Every finding on record at Rochester Manor

Based on record review and interview, the facility failed to implement a comprehensive care plan for 1 resident in a final sample of 19 residents (Resident identifier is #55).Findings Include: Review on 6/11/26 of the facility's policy Skin integrity and Wound Management, review date 6/15/25, revealed . The plan of care will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition.Resident #55Review on 6/11/26 of Resident #55;'s care plan revealed an intervention of Weekly wound assessment to include measurements and description of wound status, dated 8/21/25 within the focus area of risk for skin breakdown.Interview on 6/8/26 at approximately 9:26 a.m. with Resident #55 revealed that they had a wound on their leg that had been present for approximately 2 years. Review on 6/9/26 of Resident #55's wound progress notes revealed that the medical record did not contain wound assessments between the period of 3/18/26 to 4/1/26 and 4/22/26 to 5/6/26; (both 14 days). Further review revealed that the wound progress note, dated 6/3/26, did not contain wound measurements.Interview on 6/11/26 at approximately 2:19 p.m. with Staff D (Director of Nursing) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to facilitate ordered services from an outside provider for 1 of 3 residents reviewed for Urinary catheter/UTI (Urinary Tract Infection) in a final sample of 19 residents. (Resident identifier is #36.)Findings include:Interview on 6/8/26 at approximately 10:34 a.m. with Resident #36 revealed that they were waiting for an appointment that was very important to them. Review 6/8/26 of Resident #36's Physician's orders revealed an order dated 5/26/26, please arrange for urgent follow up with urology. to consider prophylactic abx (antibiotics) given repeated hospitalizations with urosepsis and chronic indwelling foley.Interview on 6/11/26 at approximately 1:18 p.m. with Staff A (Licensed Practical Nurse) revealed that the facility had not contacted a Urologist for Resident #36.Review on 6/11/26 of the facility's policy Transcription of Orders, Review date 3/20/26, revealed . Orders from an authorized independent practitioner are accepted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) . Purpose To establish requirements for accepting, transcribing and reviewing orders.

Based on interview and record review, it was determined that the facility failed to report an injury of unknown source to the State Survey Agency (SSA) for 1 of 1 residents reviewed for neglect. (Resident identifier is #1).Findings include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m., revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left Upper Extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [Deep Vein Thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. There was no additional paperwork from the hospital for the emergency room visit in Resident #1's medical record.Interview on 1/14/26 at 1:25 p.m. with Staff E (Registered Nurse) revealed that on 12/8/25, prior to the resident returning to the facility from the Emergency Room, they received a phone call from the Hospital emergency room and a verbal report that Resident #1 had a fracture. Interview on 1/14/26 at 12:30 p.m. with Staff B (Director of Nursing) revealed that the facility did not send a report to the SSA for the above elbow fracture (injury of unknown origin).Review on 1/14/26 of the facility's policy titled Abuse Prohibition revised 11/14/25 revealed, . 6.4 Injuries of unknown source will be investigated to determine is abuse or neglect is suspected. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administer or designee will perform the following . 7.1 Enter allegation into the [omitted name of facility software system] Risk Management Portal . 7.3 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source) . not less than two (2) hours after the allegation is made if the event results in serious bodily injury . 9. The Administrator or designee will . 9.2 Report finding of all completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state-approved forms .

Based on interview and record review, it was determined that the facility failed to thoroughly investigate an injury of unknown source for 1 of 1 resident reviewed for neglect. (Resident Identifier is #1). Findings include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m. revealed, a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left Upper Extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [Deep Vein Thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. Interview on 1/14/26 at 12:30 p.m. with Staff B (Director of Nursing) revealed that the facility did not do an investigation regarding the above elbow fracture.Review on 1/14/26 of the facility's policy titled Abuse Prohibition revised 11/14/25 revealed, . 6.4 Injuries of unknown source will be investigated to determine is abuse or neglect is suspected. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administer or designee will perform the following . 7.1 Enter allegation into the [omitted name of facility software system] Risk Management Portal . 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on : 7.7.1 whether abuse or neglect occurred and to what extent; 7.7.2 clinical examination for signs of injuries, if indicated; 7.7.3 causative factors; and 7.7.4 interventions to prevent further injury. 7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included .

Based on record review and interview, it was determined that the facility failed to provide notice to the resident or the resident representative(s) of transfer and bed hold for 1 of 2 residents reviewed for hospitalization (Resident identifier is #1).Findings include:Review on 1/14/26 of Resident #1's progress note dated 12/8/25 with an effective time of 11:26 a.m. revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left upper extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [deep vein thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information from the local hospital, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. Review on 1/14/26 of Resident #1's medical record revealed there was no Notice of Transfer/Discharge completed for the 12/8/25 transfer to the hospital.Interview on 1/14/26 at 2:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Review on 1/14/26 of the facility's policy Discharge and Transfer revised on 6/11/25 revealed, . 5. For patients transferred to a hospital: For unplanned, acute transfers, the patient must be permitted to return the Center. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific form. 5.4 A copy of the state specific or E-Interact form will be placed in the patient's medical record.

Based on interview and record review, it was determined that the facility failed to ensure that resident medical records were complete and accurately documented for 1 of 4 medical records reviewed. (Resident Identifier is #1.)Findings Include:Review on 1/14/26 of Resident #1's progress note, dated 12/8/25 at 11:26 a.m., revealed a note by Staff D (Physician Assistant) that read, Chief complaint: Nursing request eval [evaluation] for LUE [Left upper extremity] swelling. New LUE edema exam. Most consistent with dependent edema in setting of severe hypoalbuminemia, as well as patient reported sleeping on left side. Though some of the swelling to LUE does not appear to be pitting, and there is minimal erythema/warmth and slight tenderness. Doubt cellulitis though there is some concern for LUE DVT [deep vein thrombosis]. Will transfer emergently to hospital for Doppler study rule out LUE DVT.Review on 1/14/26 of Resident #1's hospital Patient Visit Information from the local hospital, dated 12/8/25 at 11:02 a.m., revealed, You were seen today for: Closed fracture of radial head. elbow fracture. Further review revealed follow-up care for Orthopedic Surgery and Family Medicine in 2 days, to keep the arm elevated to reduce pain/swelling and ice pack to the injured area. There was no additional paperwork from the hospital in the medical record.Review on 1/14/26 of Resident #1's nursing progress notes and nursing assessments for 12/8/25 and 12/9/25 revealed no documentation of when Resident #1 was transferred to the hospital or when they returned to the facility. Upon return to the facility there was no documentation that Resident #1's was assessed or that recommendations from the hospital were reviewed or implemented. Interview on 1/14/26 at 12:30 p.m. with Staff B (Director of Nursing) confirmed that there was no nursing documentation in Resident #1's medical record regarding when they went to the emergency room or when they returned on 12/8/25. Review on 1/14/26 of the facility's policy titled Nursing Documentation revised 5/1/23 revealed, . 2. Documentation included information about the patient's status, nursing assessment and interventions, expected outcomes, evaluation of the patient's outcomes, and responses to nursing care. 3. Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion as outlined by other policies and procedures . 5. The patient's record specifies what nursing interventions were performed by whom, when, and where. 6. All patient information will be documented, scanned, or entered in the appropriate section of the clinical record following established guidelines .

Based on interview and record review, it was determined that the facility failed to follow it's grievance policy for tracking, investigating, and prompt resolution of grievances for 1 out of 1 resident reviewed for grievances (Resident identifiers is #4). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently throughout the day and evening and has for some time now. Resident #4 stated they have voiced this concern to staff and nothing has been done to help keep Resident #23 out of their room. Interview on 6/6/25 at approximately 12:15 p.m. with Staff J (Infection Preventionist) stated that on 5/12/25 they spoke to Resident #4 and their roommate regarding Resident #23 wandering into their room. Staff J stated that this information was written up on a grievance form and brought to the managers morning meeting on 5/13/25. Interview on 6/6/25 at approximately 12:30 p.m. with Staff D (Administrator) revealed that the grievance from Resident #4 on 5/12/25 was not logged on the Grievance/Complaint log. Interview with Staff D further revealed that there was no investigation into Resident #4's grievance nor corrective actions taken, if needed. Review on 6/6/25 of the facility policy titledOPS204 Grievance/Concern, revised 10/15/24, revealed .Purpose: to Assure prompt receipt and resolution of patient or representative grievance/concern .4. Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance Concern Log. 5. When the grievance/concern is logged, the Administrator and appropriate departments manager will be notified. 5.1 Immediate action will be taken to prevent further potential violations of any patient rights while the alleged violation is being investigated .6. The department manger will: 6.1 Contact the person filing the grievance to acknowledge receipt; 6.2 Investigate the grievance; 6.3 Take corrective actions, if needed; 6.4 Engage the support of the Ombudsman, if warranted; and 6.5 Notify the person filing the grievance of resolution in a timely manner .

Based on interview and record review, it was determined that the facility failed to thoroughly investigate after a resident's fall for 1 of 1 resident reviewed for falls in a final sample of 18 residents. (Resident Identifier is #82). Findings include: Review on 6/6/25 of the facility's policy titled Abuse Prohibition revised on 10/24/22 revealed, .The Center will implement an abuse prohibition program through the following: .Investigation of incidents and allegations; . Reporting of incidents, investigations, and Center response to the results of their investigations .10. At monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse, neglect, misappropriation of patient property, and exploitation that were reported to the state to: 10.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences; 10.2 Identify situations which a potential for risk; and 10.3 Determine what preventative measures will be implemented by staff. Review on 6/6/25 of Resident #82's Progress Note dated 4/24/25 at 5:22 p.m. and signed by Staff C (Registered Nurse) revealed, Pt's [Patient's] roommate came out in hall looking for a nurse, saying that pt had fallen, Nurse responded immediately, abd [abdomen] pt was found on the ground laying on [pronoun omitted] left side. Pt was unresponsive and not able to follow cues. 911 was immediately notified. Pt was observed to have twitches, and a pillow was applied to under [pronoun was omitted] head. Pt was asked to wait on the floor. 911 was notified. Daughter updated, PA [Physician Assistant] updated, Report called into [Hospital name omitted]. Pt was unable to respond appropriately to questions, Breathing WNL [Within Normal Limits]. Pt. sent with BIPAP [Bilevel Positive Airway Pressure] machine and Daughter called back and was updated on pt's situation. Pt. transferred to [Pronoun omitted] by EMTs [Emergency Medical Technician] at 5:00 p.m. on 4/24/25. Interview on 6/6/25 at 11:00 a.m. with Staff C confirmed the above and revealed that Resident #82 was unresponsive to answering questions. Staff C found Resident #82 by his/her bed so assumed he/she fell out of bed, but is not sure, since the resident was unable to answer any questions. Staff C assessed Resident#82 where he/she had fallen and did not move the Resident #82, but EMS providers arrive within 5 minutes of calling them. Further interview with Staff C on 6/6/25 at approximately 11:00 a.m. revealed that he/she fill in the required incident report and EMS paperwork, but no other paperwork was asked for regarding the fall for an investigation. Interview on 6/6/25 at approximately 10:30 a.m. with Staff B (Director of Nursing) and Staff D (Administrator), revealed that the facility did not attempt to further investigate into the fall to see what the circumstances were. Staff B and Staff D confirmed that neither one had interviewed the roommate or staff after the fall. Staff B and Staff C confirmed the facility had no evidence the facility had interview or investigated the fall. Review on 6/6/25 of the facility's policy titled Falls Management revised on 3/15/24 revealed, . A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., patient pushes another patient 5. Post-Fall Management: . 5.5 Document circumstances of the fall, post -fall assessment , and patient outcome;

Based on interview, and record review, it was determined that the facility failed to revise a care plan for 1 resident in a final sample of 18 residents (Resident identifiers is #23). Findings include: Interview on 6/4/25 at approximately 11:45 a.m. with Resident #4 revealed that Resident #23 wanders into their room frequently in the evening and night for some time now. Interview on 6/6/25 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) stated that Resident #23 will wander into Resident #4's room sometimes. Staff E said the staff will redirect Resident #23 when this occurs. Interview on 6/6/25 at approximately 11:55 a.m. with Staff F (Licensed Nursing Assistant) stated that Resident #23 will wander into Resident #4's room. Staff F said that staff will redirect Resident #23 with items to fidget with and will also try to engage her in activities. Review on 6/5/25 of Resident #23's progress notes revealed the following: On 4/11/25, Resident #23 required frequent redirection as he/she enters other resident's rooms and touches other resident's walkers; On 5/1/25, Resident #23 has been having increased behaviors; On 5/28/25, Resident #23 sleeps intermittently, wanders at night; On 5/29/25, Resident #23 goes into the nurse's station and other residents rooms and Resident #23 can be difficult to redirect and often becomes agitated. Review on 6/5/25 of Resident #23's care plan revealed a care plan, initiated on 10/5/22, for elopement risk related to Cognitive loss/Dementia. Further review of Resident #23's care plan revealed no care plan interventions for wandering into others rooms. Interview on 6/6/25 at approximately 8:50 a.m. with Staff G (Director of Social Services) confirmed that Resident #23 does wander into others rooms and that Resident #23's care plan does not have interventions to address Resident #23's wandering. Review on 6/6/25 of the facility policy titled NSG 206 Behaviors: Management of Symptoms, revised 7/1/24, revealed .Purpose: To identify, prevent and manage behavioral symptoms by: Using non-pharmacological approaches as initial interventions and ongoing; Promoting a therapeutic and safe environment for patients and staff: Monitoring outcomes of care plan interventions. To Minimize the use of psychotropic medications, including antipsychotics, for patients with behavioral symptoms and/or dementia .Practice Standards .2. Staff will monitor for and document in the medical records any exhibited behavioral symptoms .3. Identify, to the extent possible, potential underlying causes of behavioral symptoms .4. Implement individualized, person-centered, non pharmacologic interventions as the initial behavior mitigation strategy and update care plan accordingly .

Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 4 residents reviewed for medication administration in a final sample of 18 residents (Resident Identifiers is #77). Findings include: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME]; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022. Page 597 - Safe Medication Preparation: Right Time With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of the maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapeutic responses in a patient. Interview on 6/4/25 at approximately 11:00 a.m. with Resident #77 revealed that his/her short acting insulins are often given late. He/she stated it has happened multiple times since his/her admission within the last month and it didn't matter which meal. He/She indicated one time he/she had chocolate cake by the time the nurse gave him/her their insulin. Review on 6/4/25 of Resident #77's admission's Minimum Data Set (MDS) with an assessment reference date of 5/19/25 revealed Resident #77 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Review on 6/4/25 of the facility's mealtime schedule revealed that breakfast is at 8:00 a.m., lunch is at 12:30 p.m., and dinner is 6:15 p.m. The meals trays are delivered to the individual rooms. Review on 6/5/25 of the manufacturer's instructions for Insulin Lispro revealed Lispro is given within 15 minutes before a meal, or right after eating. Review on 6/5/25 of the manufacturer's instructions for Glargin-ygf revealed .Administer Insulin Glargine-yfgn subcutaneously once daily at any time of day but at the same time every day . Review on 6/4/25 of Resident #77's Location of Administration Report from 5/1/2025 through 5/31/2025 revealed the following days that the short acting insulin was not given per the manufacturer's instructions: On 5/17/25 HumaLog Kwikpen 100 Unit/ML (milliliters) (Insulin Lispro) (short acting insulin) inject as per sliding scale: if 70 - 150 = 0 units; 151-200 = 2 units; 201- 250= 4 units; 251-300= 6 units; 301-351= 8 units; 351-400 = 10 units> 400 12 units and call provider, subcutaneously before meals for DM (Diabetes Mellitus) was administered at 7:17 p.m. and dinner mealtimes are 6:15 p.m. On 5/21/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD (Medical Doctor) over 400, subcutaneously three times a day for DM, was administered at 6:44 a.m. and breakfast mealtimes at 8:00 a.m. On 5/22/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD 400, subcutaneously three times a day for DM, was administered at 6:51 a.m. and the breakfast mealtimes are 8:00 a.m. On 5/24/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:53 a.m. while the breakfast mealtimes are at 8:00 a.m. On 5/25/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:37 a.m., while the breakfast mealtime is at 8:00 a.m. On 5/26/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:58 a.m., while the breakfast mealtime is at 8:00 a.m. On 5/27/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 5:59 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 11:05 and the lunch mealtime is scheduled for 12:30 p.m. On 5/28/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:10 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 11:21 a.m. and the lunch mealtime is scheduled for 12:30 p.m. On 5/29/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:48 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 5/30/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:45 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 5/31/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, it was given at 6:27 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM,. it was given at 4:55 p.m. and the dinner mealtime is scheduled for 6:15 p.m. Further Review of Resident #77's Location of Administration Report For May 2025 revealed the following long acting insulins were given more than an hour after the ordered time: On 5/18/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:14 p.m. On 5/20/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. was given at 8:19 p.m. On 5/22/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:44 p.m. On 5/27/25 Insulin Glargine-yfgn (long-acting insulin) 100 units/ML inject 10 unit subcutaneously two times a day for diabetes, was scheduled for 6:00 p.m. and was given at 7:21 p.m. Review on 6/4/25 of Resident #77's Location of Administration Report from 6/1/2025 through 6/4/2025 revealed the following days that the short acting insulin was not given per the manufacturer's instructions: On 6/1/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, it was given at 6:50 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. On 6/2/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:37 a.m. and the breakfast mealtime is scheduled for 8:00 a.m. Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 5:44 p.m. and the dinner mealtime is scheduled at 6:15 p.m. On 6/3/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:43 a.m. and the breakfast mealtime is scheduled at 8:00 a.m. On 6/4/25 Insulin Lispro 100 unit/ML inject as per sliding scale: 151-200 = 2 units; 201- 250= 4 units; 251-300= 8 units; 301-400= 10 units; 401-402=12 call MD over 400, subcutaneously three times a day for DM, was given at 6:53 a.m. and the breakfast mealtime is scheduled at 8:00 a.m. Interview on 6/5/25 at approximately 7:00 a.m. with Staff B (Director of Nursing) confirmed that the above medications were administered late. Interview further revealed that Staff B was not notified of the late medications and therefore the physician was not aware. Review on 6/5/25 of the facility's policy titled Medication Administration with a date of 1/25 revealed, Medication Administration: 1. Medications are administrated in accordance with written orders of the prescriber .3. Medication administration timing parameters include the following .b. Medications to be given with meals are to be scheduled for administration at the residents' meal times .14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes.

Based on interview and record review, it was determined that the facility failed to ensure that trauma survivors have interventions identified to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for mood and behaviors in a final sample of 18 residents. (Resident identifier is #4). Findings include: Review on 6/5/25 of Resident #4's Psychiatric note, dated 5/13/25, revealed the following: .[Pronoun omitted] was referred for psychiatric medication management services for depression, anxiety, and PTSD [Post-Traumatic Stress Disorder] .[Name omitted] reports ongoing depressive and anxiety symptoms related to situational stressors .[Pronoun omitted] has also had a difficulty with several residents here and feels uncomfortable around them .[Name omitted] reports chronic nightmares and poor sleep related to childhood molestation .PTSD based symptoms nightmares .Chronic PTSD: chronic nightmares and flashbacks related to childhood sexual abuse perpetrated by her brother, [Name omitted]. Appears to have relational difficulties related to her childhood trauma . Review on 6/5/25 of Resident #4's medical record revealed a care plan, initiated on 3/11/25, that for reported past experience of trauma as evidenced by: Repeated, disturbing memories, thoughts or images of a stressful experience from the related history of abuse. Further review of Resident #4's care plan revealed no identified triggers and interventions. Interview on 6/6/25 at 9:30 a.m. with Staff H (Unit Manager) revealed they were unaware of trauma or PTSD for Resident #4. Interview on 6/6/25 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) revealed they were unaware of Resident #4 having trauma. Interview on 6/6/25 at approximately 11:55 a.m. with Staff F (Licensed Nursing Assistant) revealed they were unaware of Resident #4 having trauma. Review on 6/6/25 of Resident #4's admission social services assessment, dated 1/13/25, revealed .C. Mental Health & Wellness .4. Trauma History 1. Does the patient/resident report or does the medical record reflect any history of trauma and /or Post-Traumatic Stress Disorder (PTSD)? YES . 1a 1. if yes select type of trauma and describe using the corresponding comment box .m. Other .m1. Comments car accident and husband passing away . Review on 6/6/25 of Resident #4's quarterly social services assessment, dated 4/9/25, revealed that .C. Mental Health & Wellness .4. Trauma History 2a. Ask: in in the past month , have you had repeated, disturbing memories, thoughts or images of experiences from the past? marked 3. Moderately 2b. Ask: In the past month, have you felt very upset when something reminded you of a stressful experience from the past? Marked 3. Moderately, 5. Comments Mental Health & Wellness Comments a. Use to elaborate on patient's/resident's mental health and wellness: VA [Vehicular Accident] that took place and her husbands passing . Interview on 6/6/25 at approximately 9:a.m. with Staff G (Director of Social Services) revealed that Resident #4 has informed them that they have been sexually abused in their childhood, and does not mind male caregivers. Staff G stated that Resident #4 does not like to feel trapped and that is why she has a door bed and not a window. Staff G stated that Resident #4's the care plan does not address the history of sexual abuse or that she does not like to be trapped. Review on 6/6/25 of the facility policy titled SS100 Social Services Assessment revised 3/15/24, revealed .Purpose: To determine the patient's social, functional, emotional, and cognitive status and history of trauma and/or post-traumatic stress disorder (PTSD). To develop an individualized Social Services plan of care.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for 1 of 1 resident observed for wound care in the final survey sample of 18 residents. (Resident identifier is #66). Findings include Observation on 6/4/25 at approximately 10:00 a.m. with Staff A (Licensed Practical Nurse) performing wound care for Resident #66 revealed the following: Staff A entered Resident #66's room and placed wound care supplies on a sterile field on the bedside table. Staff A pulled a pair of scissors out of his/her nursing scrub top pocket and placed it onto the bedside table without disinfecting/cleaning the scissors. Right great toe metatarsal wound care: Staff A donned gloves then proceeded to cut Resident #66's right foot dressing off with the unclean scissors and placed them back onto the bedside table with the wound care supplies. After removing the old dressing, Staff A cleaned the right great toe metatarsal wound with normal saline. Staff A used the unclean scissors to cut the new foam dressing and applied it to the ball of the right great toe and then secured it with a border gauze dressing. Staff A doffed their gloves. Staff A did not change his/her gloves between removing the old dressing and applying the new dressing. Left Plantar Foot wound care: Staff A donned a new pair of gloves. Staff A used the unclean scissors to cut the old dressing off and placed them back onto the bedside table with the wound care care supplies. The left plantar foot wound was cleaned with the wound cleanser. Staff A applied a calcium alginate, covered it with a foam dressing, and secured it with border gauze. Staff A doffed their gloves. Staff A did not change his/her gloves between removing the old dressing and applying the new dressing. Interview on 6/4/25 at approximately 10:30 a.m. with Staff A confirmed the above observations. Review on 6/4/25 of the facility policy titled Wound Dressings: Aseptic, revised 2/24/25, revealed .4. Prepare a clean, uncluttered, disinfected surface. 5. Create an aseptic field at bedside and place clean barrier on over-bed table. Place supplies on barrier .16.1 Apply clean gloves .16.2 Discard soiled dressing and gloves in the appropriate receptacle .18 Apply gloves. Review on 6/4/25 of the CDC's website titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), retrieved from: https://www.cdc.gov/infection-control/hcp/isolation-precautions/summary-recommendations.html, revealed .Summary of Recommendations .IV. Standard Precautions .IV.A. Hand hygiene .Perform hand hygiene ~ in the following clinical situations: .If hands will be moving from a contaminated-body site to a clean-body site during patient care .After removing gloves .IV.B. Personal protective equipment (PPE) .IV.B.2.Gloves V.B.2.a.Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur .IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) .

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen observed. Findings include: Review on 4/4/24 of the U.S. Food and Drug Administration Food Code dated 2017 retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: . On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods . Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . Observation on 4/2/24 at 8:25 a.m. of the walk-in refrigerator revealed the following: Seventeen (17) soft moist green peppers with white and black spots visible on all of the peppers in the case Fifteen (15) soft moist celery stalks with brown spots visible on all of the celery in a bin with no lid Three (3) bags of hearts of romaine lettuce with brown spots visible on the outer leaves Twenty-eight (28) 4-ounce cartons of Ready Care Chocolate Shakes with no thawed date or use by date One (1) clear plastic container of meat sauce with no prepared date or use by date One (1) large metal tray of mashed sweet potatoes with no prepared date or use by date One (1) gallon size zip lock bag of cooked ham with no prepared date or use by date Three (3) individually wrapped packages of sliced white cheese with no opened date or use by date Interview on 4/2/24 at 8:30 a.m. with Staff B (Culinary Manager) confirmed the above findings. Review on 4/2/24 of the facility's policy titled Receiving revised 2/2023, revealed: .5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Review on 4/2/24 of the manufacturer's instructions for Ready Care Chocolate Shakes under storage and handling revealed .After thawing keep refrigerated. Use within 14 days after thawing . Review on 4/2/24 of the facility's policy titled Labeling and Dating Chart revealed: .Ready to eat, time/temperature control for safety foods including but not limited to: .cheese . sliced meats . use by date 7 days after opening .

Based on interview and record review, it was determined that the facility failed to ensure that a resident had adequate devices to prevent a fall, resulting in a fracture, for 1 of 3 residents reviewed for accident hazards in a final sample of 29 residents (Resident identifier is #86). Finding include: Interview on 3/22/23 at 11:03 a.m. with Resident #86 revealed Resident #86 was admitted to the facility for skilled nursing services on 3/2/23. Resident #86 stated that upon admission, he/she was asked if he/she needed bed rails. Resident #86 stated Absolutely, I'm weak and have a history of falls. Further interview with Resident #86 revealed that bed rails were never installed on their bed. Resident #86 stated that on 3/5/23 while care was being provided, he/she rolled to the right and fell out of bed and landed on his/her right side of his/her roommates intravenous (IV) pole. Resident #86 stated that he/she broke multiple ribs during that fall. Review on 3/24/23 of Resident #86's Minimum Data Set (MDS) with an assessment reference date of 3/9/23 revealed Resident #86 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15 and a weight of 340 pounds. Review on 3/24/23 of Resident #86's progress notes revealed the following entries: 3/2/23 at 18:35, entered by Staff F (Licensed Practical Nurse (LPN)), Resident admitted for weakness. Resident noted to have history of falls prior to admission. 3/2/23 at 19:21, entered by Staff F, Bed rail evaluation complete . Final determination was that bed rails will be implemented. Type of rail, bar or pole: (2) 1/4 left upper, right upper. Consent obtained. Physician order obtained. 3/5/23 at 09:57 entered by Staff F, Resident was heard yelling upon entering room, observed resident laying on the floor in between 2 beds. C/O [complains of] right side pain. Patient stated I rolled out of bed. Licensed Nursing Assistant (LNA) was in room, LNA stated [Pronoun omitted] rolled over to get off the bed pan and just kept rolling. 911 called. Review on 3/24/23 of Resident #86's Emergency Department note dated 3/5/23 revealed Resident #86 sustained multiple rib fractures to the right side, a traumatic perinephric hematoma of the right kidney and a right side pneumothorax. Review on 3/24/23 of Resident #86's Bed Rail Evaluation dated 3/2/23 at 7:21 p.m., [name omitted] will utilize (2) 1/4 bed rail(s) with assistance for turning side to side/holding self to one side. Review on 3/24/23 of Resident #86's active order for side rails ordered on 3/2/23 revealed that Resident #86 may use (2) 1/4 side rails for mobility and positioning in bed. Review of Resident #86's current care plan interventions created 3/2/23 revealed: .Focus: [name omitted] required assistance for mobility related to: Weakness .Goal: [name omitted] will utilize 2 1/4 bed rails(S) .turning and repositioning while in bed . Review on 3/24/23 of facilities work order #5538 for two (2) side rails for room [ROOM NUMBER]-1 created on 3/2/23 at 8:43 p.m. by Staff F. Interview on 3/27/23 at 10:30 a.m. revealed with Staff H (Registered Nurse) stated that Resident #86 refused to get out of bed when the facility attempted to place the side rails on their bed because a new bariatric bed had been ordered and arriving soon (that had side rails). Interview on 3/24/23 at 12:50 p.m. revealed that Resident #86 stated he/she stated they never refused to get out of bed on 3/3/23 for the side rails to be installed and wanted the side rails. Interview on 3/24/23 at 12:30 p.m. with Staff C (Maintenance Supervisor) revealed work order #5538 was canceled on 3/3/23 when staff told Staff C that the bed was coming the following day. Interview on 3/24/23 at 12:45 p.m. with Staff G (Administrator) revealed that there was no documentation in Resident #86's medical record that Resident #86 refused to get out of bed on 3/3/23 for the side rails to be installed. Interview on 3/24/23 at 2:00 p.m. with Staff G revealed that the facility had identified that a failure had occurred and implemented a Quality Assurance Plan for side rail not occurring timely. The rails were immediately added to Resident #86's bed on 3/5/23 Review of the facility's policy titled, Bed Rails, revised September 1, 2022, revealed Practice Standards . 1. Complete the Bed Rail Evaluation to determine the need for bed rails . 2.6 Notify the Maintenance Department to install bed rails . Review of the facility's policy titled, Bed Safety, revised March 1, 2022, revealed Policy: .If at any time it is determined by nursing that bed rails are needed for a patient: Maintenance will ensure correct installation of bed rails . Purpose: To provide bed safety for patients . Review of the facility's Side Rail Implementation - Project Charter and Performance Improvement Plan state date 3/9/23 revealed Problem: Side rail application not occurring timely and policies and procedures regarding side rails . Root Cause Category/Explanation: Resident had fall out of bed 3 days s/p [status post] admission and indicated he/she felt fall could have been mitigated if side rails had been applied upon admission when he/she had assessment and signed consent .

Based on observation, interview, and record review, it was determined that the facility failed to provide privacy of medical records on 1 of 4 units (Resident identifiers are #8 and #17). Findings include: Observations on 3/22/23 at 11:00 a.m., 12:00 p.m., and again at 2:00 p.m., revealed Resident #8's and Resident #17's Radiology Exam Order containing Resident #8's and Resident #17's name, date of birth, and image results stored face-up on the top counter of the nurse station viewable to unauthorized personnel on B-Wing. Observation on 3/22/23 at approximately 2:00 p.m., a document titled Rochester Manor Census List for B Wing Rooms 15-28 revealed full resident names, diet types and dietary notes stored face-up on the top counter of the nurse station viewable to unauthorized personnel. Interview on 3/22/23 at approximately 2:15 p.m. with Staff D (Licensed Practical Nurse) revealed staff utilize the counter for medical record documents due to lack of space. Interview on 3/22/23 at approximately 2:20 p.m. with Staff A (Director of Nursing) confirmed the observations. Review on 3/22/23/23 of the facility's policy titled 4.6 Health Insurance Portability and Accountability Act (HIPPA), last revised 5/1/22, revealed: Service locations will keep confidential all information contained in the patients'/residents' (hereinafter patient) records, regardless of the form or storage method . 4. Secure patient records containing protected health information such that they are not readily accessible by unauthorized parties.

Based on observation, interview, and policy review, it was determined that the facility failed to store food according to acceptable standards for food safety to prevent foodborne illness in the main kitchen and 1 of 2 unit kitchenettes observed. Findings include: Review on [DATE] of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind . Observation on [DATE] at 9:00 a.m. in the main kitchen with Staff E (Culinary Director) revealed: Two (2) packages of hot dog rolls with a use by date of [DATE]; Six (6) packages of long grinder rolls with a use by date of [DATE]; Three (3) loaves of white bread with no use by date; Two (2) packages of round sandwich rolls with no use by date. Interview on [DATE] at 9:05 a.m. with Staff E confirmed the above were expired or without a use by date. Observation at [DATE] at 9:25 a.m. of the walk in refrigerator revealed: Twenty-Six (26) soft moist green peppers with black spots visible on all of the peppers in the case; Twelve (12) soft moist celery stalks with brown spots visible on all of the celery in an open bin; Two (2) six packs of hard boiled eggs with no label or use by date. Interview on [DATE] at 9:30 a.m. with Staff E confirmed that the hard boiled eggs should have been labeled with a use by date. Staff E stated the green peppers and the celery should have been discarded. Observation on [DATE] at 9:40 a.m. of A kitchenette revealed: Two (2) packages of English muffins with no use by date; Two (2) packages of round sandwich rolls with no use by date; One (1) package of small dinner rolls with no use by date; One (1) package of white bread with no use by date. Interview on [DATE] at 9:42 a.m. with Staff E confirmed the above were open with no use by date. Review on [DATE] of the facility's policy titled, Food Handling, revised [DATE], revealed Use By dating guidelines: 25. Foods that are marked with the manufacturer's use by date .Once a product has been prepared or portioned, a new use by date is established . 26. Foods in dry storage are in closed, labeled, and dated containers . For products that have been opened by not fully used, a use by date is included on the label. Review on [DATE] of the facility's policy titled, Refrigerated/Frozen Storage, revised [DATE], revealed Process: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened .

Based on interview, record review, and policy review, it was determined that the facility failed to implement an antibiotic stewardship program which included a system to track and monitor antibiotic use during 2 of 6 months reviewed. Findings include: Review on 3/24/23 of the facility's Infection Control Monthly Line Listing for January and February 2023 revealed tracking for the use of antibiotics for 14 residents. The line listings did not indicated clinical signs and symptoms to determine if the residents met the criteria for the use of antibiotics. For the month of January 2023 there were 5 residents receiving antibiotics (3-urinary tract infections (UTI), 1-osteomyelitis, and 1- hordeolum). For the month of February 2023 there were 9 residents receiving antibiotics (2-c-difficile, 3-pneumonia, 1-UTI, 1-surgical wound, 1- cellulitis, and 1-conjunctivitis). Interview on 3/24/23 at 9:10 a.m. with Staff B (Infection Preventionist) and Staff A (Director of Nursing) confirmed the line lists for January and February 2023 did not contain clinical signs and symptoms. Staff B stated that signs and symptoms were on the Infection Control Reporting Form but was not able to provide completed forms for residents on the above line lists. Review on 3/24/23 of facility policy titled, IC402 Antibiotic Stewardship, last revised 10/24/22, revealed: 5. Tracking - Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions: 5.1 Monitor measures of antibiotic use by auditing available reports and patient medical records for adherence. Monitor: 5.1.1 Clinical evaluation documentation (e.g., signs/symptoms, vital signs, physical exam findings); .

Based on interview and record review, it was determined that the facility failed to follow the resident's scheduled smoking times per the resident's care plan for 1 out of 1 residents reviewed for smoking in a survey sample of 22 residents. (Resident identifier is # 63.) Findings include: Interview on 4/25/22 at 6:37 p.m. with Staff B (Licensed Practical Nurse (LPN)) during the entrance meeting revealed that Resident #63 was the only resident in the facility who smoked. Review on 4/26/22 of a paper titled SMOKERS (provided by the facility at entrance) revealed that Resident #63 was the only resident listed. The scheduled times for smoking were listed as follows: Between 10:00 a.m. and 10:45 a.m.; Between 1:00 p.m. and 2 p.m.; and Between 6:00 p.m. and 7 p.m. Further review revealed that Resident #63 needed to be brought to the smoking area in the courtyard by a staff member due to uneven surfaces. Review on 4/26/22 of Resident #63's 4/23/22 at 8:51 p.m. progress note revealed .Res[ident] yelling out very loudly SOMEBODY TAKE ME OUT FOR A SMOKE! Informed that staff are all busy at the moment . He was repeatedly told that they were too busy at the moment . Review on 4/27/22 of Resident #63's Smoking Evaluation dated 2/8/22 revealed that Resident #63 required supervision to smoke due to Resident #63 was unable to ambulate to the smoking area safely. Review on 4/27/22 of Resident #63's Minimum Data Set (Assessment Reference Date of 2/11/22) revealed that Resident #63's BIMS (Brief Interview of Mental Status) score was 14 (meaning intact cognition). Review on 4/27/22 of Resident #63's care plan created on 3/2/22 revealed that Resident #63 may smoke with supervision. Further review under Interventions revealed that Resident #63's preferred times to smoke were between 10:00 a.m.-10:45 a.m., 1:00 p.m.-2:00 p.m., and 6:00 p.m.-7:00 p.m. Interview on 4/27/22 at 1:35 p.m. with Resident #63 revealed he/she had not been taken out to smoke this day, and had been last out to smoke on 4/26/22 in the mid-afternoon. Resident #63 stated he/she was upset that he/she had not been taken out to smoke. Resident #63 stated the smoking area was in the courtyard and had a covered gazebo to protect from the weather elements. Interview on 4/27/22 at 1:45 p.m. with Staff C (Licensed Nursing Assistant) confirmed that Resident #63 had not been yet been assisted outside to smoke that day during his/her shift (7:00 a.m. to 3:00 p.m.). Interview on 4/27/22 at 1:45 p.m. with Staff D (LPN) revealed that he/she secured Resident #63's cigarettes and lighter in the medication cart. Staff D confirmed that Resident #63 had not yet been assisted to smoke during his/her shift (7:00 a.m. to 3:00 p.m.). Interview on 4/27/22 at 1:45 p.m. with Staff A (Unit Manager) revealed that Resident #63's smoking breaks could not impact staff providing care to other residents and that there was not one staff member responsible for ensuring Resident #63 had his/her smoke breaks. Staff A stated that other departments such as maintenance or medical records would often take Resident #63 to smoke. Staff A confirmed he/she had last taken Resident #63 out to smoke on 4/26/22 in the afternoon. Staff A did not know if Resident #63 had been taken out on 4/26/22 for the evening smoke break. Interview on 4/27/22 at 2:47 p.m. with Staff A revealed that Resident #63 had agreed to the smoking times with Staff A. Staff A stated that the facility does not track or document when Resident #63 smokes. Review on 4/27/22 of the facility's policy titled Smoking, reviewed on 11/4/19, revealed .For Centers that allow smoking . Patients will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necesassary, will be supervised .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with pressure ulcers had documentation of weekly assessments that contained measurements and description of the pressure ulcers for 1 out of 3 residents reviewed for pressure ulcers in a final sample of 22 residents. (Resident identifier is #52.) Findings include: Review of National Pressure Ulcer Advisory Panel (March 2014) The NPUAP Selected 'Quality of Care Regulations made easy . (See http://www.npuap.org/wp-content/uploads/2014/03/NPUAP-F-tag-final-March-2014.pdf accessed 1/29/2018) .Pressure Ulcers: With each dressing change or at least weekly .an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: -Location and staging -Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; -Exudate, if present: type (such as purulent/serous) , color, odor and approximate amount; -Pain, if present: nature and frequency (e.g., whether episodic or continuous); -Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and -Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Review on 4/26/22 of Resident #52's skin checks dated 2/28/22 thru 4/25/22 revealed the following: Skin Check dated, 2/28/22 A. Skin Check 1. Skin injury/Wound (s) Identified 1. Yes 2. New Skin Injury/Wound (s) Identified 0. No C. Previously Noted Skin Injury/Wound (s) 8. Pressure (checked) . 8a. Location (s) Toes, not new onset . Skin Check dated, 3/7/22 A. Skin Check 1. Skin Injury/Wound (s) Identified 0. No Skin Check dated, 3/14/22 A. Skin Check 1. Skin injury/Wound (s) Identified 1. Yes 2. New Skin Injury/Wound (s) Identified 0. No C. Previously Noted Skin Injury/Wound (s) 8. Pressure (checked) . 8a. Location (s) Areas on bi lat (bilateral) feet. Not of new onset. . Skin Check dated, 4/4/22 A. Skin Check 1. Skin injury/Wound (s) Identified 1. Yes 2. New Skin Injury/Wound (s) Identified 0. No C. Previously Noted Skin Injury/Wound (s) 8. Pressure (checked) . 8a. Location (s) R (right) foot/toes multiple scabs . Skin Check dated, 4/11/22 A. Skin Check 1. Skin injury/Wound (s) Identified 1. Yes 2. New Skin Injury/Wound (s) Identified 0. No C. Previously Noted Skin Injury/Wound (s) 8. Pressure (checked) . 8a. Location (s) Toes, on right foot scabbed areas . Skin Check dated, 4/18/22 A. Skin Check 1. Skin injury/Wound (s) Identified 0. No . Skin Check dated, 4/25/22 A. Skin Check 1. Skin injury/Wound (s) Identified 2. No . Interview on 4/27/22 at approximately 12:30 p.m. with Staff F (Regional) confirmed that there was no weekly skin check done on Resident # 52 3/22/22. Observation on 4/27/22 at approximately 2:45 p.m. with Staff A (Unit Manager) of Resident #52's feet revealed the following areas: Right foot, great toe scabbed area measuring 0.7 cm (centimeters) x 0.6 cm Right foot, 3rd toe scabbed area measuring 0.3 cm x 0.2 cm. Right foot, 4th toe scabbed area measuring 0.5 cm x 0.3 cm. Interview on 4/27/22 with Staff A revealed that he/she was unaware of the 3 scabbed areas on Resident #52's feet and there were no other measurements of the areas. Review on 4/27/22 of the facility policy titled, NSG236 Skin Integrity Management, Revision date 6/1/21 revealed: .Purpose To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Practice Standards .3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information 3.2 Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in PointClickCare (PCC) . 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document 7. Notify physician/APP (Advanced Practice Provider) to obtain orders.

Based on interview and record review, it was determined that the facility failed to ensure that the attending physician addressed irregularities identified by the pharmacist during medication regimen review for 3 out of 7 residents reviewed for unnecessary medications in a final sample of 22 residents. (Resident identifiers are #50, #55, and #88.) Findings include: Resident #50 Review on 4/27/22 of Resident #50's progress notes revealed that a Drug Regimen Review was completed by the pharmacy consultant on 3/21/22. The progress notes indicated the pharmacist had submitted an medication irregularity report to make recommendations to the physician. Interview on 4/27/22 at 12:30 p.m. with Staff F (Regional Administrator) revealed they could not provide the medication irregularity report for March 2022. Resident #55 Review on 4/26/22 of Resident #55's pharmacist consultations revealed the following recommendations for the physician to address: 1. 5/26/21 Comment: TO NURSING UNIT MANAGER The pharmacy recommendation(s) for [pronoun omitted] from April do not seem to be in the chart. Recommendation: Please follow up with the recipient(s) of the outstanding pharmacy recommendations to ensure compliance. Specifically, the recommendations in question are: -[MEDICATION(S)] -[MEDICATION(S)] -[MEDICATION(S)] 2. 6/23/21 Comment: [pronoun omitted] receives [MEDICATION(S)] ([MEDICATION(S)]) 5 mg (milligrams) BID (twice daily) and has two or more of the following characteristics; age greater than or equal to [AGE] years, body weight less than or equal to 60 kg (kilograms), or serum creatinine greater than or equal to 1.5 mg/dl (decileter). Recommendation: Please consider decreasing [MEDICATION(S)] ([MEDICATION(S)]) dose to 2.5 mg twice daily. 3. 7/11/21 Comment: [pronoun omitted] has experienced a recent fall or is at moderate risk of falls while taking [MEDICATION(S)] 20 mg qd (daily). Recommendations: Please consider a trial of [MEDICATION(S)] 10 mg qd. 4. 9/29/21 REPEATED RECOMMENDATION from 7/11/21. Please respond promptly to assure facility compliance with Federal regulations. [pronoun omitted] has experienced a recent fall or is at moderate to high risk of falls while taking [MEDICATION(S)] 20 mg qd. Recommendation: Please consider a trial of [MEDICATION(S)] 10 mg qd. Interview on 4/27/22 at approximately 8:30 a.m. with Staff A (Unit Manager) revealed that the above pharmacy recommendations were not addressed by the physician. Interview on 4/27/22 at approximately 12:15 p.m. with Staff F revealed that the facility was unable to provide the April 2021 pharmacy recommendation. Resident #88 Review on 4/27/22 of Resident #88's pharmacist recommendation to physician dated 12/1/21 - 12/31/22 revealed a recommendation to adjust the dose of [MEDICATION(S)] (pain medication) from 900 mg (milligrams) by mouth three times a day to 700 mg by mouth every 12 hours, until renal function normalizes. Further review revealed that there was no documentation that this recommendation was reviewed by the physician. Review on 4/27/22 of Resident #88's active physician orders revealed a current order for [MEDICATION(S)] 900 mg by mouth three times a day for pain, start date 12/21/22. Interview on 4/27/22 at approximately 12:40 p.m. with Staff A (Unit Manager) confirmed the pharmacist recommendation dated 12/1/22- 12/31/22 had not been addressed by the physician. Review on 4/27/22 of facilities policy titled Medication Regimen Review revealed . the attending physician/ APN ( Advanced Practice Nurse)/ PA (Physician Assistant) must review each MRR (medication regimen review) consultation report, document a response, sign and return the report to the center . response must be received within 30 days of the date of the MRR consultation report . if the attending physician/APN/PA does not choose to follow the pharmacist recommendations, it is his/her responsibility to document the clinical reason in the medical record .