyor observed that the air temperature in the East Two Unit Sitting Room was cold. The surveyor further observed there were two heating units in the room which were not operating and cold to the touch. One heating unit was observed to be in a state of disrepair, with missing knobs, and the base board had fallen off and was on the floor with towels placed underneath. The surveyor failed to observe a thermostat in the Sitting Room and felt cold air blowing from the outside of the building through one of the heating units. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of a possible 15. During an interview on 1/12/26 at 8:37 A.M., Resident #41 said that he/she could not eat his/her meals in the sitting room on the East Two Unit Sitting Room because the temperature was too cold in the room. Resident #41 said that the heating unit was broken since last summer, that he/she really enjoys having meals with other Residents on the unit in there and often had to put on extra layers of clothing to eat in the Sitting Room comfortably. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #69 was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12 out of a possible 15. During an interview on 1/12/26 at 8:49 A.M., Resident #69 said that the East Two Unit Sitting Room where they serve his/her meals was cold and he/she does not want to eat his/her meals in the Sitting Room because of the cold temperature. During an interview on 1/12/26 at 8:50 A.M., Nurse #2 said that the heat on the East Two Unit Sitting Room had not been working for months and that it had been preventing the residents on the unit from being able to eat or socialize in there as often as they would like to. Nurse #2 also said that the other Sitting Room on the [NAME] Two Unit was cold, which results in most residents eating their meals in their bedrooms. On 1/12/26 at 8:56 A.M., the surveyor and the Maintenance Director made environmental rounds using the Maintenance Director's handheld thermostat device, and the following temperatures were observed: -East Two Sitting Room: 66.9 degrees -West Two Sitting Room: 68 degrees -West One Sitting Room: 69 degrees During an interview at the time, the Maintenance Director said that the heating units in the Sitting Rooms on East Two, [NAME] Two and [NAME] One have been broken for months and that the temperatures in each room should be at least above 71 degrees. The Maintenance Director also said that he could feel the wind blowing through one of the broken heating units on East Two, that the towels should not have been placed in the heating unit and that the Sitting Room felt cold. The Maintenance Director said that he had not been monitoring the temperatures in the Sitting Rooms or completing any audits regarding the broken heating units. During an interview on 1/12/26 at 12:55 P.M., the Administrator said that they have been trying to get the broken heating units repaired, but they have been waiting on parts to arrive for them to be installed. The Administrator also said that the building did not have a policy on a Homelike Environment or temperature expectations in resident areas. 2. Resident # 71 was admitted to the facility in April 2024 with diagnoses including Seizures and Muscle Weakness. Review of the Minimum Data Set (MDS) Assessment, dated 12/3/25 indicated Resident #71: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. -required substantial/maximal (helper lifts or holds trunk or limbs and provides more than half the effort) assistance to roll left to right. -was dependent for personal hygiene, as well for upper and lower body dressing. On 1/7/26 at 10:13 A.M., the surveyor observed Resident #71 lying in bed with padded side rail attachments to both left and right sided bedrails. During an interview at the time, Resident #71 said that the bedrails were padded so that he/she did not hit his/her head against the bedrails. The surveyor observed both left and right sided bedrail padding to be missing approximately 80% of the black vinyl-like material and exposing a white fabric-like material. The white fabric-like material was observed to be stained with a brown and pink substance. Resident #71 said no one had offered to replace the padding and he/she had never seen anyone attempt to clean the padding. On 1/13/26 at 12:00 P.M., the surveyor observed Resident #71 lying in bed with padded bedrail attachments to the left and right bedrails. The surveyor observed Resident #71's padded bedrails to have the protective black covering worn off with white fabric exposed to the left and right bedrails. The right sided pad was stained with brown and pink substance and the left side with brown substance. The surveyor also observed the top seam of the left sided pad to be exposed with a rough edge. During an interview at the time, Resident #71 said the padded rails bother him/her, the pads should be replaced, and they are dirty and gross. Resident #71 said that the bedrail padding with tears and stains had been on his/her bed for a long time. During an interview on 1/13/26 at 12:15 P.M., Certified Nurse Aide (CNA) #2 said he was assigned to provide care for Resident #71 and had provided care for Resident #71 in the past. CNA #2 said that Resident #71's padded bedrails were needed because Resident #71 was unable move or transfer by himself/herself. CNA #2 said that Resident #71's padded bedrails were unable to be removed for cleaning because they were screwed into place. The surveyor and CNA #2 observed the Resident's padded bedrails and CNA #2 said that both pads were missing the protective vinyl-like covering, had exposed fabric and were stained. CNA #2 said that the padding had been ripped and stained for a while and should have been cleaned or fixed. During an interview and observation on 1/13/26 at 12:35 P.M., Nurse #7 said that he had been assigned to Resident #71 today and had provided care to Resident #71 in the past. Nurse #7 said that the Resident's padded bedrails were in place because the Resident had left sided weakness. Nurse #7 said that the padded bedrails were screwed into place, the padding was old, stained and the original cover was missing. Nurse #7 said that if the padding had been washed the stains could have been removed. During an interview on 1/13/26 at 12:44 P.M., the Infection Preventionist (IP) said she conducted environmental rounds every month together with the Administrator, Maintenance Director, Housekeeping Director and generally another nursing team member. The IP said that environmental rounds reviewed every part of the facility from floor to cleaning and everything in between. The IP said that when concerns were identified with the facility environment a corrective action would be initiated to correct the concern. The IP said resident rooms and equipment are reviewed during the monthly environmental rounds. The surveyor and the IP observed the Resident #71's padded bedrails and the IP said that the Resident's padded bedrails were a concern because the pads were missing the protective black covering and exposing fabric that could not be properly disinfected. The IP said that the torn and stained pads were not homelike and should have been replaced. During an interview on 1/13/26 at 12:50 P.M., the Director of Nursing (DON) said she would expect all staff to report Resident #71's equipment being in poor operational condition to the maintenance department. The DON said that she had time to observe the Resident's padded bedrails today and that the Resident has had the same padded bedrails for several years. The DON said that the Resident's padded bedrails were a concern because of the risk to the Resident for skin tears and not presenting as a home-like environment due the worn condition of the padded bedrails. During an interview on 1/13/26 at 1:00 P.M., the Maintenance Director said he had not been notified about concerns related to Resident #71's bedrails. The Maintenance Director said he conducted rounds on resident beds twice a year. The Maintenance Director said that Resident #71's bed was owned by the facility and had padded side rails that were screwed into place. The surveyor and the Maintenance Director observed the Resident's padded bedrails, and he said that the Resident's padded siderails had the worn off the protective covering, were stained, and had rough edges that could cause injury to the Resident's skin. The Maintenance Director said that the padded bedrails were not homelike or safe and needed to be replaced.

Based on observations, interviews, and records reviewed, the facility failed to provide appropriate treatment to maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#112), who was diagnosed with dementia, out of a total sample of 28 residents. Specifically, the facility failed to provide timely assistance for Resident #112 when the Resident: -had a diagnosis of dementia. -received medication to improve urine flow. -received medication to treat constipation. -was dependent on staff for toileting and toilet transfers. -verbally expressed the need to use the bathroom repeatedly. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), dated June 2023, indicated the following: -The purpose was to provide the level of care required by each individual resident. -Staff provided assistance to complete ADLs per the person-centered evaluation and care plan. -ADLs included toileting and toilet hygiene. Resident #112 was admitted to the facility in January 2024 with diagnoses including Dementia with Behavioral Disturbance, difficulty walking, and Chronic Kidney Disease (CKD). Review of Resident #112's Physician orders, dated 1/18/24 with no stop date indicated the following: -Furosemide (diuretic medication) oral tablet 20 milligrams (mg); give 20 mg by mouth one time a day every Monday, Wednesday, Friday. -Flomax (medication used to relax the bladder and help improve urine flow) capsule 0.4 mg; give one capsule by mouth one time a day. -Polyethylene Glycol 3350, 17 grams (gm)/scoop; give one scoop by mouth two times a day for constipation. Give with four to eight oz (ounces) fluid. Review of Resident #112's active Care Plan indicated the following: -The Resident had an activity of daily living (ADL) performance deficit related to .impaired mobility, . dementia (revised 9/10/25). -The Resident was totally dependent on one to two staff for toilet use. -The Resident had a deficit in functional mobility related to dementia (revised 9/20/25). -The Resident required two staff and a mechanical lift for transfers. -The Resident had impaired cognitive function due to dementia (revised 3/18/25). -Resident will be encouraged to make choices/decisions regarding daily ADLs. -The Resident had a potential communication problem related to . impaired cognition (revised 2/21/24). -Anticipate and meet needs. -The Resident had frequent bladder incontinence related to altered mental status and dementia (revised 6/21/24). -The Resident used disposable briefs; change as needed. -Clean peri area with each incontinent episode. -Monitor . for signs/symptoms of UTI (urinary tract infection). -Monitor . any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, ., medication side effects. Review of Resident #112's Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of two out of 15 total possible points. -The Resident had moderate difficulty with hearing. -The Resident was usually understood. -The Resident had clear speech. -The Resident received diuretic medication. -The Resident was dependent on staff for toilet transfers, toileting hygiene, and lower body dressing. -The Resident was always incontinent of bladder. On 1/8/26 from 9:58 A.M. through 10:30 A.M., the surveyor observed the following on the [NAME] One Unit: -Resident #112 sat in a wheelchair in the hallway, just outside of his/her room near the nurses' station, and called out loudly two times, that he/she wanted to use the bathroom. -The surveyor observed two staff members seated at the nurses' station and one Nurse who stood at the medication cart in the same hallway as the Resident. -At 10:04 A.M., Resident #112 called out again two times, loudly, that he/she wanted to use the bathroom. -At 10:06 A.M., Nurse #1 approached Resident #112 and said the Resident needed to wait for his/her assigned Certified Nurse Aide (CNA) to return to the Unit for the Resident to use the toilet. -Nurse #1 then asked the Resident if he/she wanted to go to an activity and the Resident said, I want to go the best way here! -Nurse #1 gestured for the Resident to follow her and the Resident began propelling his/her wheelchair toward Nurse #1 and the Activity Room. -An activity staff member then approached Resident #112 and assisted the Resident to the Activity Room at 10:08 A.M. -At 10:11 A.M., while in the Activity Room with an activity staff member present, Resident #112 called out that he/she wanted to use the toilet. -The activity staff member said that the Resident would need to wait for his/her CNA. -At 10:13 A.M., Resident #112 called out, Let's go! and propelled his/her wheelchair away from the table and began to propel toward the Activity Room door exit. -At 10:16 A.M. another staff member assisted Resident #112 out of the Activity Room. -The surveyor observed Resident #116 sit in the doorway to the office of the staff member who assisted the Resident out of the Activity Room until 10:30 A.M. -At this time, the surveyor observed that Nurse #1 was seated at the nurses' station with one other staff member. During an interview at the time, Nurse #1 said there were four CNAs working on the Unit that day and that the CNA assigned to care for Resident #112 had been off the Unit when the Resident originally requested to use the toilet. Nurse #1 said that the Resident required assist of two staff members with the use of a mechanical lift for transfers and that she would not have been able to assist the Resident herself to use the toilet. Nurse #1 said the other CNAs were busy when the Resident had requested to use the toilet. Nurse #1 said she was not sure if the Resident's assigned CNA was back on the Unit yet. When asked whether any staff were available to assist the Resident between 9:58 A.M. and 10:30 A.M., Nurse #1 said she was not sure about that time frame. On 1/8/26 at 10:31 A.M., the surveyor observed the following: -CNA #1 was in the hallway on the [NAME] One Unit. -Nurse #1 said to CNA #1 that Resident #112 needed to use the toilet. -Nurse #1 said she would go locate the Resident if CNA #1 could retrieve the mechanical lift so that they could bring the Resident to the toilet. During an interview at the time, CNA #1 said that he had been off the Unit for a break earlier that morning and that he had returned to the Unit at 10:15 A.M. CNA #1 said that no one had informed him that Resident #112 was asking to use the toilet. CNA #1 said that Resident #112 was always incontinent and was dependent on staff for incontinent care. On 1/8/26 at 10:34 A.M. (36 minutes after the Resident requested to use the toilet), the surveyor observed Nurse #1 assist Resident #112 into his/her room. CNA #1 followed with the mechanical lift and closed the door. During an interview on 1/8/26 at 11:35 A.M., the Director of Nursing (DON) said that Resident #112 was incontinent and that the Resident's expression to use the bathroom may have been related to something obstructing his/her flow of urine or could have indicated discomfort. The DON said that the Resident should not have been required to wait for his/her assigned CNA to address his/her needs and that other staff on the Unit could have assisted. The DON said that if staff on the Unit were busy when Resident #112 requested to use the toilet, assistance could have been obtained from another staff member in the facility.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#43), out of one applicable resident receiving dialysis (process that filters waste, salt, and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 28 residents. Specifically, for Resident #43, the facility failed to:-ensure that dialysis communication forms included updated and active Physician orders on the Resident's dialysis care and services.-communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to the Resident. Findings Include:Review of the facility policy titled Hemodialysis, revised 1/26, include but was not limited to:*The Licensed Nurse will obtain the healthcare provider orders for hemodialysis which should include the following:-Dialysis Days (Example (Ex: Monday-Wednesday-Friday) and location of the dialysis clinic-Schedule Dialysis time-Labs, if needed-Clarify with Physician hemodialysis medications are to be given pre-dialysis or held.-Dietary needs - renal diet.-Dialysis weights (post weights) will be used by the center as the resident's weight-Vital signs and assessing dialyzing site-Establish a communication book which includes any pertinent information on the resident, that is (i.e.,) vital signs, including blood pressure, and the site used to take the blood pressure, medications given prior to dialysis, any lab values done at the center, any or new deleted medications, and any significant changes since the last dialysis treatment. Review of the facility Outpatient Dialysis Service Agreement with the Dialysis Center, effective 7/1/2016, include but was not limited to:*The Nursing facility shall ensure that all appropriate medical and administrative information accompany all residents at the time of transfer or referral to the End Stage Renal Disease (ESRD-gradual loss of kidney function) Dialysis Unit. This information shall include, but is not limited to, where appropriate, the following:-Appropriate medical records, including history of the resident's illness, including laboratory and x-ray findings.-Treatment presently being provided to the residents, including medications-Prescription for treatment. Resident #43 was admitted to the facility in December 2025 with diagnoses including End Stage Renal Disease (ESRD) and dependence of Renal Dialysis. Review of the Minimum Data Set (MDS) Assessment, dated 12/22/26, indicated Resident #43:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of 15 possible points. -received Dialysis treatment. Review of Resident #43's January 2026 Physician's orders indicated:-Dialysis every Monday, Wednesday and Friday at 4:00 P.M, pick up at 3:30 P.M., return to the facility approximately 8:30 P.M. every shift, initiated 12/16/25. -Monitor Vital Signs every Day shift (7:00 A.M. - 3:00 P.M.), initiated 12/16/25 Review of Resident #43's Dialysis Communication Book failed to provide evidence of any completed communication sent to the Dialysis Center from the facility for any dialysis days in December 2025, or January 2026. Further review of Resident #43's Dialysis Communication Book failed to provide evidence of active Physician orders sent to the Dialysis Center from the facility for any dialysis days in January 2026. Review of Resident #43's clinical record failed to provide any evidence of ongoing communication by the facility with the dialysis center. On 1/8/26 at 8:09 A.M., the surveyor observed Resident #43's dialysis communication book at the nurse's station which contained copies of blank facility daily dialysis communications forms. The dialysis communication form required information on the Resident name, code status, vital signs, allergies, last time meal or snack was consumed, current diet, fluid restrictions and medications administered prior to leaving for dialysis. The surveyor observed incomplete dialysis communication forms in the binder from the facility to the dialysis center for December 2025 and January 2026. During an interview on 1/8/26 at 3:22 P.M., Unit Manager (UM) #1 said that Resident #43 has dialysis treatments three times a week on Mondays, Wednesdays, and Fridays. UM #1 said prior to the Resident going for dialysis, nursing staff would assess vital signs and document the finding on the dialysis communication book along with the Resident face sheet and medication list. The surveyor and UM #1 reviewed the dialysis communication book and the pages in the dialysis communication book that were not completed. UM #1 and Staff Development Coordinator/Infection Preventionist (SDC/IP) at the time reviewed Resident #43's dialysis communication book and the SDC/IP said that the dialysis communication form was a new form that was implemented to allow nursing staff to complete for residents who attends dialysis. The SDC/IP said that the dialysis communication form should be completed and sent with the Resident to dialysis, but it was not completed. During an interview on 1/9/26 at 11:08 A.M., the Director of Nursing (DON) said that the dialysis communication book was mainly for the dialysis center to communicate with the facility. The DON said that the facility was having difficulties with dialysis in obtaining residents post weight after dialysis and the form was generated to communicate with the dialysis center. During an interview on 1/9/26 at 1:13 P.M., Dialysis Center Nurse #1 said that Resident #43 attends dialysis treatment with the dialysis communication form blank and not completed from the facility prior to the Resident coming into the dialysis center. Dialysis Center Nurse #1 said that it would be helpful if the facility would assess the Resident's vital signs, active Physician orders, medications taken and/or not taken prior to dialysis treatment, any upcoming appointments that were upcoming that would interfere with dialysis treatment and if something changes on the form, but this had not been done. During an interview on 1/9/26 at 2:50 P.M., UM #2 said that the dialysis communication form had been completed but there was no evidence of Resident #43's active Physician orders in the dialysis communication book and there should have been active Physician orders for January 2026 in the book. UM #2 also said that active Physician orders are updated monthly and placed in the dialysis communication book. During an interview on 1/9/26 at 4:40 P.M., the DON said that the Resident's dialysis communication book should include active Physician orders. The DON also said that the Physician orders are printed and updated monthly and placed in the dialysis communication book. The DON further said that the expectation for nursing staff was to ensure that the dialysis communication binder includes active Physician orders in the binder and the facility decided that the dialysis communication form should be completed by nursing staff prior to the Resident going for treatment.

Based on observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (nutrients provided directly into the stomach), for one Resident (#2) out of a total sample of 28 residents.Specifically, for Resident #2, the facility failed to ensure that enteral feeds and fluids being administered through the Percutaneous Endoscopic Gastrostomy Tube (PEG Tube) and /or Feeding Tube (medical device that provides a direct route for delivering nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), were labeled and dated appropriately. Findings include:Review of the facility policy titled Enteral Nutrition, revised 6/2023, included but was not limited to: *Continuous feeding/Ready to hang feeding:-Date-Time-Initial the feeding -Initial the tubing Resident #2 was admitted to the facility in December 2025, with diagnoses including Dysphagia oropharyngeal phase following Cerebral Infarction, and Gastrostomy Status. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #2: -was rarely/never understood and had short- and long-term memory loss.-had a memory impairment during the reference period. -received nutrition via a feeding tube. -received over 51 percent (%) of their calories via tube feed.-received fluid intake via a feeding tube and received over 501 cc (cubic centimeters) of fluid for hydration per day. Review of Resident #2's January 2026 Physician's orders indicated:-NPO (nothing by mouth) - tube feeding only diet. NPO texture, NPO consistency, initiated 12/1/25.-Enteral Feed order: Every shift (7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M.) Glucerna 1.5 @ 45 ml/hr. (milliliters per hour) continuous (total volume in 24 hrs. [hour] = 1080 ml), initiated 12/1/25. -Peg Tube Water Flush: 250 ml (milliliters) every 4 hours every shift (7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M.) for water flushes, initiated 12/1/25. -Flush feeding tube with 30 cc of water before and 30 cc of water after each medication administration, initiated 12/1/25.-Flush feeding tube with 30 cc of water before and 30 cc of water after each formula administration, initiated 12/1/25. On 1/7/26 at 11:00 A.M., the surveyor observed Resident #2 lying in his/her bed and an enteral feeding pump was affixed to a pole positioned next to the bed. The surveyor also observed one ready to hang bottle and a clear plastic bag containing clear fluid hanging on the pole above the enteral feeding pump. The ready to hang bottle contained approximately 300 ml of a beige colored liquid, and the clear plastic bag contained approximately 750 ml of a clear liquid. The enteral feeding machine was observed to be connected to the Resident and set to infuse at 45 ml/hr. The ready to hang bag was observed with a manufacturer label that indicated Glucerna with Carbsteady 1.5 Calorie. The surveyor failed to observe a label, date, or identifying contents on either the bottle or clear plastic bag hanging on the enteral feeding pump being administered to Resident #2. On 1/9/26 at 7:52 A.M., the surveyor observed Resident #2 lying in bed with his/ her eyes open and watching television in his/her room. The surveyor observed the enteral feeding pump was set to infuse at 45 ml/hr. The surveyor observed the ready to hang enteral feed bottle and a clear plastic bag hanging on the pole above the enteral feeding pump. The ready to hang bottle contained a beige liquid, and the clear plastic bag contained a clear liquid. The surveyor observed that the bottle and the clear plastic bag hanging on the feeding pump did not have a label, date, or time at which they were hung. On 1/9/26 at 7:58 A.M., the surveyor and Nurse #3 observed Resident #2 lying in bed with the enteral feeding pump running. During an interview at the time, Nurse #3 said that she works with the agency and Resident #2's enteral feed was hung by the 3:00 P.M. to 11:00 P.M. shift. Nurse #3 said that the enteral feed was continuous. Nurse #3 said that the rate of the enteral feeding and water flushes are programmed by a Nurse into the enteral feed machine and Resident #2 received Glucerna 1.5 Cal at 45ml/hr. with automatic water flushes set at 240 ml every 4 hours. The surveyor and Nurse #3 observed approximately 450 ml of beige liquid remaining in the ready to hang bottle which Nurse #3 identified as Glucerna 1.5 Calorie product, and the plastic bag of clear liquid was identified as water for water flushes. The screen on the feeding pump machine connected to the Resident indicated 550 ml of the beige liquid had been administered to Resident #2. Nurse #3 said that the water bag and the ready to hang Glucerna bag were not labeled or dated and should have been. Nurse #3 said that typically when an enteral feeding bag and the flush are administered, both bags should be labeled with the Resident's name, date, time, formula administration set and the initial of the Nurse who hung the enteral feed and the water flushes bags. During an interview on 1/9/26 at 8:23 A.M., Unit Manager (UM) #1 said Resident #2's enteral feed was placed on hold and the feed was resumed the previous shift. UM #1 said Resident #2's enteral feed had been running since 8:30 P.M. on 1/8/26 when the Physician Assistant (PA) ordered Resident #2's enteral feed to be resumed. UM #1 also said that Resident #2 had received the enteral feed and flushes for the past 24 hours. UM #1 further said that enteral feed and hydration water flushes should be labeled with the Resident's name, date, time and the flow rate according to the Physician orders prior to the enteral feed administration but this was not done. During an interview on 1/9/26 at 11:05 A.M., the Director of Nursing (DON) said that the expectation for Nursing staff on enteral feeds is that nursing staff label the enteral feed and the water flushes with Resident #2's name, date, time, formula administration rate set by the Physician and the Nurse who hung the bags would initial prior to administering to Resident #2.

Based on observation, interviews, and records review, the facility failed to provide services that met professional standards of quality relative to neurological evaluation, for one Resident (#54) out of a total sample of 28 residents. Specifically, the facility failed to evaluate Resident #54's neurological status according to the Nurse Practitioner's (NP) order after: -The Resident sustained a fall and struck his/her head. -The Resident was prescribed for anticoagulant (blood thinning) medication. -The NP ordered neurological checks to be completed according to the facility's policy, placing the Resident at risk for unidentified neurological complications. Findings include: Review of the facility's policy titled Neurological Evaluation Policy, dated August 2011 and last revised 4/30/25, indicated the following: -Licensed Nurses perform neurological evaluations when a resident experiences any of the following: *potential or confirmed head injury *unwitnessed fall *a witnessed fall for those receiving anticoagulants/antiplatelets *other events suggesting potential neurological impairment -The purpose was to accurately evaluate and monitor changes in a resident's neurological status to ensure timely notification of the treating healthcare provider and initiation of appropriate treatment. -The neurological/vital sign flowsheet includes vital signs (temperature, pulse, respirations, oxygen saturation level, and blood pressure) and record of a clinical evaluation of neurological observations, including Glascow Coma. -For residents who hit their head or have an unwitnessed fall, after the initial evaluation: *Repeat neurological check in 15 minutes. *Repeat every hour for the next four hours. *Continue every four hours for the first 24 hours, or as per healthcare provider's instructions. -Document all findings on the neurological/vital sign check flowsheet in the electronic health record. Resident #54 was admitted to the facility in June 2024 with diagnoses including Atrial Fibrillation (A-Fib), iron deficiency Anemia, abnormalities of gait and mobility, and long-term use of anticoagulants. Review of Resident #54's Physician orders, dated 4/11/25 with no stop date, indicated:-Eliquis oral tablet 5 milligrams (mg); give five mg by mouth two times a day for A-Fib. Review of the Minimum Data Set (MDS) Assessment, dated 11/12/25, indicated Resident #54: -had adequate hearing. -had clear speech. -was understood and understood others. -was independent for transfers. -was taking anticoagulant medication. Review of Resident #54's Nursing Progress Note, dated 1/3/26, indicated the following: -The Resident fell out of bed around 4:30 A.M. -The NP was notified. -The Resident had a bump on his/her forehead. Review of Resident #54's Nurse Practitioner Progress Note, dated 1/3/26, indicated the following: -The Resident was assessed for an unwitnessed fall with head strike. -The Resident was on Eliquis (anticoagulant medication). -The Resident presented with a hematoma on his/her frontal head. -The NP ordered: Neuro (neurological) checks and vital signs per facility protocol. Review of Resident #54's Neurological Monitoring Evaluation, dated 1/3/26, indicated: -An initial evaluation of neurological status was completed immediately following the Resident's head strike. -An evaluation of the Resident's neurological status was completed 15 minutes after the initial neurological evaluation. -No evidence that neurological evaluation was completed for the Resident every hour for the next four hours. -No evidence that neurological evaluation was completed for the Resident every four hours for the first 24 hours following the Resident's head strike. On 1/7/26 at 9:53 A.M., the surveyor observed Resident #54 was sitting on his/her bed. The surveyor observed that the Resident had purple discoloration to his/her face that began above his/her eyebrows and extended down and around his/her eyes and bridge of the nose. During an interview at the time, Resident #54 said that he/she had sustained a fall with head strike in his/her room during the previous weekend. During an interview on 1/9/26 at 8:11 A.M., the Assistant Director of Nursing (ADON) said that the neuro checklist for Nurses to complete neurological checks for residents was included in the fall investigation packets stored on the Unit. At this time, the ADON provided a sample fall investigation packet from the filing cabinet at the nurses' station on the Unit which included the Unwitnessed Fall Neuro Checklist. The surveyor and the ADON reviewed Resident #54's Neurological Monitoring Evaluation and the ADON said that the Nurses should have completed Resident #54's neurological checks immediately, 15 minutes following the head strike, hourly for four hours, then every four hours for the first 24 hours. The ADON said it was important for the Nurses to have completed the required neurological evaluations, to ensure the Resident was monitored for any changes in neurological condition following his/her head strike.

Based on observations, interviews, and record review, the facility failed to ensure that appropriate access to the call light system was provided for one Resident (#20) out of a total sample size of 28 residents. Specifically for Resident #20, the facility staff failed to ensure that the call light was positioned within his/her reach for use when the Resident required staff assistance with Activities of Daily Living (ADL) care and was a falls risk due to generalized weakness. Findings include: Review of the facility policy titled Administration: Residents' [NAME] of Rights Policy, last revised February 2024, indicated the following: -It is the policy of the facility to adhere, inform and educate residents and staff of the Residents' [NAME] of Rights. -You have the right to be treated with consideration, respect and full recognition of your dignity and individuality. -You have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences except when your health or safety or the health or safety of others would be endangered by such accommodation. -You have the right to communicate with people both inside and outside the facility. Resident #20 was admitted to the facility in November 2017 with diagnoses including Cerebral Palsy, Quadriplegia, history of falling, generalized weakness and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of the Care Plan, last revised 9/30/25, indicated Resident #20: -had an ADL (Activities of Daily Living) self-care performance deficit and required the assistance of 1 - 2 staff for repositioning, turning, which includes weight shift/toileting/incontinent care every 2 hours and as needed (PRN). -was at risk for falling due to generalized weakness with an intervention in place to ensure that the Resident's call light was within reach and encouraged the Resident to use it for assistance. On 1/7/26 at 9:45 A.M., the surveyor observed Resident #20 lying in bed leaning to the left side of the bed and the head of the bed elevated approximately 20 degrees. The surveyor also observed the call light cord wrapped around the right upper siderail of the Resident's bed. On 1/8/26 at 9:08 A.M., the surveyor observed Resident #20 lying in bed with the head of the bed elevated and a breakfast tray placed on a table in front of the Resident. The surveyor observed the call light cord wrapped around the right upper bed rail and the remainder of the cord dangling from the bed rail to the floor. During an interview at the time, the surveyor asked Resident #20 if he/she was able to reach and activate the call light, the Resident was unable to reach the call light. Resident #20 said that unless he/she can grasp the correct end of the call light, he/she is unable to use the light. Resident #20 also said that if he/she needs assistance he/she just waits for the next time staff come into his/her room. On 1/8/26 at 12:34 P.M., the surveyor observed Resident #20 seated in a wheelchair in his/her room positioned on the left side of the bed. The surveyor further observed that the call light was wrapped around the right upper side rail with the remainder of the call light cord dangling from the right side of the bed to the floor. On 1/12/26 at 8:18 A.M., the surveyor observed Resident #20 reclining in bed eating breakfast and the call light cord wrapped around the right upper side rail of the bed and the remainder of the cord dangling from the right side of the bed to the floor. Resident #20 said that it bothers him/her that staff forget to place the call light on the blanket and where he/she can reach the call light. On 1/12/26 at 9:56 A.M., the surveyor and Assistant Director of Nurses (ADON) observed that the Resident's call light was out of reach, and he/she was unable to activate the call light that was wrapped around the right upper side rail of the Resident's bed with the remainder of the cord dangling to the floor. During an interview at the time, the ADON said that Resident #20 should have his/her call light always placed within reach so that he/she can call for assistance when needed. The ADON said that Resident #20 required assistance with almost all ADL care and if the call light was not accessible then he/she could not call for assistance.

Based on observation, record review, and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process, for one Resident (#3) out of a total sample of 28 residents.Specifically, the facility staff failed to assess Resident #3's cognitive status and mood through the required resident interview process when the Resident had difficulty with communication and a fluctuating ability to communicate. Findings include:Resident #3 was admitted to the facility in August 2024 with diagnoses including Multiple Sclerosis, Hemiplegia and Hemiparesis and locked-in state. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3:-had minimal difficulty with hearing.-could sometimes make him/herself understood.-sometimes understands others.-did not have the BIMS (Brief Interview for Mental Status) and the Staff Assessment for Mental Status conducted for the assessment. -did not have the Mood interview and the Staff Assessment for Resident Mood conducted for the assessment. Review of Resident #3's Care Plan for Communication, last reviewed 8/19/25, indicated:-the Resident had a communication problem due to weak or absent voice.-when the Resident closes his/her eyes he/she means no.-when the Resident opens his/her eyes he/she means yes.-allow adequate time to respond, repeat as necessary, do not rush.-ask yes/no questions if appropriate, use simple, brief, consistent words/cues. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3:-had adequate hearing.-usually understands others.-did not have the BIMS assessment and the Staff Assessment for Mental Status conducted. -did not have the Mood interview and the Staff Assessment for Resident Mood conducted. Review of Resident #3's clinical record failed to indicate any documentation or rationale as to why staff did not conduct the Cognitive or Mood Interviews with the Resident on 7/30/25 and 10/30/25. Review of the Nurse Practitioner's (NP) Progress Notes dated 12/18/25, indicated that Resident #3 was unable to move any extremities, was awake and alert and could communicate yes/no and mouth some words. On 1/7/26 at 10:32 A.M., the surveyor observed Resident #3 lying in bed. During an interview at the time, the Resident was able to mouth answers to the surveyor's questions as well as communicate yes or no answers. During an interview on 1/12/26 at 11:30 A.M., the MDS Nurse said that the staff assessments should have been attempted with Resident #3 on 7/30/25 and 10/30/25, and they had not been. The MDS Nurse also said that it is important to attempt to complete the interviews with the Residents so that the Residents could have the opportunity to participate in their plan of care.

Based on records reviewed and interviews, for two of three sampled residents, (Resident #1 and #2), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs within 48 hours of admission, or in the absence of a baseline care plans that comprehensive care plans had been developed with in 48 hours. Findings include: Review of the Facility Policy titled, Baseline/Comprehensive Person-Centered Care Plan, dated as last revised 3/2023, indicated that a baseline care plan must be developed within 48 hours of admission. The baseline care plan includes at least a minimum of healthcare information necessary to provide proper care for the residents. 1) Resident #1 was admitted to the Facility in September 2024, diagnoses included End Stage Renal Disease (ESRD) and dependent on hemodialysis three days a week, history of a heart transplant [AGE] years ago, chronic anemia, and diabetes mellitus. Review of Resident #1's Original Admission Nursing Evaluation, dated 09/06/24, indicated his/her immediate care needs were identified as follows; -ESRD with hemodialysis three times per week; -Alteration in skin integrity with multiple pressure injuries; -Alteration in comfort; -Alteration in respiratory status requiring oxygen via a nasal cannula; -Alteration in mood related to anxiety and depression with psychotropic medication use; and -Need for physical and occupational therapy. Review of Resident #1's Medical Record indicated there was no documentation to support that either Baseline Care Plans and/or Comprehensive Care Plans were developed and implemented that addressed these areas of concern within 48 hours of his/her admission. 2) Resident #2 was admitted in October 2024, diagnoses included urinary tract infection, acute on chronic respiratory distress, chronic obstructive pulmonary disease (COPD), malnutrition, and urinary retention with an indwelling catheter in place. Review of Resident #2's Discharge Summary, dated 10/02/24, indicated his/her immediate care needs were identified as followed; -Urinary tract infection, urinary retention with an indwelling catheter in place; -Acute on chronic respiratory distress with use of multiple inhalers; -Diabetes Mellitus with risk for skin breakdown; and -Risk for abnormal bleeding related to anticoagulant use. Review of Resident #2's Medical Record indicated there was no documentation to support that either Baseline Care Plans and/or Comprehensive Care Plans that addressed these areas of concern, were developed and implemented within 48 hours of his/her admission. During a telephone interview on 10/18/24 at 1:24 P.M., the Evening Supervisor said that she was not very good at care plans and only puts in the fall risk and activities of daily living care plans upon admission. The Evening Supervisor said that the Nurse responsible for completing the Nursing Admission Packet are responsible for completing the Baseline Care Plans for the resident. During an interview on 10/15/24 at 1:22 P.M., the Assistant Director of Nurses (ADON) said that the Unit Manager is usually responsible for developing a resident's baseline care plan and said that management staff does a chart check within 48 hours of admission. The ADON said that it is the Facility's expectation for nursing to initiate a resident's baseline care plan upon admission and must be completed within 48 hours of admission. During an interview on 10/15/24 at 2:03 P.M., the Director of Nurses (DON) said that it is the responsibility of the nurses to initiate and complete baseline care plans for the residents and said that the management team is responsible for doing chart audits to ensure completion. The DON said that it is the Facility's expectation to complete each resident's baseline care plans within 48 hours of admission per the facility policy.

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, the Facility failed to ensure Resident #1's physician had been notified of a missed dialysis session, when on 09/13/24, due to a transport issue, Resident #1 missed his/her scheduled appointment, and required transfer to the Hospital Emergency Department for evaluation and dialysis treatment. Findings include: Review of the Facility Policy titled Change of Condition Notification, dated as lest revised 04/2023, indicated that the facility will inform the resident, resident 's healthcare provider, and the resident's family/legal representative when there is a change of condition. The Policy further indicated that the facility must consult with the resident's healthcare provider when there is an incident involving the resident which may result in injury or require medical treatment and must be documented in the electronic medical record. Resident #1 was admitted to the Facility in September 2024, diagnoses included End Stage Renal Disease (ESRD) and dependent on hemodialysis three days a week, history of a heart transplant [AGE] years ago, chronic anemia, and diabetes mellitus. Review of Resident #1's Physician Orders, dated 09/06/24, indicated to provide hemodialysis three times per week on Monday, Wednesday, and Fridays. Review of Resident #1's Nurse Progress Note, dated 09/13/24, indicated that his/her spouse was transporting him/her to dialysis secondary to transportation issues. During a telephone interview on 10/15/24 at 4:13 P.M., Family Member #1 said that she had called the transport company on 09/13/24 asking why they did not pick Resident #1 up for his/her dialysis session and said that they informed her that they had gone to the facility to pick him/her up, waited 15 minutes and even went into the Facility to see if he/she was in the lobby. Family Member #1 said after driving Resident #1 to the appointment, the dialysis center staff were unable to assist with getting Resident #1 out of the care, so Resident #1 was not able to be dialyzed that day (09/13/24) and that she informed nursing staff that he/she missed that day's dialysis session, upon their return to the facility. Review of Resident #1's Medical Record for 09/13/24, indicated that there was no documentation to support that he/she had not received dialysis that day or that his/her Physician was made aware of the missed dialysis session. During a telephone interview on 10/18/24 at 1:24 P.M., the Evening Nurse Supervisor said that she was working on 09/13/24, the evening that Resident #1 spouse transported him/her to and from dialysis, and that she was aware that he/she had not received dialysis. The Evening Supervisor said that to the best of her knowledge, no one informed Resident #1's Physician that he/she missed his/her dialysis session, that missing a dialysis session was very significant and the Physician should have been notified. During a telephone interview on 10/23/24 at 10:02 A.M., the Nurse Practitioner said that she had not been informed of Resident #1 missing a dialysis session and said she would have expected the nursing staff to inform his/her provider. During a telephone interview on 10/23/24 at 2:49 P.M., the Physician said she was unaware that Resident #1 had missed a dialysis session and that missing a dialysis session is important information that should have been reported. During an interview on 10/15/24 at 1:22 P.M., the Assistant Director of Nurses said she was unaware that Resident #1 had missed his/her scheduled dialysis day on 09/13/24 and said that his/her physician/provider should have been notified so that another dialysis session could be arranged. During an interview on 10/15/24 at 2:03 P.M., the Director of Nurses said that she was not aware that Resident #1 missed a dialysis session, or that nursing had not informed his/her physician. The DON said that it is the Facility's expectation that nursing staff inform a resident's physician of a missed dialysis session.

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, 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 days later required transfer to the Hospital Emergency Department (ED) for evaluation of changes in his/her mental status, and required dialysis treatment. Findings include: Review of the Facility Policy titled Hemodialysis, dated as last revised 6/2023, indicated that a resident who is admitted to the facility requiring hemodialysis, with their consent, will have their dialysis needs met. The Policy further indicated that the resident would leave the facility to obtain hemodialysis to a dialysis center agreed upon by the resident and the physician and the resident will be transported via wheelchair/stretcher to and from the facility by inside and outside Transportation Company on their assigned hemodialysis days. Review of the Facility's Outpatient Dialysis Services Agreement, dated 03/2022, indicated that the Nursing Facility shall have the responsibility for arranging suitable transportation of the resident to and from the dialysis unit, including the selection of the mode of transportation, qualified personnel to accompany the resident and transportation equipment usually associated with this type of transport or referral including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. Resident #1 was admitted to the Facility in September 2024, diagnoses included End Stage Renal Disease (ESRD) and dependent on hemodialysis three days a week, history of a heart transplant [AGE] years ago, chronic anemia, and diabetes mellitus. Review of Resident #1's Hospital Discharge Summary, dated 09/12/24, indicated he/she had dialysis last on 09/11/24 and was due to have his/her next session via outpatient on 09/13/24. Review of Resident #1's Physician Orders, dated 09/12/24, indicated to provide Hemodialysis three times per week, Monday, Wednesday, and Fridays. Review of Resident #1's Nurse Progress Note, dated 09/13/24, indicated that his/her spouse was transporting him/her to dialysis secondary to transportation issues. During a telephone interview on 10/15/24 at 4:13 P.M., Family Member #1 said after driving Resident #1 to his/her dialysis appointment, because of an issue with the transportation company, the dialysis center staff told her that they were unable to help assist with getting Resident #1 out of the car, so he/she was not able to get dialysis (09/13/24). Family Member #1 said she brought Resident #1 back to the facility and informed nursing staff that Resident #1 had not gotten his/her dialysis treatment that day. Review of Resident #1's Medical Record Nursing Progress Notes for 09/13/24, indicated that there was no documentation to support that he/she had not received his/her dialysis treatment that day or that his/her Physician was made aware of the missed dialysis session. Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated 09/16/24, indicated she was called to assess Resident #1 that morning secondary to him/her being unresponsive. The Note indicated that he/she had received an increased dose of Oxycodone (narcotic), he/she was later checked and found to be unresponsive, Narcan was administered without effect and Resident #1 was transported to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Emergency Department report, dated 09/16/24, indicated that he/she was found to have an altered mental status and was hypoxic. The ED report indicated he/she was unable to engage in conversation, his/her eyes were closed and having clonus (neurological condition that causes involuntary, rhythmic contractions and relaxations) and jerky movement. Resident #1's Potassium was 6.1 milliequivalents per liter (mEq/L, normal range is 3.5 to 5.2), and Resident #1 required emergent dialysis treatment. During a telephone interview on 10/23/24 at 10:02 A.M., the Nurse Practitioner said that she had not been informed of Resident #1 missing a dialysis session on 09/13/24 and said she would have expected the nursing staff to inform his/her provider. During a telephone interview on 10/23/24 at 2:49 P.M., the Physician said she was unaware that Resident #1 had missed a dialysis session on 09/13/24 and said missing a dialysis session is very significant. During an interview on 10/15/24 at 1:22 P.M., the Assistant Director of Nurses said she was unaware that Resident #1 had missed his/her scheduled dialysis day and that his/her physician should have been notified so that another dialysis session could be arranged. During an interview on 10/15/24 at 2:03 P.M., the Director of Nurses said that she was not aware that Resident #1 missed a dialysis session, and that nursing had not informed his/her physician. The DON said that it is the Facility's expectation that nursing staff inform a resident's physician of a missed dialysis session and ensure appropriate transportation is set-up for each resident requiring dialysis.

Based on record reviews and interviews for one of three sampled residents (Resident #1), who upon admission and then re-admission, the Facility failed to ensure he/she was free from a significant medication errors, when medications from his/her Hospital Discharge Summary (s) were not accurately reconciled by Nursing and he/she was administered the incorrect dosage of medications for multiple days. Findings include: Review of the facility Policy titled, Medication Reconciliation, dated as last revised 04/2023, indicated that the medication reconciliation process is to be completed at admission, re-admission, and discharge by the nursing staff. The Policy further indicated that the purpose is to identify clarifications and discrepancies that needed to be resolved with the primary care physician to ensure the resident's safety and prevent negative outcomes as related to medication management. Review of the Facility Policy titled Medication Error, dated as last revised 5/2023, indicated that a medication error is a discrepancy between what the healthcare provider ordered and what the resident received. Resident #1 was admitted to the Facility in September 2024, diagnoses included End Stage Renal Disease (ESRD) and dependent on hemodialysis three days a week, history of a heart transplant [AGE] years ago, chronic anemia, and diabetes mellitus. Resident #1 was re-hospitalized from the Facility and readmitted again days later in relation to a fall with head strike and multiple fractured ribs. A) Review of Resident #1's Hospital Discharge (DC) Summary, dated 09/06/24, indicated that the following medications were being administered while hospitalized ; -Neurontin (Gabapentin, anticonvulsant) 300 milligram (mg) capsule (total of 300 mg a day, three times a week), take by mouth three (3) times a week on Monday, Wednesday, and Friday (Dialysis days, start taking on 09/09/24). -Nitroglycerin 2 percent (%) ointment, place 0.05 inch onto the skin two (2) times a day, once in the morning and once in the afternoon, as a scheduled dose. However, review of Resident #1's Physician's Orders, dated 09/06/24, indicated to administer the following; -Neurontin 300 mg capsule, take by mouth 3 times a day (total of 900 mg, every day). -Nitroglycerin 2 % ointment, place 0.05 inch onto the skin every 15 minutes PRN (as needed) for chest pain, may give up to 2 times per day, therefore it was only administered as needed, and not scheduled per his/her Hospital DC Summary. Review of Resident #1's Medication Administration Record (MAR), dated 09/07/24 through 09/10/24, indicated he/she received nine (9) doses of Neurontin 300 mg (for a total of 2700 mg) but he/she should have only received one dose on 09/09/24 (for a total of 300 mg) per his/her physician's order. Review of Resident #1's Medication Reconciliation Form, dated 09/06/24, indicated that medications were reviewed with the on-call provider and no issues had been identified. During a telephone interview on 10/17/24 at 10:01 A.M., Nurse #1 said that she usually looks at the Hospital Discharge Summary medication list and then calls the on-call provider, unless there is a provider in-house at the time of admission. Nurse #1 said she does not recall any details of Resident #1's medication reconciliation and said she did not notice the discrepancy with his/her Neurontin. During an interview on 10/15/24 at 1:22 P.M., the Assistant Director of Nurses (ADON) said that medication reconciliation consisted of Nursing matching medications lists from all sources and clarifying any discrepancies with the provider. B) Review of Resident #1's Hospital Discharge Summary, dated 09/12/24, indicated that the following medications were being administered while hospitalized ; -Tacrolimus (helps to prevent organ rejection) one (1) mg capsule, take one capsule by mouth 2 times a day (for a total of 2 mg daily); However, review of Resident #1's Medication Administration Record (MAR), dated 09/13/24 through 09/16/24, indicated the following: - there were duplicate physician's orders for the Tacrolimus 1 mg capsule, take one capsule by mouth 2 times a day. -both orders on the MAR for the Tacrolimus had been signed off as being administered by nurses on 09/13/24 and 09/15/24, - therefore Resident #1 was being administered a total of 4 mg a day, not 2 mg a day, per the Hospital DC summary. During a telephone interview on 10/17/24 at 2:36 P.M., Nurse #2 said that the only medication she remembered being questioned upon his/her readmission was Resident #1's Plavix (used to prevent blood clots). Nurse #2 said she did not recall seeing a duplicate order for his/her Tacrolimus upon admission. During a telephone interview on 10/17/24 at 1:50 P.M., the DON said that she was not aware that there were any medication errors made with the admission or readmission with Resident #1's reconciliation and/or transcription of medications. During an interview on 10/15/24 at 2:03 P.M., the Director of Nurses (DON) said that she was not aware of any issues with Resident #1's medication reconciliation process for his/her admission or readmission. The DON said that it is the Facility's expectation to include having two licensed nurses complete and sign any resident's medication reconciliation upon admission and readmission and said the nurse management will do a chart audit within 48 hours to ensure accuracy.

Based on observation, interview, record and policy review, the facility failed to implement infection control measures according to professional standards of practice on one Unit (East One Unit) out of four resident units, and for two Residents (#65 and #84) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure that staff who worked on the East One Unit and considered as exposed to COVID-19, completed initial and requisite outbreak testing when the facility was experiencing an outbreak of COVID-19 on the East One Unit, increasing the risk for transmission of infection to residents and staff. 2. Ensure timely and effective implementation of interventions to prevent the transmission of Clostridium Difficile (C. Diff: bacterium that causes diarrhea and colitis [an inflammation of the colon] and can be life-threatening) when Resident #65 was actively being treated for C.diff and required the use of Contact Precautions (use of proper hand hygiene, gloves, and gown upon entering/exiting the environment of the infected individual). 3. Ensure that nursing staff dispensed medications in a safe and sanitary manner and according to professional standards of practice. 4. Ensure that staff followed the PPE requirement for the Droplet Precautions, where a door sign outlined the required personal protective equipment (PPE) needed to be worn before staff entered the room. 5. Ensure that proper cleaning and disinfection of a glucometer machine was conducted after the glucometer machine was used to check Resident #84's blood sugar level, increasing the risk of contamination and transmission of infection. Findings include: 1. Review of the facility's policy titled Clinical Guide for Operations During COVID-19 Health Emergency, dated 3/13/23, indicated the following: -To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the Department of Public Health (DPH). -An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. -Once a new case is identified in a facility, following the requisite outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case . unless a DPH epidemiologist directs otherwise. Review of the Massachusetts (MA) DPH guidelines titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 5/10/23 indicated the following: - . Long-term care facilities are required to perform outbreak testing of residents and staff as soon as possible when a case is identified. -If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after any exposure, if known. -Once a new case is identified in a facility, following outbreak testing, long-term care facilities should test exposed residents and staff at least every 48 hours on the affected unit until the facility goes seven days without a new case unless a DPH epidemiologist directs otherwise. During an interview on 9/25/24 at 8:09 A.M., the Administrator said there were currently residents in the building with facility transmission of COVID-19. During an interview on 9/26/24 at 12:20 P.M., the Infection Preventionist (IP) said the facility was experiencing an outbreak of COVID-19 on the East One Unit. The IP said the outbreak began on 9/11/24, when one resident was symptomatic, and tested positive for COVID-19. The IP said the Unit One Unit Manager (UM) became symptomatic and tested positive for COVID-19 on 9/12/24. The IP said that outbreak testing indicated for resident positive tests on 9/13/24, that outbreak testing continued every 48 hours for residents on the Unit, and that the most recent positive case of COVID-19 on the Unit was identified on 9/25/24. The IP said staff who worked on the East One Unit were not required to perform outbreak testing and were only required to test if they became symptomatic. The IP further said the facility followed MA DPH guidance for COVID-19 testing and that she did not realize staff on the affected Unit were required to perform outbreak testing. 2. Review of the Centers for Disease Control and Prevention (CDC) Guidelines titled About C. diff, dated March 6, 2024, indicated the following: -C. Diff can affect anyone. Most cases of C. Diff occur when you've been taking antibiotics for something else or not long after you've finished. -About 1 in 6 patients who get C. Diff will get it again in the subsequent 2-8 weeks. -Symptoms include diarrhea, fever, stomach tenderness or pain, loss of appetite, and nausea. -C. Diff germs spread from person to person in poop (stool), but the bacteria are often found in the environment. -When C. Diff germs are outside the body, they become spores (an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces .). -The germs become active again when you swallow these spores and they reach the intestines. -Reduce the spread of C. Diff by washing your hands with soap and water after using the bathroom and always before you eat. Resident #65 was admitted to the facility in February 2024, with a diagnosis of Crohn's Disease (chronic nflammatory bowel disease that affects the lining of the difestive tract) and Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident #65's Minimum Data Set (MDS) Assessment, dated 7/31/24, indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total points. -The Resident required supervision or touching assistance from staff for toilet transfers. -The Resident required partial/moderate assistance (helper does less than half the effort) for toilet hygiene. -The Resident was frequently incontinent of bowel. Review of Resident #65's clinical record indicated the Resident was transferred from the facility to the hospital on 8/30/24. Review of Resident #65's Hospital Discharge Summary, dated 9/6/24, indicated the following: -The Resident had a history of C. Diff and recurrent C. Diff. -The Resident had been diagnosed with Active Colitis (inflammation of the colon) due to C. Diff. -Vancomycin (antibiotic) treatment had been initiated for the Resident while in the hospital for treatment of C. Diff. -The Resident was to continue the use of Vancomycin taper (gradual reduction of medication dosage) for treatment of C. Diff upon return to the facility. Review of Resident #65's Physician Progress Note dated 9/20/24, indicated the Resident continued on the Vancomycin taper. Review of Resident #65's clinical record indicated the Resident was transferred to the hospital again on 9/20/24 and returned to the facility on [DATE]. Review of Resident #65's Nurse Practitioner (NP) Progress Note dated 9/23/24, indicated the following: -The NP visit with the Resident was for readmission to the facility from the hospital. -The Resident's diarrhea had improved over the previous 48 hours at the hospital. -The Resident required continued treatment for C. Diff with oral Vancomycin. Review of Resident #65's September 2024 Physician's orders indicated the following: -Vancomycin Oral Capsule 125 mg by mouth two times a day for C. Diff for seven days, start date 9/21/24 and discontinue date 9/22/24. -Vancomycin Oral Capsule 125 mg (milligrams). Give one capsule by mouth two times a day for C. Diff for five days, start date 9/22/24. -Maintain Contact Precautions related to C. Diff every shift, start date 9/25/24. Review of Resident #65's September 2024 Activity of Daily Living (ADL) flowsheets indicated the following: -The Resident used the toilet with supervision/touch assist from staff on 9/22/24 at 8:34 P.M. -The Resident used the toilet independently and was incontinent of a large sized bowel movement on 9/24/24 at 12:43 P.M. -The Resident used the toilet independently and was incontinent of a medium sized bowel movement on 9/25/24 at 12:10 P.M. During an observation and interview on 9/25/24 between 1:39 P.M. and 1:55 P.M., the surveyor observed the following from outside of Resident #65's room: -A Contact Precaution sign was posted on the outer doorframe to the Resident's room. -The name plate outside the door indicated three residents resided in the room. -Resident was #65 lying on his/her bed which was the bed on the door side of the room. At the time, the surveyor donned a gown and gloves and entered Resident #65's room. The Resident said he/she had not been feeling well and that he/she had been having loose stools and fecal incontinence. Resident #65 said that staff assisted him/her to the bathroom when he/she had to have a bowel movement, but that the bathroom was shared between two resident rooms so sometimes he/she would have to wait to use the bathroom. Resident #65 also said that he/she had an infection that was causing the loose stools and that he/she did not want to get anyone else sick. The surveyor observed that the bathroom in Resident #65's room adjoined with another resident room that also housed three residents. Upon preparing to exit Resident #65's room, the surveyor entered the bathroom and washed their hands with soap and water, then observed there were no paper towels or paper towel dispenser in the bathroom so had to carefully air dry their hands. On 9/25/24 at 4:30 P.M., the surveyor observed Resident #65 lying in bed and observed Certified Nurses Aide (CNA) #7 don a gown and gloves and enter Resident #65's room. The surveyor observed CNA #7 handle the Resident's bed linens that were already in the bed and in contact with the Resident, then provide the Resident with an additional blanket. CNA #7 then removed her gown and gloves and exited the room, performing hand hygiene with an alcohol based hand rub (not soap and water). Another resident in the room then requested a snack and CNA #7 responded that she would get him/her some cookies. The surveyor observed CNA #7 walk down the hallway toward the nurses station and when she reached the nurses station, leaned forward placing her arms and hands on the nurses station countertop while talking to another staff member. The surveyor observed a resident walk toward the nurses station and approach CNA #7, they engaged in brief conversation, and the surveyor observed CNA #7 place her hand on the resident's shoulder. The surveyor then observed CNA #7 turn toward the Unit Nourishment Kitchen, use her hand to enter the code to enter the Unit Nourishment Kitchen and open the door. The surveyor did not observe CNA #7 wash her hands with soap and water at any time between exiting Resident #65's room and entering the Unit Nourishment Kitchen. During an interview on 9/25/24 at 5:00 P.M., CNA #7 said she was aware that hand hygiene using soap and water was required after working in Resident #65's room. CNA #7 also said there were no paper towels in the bathroom in the Resident's room for staff to dry their hands after handwashing. During an interview on 9/25/24 at 5:20 P.M., the Director of Nursing (DON) said that all staff who worked in Resident #65's room were required to perform hand hygiene using soap and water when exiting the room because the Resident had C. Diff. The DON also said she was unaware that the shared bathroom in the Resident's room had no paper towel holder and no paper towels. The DON said that a paper towel holder with paper towels needed to be accessible for staff to wash their hands. During an observation and interview on 9/26/24 at 9:00 A.M., the surveyor observed a commode positioned next to Resident #65's bed. At the time, the Resident said he/she did not know why the commode was brought into the room, but someone had brought it in room the previous evening. Resident #65 said he/she had not used it yet and was unsure whether he/she was supposed to use it independently. Resident #65 said prior to the placement of the commode at his/her bedside, he/she had been using the shared resident bathroom that was in the room. During an interview on 9/26/24 at 9:32 A.M., Nurse #3 said she did not know why Resident #65 now had a commode at his/her bedside. Nurse #3 said she knew that Resident #65 was being treated for C. Diff, but that in her experience, Residents with C. Diff would use the toilet and the other Residents would be supplied with a commode. Nurse #3 said she thought Resident #65 may have had the commode because there wasn't enough space in the rooms for five other Residents to have commodes. Nurse #3 further said no matter what, a Resident with C Diff. should not be sharing the same toileting surface as other Residents. Nurse #3 also said she had learned that C. Diff spores can live on surfaces in the environment for months and that a Resident sharing a toileting surface with other Residents would increase the risk for transmission of C. Diff to the other Residents. During an interview on 9/26/24 at 12:20 P.M., the Infection Preventionist (IP) said any Resident identified with C. Diff would be provided a commode at the bedside by the facility. The IP said Resident #65 had been undergoing treatment for C. Diff prior to his/her transfer to the hospital on 9/20/24 and that treatment for C. Diff continued upon his/her return from the hospital on 9/22/24. The IP said she realized when she reviewed Resident #65's record and spoke with the Resident and staff the previous day that no commode had been provided for the Resident, so she provided one at that time. The IP said the commode should have been in place when Resident #65 returned from the hospital, but it was not. The IP also said that staff were required to wash their hands with soap and water every time they exited the Resident's room, rather than use alcohol based hand rub, to reduce the risk for transmitting C.Diff. 44337 3. On 9/30/24 at 9:13 A.M., the surveyor observed the medication administration pass with Nurse #1 and a Nurse orientee (a Nurse in orientation to the facility under Nurse #1's supervision) on the East Nursing Unit on the first floor. The surveyor and Nurse #1 observed the Nurse orientee spill a medication tablet onto a piece of paper on top of the medication cart while pouring medications into a medicine cup to dispense to a resident. The surveyor observed Nurse #1 instruct the Nurse orientee to put on gloves, pick up the medication tablet from the paper and place it into the medicine cup with other prepared medications. During an interview at the time, Nurse #1 said she should not have instructed the Nurse orientee to place the spilled medication tablet into the medicine cup because the medication might have been contaminated. Nurse #1 said the medication should have been discarded and a new tablet should have been dispensed. 47901 4. On 9/26/24 at 8:26 A.M., the surveyor observed CNA #2 enter a room with Droplet Precautions sign at the door, outlining the required personal protective equipment (PPE) needed to be worn before staff entered the room. The sign indicated the appropriate PPE to be used when providing care included gloves, gown, mask, and goggles/face shield. The surveyor observed CNA #2 don (put on) a gown, gloves, and mask but he did not wear goggles or a face shield. The surveyor observed Unit Manager (UM) #2 stood at the room entrance and handed CNA #2 a breakfast tray, and the CNA was observed without eye protection. During an interview on 9/26/24 at 8:28 A.M., CNA #2 said he did not have eye protection on, and he should have. During an interview at the same time, UM #2 said CNA #2 should have had eye protection on but he did not. On 9/26/24 at 9:01 A.M., the surveyor observed CNA #1 ambulate a resident to the bathroom and then make the resident's bed. The surveyor observed signage outside the Resident's room indicating Enhanced Barrier Precautions (EBP- protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] during high contact resident care) and the appropriate PPE to be used for resident care included gown and gloves. CNA #1 was not observed wearing a gown or gloves. During an interview at the time CNA #1 said she was not aware she needed to wear any PPE for walking the Resident and for making his/her bed. The surveyor and CNA #1 reviewed the Enhanced Barrier Precaution sign at the Resident's door and CNA #1 said she should have worn a gown and gloves, but she did not. 5. Resident #84 was admitted to the facility in November 2021 with diagnosis of Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). Review of Resident #84's September 2024 Physician's orders indicated: -Resident was on Enhanced Barrier Precautions related to Stage 4 pressure ulcers. On 9/27/24 at 12:16 P.M., the surveyor observed Nurse #1 perform blood glucose testing on Resident #84 in the Resident's room. The Nurse removed the used test strip from the glucometer machine, then placed the machine in the case. The surveyor did not observe Nurse #1 clean or sanitize the glucometer machine before storing it in the case. During an interview on 9/27/24 at 12:38 P.M., Nurse #1 said she did not have a bleach wipe while she was in the Precautions room. Nurse #1 said she should have wiped off the glucometer machine with a facility approved bleach wipe after performing the finger stick blood glucose test, but she did not.

Based on observation, interview, and policy review, the facility failed to provide a dignified dining experience for one Resident (#79), out of a total sample of 27 residents. Specifically, the facility staff remained standing and stood over Resident #79 while assisting the Resident during a breakfast meal. Findngs include: Resident #79 was admitted to the facility in April 2024, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and Malnutrition (condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health). Review of Resident #79's MDS Assessment, dated 7/30/24, indicated that the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of a total 15. On 9/26/24 at 9:13 A.M., the surveyor observed Resident #79 lying in bed with the head of the bed elevated. The surveyor also observed Certified Nurses Aide (CNA) #6 standing over Resident #79 while assisting him/her with the breakfast meal. During an interview and observation at the time, Unit Manager (UM) #2 said that CNA #6 should be seated next to the Resident and not standing over him/her while assisting with the breakfast meal. Review of the facility document titled CNA Standard of Care Information Sheet, updated March 2023, indicated the following: -Each resident is always treated with dignity and respect. -Allow ample time for feeding - sit at eye level to feed if assistance is needed. During an interview on 9/30/24 at 1:40 P.M., the Director of Nursing (DON) said that the facility provided training to the CNAs using the CNA Standard of Care Information Sheet. The DON said that CNAs should be seated while assisting Residents with meals and not standing over the Residents while assisting with meals.

Based on record review, and interview, the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for two Residents (#40 and #9), out of a total sample of 27 residents. Specifically, facility staff failed to review and revise comprehensive care plans following: 1. one comprehensive and one quarterly review assessment for Resident #40. 2. one comprehensive review assessment for Resident #9. Findings include: 1. Resident #40 was admitted to the facility in June 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD: group of lung diseases that worsen over time and prevent air flow to the lungs causing difficulty breathing). Review of Resident #40's clinical record indicated the following: -A comprehensive review assessment, dated 5/24/24, had been completed. -A quarterly review assessment, dated 8/17/24, had been completed. Further review of Resident #40's clinical record included no evidence the Resident's comprehensive care plan had been reviewed and revised by the IDT following either the 5/24/24 and 8/17/24 assessments. During an interview on 10/2/24 at 1:45 P.M., the Social Worker (SW) said that Resident #40 had been scheduled for an IDT meeting to review and revise his/her care plan following the comprehensive review assessment, but that the IDT meeting did not occur because the SW was unavailable and the meeting was not rescheduled. The SW also said that an IDT meeting to review and revise Resident #40's comprehensive care plan following the quarterly review assessment had not been scheduled, so it was never done. 48206 2. Resident #9 was admitted to the facility in July 2024, with diagnoses including Schizoaffective Disorder (chronic mental health condition characterized primarily by symptoms of Schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and Congenital Hydrocephalus (a birth defect that causes a buildup of cerebrospinal fluid (CSF) in the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #9: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible total 15, -had a Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) but it was not activated (evaluation of capacity by a Physician that a Resident is unable to make medical decisions). Review of Resident #9's medical record indicated the following: -A comprehensive MDS Assessment, dated 7/8/24, had been completed. -Resident #9 was transferred to the hospital on 7/8/24. -Resident #9 returned to the facility on [DATE]. Review of Resident #9's Plan of Care indicated that the care plans were initiated on 7/8/24. During an interview on 9/25/24 at 1:51 P.M., Resident #9 said that he/she wanted to explore options for discharge to the community, but he/she had not spoken with anyone in the facility about his/her options and had not met with the SW, but would like to. Further review of Resident #9's medical record did not indicate evidence of the plan of care being reviewed with the Resident after his/her re-admission to the facility on [DATE]. During an interview on 9/26/24 at 4:05 P.M., the SW said that there was no evidence that Resident #9 participated in any care plan meetings or that a discussion about his/her plan of care occurred. Please Refer to F660

Based on interview, record and policy review, the facility failed to ensure its staff implement the plan of care for one Resident (#75) relative to weight measurements, out of a total sample of 27 residents. Specifically, the facility staff failed to perform weight measurements for Resident #75 when the Resident had been readmitted to the facility with a gastrostomy tube (G-tube: a small flexible tube surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medicine), a diagnosis of Malnutrition and a significant change in condition. Findings include: Resident #75 was admitted to the facility in August 2024, with diagnoses of G-tube placement and Malnutrition (condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health). Review of the facility policy titled Weight Policy and Procedure last revised January 2023, indicated the following: -Each resident's weight will be obtained and documented upon admission, re-admission, monthly, or significant change in condition, and documented in the electronic medical record. On 9/25/24 at 9:40 A.M. the surveyor observed Resident #75 lying in bed with enteral (through a G-tube to the stomach) nutrition infusing through the Resident's G-tube. Review of the Nursing Progress Note, dated 8/30/24, indicated: -Resident #75 returned to the facility after a 28-day hospital admission -G-tube was placed during hospitalization -Resident experienced a significant change in status due to decline in activities of daily living (ADL: a term used to describe fundamental skills needed to care for oneself such as bathing, dressing, eating, and grooming) status, weight loss, and a new pressure ulcer. Review of the Nutritional Evaluation effective 9/4/24 indicated the following recommendations: -Monitor/evaluate weight changes -Notify Registered Dietitian and Physician of significant weight changes -Obtain/record weights as indicated Review of the active Physician orders indicated the following: -Weekly weight every day shift, every Tuesday. Notify Physician/Nurse Practitioner if weight fluctuates by -5 pounds in one week, initiated 8/31/24 Review of the facility weight record indicated the facility had obtained weight measurements for the weeks of 8/30/24, 9/6/24, and 9/14/24 for Resident #75. Further review of the facility weight record indicated no evidence that Resident #75 had been weighed weekly on 9/20/24 and 9/27/24 as ordered. During an interview on 10/1/24 at 10:35 A.M., Certified Nurse Aide (CNA) #6 said that he worked at the facility full time and often provided care for Resident #75. CNA #6 said that he was not sure how often Resident #75 should have been weighed. CNA #6 said that at the beginning of each month a weight list is posted at the nurses station that lists all of the residents on the unit and when the residents are supposed to be weighed. CNA #6 also said that the CNAs are responsible for obtaining the weight measurements for the residents. During an interview on 10/1/24 at 12:12 P.M., Nurse #6 said that Resident #75 had a Physician's order to be weighed weekly. Nurse #6 also said that the Resident had not been weighed on 9/20/24 and 9/27/24 as ordered, but should have been weighed.

Based on observation, interview, record and policy reviewed, the facility failed to notify the Physician/Nurse Practitioner (NP) of the need to alter treatments, based on specialist medical practitioners' recommendations for two Residents (#84 and #79), out of a total sample of 27 residents. Specifically, the facility failed to notify the Physician/NP of: 1. a recommended change in treatment from Resident #84's Wound Care Consultant to cleanse two Stage Four pressure ulcers (PUs: full-thickness skin and tissue loss, usually over a bony prominence, with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), which increased the Resident's risk for infection and delayed healing. 2. a recommended change in treatment from Resident #79's Urologist (Physician who specializes in treatment of the urinary tract) relative to the size change of the Resident's indwelling urinary catheter, increasing the Resident's risk for indwelling urinary catheter associated complications. Findings include: 1. Resident #84 was admitted to the facility in March 2021, with diagnoses including Other Paralytic Syndrome (complete or partial weakness of the body or part of the body, which can occur suddenly or gradually as a result of conditions that affect the brain, spinal cord, or nerves) following Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area). Review of Resident #84's Chronic Wound Care Plan, initiated 4/10/24, indicated the following: -The Resident required Enhanced Barrier Precautions (EBPs: risk-based approach of personal protective equipment [PPE] use to reduce the spread of organisms during high contact resident care, including wound care) due to chronic wound - pressure ulcer. Review of Resident #84's Pressure Ulcer Care Plan, initiated 11/2/23, indicated the following: -The Resident had Stage Four PUs to his/her right and left buttocks. -Staff were to monitor for signs and symptoms of wound infection. -Staff were to update the Physician with changes. Review of Resident #84's Bowel Incontinence Care Plan, initiated 8/6/21, indicated the following: -The Resident had bowel incontinence related to paraplegia (paralysis of legs and lower body). -The Resident used disposable briefs. -The Resident required facility staff to provide bowel incontinence care. Review of two active Physician orders, dated 3/5/24, indicated the following relative to Resident #84's PU care: -Treatment to left buttock wound: 1. NS (Normal Saline: sterile solution) wash. 2. Pat dry . -Treatment to right buttock wound: 1. NS wash. 2. Pat dry . Review of Resident #84's Wound Center Consult Report, dated 8/6/24, indicated the following: -The Physician Assistant (PA) Wound Care Specialist assessed Resident #84 that same day relative to care of right and left ischial (lower back region of the hip bone) ulcers. -A recommendation was made by the PA Wound Care Specialist to cleanse the ulcers by washing them daily with soap and water. Review of Resident #84's clinical record indicated no evidence that the facility notified the Physician/NP of the PA Wound Care Specialist's recommendation to wash the Resident's right and left ischial ulcers daily with soap and water (a change from the NS). On 10/1/24 at 10:45 A.M., Surveyor #2 observed the following during PU care provided by Nurse #2 to Resident #84: -Nurse #2 removed the dressings from each of the Resident's ischial regions. -Two open ulcers were present, one on each of the Resident's ischial regions. -Nurse #2 cleansed both open ulcers using NS before patting them dry and applying the new dressings. Surveyor #2 did not observe Nurse #2 use soap and water to cleanse either open ulcers during the PU care observation. During a telephone interview on 10/2/24 at 11:38 A.M., the PA Wound Care Specialist said she assessed Resident #84 at the Wound Center on 8/6/24, and recommended daily soap and water cleansing to the Resident's right and left ischial ulcers. The PA Wound Care Specialist said she recommended soap and water cleansing versus the use of wound cleanser because soap and water decreases the bacterial load (quantity of bacteria present in a wound that may delay healing) in a wound more than a NS wash. The PA Wound Care Specialist said sometimes wound dressings needed to be changed more than once a day, in order to keep the wounds clean for Residents due to incontinence or a significant amount of wound drainage. The PA Wound Care Specialist further said if Resident #84 required dressing changes more frequently than once a day, that was fine, and that each time the dressing was changed, the ulcers should be cleansed with soap and water to decrease the bacterial load. During an interview on 10/2/24 at 11:56 A.M. with NP #1 and NP #2, NP #1 said she worked at the facility three days per week and NP #2 said she worked at the facility two days per week. NP #1 said when specialist consultants made treatment recommendations for residents, she usually agreed with the recommendations because the area of consultation was that consultant's specialty. NP #1 said when Residents returned to the facility from a specialty consultation, the Nurse receiving the consultation recommendations would notify her or NP #2 of the treatment recommendations so that orders could be obtained. NP #1 also said if she was in the facility when a Resident returned with consultation recommendations, the Nurse would show her the consult report form so she could review it, she would sign the consult report form, and then provide instruction to the Nurse on any new orders. At the time, NP #2 said that if the NPs were not in the facility when wound consultation recommendations came back, the Nurse was to notify them by telephone to obtain orders. The surveyor reviewed Resident #84's Wound Center Consult Report, dated 8/6/24, including the recommendation for cleansing the Resident's PUs with soap and water with NP #1 and NP #2. NP #1 and NP #2 both said they did not recall being notified of the PA Wound Care Specialist's recommendation to cleanse the Resident's PUs with soap and water. NP #2 said the PA Wound Care Specialist's recommendation should have been communicated by the facility so that orders could have been obtained to implement the recommendation into the Resident's PU treatment. During an interview on 10/2/24 at 1:00 P.M. Unit Manager (UM) #1 said she was the designated Wound Nurse for the facility and would always talk to NP #1 about Residents' wound care treatment recommendations. UM #1 said Resident #84 was assessed at the Wound Center on 8/6/24, and that she was aware of the PA Wound Care Specialist's recommendation to cleanse the Resident's PUs with soap and water, but that the Nurses always just used wound cleanser instead at the facility. UM #1 said that Resident #84 required dressing changes more frequently than once a day due to significant wound drainage and fecal incontinence. UM #1 said she did not consider Resident #84 as at risk for acquiring wound infections. No evidence that either of the facility's NPs were notified of the Wound Center's PA Wound Care Specialist recommendation to cleanse Resident #84's PUs with soap and water was provided to the surveyor by the end of the survey period. 44337 2. Resident #79 was admitted to the facility in April of 2024 with diagnoses including Urinary Retention (difficulty urinating and completely emptying the bladder), and Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). Review of the facility policy titled Change of Condition Notification last revised in April 2023, indicated the following: -The facility will inform the Resident, the Resident's healthcare provider, and the Resident's family/legal representative when there is a change in condition. Review of the active Physician's orders indicated the following: -Indwelling urinary catheter 20 French with a 10 cc (cubic centimeter) balloon to straight drainage for urinary retention, initiated 8/24/24. Review of the Resident's medical record indicated a Urology Consult Form dated 9/12/24, that indicated: -a new 16 French (Fr) 10 cc balloon indwelling catheter had been placed. -the Resident was to return to the Urologist in four weeks for a catheter change. Further review of the Urology Consult Form did not indicate that the Physician had been notified of the change in Resident #75's treatment plan. Review of the Nurses Progress Notes for September 2024, indicated no evidence that the Physician had been notified of the change in Resident #75's treatment plan relative to the Urology consult. On 9/26/24 at 8:47 A.M., the surveyor, Certified Nurses Aide (CNA) #6 and Unit Manager (UM) #2 observed that Resident #75 had a 16 Fr/ 10 cc balloon indwelling urinary catheter in place. During an interview and record review with UM #2 on 9/26/24 at 1:45 P.M., UM #2 said that when a Resident goes to an outside Provider for an appointment, a Consult Form is sent with the Resident so that the outside Provider can communicate any treatment changes back to the facility. UM #2 said that usually the Consult Form or the information documented on the Consult Form is provided to the Resident's Physician and a notation is made on the Consult Form indicating the information had been communicated to the Physician. UM #2 said that Resident #75 had gone out to a Urology appointment on 9/12/24. UM #2 said that she was not sure if the Physician had been made aware of Resident #75's treatment change because there was no notation made on the Consult Form and the Physician orders for Resident #75 had not been updated. UM #2 also said that there was no evidence documented in the Nursing Progress Notes that indicated the Physician had been notified of the change in treatment for Resident #75. UM #2 said that she would notify Resident #75's Physician of the Urology Consult Form and obtain a Physician's order for the correct treatment plan for the Resident.

Based on observation, interview, and record review, the facility failed to provide appropriate pain management for one Resident (#84), out of a total sample of 27 residents, when Physician ordered pain medications were not administered in a timely manner. Specifically, for Resident #84, the facility staff failed to administer three pain medications as scheduled during the morning medication pass, resulting in the Resident experiencing unrelieved pain. Findings include: Review of the facility's policy titled Pain Management, revised April 2023, indicated: -Qualified staff will monitor the resident's response to pain management according to CMS, State, specific rules and regulations and facility practice guidelines. -To improve the resident's wellbeing by increasing comfort and reducing depression and anxiety. -To monitor treatment efficacy and side effects. -Administer pain relief medications when needed and monitor for effect. -To evaluate pain status and treatment effects on a regular basis, example during routine medication pass. Resident #84 was admitted to the facility in November 2021, with diagnoses including Paralytic Syndrome (a medical condition that cause neuromuscular weakness and paralysis), Headache (painful sensation in any part of the head), Osteoporosis (weak and brittle bones), Chronic Pain (persistent pain) and Diabetic Neuropathy (nerve pain that occur with diabetes). Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -The Resident had impairment on both upper and lower extremities. -The Resident had frequent pain that affects sleep. -The Resident was on scheduled pain medications. -The Resident was dependent on staff for activities of daily living (ADLs - bathing, dressing, grooming). Review of Resident #84's Physician's orders, dated 9/2/24, indicated: -Acetaminophen Oral Syrup (pain reliever/fever reducer medication) give 30 milliliters (ml) via g-tube (gastrostomy) three times a day for pain, ordered 8/15/24. -Gabapentin (anticonvulsant medication used to treat neuropathic pain) Oral Capsule 300 milligrams (mg) give via g-tube two times a day for neuropathic pain to be administered at 8:00 A.M. and 2:00 P.M. for neuropathic pain, ordered 2/20/24. -Gabapentin Oral Capsule 400 mg, give via g-tube one time a day for neuropathic pain, ordered 2/20/24. -Lidocaine (anesthetic medication) External Patch 4%, apply to lower back topically two times a day for back pain and remove per schedule, ordered 3/13/23. -Tramadol (narcotic analgesic medication) HCL oral tablet 50 mg, give 0.5 tablet via g-tube four times a day for moderate to severe pain, ordered 5/22/24. Review of Resident #84's September 2024 Medication Administration Record (MAR) indicated: -Acetaminophen oral syrup 30 ml via g-tube three times a day, scheduled for 8:00 A.M., 2:00 P.M., and 8:00 P.M. -Tramadol 50 mg oral tablet via g-tube four times a day scheduled for 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M. -Gabapentin Oral Capsule 300 mg via g-tube two times a day, scheduled for 8:00 A.M. and 2:00 P.M. -Gabapentin Oral Capsule 400 mg via g-tube one time a day, scheduled for 8:00 P.M. -Lidocaine External Patch 4% apply to lower back topically two times a day for back pain, scheduled to remove old patch at 8:00 A.M. and 8:00 P.M. Review of Resident #84's MAR on 9/27/24 at 12:00 P.M. indicated the following medications had been signed off as being administered: -Acetaminophen medication - 8:00 A.M. -Tramadol medication - 9:00 A.M. -Gabapentin medication 8:00 A.M. During an interview on 9/27/24 at 12:05 P.M., Nurse #1 said she had signed off the medications as given, but she had not given them as yet and was preparing to administer the medications at the time (3 and 4 hours late). During a medication administration observation on 9/27/24 at 12:16 P.M., the surveyor observed Nurse #1 administer medications that were crushed in liquid to Resident #84. The Resident told Nurse #1 that he/she had a headache of 6 out 10 on the pain numeric scale. During an interview at the time, Nurse #1 said she had administered the Tramadol medication. During a follow-up interview on 9/27/24 at 12:38 P.M., Nurse #1 said she had not administered the 8:00 A.M. Acetaminophen, the 9:00 A.M. Tramadol and the 8:00 A.M. Gabapentin medication (at the scheduled time) because she had been late. During an interview on 9/27/24 at 1:10 P.M., with Nurse Practitioner (NP) #1, NP #1 said she received a call from the facility at 12:06 P.M., informing her that Resident #84 had missed his/her morning medications. NP #1 said she was not aware that the Resident's morning medications were his/her pain medications. NP #1 said Resident #84 had been very particular about not receiving opioid medications and the Resident and the NP had agreed on taking the Acetaminophen, Tramadol, and Gabapentin medications on schedule to avoid any unrelieved pain. NP #1 said facility staff had not made her aware of Resident #84's pain level being 6 out of 10 on the numerical pain scale. Please Refer to F760.

Based on interview, policy and record review, the facility failed to develop and implement an effective discharge planning process for one Resident (#9), out of a total sample of 27 residents. Specifically, for Resident #9, the facility failed to identify the discharge needs and involve the Resident in the development of a discharge plan. Findings include: Review of the facility policy titled Team Based Assessment (TBA), revised February 2023, indicated: -Within two to three business days of admission, an Interdisciplinary Team (IDT) meeting will be scheduled . -Together with the residents, their family or responsible party, the following members of the IDT will be present: Licensed Rehab Therapist, Licensed Nursing Manager Designee, MDS (Minimum Data Set) Coordinator, Social Worker, Business Office Manager . -The meeting will address the following: >Resident input: Expectation of their stay, anticipation of discharge, and Resident's goals for discharge >Social Service needs: anticipation of need for community services, VNA (Visiting Nurse Association), assessment of prior living conditions and plan for equipment needs following discharge; assessment of caregiver involvement following discharge, initiation of a working discharge plan -At the culmination of the meeting, the resident/point-person/responsible party and the IDT will: >Have a clear understanding of the goals needed to reach a successful discharge >Have been given an estimated length of stay -Summary of the TBA will be documented in the Weekly Skilled Review/Discharge Plan and Prep Guide in PCC (Point Click Care- electronic health record). Resident #9 was admitted to the facility in July 2024, with diagnoses including Schizoaffective Disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and Congenital Hydrocephalus (a birth defect that causes building of cerebrospinal fluid in the brain). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -Resident participated in the assessment. -Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible total 15. -Resident's goal was to discharge to the community. -Active discharge planning was occurring. -A referral had been made to the Local Contact Agency. During an interview on 9/25/24 at 1:51 P.M., Resident #9 said that he/she wanted to explore options for discharge to the community and previously had an apartment he/she wanted to return to with nursing and counseling support services. Resident #9 further said that he/she had not spoken with anyone in the facility about his/her discharge options and had not met with the Social Worker (SW), but would like to. Review of the SW Initial assessment dated [DATE], indicated: -Resident #9 was their own responsible party. -Resident supplied answers for the assessment. -Resident's overall goal was to discharge to the community. -Referral had previously been made to the Local Contact Agency. -Discharge plan with goal to discharge to the community was initiated. Review of the Plan of Care relative to the need for safe and appropriate discharge, initiated 7/8/24 and last revised 9/4/24, indicated the following: -Resident's goal to discharge to the community was initiated 7/8/24 -Resident goal was revised to remain in the facility on 9/4/24. -Intervention to assess discharge needs beginning on day of admission, at initial care plan meeting, and through the stay was currently active. -Intervention to assess the need for home health services and community resources as appropriate was resolved on 9/4/24. -Intervention to assess learning needs and barriers toward discharge planning was resolved on 9/4/24. Review of the SW Social Determinants of Health Note dated 9/4/24, did not indicate any discussion regarding return to the community with Resident #9 or why the Plan of Care for need of safe and appropriate discharge had been revised for the Resident to remain in the nursing facility. Review of the Behavioral Healthcare Note dated 9/11/24, indicated the Resident continues to wish he/she could be living independently with wrap around support again. During an interview on 9/26/24 at 8:20 A.M., the Social Worker (SW) said that Resident #9 was previously living in a setting where he/she needed to be able to ambulate and perform ADLs (activities of daily living, i.e. bathing, dressing, toileting) to safely return to the community. The SW said the Resident had homecare services in the community setting and had an involved and supportive family member who was a Health Care Proxy. The SW said that Resident #9 was his/her own responsible party and the HCP was not invoked. During a follow-up interview with the Director of Nursing (DON) and the SW on 9/26/24 at 4:05 P.M., the DON said that when Resident #9 admitted to the facility, the Resident was likely to require long term care as the Resident lived in a group home for many years, but the group home was not able to take the Resident back because the group home could not care for him/her. The SW said that there was no evidence that Resident #9 participated in any meetings relative to discharge planning or that a Team Based Assessment had occurred. Further review of Resident #9's medical record did not indicate evidence of evaluation for discharge planning, inclusion of Resident #9 in discussion about goals of discharge, establishment of a working discharge plan, discussion with the Resident's prior group home, what Local Contact Agency to which a referral had been made, or why return to the community was not feasible. The facility did not provide any further information related to discharge planning for Resident #9 to the survey team at the time of survey exit.

Based on observation, interview, and record review, the facility failed to provide care and services according to professional standards of practice for two Residents (#124 and #84), out of a total sample of 27 residents, with an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) increasing the Residents' risk for indwelling urinary catheter complications. Specifically, the facility staff failed to: 1. For Resident #124, follow Physician orders to insert the Foley catheter with the correct balloon size and switch the Foley catheter bag from straight drainage to leg bag upon the Resident getting out of bed in the morning. 2. For Resident #84, obtain a Physician order to include indications, the type and amount of solution required to flush (manual injection with normal saline to clean or clear the catheter) and irrigate the Resident's indwelling urinary catheter. Findings include: Review of the facility's policy titled Urinary Catheterization, revised April 2024, indicated: -Urinary catheterizations are the aseptic process of inserting a sterile hollow pliable tube into the urethra to facilitate urine drainage into a closed drainage system. -Urinary catheters should be placed only under direction of a Physician order. -Physician order to include catheter type, size, diagnoses for use, irrigation if indicated, and drainage collection type. 1. Resident #124 was admitted to the facility in September 2024 with diagnoses of Benign Prostatic Hyperplasia (BPH - enlargement of the prostate gland that can block the flow of urine out of the bladder), Chronic Kidney Disease (CKD - long standing disease of the kidneys leading to renal failure), and Retention of Urine (inability to completely empty the bladder of urine). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #124 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out a total score of 15. On 9/25/24 at 8:54 A.M., the surveyor observed Resident #124 ambulating in the hallway with a walker. The surveyor observed that the Resident had a Foley catheter and the catheter tubing was visible through his/her pants. On 9/25/24 at 1:55 P.M., the surveyor observed Resident #124 ambulating in the hallway with the Physical Therapist (PT). The surveyor observed the Resident had a catheter tubing that went down through his/her pants and hung on the base of the walker while ambulating. Review of Resident #124's September 2024 Physician's orders indicated: -Change catheter drainage bag from straight drainage to leg bag upon Resident getting out of bed in the morning, initiated 9/6/24. -Change from leg bag to straight drainage at hour of sleep and document in the Point of Care, initiated 9/6/24. -Indwelling catheter 16 French (Fr) with 10 ml (milliliters) of balloon to straight drainage for Urinary Retention, initiated 9/9/24. Review of Resident #124's Care Plan dated 9/9/24, indicated Foley catheter related to BPH, Urinary Retention, Obstructive Uropathy 16 Fr (French) with 10 ml balloon. During an interview on 9/26/24 at 7:59 A.M., Resident #124 said the facility staff had not offered him/her a leg bag. During an interview on 9/26/24 at 10:01 A.M., Nurse #2 said he had not offered Resident #124 a leg bag and that a leg bag would provide dignity and independence. Nurse #2 observed Resident #124's Foley catheter with the surveyor and Nurse #2 said Resident #124's Foley catheter size was 16 French and 5 ml balloon. Nurse #2 said the balloon was not what the Physician had ordered and that the balloon size should have been a 10 ml balloon. During an interview on 9/26/24 at 11:10 A.M., Unit Manager (UM) #1 said she had no idea why the leg bag was ordered for Resident #124. UM #2 further said facility staff should have followed Physician's orders and offered the leg bag to the Resident, but they had not. 42761 2. Review of Lippincott Nursing Procedures - 9th Edition (2023) guidelines titled, Indwelling Urinary Catheter Irrigation indicated the following: -Indwelling urinary (Foley) catheter obstructions sometimes occur and require irrigation. -To relieve an obstruction resulting from clots, mucus, or other causes, an intermittent method of irrigation may be used. -Supplies needed include prescribed irrigating solution . 30 to 60 ml (milliliter) syringes . -Verify the Practitioner's order. -Gather and prepare the appropriate equipment . - . pour the prescribed amount of sterile irrigating solution into a sterile basin. -Place the tip of the syringe into the solution and fill the syringe with the appropriate amount. -Instill the irrigating solution into the catheter. -If necessary, repeat the procedure until you've instilled the prescribed amount of irrigating solution. -Document the date and time of irrigation as well as the type and volume of irrigating solution instilled. Review of the facility policy titled Urinary Catheterization, dated April 2024, indicated the following: -Urinary catheters were to be placed only under the direction of a Physician order. -Physician order to include . irrigation (flush: procedure to open a blocked urinary catheter) if indicated . Resident #84 was admitted to the facility in March 2021, with diagnoses including Retention of Urine. Review of Resident #84's clinical record indicated that the use of an indwelling urinary catheter had been initiated on 12/21/23. Review of Resident #84's July 2024 Treatment Administration Record (TAR) indicated Nurse #1 flushed the Resident's indwelling urinary catheter on 7/4/24. Review of Resident #84's July 2024 Progress Notes included no information relative to indications and the procedure used for flushing the Resident's indwelling urinary catheter on 7/4/24. Review of Resident #84's August 2024 TAR indicated Nurse #1 flushed the Resident's indwelling urinary catheter on 8/29/24. Review of Resident #84's August 2024 Progress Notes included no information relative to indications and the procedure used for flushing the Resident's indwelling urinary catheter on 8/29/24. Review of Resident #84's September 2024 active Physician's orders indicated the following: -Catheter flushes (PRN [as needed] schedule) Document: color of urine . resistance . sediment . as needed for catheter flush, initiated 12/21/23. -Indwelling catheter 16 French with 10 cc[or ml] balloon to straight drainage, initiated 5/17/24. Further review of the Physician's orders included no instructions relative to indications for flushing the catheter and no instructions relative to what solution and how much of the solution should be used to flush the catheter. Review of Resident #84's Indwelling Urinary Catheter Care Plan, initiated 9/25/24, indicated the following: -The Resident had an indwelling urinary catheter. -No interventions relative to indications to flush the catheter. -No interventions relative to what solution and how much of the solution would be used to flush the catheter. On 9/25/24 at 12:00 P.M., the surveyor observed Resident #84 sitting partially upright in bed. The surveyor observed a clear plastic tube, extending out from under the bed sheet on the right side of the bed, that led to a privacy bag which was connected to the bed frame. During an interview at the time, Resident #84 said that the tube observed by the surveyor was his/her indwelling urinary catheter tube. During an interview on 9/27/24 a 11:59 A.M., the Staff Development Coordinator (SDC) said that she provided training to Licensed Nurses relative to indwelling urinary catheter care. The SDC said that a Physician order was required in order for Nurses to flush Residents' indwelling urinary catheters and that the order needed to include instructions relative to indications for flushing the catheter as well as what solution, and how much of that solution, was to be used to flush the urinary catheter. The SDC said that the indications and solution/amount of solution used to flush a catheter needed to be determined by the Physician based on the individual needs of the Resident. During a telephone interview on 10/2/25 at 9:25 A.M., Nurse #1 said that Residents with indwelling urinary catheters required a Physician order to flush their catheters and that the Physician order would include the information relative to indications for flushing as well as what solution, and how much of that solution, should be used to flush the catheter. Nurse #1 said she could not recall the details of how the Resident presented that indicated Resident #84's indwelling urinary catheter needed to be flushed nor could she recall the instructions included in the Physician order for flushing the Resident's indwelling urinary catheter when Nurse #1 flushed the catheter on 7/4/24 and 8/29/24.

Based on observation, record review, and interview, the facility failed to provide adequate supervision and develop or implement effective fall prevention interventions for two Residents (#116 and #35) related to three falls with major injury, failed to investigate a fall for one Resident (#116) and failed to provide adequate supervision during meals for one Resident (#3) at risk for aspiration, out of a total sample of 24 residents. Findings include: Review of the facility's Accident/Incident (A/I) Policy, revised 12/2018, indicated, but is not limited to: -All occurrences are investigated in a timely manner and preventative measures initiated. -The Accident/Incident report must be completed on the shift that the event occurred or was discovered. -The nursing supervisor and or charge nurse will immediately initiate an investigation for all accidents/ incidents. The investigation will include written statements from staff members caring for the resident and from persons having knowledge of the event. The investigation will be completed within 72 hours of the incident. -A written statement will be obtained from any staff member who witnesses occurrence. If the resident makes a statement his/her statement will be included. -All sections of the Accident/Incident form will be completed and signed by the person filling it out-do not leave any blanks. -Describe the event accurately and concisely; document only facts, clinical observations, actions and information about the occurrence. Do not give opinions or conjecture. 1. For Resident #116, the facility failed to provide adequate supervision and develop or implement effective fall prevention interventions related to one fall resulting in a fractured patella (knee cap) and fractured nasal bones and one fall resulting in a head injury. The facility also did not have evidence that a fall on 9/15/21 was investigated or that new interventions were put into place after the fall. Resident #116 was admitted to the facility in October 2020 with diagnoses including dementia with behavioral disturbance and [CONDITION(S)] (a medical condition in which the bones become brittle and fragile from loss of tissue). Review of the care plan, revised 5/31/21, indicated Resident #116 had limited physical mobility and required assistance or continual monitoring/supervision/cueing when walking with a walker. Review of a Minimum Data Set (MDS) assessment, dated 6/18/21, indicated Resident #116 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and required limited assistance of one person (Resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight-bearing assistance) for walking with a walker. Review of Nurse's Note, dated 7/11/21, indicated Resident #116 slid from a low bed to the bedside mat. Review of the corresponding fall investigation indicated the following: -time of occurrence 2:00 P.M. -fall was unwitnessed (witness section of the A/I report was blank) -Resident #116 tried to sit up in bed and slid to the floor mat. -no injuries were sustained -the falls checklist indicated unwitnessed falls required 72 hour neuro checks -Corrective action taken: Encourage resident to sit in a chair instead of sitting in bed. During an interview on 10/22/21 at 4:11 P.M., the Director of Nurses (DON) said the fall on 7/11/21 was unwitnessed. She further said unwitnessed falls required 72 hour neurological checks but she had no evidence they were done. The surveyor asked about the corrective action noted on the investigation (to encourage the Resident to sit in the straight chair instead of the bed). The DON said it was not an effective intervention, given the Resident's impaired cognitive status. The DON then reviewed the Resident's fall care plan with the surveyor and said she could not find any new interventions on the care plan that were initiated in response to the 7/11/21 fall. She further said the expectation was to update the care plan with new interventions on the day of each fall. Review of a Nurse's Note, dated 7/20/21, indicated Resident #116 had a fall while ambulating in the hallway. The note said the Resident fell face flat on the floor and was noted to have a nose bleed and cut nose. Review of the corresponding fall investigation (by Nurse #3) indicated the following: -time of occurrence 6:00 P.M. -Certified Nurse Aide (CNA) statements indicated they did not witness the fall -fall was potentially unwitnessed (based on conflicting information in report vs interviews and witness section of A/I report was blank). -Summary of Investigation Report, Description of the Event: Resident fell while ambulating in the hallway without a walker. -Immediate intervention: Re-educate the resident to use a walker at all times. Review of an undated, unsigned summary submitted to the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) by the DON on 7/26/21 indicated the following: -Resident #116 required limited assist of one person to walk with a walker. -The Resident wandered to the adjacent unit without a walker. The Nurse was escorting Resident #116 to his/her room, to obtain his/her walker, when without any warning Resident #116 transitioned to a quick pace, walking away from the nurse and as the nurse called his/her name, the Resident lurched forward and fell to the ground onto his/her face. -An X-ray revealed a [MEDICATION(S)] patella fracture and a CT scan revealed a nasal fracture. -New interventions included keeping walker in reach, adding the Resident's name to the walker and frequent reminders to use the walker. Resident now uses a wheelchair for mobility. During an interview on 10/22/21 at 3:06 P.M. Nurse #2 told the surveyor her account of what happened when Resident #116 fell on [DATE]. Nurse #2 said she went to the other unit (West 1) to get a tea bag for a resident and she found Resident #116 wandering on West 1 without a walker. Nurse #2 said there was no other staff around so she sat Resident #116 down and left him/her to go back to his/her room on East 1 to get the walker. She said by the time she came back with the walker, Resident #116 had walked back toward East 1 and fell . For clarification, the surveyor asked Nurse #2 if she assisted Resident #116 with ambulating back to East 1 and she said no. The surveyor asked if the nurse documented that description of the event anywhere and she said she thought she had. Nurse #2 reviewed the A/I report and said she could not see where she had documented that account of the event. During an interview on 10/22/21 at 4:11 P.M. the DON said the summary of the event she submitted to DPH via HCFRS was based on a phone interview she had with Nurse #2. She said she didn't understand why the nurse did not provide the same detailed description of the event on the A/I report or during her interview and she said she should have further discussed the discrepancy with Nurse #2 when she reviewed the A/I report and fall investigation, but she had not. The DON further said Resident #116 was not a candidate for re-education based on his/her poor cognition and required assist when walking. (Based on the inconsistent accounts of the event it could not be determined that the Resident was assisted as required). Review of a Nurse's Note, dated 9/15/21, indicated Resident #116 was sitting in a wheelchair and then seen self-transferring. The Resident was unable to maintain a standing position and fell to the floor. During an interview on 10/22/21 at 10:20 A.M., the DON said she could not find an A/I report or documented evidence of a fall investigation for the fall that occurred on 9/15/21. She said Unit Manager (UM) #1 was working at the time of the fall. During an interview on 10/22/21 at 12:48 P.M., the DON brought UM #1 to speak with the surveyor about Resident #116's fall on 9/15/21. UM #1 said she remembered completing an investigation the day of the fall but did not have documented evidence to provide to the surveyor. The DON said she and the corporate nurse looked for the A/I report and investigation and could not find it. When the surveyor asked UM #1 if she recalled the time of the fall, she responded, sometime after lunch. UM #1 said Resident #116 was near the nurse's station when he/she stood from the wheelchair and fell . She said she assessed the Resident after the fall with help from another nurse and determined there were no injuries. UM #1 said she completed an investigation but the DON said it was not located. The surveyor asked what new interventions were put into place at the outcome of the investigation. The DON said the Resident was given a snack and a bedside table and he/she didn't attempt to stand again. The DON said Resident #116 couldn't express him/herself and may have been looking for something to eat. The surveyor asked the DON and UM #1 what new care plan interventions were put into place after the fall from the wheelchair. The DON and UM #1 said the Resident was already on therapy services at the time of the fall and she did not have evidence of new interventions on the Resident's interdisciplinary care plan after the fall on 9/15/21. Review of a Physical Therapy Discharge summary, 10/1/21, Resident #116 was dependent on staff for bed mobility (rolling left to right and sitting up on the edge of the bed) and required substantial/maximal assistance transferring. The resident was non-ambulatory at the time of the assessment. Review of a Nurse's Note, dated 10/8/21, indicated Resident #116 was found lying face down on the floor with the wheelchair on top of him/her and blood noted under the head. Resident was sent to the hospital by the physician. Review of the corresponding fall investigation indicated the following: -time of occurrence 2:00 P.M. -unwitnessed fall -sustained a scalp laceration that required 9 staples -investigation determined resident may have attempted to stand and got tangled in the foot pedals of the wheelchair. -new interventions included physical therapy and foot board for wheelchair During an interview on 10/22/21 at 4:11 P.M., the DON reviewed the fall with the surveyor and said the fall on 10/8/21 occurred in the Resident's room and was unwitnessed. When the surveyor asked again if any new interventions had been put in place following the fall from the wheelchair on 9/15/21 (for which there was no evidence of an investigation or new fall interventions) that may have prevented the fall on 10/8/21, the DON said she had no evidence of any new fall interventions from 9/15/21. 2. For Resident #3, the facility failed to provide supervision with meal intake, as ordered, when the Resident was at risk for aspiration (when contents such as food, drink, or saliva enters the lungs). Resident #3 was admitted to the facility with diagnoses including acute [CONDITION(S)] with [CONDITION(S)] and dysphagia (condition with difficulty in swallowing food or liquid). Review of a Nurse's Note, dated 10/4/21, indicated the following: the respiratory therapist was called to Resident #3's bedside by the nurse due to an oxygen saturation rate of 64%. The Resident was orally suctioned a for large amount of an orange substance. The Resident was sent to the hospital for a possible aspiration event. Review of the hospital discharge paperwork, dated 10/12/21, indicated Resident #3's primary diagnoses were aspiration pneumonia of the left lower lobe and acute hypoxemic [CONDITION(S)] (resolved at time of discharge). A modified [MEDICATION(S)] swallow (MBS) test was performed at the hospital. Discharge recommendations were for a pureed diet with honey thickened liquids. Review of a Speech and Language Pathologist (SLP) Evaluation and Plan of Treatment, dated 10/13/21, indicated Resident #3 was referred to speech therapy due to recurrent aspiration pneumonia, compromised pulmonary status, and reassessment of swallowing function. The assessment indicated Resident #3 had moderate-severe oropharyngeal dysphagia and required supervision/assistance during the meal for swallowing safety. Review of the Physician's Order, dated 10/15/21, indicated the following: Aspiration precautions (measures taken to prevent a person from inhaling solids or liquids into the lungs, or choking). Pills crushed in puree unless contraindicated. Assistance with feeding/supervision. Low concentrated sweets/heart healthy diet, pureed texture, moderately thick liquids. On 10/20/21 at 9:22 A.M. the surveyor observed Resident #3 alone in bed with breakfast on a bedside table in front of him/her. The Resident was slumped over and poorly positioned. Breakfast consisted of pureed sausage and eggs. When the surveyor asked Resident #3 about the meal, the Resident lifted the cover off the food and said he/she was not very hungry. The food appeared untouched. On 10/21/21 from 8:37 A.M. to 8:48 A.M., the surveyor observed that Resident #3 ate breakfast alone in his/her room without supervision or staff assistance. The surveyor observed Resident #3 had difficulty sitting up on the edge of the bed and had dropped oatmeal on the sheets and the front of his/her hospital gown. Resident #3 said he/she liked the oatmeal but didn't care for the eggs. During the observation, staff did not enter the room to supervise or assist the resident with breakfast. During an interview on 10/22/21 at 10:23 A.M., the DON said the facility did not have a written policy pertaining to aspiration or aspiration precautions. She further said they followed the recommendations of the SLP. On 10/22/21 at 12:30 P.M., the surveyor observed an activity staff member deliver a covered lunch tray and position it in front of Resident #3 on the bedside table, while the Resident was asleep. From 12:38 P.M. through 12:46 P.M. the surveyor observed Resident #3 sitting up in bed eating lunch and drinking a honey thickened beverage alone in his/her room. The surveyor observed Certified Nurses Aide (CNA) #2 prepping a lunch tray for a resident in the next room. The surveyor approached the CNA as she exited the room to inquire about Resident #3. CNA #2 said Resident #3 required supervision at meals. The CNA then walked away from the surveyor and entered Resident #3's room. Upon seeing Resident #3 had eaten 100% of the food on the tray, CNA #2 said to the Resident, You didn't wait for me. During an interview on 10/26/21 at 9:40 A.M., Unit Manager #1 reviewed the Physician's Orders and the care plan with the surveyor and said she did not realize Resident #3 required supervision with intake. 3. For Resident #35 the facility failed to provide adequate supervision and assistance to prevent a fall with major injury. Resident #35 was admitted to the facility in May 2021. Review of the Minimum Data Set (MDS) assessment, dated 8/13/21, indicated the Resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 6 out of 15, and required extensive assistance of one for transfers, walking in room, and toilet use. Review of an Incident Report, dated 10/16/21, indicated the Resident sustained a fall. The Resident had been seated in his/her wheelchair in the hallway, stood up unassisted and fell . The Resident stated that he/she had to go to the bathroom, lost his/her balance, slipped and fell . The Resident did not sustain an injury. Review of the care plan for Activities of Daily Living (ADL) deficit indicated the Resident required assist of one for transfers and toilet use. Review of the care plan for Falls indicated the Resident was at risk for falls related to unsteady gait, poor balance, and poor communication/comprehension. Further review indicated no new interventions were put in place following the fall on 10/16/21. Review of an Incident Report, dated 10/21/21, indicated the Resident sustained an unwitnessed fall in the bathroom. The Resident was found on the bathroom floor and stated that he/she walked from the bed to the bathroom, lost his/her balance and fell . During an interview on 10/22/21 at 8:A.M., the Director of Nurses (DON) reported to the surveyor that the Resident was sent to the hospital the previous night following the fall, and had been admitted with a diagnosis of a fractured femur. During an interview on 10/26/21 at 11:24 A.M., the DON reviewed the two incident reports and said there were no revisions made to the care plan after the 10/16/21 fall other than to remind the Resident not to transfer or ambulate independently. She said the Resident required supervision/assistance but didn't receive it surrounding the falls listed above. She said the Resident liked to be independent but she understood the facility was responsible to keep him/her safe. Refer to F 690