Every finding on record at River Terrace Rehabilitation and Healthcare CTR

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 02/25/25, Nurse #1 administered another resident's blood pressure medication to him/her in error. Resident #1 later experienced a change in condition, was lethargic, and his/her blood pressure was low, for which he/she required treatment and increased monitoring by nursing until his/her blood pressure stabilized. Findings include: The Facility Policy, titled Adverse Consequences and Medication Errors, dated as revised 02/2023, indicated medication errors were defined as the preparation or administration of drugs or biologicals which was not in accordance with physician's orders, and included administration of the wrong medication, and administration to the wrong resident. The Policy also indicated that a significant medication error was defined as one in which the resident required treatment with a prescription medication. The Facility Policy, titled Administering Medications, dated as revised 04/2019, indicated: -The nurse administering the medications would verify the resident's identity before giving the medication to him/her, and methods of identifying the resident included checking his/her identification wrist band, checking the photograph attached to his/her medical record, and if necessary, verifying the resident identification with other Facility personnel. -The nurse administering medications would check the medication label three times to verify the right resident, right medication, right dosage, and right route of administration before giving the medication. According to MayoClinic.org, low blood pressure is a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number or 60 mm Hg for the bottom number, and extreme low blood pressure can lead to a condition called shock, which can be life threatening. Review of the Facility's Incident Report Form, dated 03/03/25, indicated that on 02/25/25, at 03:00 P.M., nursing staff noticed that Resident #1 was lethargic, had difficulty standing while transferring, and his/her blood pressure was 84/46 mm Hg (hypotensive). The Incident Report indicated Resident #1's spouse was present, and said he/she thought Resident #1 might have been given his/her roommate's (Resident #2's) medication, in error. The Incident Report indicated that it was determined that Nurse #1 had administered Resident #2's scheduled 1:00 P.M., Hydralazine (lowers blood pressure) 30 milligrams (mg) to Resident #1, in error. On 02/25/25, Resident #1 and Resident #2 were roommates. Resident #1 was admitted to the Facility in February 2025, diagnoses included Left femur fracture, dementia, acute diastolic heart failure (left heart ventricle is stiff and does not relax properly between heartbeats. Diastolic heart failure can lead to decreased blood flow) and Atrial fibrillation (irregular heart rhythm). Review of Resident #1's Medication Administration Record (MAR), dated 02/25/25, indicated he/she did not have a physician's order for Hydralazine. Resident #2 was admitted to the Facility in January 2025, diagnoses included hypertension. Review of Resident #2's MAR, dated 02/25/25 indicated he/she had an order for Hydralazine Hydrochloride, 10 milligrams (mg) tablet, administer three tablets (30 mg) by mouth, four times daily. Review of Resident #1's Blood Pressure Summary Report, dated 12/12/25 through 12/24/25 indicated that during this time period, his/her lowest measured blood pressure was 104/51 mm Hg. Review of Resident #1's Nurse Progress Note, dated 02/25/25, timed 05:28 P.M., indicated he/she received Hydralazine 30 mg (in error), his/her Blood Pressure was low, the physician was notified, nursing placed him/her in the Trendelenburg (feet elevated) position, intravenous (IV, anything that is administered into vein) fluids were initiated, and nursing initiated increased monitoring of his/her Blood Pressure. During a telephone interview on 05/05/25 at 10:28 A.M., Nurse #1 said he did not work on the East Wing very often, and was not familiar with the unit Resident #1 and Resident #2 lived on. Nurse #1 said that on 02/25/25 at 01:30 P.M., he prepared Resident #2's scheduled Hydralazine dose, and was about to administer it, when a staff member interrupted him because another resident (Resident #3) needed assistance. Nurse #1 said he placed the medication cup with Resident #2's Hydralazine in the top drawer of the medication cart, locked it, and went to attended to Resident #3. Nurse #1 said when he returned to the medication cart at 02:00 P.M., he took the Hydralazine out from the medication cart drawer, and looked at the computer screen to see which resident the Hydralazine was intended for. Nurse #1 said he must have clicked (signed off in the electronic MAR) that he had completed Resident #2's medication pass, and therefore Resident #1's profile was on the screen. Nurse #1 said he did not review the medications against the MAR at that time, and went into the room, saw Resident #1 and administered the Hydralazine (that was ordered for Resident #2) to him/her, in error. During an interview on 05/05/25 at 11:40 A.M., Certified Nurse Aide (CNA) #1 said she was familiar with Resident #1, that he/she usually transferred easily with one staff assist, however on 02/25/25 at 03:00 P.M., he/she was drowsy and had a hard time standing, so she was not able to transfer him/her alone. CNA #1 said Resident #1's spouse was visiting and asked her if Resident #1 had been started on a new blood pressure medication, and told her that Nurse #1 had given Resident #1 something for his/her blood pressure earlier that afternoon. CNA #1 said she immediately notified Unit Manager #1 that something was wrong. During an interview on 05/05/25 at 08:10 A.M., Unit Manager #1 said that on 02/25/25 at 03:00 P.M., CNA #1 notified him that Resident #1 was not feeling well. Unit Manager #1 said he went to assess Resident #1, and his/her spouse said that earlier, Nurse #1 had given him/her three small white pills that he/she had not gotten before, and suspected they were someone else's medication. Unit Manager #1 said Resident #1 was lethargic, weak, and his/her blood pressure was low. Unit Manager #1 said he cross checked Resident #1's and Resident #2's MARs and saw that Resident #2 was scheduled to receive Hydralazine, three 10 mg tablets, and that they were small white tablets. Unit Manager #1 said he asked Nurse #1 if he had accidentally administered Resident #2's Hydralazine to Resident #1, and said Nurse #1 then realized that he had made a medication error. During an interview on 05/05/25 at 10:52 A.M., the Director of Nurses (DON) said that on 02/25/25 at 03:00 P.M., Unit Manager #1 told her that Nurse #1 had administered Resident #2's Hydralazine to Resident #1 in error. The DON said she notified the physician of the medication error, and obtained physician's orders for Resident #1 to receive Normal Saline, 1 Liter via IV at 100 mL/hour, and increased monitoring of his/her blood pressure. Review of Resident #1's MAR indicated nursing monitored his/her blood pressure as ordered, and by 04:00 P.M., his/her blood pressure measured 130/68 mm Hg and had stabilized. Review of Resident #1's Nurse Progress Note, dated 02/25/25, timed 11:55 P.M., indicated he/she had self-removed his/her IV line after infusion of 600 mL of Normal Saline, his/her physician was notified, and no further orders were obtained. The Progress Note indicated Resident #1's Blood Pressure was stable at that time and measured 102/59 mm Hg. The DON said Nurse #1 should have compared the medications he prepared against the MAR and correctly identified the resident that the medications were prescribed for before he administered the medication, but had not. On 05/05/25, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 02/25/25, Resident #1's physician was notified of the medication error, new orders were obtained, and he/she recovered from the hypotension caused by the accidental overdose of Hydralazine B) 02/25/25, The Ad-Hoc Quality Assurance Performance Improvement Action Plan indicated the Facility Leadership developed a plan to correct the deficient practice and ensure that residents were free from significant medication errors. C) 02/26/25, The DON/designee conducted an initial audit to determine if residents were being properly identified by nursing prior to medication administration. Audits will continue weekly until 04/04/25, then bi-weekly. D) 02/26/25, The DON/designee conducted an audit of resident photos and updated them as needed to most accurately reflect the residents' appearances. E) 02/27/25, The DON, ADON, and SDC educated all Facility staff that nurses should not be disturbed during medication preparation and administration, unless the interruption is critical. F) 02/27/25, The DON/designee provided signs to be posted on each medication cart that indicate not to disturb nurses during medication administration. G) 03/03/25, The DON, ADON, and SDC educated all Licensed staff on medication administration best practices, with focus on identification of residents prior to medication administration and avoiding common medication errors. H) The Facility will monitor compliance at monthly and quarterly Quality Assurance Meetings. I) The Director of Nurses and/or designee are responsible for ongoing compliance.

Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#12) out of a total sample of 18 residents. Specifically, the facility failed to code all of the Resident's psychiatric and mood disorder diagnoses on four separate MDS Assessments. Findings include: Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 (RAI) User's Manual (https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf) indicated the following: -document all active diagnoses on the MDS -psychiatric/mood disorder >anxiety disorder >schizophrenia (e.g., schizoaffective and schizophreniform disorders) -active diagnoses in the last 7 days >A medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring or is prescribed to decrease active symptoms of a condition Resident #12 was admitted to the facility in April 2022, with diagnoses including Schizoaffective Disorder, Bipolar Type (a serious mental illness that combines both schizophrenia [affects how the person thinks and behaves with symptoms including hallucinations, delusions, disorganized thinking and speech, etc.] and mood disorder [causes manic and depressive episodes]). Review of Resident #12's Psychiatric Nurse Practitioner Visit Note dated 4/1/24, indicated the following: -a diagnosis of Anxiety Disorder. -the recommendation to restart the Resident on Ativan (an antianxiety medication) due to increased symptoms of anxiety after discontinuation. Review of Resident #12's Physician Orders indicated: -an active order for Aripiprazole (an antipsychotic medication) 20 milligrams (mg) every evening, initiated on 2/29/24. -an inactive order for Ativan 0.5 mg daily, initiated on 4/2/24 and updated on 6/8/24. -an active order for Ativan 0.5 mg daily, initiated on 6/8/24. Review of Resident #12's Medication Administration Records indicated the following: -in March 2024 the Resident received Aripiprazole as ordered. -in June 2024 the Resident received Aripiprazole and Ativan as ordered. -in August 2024 the Resident received Ativan as ordered. -in November 2024 the Resident received Ativan as ordered. Review of Resident #12's MDS assessment dated [DATE] indicated: -Schizophrenia was not coded as an active diagnosis. -Antipsychotics were received on a routine basis. Review of Resident #12's MDS assessment dated [DATE] indicated: -Schizophrenia and Anxiety were not coded as active diagnoses. -Antipsychotics were received on a routine basis. -Antianxiety medication was in use. Review of Resident #12's MDS assessment dated [DATE] indicated: -Anxiety disorder was not coded as an active diagnosis. -Antianxiety medication was in use. Review of Resident #12's MDS assessment dated [DATE] indicated: -Anxiety disorder was not coded as an active diagnosis. -Antianxiety medication was in use. During an interview on 12/26/24 at 11:20 A.M., the MDS Nurse said the facility followed the RAI manual and did not have a formal policy for MDS completion. The MDS Nurse further said the following: -the 3/9/24 MDS Assessment should have been coded with Schizophrenia as an active diagnosis, but it was not. -the 6/6/24 MDS Assessment should have been coded with Schizophrenia and Anxiety Disorder as active diagnoses, but it was not. -the 8/29/24 and 11/27/24 MDS Assessments should have been coded with Anxiety Disorder as an active diagnosis, but they were not.

Based on observation, interview and record review, the facility staff failed to implement the plan of care for one Resident (#46) related to the use of a Prevalon boot (a boot worn to relieve pressure to the heel), out of a total sample of 18 residents. Findings include: Resident #46 was admitted to the facility in December 2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 4/13/22, indicated that Resident #46 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15. Review of the current physician orders, initiated on 4/27/22, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/22 at 9:15 A.M., the surveyor observed Resident #46 seated in his/her wheelchair with a dressing to the right foot and a non skid sock in place over the dressing. The Resident did not have a Prevalon boot applied to his/her foot. On 5/25/22 at 11:04 A.M., the surveyor observed Resident #46 seated in his/her wheelchair with a non-skid sock over a dressing to the right foot. During an interview, the Resident said that he/she doesn't wear any shoes or special boots but usually wears a slipper on his left foot and a sock on his right foot. Resident #46 said that he/she tried a shoe on the right foot a few weeks ago but it was too heavy for him/her to wear. During an interview on 5/26/22 at 10:49 A.M., unit manager #1 said that Resident #46 had refused the Prevalon boot. Upon review of the Treatment Administration Record with the surveyor, unit manager #1 said that there was no documentation that the Resident had refused the Prevalon boot, and that if the Prevalon boot was ordered it should be on the Resident.

Based on observation, record review and interview, the facility failed to ensure menus were followed. Findings include: Review of the facility's Menu Policy, revised (MONTH) of (YEAR), indicated the following: -Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. -A menu substitution log will be maintained on file. Review of the facility's Menu Substitution Log, undated, indicated the following required information: -menu cycle, day, meal, date, food item substituted, food item omitted -initials of qualified dietitian or qualified director of food and nutrition On 12/5/19 at 11:30 [NAME]M. the lunch meal service was observed. Review of the facility menu for the lunch indicated the following items were to be served: -braised pork tips, rice pilaf, and sautéed spinach with garlic, dinner roll/bread, margarine and cherry crisp. The alternate meal included the following: -chicken tenders, buttered noodles and green beans. The surveyor observed the following items in the steam table being served based on the residents' diet orders: -a gravy mixture including pork pieces, plain rice, spinach, green beans, breaded chicken strips, mashed potatoes, pureed meat, pureed vegetables, ground meat and dinner rolls. On 12/5/19 at 11:30 [NAME]M., during an interview with Diet Aide #1, when asked what he would serve if someone wanted pork without gravy, he said chicken strips; I just do what my boss tells me. On 12/05/19 at 1:45 P.M., during an interview with the Food Service Director, the FSD said the foods on the menu as posted should have been served, but were not. She said if the cook made changes to the menu and served something different, he should have documented why changes were made and what was substituted. She said there was no documentation for menu substitutions at lunch and she was not notified of any menus changes. She also said the pork should have been separated from the gravy, before it was served and was unsure why the cook made it that way.

Based on observation, interview and record review, the facility failed to ensure food was palatable and at safe and appetizing temperature in 3 out of 4 dining locations. Findings include: Review of the facility policy for Food Quality and Palatability, dated (MONTH) (YEAR), indicated that food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Review of the facility policy for Meal Distribution, dated (MONTH) (YEAR), indicated meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. On 12/5/19 at 10:30 [NAME]M., during the Resident Council meeting, 6 out of 8 residents stated the food was cold at all meals. One resident said the cart sits in the Fine Dining Room for 20 minutes before it is served while the residents sit and wait. Review of the facility's Service Line Checklist (daily food temperatures taken prior to meal service), dated 12/6/19, indicated that hot foods were to be greater or equal to 135 degrees Fahrenheit (F) and cold foods were to be less than or equal to 41 degrees F. On 12/06/19 at 7:25 [NAME]M., during an observation of the kitchen, the toast was observed to be premade and resting in an uncovered metal container on top of the steam table. The super cereal and oatmeal was pre-poured and stacked. At 7:40 [NAME]M., the Special Care Unit breakfast truck left the kitchen. The surveyor received the test tray at 8:00 [NAME]M. after all breakfast trays were served. Test tray temperatures were taken with the Regional Health Information Specialist. The food temperatures were as follows: -Milk: 50 degrees F, tasted warm -Orange juice: 60 degrees F, tasted warm -Oatmeal: 138 degrees F, bland -Super cereal: 130 degrees F, bland -Pureed toast: 118 degrees F, very bland with a paste like taste and consistency -Scrambled egg: 116 degrees F, bland On 12/06/19 at 7:57 [NAME]M., during an observation, the breakfast truck arrived on the East unit. The last tray was served at 8:08 [NAME]M. Test tray temperatures were taken with Unit Manager (UM) #1. The food temperatures were as follows: -Puree bread: 98 degrees F, very salty, cool to taste. UM #1 tasted it and said she couldn't identify what it was. -Puree egg: 90 degrees F, cool to taste and very bland -Scrambled egg: 92 degrees F, cool to taste -Peach coffee cake: 88 degrees F -Oatmeal: 120 degrees F -Milk: 48 degrees F -Orange juice: 52 degrees F Following the test tray, UM #1 said she didn't know what the food temperatures were supposed to be. On 12/06/19 at 8:20 [NAME]M., during an observation, the Assistant Director of Nurses (ADON) took a resident's tray from the East Unit meal truck and brought it to the Fine Dining Room where the resident was seated. The surveyor requested a meal replacement for the resident and took the temperature of the breakfast meal tray that started on the East unit and traveled to the Fine Dining Room. Test temperatures were taken with the ADON. The food temperatures were as follows: -Scrambled egg: 92 degrees F, cool to taste, bland -Peach coffee cake: 80 degrees F, with custard consistency -Oatmeal: 116 degrees F -Milk: 52 degrees F, tasted warm -Orange juice: 58 degrees F, tasted warm On 12/06/19 at 7:45 [NAME]M., during an observation of the Fine Dining Room, the breakfast truck arrived at 8:06 [NAME]M. and the last tray was passed at 8:18 [NAME]M. Test tray temperatures were taken with Nurse #1. The food temperatures were as follows: -Scrambled eggs: 90 degrees, tasted cool and bland -Peach coffee cake: dry consistency -Pureed toast: salty tasted like raw dough -Oatmeal: 140 degrees F, tasted warm and bland -Super cereal: 130 degrees F, bland -Orange juice: 50 degrees F On 12/06/19 at 9:00 [NAME]M., during an interview with Food Service Director and the Regional Manager, they stated that how the food was prepared may have caused it to taste bland.

Based on document review and interview, the facility failed to ensure proper sanitation and food handling practices were maintained to prevent the outbreak of foodborne illnesses. Findings include: Review of the facility's Service Line Checklist, undated, indicated the following: -Item names and temperatures for all hot food and cold foods should be taken prior to service and recorded in the boxes below. -Temperatures: Hot foods greater than/equal to 135 degrees Fahrenheit (F), cold foods less than/equal to 41 degrees F. Review of the 12/03/19 temperature log for the lunch meal indicated the following items had no documented temperatures: -milk, hot beverages, cold beverages and juice The same log indicated the soup and pureed soup temperatures were documented as 105 degrees F and 108 degrees F, respectively, for the lunch meal. Review of the 12/05/19 temperature log for the lunch meal indicated the following items had no documented temperatures: -milk, hot beverages, cold beverages and juice The same log indicated the following items had no documented temperatures: -hot beverages, cold beverages and juice for the breakfast meal On 12/05/19 at 1:45 P.M., during an interview the Food Service Director (FSD), she said the cook should have recorded all food and beverage temperatures before the meal service, as required, but they were not all recorded. She also said that if a food item is above or below the required temperatures then corrective action should have occurred. She said she was not sure if the cook corrected the soup temperatures on 12/3/19, but the cook should have and the cook should have documented the corrected temperatures.

Based on observation, record review and interview, the facility failed to implement the plan of care for one resident (#26) in a total sample of 19 residents. Findings included: Resident #26 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. -Geri-sleeves to bilateral upper extremities (BUE), remove for care and assessment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/2/19, indicated Resident #26 had moderate cognitive impairment as evidenced by a score of 11 out of 15 on the Brief Interview for Mood Status (BIMS) and had intact skin. Review of the Weekly Skin Check, dated 11/28/19, indicated Resident #26 had bruises to his/her BUE, was on [MEDICATION NAME] (steroid) and had a [DIAGNOSES REDACTED]. On 12/4/19 at 8:32 [NAME]M., during an interview, Resident #26 was seated in a wheelchair in the dining room. He/she was wearing a long sleeve shirt, pants and did not have on Geri-sleeves. He/she said his/her arms and hands are bruised and sometimes had bumps them. On 12/4/19 at 3:31 P.M., Resident #26 was observed sitting in the wheelchair, wearing a long shirt and did not have on Geri-sleeves. Review of the Weekly Skin Check, dated 12/5/19, indicated Resident #26 had large bruising to the right lateral side, under right arm and right upper arm. On 12/5/19 at 8:41 [NAME]M., Resident #26 was observed in the dining room and did not have on Geri-sleeves. On 12/05/19 at 1:40 P.M., during an interview and observation, Nurse #1 and the surveyor observed Resident #26 in his/her room and they were not wearing Geri-sleeves. Nurse #1 said that sometimes the Geri-sleeves are put on, but not all the time. She stated that Resident #26's arms bruise easily. Nurse #1 said the Certified Nurse's Aide (CNA) should have put them on the resident every day. She said there was no documentation of whether or not the Geri-sleeves were applied to the resident's BUE daily, as ordered. She said they should have been applied as ordered.

Based on observation, interview and record review, the facility failed to ensure that respiratory care and services related to use of a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) were provided for one resident (#17) out of a total sample of 19 residents. Findings include: Review of the facility policy for [MEDICAL CONDITION] and Bi-level Positive Air Pressure ([MEDICAL CONDITION]) Support, dated (MONTH) (YEAR), indicated the following: Purpose: .To improve arterial oxygenation in residents with .obstructive sleep apnea (sleep disorder in which breathing repeatedly starts and stops). Preparation: .Review the physician's order to determine the oxygen concentration and flow, and the positive end-expiratory pressure (PEEP) for the machine. General Guidelines for Cleaning: Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week as needed. Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace disposable filters monthly. Masks, nasal pillows and tubing: Clean daily. Rinse with warm water and allow it to air dry between uses. Documentation: .Time [MEDICAL CONDITION] was started and duration of therapy. Mode and settings for the [MEDICAL CONDITION] . For Resident #17 the facility failed to ensure respiratory care and services related to their [MEDICAL CONDITION] machine were provided. Resident #17 was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set assessment, dated 9/20/19, indicated Resident #17 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the (MONTH) 2019 Physician's orders indicated to apply resident's personal [MEDICAL CONDITION] at bedtime and remove per schedule. There were no orders for the care of the [MEDICAL CONDITION] machine, tubing, mask, or filter. Review of the (MONTH) 2019 Treatment Administration Record (TAR) indicated the [MEDICAL CONDITION] was administered daily from 9/18/19 through 9/30/19. Review of the (MONTH) 2019 TAR indicated the [MEDICAL CONDITION] was administered daily. Review of the (MONTH) 2019 TAR indicated the [MEDICAL CONDITION] was administered daily. Review of the (MONTH) 2019 TAR indicated the [MEDICAL CONDITION] was administered from 12/1/19 through 12/6/19. On 12/04/19 at 8:42 [NAME]M., during an observation and interview, Resident #17 was observed in bed and a [MEDICAL CONDITION] mask was observed in his/her bedside drawer, which was opened. The mask was leaning close to the urinal which was also in the drawer. Resident #17 said the staff had cleaned the mask in the past, but not regularly. The resident went on to say that he/she used the [MEDICAL CONDITION] nightly and sometimes runs a towel through it to keep it clean. On 12/05/19 at 10:44 [NAME]M., Resident #17 was observed in bed watching TV with [MEDICAL CONDITION] tubing and mask in the bed side drawer. On 12/05/19 at 10:59 [NAME]M., during an interview with Unit Manager (UM) #1, UM #1 stated that they should be cleaning the [MEDICAL CONDITION] mask daily and the tubing weekly. She reviewed the orders and the current TAR and said that there were was no orders for the care of the [MEDICAL CONDITION], as required.

Based on interview and record review, the facility failed to ensure that an as needed (PRN) order for an anti-psychotic medication was limited to 14 days for one resident (#32) and failed to ensure PRN orders for [MEDICAL CONDITION] medication included the duration of use for two residents (#27 and #48). Findings include: Review of the facility policy for Anti-psychotic Medication Use, dated (MONTH) (YEAR), indicated the following: -Residents will not receive PRN doses of [MEDICAL CONDITION] medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. -The need to continue PRN orders for [MEDICAL CONDITION] medications beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. -PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. 1. For Resident #32 the facility failed to evaluate a PRN anti-psychotic order after 14 days. Resident #32 was admitted to the facility in (MONTH) 2019. Review of the Physician's order summary report indicated an order for [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the Physician's order summary report indicated an order to discontinue the PRN [MEDICATION NAME] 50 mg on 11/15/19. Further review indicated a new order for [MEDICATION NAME] 50 mg one tablet every 8 hours as needed for anxiety/agitation was initiated on 11/15/19 and did not include a stop date. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. On 12/05/19 at 10:55 [NAME]M., during an interview with the Director of Nurses (DON), the DON stated they did not have a stop date for the PRN [MEDICATION NAME] order prior to that day, as required. 2. For Resident #27, the facility failed to ensure an as needed (PRN) order for [MEDICAL CONDITION] included an end date. Resident #27 was admitted to the facility in (MONTH) of 2019. Review of the physician's orders indicated there was no end date for a PRN order, dated 10/14/19, for [MEDICATION NAME] ([MEDICAL CONDITION] medication, used to treat anxiety) 0.5 mg every 12 hours as needed. Review of an undated pharmacy recommendation, indicated an end date should have been added to the [MEDICATION NAME] order. On 12/6/19 at 12:13 P.M., during an interview with the Director of Nursing (DON), the DON stated the PRN [MEDICATION NAME] order did not have an end date as it should. She also stated that there was no date or signature on the pharmacy recommendation. 3. Resident #48 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set Assessment, dated 10/23/19, indicated Resident #48 had moderately impaired cognition as evidenced by a score of 8 out of 15 on the Brief Interview of Mental Status (BIMS), had no signs of depression and had physical and verbal behavioral symptoms directed towards others. Review of the Physician's order, dated 10/25/19, indicated to give Trazadone (an anti-depressant) 25 mg, every 12 hours, as needed for agitation. There was no duration of use ordered. Review of the Consultant pharmacist's Medication Review, dated (MONTH) 2019, indicated a recommendation to obtain a stop order for the as needed Trazadone. Review of the Medication Administration Record [REDACTED]. Review of the MAR, dated (MONTH) 2019, indicated Resident #48 received the Trazadone 25 mg, 24 times. Review of the MAR, dated (MONTH) 2019, indicated Resident #48 received the Trazadone 25 mg, 6 times, from 12/1/19 through 12/6/19. On 12/6/19 at 11:04 [NAME]M., during an interview with Regional Nurse #1, she said she thought if the physician documented the rationale for continued use that was enough. She said that she did not know that duration had to be written in addition to the rationale. Please refer to F 842

Based on document review and interview, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the function of the facility's food and nutrition service department, when the dietitian employed was not full time. Findings include: On 12/5/19 at 11:30 [NAME]M., during an interview with the Food Service Director (FSD), she said she was not a certified dietary manager and had not yet completed the required course work to get her certification. She also said the Registered Dietitian was not a full time employee of the facility. Review of the documentation provided by the food service management company, undated, indicated the FSD's date of hire was 2/18/19. On 12/05/19 at 1:45 P.M., during an interview with the FSD, she said she understood she was required to be a certified dietary manager, but was not, as required.

Based on interview and record review, the facility failed to maintain complete and readily accessible medical records for 2 residents (#32 and #27) out of a total sample of 19 residents. Findings include: 1. For Resident #32 the facility failed to ensure monthly pharmacy consult reports were maintained and accessible in the medical record. Resident #32 was admitted to the facility in (MONTH) 2019. Review of the progress notes indicated the Pharmacist was in on 10/18/19 and 11/15/19 and to refer to the report. On 12/5/19 at 9:25 [NAME]M., during an interview with Unit Manager (UM) #1, she stated that sometimes the reports get emailed to them; she stated she could not determine if there were recommendations made and would attempt to locate the original reports. On 12/05/19 at 10:55 [NAME]M., during an interview the Director of Nurses (DON), she provided the surveyor with one undated pharmacist report and said she couldn't find the other recommendation. She stated she kept the pharmacy recommendations in a binder in her office. 2. For Resident #27, the facility failed to maintain monthly pharmacy recommendations. Resident #27 was admitted to the facility in (MONTH) of 2019. Review of a pharmacy note, dated 11/15/19, indicated that the pharmacist reviewed MEDICATION ORDERS FOR [REDACTED]. Further review of the clinical record indicated there was no pharmacy report for (MONTH) of 2019. On 12/6/19 at 12:13 P.M., during an interview with the Director of Nursing (DON), she stated there was no pharmacy report for (MONTH) of 2019. She stated that the pharmacy documentation process had changed, and the pharmacy reports were currently emailed to her. She further stated that she printed the reports and kept them in a binder in her office.

Based on observation and interview, the Facility staff failed to preserve the dignity of 3 residents (#12,41,73) out of a total sample of 18 residents and failed to ensure one resident was assisted to eat when his/her tablemates were eating. Findings include: 1. During an interview on 10/17/18 at 11:25 AM., Resident #12 told Surveyor #1 that when he/she asks the staff to be taken to the bathroom, he/she is told to (urinate) in an adult diaper. 2. During an interview on 10/17/18 at 9:35 A.M., Resident #73 told Surveyor #1 that he/she is made to wear a diaper even though he/she is continent of urine. He/she said that when she asks staff members to take him/her to the bathroom, he/she is told to (urinate) in the diaper because they don't have time. During a telephone interview with Surveyor #2 on 10/18/18 at 9:40 A.M., Resident #73's daughter said that approximately 2 weeks ago she arrived at the Facility to find her parent seated in a wheel chair in his/her room, clothed only in a zip up jacket and a diaper. She said that she has spoken to multiple staff members about the use of a diaper, and that the staff continue to place a diaper on Resident #73 even though he/she is continent. During an interview on 10/19/18 at 12:07 P.M., the Executive Director agreed that the above was unacceptable. 3. Review of the careplan for Resident #41 indicates that he/she requires total assistance from staff for eating. On 10/17/18 at 11:58 AM Surveyor #1 observed Resident #41 eating his/her lunch in the Dining Room. Resident #41 was seated in a wheelchair at a table, and had been served a plate of noodles and a sandwich. Spilled food items were noted on his/her clothing. There was an unopened carton of milk next to the plate. Resident #41 was holding a spoon and made multiple attempts to scoop noodles from his/her plate, and was not able to. Resident #41 then picked up a sandwich and dropped it on the floor. Resident #41 then picked up a bowl of pudding and attempted to drink it. Resident #41 was seated at a table with 2 other residents who were watching him/her spill items and rolling their eyes. Resident #41 was not assisted by staff members to eat . On 10/18/18 at 12:19 PM, Surveyor #1 observed Resident #41 during the noon meal. Resident #41 was seated at a table in the Dining Room. Resident #41 had been served a plate with a sausage grinder, potatoes and vegetable. Resident #41 was attempting to scoop items from the plate with a spoon, and was not able to get the food from the plate into his/her mouth. Resident #41 picked the sausage up with his/her hands, took a bite and put it back on the plate. Resident #41 was observed to pick up his/her paper diet ticket and take a bite out of it, then remove it from his/her mouth. At 12:47 PM a staff member approached Resident #41 and cut up the sausage, placed a fork in his/her hand and guided his/her hand to the plate, then left. Resident #41 then made multiple attempts to eat a bowl of pudding with a fork. He/she was unable to get any pudding to his/her mouth. Throughout the meal Resident #41 was observed by his/her tablemates, who made faces at Resident #41. On 10/19/18 at 8:49 AM, Surveyor #1 observed Resident #41 in his/her room. Resident #41 was seated in a wheelchair next to the bed. There were eggs and crumbs of food on his/her shirt and pants. There was most of a donut in his/her lap, and eggs and crumbs on the floor. During an interview on 10/19/18 at 9:AM the DON said that Resident #41 was supposed to eat in the Dining Room with staff assistance. 4. During the breakfast meal observation on 10/18/18, Surveyor #3 noted the following; -The breakfast cart was delivered at 8:10 A.M., to the large Dining room -At 8:42 A.M. 3 of 4 residents seated at the 2nd table had eaten 100% of their meals -The 4th resident had an untouched meal in front of him/her -A staff member then began to assist the 4th resident with eating the meal -At 8:55 A.M., a resident at the first table was noted to have consumed all of his/her fluids, and had not eaten any food. CNA #1 said that the resident sometimes needs verbal cueing and encouragement to eat, and then cued the resident to eat. The Resident took a bite of food, at which time CNA #1 walked away and the resident stopped eating

Based on medical record review and interview, the Facility failed to respect the right of 1 of 18 sampled residents (Resident #28) to formulate an advanced directive. Findings include: Resident #28 was admitted to the Facility in 4/2017 with [DIAGNOSES REDACTED]. Medical record review indicated that Resident #28's Health Care Proxy (HCP) was invoked on 4/7/17 (meaning that the HCP makes medical decisions). Review of a document titled Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) dated 4/4/17 indicated; - Do Not Resuscitate - Do Not Intubate - Do Not Use Non-invasive Ventilation - Transfer to Hospital - No [MEDICAL TREATMENT] - Use artificial nutrition, but short term only - Use artificial hydration, but short term only Review of the signature section on page 1 of the MOLST document indicated Verbal telephone in the area for the HCP's signature. Review of the signature section on page 2 of the MOLST document was not signed in the area for a Physician, Nurse Practitioner or Physician Assistant signature to validate the document. During an interview on 10/19/18 at 2:42 PM the DON confirmed that the Physician did not sign the MOLST.

Based on observation, record review, and interview, the Facility failed to protect 1 of 18 sampled residents, (Resident #41) from physical abuse. Findings include: Resident #41 was admitted to the Facility in 8/2018 with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. On 10/19/18 at 8:49 A.M., Surveyor #1 observed Resident #41 in his/her room, seated in a wheel chair. Resident #41 was holding his/her right arm with his/her left arm, and grimacing. Surveyor #1 noted several spots of a red substance on Resident #41's shirt sleeve, which appeared to be blood. Purple discoloration was noted on the middle finger of Resident #41's right hand. When Surveyor #1 asked Resident #41 what was wrong, he/she said that (the staff) are rough and tough around here, and that he/she had been ripped out of bed. A staff member stopped in the doorway, and looked in the room. Resident #41 said, There she is again. Resident #41 rolled up his/her right sleeve, revealing 2 purple discolored areas. The Surveyor requested a nearby staff member to contact the Director of Nursing, (DON). The DON came to Resident #41's room and initiated an investigation.

Based on observation, record review and interview, the Facility failed to preserve the right to be free from physical restraints for 1 of 18 sampled residents (Resident #40). Findings include: Review of the Facility policy for Use of Restraints (revised 12/07) indicates that The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Resident #40 was admitted to the Facility in 5/2018 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment, and restraints were not used. During a tour on 10/18/18 at 2:00 P.M., Surveyor #3 observed Resident #40 ambulating in the hall independently toward the staff at the nurses desk. Review of the medical record indicated that Resident #40 was found on the floor after a fall out of bed on 7/16/18. Resident #40 told the staff at the time that he/she could not support his/her weight and rise from the low bed when trying to get up and go to the bathroom. Further review indicated interventions which included neurological assessments, Physical Therapy/Occupational Therapy screens, toileting schedule, and a medication review. Surveyor #3 observed a low bed (a bed that may prevent a resident from rising) was in use for Resident #40. Further review of the medical record did not indicate that a restraint assessment had been completed or that an informed consent for use of a low bed had been obtained. During an interview on 10/19/18 at 10:18 A.M., Nurse #2 said that the low bed prevented Resident #40 from getting out of bed independently.

Based on observation, record review and interview, the Facility failed to implement the care plan for 2 of 18 sampled residents, (Resident #41, Resident #9). Findings include: 1. Resident #41 was admitted to the Facility in 8/2018 with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. Review of Resident #41's care plan indicates an intervention dated 8/23/18, I require total assistance to eat. On 10/17/18 at 11:58 A.M., Surveyor #1 observed Resident #41 eating his/her lunch in the Dining Room. Resident #41 was seated in a wheelchair at a table, and had been served a plate of noodles and a sandwich. Spilled food items were noted on his/her clothing. There was an unopened carton of milk next to the plate. Resident #41 was holding a spoon and made multiple attempts to scoop noodles from his/her plate, and was not able to. Resident #41 then picked up a sandwich and dropped it on the floor. Resident #41 then picked up a bowl of pudding and attempted to drink it. At 12:08 P.M. a staff member approached Resident #41 and asked if he/she wanted the container of milk opened. Surveyor #1 told the staff member that Resident #41 had dropped his/her sandwich. A new plate of food was brought to Resident #41 at 12:14 P.M., which he/she declined. Resident #41 was not assisted by staff members to eat . On 10/18/18 at 12:19 P.M., Surveyor #1 observed Resident #41 during the noon meal. Resident #41 was seated at a table in the Dining Room. Resident #41 had been served a plate with a sausage grinder, potatoes and vegetable. Resident #41 was attempting to scoop items from the plate with a spoon, and was not able to get the food from the plate into his/her mouth. Resident #41 picked the sausage up with his/her hands, took a bite and put it back on the plate. Resident #41 was observed to pick up his/her paper diet ticket and take a bite out of it, then remove it from his/her mouth. At 12:47 P.M., a staff member approached Resident #41 and cut up the sausage, placed a fork in his/her hand and guided his/her hand to the plate, then left. Resident #41 then made multiple attempts to eat a bowl of pudding with a fork. He/she was unable to get any pudding to his/her mouth. At 12:52 P.M., a staff member returned to Resident #41 and placed a spoon in his/her hand, and asked if he/she wanted assistance, which Resident #41 declined. On 10/19/18 at 8:49 A.M., Surveyor #1 observed Resident #41 in his/her room. Resident #41 was seated in a wheelchair next to the bed. There were eggs and crumbs of food on his/her shirt and pants. There was most of a donut in his/her lap, and eggs and crumbs on the floor. During an interview on 10/19/18 at 9:00 A.M. the DON said that she did not know why Resident #41 had eaten in his/her room, and that he/she was supposed to eat in the Dining Room with staff assistance. 2. Resident #9 was admitted to the Facility in 2/2018 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score was a 14 out of 15, resident is alert and oriented to person, place and thing, occasionally forgetful. Review of the medical record indicated that Resident #9 has a right lower leg wound. Review of a Health Status note dated 10/14/18 indicated right leg wound was previously bruising which turned into a wound, skin is peeled away, has a beefy wound base, and mild serosanguinous (yellow/red) drainage. The note indicates that the physician was notified and ordered a dry sterile dressing and to notify the primary care physician in the morning. Review of a Nurse Practitioner Note dated 10/16/18 indicated that the right lower leg wound had active bleeding with dressing changes, and Resident #9 is to continue on [MEDICATION NAME] (an antibiotic ointment) and change 4x4 dressing to a non adherent pad. Review of a Health Status note dated 10/16/18 indicated a right lower leg wound dressing is intact. Review of the Physician order [REDACTED]. Review of the care plan for Resident #9 does not indicate a right lower leg wound and dressing change order. During an interview on 10/19/18 at 9:49 A.M., the Unit Manager reviewed the active and discontinued electronic Physician orders [REDACTED].#2 and confirmed that the orders were not there and said she was uncertain what had happened. Further review with Unit Manager #1 of the Physician telephone orders in the paper medical record indicated an order dated 10/16/18 to wash site (right lower leg) with house wound wash, pat dry, apply [MEDICATION NAME] to 4X4 gauze, apply gauze to wound, wrap with Kerlix, once daily until wound is healed. The Physician telephone order was noted by a nurse and signed by the Physician. Surveyor #2 and Unit Manager #1 reviewed the Treatment record for Resident #9 and noted that the wound order was listed with a start date of 10/16/18 at 8:00 A.M., and an end date of 10/16/18 at 4:41 P.M. Unit Manager #1 told Surveyor #2 that the order was entered incorrectly. During a follow up interview on 10/19/18 at 11:00 A.M., Resident #9 said that the nursing staff change the wraps to the right lower leg just about every day. Surveyor #2 observed an ace wrap on both lower legs.

Based on observation, record review, and interview, the facility failed to provide care and services for end of life choices (Hospice care) as requested for 1 of 18 sampled residents (Resident #51), Findings include: Review of the Hospice Program policy (revised 7/2017) indicates residents not eligible for Medicare may elect to receive hospice services with contracted providers and pay for these services privately. Resident #51 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview for Mental Status (BIMS) score was a 13 out of 15, resident is alert and oriented to person, place and thing, occasionally forgetful. Record review indicated that Resident #51's HCP was invoked (meaning that the HCP makes medical decisions) on 9/4/18 due to declining medical condition. Review of a Physician order [REDACTED]. Review of a Nurse Practitioner note dated 9/18/18 indicates that a Hospice consult is in place. Review of a Social Worker note dated 9/11/18 indicated that the Social Worker met with the Executive Director regarding obtaining a one time contract with the requested Hospice provider and that Resident #51's sibling would reach out to a VNA service for Hospice care. Review of a Nurse Practitioner note dated 10/9/18 indicates that a Hospice consult is in place. Review of a physician progress notes [REDACTED]. Further review of the medical record does not indicate that Hospice services were obtained for Resident #51. During an interview on 10/17/18 at 2:24 P.M., the Unit Manger said that Resident #51's insurance does not cover the Hospice provider contracted by the facility, so Resident #51 is comfort measures only, provided by facility staff. During an interview on 10/19/18 at 11:45 A.M., the Social Worker said Resident #51 and his/her HCP were okay with staff providing end of life care and that the insurance company contracts with one Hospice provider, and the facility does not contract with that Hospice. The Social Worker said that she was unsure what the Executive Director did regarding obtaining a one time contract with the Hospice provider. During an interview on 10/19/18 at 11:50 A.M., the Executive Director said that Resident #51's family was not sure they wanted to go with the facility contracted Hospice provider, and may pursue another provider. She also said that the family did not provide the facility with a definitive answer as to which Hospice provider they would like to use. The Executive Director said that the facility provides end of life care which includes pain management, social service support and psychiatric services if needed. Review of the medical record indicated that the Social Worker last visited with Resident #51 on 9/7/18. The medical record did not indicate that Resident #51 has received psychiatric services. During an interview on 10/19/18 at 11:55 A.M., Resident #51 said he/she would like to be on Hospice services and further said he/she would be returning to the lake house after lunch. Surveyor #2 interviewed Resident #51's HCP over the phone on 10/19/18 at 12:06 P.M., who said he thought Resident #51 was on Hospice services and that the facility informed him that the facility would provide palliative services. The HCP further said he would consent to Hospice services, as the Physician told the family upon discharge from the hospital, that Resident #51 was unable to return home and had a limited time to live.

Based on observation, interview, and record review the facility staff failed to ensure adequate infection control related to water system management, linen handling, and resident's personal/activity items. Findings include: 1. The facility staff failed to ensure adequate infection control related to the transport of residents' personal laundry. During inspection of the laundry on 10/17/18 at 10:00 A.M., the surveyor observed a covered linen cart used to transport clean personal laundry to the residents' rooms. Below the clean linen were several bins. According to the District Laundry Manager, these bins were used to transport items like socks, but were not used. The bins were very dusty, with food items and wrappers observed in the bins. There was no clothing in the bins, but they were just below the clean personal laundry. The Laundry Manager agreed they were dirty and would be removed from the cart used to transport clean personal laundry. 2. The facility staff failed to conduct a facility inspection and implement a water management team relative to water management and the spread of water borne pathogens. Review of the policy statement for Legionella Water Management Program, adopted 5/2018, indicted the following: -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. -The water management program is based on the Centers for Disease Control (CDC) and Prevention recommendations for developing a Legionella (a bacteria that grows in stagnant water) water management program. Review of the CDC form titled Identifying Buildings at Increased Risk, completed 5/22/18, indicated the facility was at increased risk and the facility should have a water management program. Review of the CDC Prevention Recommendations indicated the facility should conduct a seven step assessment of the facility relative to the water system. In addition, the facility should establish a water management program team which should include someone who understands accreditation standards and licensing requirements, someone with expertise in infection prevention and a clinician with expertise in infectious disease. During an interview with the Administrator and the Maintenance Director on 10/17/18 at 3:22 P.M., the Administrator said they had not done a facility assessment to identify where Legionella, as well as other water borne pathogens, could grow and spread in the water system. The Administrator was unable to produce evidence of any water management team meeting, nor could identify anyone with knowledge about water management. 3. The Facility failed to implement infection control practices and cleaning policies for items used by multiple residents (stuffed animals). Review of the Facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 7/2014 indicated that Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. During an observation of the secure unit on 10/17/18 at 08:53 A.M., Surveyor #3 observed a basket of stuffed animals on the windowsill in the day room. The staff gave multiple stuffed animals out to residents after breakfast. One resident was observed putting a light brown stuffed dog in his/her mouth. During a tour on 10/17/18 at 2:35 P.M., Surveyor #3 observed that the stuffed animals had been returned to the basket on the windowsill. During tours on 10/18/18 at 7:45 A.M., and on 10/18/18 at 2:30 P.M., Surveyor #3 observed that the stuffed animals remained in the basket. During a tour on 10/19/18 at 8:50 A.M., Surveyor #3 observed a staff member handing out multiple stuffed animals from the basket to residents in the dayroom. During an interview on 10/19/18 at 8:50 A.M., CNA #2 said she didn't know about the infection control process in regards to stuffed animals and cleaning them. During an interview on 10/19/18 at 9:26 A.M., the Activity Director said that the stuffed animals on the secure unit are washed once a month or if soiled, more frequently. She was unable to provide documentation regarding the cleaning of the stuffed animals. The Activity Director said that there is no policy for cleaning the stuffed animals, or for the cleaning and disinfection of resident care items.

Based on observation, and staff interviews, the facility failed to ensure that adequate infection control practices were followed for 3 of 15 sampled residents (#2, #5 and #11), and for 3 of 3 non-sampled residents (NS #1, NS #2 and NS #3). This was related to cross contamination of patient treatments and supplies on 2 of 3 Units. Findings include: 1. The Surveyor observed the East Unit medication cart and interviewed Nurse #1 and Unit Manager (UM) #1 on 4/22/15 from 8:30 A.M. to 8:40 A.M., which indicated the following: There were approximately 20 unprotected (not in a package) cotton tip applicators lying in the bottom of the first drawer with a nail clipper on top of the applicators. During an interview with Nurse #1, she said that the nail clippers are used to cut the patient's nails on the Unit and the cotton tip applicators are used to apply treatments (ointments/creams) to wounds. The unprotected applicators created a potential for cross contamination and facility acquired infections. The Surveyor observed 2 rolls of tape and a pair of scissors in the first drawer of the treatment cart. Next to the scissors was an opened tube of Clobestasol (a topical steroid), not stored separately. During an interview with Nurse #1, she said that the scissors and the tape are used for the resident dressing changes on the Unit. She said that the Clobestasol needed to be stored in a plastic bag, and that it was used for the pemphigous lesions (large blisters) on Resident #11's leg. 2. The Surveyor observed the medication cart on the West Unit and interviewed Nurse #1 and UM #1 on 4/22/15 at 9:05 A.M., which indicated there was a bottle of used BioFreeze (a topical pain relief medication) with the nozzle of the pump inside a ripped sleeve of 4 inch by 4 inch gauze pads (used for dressing changes). The BioFreeze was used for treating back and joint pain for 3 Non-Sampled Residents (NS #1, NS #2 and NS #3), and for 2 sampled Residents (#2 and #5). During an interview with UM #1 on 4/22/15 at 9:05 A.M., she said that storing the BioFreeze with the nozzle of the pump inside of the ripped sleeve of gauze pads, in the treatment cart was not acceptable, and she would address the issue.

Based on record review and staff interview, the facility failed to ensure that the individual exercising the resident's rights had the authority to do so for 1 resident (#9) out of 15 sampled residents. Findings include: Resident #9 was admitted to the facility in 11/2013 with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 10/16/14, indicated that the resident was moderately cognitively impaired, had a [DIAGNOSES REDACTED]. Review of the current Rogers Treatment Plan (court order to administer antipsychotic medications), dated 11/14/14, indicated that the facility could administer [MEDICATION NAME] (antipsychotic medication) 150 milligrams (mg.) per day to the resident. Review of the physician's orders [REDACTED]., daily at 8:00 P.M. During a interview with the Social Worker on 4/22/15 at 9:30 A.M., she said that the Rogers Order Treatment Plan indicated the facility could administer [MEDICATION NAME] 150 mg. per day and the resident received [MEDICATION NAME] 175 mg. per day, which is 25 mg. more than is allowed by the court.

Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1's plan of care for the assistance of two nursing staff to position and provide incontinence care to Resident #1 was followed. On 9/14/12, CNA #1 provided incontinence care to Resident #1 by herself, per her usual routine, and left Resident #1 alone in bed to assist Resident #1's Roommate to the bathroom. When CNA #1 came out of the bathroom, she observed Resident #1 slide out of his/her bed to the floor. Resident #1 sustained a right humerus fracture, a right tibia fracture, and a right knee laceration. Findings include: The Profile information record indicated that the staff admitted Resident #1 to the Facility in March, 2011. Resident #1's [DIAGNOSES REDACTED]. The December, 2011 physician orders [REDACTED]. The Resident Profile, dated 7/8/12, included: dependent on 2 staff for toileting; 1/4 side rails, and 2 staff for positioning. The Significant Change in Status Minimum Data Set (MDS) assessment, completed on 8/14/12, indicated that Resident #1 had cognitive impairment. The MDS assessment indicated that Resident #1 was dependent on 2 staff for bed mobility, toilet use, and transfer activities. The MDS assessment indicated that Resident # 1 was incontinent of bowel and bladder functions. The Surveyor interviewed Nurse #1 on 10/9/12, at 3:00 P.M. The Surveyor interviewed Nurse #3 on 10/4/12, at 4:00 P.M. Nurse #3 said she was not aware that Resident #1 was to always have 2 staff for incontinence care. Nurse #1 and Nurse #3 said usually the female CNAs asked them to assist when they provided incontinence care to Resident #1. Nurse #1 and Nurse #3 said CNA #1 never asked them to assist with the provision of incontinence care to Resident #1. Nurse #1 said she worked on Resident #1's unit one night a week and CNA #1 was usually not assigned on that unit. Nurse #3 said she assumed CNA #1 was able to provide incontinence care to Resident #1 by herself and had no issues. Nurse #3 said she was not aware that Resident #1 was to always have 2 staff for incontinence care. The Surveyor interviewed Nurse #2 on 10/3/12, at 11:40 A.M. Nurse #2 said she believed that 1 or 2 staff could safely position and provide incontinence care to Resident #1 pending Resident #1's physical and mental status. Nurse #2 said sometimes Resident #1 required increased positioning related to sliding from the air mattress. The Surveyor interviewed CNA #2 on 10/4/12, at 7:30 A.M. The Surveyor interviewed CNA #3 on 10/3/12, at 1:30 P.M. The Surveyor interviewed CNA #4 on 10/3/12, at 12:15 P.M. The Surveyor interviewed CNA #5 on 10/3/12, at 10:10 A.M. The Surveyor interviewed CNA #6 on 10/3/12, at 5:15 A.M. The Surveyor interviewed CNA #7 on 10/3/12, at 5:28 A.M. The Surveyor interviewed CNA #8 on 10/3/12, at 11:40 A.M. The Surveyor interviewed CNA #9 on 10/3/12, at 3:15 P.M. The Surveyor interviewed CNA #10 on 10/4/12, at 8:30 A.M. CNA #8 said 2 staff usually positioned and provided incontinence care to Resident #1. CNA #8 said sometimes Resident #1 held the side rail. CNA #8 said approximately once a week, she was not able to get another CNA to assist her and she positioned and provided incontinence care to Resident #1 by herself. CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, CNA #9, and CNA #10 said Resident #1 required 2 staff for positioning and incontinence care. CNA #2, CNA #4, and CNA #5 said Resident #1 was not safe to lie on his/her side in bed related to the air mattress. The Surveyor interviewed CNA #1 on 10/3/12, at 12:20 P.M. CNA #1 said she did not have time to read the care cards on all of the residents on Resident #1's unit. CNA #1 said she was aware that Resident #1 required 2 staff for transfer activities and positioning when Resident #1 was out of bed. CNA #1 said when she started working on the night shift, approximately 5 weeks prior to the incident, no one told her to ask the nurse for assistance and no one told her to use 2 staff when she positioned and/or provided incontinence care to Resident #1. CNA #2 said she provided incontinence care and positioned Resident #1 during the 5 weeks she worked on Resident #1's unit by herself and had no issues. CNA #1 said the nurse assisted her with boosting Resident #1 up in bed when needed. CNA #1 said on 9/14/12, during first personal care rounds, she provided incontinence care to Resident #1 and positioned Resident #1 on his/her side toward the window by herself per her usual practice. CNA #1 said she placed a pillow behind Resident #1's back and under his/her legs. CNA #1 said at approximately 5:30 A.M., Resident #1 was incontinent of urine and the bed linen was wet with urine. CNA #1 said she provided incontinence care to Resident #1. CNA #1 said the Roommate asked for assistance to the bathroom. CNA #1 said she told the Roommate she would assist him/her as soon as possible. CNA #1 said she then turned Resident #1 toward the window on his/her side, placed new bed linen under Resident #1, turned Resident #1 to the other side, and removed the soiled bed linen. CNA #1 said Resident #1 was on his/her side facing away from the window. CNA #1 said the Roommate kept asking to go to the bathroom during her provision of incontinence care to Resident #1. CNA #1 said she told Resident #1 she would assist the Roommate to the bathroom and then finish assisting Resident #1. CNA #1 said the bed was in the lowest position. CNA #1 said she had not placed the pillow behind Resident #1's back and under his/her legs. CNA #1 said Resident #1 appeared safely positioned in bed. CNA #1 said she assisted the Roommate to the bathroom and told him/her she would be right back. CNA #1 said she came out of the bathroom, which was near the foot of Resident #1's bed. CNA #1 said she observed Resident #1's leg over the bed on the side not facing the window. CNA #1 said she ran to the window side of the bed and tried to pull Resident #1 back onto the bed. CNA #1 said she yelled for help. CNA #1 said Resident #1 continued to roll toward the side of the bed not near the window, and Resident #1 fell to his/her knees. CNA #1 said CNA #2 came into the room and summoned Nurse #1. Nurse #1's statement, dated 9/14/12 indicated that on 9/14/12, at approximately 5:45 A.M., CNA #2 called her to Resident #1's room. The statement indicated that Resident #1 was kneeling on the floor with his/her right leg bent behind him/her. The statement indicated that Resident #1's left hand was attached to the siderail on his/her bed.The statement indicated that the fitted sheet on the left side of the bed was not attached to the mattress. The statement indicated that CNA #1 said she was changing Resident #1; Resident #1 started to slide out of bed, CNA #1 ran to the other side of the bed, and CNA #1 used herself to assist Resident #1 to the floor. The nurse's note, dated 9/14/12, at 7:18 A.M., indicated that at approximately 5:45 A.M. Resident #1 was on the floor with blood coming from his/her kneecap. The nurse's note indicated that Resident #1 had an 8 centimeter (cm) open wound on the kneecap. The nurse's note indicated that CNA #1 said while she turned Resident #1, Resident #1 slid out of the bed and she ran to the other side of the bed to "catch" Resident #1. The nurse's note indicated that she assisted Resident#1 to the floor by using her body weight. The nurse's note indicated that the nurse transferred Resident #1 to the Hospital. The nurse's note, dated 9/14/12, at 7:18 A.M., indicated that the Hospital Orthopedic Physician reported that Resident #1's leg twisted while sliding out of bed and Resident #1's old knee replacement broke apart and pushed through his/her skin. The Surveyor interviewed the Director of Nurses (DON) on 10/3/12, at 8:00 A.M. The DON said CNA #1 told her she provided incontinence care and positioned Resident #1 by herself. The DON said CNA #1 told her that she did not ask for assistance prior to providing incontinence care to Resident #1. The DON said CNA #1 did not follow the plan of care. The DON said Resident #1 sustained a right humerus fracture, a right tibia fracture, and a right knee laceration.

Based on record review, observation, as well as staff and resident interviews, the facility failed to ensure that the physician was promptly notified for 2 (#1 and #6) of 15 sampled residents. Findings included: 1. For Resident #1, the facility failed to notify the Physician that the resident was experiencing increased pain. Resident #1 was admitted to the facility in 6/09. [DIAGNOSES REDACTED]. Review of the January, February, and March 2011 MARs (Medication Administration Records), and corresponding Nurses' Notes, indicated the resident complained of pain, and was not consistently medicated for pain despite the every shift Pain Assessment on the MAR indicated [REDACTED]. Review of the clinical record also had no evidence that the Physician was notified of the continuing increased pain as follows: - 1/1/11 - 1/6-1/8/11 - 1/19/11 - 1/25-1/28/11 - 2/2 and 2/3/11 - 2/23-2/25/11 On 3/8/11 at approximately 8:40 A.M., the resident was observed lying in bed by the surveyor and Nurse #4. On the resident's right inner ankle, the surveyor observed a large area of deep red inflammation surrounding the dressing. The surveyor observed that the resident had facial grimacing, and asked how the resident was doing. The resident said, "It hurts, it hurts!" The surveyor asked the resident, "On a scale of 1-10 with 10 being the worst pain, what is your pain right now?" The resident replied, "It's a 10." Nurse #4 told the surveyor that the resident couldn't have any pain medication ([MEDICATION NAME]) yet, because it had been given at about 5:30 A.M. The surveyor asked Nurse #4 if the resident had any other orders for pain medication, and the nurse indicated no, but the [MEDICATION NAME] is scheduled every night at bedtime, and every 4 hours as needed. After discussion with Nurse #4 and the Director of Nurses on 3/8/11 at approximately 1:00 P.M., the Physician was notified that the resident was still having pain after the [MEDICATION NAME] was administered. The Physician ordered the narcotic pain medication [MEDICATION NAME] one tablet by mouth every 6 hours (prn) needed for pain. On 3/9/11 at approximately 7:30 A.M., the surveyor observed Nurse #4 conduct the treatment to the resident's right malleolus. The resident indicated that the pain was 6 on a scale of 1-10. After further discussion with Nurse #4 and the Director of Nurses on 3/9/11 at approximately 8:30 A.M., the Physician was again contacted who ordered [MEDICATION NAME] one tablet by mouth scheduled twice daily at 9:00 A.M., and 9:00 P.M., as well as the prn dose every 6 hours. Please refer to F282, Example #1 and F309. 2. For Resident #6, the facility failed to promptly consult/notify the physician for: a. Potential interventions/treatment when the resident was identified with a greater than 3 lb (pound) weight gain. b. Orders and treatment related to a F/C (Foley Catheter). c. Potential interventions related to a IV (Intravenous) lock device. Resident #6 was readmitted back to the facility from the hospital in 11/10. a. Review of the physician's orders [REDACTED]. Review of the 1/12/11 Dietician's note, indicated that the Resident's weight had {increased} to "168 lbs (greater than 3 lb weight gain)." There was no indication that the physician was notified; and this was acknowledged (on 3/8/11 at 3:00 P.M.) by the ADON (Assistant Director of Nursing). Review of the 2/24/11 Dietician's note, indicated that the Resident had a significant weight gain over the past month, and documented the "2/11" weight as being 183 (15 pounds). There was no indication that the physician was notified; and this was acknowledged by the ADON (on 3/8/11 at 3:00 P.M.). The "Patient Nursing Evaluation" form (dated 3/4/11) indicated that the Resident received diuretics and had [MEDICAL CONDITION] to bilateral legs. During discussion with the Dietician (on 3/10/11 at 7:58 A.M.), the Dietician acknowledged that the physician should have been notified of the greater than 3 lb weight gain, as ordered. The Dietician told the surveyor that he/she instructed nursing to contact the physician regarding the significant weight gain on 2/24/11, and updated the care plan to include this. The updated "Nutrition - at risk" care plan (dated 2/24/11) included the following: - Notify the physician of significant weight changes. The surveyor observed Resident #6 sitting in a W/C (wheelchair) adjacent to the Nursing Desk (on 3/8/11 from 2:00 P.M. to 3:12 P.M.). Resident #6 complained of discomfort to the left foot. The Resident's feet and legs were swollen (current weight was identified as being 200 lbs on 3/9/11 at 8:20 A.M.). Please refer to F282, Example 4 (a) and F325. b. According to the clinical record, Resident #6 had a history of [REDACTED]. The "Patient Nursing Evaluation" form, signed as completed by Nurse #2 (on 3/4/11), indicated that the Resident had a size#16 French indwelling F/C. There was a preprinted section below where the indwelling F/C was checked, and included the following instruction: - If indwelling catheter is checked, complete Evaluation to Medical justification for Indwelling Catheter use. If catheter is not justified, consult physician regarding discontinuing indwelling catheter (justification for F/C was not completed). The surveyor observed Resident #6 sitting in a W/C (Main Dining Room, on 3/8/11 at 11:15 A.M.) with a F/C drainage bag tucked inside a pillow case. On 3/8/11 at 1:55 P.M., Nurse #2 told the surveyor that he/she was the one who readmitted the resident back to the facility on [DATE] at 4:42 P.M.; and did not address the justification for use of the F/C; did not notify, verify, document orders, nor treatments with the physician for Resident #6's new F/C, as required. Please refer to F279 and F315. c. The surveyor observed Resident #6 sitting up in a W/C in the Main Dining Room (on 3/8/11 at 11:15 A.M.). The Resident had a double port IV access device on top of the left hand. During discussion with Nurse #2 on 3/8/11 at 1:55 P.M., Nurse #2 stated that he/she forgot about the IV device, as the last dose of the IV antibiotic was administered yesterday by another nurse (Nurse #6 on 3/7/11 at 9:00 A.M.). Nurse #2 told the surveyor that the IV device was not being used (locked); and confirmed that the physician should have been notified in order to obtain specific instructions as to whether the IV device should be discontinued or not. Please refer to F282, Example #4 (c), F315, and F328, Example #1.

Based on record review and staff interview, the facility failed to follow the written plan of care for pain, restraint use, weight loss, and intravenous care, for 4 sampled residents (#1, #2, #3, and #6), in a total sample of 15 residents. Findings included: 1. For Resident #1, the facility failed to medicate the resident for pain per physician's orders [REDACTED]. Resident #1 was admitted to the facility in 6/09. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. (milligrams) by mouth (or a suppository per rectum) every 4 hours as needed for pain or temperature greater than 100. Review of the plan of care addressing Skin Breakdown (updated 12/10), indicated the resident had a "diabetic neuropathic ulcer" on the right inner malleolus. Approaches were: Treatments as ordered, and to Monitor for pain, and medicate as needed. The plan of care addressing the Potential for pain (updated 11/10 and 12/10) was due to mild [MEDICAL CONDITION] and right ankle wound. Approaches included: - Assess characteristics of pain, location, duration, quality, aggravating/alleviating factors, and document; - Medications as ordered; - Medicate as needed for complaints of pain. Review of the January, February and March 2011 MARs (Medication Administration Records) and corresponding Nurses' Notes indicated the resident complained of increased pain on at least 14 days, and was not medicated per physician's orders [REDACTED]. The surveyor observed that the resident was lying in bed, and had facial grimacing. The surveyor asked how the resident was doing. The resident answered that on a scale of 1-10, the pain was a 10. After discussion with Nurse #4 and the Director of Nurses on 3/8/11, at approximately 1:00 P.M., it was acknowledged the resident was not always medicated for pain per order and care plan, and that the resident's pain characteristics (location, duration, quality, aggravating/alleviating factors) were not documented per care plan. Please refer to F157, Example #1 and F309. 2. For Resident #3, the facility failed to release the restraint for meals per physician's orders [REDACTED]. Resident #3 was admitted to the facility in January 2011, with [DIAGNOSES REDACTED]. The plan of care addressing Physical Restraints (dated 2/2/11) included the following approaches: - Check resident and remove for restraint free times per facility protocol, offer opportunities for restraint-free time and physical activity daily. - Reassess quarterly or as needed for continued necessity and appropriateness. Review of the February 2011 physician's orders [REDACTED]. On 3/8/11, at 8:35 A.M., the resident was observed by the surveyor, sitting in the wheelchair in the supervised dining room next to a CNA (Certified Nursing Assistant). The resident was eating breakfast (self feeding), and had the waist restraint on which was not released during meals and 1:1, per physician's orders [REDACTED]. On 3/8/11, at 11:43 A.M., the resident was again observed by the surveyor, sitting in the wheelchair in the supervised dining room with the waist restraint buckled. Residents were being served lunch at the time. On 3/10/11, at 8:25 A.M., the resident was observed by the surveyor sitting in the wheelchair in the supervised dining room next to a CNA. The waist restraint was on, and not released per physician's orders [REDACTED]. Interview on 3/10/11 at approximately 10:30 A.M., with the Director of Nurses, acknowledged that staff was not consistently releasing the resident's restraint per physician's orders [REDACTED]. 3. For Resident #2, the facility failed to follow physician's orders [REDACTED]. Resident #2 was admitted to the facility in 12/08. [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) Assessment of 1/4/11 indicated the resident: had short term memory loss and poor decision-making abilities; required total assistance from staff for bed mobility, dressing, toilet use, personal hygiene, and bathing; required extensive assistance from staff for transfers; did not ambulate, and was at risk for developing a pressure area. The 1/11 signed physician's orders [REDACTED].M. shift, to check for open/pressure areas, and to report to the Physician if present. A 3/2/11 physician's orders [REDACTED]. Change dressing every 3 days and as needed for soilage. On 3/8/11 at approximately 8:30 A.M. during the initial tour of the facility, the surveyor and Nurse #4 observed the resident lying in bed. The right heel had no dressing on as ordered, and there were large, dead skin flaps hanging from the heel. The surveyor also observed that neither foot had Lamb's Wool between the toes as ordered. On 3/9/11 at approximately 11:00 A.M., the surveyor observed Nurse #4 change the dressings on the resident's feet while the resident was lying in bed. The right heel again had no dressing on as ordered. The surveyor observed, and Nurse #4 confirmed that the right heel again had no dressing on as ordered, and neither foot had Lamb's Wool between the toes as ordered. Nurse #4 then applied Lamb's Wool and applied a dressing on the resident's affected heel as ordered. 4. For Resident #6, the Facility failed to follow the physician's orders [REDACTED]. a. Obtain/monitor/evaluate weights; report greater than 3 lb weight gain to physician. b. Administer Acidophilus three times per day. c. Flush and monitor the short IV (intravenous) lock device. Resident #6 was readmitted to the Facility in 11/10. a. Review of the Nutrition care plan (updated 12/1/10) identified that the resident had a history of [REDACTED]." The physician's orders [REDACTED]. - Weight every other day - If weight gain greater than 3 pounds (lbs) notify MD (order date 11/30/10). The December, 2010 Medication Record revealed there were only two weights obtained for the entire month of December (12/2/10, 164 lbs and 12/4/10, 162 lbs). Weights were not obtained and/or monitored, as ordered/planned; and this was confirmed by the ADON on 3/8/11 at 3:00 P.M.). The January, 2011 Medication Record revealed there were no weights documented as being obtained for the month of January. According to the Units' monthly weight sheets, Resident #6 weighed "168" lbs in January, 2011. Weights were not obtained every other day, nor monitored, as ordered / planned. The Physician was not notified when the resident's weight was identified as being greater than 3 lbs (previously 162 lbs on 12/4/10), as ordered; and this was confirmed by the ADON (on 3/8/11 at 3:00 P.M.). A nursing note, dated 1/12/11, documented that the Resident's weight was "174" lbs. The Facility did not notify the Physician of the 6 lb weight gain (168 lbs of 1/11 to 174 lbs on 1/12/11); and this was confirmed by the ADON (on 3/8/11 at 3:00 P.M.). The February, 2011 Medication Record revealed that the Resident's weight was not documented, as ordered. Review of the "Nutrition - at risk," care plan (rewritten 2/24/11), indicated that the resident had a history of [REDACTED]. - Monitor/evaluate weight/weight changes. - Notify the Physician of significant weight changes. Review of the Contracted Infusion Therapy Orders, dated 3/4/11, identified that the Resident weighed "185 lbs (nursing note 1/12/11 documented 174 lbs, now 9 lb weight increase)." The Physician was not notified with a greater than 3 lb weight increase (from 174 lbs on 1/12/11 to 185 lbs on 3/4/11), as ordered. Review of the March, 2011 Medication Record revealed that the Resident's weight was not obtained every other day, as ordered; and this was confirmed by the ADON on 3/8/11 at 3:00 P.M.. On 3/8/11 at 3:00 P.M., the ADON acknowledged that the Physician was not notified when there was a weight increase of greater than 3 lbs identified (12/4/10 as 162 lbs to 185 lbs on 3/4/11 (23 lbs, significant change in weight). During an interview with the Dietician (on 3/10/11 at 7:58 A.M.), the Dietician acknowledged the Resident should have been weighed every other day, due to variable weights, [MEDICAL CONDITION], and as the Physician instructed. The Dietician acknowledged that the weights greater than 3 lbs should have been reported to the Physician, as ordered for Resident #6, and were not. b. Review of the 3/4/11 "admission orders [REDACTED]. Nurse #2 documented that a verbal order was obtained by the Physician for this medication. Review of the corresponding March, 2011 Medication Records revealed that the Acidophilus was never transcribed; therefore, the Resident never received this medication as ordered. During discussion with Nurse #2 on 3/8/11 at 1:46 P.M., Nurse #2 told the surveyor that when a resident returns from the hospital, that an admission orders [REDACTED]. Nurse #2 said that these admission orders [REDACTED]. Nurse #2 confirmed that Resident #6 should have received the Acidophilus medication that was ordered by the Physician on 3/4/11, and did not; subsequently, Resident #6 missed 13 doses. c. According to the Hospital transfer physician's orders [REDACTED]. A nursing note, dated 3/4/11, indicated that the Resident required an IV in order to receive the IV antibiotic. The Pharmacy's Infusion Support Department was notified; and a peripheral catheter IV device was placed in the Resident's right hand. The Infusion Therapy Orders, dated 3/4/11, included the following: - [MEDICATION NAME] 1 Gram daily x 3 days starting 3/5/11. - Flush before each use with 10 ml (milliliters) of Saline. - Whenever a lumen (port) is "Locked (not being used)" flush with 10 ml of Saline at least Q (every) 8 hours (If medication is given only once a day, the catheter lumen still needs to be flushed on the other shifts). The corresponding Infusion Therapy Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. by Nurse #6. The Saline and amount of Saline solution for flushing the IV device were not identified on the ITMAR, that was ordered by the Physician. A second document, entitled "IV Med Record pg (page) 2" included preprinted instructions which included the following with regards to flushing and assessment of the IV device: - Flush IV before & after each use: Pre = 10 ml Saline Post = 10 ml Saline - Flush IV cath (catheter) a minimum of Q 8 hours and as needed whenever IV is locked: 10 ml Saline. (This form had dated sections for flushing the IV, before and after use. Flushing of the IV device was not done on 3/5, 3/6 and 3/7/11, as ordered. Additionally, flushing the IV when it was locked was not done on 3/5, 3/6, 3/7 and 3/8/11, as instructed/planned.) - IV assessment Q (every) shift. Initials indicate no visible or palpable signs of complications at insertion site or along vein pathway. The IV assessment was not done, as instructed on 3/6 and 3/7/11 for the 3:00 P.M. to 11:00 P.M. shift; or on 3/8/11 for the 11:00 P.M. to 7:00 A.M. shift, as planned. The Infusion Support Services consult form identified a Nursing Care Plan, and included the following interventions for the peripheral catheter IV device: - IV site checks Q 4 - 8 hours with documentation(signs/symptoms infection, catheter integrity). During review and discussion with Nurse #2 on 3/8/11 at 1:55 P.M., Nurse #2 stated that he/she had not flushed, checked or assessed the peripheral catheter IV device, as planned/instructed. In fact, Nurse #2 stated that he/she thought the site was still in the Resident's right hand; was a single port; and was not aware the site had been changed on 3/5/11 by Nurse #7. Nurse #2 stated that he/she "forgot about it," as the Resident's last dose of the IV [MEDICATION NAME] was administered on "3/7/11 at 9:00 A.M.," but would contact the Physician now for further instructions. Please refer to F157, Example #2, F325, F328, Example #1, and F514, Example #1.

Based on record review, observations, and confirmed by resident and staff interviews, the facility failed to ensure that 1 of 5 applicable residents with pain (#1), in a total sample of 15 residents, received the necessary care and services to attain the highest level of functioning and well-being possible. Findings included: For Resident #1, the facility failed to administer pain medication as ordered, and to alert the Physician that the present pain medication was inadequate. Resident #1 was admitted to the facility in 6/09. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. (milligrams) by mouth (or a suppository per rectum) every 4 hours as needed for pain or temperature greater than 100. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was alert, oriented, and able to make decisions; was independent for bed mobility; required supervision for transfers, ambulation, and eating; required extensive assistance from staff for toilet use, required total assistance from staff for dressing, personal hygiene, and bathing; had no complaints of pain, and had no foot problems. A physician's orders [REDACTED]. Review of the plan of care addressing the Potential for Skin Breakdown, (updated 12/10) indicated the resident had an open area (documented by the facility as a diabetic neuropathic ulcer) on the right ankle (right inner malleolus). Approaches were: Treatments as ordered, Monitor for pain, and Medicate as needed. The plan of care addressing the Potential for pain (updated 11/10 and 12/10) due to mild [MEDICAL CONDITION] and right ankle wound indicated the resident would have no complaints of pain or discomfort as evidenced by relaxed facial expression, and verbalizing no pain daily for 90 days. Approaches included: - Report complaints and signs of pain to nurse; - Assess characteristics of pain, location, duration, quality, aggravating/alleviating factors, and document; - Encourage resident to report early pain symptoms; - Medications as ordered; - Medicate at bedtime for ankle pain; - Medicate as needed for complaints of pain; - Surgical Consult for right ankle ulcer (3/8/11). Review of the clinical record indicated the diabetic ulcer on the resident's right inner ankle became inflammed and infected, which required treatment with the anti-infective medication Keflex 500 mg. three times daily for 7 days beginning 12/18/10. Review of the January, February, and March 2011 MARs (Medication Administration Records) and corresponding Nurses' Notes indicated the resident complained of increased pain, and was not medicated per physician's orders [REDACTED]. Review of the clinical record also had no evidence that the Physician was notified of the continuing increased pain as follows: - 1/1, A Nurse's note on the 7:00 A.M.-3:00 P.M. shift indicated the resident was, "still" complaining of pain in the right ankle (when touched), and the ankle was also red. The pain assessment on the MAR indicated 0" (indicating no pain) despite the nurse's note. The MAR indicated [REDACTED]. - 1/6 and 1/7, on the 7:00 A.M.-3:00 P.M. shift, the pain assessment indicated the resident complained of pain that was 4 out of 10 on the pain scale. There was no evidence that the resident was medicated for pain, or that the Physician had been notified of the increased pain. - 1/8, The 11:00 P.M.-7:00 A.M. shift pain assessment indicated the resident complained of pain that was 5 out of 10 on the pain scale. There was no evidence that the resident was medicated for pain. - 1/19, 1/25, 1/26, 1/27, 1/28, and 2/2, on the 7:00 A.M.-3:00 P.M. shift, the pain assessment indicated the resident complained of pain that was 4 out of 10. There was no evidence the resident was medicated for pain, or that the Physician was notified of the continuing pain. - 2/3 on the 7:00 A.M.-3:00 P.M. shift, the pain assessment indicated the resident complained of pain that was 3 out of 10. There was no evidence the resident was medicated for pain. - 2/23, on the 7:00 A.M.-3:00 P.M. shift, the pain assessment indicated the resident complained of pain that was 4 out of 10 on the pain scale. There was no evidence the resident was medicated for pain. - 2/24 and 2/25, on the 7:00 A.M.-3:00 P.M. shift, the pain assessment indicated the resident complained of pain that was 3 out of 10 on the pain scale. There was no evidence the resident was medicated for pain. On 3/8/11 at approximately 8:40 A.M., the resident was observed lying in bed by the surveyor and Nurse #4. On the resident's right inner ankle the surveyor observed a large area of deep red inflammation surrounding the dressing. Nurse #4 indicated the resident was going out "today" for a scan to rule out osteo[DIAGNOSES REDACTED]. The surveyor observed that the resident had facial grimacing, and asked how the resident was doing. The resident said, "It hurts, it hurts!" The surveyor asked the resident, "On a scale of 1-10 with 10 being the worst pain, what is your pain right now?" The resident replied, "It's a 10." Nurse #4 told the surveyor that the resident couldn't have any pain medication ([MEDICATION NAME]) yet, because it had been given at about 5:30 A.M. The surveyor asked Nurse #4 if the resident had any other orders for a pain medication, and the nurse indicated no, but the [MEDICATION NAME] is scheduled every night at bedtime, and every 4 hours as needed. After discussion with Nurse #4 and the Director of Nurses on 3/8/11 at approximately 1:00 P.M., the Physician was notified that the resident was still having pain after the [MEDICATION NAME] was administered. The Physician ordered the narcotic pain medication [MEDICATION NAME] one tablet by mouth every 6 hours as needed for pain. On 3/9/11 at approximately 7:30 A.M., the surveyor observed Nurse #4 conduct the treatment to the resident's right malleolus. The resident indicated that the pain was 6 on a scale of 1-10. After further discussion with Nurse #4 and the Director of Nurses on 3/9/11 at approximately 8:30 A.M., the Physician was again contacted who ordered [MEDICATION NAME] one tablet by mouth scheduled twice daily at 9:00 A.M., and 9:00 P.M., as well as the prn dose every 6 hours. Please refer to F157, Example #1, F282, Example #1, and F514, Example #4.

Based on record review, observation, and acknowledged during staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 5 applicable residents (#3), in a total sample of 15 residents. Findings included: For Resident #3, the facility failed to provide effective interventions and adequate supervision to prevent the resident from falls as evidenced by resident left unsupervised after 2 falls in one day, and then fell again sustaining injury. The resident's lap belt was removed without an evaluation by the facility which resulted in falls. Resident #3 was admitted to the facility in January 2011 with [DIAGNOSES REDACTED]. Review of the Wander/Elopement Risk Evaluation dated 1/20/11 indicated the resident had a history of [REDACTED]. The Plan of Care addressing Falls, initiated 1/20/11, indicated the resident was at risk for falls related to Psychotropic Medication use, Gait/balance deficit, Poor Safety Awareness, and Lethargy. Approaches included: - Assist resident transferring bed/chair with 1 assist using a rolling walker; - Velcro belt on w/c. Release per Protocol (discontinued 2/4/11). Review of the 1/21/11 Interdisciplinary Physical Restraint Evaluation, indicated the facility placed a self-releasing Velcro belt in the resident's wheelchair, while assessing the resident's ability to ambulate independently. Review of Resident Progress Notes, from 1/21 to 1/25/11, revealed the resident was agitated, aggressive, anxious, combative, resistant to care, was redirected without success, and/or wandered at least daily. Examples are: A Resident Progress Note of 1/21/11 indicated the resident became very agitated and aggressive, and removed the Velcro belt in the wheelchair. A Resident Progress Note of 1/24/11 indicated the resident was "roaming in hallway. Attempts to remove lap belt several x's (times)...." The Initial MDS (Minimum Data Set) assessment dated [DATE] indicated the resident had: short and long term memory loss and poor decision-making abilities; required supervision from staff while in the wheelchair on and off the unit; required limited assistance from staff for transfers and ambulation (room and hallways); required extensive assistance from staff for bed mobility, toilet use and activities of daily living; was rarely or never understood by others, and could rarely or never understand others. The undated Resident Profile (Certified Nursing Assistant Care Plan) indicated the resident required "Continual Monitoring & Sup (supervision)" in the wheelchair; wheelchair mobility with assistance; had a belt in the wheelchair; required assistance of 2 staff members for positioning; wandered and was resistive to care; was a "Fall Risk", and required assistance of one staff member for transfers. Review of Resident Progress Notes, from 1/25/11 to 2/1/11, revealed the resident was agitated, aggressive, anxious, combative, resistant to care, was redirected without success, and/or wandered at least daily. Examples are: Resident Progress Notes of 1/27 and 1/28/11 indicated the resident was self-propelling in the wheelchair with no sense of direction or safety awareness, and was continually redirected with poor effect. A Resident Progress Note of 1/29/11 revealed the resident was "restless", "agitated", "combative," and yelling out during morning care, and that while in the wheelchair, had attempted to stand unassisted after releasing the Velcro belt. Review of the clinical record indicated there were no notes from 2/2/11 to 2/5/11. A physician's orders [REDACTED]. There was no evidence in the clinical record that the resident was evaluated for a restraint reduction or that direct care staff were educated/inserviced on new interventions after the resident's belt had been discontinued. Review of the clinical record revealed the facility did not follow their own Restraint Policy as follows: - ..."A systematic and gradual process to reduce the use of restraints is in effect for each resident whose care plans indicate the need for restraints...." A Resident Progress Note and Resident Event Report Worksheet dated 2/6/11 indicated the resident pulled self from the wheelchair (using the railings in the hallway) and fell on the floor at 8:00 A.M. There was no injury. The Post Fall Evaluation indicated the resident had been sitting on the edge of the chair at the time of the fall. The nurse's note at the time of fall indicated the fall was witnessed by 3 staff members, and that the resident would be monitored. Review of the Resident Event Report Worksheet dated 2/6/11 indicated the resident fell twice more on 2/6/11 at 1:30 and 1:40 P.M. in the resident's room while left unattended. The fall at 1:30 P.M. was witnessed by a housekeeper, who notified the nurse on duty. There was no apparent injury at this time. The nurse then left the resident in the room unattended, and the resident fell again (third of the day) at 1:40 P.M. The resident began complaining of pain in the groin area, and was sent to the emergency room per physician's orders [REDACTED]. A physician's orders [REDACTED]. On 3/8/11 at 2:10 P.M., the surveyor observed the resident self propelling with the feet in the wheelchair. The Velcro Belt was on per order. On 3/10/11 at 8:00 A.M., the surveyor observed the resident self propelling with the feet in the wheelchair on the way to breakfast. The Velcro Belt was on per order. During a meeting/interview with the Occupational Therapist (OTR), Physical Therapist (RPT), Physical Therapy Aide (PTA) #2, Director of Nurses (DON), and the Regional Director of Rehab on 3/10/11 at approximately 10:30 A.M., it was confirmed that on 2/4/11 the DON, the OTR, and PTA #2 decided the resident had not attempted to stand unassisted, and that the Velcro Belt should be discontinued, despite the nurse's note of 1/29/11, (8 days prior to the falls), indicating the resident had released the belt and attempted to stand unassisted. During the above interview, it was confirmed that the OTR and PTA #2, were not as familiar with the resident as the Physical Therapist who had been providing services since admission to the facility. The OTR and PTA #2 had been providing services for about 2 days when it was decided to discontinue the seat belt without the benefit of conducting an Interdisciplinary Meeting to discuss a trial reduction or other options before discontinuing the belt (per Restraint Policy). Further discussion confirmed there was no evidence in the record that would indicate that staff had been educated/inserviced on the removal of the seat belt. PTA #2 indicated the resident seemed fearful of standing, and that they (DON, PTA #2, and OTR) didn't think the resident would attempt to stand unassisted.

Based on record review, policy review, observations, and staff interviews, the facility failed to develop and implement an individualized plan to maintain adequate hydration and health for 1 of 2 applicable residents (#4) in a total sample of 15 residents. Findings included: For Resident #4, the facility failed to develop and implement an individualized plan to prevent dehydration and acute [MEDICAL CONDITION] for a resident who was high risk for dehydration. Resident #4 was admitted to the facility in 6/07. [DIAGNOSES REDACTED]. Review of the facility's Fluid Intake and Output Measurement policy indicated, "...Intake and output (I&O) measurement is recorded for residents according to the following criteria: - Residents identified as at high risk for dehydration To determine if a resident at high risk for dehydration needs to be on intake and output, the interdisciplinary team should consider the following: a. Current consumption of fluids (Is the resident consuming adequate fluids consistently?) b. Stability of nutrition (Is the resident eating well consistently?) c. Signs and symptoms of dehydration...." During a review of the last full Medical Nutrition Therapy Assessment of 4/10, it was revealed the resident's estimated fluid need was 1650 cubic centimeters (cc) a day. Review of the 12/21/10 Quarterly MDS (Minimum Data Set) Assessment indicated the resident: had short term memory impairment; required assistance from staff for activities of daily living; did not ambulate, was dependent on staff for eating, and was incontinent of bowel and bladder. The 12/22/10 quarterly Medical Nutrition Therapy Review indicated the resident had a [DIAGNOSES REDACTED]. The 12/22/10 Nutrition Comprehensive Care Plan indicated the resident's problems were: variable p.o. (by mouth) intakes; difficulty swallowing/dysphasia; difficulty chewing, and was at risk for dehydration. The goal was for the resident to consume at least 80% of the meal, have labs within the Physician's parameters, and will not develop signs/symptoms of dehydration. The 12/30/10 Resident Profile Sheet (CNA care plan), indicated the resident was on a pureed diet with thin liquids, and was totally dependent for feeding. A Nurse's Note dated 1/31/11, on the 3:00-11:00 P.M. shift, revealed the resident appeared to be tired, did not eat a lot of dinner, but had consumed two mighty shakes. The Nurse's Note dated 2/1/11, on the 3:00 -11:00 P.M. shift (there was no 11:00 PM -7:00 A.M. or 7:00 A.M. -3:00 P.M. nurse's note), revealed the resident, "..continues to appear tired this shift, pale.... will continue to monitor." The 2/1/11 Medication Administration Record (MAR) and the Meal and Fluid Monitoring form, indicated the resident's total intake was less than the estimated fluid goal of 1650 cc. in 24 hours. The Nurse's Note dated 2/2/11, on the 3:00 P.M. -11:00 P.M. shift (there was no 11:00 P.M. -7:00 A.M. or 7:00 A.M. -3:00 A.M. nurse's note), indicated the resident appeared quiet and tired this shift, had a poor appetite, and was complaining of burning upon urination (risk factor for dehydration). An order was obtained for a urinalysis with culture and sensitivity. Review of the 2/2/11 MAR and the Meal and Fluid Monitoring form, indicated the resident's total intake was less than the estimated fluid goal of 1650 cc. in 24 hours. The Nurse's Note dated 2/3/11, on the 7:00 A.M. -3:00 P.M. shift (there was no 11:00 P.M. -7:00 A.M. nurse's note), it was revealed the resident was lethargic and had a poor appetite. The 2/3/11 MAR and the Meal and Fluid Monitoring form, revealed the resident's total intake was less than the estimated fluid goal of 1650 cc. in 24 hours. The Nurse's Note dated 2/4/11, on the 7:00 A.M. -3:00 P.M. shift, revealed the resident had lab work drawn, and the results were pending. The 2/4/11 MAR and the Meal and Fluid Monitoring form, revealed the resident's total intake was less than the estimated fluid goal of 1650 cc. in 24 hours. A Laboratory Report dated 2/4/11 revealed the following results: - Sodium elevated at 160 (normal levels range 133-145); - Potassium elevated at 5.5 (normal levels range 3.3-5.1) - BUN (Blood Urea Nitrogen) elevated at 70 (normal levels range 10-24); - Creatinine level 2.3 (normal ranges 0.7-1.5); - GFR (Glomerular Filtration Rate) which is an indicator of kidney disease (or acute condition), was low at 21 (under 60 is abnormal) A low GFR is a high risk factor for dehydration; - White Blood Cell elevated at 13.9 (normal levels range 4.8-10.8); - Red Blood Cell decreased at 3.64 (normal levels range 4.00-5.10); - Hemoglobin level at 10.7 (normal level range 12.1-15.7) and, - Hematocrit was with in normal limits. The Nurse's Note of 2/4/11 at 10:00 P.M., revealed the resident remained pale, lethargic, and had a poor appetite. The Physician was notified, and the resident was sent to the emergency room for an evaluation. An entry at 11:30 P.M., revealed the resident was admitted to the hospital with [REDACTED]. The emergency room report of 2/5/11 at 1:00 A.M., (by the Attending Physician) included, "...oral mucosa is very dry...the patient is delirious with lethargy..." The Assessment and Plan was to admit the resident with "..metabolic [MEDICAL CONDITION] and is noted to have severe [MEDICAL CONDITION] and evidence of acute kidney injury..." The resident is "...noted to have leukocytosis, unclear if this is partially due to the severe dehydration..." A review of the Hospital dictation from the Attending Physician dated 2/5/11, indicated the resident had a urinary tract infection, and was being treated with an anti-infective medication. The resident's Hematocrit had decreased while in the hospital, requiring 2 units of red blood cells to be infused. A review of the Nephrology Consult dated 2/5/11 included, "... The patient with acute [MEDICAL CONDITION] and [MEDICAL CONDITION] from dehydration. Clearly the poor p.o. intake in the past few days is {sic} made the resident's renal function and sodium abnormal." "...I do think that a {sic} renal function will also improve with rehydration...." During review of the Meal and Fluid Monitoring Form, the surveyor observed that staff were documenting that the resident was still consuming meals on 2/5/11, despite the resident being in the hospital on that date (100% of breakfast, 75% of lunch, and 600 cc. of fluid). During an observation on 3/8/11 at 8:30 A.M., the resident was observed in the wheelchair in the supervised dining room. The resident was being fed by a Certified Nursing Assistant (CNA). During an interview on 3/8/11 at 1:50 P.M. with Nurse #1, it was confirmed the resident was not placed on Input and Output to monitor recommended fluid intake per policy. During an interview on 3/9/11 at 4:40 P.M., with the Administer and Director of Nurses, it was acknowledged that the resident was admitted to the hospital with [REDACTED]. Please refer to F514, Example #5.