Every finding on record at Riverbend of South Natick

Based on observations, interviews, and record review, the facility failed to ensure that appropriate infection prevention and control measures were followed for one Resident (#18) out of a total sample of 13 residents. Specifically, for Resident #18, the facility failed to implement and adhere to Contact Precautions to reduce the potential spread of infection when the Resident was diagnosed with Scabies (skin infection/rash caused by a parasitic mite, that can be spread by skin-to-skin contact) putting staff, other residents, and visitors at risk for the spread of infection. Findings include: Review of the facility policy titled Transmission Based Precautions, undated, indicated but was not limited to the following: -Use Personal Protective Equipment (PPE) appropriately, including gloves and gown.Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the facility policy titled Infections-Clinical Protocol, revised July 2016, indicated but was not limited to the following: -Skin/Soft Tissue Infection (SSTI): .Consider scabies in any resident with unexplained generalized rash. It may be helpful to consult a dermatologist and/or obtain scrapings for evaluation of mites, eggs, or mite feces. Review of the U.S. Centers for Disease Control and Prevention (CDC) Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions, updated 2/7/25, indicated that the Scabies infection should have Contact plus Standard precautions implemented until 24 hours after initiation of effective therapy. Resident #18 was admitted to the facility in September 2023, with diagnoses including hemiplegia (weakness or paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body) following cerebral infarction (stroke), chronic kidney disease, and Scabies. Review of Resident #18's current Care Plan dated 7/16/25, indicated: -Resident had actual skin impairment due to Scabies rash. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #18: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15. -had ointments or medications applied to areas of the body other than to his/her feet. Review of Resident #18's Report of Consultation dated 8/4/25, indicated: -consulted with a dermatologist on 8/4/25 at 3:40 P.M. due to rash to back, arms and chest with ongoing itching and rash, with last treatment performed on 7/31/25. -was diagnosed with Scabies on 8/4/25, with positive findings under the microscope. -was recommended for treatment, including Ivermectin (anti-parasite medication). During an interview on 8/5/25 at 8:13 A.M., Resident #18 said he/she attended a dermatology appointment on 8/4/25 and had been diagnosed with a Scabies infection. The surveyor observed that there was no signage present regarding transmission-based precautions on the Resident's bedroom door or outside of the Resident's bedroom door. Review of Resident #18's clinical record indicated that the Resident was not placed on Contact Precautions until 8/5/25. During an interview on 8/5/25 at 8:32 A.M. with the Assistant Director of Nurses (ADON) and the Director of Nursing (DON), the ADON said that Resident #18 attended a dermatology appointment on 8/4/25 due to recent treatment for a Scabies infection. The DON said that the Resident should have been placed on Contact Precautions upon return to the facility following the dermatology appointment on 8/4/25 due to a diagnosis of Scabies but had not been placed on Contact Precautions at that time. On 8/5/25 at 8:58 A.M., the surveyor observed the ADON hang a STOP sign on Resident #18's room door. During an interview at the time, the ADON said she had placed the Contact Precautions sign and the bin containing PPE outside the Resident's door that morning (after the surveyor's observation at 8:13 A.M.). The surveyor observed the Contact Precautions sign was published by the CDC and indicated that everyone must clean their hands, including before entering and when leaving the room. The Contact Precautions sign also indicated that Providers and staff must also: 1) Put on gloves before room entry. Discard gloves before room exit. 2) Put on gown before room entry. Discard gown before room exit.3) Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The ADON said that there was a potential risk for the spread of infection when transmission-based precautions were not implemented and should have been. On 8/5/25 at 8:40 A.M., the surveyor observed Nurse #2 walk into Resident #18's room to deliver the Resident's breakfast meal and did not don PPE prior to entering the Resident's room. Nurse #2 was observed delivering the Resident's breakfast meal and then exiting the Resident's room. During an interview at the time, Nurse #2 said Resident #18 attended a dermatology appointment on 8/4/25 and had a rash, but Nurse #2 was not aware of what caused the rash. Nurse #2 said the Contact Precautions sign outside of the Resident's room indicated that gloves and a gown must be worn when caring for the Resident. Nurse #2 said that she did not need to put on gloves or a gown when delivering the Resident his/her breakfast meal because she did not have to touch the Resident. On 8/5/25 at 2:24 P.M., the surveyor observed Laundry Personnel #1 walk into Resident #18's room and did not don PPE prior to entering the Resident's room. Laundry Personnel #1 was observed opening the Resident's closet, prior to exiting the Resident's room. During an interview at the time, Laundry Personnel #1 said she put Resident #18's clean clothes into his/her closet. Referring to the Contact Precautions sign outside of the Resident's room, Laundry Personnel #1 said she should have put on PPE prior to entering the Resident's room. At that time, Laundry Personnel #1 was observed removing a gown from the PPE bin and entering the Resident's bedroom without donning the gown or any PPE and demonstrated to the surveyor how she would discard a PPE gown in the Resident's trash can. Laundry Personnel #1 said she did not don PPE when she put clothes into the Resident's closet because she did not feel it was bad not to wear the PPE. Laundry Personnel #1 said the purpose of the PPE was to protect herself and to prevent the spread of infection to other residents. On 8/5/25 at 3:15 P.M., Certified Nurse Aide (CNA) #1 was observed to walk into Resident #18's room and did not don PPE prior to entering the Resident's bedroom. CNA #1 was observed to pick up a cup in the Resident's bedroom and hand it to the Resident and then place her hand on the Resident's shoulder prior to exiting the Resident's bedroom. During an interview at the time, CNA #1 referring to the Contact Precautions sign outside Resident #18's door, said that she should wear a mask and gown prior to entering the Resident's room, however it was not necessary to wear gloves unless she was going to touch the Resident. CNA #1 said there was a potential risk for contracting the scabies infection and for spreading the infection to another resident when she did not wear the required PPE. During an interview on 8/5/25 at 4:23 P.M., the DON said Resident #18 was placed on Contact Precautions on 8/5/25 and the expectation was that staff don the appropriate PPE before entering Resident #18's room and that the PPE was removed before exiting the Resident's room. The DON said that there was a potential risk for the spread of infection when staff did not use the required PPE. During an interview on 8/6/25 at 3:18 P.M., the DON said the facility follows CDC guidance for all infection control protocols, including standard and transmission-based precautions.

Based on observations, and interviews, the facility failed to post the required nurse staffing data daily in a prominent place, readily accessible to residents, staff and visitors on three out of three days observed. Specifically, the facility failed to: -Post nurse staffing data on 8/5/25, 8/6/25, and 8/7/25 in a prominent place in the facility as required. -Post nurse staffing data including the facility name, the current date, the total number and the actual hours worked by Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, in addition to the resident census. Findings include: During the facility survey, the surveyor failed to observe any evidence of the nurse staffing data that included the facility name, the current date, the resident census, the total number and the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs), posted in the facility on 8/5/25, 8/6/25 and 8/7/25. During an interview on 8/7/25 at 10:26 A.M., the Assistant Director of Nurses (ADON) said the nurse staffing data was typically posted in the front entrance lobby, however the nurse staffing data was not posted at that time. During an interview on 8/7/25 at 10:29 A.M., the Director of Nursing (DON) said the nurse staffing data was typically posted in the front entrance lobby, however the nurse staffing data was not posted at that time. During an interview on 8/7/25 at approximately 10:40 A.M., the Administrator said the nurse staffing data should be posted in the front entrance lobby, however the nurse staffing data was not posted at that time. During an interview on 8/7/25 at 12:58 P.M., the DON said the Nurse who was responsible for posting the nurse staffing data had not posted the nurse staffing data on 8/5/25, 8/6/25, and 8/7/25, because she was unable to locate the protective sleeve in which the nurse staffing data sheet was placed in and typically posted.

Based on record review and interview, the facility failed to notify the Physician of a significant change in condition for one Resident (#3) out of a total sample of 13 Residents. Specifically, the facility staff failed to notify the Physician/ Nurse Practitioner (NP) so treatment could be altered when Resident #3 was identified with significant weight loss by the Registered Dietician. Findings include: Review of the facility policy titled Weight Assessment and Intervention, undated, indicated: -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: >1 month - 5% weight loss is significant, greater than 5% is severe >3 months - 7.5% weight loss is significant, greater than 7.5% is severe >6 months - 10% weight loss is significant, greater than 10% is severe -The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia (eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight), weight loss, or increasing weight loss. Resident #3 was admitted to the facility in April 2023 with diagnoses including Dementia (progressive disease with impairment in memory and loss of judgement), Dysphagia (difficulty swallowing), Other Feeding Difficulties, Anemia (condition that develops when the blood produces a lower than normal amount of red blood cells and/or hemoglobin [protein in red blood cells that carries oxygen from the lungs to other organs/tissues] to carry oxygen to the body's tissues) and Celiac Disease (chronic digestive and immune disorder that damages the small intestine when the body has a reaction to gluten). Review of Resident #3's Weights and Vitals report provided by the facility on 6/5/24 indicated: -12/12/23: 150.0 lbs (pounds) -1/9/24: 154.0 lbs -2/13/24: 154.1 lbs -3/12/24: 156.4 lbs -4/9/24: 140 lbs (-10.49% change from 3/12/24) -5/14/24: 138.3 lbs (-1.2% change from 4/9/24 and -11.5% from 3/12/24) Review of the May 2024 Physician's orders indicated: -Weights Monthly, initiated 5/16/23 -Diet: >Puree with Thin Liquids gluten free, >lip plate with all meals, >slow pace cues 1 bite, 1 sip at a time, >1:1 supervision, initiated 3/18/24 -Ensure Original Liquid, give 237 ml (milliliters) by mouth twice daily at 8:00 A.M. and 5:00 P.M., initiated 4/24/24 Review of the Nutrition Progress notes indicated the following: >3/3/24: -Resident was able to eat his/her meal with minimal assistance. -Weight remains stable at 154# (lbs), continues with gluten free (therapeutic diet) and puree (mechanically altered texture) diet. -Intake is excellent, eating 100% of most meals. -Will continue to monitor weight, intake, and skin. >4/16/24 (recorded as late entry note on 4/22/24): -A reweight has been requested due to a 16-lb. weight change over the course of one month [3/12/24 - 4/9/24], despite the Resident maintaining excellent intake -We scheduled him/her to be weighed the following day. -Will follow up regarding accuracy. >4/23/24: -The recent weight measurement shows a further decline, now at 133 lbs. compared to 154 lbs. during the annual check-up indicating a -21 lbs. weight change and -7 lbs. since the beginning of April 2024. -The Resident's IBW (Ideal Body Weight) is 130 lbs. +/- 10% (117-143 lbs.), and he/she is currently within ideals, and therefore weight loss is not warranted at this time. -Nursing is aware of the weight loss and will notify the Nurse Practitioner/Medical Doctor. - Recommend initiating Ensure twice daily to help prevent further weight loss and obtain labs. -Will remain involved and reassess. Review of the Nursing Progress Note dated 4/24/24 indicated: -Following recent weight loss, NP (Nurse Practitioner) called with the Dietician's recommendations. -New orders for Ensure (nutritional supplement) twice daily to prevent further weight loss. -Family notified. -Plan of care ongoing. Review of the Physician Progress Notes indicated: -4/11/24: Resident #3 had diagnoses of adult failure to thrive (FTT: syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms and impaired immune function) and moderately advanced Dementia requiring support for ADLs (activities of daily living such as bathing, dressing, eating). Further review of the Physician Progress Notes failed to indicate any concerns, discussion, or intervention regarding the Resident's recent weight loss on 4/9/24. -5/16/24: The Physician Progress Notes failed to indicate any concerns, discussion, or intervention regarding the Resident's recent weight loss or nutritional status. Further review of the medical record failed to indicate that the NP or the Physician evaluated the Resident for nutritional risk or impaired nutrition after the significant weight loss was identified on 4/9/24. During an interview on 6/5/24 at 9:16 A.M., the Nurse Practitioner (NP) said typically the DON (Director of Nurses), or nursing staff communicate any weight loss to her. The surveyor and NP reviewed Resident #3's medical record and the NP said the Resident's weight loss from 3/12/24 to 4/9/24 was concerning and that she was not made aware of the weight loss, only the recommendation by the Dietician to add twice daily Ensure supplement on 4/24/24. Please Refer to F692

Based on observation, record review and interview the facility failed to ensure one Resident (#27) was free from a potential restraint, out of a total sample of 13 residents. Specifically, the facility failed to assess the use of the right side of the bed positioned flush against the wall, preventing Resident #27 from exiting the right side of bed, being used as a potential restraint. Findings include: Review of the facility policy titled Restraints, undated, indicated the following: -The intent of this policy is for each person to reach his or her practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. -A restraint used for any reason other than medical symptoms, violates the rights of the residents, reduces their quality of life, and presents significant physical and psychological risks. -Physical Restraints are defined as any method, physical or mechanical device, material, or equipment attached to or adjacent to the resident's body, that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Resident #27 was admitted to the facility in December 2023 with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language) and Intraductal Carcinoma of the breast (a non-invasive or pre-invasive breast cancer). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of a total score of 15. On 5/30/24 at 9:33 A.M., the surveyor observed Resident #27 asleep in bed with the right side of the bed positioned flush against the wall. On 6/4/24 at 8:50 A.M., the surveyor observed Resident #27 lying in bed, with the right side of the bed positioned flush against the wall. The surveyor also observed that the head of the bed was elevated. Review of Resident #27's Physician's orders dated 5/1/24 through 6/30/24, did not indicate any orders for the Resident to have the bed positioned flush against the wall on the right side of the bed. Review of Resident #27's clinical record did not provide any evidence that an assessment relative to positioning the right side of Resident #27's bed flush against the wall, had been completed as a potential restraint. Further review of Resident #27's clinical record did not provide any evidence documented in the progress notes relative to positioning Resident #27's bed flush against the wall to the right side of the bed. Review of Resident #27's current care plan last revised 5/29/24, did not provide any evidence of care planning relative to positioning the right side of Resident #27's bed flush against the wall. During an interview and observation on 6/4/24 at 12:41 P.M., of Resident #27 lying in bed, Unit Manager (UM) #1 said that she did not know why Resident #27's bed was against the wall. UM #1 further said she was not sure if an assessment as a potential restraint had been completed relative to positioning the right side of Resident #27's bed flush against the wall. During an interview on 6/4/24 at 1:09 P.M., Certified Nurses Aide (CNA) #1 said he worked full-time on the 2nd floor unit and often provided care to Resident #27. CNA #1 said Resident #27's bed was flush against the wall because the space in the room was small. CNA #1 said that Resident #27 sits up in the chair sometimes but prefers to be in bed with the head of the bed elevated. During an interview on 6/4/24 at 2:23 P.M., UM #1 said that she could not provide any evidence that positioning the bed flush against the wall to the right side of the bed had been assessed as a potential restraint for the Resident. UM #1 also said that there was no Physician's order or care plan in place for the positioning of Resident #27's bed flush against the wall to the right side of the bed. UM #1 said that there should have been a restraint assessment performed, a Physician's order obtained, and a care plan put into place for the positioning of the right side of Resident #27's bed flush against the wall.

Based on policy, record review and interview, the facility failed to refer one Resident (#17) out of a total sample of 13 residents, for a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals are not inappropriately placed in long term care) Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen (a pre-admission screening process used to determine if a person has a diagnosis or suspected diagnosis of developmental disabilities/related conditions or mental illness) for mental illness (MI), intellectual disability, or related condition to determine if they require specialized services). Specifically, the facility failed to refer Resident (#17) for a Level II evaluation when the Resident had documented diagnoses of mental illness (MI) and the Level I screen completed in the hospital prior to the facility admission was inaccurate. Findings include: Review of the facility policy titled Pre-Admission Screen, undated, indicated the following: -Upon receipt of the referral the Director of Social Services will request and/or initiate the need for an onsite or telephonic completion of the pre-admission screen. -If an onsite medical record/patient review is necessary the social service/designee will complete the pre-admission screen after receiving the referral. -The original copy of the pre-admission screen will be placed in the patient's chart. Resident #17 was admitted to the facility in May 2024 with diagnoses including Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Unspecified Psychosis (a mental disorder characterized by a disconnection from reality). Review of the PASRR Level I Screening Form dated 5/8/24, indicated the Resident did not have a documented diagnosis of a mental illness or mental disorder and had not experienced any major life activity or functional impairments within the past six months, resulting in a negative PASRR Level I screen. Review of the Hospital Patient Care Referral Form dated 5/8/24, indicated Resident #17: -had a prior medical history of Mood Disorder-Depression. -was prescribed Sertraline (an anti-depressant medication). -had a Psychiatric Consult with recommendation to continue nightly Seroquel (an antipsychotic medication) with Haldol (an antipsychotic medication) through an IV (Intravenously) access as needed for agitation. Review of the facility's Initial Nurse Practitioner (NP) Visit Note dated 5/9/24, indicated that Resident #17: -had a history of Depression and Anxiety, and had medication changes to his/her antidepressant medications during his/her hospitalization . -was started on Seroquel for agitation/psychosis and received IV Haldol during his/her hospitalization . -had Psychosis and continues on Seroquel at night. During an interview on 5/31/24 at 11:39 A.M., the facility Social Worker (SW) said she was responsible for reviewing the hospital documentation provided by the admissions department and then completing the PASRR Level I screen. The surveyor and the SW reviewed the Hospital's Patient Care Referral Form dated 5/8/24, and the SW said that the PASRR Level I screen was not accurate and a Level II evaluation was needed.

Based on observation, interview, record review and policy review, the facility failed to ensure the plan of care was revised for three Residents (#8, #18 and #10), out of a total sample of 13 residents. Specifically, the facility staff failed to: 1. For Resident #8, revise the Resident's Incontinence Care Plan to reflect the current suprapubic catheter size. 2. For Resident #18, revise a Fall Care Plan after the Resident sustained a fall. 3. For Resident #10, ensure that the Resident and/or the Resident Representative were invited to participate in the Care Plan Conference Meetings. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person-Centered revised 12/2016, indicated the comprehensive care plan will: -Include assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing the goals of care -Measurable objectives and timeframes -Incorporate identified problems areas, risk factors associated with identified problems -Aid in preventing or reducing decline in the resident's functional status and/or functional levels -Enhance optimal functioning of the resident by focusing on a rehabilitative program Review of the facility policy titled Care Planning-Interdisciplinary Team, undated, indicated the following: -The care plan is based on the Resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: -Physician -Registered Nurse who has responsibility for the Resident -Dietician -Social Worker -Activity Director -Nursing Assistants responsible for the Resident's care -Charge Nurse responsible for the Resident's care -Others as appropriate or necessary to meet the needs of the Resident -The Resident, the Resident's family and/or the Resident's legal representative/guardian (a person appointed by the court to make decisions on behalf of someone else) or surrogate (an adult who has shown special care and concern for the individual, who is familiar with the individuals' personal values, is reasonably available, and is willing to serve as the surrogate) are encouraged to participate in the development of and revisions to the Resident's care plan. 1. Resident #8 was admitted to the facility in November 2022, with diagnoses including neurocognitive disorder (a group of conditions that cause a decline in mental function due to medical disease other than a psychiatric illness), retention of urine (inability to completely empty bladder of urine), and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nervous system problems). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #8 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2 out of a total 15 and had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). Review of the Urinary Incontinence Care Plan initiated 12/19/22, indicated that Resident #8 had an indwelling Foley catheter, Size 22 French (Fr) and 30 milliliters (ml) balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body). Review of Resident #8's May 2024 Physician's orders included the following: -Suprapubic catheter, Size 20 Fr and 5 ml balloon, dated 1/8/24. On 6/4/24 at 10:19 A.M., during an observation with Unit Manager (UM) #1, UM #1 said Resident #8's suprapubic catheter was Size 18 Fr with 5 ml balloon. During an interview on 6/4/24 at 1:44 P.M., the Director of Nursing (DON) said Resident #8's suprapubic catheter was Size 18 Fr and 5 ml balloon. The DON further said a Physician's order should have been obtained and the Resident's Urinary Incontinence Care Plan should have been revised for the correct catheter size but was not. 2. Resident #18 was admitted to the facility in July 2023, with diagnoses including Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), repeated falls, insomnia (sleep disorder with trouble falling asleep and/or staying asleep), and Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #18 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 5 out of a total 15 and had a history of falls. Review of the Nursing Progress Note dated 12/26/23 indicated that Resident #18 was found on the floor in his/her room leaning against the wall. The Nursing Progress Note further indicated the Resident said that he/she was getting out of bed and the chair was not locked and he/she slid onto the floor. Review of the Impaired Mobility Care Plan initiated 8/3/23 and revised 4/4/24, did not include any interventions for falls. During an interview on 5/31/24 at 10:40 A.M., the DON said the Interdisciplinary Team (IDT) reviews any Resident falls, and new interventions to prevent falls would be updated in the Resident's plan of care after review with the IDT. During a follow-up interview on 5/31/25 at 12:44 P.M., the DON said Resident #18's incident report for falls in 12/26/23 had not been reviewed by the IDT and no falls interventions had been put in place. 44337 3. Resident #10 was admitted to the facility in January 2023 with diagnoses including Diabetes Mellitus II (a long term condition in which the body has difficulty controlling sugar in the blood), left femur fracture (fracture of the thigh bone), Depression (a mental disorder characterized by a pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and Chronic Kidney Disease (CKD: a condition in which the kidneys are damaged and can no longer filter waste from the blood). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #10 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of seven out of a total score of 15. During an interview on 5/30/24 at 9:21 A.M., Resident #10 said he/she was not sure if he/she had gone to any care plan meetings. Resident #10 also said that he had broken his leg and now uses a walker because he/she is unsteady on his/her feet. Review of Resident #10's record indicated Care Plan Conference Summary Notes dated 10/19/23, 1/4/24 and 3/21/24. Further review of the Care Plan Conference Summary Notes indicated that Social Worker (SW) #1 and the Activities Director (AD) attended the care plan conferences but did not indicate that the Resident and/or the Resident Representative (RR) or any other member of the Care Planning/Interdisciplinary Team attended the care plan conferences. Review of the Social Work Progress Notes written by SW #1, dated from 10/10/23 to 5/29/24, did not provide any evidence that the Resident and/or the RR had been invited to attend the care plan conferences dated 10/19/23, 1/4/24, and 3/21/24. Further review of the Social Work Progress Notes did not indicate that the Resident and/or the RR had declined to attend the care plan conferences dated 10/19/23, 1/4/24, and 3/21/24. During an interview on 6/5/24 at 9:37 A.M., SW #1 said that she had worked at the facility for nine years and was responsible for the implementation of the care plan conference process. SW #1 said she received information from the MDS Coordinator that indicated which residents were due for a care planning conferences and then sent an email or letter to the Resident and/or the RR/family informing them of the date of the care plan conference. SW #1 said that a Certified Nurses Aide (CNA), a Nurse, the Physician, the Social Worker, the Activities Director and any other discipline involved in the Resident's care were required to attend the care plan conference. SW #1 said the Care Plan Conference Summary Notes, kept in the Resident's record, contained all documentation regarding the care plan conference and included which disciplines attended the conference and if the Resident and/or the RR/family had attended or declined to attend the conference. The surveyor and SW #1 reviewed Resident #10's Care Plan Conference Summary Notes dated 10/19/24, 1/4/24 and 3/21/24, and SW #1 said that there was no documentation that indicated Resident #10 and/or RR/family had been invited to attend or had declined to attend the care plan conference. SW #1 said if there was no documentation then that meant the Resident and/or the RR/family had not been invited to the conference. SW #1 also said that there was no documentation that reflected the required disciplines had attended Resident #10's care plan conference and there should have been documentation.

Based on record review, policy review, and interview, the facility failed to recognize and address nutritional needs timely when weight loss of greater than 10% was identified for one Resident (#3), out of a total sample of 13 residents. Specifically, the facility failed to: -notify the Registered Dietician (RD) and Physician/ Nurse Practitioner (NP) timely when the significant weight loss occurred, -implement a recommendation from the RD to obtain labs for Resident #3, -obtain a re-weigh and implement nutritional interventions timely, resulting in a two week delay of care. Findings include: Review of the facility policy titled Weight Assessment and Intervention, undated, indicated: -Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Registered Dietitian (RD) in writing. Verbal notification must be confirmed in writing. -The RD will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: >1 month- 5% weight loss is significant, greater than 5% is severe >3 months- 7.5% weight loss is significant, greater than 7.5% is severe >6 months- 10% weight loss is significant, greater than 10% is severe -Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: >Resident's target weight range >Approximate calorie, protein, and other nutrient needs compared with the Resident's current intake. >The relationship between current medical condition or clinical situation and recent fluctuations in weight; and > Whether and to what extent weight stabilization or improvement can be anticipated. -The Physician and multidisciplinary team will identify conditions and medications that may be causing Anorexia (eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight), weight loss, or increasing weight loss. For example: >Cognitive or functional decline >Chewing or swallowing abnormalities >Pain >Medication-related adverse consequences >Environmental factors >Increased need for calories and/or protein >Poor digestion or absorption Resident #3 admitted to the facility in April 2023 with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Dysphagia (difficulty swallowing), Other Feeding Difficulties, Anemia (condition that develops when the blood produces a lower than normal amount of red blood cells and/or hemoglobin [protein in red blood cells that carries oxygen from the lungs to other organs/tissues] to carry oxygen to the body's tissues), and Celiac Disease (chronic digestive and immune disorder that damages the small intestine when the body has a reaction to gluten). Review of the Resident's Care Plan for Risk of GI (Gastro-Intestinal) Distress related to Celiac Disease, initiated 4/6/23, indicated the following interventions: -Labs as ordered, initiated 4/6/23 -Monitor for signs and symptoms of nausea, vomiting, diarrhea, bloated stomach, weight loss, constipation, gas, initiated 4/6/23 Review of the Resident's Care Plan for Nutritional Status, initiated 6/19/23, indicated the following: -The Resident had an inability to tolerate regular texture meals as evidenced by the need for altered texture diet and increased risk of aspiration (when something such as food or liquid enters your airway or lungs by accident which may cause serious health problems such as pneumonia) related to dysphagia. -1:1 (one staff to be with the Resident) for all oral intake, initiated 6/19/23 -Diet as ordered, initiated 6/19/23 -Maintain adequate intake greater than 50% of most meals, initiated 6/19/23 -Continue to provide supervision for all meals, initiated 6/23/23 Review of the MDS (Minimum Data Set) Assessment, dated 5/24/24, indicated the Resident: -Had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of a total 15 -Required setup assistance with eating tasks -Had no indicators of swallowing difficulties -Last weight was 138 lbs -Had a weight loss of 5% or more in the past month and greater than 10% in the last 6 months -Had a mechanically altered diet (a type of texture-modified diet for people who have difficulty chewing and swallowing) -Had a therapeutically altered diet (a meal plan where foods and/or nutrients are adjusted to assist with controlling medical conditions or symptoms) Review of the May 2024 Physician's orders for Resident #3 indicated: -Weights Monthly, initiated 5/16/23 -Diet: >Puree with Thin Liquids Gluten Free, >lip plate (a rimmed plate) with all meals, >slow pace cues 1 bite, 1 sip at a time, >1:1 supervision, initiated 3/18/24 -Ensure Original Liquid (a liquid nutritional supplement), give 237 milliliters (mls) by mouth twice daily at 8:00 A.M. and 5:00 P.M., initiated 4/24/24 Review of Resident #3's Weights and Vitals Report provided by the facility on 6/5/24 indicated: -12/12/23: 150.0 lbs (pounds) -1/9/24: 154.0 lbs -2/13/24: 154.1 lbs -3/12/24: 156.4 lbs -4/9/24: 140 lbs (-10.49% change from 3/12/24) -5/14/24: 138.3 lbs (-1.2% change from 4/9/24 and -11.5% since 3/12/24) Review of the RD's Nutrition Progress Notes indicated the following: -3/3/24: Resident was able to eat his/her meal with minimal assistance. A few months ago, he/she needed more feeding assistance but lately, he/she initiated self-feeding. Weight remains stable at 154# (lbs), continues with gluten free (therapeutic diet) and puree (mechanically altered texture) diet. Intake is excellent, eating 100% of most meals. Will continue to monitor weight, intake, and skin. -4/16/24: (recorded as late entry note on 4/22/24) - A re-weight has been requested due to a 16-lb. weight change over the course of one month, despite the Resident maintaining excellent intake We scheduled him/her to be weighed the following day. Will follow up regarding accuracy. -4/23/24: The recent weight measurement shows a further decline, now at 133 lbs compared to 154 lbs during the annual check-up (3/12/24) indicating a -21 lbs. weight change and -7 lbs. since the beginning of April 2024. The Resident's IBW (Ideal Body Weight) is 130 lbs. +/- 10% (117-143 lbs.), and he/she is currently within ideals, and therefore weight loss is not warranted at this time. Nursing is aware of the weight loss and will notify the Nurse Practitioner/Medical Doctor. Despite being on a gluten-free puree diet, the Resident's meal intake ranges from 60-80%. He/she .requires assistance with feeding on occasion. Recommend initiating Ensure twice daily to help prevent further weight loss and obtain labs. Will remain involved and reassess. -6/2/24: His/her recent weight is 138 pounds, with no significant change over the past month. Staff report good intake of his/her supplement, Ensure [supplement] 237 mls twice daily. The last labs obtained on 1/3/24 were reviewed and were within normal limits which was improved since 10/18/23. The plan indicated to continue to monitor weight, intake, and skin. Further review of the Nutrition Progress Notes did not indicate that labwork was obtained and/or referenced per the previous RD recommendation on 4/23/24. Review of the Nursing Progress Notes dated 4/24/24, indicated: -Following recent weight loss, NP (Nurse Practitioner) [was] called with the Dietician's recommendations. -New orders for Ensure twice daily to prevent further weight loss. -Family notified. -Plan of care ongoing. Review of the Medical Record failed to indicate documentation of the weight of 133 lbs. referenced in the Nutrition Note on 4/23/24 and that labwork was obtained per the RD recommendations when the Resident's weight loss was verified. Further review of Resident #3's Medical Record failed to indicate: -that a re-weight was obtained for verification the day after the 4/9/24 weight, which indicated a significant weight loss of 16.4 lbs. in one month (10.49% loss). -that the NP or the Medical Doctor (MD) was notified. -that the NP or Medical Doctor evaluated the Resident for nutritional risk and/or impaired nutrition when the significant weight loss was identified after the re-weight was obtained on 4/23/24. During an interview on 6/4/24 at 2:43 P.M. the RD said that she prints a weight report on her weekly visits and reviews the report to see if there are any changes or discrepancies. The RD said she was not notified by Nursing of Resident #3's weight loss on 4/9/24 but discovered the weight change when reviewing the weekly weight report. The RD said that she notified Nursing of Resident #3's weight loss and recommended that labs be obtained. The RD further said that she was unable to confirm if more frequent weights were obtained between 4/9/24 and 5/14/24 as none were documented in the Weights and Vitals Report. The RD said that her recommendation for labs on 4/23/24 was verbally communicated to the nursing staff for follow-up with the MD or NP. The RD said that she would want a normal panel of labs such as a TSH (Thyroid Stimulating Hormone - measurement of thyroid levels in the blood), Albumin Levels (measurement of liver protein in the blood. Low levels would indicate kidney or liver issues) and H and H (Hematocrit and Hemoglobin - measurements of protein and red blood cells. Low levels could indicate Anemia [lower than normal amount of red blood cells]). The RD said Resident #3 did not have any labwork obtained since the RD's 4/23/24 recommendation, and that she did not recommend additional labs in her 6/2/24 note. The RD said that she did not have any direct communication regarding Resident #3's weight loss/nutritional status with the NP or MD, and that she relied on Nursing to communicate any dietary recommendations to the MD or NP. During an interview on 6/5/24 at 9:16 A.M., the NP said that when a Resident experiences a weight loss, the facility would typically re-weigh the Resident to verify the weight loss, do weekly weights for 4 weeks to see if the Resident's weight was stable, would add nutritional supplements, review the Resident's intake and appetite, perform a KUB (Kidney Ureter Bladder scan) to determine if there was constipation, obtain updated labwork, and do a medication review for concerns for sedation (the calming of mental excitement or abatement of physiological function, especially by the administration of a drug). The NP said that typically the Director of Nursing (DON) or Nursing staff communicate to her any weight loss. The NP said she was available Monday through Friday 8:00 A.M. to 5:00 P.M. and that her office has on-call staff that are available afterhours. The NP said that she had not communicated with the RD directly. The surveyor and the NP reviewed Resident #3's record and the NP said that labwork for Resident #3 had not been obtained since 1/3/24. The NP further said Resident #3's weight loss from 3/12/24 to 4/9/24 was concerning and that she was not notified of the Resident's weight loss but was notified of the recommendation to add the Ensure supplement twice daily on 4/24/24. During an interview on 6/5/24 at 9:45 A.M., the Unit Manager (UM) said the CNA's (Certified Nurses Aides) were to obtain weights as ordered by the MD and document them in the medical record. The UM said that if a resident had an identified weight loss, the Nursing staff would contact the RD, the MD or NP, and the resident's family to discuss the weight loss. The UM said she would expect to be notified of the weight loss to begin an assessment which would include ordering labwork, review of the Resident's ability to eat, bowel regimen, review of any issues with pain, mouth or dental needs, and medications. The UM said that she had not participated in any multidisciplinary meetings relative to residents at risk or experiencing weight loss. During an interview on 6/5/24 at 10:08 A.M, the DON said that the process regarding weight assessment for Resident #3 was not followed and should have been.

Based on review and interview, the facility failed to provide evidence that the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to provide evidence that at least eight consecutive hours of RN coverage was provided on 5/4/24 and 5/11/24, when no Nurse staff waivers were in place, and there was no Director of Nursing (DON) serving as a charge nurse placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses' Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Findings include: Review of the Daily Nurse Staff Schedule provided by the facility for 5/1/24 through 5/31/24 indicated no evidence that the required eight consecutive hours of RN covered was provided on Saturday 5/4/24 and Saturday 5/11/24. During an interview on 5/30/24 at 4:58 P.M., the facility Scheduler said the facility was not able to have RN coverage for 5/4/24 and 5/11/24. During an interview on 5/31/24 at 2:21 P.M., the Director of Nursing (DON) said she was not employed in the facility at the time and could not have covered Saturday 5/4/24 or Saturday 5/11/24 as a charge nurse. During an interview on 5/30/24 at 5:09 P.M., the facility Administrator said the facility had no RN coverage for 5/4/24 and 5/11/24.

Based on observation, record review, policy review, and interview, the facility failed to ensure that the medication error rate was not five percent (5%) or greater when Nurse #1 made four errors out of 25 opportunities, resulting in a medication error rate of 16% for two Residents (#9 and #4). Specifically, Nurse #1 failed to: 1. For Resident #9, a. administer the correct dose of Cholecalciferol (Vitamin D3 - drug class vitamin used to treat Vitamin D deficiency) medication. b. observe and encourage the Resident to completely take all of his/her MiraLAX (used to treat constipation) medication. 2. For Resident #4, a. accurately check the Resident's blood pressure and heart rate as ordered prior to administering Metoprolol (used to lower blood pressure) medication. b. offer and encourage the Resident to rinse his/her mouth after administering orally inhaled medication to prevent fungal infections. c. administer the correct dose of Vitamin B12 medication per Physician's Orders. Findings include: Review of the facility policy titled Administering medications, revised 2012, indicated the following: -Vital signs must be checked/verified for each resident prior to administering medications, if necessary. -The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. -Medication must be administered in accordance with the orders, including any required time frame. 1. Resident #9 was admitted to the facility in February 2024, with diagnoses including CVA (cerebrovascular accident or stroke: [damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area]), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). On 5/31/24 at 7:36 A.M., during a medication pass procedure, the surveyor observed Nurse #1 prepare and administer the following medications to Resident #9: -Cholecalciferol (Vitamin D3) 25 micrograms (mcg) - 1 tablet (not two tablets as ordered) -Buspirone (used to treat general anxiety disorder) 15 milligram (mg) - 1 tablet -Metformin (used to control blood sugar) 500 mg - 1 tablet -MiraLAX 17 grams (g) (used to soften stool) - 1 scoop -Atorvastatin (used to control cholesterol in the blood) 20 mg - 1 tablet -Escitalopram (used to control Depression) 10 mg - 1 tablet The surveyor observed Nurse #1 pour the MiraLAX powder 17 grams into a cup with water, entered Resident #9's room and handed Resident #9 the previously prepared medications in a cup. The surveyor observed that the Resident swallowed the medications with a sip of the water that contained the MiraLAX powder which had settled at the bottom of the water in the cup. The Resident was observed to place the remaining water with the MiraLAX powder on the table. The surveyor observed that the Nurse exited the room without ensuring that the Resident drank all the MiraLAX medication. Review of Resident #9's May 2024 Medication Administration Records (MAR) indicated: -8:00 A.M., Vitamin D3 25 mcg - 2 tablets -8:00 A.M., Buspirone 15 mg - 1 tablet -8:00 A.M., Metformin 500 mg - 1 tablet -8:00 A.M., MiraLAX 17 gm - 1 scoop, mix in 6 ounces fluid of choice -8:00 A.M., Atorvastatin 20 mg - 1 tablet -8:00 A.M., Escitalopram 10 mg - 1 tablet 2. Resident #4 was admitted to the facility in February 2024, with diagnoses including Hypertension (high blood pressure), Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs), Coronary Artery Disease (CAD: heart condition that occurs when fatty deposits of plaque build up in the coronary arteries causing them to narrow and restrict blood flow to the heart) and Depression. On 5/31/24 at 7:50 A.M., the surveyor observed Nurse #1 prepare and administer the following medications to Resident #4: -Vitamin B12 (used to strengthen the immune system) 100 mcg, 1 tablet -GERI KOT (used to soften stool) 8.6 mg, 2 tablets -Magnesium Oxide 400 mg, 1 tablet -Fluticasone furoate/Vilanterol Ellipta Inhalation powder (Breo Ellipta)100 mcg/25 mcg -Buspirone (used to treat depression) 15 mg, 1 tablet -Sertraline (used to treat depression)100 mg, 1 tablet -Sertraline 25 mg, 3 tablets -Famotidine (used to treat acid reflux) 20 mg, 1 tablet -Metoprolol (used to control blood pressure) 50 mg, 1 tablet -Creon 6 (helps to digest food) 6000 international unit (IU), 1 capsule -Refresh eye drops a. The surveyor observed Nurse #1 enter Resident #4's room with a blood pressure cuff and the previously prepared medications in a medication cup. Nurse #1 wrapped the blood pressure cuff on Resident #4's right lower arm, (closest to the wrist), inflated the cuff, then deflated the cuff and removed the cuff from the Resident's arm. The surveyor did not observe Nurse #1 use a stethoscope while obtaining the blood pressure measurement. b. The surveyor further observed Nurse #1 remove a tissue from her pocket, instilled one drop of the Refresh eye drop into each of Resident #4's eyes and then wiped both of the Resident's eyes with the same tissue. Nurse #1 then gave Resident #4 the Breo Ellipta inhaler and the Resident inhaled one puff of the medication orally. The surveyor observed Nurse #1 exit the Resident's room and placed the Breo Ellipta inhaler medication, and the Refresh eye drop together with the blood pressure cuff back into the medication cart. The surveyor observed that Nurse #1 entered Resident #4's blood pressure reading into the electronic medical record (EMR) as 127/68 mmHg (millimeters of mercury). When the surveyor asked Nurse #1 how the blood pressure reading was obtained, Nurse #1 said she forgot her stethoscope. Nurse #1 then said she needed to obtain Resident #4's heart rate. The surveyor observed Nurse #1 re-enter Resident #4's room and held his/her hand, then said she needed to look for a watch. Nurse #1 was observed walking around the unit asking the other staff members if anyone had a watch. At 8:27 A.M., Certified Nurses Aide (CNA) #1 brought Nurse #1 a wall clock. Nurse #1 took the wall clock from CNA #1, entered Resident #4's room, held the Resident's hand while watching the clock for about 30 seconds, then exited the room and documented a heart rate of 76 bpm (beats per minute). During an interview on 5/31/24 at 8:41 A.M., the Director of Nursing (DON) said a blood pressure measurement cannot be obtained with just a blood pressure cuff and without a stethoscope. The DON said that the blood pressure reading of 127/68 mmHg for Resident #4 documented by Nurse #1 was an error. On 5/31/24 at 8:45 A.M., Unit Manager (UM) #1 came to the unit and assumed responsibility of the medication cart from Nurse #1 and UM #1 continued with the medication administration procedure to the unit residents. Review of Resident #4's May 2024 Physician Orders indicated: -Artificial Tears one drop into each eye ordered 2/15/24 -Breo Ellipta 100-25 mcg one puff inhale into lungs once daily, rinse mouth after each use ordered 2/20/24 -Buspirone 15 mg tablet, ordered 2/20/24 -Creon 6,000-unit capsule, ordered 2/20/24 -Famotidine 29 mg tablet, ordered 4/24/24 -Furosemide 40 mg tablet, ordered 2/20/24 -Magnesium Oxide 400 mg tablet, ordered 2/15/24 -Metoprolol 50 mg tablet, ordered 4/24/24 -Senna 8.6 mg (2) tablets, ordered 2/15/24 -Sertraline 100 mg tablet, ordered 2/20/24 -Sertraline 25 mg (3) tablets, ordered 2/20/24 -Vitamin B12 500 mcg tablet, ordered 2/15/24 Review of Resident #4's May 2024 MAR indicated: -8:00 A.M., Artificial Tears 1 drop into each eye -8:00 A.M., Breo Ellipta 100-25 mcg inhaler, one puff into lungs once daily, rinse mouth after each use. -8:00 A.M., Buspirone 15 mg, 1 tablet -8:00 A.M, Creon 6,000 IU, 1 capsule -8:00 A.M., Famotidine 20 mg, 1 tablet -8:00 A.M., Furosemide 40 mg, 1 tablet -8:00 A.M., Magnesium 400 mg, 1 tablet -8:00 A.M., Metoprolol 50 mg, 1 tablet, hold for systolic blood pressure less than 100 and heart rate less than 50 -8:00 A.M., Senna 8.6 mg, 2 tablets -8:00 A.M., Sertraline 100 mg, 1 tablet -8:00 A.M., Sertraline 25 mg, 3 tablets -8:00 A.M., Vitamin B12 500 mcg, 1 tablet During an interview on 5/31/24 at 11:03 A.M., UM #1 said Resident #9 should have received two tablets of Vitamin D3 and Nurse #1 should have observed Resident #9 drink the entire cup of water mixed with the MiraLAX medication as ordered by the Physician. UM #1 also said that a blood pressure and heart rate measurements should have been obtained before Nurse #1 administered the Metoprolol medication to Resident #4. UM #1 further said that Nurse #1 should have given Vitamin B12 500 mcg, not 100 mcg to Resident #4 and that Resident #4 should have rinsed his/her mouth after using the oral inhaler. During an interview on 5/31/24 at 11:47 A.M., the DON said she would report to the Medical Doctor (MD) about Resident #9 receiving 1 tablet of Vitamin D3 instead of 2 tablets and that it was an error. The DON further said she would report to the MD about Resident #4 receiving Metoprolol without a blood pressure and heart rate reading, that the Resident #4 received Vitamin B12 100 mcg instead of 500 mcg and the Resident did not rinse his/her mouth after orally inhaling Breo Ellipta Medication and that these are medication errors. Please Refer to F760 and F880

Based on observation, interview, record and policy review, the facility failed to ensure that the facility residents were free of significant medication errors for one Resident (#4) out of five residents observed, out of a total sample of 13 residents, during the medication pass process. Specifically, for Resident #4, the facility staff failed to assess blood pressure and heart rate parameters as ordered prior to administering Metoprolol (used to treat high blood pressure) medication. Findings include: Review of the facility policy titled Administering medications, revised 2012, indicated the following: -Vital signs must be checked/verified for each resident prior to administering medications, if necessary. -The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. -Medication must be administered in accordance with the orders, including any required time frame. Resident #4 was admitted to the facility in February 2024 with a diagnosis including Hypertension (high blood pressure), Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs), and Coronary Artery Disease (CAD: heart condition that occurs when fatty deposits of plaque build up in the coronary arteries causing them to narrow and restrict blood flow to the heart). Review of Resident #4's May 2024 Physician's orders indicated: -Artificial Tears: one drop into each eye, ordered 2/15/24 -Breo Ellipta: 100-25 mcg one puff inhale into lungs once daily, rinse mouth after each use, ordered 2/20/24 -Buspirone: 15 mg tablet, ordered 2/20/24 -Creon: 6,000-unit capsule, ordered 2/20/24 -Famotidine: 29 mg tablet, ordered 4/24/24 -Furosemide: 40 mg tablet, ordered 2/20/24 -Magnesium Oxide: 400 mg tablet, ordered 2/15/24 -Metoprolol: 50 mg tablet, ordered 4/24/24 -Senna: 8.6 mg (2) tablets, ordered 2/15/24 -Sertraline: 100 mg tablet, ordered 2/20/24 -Sertraline: 25 mg (3) tablets, ordered 2/20/24 -Vitamin B12: 500 mcg tablet, ordered 2/15/24 Review of Resident #4's May 2024 Medication Administration Record indicated: -8:00 A.M., Artificial Tears 1 drop into each eye -8:00 A.M., Breo Ellipta 100-25 mcg inhaler, one puff into lungs once daily, rinse mouth after each use. -8:00 A.M., Buspirone 15 mg, 1 tablet -8:00 A.M., Creon 6,000 IU, 1 capsule -8:00 A.M., Famotidine 20 mg, 1 tablet -8:00 A.M., Furosemide 40 mg, 1 tablet -8:00 A.M., Magnesium 400 mg, 1 tablet -8:00 A.M., Metoprolol 50 mg, 1 tablet, hold for systolic blood pressure less than 100 and heart rate less than 50 -8:00 A.M., Senna 8.6 mg, 2 tablets -8:00 A.M., Sertraline 100 mg, 1 tablet -8:00 A.M., Sertraline 25 mg, 3 tablets -8:00 A.M., Vitamin B12 500 mcg, 1 tablet On 5/31/24 at 7:50 A.M., the surveyor observed Nurse #1 prepare and administer the following medications to Resident #4: -Vitamin B12 (used to strengthen immune system)100 mcg, 1 tablet -GERI KOT (used to soften stool) 8.6 mg, 2 tablets -Magnesium Oxide 400 mg, 1 tablet -Fluticasone furoate/Vilanterol Ellipta Inhalation powder (Breo Ellipta) 100 mcg/25 mcg -Buspirone (used to treat depression) 15 mg, 1 tablet -Sertraline (used to treat depression )100 mg, 1 tablet -Sertraline 25 mg, 3 tablets -Famotidine (used to treat acid reflux) 20 mg, 1 tablet -Metoprolol (used to control blood pressure) 50 mg, 1 tablet -Creon 6 (helps to digest food) 6000 international unit (IU), 1 capsule -Refresh eye drops The surveyor did not observe Nurse #1 obtaining an appropriate blood pressure measurement or heart rate parameters before administering the Metoprolol medication to Resident #4. During an interview on 5/31/24 at 11:03 A.M., Unit Manager (UM) #1 said Nurse #1 should have obtained Resident #4's blood pressure and heart rate before she administered the Metoprolol medication to the Resident. During an interview on 5/31/24 at 11:47 a.m., the Director of Nursing (DON) said she would report to the Medical Doctor (MD) about Resident #4 receiving the Metoprolol medication without the blood pressure and heart rate measurements. The DON further said that Nurse #1 had been sent home.

Based on observation, interview and policy review, the facility failed to ensure that infection control standards of practice were followed by Nurse #1 to prevent the spread of infections during the medication administration process for two Residents (#9 and #4) out of five residents observed, out of a total sample of 13 residents. Specifically, the facility failed to ensure that Nurse #1 performed appropriate hand hygiene before and after the medication administration process for Resident #9 and before and after the administration of eye drops for Resident #4. Findings include: Review of the Centers for Disease Control (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, revised April 12, 2024 (reference CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings | Infection Control | CDC) indicated the following: -Use Standard Precautions to care for all patients in all settings. -Standard Precautions include: hand hygiene -Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. -These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients. Review of the facility policy titled Employees' Responsibilities for Infection Prevent and Control, not dated, indicated All employees of this facility are responsible for practicing good infection prevention and control measures and for carrying out the policies and procedures instituted by the facility, such as hand hygiene and personal hygiene. Review of the facility policy titled Be Involved in [Resident] Care, undated, indicated: -Be aware that germs can spread on the hands of healthcare workers. -Practicing good hand washing can reduce [Resident] risk of infection. -Know that all healthcare workers are expected to use hand hygiene before they touch [a Resident], [Resident's] surroundings, and afterwards. Review of the facility policy titled, Administering Medications, revised December 2012 indicated: -Staff shall follow established facility infection control procedures for the administration of medications including eye drops . Resident #9 was admitted to the facility in February 2024, with diagnoses including CVA (cerebrovascular accident or stroke: [damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area]), Anxiety (feeling of unease, such as worry or fear, that can be mild or severe/ intense, excessive, and persistent worry and fear about everyday situations), Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood). On 5/31/24 at 7:36 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #9. The surveyor did not observe Nurse #1 performing hand hygiene before or after the medication administration process. Resident #4 was admitted to the facility in February 2024, with diagnoses including Hypertension (high blood pressure), Heart Failure (HF: when the heart is unable to pump blood as it should resulting in fluid buildup in the feet, arms, lungs and other organs), Coronary Artery Disease (CAD: heart condition that occurs when fatty deposits of plaque build up in the coronary arteries causing them to narrow and restrict blood flow to the heart) and Depression. On 5/31/24 at 7:50 A.M., the surveyor observed Nurse #1 prepare and administer medications including eye drops to Resident #4. The surveyor observed that Nurse #1 did not perform hand hygiene before and after the eye drop administration. The surveyor further observed that Nurse #1 removed a tissue from her pocket, instill one drop of the eye drop medication to each eye of the Resident, then wiped both of the Resident's eyes with the same tissue, and discarded the tissue. During an interview on 5/31/24 at 8:40 A.M., Nurse #1 said she had been very busy and forgot to perform hand hygiene during the medication administration process. During an interview on 5/31/24 at 12:44 P.M., the Director of Nursing (DON) said Nurse #1 had been sent home. The DON said Nurse #1 should have washed and/or sanitized her hands before and after administering the eye drop medication for Resident #4.

Based on interview, record review, and policy review, the facility failed to offer the Pneumococcal Vaccination as recommended for three Residents (#5, 10, and #18) out of five applicable Residents, in a total sample of 13 Residents, putting the residents at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that: 1. Resident #5's immunization consent form was complete and accurate, and the Resident was offered any eligible Pneumococcal Vaccination after admission to the facility. 2. Resident #10 was offered, received or declined any eligible Pneumococcal Vaccination after admission to the facility. 3. Resident #18 was offered, received, or declined any Pneumococcal Vaccination after admission to the facility. Findings include: Review of the CDC (Centers for Disease Control) website: Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years (cdc.gov), dated 3/15/23 indicated but was not limited to the following: -For adults 65 and over who have not had any prior Pneumococcal Vaccines, then the patient and provider may choose Pneumococcal Conjugate Vaccine (PCV) 20 or PCV15 followed by Pneumococcal Polysaccharide Vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23), and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). Review of the facility policy titled Pneumococcal Vaccination of Residents last revised 9/2022, indicated the following: -Each Resident or their responsible party will be asked on admission if they have previously received either the Prevnar 13/15 or the Polysaccharide 23 or the Prevnar 20 Pneumococcal vaccine. -The records that accompany the Resident will be used to determine immunization status. -The facility will contact the Resident's PCP to obtain all previous vaccination records on file. -If there is no evidence of vaccination, the Resident will be offered the appropriate vaccine at that time. -The Resident and/or their responsible party will be educated on the risks and benefits of the pneumococcal vaccine. -Pneumococcal candidates for vaccination: >[AGE] years or older >Serious long term health problems >Resistance to Infection -Procedure: >Obtain consent >Educate Resident and/or responsible party >Document vaccination in IMAR (Medication Administration Record) 1. Resident #5 was admitted to the facility in September 2023, and was over the age of 65. Review of the MIIS (Massachusetts Immunization Information System) record provided by the facility indicated that Resident #5 had his/her last Pneumococcal Vaccination (PCV13) in July 2018. Review of the Consent for Immunization Form, dated 10/10/23, indicated the Pneumococcal (PPV23) Vaccine was already received this season, but the form failed to indicate the date the Resident received the PPV23 Vaccine. Review of the Consent for Immunization Form, dated 5/31/24, indicated a verbal consent was obtained from the Responsible Party consenting to the PCV13 Pneumococcal Vaccination. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #5 based on his/her history of Pneumococcal vaccination: -Based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Review of the Medical Record failed to indicate Resident #5 had a medical contraindication to or had been offered, received, or declined the appropriate Pneumococcal Vaccination on admission to the facility when the Resident was eligible for an updated dose prior to 5/31/24. 2. Resident #10 was admitted to the facility in January 2023, and was over the age of 65. Review of the MIIS record provided by the facility indicated Resident #10 had his/her last Pneumococcal Vaccination (PCV13) in June 2015. Review of the Consent for Immunization Form, dated 5/31/24, indicated a verbal consent was obtained from the Responsible Party consenting to the PCV13 Pneumococcal Vaccination. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #10 based on his/her history of Pneumococcal vaccination: -Give one dose of PCV20 at least 1 year after PCV13 or give one dose of PPSV23 at least 8 weeks after PCV13. Review of the Medical Record failed to indicate Resident #10 had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination on admission to the facility when the Resident was eligible for an updated dose prior to 5/31/24. 3. Resident #18 was admitted to the facility in July 2023 and was over the age of 65. Review of the MIIS record provided by the facility indicated that Resident #18 had his/her last Pneumococcal Vaccination (PPSV23) in December 2008. Review of the Consent for Immunization Form, dated 6/3/24, indicated a verbal consent was obtained from the Responsible Party consenting to PCV13 Pneumococcal Vaccination. Review of the CDC Pneumovax Advisor tool indicated the following recommendation for Resident #18 based on his/her history of Pneumococcal Vaccination: -Give one dose of PCV15 or PCV20 at least 1 year after the last dose of PPSV23. Review of the Medical Record failed to indicate Resident #18 had a medical contraindication to or had been offered, received, or declined a Pneumococcal Vaccination on admission to the facility when the Resident was eligible for an updated dose prior to 6/3/24. During an interview on 6/4/24 at 1:36 P.M., the Director of Nursing (DON), who also served as the facility Infection Preventionist (IP), said that the facility should have offered Pneumococcal Vaccinations to Residents #5 and #10 prior to 5/31/24, and to Resident #18 prior to 6/3/24 and had not, as required.

Based on interview and record review, the facility failed to accurately code Minimum Data Set (MDS) assessments for one Resident (#27) out of a total sample of 13 residents. Specifically, for Resident #27, the facility staff failed to accurately code two consecutive MDS assessments relative to Hospice services. Findings include: Resident #27 was admitted to the facility in December 2023 with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language) and Intraductal Carcinoma of the breast (a non-invasive or pre-invasive breast cancer). Review of Resident #27's clinical record indicated a Skilled Nursing Facility Notification Form that reflected the Resident had been started on Hospice services effective 9/8/23. Review of the Admission Progress Notes dated 12/27/23, indicated Resident #27 was admitted to the facility on Hospice services. Further review of the Resident's clinical record included a Nutrition Progress Note dated 5/30/24, that indicated Resident #27 continued under the care of Hospice services. Review of Resident #27's MDS assessments dated 12/26/24 and 3/8/24, did not indicate that the Resident was receiving Hospice services. During an interview on 6/5/24 at 7:58 A.M., the MDS Coordinator said that she had worked at the facility since the end of December 2023 and was responsible for coding MDS information for all residents in the facility. The MDS Coordinator said the MDS assessments dated 12/26/23 and 3/8/24, were coded incorrectly because the assessments did not reflect that Resident #27 was receiving Hospice services.

Based on observation, policy review, interview, and record review, the facility failed to ensure its staff implemented appropriate infection control practices related to the use of Personal Protective Equipment (PPE) on two out of two units and also failed to implement a surveillance plan for the presence of Legionella. Specifically, the facility failed to: 1) ensure the proper use of wearing face masks while on the unit, 2) ensure the proper removal of face masks and cleaning of eye protection when exiting a resident room with a known COVID-19 infection, 3) provide trash receptacles inside of resident rooms who were on transmission based precautions, to allow for the removal of contaminated PPE prior to exiting the room on one of two units, 4) ensure staff wore the appropriate PPE to enter a resident room with a known COVID-19 infection, and 5) implement a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility. Findings include: Review of the facility policy titled Use of Personal Protective Equipment (PPE), undated, indicated: -All long-term care facility personnel should wear a face mask while on nursing units. -Full PPE should be worn before entering the room of any resident with known or suspected COVID-19 per Centers for Disease Control (CDC) guidance. Upon exiting room Full PPE (including mask) should be removed, hands washed and a new mask put on. (Eye (protection) can be wiped down with provided wipes). Review of the Massachusetts Department of Public Health (DPH) Memorandum titled: Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/22, indicated that - All long-term care facility personnel should wear a face mask while they are in the facility. 1) The facility failed to ensure that its staff followed the facility protocol relative to the use of Personal Protective Equipment (PPE). Specifically, the proper wearing of face masks while on the resident care unit. During an obseravtion on 1/5/23 at 7:52 A.M., the surveyor observed Nurse #1 wearing her face mask below her chin while checking resident food trays. When the surveyor approached, Nurse #1 adjusted her face mask to cover her nose and mouth, and did not perform hand hygiene after touching the mask. When asked Nurse #1 said that she gets hot sometimes and just puts the face mask down for a bit. Nurse #1 said that she has had training on the proper way to wear a face mask and was aware that she should always have her face mask covering her nose and mouth, also that if she touches her face mask she should replace it and wash her hands, but she had not done either today as she should have. During an observation on 1/5/23 at 8:36 A.M., the surveyor observed Nurse #1 standing at the medication cart continuing to wear her mask below her nose. Nurse #1 was also observed touching her face mask repeatedly without performing hand hygiene afterward. During an interview on 1/5/23 at 9:46 A.M., the Director of Nursing (DON) said there was an expectation that staff face masks should always cover the nose and the mouth, and if the staff member touches their mask they should perform hand hygiene. 2) The facility failed to ensure that it's staff followed the facility protocol relative to the use of Personal Protective Equipment (PPE). Specifically, the doffing (removal) of face mask and cleaning of eye protection when exiting a resident bedroom with known COVID-19 infection. During an observation and interview on 1/5/23 at 7:47 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 exiting room [ROOM NUMBER] on the second floor of the facility. There was an isolation precaution sign posted outside the bedroom door of room [ROOM NUMBER]. CNA #1 removed his gown and gloves just inside the door, and performed hand hygiene. CNA #1 did not remove/replace his mask and sanitize/replace his face shield upon exiting the bedroom and proceeding down the second floor hallway. When asked what the process was for doffing PPE upon exiting a resident bedroom that was designated as an isolation precaution bedroom, CNA #1 explained that when he exits a precaution room, he takes off his gloves and gown, washes his hands, but does not clean his face shield until he goes to another room and that he keeps the same mask on throughout the day. During an interview on 1/5/23 at 9:46 A.M., the DON said that if a CNA was exiting a COVID-19 positive resident room that was designated with isolation precautions and then going to another COVID-19 positive isolation precaution resident bedroom, they did not need to change their mask or sanitize their face shield. She said that the only time the staff are directed to change their face mask and cleanse their face shield was when they were going from a precaution room to a room without precautions. The DON said that she would actually need to check on the policy for PPE use in reference to the doffing upon exiting an isolation precaution bedroom. 37086 3. The facility failed to ensure trash receptacles on Unit One were placed inside of resident rooms who were on transmission based precautions related to an active COVID-19 infection, to allow for the removal of contaminated PPE prior to exiting the room. -During an observation on 1/4/23 at 7:57 A.M., the surveyor observed two Certified Nurse Aides (CNAs) come out of two different resident rooms who were on Isolation Precautions due to active COVID-19 infections. They both had full PPE on (mask, eye protection, gowns, and gloves) and proceeded down the hallway to one of the trash receptacles to remove their PPE. -During an observation on 1/4/23 at 10:30 A.M., the surveyor observed multiple staff coming out of resident rooms on Unit One with full PPE on, who proceeded down the hallway to use one of the trash receptacles to remove their PPE. -During an observation on 1/5/23 at 7:39 A.M., the surveyor observed Nurse #1 exit a resident room that had an Isolation Precaution sign on the door due to an active COVID-19 infection. Nurse #1 exited the room with full PPE on, and proceeded down the hallway. Nurse #1 said that she was the nurse on the upstairs unit and she was headed back upstairs. Nurse #1 said the room was COVID-19 positive and that the sign indicated she was supposed to remove her PPE prior to exiting the room and she did not. During an interview on 1/6/23 at 8:52 A.M., the Director of Nurses (DON) said it was her expectation that the staff remove their PPE prior to exiting an isolation room. She said the staff should not come out of a room with contaminated PPE on. The DON said they had been instructed to remove their contaminated PPE in the room and then bring it to one of the trash receptacles and she didn't know why the staff did otherwise. 4. The facility failed to ensure staff wore the appropriate PPE to enter a resident room with a known COVID-19 infection. During an observation on 1/4/23 at 8:49 A.M., the surveyor observed an Isolation Precaution sign on the door of Resident #26's room that indicated a mask, gown, gloves and eye protection should be worn to enter the room. -During an observation on 1/4/23 at 8:53 A.M., the surveyor observed the Social Worker (SW) in Resident #26's room, setting up drinks for the Resident. The SW had a mask and eye protection on but did not have gloves and a gown on as the Isolation Precaution sign indicated. During an interview on 1/4/23 at 8:55 A.M., the SW said that she thought she only needed to wear a gown and gloves for high contact care and that giving the Resident a straw was not high contact. The SW said the Resident was currently active for COVID-19. 5. The facility failed to implement a surveillance plan to identify the presence of Legionella in the facility. Review of the facility's undated policy, titled Legionella Water Management Program, indicated the following: The water management program includes the following elements: -A detailed description and diagram of the water system in the facility -The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. -Specific measure used to control the introduction and/or spread of Legionella -The control limits or parameters that are acceptable and that are monitored -A diagram of where control measures are applied -A system to monitor control limits and the effectiveness of control measures During an interview on 1/5/23 at 2:50 P.M., the Regional Maintenance Director said that he oversaw several buildings but the last Maintenance Director for this facility left sometime around early November. He said he would have to see what he could find from what the previous Maintenance Director left and would get back to the surveyor with the information. During an interview on 1/6/23 at 10:06 A.M., the Regional Maintenance Director said he could not find anything specific to show the management of Legionella surveillance in the building (no diagrams of the water system or control measures were provided). He said they reached out to a company in December 2022 to assist with Legionella management but had not yet signed a contract with them.

Based on record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. One of two nurses observed failed to administer medications, as ordered, for four of seven Residents (#16, #3, #6, #20) observed. The medication error rate was calculated at 18.52% with 27 opportunities for error. Findings include: 1. During an observation on 1/5/23 at 8:51 A.M., the surveyor observed Nurse #2 administer the following medications (along with other prescribed medications) to Resident #16: -Multivitamin one tablet by mouth. -Polyethylene Glycol (laxative) 3350 17 grams (gm) in 4 ounces of water. Review of the January 2023 Physician's Orders for Resident #16 indicated the following: -Multivitamin with minerals one tablet by mouth daily. -Polyethylene Glycol 3350 17gm in 8 ounces of water. 2. During an observation on 1/5/23 at 9:07 A.M., the surveyor observed Nurse #2 administer the following medication (along with other prescribed medications) to Resident #3: -Calcium 600 milligrams (mg) with Vitamin D3 400 international units (iu) one tablet by mouth. Review of the January 2023 Physician's Orders for Resident #3 indicated the following: -Calcium 600 mg one tablet by mouth daily. 3. During an observation on 1/5/23 at 9:15 A.M., the surveyor observed Nurse #2 administer the following medications (along with other prescribed medications) to Resident #6: -Calcium 600 mg with Vitamin D3 400 iu one tablet by mouth. -Metoprolol (used to treat blood pressure) 25 mg one tablet by mouth. Review of the January 2023 Physician's Orders for Resident #6 indicated the following: -Calcium 600 mg by mouth once a day. - Metoprolol 25 mg Extended Release (ER-formulated to keep dosage at a steady level) one tablet by mouth daily. 4. During an observation on 1/5/23 at 9:34 A.M., the surveyor observed Nurse #2 prepare medications to administer to Resident #20. Nurse #2 placed the following medications in a bag and crushed them: -one Docusate Sodium 100 mg tab -one Vitamin D 1,000 iu tablet -one Metoprolol Succinate ER 50 mg tablet The surveyor intervened and asked Nurse #2 if she should crush the Metoprolol since it's an extended release medication. Nurse #2 said she should not have crushed an extended release tablet. Review of the January 2023 Physician's Orders for Resident #20 indicated the following: -Docusate Sodium 100 mg by mouth daily. -Vitamin D 1,000 iu tablet by mouth daily. -Metoprolol Succinate ER 50 mg tablet by mouth daily. During an interview on 1/5/23 at 10:20 A.M., Nurse #2 took the bottle of Multivitamins out of the medication cart and reviewed it with the surveyor. She said she did not realize that it did not include minerals, as ordered. She then took the bottle of Calcium out and said they had told the Physician that they only had Calcium with Vitamin D, but they never changed the orders to reflect that. Nurse #2 said the Polyethylene Glycol should have been administered in 8 ounces of water and not 4 ounces of water. She said the Metoprolol she administered to Resident #6 was taken from the emergency kit and was not Extended Release, as was ordered by the Physician.

Based on record review and interview, the facility failed to ensure that its staff accurately executed advance directives (a written statement about a resident's wishes regarding medical treatment) for two Residents (#24 and #26) out of a total sample of 12 Residents. Specifically, 1) the facility failed to offer the opportunity to formulate an advanced directive for one Resident (#24), and 2) the facility failed to have an advanced directive reviewed and signed by a Physician for validation for one Resident (#26). Findings include: 1. Resident #24 was admitted to the facility in [DATE]. Review of the clinical record indicated the Massachusetts Order for Life Sustaining Treatment (MOLST) form was blank. Review of the [DATE] Physician's Orders indicated no order for Advanced Directives. During an interview on [DATE] at 7:30 A.M., Nurse #2 said that when there was an emergency, the nurses were supposed to refer to the clinical record and follow the directives on the MOLST. She said the MOLST for Resident #24 was blank and it should have been filled out to determine the Resident's code status. Nurse #2 said if the MOLST was not filled out, they would treat the Resident as a full code (initiate Cardio-Pulmonary Resuscitation-CPR). 2. Resident #26 was admitted to the facility in [DATE]. Review of the clinical record indicated the MOLST was completed by the Resident's Health Care Proxy (HCP) and indicated Do Not Resuscitate (DNR), Do Not Intubate (DNI) and Do Not Transfer to the Hospital. Further review indicated the MOLST was not signed by the Physician. Review of the [DATE] Physician's Orders indicated no order for Advanced Directives. During an interview on [DATE] at 9:58 A.M., the Social Worker reviewed the MOLST and said it should have been signed by the Physician to implement the Advanced Directives.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for the care of a urinary catheter (a tube placed through the urethra into the bladder to drain urine) for one Resident (#19) out of one applicable sampled resident, in a total of 12 sampled residents. Specifically, the facility failed to ensure the catheter tubing was securely placed to prevent possible dislodgement and trauma. Findings include: Review of the facility's undated policy, titled Indwelling Urinary Catheter Care, indicated the following: -Be sure the catheter is properly anchored to prevent accidental tears of the urinary meatus. -Be sure the catheter, drainage system, and bag are properly positioned to maintain urine flow. -Exercise caution with mobility and positioning of the resident to prevent accidental removal. Resident #19 was admitted to the facility in January 2021 with diagnoses including, Benign Prostatic Hyperplasia (prostate enlargement that can interrupt the flow of urine), flaccid neuropathic bladder (can cause urinary retention) and urinary retention. Review of a Minimum Data Set (MDS) assessment, dated 10/31/22, indicated the Resident had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS). During an observation on 1/4/23 at 8:09 A.M., the surveyor observed Resident #19 seated in a wheelchair in his/her room. The Resident had shorts on and the catheter secure device (a device used to anchor the tubing) was in place on the right upper leg but the catheter tubing was not in the device. The catheter tubing came out from the Resident's shorts and was attached to a bed side drainage bag (used to collect the urine). The tubing was loose and not in the secure device. Review of a Urology Consult, dated 11/22/22, indicated a recommendation to ensure the catheter is always in place and not pulling or causing tension and to use a leg bag (a bag used to collect urine which is attached to the Resident's leg instead of a bed side drainage bag) during the day and an overnight drainage (bed side drainage) bag at night. During an observation on 1/4/23 at 1:26 P.M., the surveyor observed the Resident seated in a wheelchair in his/her room. The Resident had shorts on and the catheter secure device was in place on the right upper leg but the catheter tubing was not in the device. During an observation on 1/5/23 at 7:20 A.M., the surveyor observed the Resident asleep in bed with his/her walker next to the bed. The catheter tubing went from the Resident, to the drainage bag, which was hooked on the bottom bar of the walker (not to the bed where the Resident was lying). During an observation on 1/5/23 at 8:32 A.M., the surveyor observed the Resident seated in bed, finishing breakfast. The catheter tubing was placed in the catheter secure device and then drained to the drainage bag, which was hooked on the bottom bar of the walker (not to the bed where the Resident was seated). During an observation on 1/5/23 at 11:18 A.M., the surveyor observed the Resident being wheeled in the wheelchair to attend an activity group. The Resident was holding the catheter tubing up in his/her hand, (higher than bladder level, which could interrupt urine flow) and the drainage bag was attached to the back of the wheelchair. During an interview on 1/5/23 at 1:15 P.M., Certified Nurse Aide (CNA) #2 said he took care of the Resident. He said that sometimes they used a leg bag during the day but he understood they had not used one that day or the day before. CNA #2 said the Resident often moved the catheter drainage bag on their own. During an interview on 1/5/23 at 1:26 P.M., Nurse #1 said that the Resident usually wore a leg bag but she knew he/she had not worn one in the past two days. She said if the bed side drainage bag was in use, it should be close to the Resident.

Based on record review, and staff interview, the facility and its staff failed to ensure that each Resident's medication regimen was modified in conjunction with residents, their families, and/or representative(s). Specifically, the facility staff failed to ensure Resident (#4's) psychotropic consent form was signed by the Resident or Resident's Legal Representative, reflecting the current dose of medication being administered for one out of a total sample of 12 residents. Findings include: Resident #4 was admitted to the facility in September 2022 with diagnoses which included Dementia, Mood Disturbance, Unspecified Psychosis and Anxiety. Review of the Minimum Data Set (MDS) assessment, dated 12/20/22, indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating he/she had severely impaired cognition. Review of the Physician's Orders for Resident #4, dated January 2023, indicated: -Risperidone (Anti-psychotic medication that is used to treat certain mental/mood disorders) 0.25 milligrams (mg) by mouth daily 8:00 A.M., date ordered 11/22/22. -Risperidone 0.25 (mg) by mouth (two tabs at bedtime), date ordered 11/22/22. Review of Resident #4's Medication Administration Record (MAR) for January 2023, indicated he/she was receiving psychotropic medications per Physician's order. Review of the Informed Consent for Psychotropic Administration form, dated 9/27/22, indicated Risperidone 0.25 (mg) daily at 8:00 A.M and Risperidone 0.25 (mg) at bedtime The consent form had been signed by Resident #4's Legal Representative. During an interview and record review on 1/6/23 at 10: 24 A.M., Nurse #2 indicated that the Risperidone informed consent for Resident #4 did not reflect the current dosage being administered and said that a new consent should have been signed with the increased dose of medication.

Based on observation, interview, and record review, the facility failed to ensure routine dental services were provided for one Resident (#24) out of a sample of 12 residents. Findings include: Resident #24 was admitted to the facility in March 2022. During an observation on 1/4/23 at 8:23 A.M., the surveyor observed the Resident in his/her room. He/she had several missing teeth and no dentures or partial dentures were in place. The Resident told the surveyor that he/she had not been seen by a Dentist in some time, but would like to be. Review of the clinical record indicated the consent form for dental services was blank. Further review indicated no evidence the Resident had been seen by a Dentist since admission to the facility. During an interview on 1/5/23 at 9:50 A.M., the Social Worker said they try to obtain consents for dental services upon admission to the facility, but that didn't always happen. She reviewed the clinical record with the surveyor and said the dental consent was left blank and services were not addressed for this Resident as they should have been.

2. For Resident #26 the facility staff failed to ensure resident equipment was clean and in good repair. Resident #26 was admitted to the facility in September of 2016. Review of the Annual Minimum Data Set Assessment, dated 11/12/19, indicated Resident #26 was non-ambulatory and was dependent for locomotion both on and off the unit. During an observation on 12/12/19 at 9:28 A.M., Resident #26's Geri Chair had exposed foam along the entire length of the bilateral chair arms. During an observation and interview on 12/18/19 at 10:47 A.M., with the Director of Nurses (DON), the DON stated the equipment was monitored by the rehabilitation department and she would talk to the Administrator about getting the chair replaced. Based on observation and interview, the facility failed to provide a comfortable environment for two residents (#29 and #8) and maintain equipment for one resident (#26) out of a total sample of 12 residents. Findings include: 1. On 12/12/19 at 10:15 A.M., the surveyor walked down the 1st floor resident hallway and felt a notable decrease in temperature at the end of the hallway and in Room 17. During an observation and interview on 12/12/19 at 10:16 A.M., the surveyor observed Resident #8 standing in his/her room dressed in a sweater with a bulky bathrobe over it. Resident #8 said he/she was cold. The surveyor then observed Resident #29 lying in bed with blankets on; he/she was unable to answer the surveyor's questions. During an observation and interview on 12/12/19 at 10:22 A.M., the surveyor asked the Interim Director of Maintenance to check the temperature in Room 17. He said the temperature in Room 17 was 60 degrees. He said he monitors resident room temperatures every day, but did not keep a log. He also said the temperature in resident rooms should be at least 65 degrees.

Based on record observation, record review and staff interview, the facility failed to develop a comprehensive care plan for 4 residents (#2, #5, #6, #11) in a total sample of 10 residents. Findings include: 1. For Resident #6, the facility failed to develop a care plan for constipation. Resident #6 was cognitively impaired with [DIAGNOSES REDACTED]. The facility failed to develop a care plan to address constipation prior to a hospitalization on [DATE], when the resident was admitted for behavioral problems and was found to be severely constipated with rectal impaction. Following the resident's readmission to the nursing home on 12/26/12, the facility did not revise the care plan to include constipation. A "General Report" from the neuropsychiatry unit at the hospital on [DATE], stated the following, "The medical issue that was also complicated at the time of admission was an acute constipation with impacted rectum, which was acutely distressful for the patient, as he has not moved bowel prior to admission for several days .... Since admission his bowel regimen was started. He moved his bowels." The annual Minimum Data Set ((MDS) dated [DATE], indicated the resident was cognitively impaired and required extensive staff assistance with ambulation and activities of daily living. The resident was incontinent of urine and continent of bowel. The quarterly MDS of 2/25/13, indicated the resident had declined to being incontinent of bowel. the MDS indicated the resident had no pain. At the time of the hospitalization , 12/17/12, the resident was receiving [MEDICATION NAME] (opioid [MEDICATION NAME]) 50 milligrams (mg.) three times a day for pain and had a order to receive an as needed (prn) dose twice a day. According to the Nursing Drug Handbook 2012, one of [MEDICATION NAME]'s side effects is constipation. The resident would have been considered high risk for constipation due to taking [MEDICATION NAME]. Prior to the hospitalization the resident was receiving the following medications for constipation a) [MEDICATION NAME] sodium 100 mg. twice daily; b) [MEDICATION NAME] 8.6 mg. one tablet at hours of sleep; c) [MEDICATION NAME] 10 mg. suppository one rectally daily as needed (prn); d) Milk of Magnesia (MOM) suspension 30 milliliter (ml.) daily as needed (prn) for constipation; e) Fleet enema one rectally daily as needed (prn) for constipation. In addition the Nurse Practitioner (NP) ordered MOM 30 cc's every other day on 12/1/12. The as needed (prn) constipation medications did not include parameters to use when the resident was having specific symptoms/needs i.e., needed more bulk in the stool, needed more fluid in the stool. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility staff were unable to provide any records of bowel movements for the resident for the weeks prior to the rectal impaction. During interview on 4/10/13 at 2:00 P.M., the Director of Nurses (DON) stated that the facility kept a bowel book but pages were thrown out after 2 weeks. On 12/5/13 a nurse's notes indicated that the resident exhibited aggressive and angry behavior. The note indicated positive bowel sounds in all 4 quadrants. Other than this note, there were no nurse's notes following the complaint of constipation on 12/1/12, that addressed the resident's response to increased bowel medication and whether or not the resident had bowel movements. Following the hospitalization the resident received an additional medications for constipation, [MEDICATION NAME] Powder 17 grams (gms.) diluted in fluid daily as well as the previous medications for constipation. The resident had been receiving [MEDICATION NAME] 50 mg. 2 - 3 times a day from 10/5/12 to present, except that from 12/27/12 to 2/18/13, the resident received an as needed dose twice a day. This medication made the resident a high risk for constipation. The resident had no written care plan prior to or following the hospitalization for constipation. 2. For Resident #11 the facility failed to develop a care plan for constipation. Resident #11 was admitted to the facility during 3/2013, following a hospitalization for osteoporotic fractures. The hospital discharge [DIAGNOSES REDACTED]. The hospital discharge summary dated 3/13/13, stated that the physician had been unable to discharge the resident the day before because the resident had not had a bowel movement. The physician ordered a dulcolox suppository and a KUB (A radiographic examination of the abdomen providing information about abdominal organs including kidneys, ureters and bladder). Since admission to the nursing home, the resident was receiving [MEDICATION NAME] (opioid [MEDICATION NAME]) 25 - 50 mg., from as needed to five times a day for pain. According to the Nursing Drug Handbook 2012, one of [MEDICATION NAME]'s side effects is constipation. The resident would have been considered high risk for constipation due to taking [MEDICATION NAME]. The resident received the following medications for constipation a) [MEDICATION NAME] sodium 100 mg. twice daily; b) [MEDICATION NAME] 10 mg. suppository one rectally daily as needed (prn); c) Milk of Magnesia (MOM) suspension 30 milliliter (ml.) daily as needed (prn) for constipation; d) Fleet enema one rectally daily as needed (prn) for constipation. The as needed (prn) constipation medications did not include parameters to use when the resident was having specific symptoms/needs i.e., needed more bulk in the stool, needed more fluid in the stool. Also, resident did not have a bowel regimen that indicated a specific plan to address constipation, i.e.; if the resident did not have a bowel movement in 3 days then one approach would be tried; if that did not produce a bowel movement then another approach would be tried; and if that did not produce a bowel movement then another approach would be tried. The resident's care plan was developed on 3/21/13. It did not include constipation. 3. For Resident #2, the facility failed to develop a comprehensive plan of care addressing the resident's pacemaker including interventions for monitoring the functioning of the device. Record review on 4/9/2013 indicated that Resident #2 was admitted on ,[DATE]. [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Plan entitled "Pacemaker Information" dated 2/10/2013 indicated that the resident had a permanent cardiac pacemaker. The care plan included a section entitled "Frequency of checks". The information contained in the section included "last seen 12/10/12 next appt (appointment) 6/10/13 1:30 P.M. There was no information on the type of pacemaker. There was no information regarding the rate the pacemaker was set at. There were no parameters identified for nursing to notify the physician in the event of pacemaker malfunction. The DON was interviewed on 4/10/13 at 11:00 A.M. regarding the lack of information in the pacemaker care plan. The DON was not able to provide any additional information regarding the pacemaker. 4. For Resident # 5, the care plan did not include the resident preferences for eating. Resident # 5 was admitted to the facility in 7/2005 with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment of 10/26/12 and the quarterly MDS of 1/24/13 coded the resident as requiring supervision with eating and a one-person physical assist for set up. The resident was also coded as having range of motion limitations of both upper and lower extremities with limitations to one side of the resident's body. On observation of the resident during the medication pass on 4/9/13 at 8:55 A.M., the resident was observed to be lying in bed, the head of the bed elevated, and the bilateral quarter top side rails raised. The resident had a meal tray in from of him/her with food and liquid covering the meal tray and the tray table. The resident's clothes and bed linens were also covered with food and liquids. Interview with staff nurse #1 revealed that this was the resident's preference for eating. The staff nurse stated that Resident # 5 would place all of the foods and fluids that were included on the meal tray in the tray cover and would eat the mixed food. Further observation of the resident on 4/10/13 at the noon meal revealed that the resident was observed by the surveyor mixing his/her foods in the cover of the meal plate. On interview with the C.N.A., he stated that the resident chose to eat this way, and that the resident would refuse to eat one item at a time. On further interview with the charge nurse on 4/10/13 at 1:05 P.M. she said that the resident often tried to mix foods and fluids with his/her meals to "water down" the meal by adding all of his fluids as he/she did not like the thickened pureed food. Review of the clinical record did not evidence that the resident's eating preference was included in the comprehensive care plan or the C.N.A. care card. New staff caring for the resident would not know the resident's eating preferences as they were not documented where staff caring for the reference could access the information.

Based on record review and staff interview, the facility failed to meet professional standards of quality for 2 Sampled Residents (#1 and # 5) in a total sample of 10 residents and 1 of 1 Non-sampled residents (NS # 1). Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice." 1. For Resident #1 the facility failed to ensure that the hospital discharge orders and recommendations were reconciled with the previous orders for the Resident. Resident #1 was admitted to the facility 3/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/10/13 indicated that prior to hospitalization , the Resident's medication administration included a Canasa suppository (a medication used to treat ulcerative [MEDICAL CONDITION]) at hour of sleep. Review of the hospital discharge summary dated 4/8/13 and medication list and recommendations did not include the Canasa suppository. There is no evidence that the facility nursing staff notified the physician (MD) or the nurse practitioner (NP), when editing the orders, that the Canasa suppository was not included on the readmission orders [REDACTED] In addition, there was a recommendation from the hospital for the following specific care instructions that was not included on the reconciled orders: "(He/she) has a long rectal stump and probably is having bacterial overgrowth and has increased anal sphincter tone which is preventing it from coming out appropriately. His (the MD) recommendation is to perform flushes to the rectal stump weekly to try to clear out that bacterial overgrowth to prevent future abscess formation. So the recommendation specifically is to insert a rectal tube through (his/her) anus weekly and flush with 50 cc of normal saline to allow to drain overnight then discontinue the rectal tube the following morning." There was no indication that the nurse notified the MD or NP of the recommendation. Review of the medical record indicated no MD orders or statement from the MD or NP declining the recommendation for the rectal tube intervention on a weekly basis. 2. Non-sampled Resident # 1 was admitted to the facility in 10/11 with [DIAGNOSES REDACTED]. Upon review of of the clinical record on 4/10/13 at 7:55 A.M. following medication pass, Surveyor # 1 noted that 2 of the medications for Resident A that were to be given on a daily basis had been entered incorrectly on the physician orders [REDACTED]. The resident had a current order to receive [MEDICATION NAME] 20mg. (milligrams) by mouth daily. Administration instructions indicated that the medication should be given on "Sun, Mon, Tues, Wed, Fri, Sat." Administration orders did not include Thursday. The resident also had a current order to receive [MEDICATION NAME] 10 mg. one tab by mouth twice daily. Administration instructions indicated that the medication should be given on "Sun, Mon, Tues, Wed, Fri, Sat." Administration orders did not include Thursday. Staff nurse # 2 on the first floor said that the orders had been entered in the system incorrectly and that the initial orders for the [MEDICATION NAME] and the [MEDICATION NAME] initiated on 7/11/12 included instructions that the medications had been ordered to be given daily, 7 days a week. Staff nurse # 2 verified with the Nurse Practitioner that the medications were to be given daily, 7 days a week. Review of physician orders [REDACTED]. 3. The facility failed to follow professional standards of practice by incorrectly placing a Foley catheter which resulted in the resident having pain and bleeding for 6 days. Resident # 5 was admitted to the facility in 7/2005 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. There was also a physician order [REDACTED]. On 6/25/12, the resident was seen by the consultant urologist. Prior to this date, the urologist saw the resident and changed the resident's catheter every six weeks. The Urology consultation report of 6/25/12 indicated that the resident could continue to have the Foley catheter changed in the urologist's office or the nursing staff at the nursing home could change the catheter. Review of the clinical record revealed an interim Physician order [REDACTED]. Review of the clinical record on 4/9/13 revealed a Hospital Transfer report dated 7/27/12. The report indicated that the resident was admitted to the hospital on [DATE]. Under Transfer Diagnosis, the report indicated that the resident was transferred to the hospital for mechanical problems with his/her Foley catheter after a recent change, in the nursing home by the nurses. The report further stated that the catheter was mal-positioned in the prostatic urethra, causing pain, bleeding and partial obstruction. The report continued to say that the resident had a Urinary Tract Infection [MEDICAL CONDITION], related to catheter instrumentation and changes. The report indicated that since the catheter was changed by the nurses (6 days prior), the resident was complaining of some discomfort, pain, and occasional bleeding, so the resident was sent to the hospital. On arrival to the hospital, the resident had mild sinus [MEDICAL CONDITION](fast heart rate) that the physician questioned was from pain. The urologist suspected that the Foley catheter was in the wrong position. The catheter was removed and the resident drained 500 cubic centimeters (cc's) of dark urine. A new catheter was inserted and the resident's pain was alleviated. The physician suspected that the catheter balloon was inflated in the proximal urethra. The resident was admitted to the hospital for urinary tract infection and mechanical complications from Foley malposition. On interview with the charge nurse on 4/10/13 at 9:55 A.M., she said that she was not employed at the facility when this incident occurred and could not provide any information. The facility was unable to produce the clinical records during the standard survey other that the physician orders [REDACTED]. and correctly place the Foley catheter. Upon surveyor return to the facility a week later on 4/18/13, for an extended survey visit, the facility was able to produce nursing notes for the month of 7/12. Nurses notes dated 7/19/12 at 2:00 P.M. include documentation that "2 licensed nurses changed catheter. A blood clot was noted afterward but urine clear, Foley flushed patent. APAP (Tylenol) 650 mg. (milligrams) given for discomfort." Nurses notes dated 7/20/12 include documentation "Reinforced the catheter with tape to make it stable from movement since pt. had a traumatic injury probably 2 (secondary) to catheterization." Additional documentation on the same day noted that "bleeding noted from urethra small amount of blood. Cleansed area with with NS (normal saline) and applied 4x4 gauze under the penis and the opening of Foley insertion." Further documentation at 10:00 P.M. on the same day included notes that read "there is little amount of bleeding on the urethral meatus probably 2 (secondary) to traumatic injury." Notes reveal that the Director of Nurses called the urologist and left message to call back regarding the situation of his patient. There is no indication in the nurses notes that the urologist called back on 7/20/12. Nurses notes dated 3 days later on 7/23/12 at 11:00 A.M. indicate that the NP (Nurse Practitioner) aware of dark red (maroon) colored urine in the tube. Notes indicated that the urologist was called and the facility was waiting a return call. There is no documentation in the clinical record of the urologist returning the call to the facility. The following day, 7/24/12 the NP was made aware that nursing staff were unable to successfully flush the resident's Foley catheter. The resident's sister who served as the HCP (health care proxy) was notified by the facility and reported that she wanted the Foley catheter to be changed in the hospital. The NP ordered the resident transferred to the hospital emergency room . According to nurses note on 7/24/12 at 7:00 P.M., the resident's sister returned to the facility and informed staff that "Pt. is admitted with PNA (pneumonia) and hemorrhage 2 (secondary) to catheter not inserted properly." Nurses notes written 3 days later on 7/27/12 indicate that "Pt. was readmitted to facility from hospital 2 (secondary) to problem with Foley catheter insertion, UTI, bacteremia and and pneumonia." Please see F 309.

Based on record review and staff interview, the facility failed to provide the necessary care and services for 3 residents (#1, # 5 and #6, ) in a total sample of 10, to maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Finding include: 1. For Resident #6, the facility failed to develop a care plan and provide monitoring and treatment to address constipation. The resident was admitted to the hospital on [DATE], with behavioral problems and was found to be severely constipated with rectal impaction. Resident #6 had [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated the resident was cognitively impaired and required extensive staff assistance with ambulation and activities of daily living. The resident was incontinent of urine and continent of bowel. The quarterly MDS of 2/25/13, indicated the resident had declined to being incontinent of bowel. At the time of the hospitalization , 12/17/12, the resident was receiving [MEDICATION NAME] (opioid [MEDICATION NAME]) 50 milligrams (mg.) three times a day for pain and had a order to receive an as needed (prn) dose twice a day for arthritis and low back pain. According to the Nursing Drug Handbook 2012, one of [MEDICATION NAME]'s side effects is constipation. The resident would have been considered high risk for constipation due to taking [MEDICATION NAME]. The resident did not have a written care plan for constipation. At the time of the hospitalization the resident was receiving the following medications to address constipation: 1) [MEDICATION NAME] sodium 100 mg. twice daily; 2) [MEDICATION NAME] 8.6 mg. one tablet at hours of sleep; 3) [MEDICATION NAME] 10 mg. suppository one rectally daily as needed (prn); 4) Milk of Magnesia (MOM) suspension 30 milliliter (ml.) daily as needed (prn) for constipation; 5) Fleet enema one rectally daily as needed (prn) for constipation. In addition the Nurse Practitioner (NP) ordered MOM 30 cc's every other day on 12/1/12. The as needed (prn) constipation medications did not include parameters to use when the resident was having specific symptoms/needs i.e., needed more bulk in the stool, needed more fluid in the stool. Also, resident did not have a bowel regimen that indicated a specific plan to address constipation, i.e.; if the resident did not have a bowel movement in 3 days then one approach would be tried; if that did not produce a bowel movement then another approach would be tried; and if that did not produce a bowel movement then another approach would be tried. A review of the Medication Administration Record (MAR) for December 2012 revealed that the resident did not receive any as needed medications for constipation during the 2 weeks prior to the hospitalization . Record review on 4/9/13, revealed that the resident had complained of constipation on 12/1/12. The nurse's notes for that day indicated that the nurse gave the resident MOM 30 cubic centimeters (cc's) although this was not recorded on the MAR. In addition the Nurse Practitioner (NP) ordered MOM 30 cc's every other day. Staff were unable to provide any records of bowel movements for the resident for the weeks prior to the rectal impaction. During interview on 4/10/13 at 2:00 P.M., the Director of Nurses (DON) stated that the facility kept a bowel book but pages were thrown out after 2 weeks. On 12/5/12 a nurse's notes indicated that the resident exhibited aggressive and angry behavior. The note indicated positive bowel sounds in all 4 quadrants. Other than this note, there were no nurses' notes following the complaint of constipation on 12/1/12, that addressed the resident's response to increased bowel medication and whether or not the resident had bowel movements. A nurse's note on 12/17/12 indicated the resident was severely agitated and was violently kicking and hitting staff. The resident was sent to a hospital emergency room for evaluation and was admitted to the hospital. A "General Report" from the neuropsychiatry unit at the hospital on [DATE], stated the following, "The medical issue that was also complicated at the time of admission was an acute constipation with impacted rectum, which was acutely distressful for the patient, as he has not moved bowel prior to admission for several days .... Since admission his bowel regimen was started. He moved his bowels." During interview on 4/10/13 at 11:00 A.M., the DON provided the Surveyor with nursing notes and physician orders [REDACTED]. The DON was not employed by the facility until 12/19/12 and did not have further information to provide during interview. Resident #6 was high risk for constipation due to receiving an opioid [MEDICATION NAME]. The resident had no care plan and no bowel protocol to address constipation. After the resident complained of constipation on 12/1/12, the facility intervened but did not provide monitoring to address the effectiveness of the intervention. The resident was admitted to the hospital and found to have a fecal impaction on 12/17/12. 2. The facility failed to provide the necessary care to ensure that Resident # 5 did not develop complications of pain and bleeding by incorrectly placing a Foley catheter which resulted in the resident having pain and bleeding for 6 days. Resident # 5 was admitted to the facility in 7/2005 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. There was also a physician order [REDACTED]. On 6/25/12, the resident was evaluated by the consultant urologist. Prior to this date, the urologist saw the resident and changed the resident ' s catheter every six weeks. The Urology consultation report of 6/25/12, indicated that the resident could continue to have the Foley catheter changed in the urologist's office or the nursing staff at the nursing home could change the catheter. Review of the clinical record revealed an interim Physician order [REDACTED]. Review of the clinical record on 4/9/13 revealed a Hospital Transfer report dated 7/27/12 that indicated the resident had been admitted with mechanical problems from a urinary Foley catheter after a recent change in the nursing home by nurses and a urinary tract infection related to catheter instrumentation and changes. The report indicated that the resident was admitted to the hospital on [DATE], after the Foley catheter was changed. Under Transfer Diagnosis, the report indicated that the resident was transferred to the hospital for mechanical problems with his/her Foley catheter after a recent change, in the nursing home by the nurses. The report further stated that the catheter was mal-positioned in the prostatic urethra, causing pain, bleeding and partial obstruction. The report continued to say that the resident had a Urinary Tract Infection [MEDICAL CONDITION], related to catheter instrumentation and changes. The report indicated that since the catheter was changed by the nurses (6 days prior), the resident was complaining of some discomfort, pain, and occasional bleeding, so the resident was sent to the hospital. On arrival to the hospital, the resident had mild sinus [MEDICAL CONDITION](fast heart rate) that the physician questioned was from pain. The urologist suspected that the Foley catheter was in the wrong position. The catheter was removed and the resident drained 500 cubic centimeters (cc's) of dark urine. A new catheter was inserted and the resident's pain was alleviated. The physician suspected that the catheter balloon was inflated in the proximal urethra. The resident was admitted to the hospital for urinary tract infection and mechanical complications from Foley malposition. During interview with the charge nurse on 4/10/13 at 9:55 A.M., she said that she was not working at the facility when this incident occurred and could not provide any information. The facility was unable to produce the clinical records during the standard survey other that the physician orders [REDACTED]. There was no evidence that the resident was properly assessed or that intake and output monitoring was done in an effort to determine the resident's pain and correctly place the Foley catheter. Upon surveyor return to the facility the following week on 4/18/13, for an extended survey visit, the facility was able to produce nursing notes for the month of 7/12. Nurses notes dated 7/19/12 at 2:00 P.M. include documentation that "2 licensed nurses changed catheter. A blood clot was noted afterward but urine clear, foley flushed patent. Apap (Tylenol) 650 mg. (milligrams) given for discomfort." Nurses notes dated 7/20/12 include documentation "Reinforced the catheter with tape to make it stable from movement since pt. had a traumatic injury probably 2 (secondary) to catheterization." Further nurses notes on the same day noted that "bleeding noted from urethra small amount of blood. Cleansed area with with NS (normal saline) and applied 4x4 gauze under the penis and the opening of foley insertion." Further documentation at 10:00 P.M. on the same day included notes that read "there is little amount of bleeding on the urethral meatus probably 2 (secondary) to traumatic injury." Nurses notes reveal that the Director of Nurses called the urologist on 7/20/12, and left message to call back regarding the situation of his patient. There is no indication in the nurses notes that the urologist called back on 7/20/12. Nurses notes dated 3 days later on 7/23/12 at 11:00 A.M. indicate that the NP (Nurse Practitioner) aware of dark red (maroon) colored urine in the tube. Notes indicated that the urologist was called and the facility was waiting a return call. There is no documentation in the clinical record of the urologist returning the call to the facility. The following day, 7/24/12 the NP was made aware that nursing staff were unable to successfully flush the resident's foley catheter. The resident's sister who served as the HCP (health care proxy) was notified by the facility and reported that she wanted the foley catheter to be changed in the hospital. The NP ordered the resident transferred to the hospital emergency room . According to nurses note on 7/24/12 at 7:00 P.M., the resident's sister returned to the facility and informed staff that "Pt. is admitted with PNA (pneumonia) and hemorrhage 2 (secondary) to catheter not inserted properly." Nurses notes written 3 days later on 7/27/12 indicate that "Pt. was readmitted to facility from hospital 2 (secondary) to problem with foley catheter insertion, UTI, bacteremia and and pneumonia." 3. For Resident #1 the facility failed to address a change in condition that resulted in the Resident being admitted to the hospital in [MEDICAL CONDITION] from dehydration [MEDICAL CONDITION] from a bowel infection. Resident #1 was admitted to the facility 3/2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the hospital discharge summary dated 4/8/13 "the patient was admitted with [MEDICAL CONDITION] acute [MEDICAL CONDITIONS] due to[DIAGNOSES REDACTED]icile [MEDICAL CONDITION] several liters of IV fluids and taking the appropriate medications, the patients vitals (blood pressure, pulse) quickly stabilized. His/her renal function stabilized as well, and his/her abdominal discomfort has subsided as well." According to the discharge summary "the patient has not been able to eat at his/her rehab facility for the last 7-10 days, (He/she) says (he/she) just does not have the appetite. (He/she) was given IV fluids at the facility because of extreme dehydration but refused to take anything p.o. (by mouth) and vomited April 3rd...(He/she) was found to have significant leukocytosis of 20,000 ". Record review on 4/10/13 indicated that beginning 3/30/13 a change in the Resident's normal state was noticed by family and documented in the nursing note: "the (family member) reported talking with (his/her) (relative) this morning, with the Resident was using delusional language. The (family member) told me the mother has used this type of language before, and that is usually occurred before acute [MEDICAL CONDITION] or before being diagnosed with [REDACTED]. I requested and received permission to obtain a urine dip. Unable to perform the urine dip this shift. I will attempt again on 3-11 shift". The Resident's urine is collected in a urine collection bag that is emptied by staff. The amount and color of the urine is a standard notation for nursing notes. During interview on 4/10/13 at 9:00 A.M. the Resident told the surveyor that he/she had not been able to eat or drink very much in days prior to going to the hospital. The Resident said that he/she had intermittent severe pains in the abdomen for 7-10 days prior to being hospitalized and that nursing had been told when the pains occurred. From 3/30/13 -4/3/13 nursing notes document decreasing amounts of urine drained from the suprapubic collection bag with a decline in color from light yellow on 3/29/13 to dark brown on 4/2/13. The color and quantity of urine is an indicator of a change in condition in the Resident. According to the 1998-2013 Mayo Foundation for Medical Education, normal urine color varies, depending on how much water is ingested. Fluids dilute the yellow pigments in urine, so the more that is ingested, the clearer the urine looks. When less is ingested, the color becomes more concentrated. Severe dehydration can produce urine the color of amber. Concurrently, the Resident was noted to have a high to critically high INR as noted in the following nursing notes. Review of the nursing note dated 3/30/13 3-11: "alert and verbal with episodes of confusion....increased agitation, PRN (as needed) [MEDICATION NAME] (a medication for anxiety) given + (positive) effect noted....[MEDICAL CONDITION] patent and draining, suprapubic cath(eter) patent and drained 250 dark yellow urine. Urine specimen collected and scheduled to lab to pick up tomorrow. The final result of the urine culture specimen was sent to the facility on [DATE]. At that time the NP prescribed Bactrim DS two times a day for 10 days. Review of the nurses' notes dated 3/31/13 6:40 A.M.: "Episodes of restlessness, temp(erature) 99, very confused with verbal outbursts". Review of the nurse's note dated 3/31/13, 3-11 shift: "suprapubic cath patent, drained 200 cc of dark yellow urine, no hematuria noted". Review of the nurse's note dated 4/1/13, 7-3 shift: "suprapubic cath draining dark yellow urine"....will continue to monitor." Review of the nurse's note dated 4/1/13, 3-11 shift: "INR (measurement of blood clotting factor when a patient is on blood thinning medication) 3.79 (normal range 2.00-3.00). [MEDICATION NAME] held tonight". Review of the nurse's note dated 4/2/13 7-3 shift: "Alert @ baseline oriented X 3...episode of vomiting X 1 @ 1 P.M. after lunch. NP (nurse practitioner) aware. KUB ordered by NP." Review of the nurse's note dated 4/2/13: ..."suprapubic cath patent and drained 100 cc dark brown urine". New order per (MD) start IV 50% [MEDICATION NAME] 1/2 NCL (normal saline) at 80 cc per hour give whole bag (1000 cc)....peripheral IV access initiated @ 9:00 P.M. start Bactrim DS..." Review of the NP notes dated 4/2/13 indicated "vomiting with ABD (abdominal) pain supportive care until KUB (Kidney, Ureter, and Bladder) results obtained. Review of nurses note dated 4/3/13 11-7 shift: "suprapubic tube patent draining dark yellow urine". Review of the physician orders [REDACTED]. Review of nurse's note dated 4/4/13 (no time noted) "Resident alert and oriented, IV fluids discontinued and ABT (antibiotic) therapy. Repeat INR this morning results critically high 5.82. faxed to MD for further orders. [MEDICATION NAME] has been held." Review of nurse's note dated 4/4/13 3-6 P.M. "Resident encouraged to drink fluids but only drank approx 80 mls (cc). vomited X 1 about 5 P.M. (MD) notified and did not want to wait for IV infusion team, gave order to transfer to ER (emergency room )." There is no indication in the medical record that the Resident's fluid intake and output were being monitored on a consistent basis, no evidence of any nursing intervention regarding encouraging fluid consumption from 3/30/2013-4/4/ During this same time frame, the Resident reported abdominal pain, lack of appetite, and presented with darker and darker urine in the collection bag. Although the MD did start one liter of intravenous fluid on 4/3/2013, the intervention was not effective in restoring renal function, according to the hospital discharge summary. Secondarily, the Resident was reported to be admitted [MEDICAL CONDITION] from an untreated bowel infection.