Every finding on record at Ridgewood Center, Genesis HealthCare

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received proper treatment to maintain hearing abilities for 1 of 1 residents reviewed for Communication-Sensory in a final survey sample of 22 residents. (Resident identifier is #11.)Findings include:Interview on 2/10/26 at approximately 9:00 a.m. with Resident #11 revealed that he/she had difficulty hearing and that his/her hearing aides were broken a long time ago. Further interview revealed that Resident #11 had been waiting a while to be seen for new hearing aids. Resident #11 stated the facility was aware and had given him/her a 'pocket talker,' but Resident #11 did not like using the pocket talker and would prefer hearing aids. Review on 2/11/26 of Resident #11's progress notes revealed a care plan meeting note, dated 12/16/25, . UM (Unit Manager) will see if [Resident name omitted] is on the list to be seen by [Name of Audiologist omitted] when they are in this week. Review on 2/11/26 of Resident #11's medical record revealed the last audiology consult Resident #11 was on 10/18/24. The recommendation was, Referral for family/staff notices recent decreases patient responsiveness, and a 10/24/24 visit assessment. Do Not Treat for following reason: . patient has not had [pronoun omitted] ears cleaned by ENT. (Ears, Nose and Throat provider). Pt (patient) may be added back to audiology list once [pronoun omitted] has [name of Audiologist omitted] ears cleaned by ENT. Interview on 2/11/26 at approximately 12:15 p.m. with Staff K (Registered Nurse) confirmed the above findings and that Resident #11 had not been seen by audiology.

Based on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 2 residents reviewed for new admissions and 1 of 9 residents observed during medication administration. (Resident Identifiers are #26, #31, and #52.)Findings include:Resident #52 Observation on 2/10/26 at approximately 1:53 p.m. with Staff J (Licensed Practical Nurse) during medication administration revealed Staff J placing one-half tablet of Tramadol (opioid) 50 milligram (mg) into a medication cup. Staff J then documented on the controlled drug record that Resident #52 received one-half tablet of Tramadol 50 mg and documented that 18 half-tablets remained. Observation further revealed that Resident #52's Tramadol 50 mg bingo card indicated 17 half-tablets were present. Review on 2/10/26 at approximately 1:56 p.m. of Resident #52's controlled drug record for Tramadol 50 mg (half tablets) revealed a single entry on 2/10/26 at 1:56 p.m., indicating that one half tablet was administered and 18 half tablets remained. No additional entries were documented for that date. Review on 2/10/26 at approximately 1:53 p.m. of Resident #52's Electronic Medication Record (EMAR) revealed that Tramadol 25 mg was administered on 2/10/26 at 12:29 p.m. Interview on 2/10/26 at 1:53 p.m. with Staff J confirmed the above findings and that he/she did not document the administered dose in Resident #52's controlled drug record for Tramadol 50 mg (half tablets). Review on 2/11/26 of the facility's policy titled, Controlled Substance, dated 1/25, revealed, .4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record [control drug record] when removing dose from controlled storage: (Note: Refer to state regulations for particulars regarding Scheduled Classes and proper storage.) a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR. Resident #26 Review on 2/11/26 of Resident #26's February 2026's MAR's and Narcotic Inventory Sheets revealed the following discrepancies between the MAR and Narcotic Inventory Sheets on the following dates: 2/1 (3 on Narcotic Inventory Sheet and 1 on MAR), 2/3 (2 on Narcotic Inventory Sheet and 1 on MAR), 2/4 (3 on Narcotic Inventory Sheet and 2 on MAR), 2/5 (3 on Narcotic Inventory Sheet and 1 on MAR), 2/6 (2 on Narcotic Inventory Sheet and 1 on MAR), 2/8 (2 on Narcotic Inventory Sheet and 0 on MAR), and 2/9 (1 on Narcotic Inventory Sheet and 3 on MAR). Resident #31 Review on 2/11/26 of Resident #26's January MAR and Narcotic Inventory Sheets revealed the following discrepancies between the MAR and Narcotic Inventory Sheets on the following dates: 1/16 (3 on Narcotic Inventory Sheet and 2 on MAR), 1/18 (6 on Narcotic Inventory Sheet and 5 on MAR), 1/19 (2 on Narcotic Inventory Sheet and 3 on MAR), 1/20 (3 on Narcotic Inventory Sheet and 4 on MAR), 1/21 (4 on Narcotic Inventory Sheet and 3 on MAR), 1/22 (5 on Narcotic Inventory Sheet and 4 on MAR), 1/24 (5 on Narcotic Inventory Sheet and 4 on MAR), 1/26 (5 on Narcotic Inventory Sheet and 3 on MAR), 1/27 (2 on Narcotic Inventory Sheet and 4 on MAR), 1/30 (5 on Narcotic Inventory Sheet and 4 on MAR), and 1/31 (6 on Narcotic Inventory Sheet and 4 on MAR). Interview on 2/11/26 at approximately 1:30 p.m. with Staff F (Regional Nurse) confirmed the narcotic count sheets did not match Resident #26 and Resident #31's MAR's. Review on 2/11/26 of the facility policy titled, NSG300 Controlled Drugs: Management of, Revision Date 1/31/25 revealed, . Discrepancies noted at any step of the process will be reported to appropriate persons. If a discrepancy is noted, the nursing supervisor will be notified and immediately initiate investigation using the controlled Drug Discrepancy Investigation form.Centers will upload Controlled Substance Declining Inventory sheets to the patient medical record upon discontinuation of the medication, discharge or completion .

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were appropriately labeled on 2 of 3 medication carts observed and 1 of 2 medication rooms observed and failed to ensure that expired medication was removed from the medication cart on 1 of 3 medication carts observed. (Resident identifiers are #71 and #66.)Findings include: 3rd Floor South Medication Cart Observation on [DATE] at approximately 8:30 a.m. with Staff A (Licensed Practical Nurse (LPN)) of the 3rd Floor South Medication Cart revealed: Lidocaine 1% multi-dose vial opened with no Resident identifier, no date of opening and no date of expirationResident #71 - 7 Depakote DR (Delayed Release) 125 mg (milligrams) expiration date 2/26 Interview on [DATE] at approximately 8:30 a.m. with Staff A confirmed the above findings. 2nd Floor North Medication Cart Observation on [DATE] at approximately 8:40 a.m. with Staff B (LPN) of the 2nd Floor North Medication Cart revealed:2 opened multi-dose vials of Resident #66's Fluphenazine Decanoate injection with no date of opening and no date of expiration Interview on [DATE] at approximately 8:40 a.m. with Staff B confirmed the above findings. 2nd Floor Medication Room Observation on [DATE] at approximately 8:45 a.m. of the 2nd Floor Medication Room with Staff C (Medication Nursing Assistant) revealed:1 opened multi-dose vial of Resident #66's Fluphenazine Decanoate injection labeled with a date of opening of 7/3Interview on [DATE] at approximately 8:45 a.m. with Staff C confirmed the above findings. Review on [DATE] of the facility policy titled, Medication Storage, Dated 1/25 revealed, . 14. Outdated, contaminated, discontinued or deteriorated medications, . , are immediately removed from stock, disposed of according to procedures for medication disposal.Review on [DATE] of the facility policy titled, Medications and Medication Labels, Dated 1/25 revealed, . Procedures . 2. Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label .Review on [DATE] of the CDC (Centers for Disease Control and Prevention), Safe Injection Practices, undated and provided by the facility, revealed, . Slide 13 CDC recommends the following safe injection practices for multidose vials: . Date multidose vials when first opened. Discard within 28 days unless the manufacturer specifies a shorter or longer date for that opened vial . Interview on [DATE] at approximately 1:30 p.m. with Staff G (Director of Nursing) confirmed the above findings. Further interview revealed that the facility follows the CDC recommendations above for Safe Injection Practices. Staff G also stated that the pharmacy that the facility uses reviewed the manufacturer's instructions for multi-dose vials above and because it was not mentioned in the manufacturer's instructions, they would be in use for 28 days.

Based on interview and record review, the facility failed to provide laboratory services as ordered for 1 of 2 residents reviewed for respiratory infection. (Resident identifier is #87.)Findings include: Review on 2/11/26 of Resident #87's provider note, dated 1/31/26, revealed that Resident #87 had cough, nasal congestion, an upper respiratory infection and to test for flu, RSV, and COVID STAT (immediately or without delay). Review on 2/11/26 of Resident #87's active orders revealed a diagnostic test order for influenza (flu), respiratory syncytial virus (RSV), and COVID-19 with an order date of 1/31/26. Review on 2/11/26 of Resident #87's Respiratory Multiplex PCR (Polymerase Chain Reaction) laboratory report revealed a collection date of 2/3/26 (date when a specimen was collected, four days after the order date), a received date of 2/4/26 (date when specimen was received by the laboratory), and report date of 2/4/26 (when results were reported by laboratory). Further review revealed that Resident #87 was positive for RSV. Review on 2/11/26 of Resident #87's provider note, dated 1/31/26, revealed that Resident #87 had cough, nasal congestion, an upper respiratory infection and to test for flu, RSV, and COVID STAT (immediately or without delay). Review on 2/11/26 of Resident #87's progress notes revealed no documentation of why a specimen was not collected for the above mentioned order until 2/3/26. Further review revealed no documentation indicating that a provider was notified about the reason a specimen was not collected for the above mentioned testing before 2/3/26.Interview on 2/11/26 at approximately 9:45 a.m. with Staff G (Director of Nursing) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for pressure injuries and Transmission Based Precaution (TBP) and 4 of 7 residents reviewed for TBP. (Resident identifiers are #9, #37, #93, #100, and #102.)Findings include: Resident #9 Observation on 2/10/26 at approximately 11:23 a.m. in Resident #9's room revealed an EBP signage posted outside of Resident #9's room door. Further observation revealed that Staff L (Certified Occupational Therapy Assistant) was in Resident #9's room wearing mask and gloves. Staff L was not wearing a gown. Staff L was observed with a wet washcloth and talking to Resident #9. Interview on 2/10/26 at 11:28 a.m. with Staff L revealed that he/she was assisting Resident #9 in changing their clothes (shorts and socks). Staff L confirmed that he/she did not don a gown. Staff L also revealed that he/she did not see the EBP sign on Resident #9's door. Review on 2/10/26 of Resident #9's medical record revealed that Resident #9 was on EBP for an indwelling foley catheter and pressure injuries. Resident #37 Observation on 2/10/26 at approximately 8:55 a.m. in Resident #37's room revealed a droplet precaution signage posted outside of Resident #37's door indicating to wear gown, and gloves; procedure mask and eye protection if needed. Further observation revealed Staff I (Licensed Nursing Assistant (LNA)) was carrying a meal tray into Resident #37's room wearing a mask. Staff I did not don gown and gloves. Staff I set up Resident #37's breakfast, and Staff I left Resident #37's room without discarding their used mask. Interview on 2/10/26 at approximately 9:06 a.m. with Staff I confirmed that he/she did not don gown and gloves before entering Resident #37's room and he/she did not discard their mask after leaving the room. Staff I revealed that he/she was setting up Resident #37's breakfast meal tray. Review on 2/10/26 of Resident #37's medical record revealed that was on isolation precaution (TBP) for Respiratory Syncytial Virus (RSV) infection. Resident #37 had a positive RSV PCR (Polymerase Chain Reaction) test dated 2/5/26. Resident #93 Observation on 2/10/26 at approximately 10:00 a.m. of Resident #93's room revealed a sign requiring Droplet precautions. Further observation revealed, Staff O (Maintenance Director) entered Resident #93's room wearing a surgical mask and no other PPE. Interview on 2/10/26 at approximately 10:05 a.m. with Staff O confirmed the above findings. Resident #100 Observation on 2/10/26 at approximately 11:50 a.m. outside of Resident #100's room revealed a sign requiring Droplet Precautions. Further observation revealed Staff Q (Registered Nurse) exiting Resident #100's room without changing his/her surgical mask. Interview on 2/10/26 at approximately 11:55 a.m. confirmed the above findings. Observation on 2/10/26 at approximately 12:10 p.m. revealed Staff S (Licensed Nursing Assistant) exiting Resident #100's room without changing his/her surgical mask. Interview on 2/10/26 at approximately 12:10 p.m. with Staff S confirmed the above findings. Resident #102 Observation on 2/10/26 at approximately 12:00 p.m. revealed outside of Resident #102's room revealed a sign requiring Droplet Precautions. Further observation revealed Staff R (Laundry Aide) enter Resident #102's room wearing a surgical mask and no other PPE. Staff R was then observed leaving Resident #102's room without changing his/her mask. Interview with Staff R at approximately 12:00 p.m. confirmed the above findings. Review on 2/11/26 of the facility's policy titled, Enhanced Barrier Precautions, revision date 5/1/25, revealed, .Precautions.Enhanced Barrier Precautions.Applies To.All patients with any of the following:.Chronic wounds and/or indwelling medical devices (e.g., central line, urinary catheter, enteral feeding tube.PPE Used for These Situations.During high contact patient care activities: Dressing . Review on 2/11/26 of the facility's policy titled, Transmission Based Precautions, revision date of 5/1/25, revealed, .Droplet Precautions: 10.1 Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .10.5 Healthcare personnel will wear a facemask for close contact with an infectious patient. 10.6 based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown, as well as goggles (or face shield) should be worn .

Based on interview and record review, it was determined that the facility failed to develop and implement a comphrensive care plan for 1 of 4 residents reviewed for mood and behavior in a final sample of 23 residents. (Resident identifier is #92.) Findings include: 47129 Resident #92 Review on 1/7/25 of Resident #92's medical diagnosis list revealed that Resident #92 with a diagnosis of Post Traumatic Stress Disorder (PTSD). Review on 1/7/25 of Resident #92's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/1/24, revealed that it was documented in Section I6100, Diagnosis, that Resident #92 had PTSD. Review on 1/7/25 of Resident #92's comprehensive care plan revealed that there were no focus, triggers, or interventions for Resident #92's PTSD. Interview on 1/8/25 at 9:00 a.m. with Staff I (Unit Manager) confirmed that there were no focus, triggers, or interventions for PTSD in Resident #92's comprehensive care plan.

Based on record review and policy review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample to 23 residents. (Resident identifier is #273, #101, and #73.) Findings include: 26364 Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Resident #73 Interview on 1/6/25 at approximately 10:45 a.m. with Resident #73 revealed that he/she is given his/her insulin late frequently. Resident #73 thought in December that his/her insulin given over three hours late. Review on 1/8/25 of Resident #73's Medication Administration Audit Report for December 2024 and January 2025 revealed the following insulin administrations were not given within 30 minutes before or after the scheduled time: Humalog insulin 100 units/ml 5 units was scheduled for 11:30 a.m. 12/22/24 given at 12:41 p.m. 12/26/24 given at 1:17 p.m. 12/29/24 given at 1:00 p.m. 12/31/24 given at 12:25 p.m. Humalog insulin 100 unit/mg sliding scale scheduled for 11:30 a.m. 12/22/24 given at 12:41 p.m. 12/26/24 given at 1:17 p.m. 12/31/24 given at 12:25 p.m. Humalog insulin 100unit/ml 5 units scheduled for 7:30 a.m. 12/21/24 given at 8:54 a.m. 12/29/24 given at 9:21 a.m. 12/31/24 given at 9:55 a.m. 1/1/25 given at 9:21 a.m. 1/7/25 given at 10:19 a.m. Humalog insulin 100 unit/mg sliding scale scheduled for 7:30 a.m. 12/31/24 given at 9:55 a.m. Humalog insulin 100unit/ml 5 units scheduled for 4:30 p.m. 12/21/24 given at 7:54 p.m. Humalog insulin 100 unit/mg sliding scale scheduled for 4:30 p.m. 12/21/24 given at 7:54 p.m. Tresiba FlexaTouch 200 units/ml 82 units was scheduled for 8:00 a.m., 12/29/24 given at 10:08 a.m. 12/31/24 given at 9:55 a.m. 1/7/25 given at 10:19 a.m. Interview on 1/8/25 at approximately 11:00 a.m. with Staff D (Director of Nursing) confirmed the above findings. 38218 Resident #101 Interview on 1/6/25 at approximately 9:15 a.m. with Resident #101 revealed that he/she was concerned that sometimes his/her medications and insulin had not been administered timely. Review on 1/7/25 of Resident #101's December 2024 and January 2025's Medication Administration Audit Report revealed the following insulin administrationswere not given within 30 minutes and other medication were not given within 60 minutes before or after the scheduled time: Insulin Glargine 100 unit/ml (milliliters) scheduled for 6:00 p.m. 12/7/24 given at 8:05 p.m. 12/8/24 given at 8:06 p.m. 12/15/24 given at 8:53 p.m. 12/27/24 given at 9:29 p.m. 12/28/24 given at 9:40 p.m. 1/1/25 given at 11:18 pm 1/2/25 given at 8:14 p.m. 1/3/25 given at 10:23 p.m. 1/6/25 given at 8:10 p.m. Humalog insulin 100 unit/ml sliding scale scheduled for 7:00 p.m. 12/11/24 given at 8:22 p.m. 12/24/24 given at 11:25 p.m. 12/26/24 given at 8:19 p.m. Metoprolol Succinate Extended Release 50 mg (milligrams) daily scheduled for 9:00 a.m. 12/8/24 given at 12:11 p.m. 12/9/24 given at 1:35 p.m. 12/11/24 given at 12:51 p.m. 12/12/24 given at 3:06 p.m. 12/17/24 given at 2:41 p.m. 12/18/24 given at 3:43 p.m. 12/19/24 given at 11:59 a.m. 12/23/24 given at 12/48 p.m. 12/24/24 given at 1:31 p.m. 12/27/24 given at 2:08 p.m. 12/29/24 given at 1:02 p.m. 12/30/24 given at 12:26 p.m. 1/1/25 given at 4:57 p.m. Gabapentin 100 mg, 3 times daily scheduled for 12:00 p.m. 12/12/24 given at 3:05 p.m. 12/15/24 given at 6:13 p.m. 12/18/24 given at 3:42 p.m. 12/21/24 given at 2:44 p.m. 1/1/25 given at 4:57 p.m. Humalog insulin 100 unit/ml sliding scale scheduled for 12:00 p.m. 12/18/24 given at 3:42 p.m. Gabapentin 100 mg, 3 times daily scheduled for 8:00 a.m. 12/19/24 given at 11:59 a.m. Humalog insulin 100 unit/ml sliding scale scheduled for 5:00 p.m. 12/27/24 given at 6:36 p.m. Gabapentin 100 mg, 3 times daily scheduled for 6:00 p.m. 12/28/24 given at 9:34 p.m. Interview on 1/8/25 at approximately 9:30 a.m with Staff D (Director of Nursing) confirmed the above findings. Standard Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #273 Observation on 1/6/25 at approximately 10:00 a.m. of Resident #273 revealed an undated dressing on his/her left knee. Interview on 1/6/25 at approximately 10:20 a.m. with Staff A (Registered Nurse) confirmed the above finding. Interview on 1/7/25 at approximately 8:30 a.m. with Staff A revealed that Resident #273 did have an order for a dressing change and there was no documentation of the dressing being done. Resident #101 Observation on 1/6/25 at approximately 9:15 a.m. of Resident #101's right leg revealed he/she had 3 undated dressings applied. (1 on right knee, 1 on right outer shin and 1 on right ankle). Interview on 1/6/25 at approximately 10:20 a.m. with Staff A confirmed the above findings. Review on 1/7/25 of Resident #101's January 2025's TAR's revealed the following order: Cleanse abrasions to right lower leg with VASHE. Leave gauze saturated with VASHE to wounds for approximately 1 minute Interview on 1/7/25 at approximately 8:30 a.m. with Staff A confirmed that the order is not clear as to how many abrasions Resident #101 had orders for a dressing to be applied to.

Based on interview and record review, it was determined that the facility failed to ensure that a resident who attends dialysis had interventions to care and monitor their access site and that they received physician ordered medications for 1 of 1 resident reviewed for dialysis in a final sample of 23 residents. (Resident identifier is #1.) Findings include: Interview on 1/7/25 at 1:35 p.m. with Resident #1 revealed that he/she attends dialysis 3 times a week on Monday, Wednesday, and Friday and is away from the facility from approximately 11:30 a.m. until 5:00 p.m. Review on 1/7/25 of Resident #1's January's 2025 Medication Administration Record (MAR) revealed that the medication Calcium Acetate (a phosphate binder) were documented as AW (away from center; meaning not administered) on 1/2, 1/4, and 1/6/25. Further review of Resident #1 MAR revealed that he/she has an order for Midodrine HCL (hydrochloride) Oral Tablet 5 MG (milligram) Give 2 tablets by mouth three times a day for low blood pressure 10 mg and to hold if the SBP (Systolic blood pressure) more than 160 and to be given with his/her meals. On the following dates it was documented as AW on 1/2, 1/4, and 1/6/25. Further review of the MAR revealed no orders to hold medications on dialysis days. Review on 1/7/24 of Resident #1's medical record revealed that he/she was readmitted to the facility on [DATE] and he/she goes to dialysis 3 times a week. Interview on 1/7/25 at approximately 11:00 a.m. with Staff C (Unit Manager) confirmed there were no orders in place to hold medications while at dialysis. Review on 1/7/25 or Resident #1's care plan revealed the care plan did not identify what kind of dialysis access site that Resident #1 had and there were no interventions to care of monitor thier access site. Interview on 1/7/25 with Staff C confirmed the above finding.

Based on observation and interview, it was determined that the facility failed to ensure that food trays were stored dry and in sanitary condition in the main kitchen. Findings include: Standard: Review on 1/7/25 of the U.S. FDA (Food Drug and Administration) Food Code (2017), retrieved from: https://www.fda.gov/media/110822/download, [page 151-153] revealed the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in 151 antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted . Observation on 1/7/25 at approximately 7:15 a.m. of Staff J (Dietary Aide) and Staff K (Dietary Aide) on the breakfast serving line revealed Staff J picked up trays that were stored wet in a large stack and dried each tray off with a dish towel. Interview on 1/7/25 at approximately 7:20 a.m. with Staff L (Dietary Manager) confirming the above findings and revealed they had stored the trays wet the night before.

Based on record review and interview, it was determined that the facility failed to maintain complete records for 1 of 1 record reviewed for death in a final sample of 23 (Resident identifier is #11.) Findings include: Review on 1/07/25 of Resident #11's nursing progress note ,dated 01/04/25 at 14:48, revealed .Resident time of death at 14:42 [2:42 p.m.], 2 RN [Registered Nurse] pronouncing death . No other information was present for this entry. Review on 1/07/25 at 3:15 p.m. of the facility's policy titled NSG104 Pronouncement of Patient Death, effective 5/01/23, revealed .Nurses will comply with all applicable laws and regulations regarding determination of death .1.5. A RN who has determined and pronounced death will document the clinical criteria for such determination and pronouncement in the patient's medical record. 1.5.1 Description of the discovery of the patient; 1.5.2 Any treatment of the patient undertaken; 1.5.3 Findings from assessment (presumptive and conclusive signs identified): 1.5.3.1 No carotid and peripheral pulse, 1.5.3.2 Pupils are fixed and nonreactive to light, 1.5.3.3 No response to tactile stimuli, 1.5.3.4 No respirations for one full minute, 1.5.3.5 No heart sounds for one full minute; 1.5.4 Date and time of death; 1.5.5 Individuals notified of the patient's status/death 1.5.6 Results of any communications . Interview on 1/8/25 at 12:30 p.m. with Staff D (Director of Nursing) confirmed the above findings and that the expectation is that the nurse would document in the medical record all clinical signs of death.

Based on interview and record review, it was determined that the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used one insulin pen to administer insulin to two residents on multiple days (Resident Identifiers are #1 and #2). Findings include: Interview on 6/21/24 at approximately 11:00 a.m. with Staff D (Licensed Practical Nurse (LPN)) revealed that on 6/15/24 and 6/16/24 he/she used Resident #1's used Lantus (insulin) pen to administer insulin to Resident #2 then put back Resident #1's used Lantus pen in the medication cart. Interview on 6/21/24 at approximately 10:00 a.m with Staff C (LPN) revealed that he/she used Resident #1's used Lantus pen to administer insulin to Resident #1 on 6/17/24, which was used to administer insulin to Resident #2 on 6/15/24 and 6/16/24. Staff C was not aware that Resident #1's used lantus pen was used to administer insulin to Resident #2 on above mentioned dates. Review on 6/21/24 of Resident #1's June 2024's Electronic Medication Administration Record (EMAR) revealed an active physician's order for Lantus SoloStar and was administered on 6/15/24, 6/16/24, and 6/17/24. Review on 6/21/24 of Resident #2's June 2024 EMAR revealed an active physician's order for Lantus once a day and was administered on 6/15/24 and 6/16/24. Interview on 6/21/24 at approximately 10:30 a.m. with Staff A (Administrator) confirmed the above findings. Further interview with Staff A revealed that there was an available Lantus vial for Resident #2 and an emergency supply of Lantus in the medication room refrigerator. Staff A stated that Resident #1's used Lantus pen was discarded. Staff A also revealed that they are doing ongoing monitoring through insulin audits, nurse education and competencies, and Quality Assurance meetings. Review on 6/21/24 of the Lantus manufacturer's instruction dated 2022, revealed: .Important Safety Information for Lantus .Do not share needles, insulin pens, or syringes with others .Lantus SoloSTAR is a disposable single-patient-use prefilled insulin pen . Review on 6/21/24 of the facility's pharmacy policy titled Appropriate Use of Prefilled Insulin Pen Devices, provided by the facility revealed: .Insulin pens include a number of manufacturer-unique administrative devices designed for accurate and simple insulin administration. These benefits are only realized if prefilled pen devices are used appropriately .To avoid serious patient harm .NEVER use an individual insulin pen for more than one patient . Review on 6/21/24 of the facility's policy titled, Insulin Pens, revision date of 2/28/21, revealed: .Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed . Review on 6/21/24 of the Centers for Disease Control and Prevention (CDC) handout, retrieved 6/4/24, from https://www.cdc.gov/injection-safety/media/pdfs/Insulin-Pen-Safety-Handout-P.pdf revealed: .Injection equipment (e.g., insulin pens, needles and syringes) should never be used for more than one person . It is critical to remember that insulin pens are meant for only one person . Although invisible to the eye, back flow of blood into the insulin pen can happen during an injection. This creates a risk of bloodborne and bacterial pathogen transmission to patients if the pen is used for more than one person, even when the needle is changed . Review on 6/21/24 of the facility's documentation of corrective action revealed the following: QA meeting was conducted on 6/17/24; The provider evaluated Resident #1 and Resident #2 and ordered Hepatitis panel and HIV blood tests on 6/17/24 and a retest for the hepatitis panel and HIV blood test was ordered; Facility-wide audit of all residents insulin availability was conducted on 6/17/24; Education and competencies of facility's medication availability protocol, facility's insulin pen policy, and CDC's injection safety were conducted on 6/17/24; and Insulin inventory sheet was created on 6/20/24 and initiated on 6/21/24.

Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs (Resident Identifiers are #12, #13, #17, #31, #38, #39, #47, #74, #84, #156 and #250). Findings include: Resident #38 Observation on 10/29/23 at approximately 11:00 a.m. of Resident #38 appeared upset, tearful, and sitting in his/her fecal matter in bed. Interview on 10/29/23 at approximately 11:00 a.m. with Resident #38 revealed he/she had been sitting in his/her fecal matter for approximately an hour, after utilizing the call bell for assistance. Interview on 10/29/23 at approximately 11:05 a.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed the above finding. Staff A (Administrator) stated that a Licensed Nursing Assistant (LNA) was on break leaving them short to answer call lights. Resident #156 Interview on 10/29/23 at approximately 11:10 a.m. with Resident #156 revealed after utilizing his/her call bell last week it took staff approximately a half hour to respond on two occasions and he/she urinated himself/herself while waiting for staff assistance. Staff Interviews: Interview on 10/31/23 at approximately 9:00 a.m. with Staff I (LNA) stated, Three LNAs is not enough on the second floor for this level of acuity. Interview on 10/31/23 at approximately 9:40 a.m. with Staff G (LPN) stated, We don't have enough staff on the second floor . We have fall risk and behavioral residents and I didn't have enough LNAs on my side. Interview on 10/31/23 at 10:30 a.m. with Staff J (LPN) stated, As a licensed nurse, I don't feel that resident care needs are safely met with three LNAs on the second floor. There may be a LNA that is a Medication Aide, but their focus is on medication administration, not patient care. Review on 10/31/23 of the Facility Assessment revealed that .Function: Sufficiency/Analysis Summary .consideration .Currently, the center staffs according to residents' needs based on acuity and census . Further review of the Facility Assessment revealed the following staffing levels for direct care staff: First and Second shift - 2 Nurses (Registered Nurse or Licensed Practical Nurse)/Medication Aide/Technician TBD and Nurse Aides (LNA) 1:14. Review on 10/31/23 of the Daily Staffing Sheets from 9/29/23 to 10/31/23 revealed the following: 9/29/23 - Second floor- Day shift - 3 LNAs, 0 Medication Aide -Census - 44 10/2/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 44 10/3/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 44 10/4/23 - Second floor - Day shift - 3 LNAs, 1 Medication Aide-Census - 44 10/5/23 - Second floor - Day shift - 3 LNAs, 1 Medication Aide-Census - 44 10/9/23 - Second floor - Day shift - 2 LNAs, 2 Medication Aides-Census 41 10/23/23 -Second floor - Day shift - 2 LNAs, 1 Medication Aide-Census - 38 10/29/23- Second floor - Day shift - 3 LNAs, 0 Medication Aide-Census - 43 10/30/23- Second floor - Day shift - 2 LNAs, 1 Medication Aide-Census - 43 Interview on 10/31//23 with Staff A confirmed that the above Daily Staffing Sheets were correct. Review on 10/31/23 of Census and Condition revealed the following acuity between 9/29/23 to 10/30/23: - There were 12 falls in the second floor unit, including two falls with injuries (not major), - There were 13 resident-to-resident incidents the second floor unit, - There were 13 out of 43 residents on the second floor unit needing assistance with meals. 47129 Resident #250 Interview on 10/29/23 at 12:30 p.m. with Resident #250's representative revealed that Resident #250 was admitted to the facility on [DATE] and family visits daily. Resident #250's representative stated that Resident #250 liked to get into bed around 7:30 p.m. and the family would have to provide nighttime care to make sure Resident #250 was in bed prior to the family leaving the facility because the LNAs stated they were short staffed and had to finish other tasks prior to helping Resident #250 get ready for bed. Interview on 10/30/23 at 2:00 p.m. with Resident Council (Resident identifiers are #12, #13, #17, #31, #39, #47, #74, and #84) revealed that on the weekends in the main dining room residents would wait up to an hour or sometimes longer for the meal to be served.

Based on record review and interview, it was determined that the facility failed to ensure residents were offered, educated, and received the pneumococcal and/or influenza immunization 3 of 5 residents reviewed for immunizations (Resident Identifiers are #8, #55 and #67). Findings Include: Review on 10/31/23 of Summary: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2023-24, found at https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm, revealed the .Timing of vaccination - For most persons who need only one dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue throughout the season as long as influenza viruses are circulating . Resident #8 Review on 10/31/23 of Resident #8's medical record revealed the last documented influenza immunization was administered on 12/3/21. Review on 10/31/23 of Resident #8's informed consent for the influenza vaccine revealed that they had consented to receive the influenza vaccine on 9/14/23. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D (Infection Preventionist) confirmed that Resident #8 had consented to receive the influenza vaccine but had not yet received it. Staff D stated that the facility has had influenza vaccine since 10/5/23. Resident #67 Review on 10/31/23 of Resident #67's immunization record revealed no influenza information. Review on 10/31/23 of Resident #67's informed consent for the influenza vaccine revealed they had consented to receive the influenza vaccine on 10/4/23. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed that Resident #67 had consented to receive the influenza vaccine but had not yet received it. Staff D stated that the facility had received their supply of influenza vaccinations around 10/5/23 and that they had not started the influenza vaccine administration for the second floor yet. Review on 10/31/23 of facility policy titled IC600 Influenza Immunization Program, revised on 5/1/23, revealed .Begin the process for the influenza (flu) program in early September. To achieve the highest level of immunity during peak flu season, flu vaccinations should not begin prior to September 1 of each year, unless otherwise advised by the Centers for Disease Prevention and Control (CDC) . Resident #55 Review on 10/31/23 of Resident #55's immunization record revealed their last administration of influenza was given on 3/15/23. Review on 10/31/23 of Resident #55's medical record revealed no proof that Resident #55 had been educated or offered the influenza immunization for the 2023-2024 flu season. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed the above finding. Review on 10/31/23 of the facility policy titled IC600 Influenza Immunization Program, revised on 5/1/23, revealed .Begin the process for the influenza (flu) program in early September. To achieve the highest level of immunity during peak flu season, flu vaccinations should not begin prior to September 1 of each year, unless otherwise advised by the Centers for Disease Prevention and Control (CDC) .Review Center Flu Vaccine Action Plan .Stage General Preparation .Patients- Check each patient's existing medical record for consent & standing order for annual flu vaccine .send Vaccine information statement (VIS) & appropriate letter to the patient/representative .Place a copy of the letter &VIS in the patient's medical record . Resident #67 Review on 10/31/23 of Resident #67's immunization record revealed no pneumococcal information. Review on 10/31/23 of Resident #67's medical record revealed no information that the pneumococcal immunization had been offered to Resident #67 since admission on 8/2/23. Interview on 10/31/23 at approximately 1:20 p.m. with Staff D confirmed the above finding. Review on 10/31/23 of the facilities policy titled IC601 Pneumococcal Vaccination, Revised on 11/15/22, revealed .1. Upon admission, obtain the Pneumococcal vaccination history of all patients. 1.1 Patient or resident representative may self-report vaccination history. 1.2 Document Pneumococcal vaccination history in PointClickCare (PCC) and on the Pneumococcal Consent form under Vaccination History .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 residents reviewed for restraints in a final sample of 22 residents. (Resident identifier is #12). Findings include: Observation on 10/29/23 at approximately 2:00 p.m. of Resident #12 revealed that he/she was in a wheelchair with a fastened seatbelt. Review on 10/30/23 of Resident #12's medical record revealed that there was no assessment of the seatbelt since 6/24/21 and no physician order for seatbelt usage. Further review of the medical record revealed a care plan dated 3/5/21 with an intervention to utilize and release restraint per the physician's order. Observation on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was in a wheelchair with a seatbelt fastened. Interview on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was able to remove the seatbelt on command. Interview on 10/31/23 at approximately 9:30 a.m. with Staff C (Third floor Unit Manager) confirmed that the last assessment for the use of the seat belt was on 6/24/21 and that there were no orders for the use of the seatbelt. Staff C stated that the seatbelt use was Resident #12's preference. Review on 10/31/23 of the facility policy titled, NSG233 Restraints: Use of, Revision date 6/15/22 revealed .Patients will be evaluated for the use of restraints or protective devices during the nursing assessment process. If it is determined that a protective device is being used to improve the patient's ability to move without assistance, no further assessment is needed .

Based on observation, interview and record review, it was determined that the facility failed to follow manufacturer's instruction for obtaining temperature via infrared thermometer for 2 of 3 days observed and the facility also failed to ensure that glucose test strips were labeled with open date according to manufacturer's instruction for 2 of 2 medication carts observed. Findings include: Observation on 10/17/22 at approximately 8:30 a.m. during visitor screening revealed that Staff A (Receptionist) used an infrared thermometer to obtained 4 visitor temperatures. Further observation revealed that Staff A used the thermometer on 4 visitors and held it near the visitor's neck. Observation on 10/18/22 at approximately 8:00 a.m. during visitor screening revealed that Staff A used an infrared thermometer to obtained 3 visitor temperatures. Further observation revealed that Staff A used the thermometer on 3 visitors and held it near the visitor's neck. Interview on 10/18/22 at approximately 8:00 a.m. with Staff A confirmed above findings. Review on 10/18/22 of the facility's infrared thermometer manufacturer's instruction revealed .Intended Use The device is an infrared thermometer intended to measure forehead temperature of infants and adults without contacting human body . 3rd floor high side medication cart Observation on 10/17/22 at approximately 9:10 a.m. with Staff B (Registered Nurse) of the 3rd floor high side medication cart revealed that there was 1 open bottle of glucose test strips with no open date. Review on 10/17/22 of the glucose test strip manufacturer's instruction on the glucose test strip bottle revealed use within 6 months of opening. Interview on 10/17/22 at approximately 9:10 a.m. with Staff B confirmed the above findings in the 3rd floor high side medication cart. 2nd floor low side medication cart Observation on 10/17/22 at approximately 9:15 a.m. with Staff C (Licensed Practical Nurse) of the 2nd floor low side medication cart revealed that there was 2 open bottles of glucose test strips with no open dates. Review on 10/17/22 of the glucose test strip manufacturer's instruction on the glucose test strip bottle revealed use within 6 months of opening. Interview on 10/17/22 at approximately 9:15 a.m. with Staff B confirmed the above findings in the 3rd floor high side medication cart. Review on 10/18/22 of the facility's manufacturer's instruction for the blood glucose monitoring system revealed Performing Glucose Test . Step 1 Take out the [glucose test strip brand name omitted] from the test strip bottles and close the bottle immediately. Insert the test strip to turn on the meter. Important .Record the date opened on the bottle label. Discard the bottle and any remaining test strips after 6 months from date of opening .

Based on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of 2 residents in a final sample of 21 residents (Resident identifiers are #38 and #68). Findings include: Resident #68 Review on 10/18/22 of Resident #68's Weight Summary revealed a weight recorded in error on 9/15/22 of 128 pounds, and a corrected weight of 192.8 pounds on 9/27/22. Review on 10/18/22 of Resident #68's MDS section K0200 Height and Weight dated 9/23/22, revealed the incorrect coded weight of 128 pounds. Interview on 10/19/22 at 11:35 a.m. with Staff E (Director of Nursing) confirmed the above MDS weight coding error. Review on 10/19/22 of Resident #68's Skin & Wound Evaluation dated 9/8/22 revealed an in-house acquired right heel pressure ulcer. Review on 10/19/22 of Resident #68's MDS section M0300 Current Number or Unhealed Pressure Ulcers/Injuries at Each Stage dated 9/23/22 revealed no coded unhealed pressure ulcer/injuries at each stage. Resident #68's MDS section M0300 was not completed with accurate coding to reflect the pressure ulcer. Interview on 10/19/22 at 9:30 a.m. with Staff E (Director of Nursing) confirmed the above MDS pressure ulcer coding error, he/she indicated the pressure ulcer healed on 10/17/22, as reflected on the Skin & Wound Evaluation dated 10/17/22. Resident #38 Review on 10/19/22 of Resident #38's Medical Records revealed a fall on 8/18/22. Review on 10/19/22 of Resident #38's MDS assessment reference date of 08/31/22 section J1800 any falls since admission/entry/re-entry or prior assessment was coded with a no. Interview on 10/19/22 at 9:45 a.m. with Staff E (Director of Nursing) confirmed the above MDS falls coding error. He/she stated that the fall on 8/18/22 should have been coded as a yes on the MDS for Assessment Reference Date (ARD) of 8/31/22.

1. Based on observation, interview, and record review, it was determined that the facility failed to maintain infection control practices in regards to Central Catheter Care for 1 of 1 residents reviewed for Central Catheter Care in a final survey sample of 26 residents. (Resident Identifier #503) Findings include: Resident #503 Observation on 7/20/21 at approximately 9:31 a.m. of Resident #503 revealed a PICC (Peripherally Inserted Central Catheter) line in their left arm and the PICC dressing was dated 7/9/21. Interview on 7/20/21 at approximately 9:31 a.m. with Resident #503 revealed that the PICC dressing had been changed once since their admission on 7/8/2021. Review on 7/20/21 at approximately 11:45 a.m. of Resident # 503's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 7/9/21 (discontinued on 7/14/21) to Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10 cm [centimeters] antecubital). Notify practitioner if external length has changed in since the last measurement every day shift every Wednesday and Friday for PICC dressing. -On 7/16/21 to Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10 cm antecubital). Notify practitioner if external length has changed in since the last measurement every evening shift every Friday for PICC dressing. Review on 7/20/21 at approximately 11:50 a.m. of Resident #503's July 2021 TAR (Treatment Administration Record) revealed the following: -On 7/9/21 (Friday) the PICC line dressing changed was checked off as being completed and included the measurements (catheter length and upper arm circumference). -On 7/14/21 (Wednesday) the PICC line dressing changed was scheduled to be changed, but the dressing change was not checked as being completed. -On 7/16/21 (Friday) the PICC line dressing change was checked off as being completed. There were no measurements (catheter length or arm circumference) indicated. Review on 7/20/21 at approximately 12:30 p.m. of Resident #503's nurses notes revealed no documentation of a PICC site dressing change or measurements for upper arm circumference or length of external catheter since admission on 7/8/2021. Interview on 7/20/21 at approximately 1:00 p.m. with Staff A (Licensed Practical Nurse) confirmed that the date on the PICC dressing was 7/9/21. Staff A stated that the PICC dressing and measurements are to be done weekly. Interview on 7/20/21 at approximately 3:00 p.m. with Staff B (Director of Nursing) confirmed that the PICC line dressing change on the TAR was checked off as completed on the 16th. Staff B confirmed that the PICC line dressing on Resident #503 was dated 7/9/21. Review on 7/21/20 at approximately 9:00 a.m. of facility policy titled 5.2 Central Vascular Access Device (CVAD) Dressing Change revealed, .1. Sterile dressing change using transparent dressings is performed .1.2 At least weekly . Review on 7/22/21 of the CDC (Centers for Disease Control and Prevention) website titled Guidelines for Prevention of Intravascular Catheter-Related Infections, 2011, updated October 2017, retrieved from https://www.cdc.gov/infection control/pdf/guidelines/bsi-guidelines-H.pdf revealed the following: .6. Catheter Site Dressing Regimens .7. Replace dressings used on short term CVC [Central Venous Catheter] sites at least every 7 days for transparent dressings . 2. Based on interview, observation, and record review, it was determined that the facility failed to ensure transmission-based precautions were initiated when a resident was suspected to be infectious to prevent the potential spread of infections for 1 of 1 residents reviewed for transmission-based precautions in a final sample of. (Resident identifier #499) Findings include: Resident #499 Observation on 7/20/21 at approximately 9:36 a.m. of Resident #499's doorway revealed no signage indicating transmission based precautions were to be used. Observation on 7/20/21 at approximately 12:15 p.m. of Resident #499 revealed a stop sign on door and transmission based precautions cart outside of Resident #499's door. Interview on 7/20/21 at approximately 12:15 p.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Staff A stated that the facility was notified (by the lab) around 11:00 a.m. that a stool sample obtained on 7/19/21 had tested positive for C-Diff (Clostridium difficile) and at that time precautions were initiated. Review on 7/20/21 of Resident #499's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the order was obtained for diarrhea. Review on 7/20/21 of Resident #499's lab test result collected on 7/19/21 at 2:20 p.m. revealed the sample was positive for C-Diff and the result was called to the facility on [DATE] at 11:01 a.m. Interview on 7/20/21 at approximately 1:00 p.m. with Staff B revealed that transmission based precautions should have been initiated with the initial suspicion of C-diff on 7/19/21. Review on 7/21/21 of CDC (Centers for Disease Control and Prevention) website titled Transmission Based Precautions, retrieved from https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html updated 1/7/16, revealed the following: .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission . 3. Based on observation, interview, and record review, it was determined that the facility failed to adhere the Center's for Disease Control and Prevention (CDC) recommendation on masking for 1 unit (2nd floor unit) out of 3 units observed. (Resident identifier is #300) Findings include: Review on 7/21/21 of the CDC's website titled, Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, dated 4/27/21, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html, revealed: .Updated Recommendations: 1. Visitation .What infection prevention and control practices are recommended when planning for and allowing visitation in post-acute and acute care facilities? .Visitors, regardless of their vaccination status, should wear a well-fitting cloth mask, facemask, or respirator (N95 or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators) for source control, except as described in the scenarios below . .Hand hygiene should be performed by the patient/resident and the visitors before and after contact . .Facilities should have a plan to manage visitation and visitor flow. -Visitors, regardless of their vaccination status, should physically distance (maintaining at least 6 feet between people) from other patients/residents, visitors that are not part of their group, and HCP in the facility, except as described in the scenarios below. .Facilities might need to limit the total number of visitors in the facility at one time in order to maintain recommended infection control precautions. Facilities might also need to limit the number of visitors per patient/resident at one time to maintain any required physical distancing. .Location of visitation if occurring indoors: -If the patient/resident is in a single-person room, visitation could occur in their room. -Visits for patients/residents who share a room should ideally not be conducted in the patient/resident ' s room. .If in-room visitation must occur (e.g., patient/resident is unable to leave the room), an unvaccinated roommate should not be present during the visit. If neither patient/ resident is able to leave the room, facilities should attempt to enable in-room visitation while maintaining recommended infection prevention and control practicesexternal icon?, including physical distancing and source control. .If visitation is occurring in a designated area in the facility, facilities could consider scheduling visits so that multiple visits are not occurring simultaneously, to the extent possible. If simultaneous visits do occur, everyone in the designated area should wear source control and physical distancing should be maintained between different visitation groups regardless of vaccination status . .Physical distancing and source control recommendations when both the patient/resident and all of their visitors are fully vaccinated: .While alone in the patient/resident's room or the designated visitation room, patients/residents and their visitor(s) can choose to have close contact (including touch) and to not wear source control. .Visitors should wear source control and physically distance from other healthcare personnel and other patients/residents/visitors that are not part of their group at all other times while in the facility. Physical distancing and source control recommendations when either the patient/resident or any of their visitors are not fully vaccinated: .The safest approach is for everyone to maintain physical distancing and to wear source control. However, if the patient/resident is fully vaccinated, they can choose to have close contact (including touch) with their unvaccinated visitor(s) while both continue to wear well-fitting source control . Observation on 7/21/21 at approximately 2:00 p.m. on the 2nd floor south unit revealed that 2 individuals were walking at the end of the hallway with no mask towards the 2nd floor elevator pass the nurse's station and the 2nd floor dining room. Both individuals, with no masks, walked by residents with no mask. Interview on 7/21/21 at approximately 2:05 p.m. with Staff C (Licensed Practical Nurse) confirmed the above findings. Staff C stated that above observed individuals with no mask were visitors. Staff C observed both individuals with no mask and proceeded to continue on task. Staff C was reminded that both individuals were not wearing mask and Staff C then offered both individuals new masks. Interview on 7/22/21 at approximately 8:30 a.m. with Staff B (Director of Nursing) revealed that the individuals as mentioned above were Resident #300 and his/her visitor. Review on 7/22/21 of the facility's entry screening for Covid-19 logs revealed that the visitor was screened upon entry. Review also revealed that visitor was not fully vaccinated for Covid-19. Review on 7/22/21 of Resident #300 immunization record revealed that Resident #300 was fully vaccinated for Covid-19. 4. Based on observation, interview and record review, it was determined that the facility failed to follow infection control practices for wound dressing change for 1 resident out of 4 wounds reviewed in a final sample size of 26 residents. (Resident identifier is #19.) Findings include: Review on 7/22/21 of the Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings retrieved from https://www.cdc.gov/handhygiene/providers/index.html read, in part, . Introduction to Hand Hygiene . Why Practice Hand Hygiene? Cleaning your hands reduces: The spread of potentially deadly germs .Use an Alcohol-Based Hand Sanitizer . Before moving from work on a soiled body site to a clean body site on the same patient . After contact with blood, body fluids or contaminated surfaces . Glove Use . Change gloves and perform hand hygiene during patient care, if . gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body sited on the same patient . Review on 7/22/21 of facility's policy titled, Wound Dressings: Aseptic, revision date of 6/1/21, revealed that .3. Use personal protective equipment as indicated .11. cleanse hands .13. if a break in aseptic technique occurs,, stop the procedure, remove gloves, cleanse hands, and apply clean gloves. 14. Open dressing(s) without contaminating. Keep dressing/gauze within the open packet and place it directly on top of the barrier 15. Prepare medication/ointment, if indicated, by placing on inner sterile package 16. Expose area to be treated. 16.1 Apply clean gloves. if applicable, place bed protector under or adjacent to wound site and remove soiled dressing. 16.2 Discard dressing and gloves according to infection control policy. 17. Cleanse hands. 18. Apply gloves. .22. Using swab or applicator, apply treatment medication as ordered. 23. Apply and secure clean dressing . Observation on 7/21/21 at approximately 2:15 p.m. with Staff C of Resident #19's wound dressing change revealed that Staff C did not remove gloves used to remove old dressing and cleansing the wound. Staff C scooped ointment on his/her index finger, with the dirty gloves on, and applied the ointment to Resident #19's open wound. Staff C continued to use the dirty gloves when applying the dressing to Resident #19's open wound. Staff C's dirty gloved hands touched the inner foam of the dressing which was in contact with Resident #19's open wound. Interview on 7/21/21 at approximately 2:20 p.m. with Staff C confirmed the above findings on Resident #19's wound dressing change as mentioned above. Staff C stated that he/she should have removed gloves and don new gloves when apply the ointment and new dressing.

Based on interview and record review the facility failed to use antibiotic protocols to monitor the use of antibiotics for 2 of 2 months reviewed. Findings include: Review on 7/21/21 of the facility's April 2021 and May 2021 antibiotic line listing and tracking system revealed the following: April 2021 6 of 23 residents on antibiotics did not have signs or symptoms identified consistant with McGeer's Definition of Infection. 6 of 23 residents on antibiotics did not have signs or symptoms identified or meet diagnositc criteria consistant with McGeer's Definition of Infection (i.e. chest x-ray or urin culture). May 2021: 7 of 19 residents on antibiotics did not have signs or symptoms identified consistant with McGeer's Definition of Infection. 1 of 19 residents on antibiotics did not meet diagnositc criteria consistant with McGeer's Definition of Infection (i.e. chest x-ray or urin culture). Interview on 7/22/21 at approximately 1 p.m. with Staff B (Director of Nursing) confirmed the above findings and revealed that the facility used McGeer's Definitions of Infection as criteria for determining use of antibiotics.

1. Based on observation, interview and record review, it was determined that the facility failed to follow physician's order related to medication administration via enteral tube for 1 resident out of 2 resident observed for enteral medication administration. (Resident identifier is #18.) Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/20/21 at approximately 2:00 p.m. with Staff G (Licensed Practical Nurse) revealed that Staff G did not flush Resident #18's enteral tube before and after administering Resident #18's 2:00 p.m. scheduled medications. Interview on 7/20/21 at approximately 2:15 p.m. with Staff G confirmed the above findings. Staff G stated that he/she just gave Resident #18 his/her 200 cc (cubic centimeter/milliliter) water flush at noon. Review on 7/20/21 of Resident #18's active physician's orders revealed an order to flush tube with 30 cc before and after medication administration with a start date of 9/22/20. Interview on 7/20/21 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed the above finding related to Resident #18's physician order. 2. Based on interview and record review, it was determined that the facility failed to follow physician's orders related to wound treatment for 1 resident out of 4 residents reviewed for wounds in a final sample size of 26 residents. (Resident identifier is #89.) Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 7/22/21 of Resident #89's [provider name omitted] wound care center note dated 4/7/21 revealed that Resident #89's perianal surgical wound measurement was 1.5 cm (centimeter) x 0.5 cm x 0.7 cm (length x width x depth) with serosanguinous drainage. Further review revealed dressing change instructions were remove old dressing, cleanse the wound with irrigate with Dakin's solution, apply [MEDICATION(S)] to periwound, use moist Dakins sterile gauze packed to depth with sterile q-tip as the primary dressing, use foam border as the secondary dressing, secure dressing with cloth tape if needed to be carried out twice a day for 3 weeks. Review on 7/22/21 of Resident #89's [provider name omitted] wound care center note dated 4/28/21 revealed that Resident #89's perianal surgical wound measurement was 1.5 cm x 0.5 cm x 0.8 [NAME] minimal amount of sanguinous drainage. Further review revealed dressing change instructions were to remove old dressing, cleanse the wound with irrigate with Dakin's solution, apply [MEDICATION(S)] to periwound, use [MEDICATION(S)] as the primary dressing and use foam border as the secondary dressing to be carried out every other day for 2 weeks. Review also revealed that the wound care note was initialed with a date of 4/30/21. Review on 7/22/21 of Resident #89's [provider name omitted] wound care center note dated 5/12/21 revealed that Resident #89's perianal surgical wound measurement was 2.2 cm 0.4 cm and 0.7 cm with moderate amount of serosanguinous drainage, which has increased in size and drainage in comparison to wound measurement on 4/28/21. Further review revealed that dressing change instructions were the same as noted above on 4/28/21 wound care note. Review also revealed additional instructions to please note change in dressing and to update the facility's orders to reflect the wound care center orders for Resident #89. Review on 7/22/21 of Resident #89's report of consultation dated 5/12/21 revealed .The orders for this wound changed last week & [and] per patient & your written orders you are still doing dakins per old orders. Please follow orders as written by doctor .The order is for dakins irrigation, [MEDICATION(S)] and foam border to be changes every other day. The [MEDICATION(S)] dissolves into wound and if you change it daily it does not have a chance to work properly . Review also revealed that it was initialed by wound care center nurse. Review on 7/22/21 of Resident #89's Electronic Treatment Administration Record (ETAR) for April 2021 revealed a wound treatment order with a start date of 12/31/20 for Dakins 1/4 strength solution apply to perineal area topically every day shift and evening shift for wound care. Cleanse/irrigate the wound 1/4 strength Dakins. Apply [MEDICATION(S)] to periwound. Use moist Dakins sterile gauze, gently packed to depth with sterile q-tip as the primary dressing. Use foam border as secondary dressing. Secure with cloth tape. Review on 7/22/21 of Resident #89's ETAR for May 2021 revealed the same wound treatment order with a start date of 12/31/20 as mention on April 2021 ETAR with a discontinued date of 5/27/21. Further review revealed that Resident #89 received the wound treatment order as mentioned on April 2021 on 5/5-7/21, 5/9-10/21, 5/12/21, 5/14/21, 5/16-21/21 and 5/24/21. Resident #89 received the wound treatment as mention above once on 5/2-3/21, 5/11/21, 5/13/21, 5/15/21, 5/23/21, 5/25/21 and 5/26/21. Interview on 7/22/21 at approximately 1:00 p.m. with Staff B confirmed the above findings for Resident #89. Staff B stated that the dressing change instructions dated 4/28/21 from the [provider name omitted] wound care center was missed. Staff B also stated that the dressing change instructions was reviewed on 4/30/21 and was not updated in Resident #89's ETAR until 5/27/21. 3. Based on interview and record review, it was determined that the facility failed to provide care and services according to accepted standards of clinical practice for medication administration for 1 resident out of 6 residents reviewed for unnecessary medications reviewed out of a final survey sample of 26 residents. (Resident identifiers are #68) Finding include: Practice Standard: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 7/22/21 at approximately 2:30 p.m. of Resident #68's EMAR (Electronic Medication Administration Record) revealed the following physician's order: If eat a large meal take 7 units and add to scale if elevated. If eat a small meal take 4 units and add to scale if elevated. If not eat and blood sugar elevate use scale only. With meals for DM see sliding scale Start date 6/15/21. Interview on 7/22/21 at approximately 3:00 p.m. with Staff B (Director of Nursing) confirmed that there was no indication in the above order of the reason, name or route of the medication being administered.

Based on observation, interview, and record review it was determined that the facility failed to remove expired medication from 1 of 2 medication rooms observed (3rd Floor Medication Room) and failed to date eye drops when opened and/or discard them per manufacturer's recommendations for 1 of 4 medication carts observed (2nd Floor North Cart). Findings include: 3rd Floor Medication Room Observation on [DATE] at approximately 10:15 a.m. of the the 3rd floor medication room refrigerator revealed 8 boxes containing influenza vaccine that expired on [DATE]. There were other medications stored in the refrigerator. Interview on [DATE] at approximately 10:15 a.m. with Staff A (Licensed Practical Nurse) confirmed that the influenza vaccine was expired and should have been removed from the refrigerator. Interview on [DATE] at approximately 3:30 p.m. with Staff B (Director of Nursing) confirmed the above. 2nd Floor North Cart Observation on [DATE] at 11:55 a.m. of the 2nd Floor North Cart revealed the following opened eye drop bottles: - An open bottle of [MEDICATION(S)] ([MEDICATION(S)]) dated it had been opened on [DATE] (opened for 56 days or 8.1 weeks). There was a sticker on the bottle that read after opening, do not use after 42 days; - Two opened bottles of [MEDICATION(S)] that did not have a date when opened. There was a sticker on both bottles that read after opening, do not use after 28 days; - One opened bottle of Refresh that was not dated when it had been opened. Interview on [DATE] at 11:55 a.m. with Staff C (Licensed Practical Nurse) confirmed that the [MEDICATION(S)] was beyond the use by date and was unsure of when the other bottles had been opened. Staff C did not know who should be checking the cart for expired medication for removal. Staff C confirmed that the eye drops should be dated when opened. Interview on [DATE] at approximately 3:30 p.m. with Staff B confirmed eye drops should be dated when opened and then discarded per the manufacturer's instructions. Review on [DATE] of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised on [DATE] read, in part, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacture or supplier guidelines . are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container 15. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis Review on [DATE] of the facility's policy titled Medication Administration: Eye (Drops and Ointments) revised on [DATE] read, in part, . 3. Date medication container the first time it is opened. Follow manufacturer's recommendations on when to discard an opened container. Review on [DATE] of the manufacturer's instructions for bimatropost eye drops Consumer Medicine Information read, in part, . Disposal. Throw out any remaining solution after four weeks from the date of opening. Eye drops contain a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. After this time there is a greater risk that the drops may become contaminated and cause an eye infection. A new bottle should be opened Review on [DATE] of the manufacturer's instructions for [MEDICATION(S)] read, in part, . Storage . Once a bottle is opened for use, it may be stored at room temperature . for 6 weeks Review on [DATE] of the manufacturer's instructions for Refresh Tears read, in part, . Discard 90 days after opening .

Based on record review and interview, the facility failed to provide Cardiopulmonary Resuscitation basic life to a resident requiring such emergency care to 1 resident in a survey sample of 3 residents who expired at the facility. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident # 1's physician orders [REDACTED]. Interview on [DATE] at approximately 12:57 p.m. with Staff C (Social Worker) revealed Staff C arrived at the facility on [DATE] at 8:00 a.m. and was informed that Resident # 1 had expired. Staff C asked what hospital Resident # 1 went to and Staff E (Registered Nurse/Supervisor) stated that Resident # 1 was a DNR (Do Not Resuscitate). Staff C asked to be shown the DNR order. Staff E looked in Resident # 1's medical record and was unable to find an order for [REDACTED]. Interview on [DATE] at approximately 12:30 p.m. with Staff B (Director of Nursing) confirmed that the code status is located in the electronic medical record and that is where staff are trained to look. Interview on [DATE] at approximately 2:30 p.m. with Staff A (Administrator) revealed that Staff A completed an investigation and that on [DATE] Staff F (Licensed Nursing Assistant (LNA)) checked on Resident # 1 who spoke to Staff F briefly and then became unresponsive. Staff F called for Staff D (Licensed Practical Nurse/Charge Nurse) who then assessed Resident # 1 for pulse and found none. Staff D then left the room to get a stethoscope and returned to complete assessment, and noted no heart beat present. Staff D then left the room to obtain Resident # 1's code status. Staff D was at the nurses station when Staff E RN (Registered Nurse Supervisor) arrived on the floor and checked Resident # 1's medical record for code status and stated that Resident #1 was a DNR. Interview on [DATE] at approximately 9:00 a.m. with staff F (LNA) who stated that at approximately 4:45 a.m. Staff F checked on Resident # 1 who spoke briefly and then became unresponsive. Staff F then checked Resident # 1's pulse and respirations and none were present so Staff F notified Staff D who assessed for pulse and then left the room to get a stethoscope. Staff D returned with the stethoscope and completed assessment and then left the room and did not return. Staff F stated that then Staff E pronounced the death of Resident # 1 and at approximately 6:00 a.m. Staff F returned to Resident # 1's room and provided post mortem care. Review on [DATE] of the facility policy titled Cardiac and/or Respiratory Arrest dated [DATE] in the section titled POLICY: states that: Centers support the right of every patient to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The policy further states that; If a patient does not have a DNR order, CPR/AED certified staff will initiate CPR/AED and emergency medical services (EMS) will be activated. Interview with [DATE] at approximately 2:00 p.m. with Staff E revealed Staff E returned from break to find Staff D sitting at the nurse's station. Staff D told Staff E that Resident #1 had passed away. Staff E checked the code status for Resident #1 in the electronic medical record read that Resident #1's code status was DNR. Staff E later reviewed the chart with Staff C and saw that Resident #1 was a full code. Staff E stated that they must have been looking in the wrong chart. Interview on [DATE] at approximately 2:45 p.m. with Staff D revealed that Staff E looked in the chart and told Staff D that Resident #1 had DNR as a code status. Staff D was not willing to comment further.

Based on observation, interview, and record review, the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #3, #18, and #25). Findings include: Standards: Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..." On pages 699-714 "...The prescriber often gives specific instructions about when to administer a medication." This reference also relates on page 713 that "....a registered nurse compares the list of medications on the MAR indicated [REDACTED]." Findings include: Resident #3: On 3/13/12, during a review of the medical record for Resident #3 it was revealed that the resident was admitted to the facility on [DATE] after an acute hospitalization with [DIAGNOSES REDACTED]. On 3/14/12, record review of the MDS (Minimum Data Set) for Resident #3 with ARD (Assessment Reference Date) of 1/19/12 revealed the assessment triggered for 14. Dehydration/Fluid Maintenance. The CAA (Care Area Assessment) proceeded to care plan for this problem. Record review of the care plan date with 1/26/12 initiated date revealed a focus area of: Resident exhibits or is at risk for dehydration as evidenced by fever, vomiting, diarrhea, dysphagia. The following interventions were documented in the care plan: Dietitian to evaluate estimated fluid needs... Monitor I & O (Intake & Output) per protocol and report as indicated Monitor lab work as ordered and report as indicated Monitor weight per protocol and report as indicated... Review of the nurse notes revealed that on 1/17/12 the resident had 4 episodes of vomiting with 2 watery stools. The physician was notified and the facility administered 1000 cc of IV fluid over a 10 hour period as ordered. Review of a physician note dated 1/18/12 revealed a plan to check labs, complete a Flat and upright abdominal xray and GI consult. Nurse Notes 1/19/12, 1/20/12, 1/21/12, 1/22/12 & 1/23/12 documented "Po intake encouraged" and on 1/25/12, 1/27/12, 1/30/12 the notes documented, "Encouraged fluids". Physician note dated 1/22/12 revealed that the resident denied any complaints or issues. In the physician notes also documented as assessment was listed: Dehydration with acute [MEDICAL CONDITION] improved. Under Plan, the note listed for CBC/Comp panel weekly, Renal consult for [MEDICAL CONDITION]/diabetic [MEDICAL CONDITION]. Physician visits on 1/25/12, 1/27/12, 1/29/12 document under assessment: "Dehydration with Acute [MEDICAL CONDITION] improved" On 1/31/12, nurse notes revealed the resident had poor po intake and began having loose stools. Physician visit on 2/1/12 at 7:31 a.m. revealed that the resident was seen for loose bowel movements during the night and some nausea. An interview was conducted on 3/15/12 at approximately 10:00 a.m. with Staff C (Medical Director), Staff D (Director of Nursing) and Staff E (RN Unit Manager) to review the intake records for Resident #3 for the period from 1/23/12 through the 2/1/12. During the interview, Staff C stated that Staff C preferred to monitor the hydration status of Resident #3 by assessing weekly lab values as Staff C had ordered. Review of physician's orders [REDACTED]. Record review on 3/15/12 of a Laboratory document for Resident #3 revealed the following laboratory values with 1/23/12 collection date: Test: Units: Reference Range: Hematocrit 27.4 % 40.1-51.0 BUN 9 mg/dl 7-18 Creatinine 1.37 mg/dl 0.60-1.30 Sodium 138 mmol/L Potassium 3.8 mmol/L During interview on 3/15/12 at approximately 10:15 a.m. with Staff D and Staff E, it was revealed that the facility failed to follow the physician order [REDACTED].#3. On 3/15/12 review of the hospital record (name omitted) History and Physical dated 2/1/12 revealed: "History of Present Illness: The patient is a ...with a past medical history pertinent for but is not limited to a history of [MEDICAL CONDITION] and diabetes mellitus and history of recent hospitalization at (Name omitted) Hospital for hypovolemia and dysphagia and was diagnosed with [REDACTED]. The patient was transferred from the nursing home at (facility name omitted) Ridgewood because of nausea, vomiting, diarrhea and abdominal pain and because of low blood pressure per the records... On arrival to the emergency room , the patient was found with a low blood pressure of 63/33. The patient was started on IV fluid resuscitation and was started also on [MEDICATION NAME] as pressors... Accessory data: ... hematocrit 31.6... sodium 138, potassium 4.3...BUN 32, creatinine 7.8... Assessment/Plan: 1. [MEDICAL CONDITION]/shock: Unclear etiology, mostly secondary to hypovolemia from decreased oral intake and fluid loss from nausea, vomiting and diarrhea;..." Resident #18. During review of Resident #18's medical record on 3/15/12, a physician phone order dated 8/4/11 stated "Air mattress-set to the alternating mode with 2 lights at 10 - lift side of the mattress top sheet, Place your hand vertically below air cells and check pressure bid". On 3/15/12 the air mattress settings for Resident #18 were checked. Observation revealed the indicating lights were both on (5) showing a cycle time of 20 minutes and a pressure range of 50. At this time Staff G (RN) was asked to observe Resident #18's air mattress controls panel. Staff G confirmed the settings were not as written on the physicians orders. Resident #25. Review of Potter-Perry's, Fundamentals of Nursing, 7th Edition , Copyright 2009, Mosby/Elsevier, Westline Dr., St Louis, MO, , Unit IV Professional Standards in Nursing Practice, Chapter 23, Legal Implications in Nursing Practice, page 337, Key Concepts states: "Nurses follow physicians or health care providers orders unless they believe the orders are in error or are harmful to clients." Observation, 3/14/12 at approximately 8:45 a.m. of a medication pass on the "High Side" of the first floor nursing unit conducted with Staff F, (LPN), Staff Nurse revealed Staff F obtained two (2) Acidophilus [MEDICATION NAME] from the medication room refrigerator while preparing medications for administration to Resident #25, added them to the other medications in the medication cup and administered the medications to Resident #25 at approximately 8:47 a.m. We then returned to the medication cart. Review of the MAR indicated [REDACTED]. On interview, 3/14/12 at approximately 8:49 a.m., Staff F confirmed that she had withdrawn two Acidophilus capsules from the medication refrigerator and administered them, to Resident #25 at approximately 8:47 a.m., with the other a.m medications due to be given.

Based on interview and record review, the facility failed to ensure the resident received sufficient fluids to prevent dehydration for 1 resident in a survey sample of 24. (Resident identifier is #3). Findings include: Resident #3: On 3/13/12, during a review of the medical record for Resident #3 it was revealed that the resident was admitted to the facility on [DATE] after an acute hospitalization with [DIAGNOSES REDACTED]. On 3/14/12, record review of the MDS (Minimum Data Set) for Resident #3 with ARD (Assessment Reference Date) of 1/19/12 revealed the assessment triggered for 14. Dehydration/Fluid Maintenance. The CAA (Care Area Assessment) proceeded to care plan for this problem. Record review of the care plan date with 1/26/12 initiated date revealed a focus area of: Resident exhibits or is at risk for dehydration as evidenced by fever, vomiting, diarrhea, dysphagia. The following interventions were documented in the care plan: ? Dietitian to evaluate estimated fluid needs... ? Monitor I & O (Intake & Output) per protocol and report as indicated ? Monitor lab work as ordered and report as indicated ? Monitor weight per protocol and report as indicated... On 3/14/12, review of the Nutrition Assessment for Resident #3 with effective date 1/18/12 revealed under section A. General Data a resident weight of 441.9 lbs. Under section E. (Intake), the document is coded a "yes" for 2 (Resident's Intake is suboptimal). Further review of the Nutrition Assessment under section K/ 9 (Fluid needs), the document shows 4214 cc. During interview with Staff B, (Registered Dietitian) on 3/14/12, Staff B confirmed the calculation for daily fluid needs for Resident #3 as 4214 cc. Record review on 3/14/12 of the intake monitoring report for Resident #3 revealed the following daily total fluid intakes for this resident from 1/23/12 through 2/1/12: 1/23/12 980 cc 1/28/12 480 cc 1/24/12 960 cc 1/29/12 600 cc 1/25/12 980 cc 1/30/12 800 cc 1/26/12 720 cc 1/31/12 720 cc 1/27/12 720 cc 2/1/12 120 cc prior to discharge The recorded daily intakes that were provided to the surveyor by Staff D (Director of Nursing) were well below the calculated daily fluid needs of 4214 cc as determined by Staff B. Review of the nurse notes revealed that on 1/17/12 the resident had 4 episodes of vomiting with 2 watery stools. The physician was notified and the facility administered 1000 cc of IV fluid over a 10 hour period as ordered. Review of a physician note dated 1/18/12 revealed a plan to check labs, complete a Flat and upright abdominal xray and GI consult. Nurse Notes 1/19/12, 1/20/12, 1/21/12, 1/22/12 & 1/23/12 documented "Po intake encouraged" and on 1/25/12, 1/27/12, 1/30/12 the notes documented, "Encouraged fluids". Physician note dated 1/22/12 revealed that the resident denied any complaints or issues. In the physician notes also documented as assessment was listed: Dehydration with acute [MEDICAL CONDITION] improved. Under Plan, the note listed for CBC/Comp panel weekly, Renal consult for [MEDICAL CONDITION]/diabetic [MEDICAL CONDITION]. Physician visits on 1/25/12, 1/27/12, 1/29/12 document under assessment: "Dehydration with Acute [MEDICAL CONDITION] improved" On 1/31/12, nurse notes revealed the resident had poor po intake and began having loose stools. Physician visit on 2/1/12 at 7:31 a.m. revealed that the resident was seen for loose bowel movements during the night and some nausea. An interview was conducted on 3/15/12 at approximately 10:00 a.m. with Staff C (Medical Director), Staff D (Director of Nursing) and Staff E (RN Unit Manager) to review the intake records for Resident #3 for the period from 1/23/12 through the 2/1/12. During the interview, Staff C stated that Staff C preferred to monitor the hydration status of Resident #3 by assessing weekly lab values as Staff C had ordered. Review of physician's orders [REDACTED]. Record review on 3/15/12 of a Laboratory document for Resident #3 reveals the following laboratory values with 1/23/12 collection date: Test: Units: Reference Range: Hematocrit 27.4 % 40.1-51.0 BUN 9 mg/dl 7-18 Creatinine 1.37 mg/dl 0.60-1.30 Sodium 138 mmol/L Potassium 3.8 mmol/L During interview on 3/15/12 at approximately 10:15 a.m. with Staff D and Staff E, it was revealed that the facility failed to follow the physician order [REDACTED].#3. On 3/15/12 review of the hospital record (name omitted) History and Physical dated 2/1/12 revealed: "History of Present Illness: The patient is a ...with a past medical history pertinent for but is not limited to a history of [MEDICAL CONDITION] and diabetes mellitus and history of recent hospitalization at (Name omitted) Hospital for hypovolemia and dysphagia and was diagnosed with [REDACTED]. The patient was transferred from the nursing home at (facility name omitted) Ridgewood because of nausea, vomiting, diarrhea and abdominal pain and because of low blood pressure per the records... On arrival to the emergency room , the patient was found with a low blood pressure of 63/33. The patient was started on IV fluid resuscitation and was started also on [MEDICATION NAME] as pressors... Accessory data: ... hematocrit 31.6... sodium 138, potassium 4.3...BUN 32, creatinine 7.8... Assessment/Plan: 1. [MEDICAL CONDITION]/shock: Unclear etiology, mostly secondary to hypovolemia from decreased oral intake and fluid loss from nausea, vomiting and diarrhea;..."