Every finding on record at Royal Cape Cod Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure two Residents (#28 and #10), out of a total sample of 18 residents, received care and treatment to pressure areas in accordance with professional standards to promote healing. Specifically, the facility failed:1. For Resident #28, to implement treatments as indicated to pressure ulcers on the Resident's left medial buttocks; and 2. For Resident #10, to implement treatments as indicated to a pressure ulcer on the Resident's right medial buttocks.Findings include:Review of the facility's policy titled Pressure Injury Prevention and Management Policy, revised 5/2025, indicated, but was not limited to, the following:-Assessments of pressure injuries will be performed by a licensed nurse, and documented in th [sic] resident's medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (Minimum Data Set). -Evidenced-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.-The attending physician will be notified of:i. The presence of a new pressure injury upon identification.ii. The progression towards healing, or lack of healing, of any pressure injuries weekly.iii. Any complications (such as infection, development of a sinus tract, etc.) as needed. Review of the facility's policy titled Skin Integrity Management, undated, indicated, but was not limited to, the following:-Residents with actual skin breakdown are identified, assessed and provided treatment according to standards of practice.-Refer to wound MD/wound clinic as appropriate. Implement wound care modalities. Review of the facility's policy titled Wound Treatment Management, revised 1/2025, indicated, but was not limited to, the following:-In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.-Dressing changes may be provided outside the frequency parameters in certain situations:a. Feces has seeped underneath the dressing.b. The dressing has dislodged.c. The dressing is soiled otherwise or is wet.-Treatments will be documented on the Treatment Administration Record or in the electronic health record.-The effectiveness of treatments will be monitored through ongoing assessment of the wound. 1. Resident #28 was admitted to the facility in January 2025 with diagnoses including moderate protein-calorie malnutrition and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, indicated Resident #28 was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Further review of the MDS assessment indicated the Resident had two unstageable pressure injuries presenting as deep tissue injury (DTI- pressure-related injury to subcutaneous tissues under intact skin, which may initially appear as a deep bruise) that were not present upon admission/readmission to the facility. Review of Resident #28's Care Plan indicated, but was not limited to, the following:Focus: The Resident has a DTI of the left medial buttockInterventions:-Administer medications as ordered. Monitor/document for side effects and effectiveness.-Administer treatments as ordered and monitor for effectiveness.-Assess/record/monitor wound healing every dressing change. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.-Follow facility policies/protocols for the prevention/treatment of skin breakdown.-Inform the resident/family/caregivers of any new area of skin breakdown.-Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage.-Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage)-Wound MD consult PRN Review of Resident #28's Progress Notes indicated that on 12/13/25, Nurse #2 observed two areas on the Resident's left buttocks, deep purple in color and non-blanchable. The nurse documented that area #1 measured 3 cm (centimeters) by 0.25 cm with no depth and area #2 was a 1 cm round area. Nurse #2 documented that she cleansed the areas and applied Eucerin cream. Review of Resident #28's Skin Assessment, dated 12/13/25, indicated the following:-Left buttocks- 2 new areas. #1- 3 cm Lx 0.25 cm W 0 depth. #2 - dime sized area 0 depth 1 cm round. Deep purple, non-blanchable. Review of Resident #28's medical record indicated the Resident was transferred to the hospital on [DATE]. Review of the eINTERACT Transfer Form (a document used to help clearly communicate the information that is critical for hospital staff to care for a resident) indicated the Resident had no pressure ulcers and was not receiving treatment. Review of Resident #28's Consultant Wound Physician progress notes indicated the Resident's left medial buttock deep tissue injury was first assessed by the consultant wound physician on 12/26/25. The Consultant Wound Physician documented the area of deep tissue injury to the Resident's left medial buttock measured 2.6 cm by 1.7 cm and the skin was intact with purple/maroon discoloration. The Consultant Wound Physician made the following recommendations: treatment with house barrier cream every shift and as needed to the area, turn side to side in bed as tolerated, dietitian consult, protein supplement, and upgrade off-loading chair cushion. Review of Resident #28's Certified Nursing Assistant (CNA) documentation, dated 12/17/25 through 1/2/26, indicated barrier cream was applied to the Resident's coccyx, heels, and elbows two to three times daily. The documentation did not indicate barrier cream was applied to the Resident's left medial buttocks. Review of Resident #28's Physician's Orders and Treatment Administration Record (TAR) for December 2025 indicated treatment and monitoring orders for the Resident's left buttock wounds were not implemented until 12/29/25. During an interview on 1/15/26 at 1:01 P.M., the Infection Control Nurse (who oversees the unit where Resident #28 resides) said he was not sure why the Resident did not have any new orders implemented for monitoring and/or treatment of the deep tissue areas until 16 days after they were initially discovered. During an interview on 1/20/26 at 7:13 A.M., Nurse #2 said she did not place a call to the physician or after-hours consulting service but documented the areas in the physician communication log for the physician to review later. Nurse #2 said she did not implement a new treatment as she wanted to wait and see what the physician recommended. During an interview on 1/20/26 at 9:08 A.M., the Director of Nursing (DON) said the facility implements barrier cream treatment for all residents as part of the facility's house protocol for skin breakdown prevention. The DON said the on-call provider should have been notified of the new pressure areas and notification and any recommendations should have been documented in the Resident's medical record. During an interview on 1/20/26 at 1:01 P.M., the Consultant Wound Physician said he was informed by facility staff that Resident #28 had a new area of deep tissue injury, but he forgot to check the area the first time he saw the Resident after he/she returned from the hospital, but when he saw him/her on his second visit (12/26/25) the area had improved from when it had initially been discovered. 2. Resident #10 was admitted to the facility in November 2025 with diagnoses including but not limited to spinal cord infarction and stage three (full-thickness skin loss, exposing the underlying fatty tissue) pressure ulcer of the right buttock. Review of Resident #10's MDS assessment indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15. The MDS assessment indicated Resident #10 had one stage III pressure ulcer on admission to the facility, was receiving pressure ulcer care and required assistance for functional mobility and activities of daily living. During an interview on 1/15/26 at 9:30 A.M., Resident #10 said he/she had a pressure ulcer on his/her coccyx. Resident #10 said he/she was followed by the consultant wound physician (MD) in the facility on a weekly basis and his/her dressings were changed daily. Review of Resident #10's comprehensive care plan for his/her stage III right buttock pressure ulcer indicated interventions including but not limited to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing every shift and monitor dressing every shift to ensure it is intact and adhering. Review of the Consultant Wound MD notes, dated 12/12/25, 12/17/25 and 12/26/25, indicated the following treatment recommendations for the stage III right medial buttock pressure ulcer: - Cleanse with normal saline, apply calcium alginate, cover with gauze island with border dressing and apply skin prep and house barrier cream to periwound. Review of the December 2025 TAR indicated the following treatment was applied to Resident #10's stage III right medial buttock pressure ulcer from 12/1/25 through 12/31/25: - Cleanse with normal saline, apply xeroform, cover with gauze island with border dressing and apply skin prep and house barrier cream to periwound. Review of Resident #10's medical record failed to indicate his/her treatment orders for the stage III right medial buttock pressure ulcer were updated to match the Wound Consultant MD recommendations for calcium alginate until 12/31/25, 19 days after it was first recommended. Review of Resident #10's medical record failed to include documentation indicating the change in the treatment order from the Consultant Wound MD recommendation for calcium alginate to xeroform between 12/12/25 and 12/31/25. During an interview on 1/16/26 at 9:37 A.M., Nurse #1 said Resident #10 is followed by the Consultant Wound MD for his/her pressure ulcers. Nurse #1 said the Consultant Wound MD typically visits the facility on Tuesdays and Fridays. Nurse #1 said either the nurse on the unit or the unit manager completes the assessment and dressing change with the Consultant Wound MD. Nurse #1 said after the Consultant Wound MD uploads their notes the Assistant Director of Nursing (ADON) updates the recommendations into the medical record. During an interview on 1/16/26 at 12:40 P.M., the ADON said after the Wound Consultant MD sends over their treatment recommendations either herself or the overnight nurse reviews the recommendations and updates the treatment orders in the medical record. The ADON said facility providers accept Wound Consultant MD recommendations as treatment orders. During an interview on 1/20/26 at 8:33 A.M., the ADON reviewed Resident #10's medical record, including the Wound Consultant MD recommendations and treatment orders. The ADON said the Wound Consultant MD recommendations from 12/12/25, 12/17/25 and 12/26/25 included application of calcium alginate and not xeroform. The ADON said the treatment orders from 12/1/25 through 12/31/25 for the stage III right medial buttock pressure ulcer order did not match the Wound Consultant MD recommendations and should have been updated to match those recommendations.

Based on record review and interview, the facility failed to ensure for two Residents (#34, #6), from a total sample of 18 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed for Residents #34 and #6 to ensure a gradual dose reduction (GDR) of psychotropic medication was attempted in an effort to discontinue these drugs, unless documented in the medical record by the prescriber as clinically contraindicated. Findings include:Review of the facility's policy titled Use of Psychotropic Medication, revised December 2024, indicated but was not limited to the following: - The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with the residents, their families, and/or representatives, other professionals, and the interdisciplinary team. - Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. A. Resident #34 was admitted to the facility in October 2022 with diagnoses including bipolar disorder, dementia with behavioral disturbances, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and received antipsychotic medication daily. Review of the medical record indicated Physician's Orders included but was not limited to: - Ativan Tablet 0.5 milligrams (MG) (used to treat anxiety) Give 0.5 MG by mouth one time a day (7/21/25). - Cymbalta Oral Capsule Delayed Release Particles 30 MG (use to treat depression). Give 30 MG by mouth one time a day (8/23/25). - Doxepin HCL Oral Capsule 10 MG (used to treat depression). Give 1 capsule by mouth at bedtime for sleep (12/18/25). - Wellbutrin XL Tablet extended Release 24 Hour 150 MG (used to treat depression). Give 300 MG by mouth one time a day (12/12/25). - Lurasidone HCl Oral Tablet 20 MG (used to treat bipolar disorder). Give 1 tablet by mouth at bedtime (9/23/25). Review of the Pharmacy recommendations, dated 12/22/25, indicated the last GDR recommendation for Doxepin, Wellbutrin, Ativan, Lurasidone was declined on 10/23/24 by the Nurse Practitioner (NP), with an indication that Resident #34 was having psychiatric symptoms at the time. Review of February 2025 through January 2026 Medication Administration Records (MAR) indicated psychotropic medications were administered as ordered by the physician. Review of Resident #34's Physician (MD) and Nurse Practitioner (NP) progress notes from February 2025 through January 2026 failed to indicate documentation that a GDR was attempted or a rationale for why a GDR was clinically contraindicated for Resident #34 as follows: - NP progress note, 2/17/25, mood and behaviors are stable, not agitated, cooperative, anxiety stable, continue Ativan. Continue all current prescribed medications and monitor. - NP progress note, 3/20/25, moods and behaviors are stable, not agitated, cooperative. Continue Wellbutrin and Ativan. Continue all current prescription medication. - NP progress note, 3/30/25, continue Wellbutrin and Ativan. Continue all current prescription medication. - NP progress note, 4/21/25, continue Wellbutrin. Continue all current prescription medication. - NP progress note, 6/7/25, continue Wellbutrin. Continue all current prescription medication. - MD progress note, 6/25/25, continue current psychotropic medications. Continue all current prescription medication. - NP progress note, 7/7/25, mood and behaviors are stable, cooperative. Continue Ativan. Continue current psychotropic medications. - NP progress note, 9/12/25, mood and behaviors stable, cooperative, continue Ativan, continue current psychotropic medication. - MD progress note, 9/24/25, cooperative, continue all current prescription medication. - NP progress note, 10/29/25, psych cooperative, continue all prescription medication. - NP progress note, 11/14/25, mood and behavior stable, cooperative. Continue current psychotropic medication. - NP progress note, 12/2/25, cooperative, continue current psychotropic medication. - MD progress note, 12/17/25, cooperative, continue all current prescription medication. During an interview on 1/15/26 at 12:00 P.M., Unit Manager #1 said all recommendations for GDRs go to the Director of Nursing (DON) for review with prescriber and any recommendations would be documented. During an interview on 1/20/26 at 11:21 A.M., the DON said GDR recommendations are reviewed by herself and the providers when recommended by the pharmacist and/or psych NP. The DON said providers and herself will re-evaluate a resident's need for a GDR approximately every six months. The DON said she was unable to find any clinical contraindication documentation on a GDR for Resident #34. B. Resident #6 was admitted to the facility in September 2023 and had diagnoses including anxiety, depression and Post-Traumatic Stress Disorder (PTSD). Review of the MDS assessment, dated 11/26/25, indicated Resident #6 was cognitively intact as evidenced by a BIMS score of 15 out of 15, and received psychotropic medication daily. Review of the medical record indicated Physician's Orders including but not limited to: -Venlafaxine XR (Effexor-antidepressant) 75 MG two times a day for persistent emotional storming (7/8/25) -Mirtazapine (Remeron-antidepressant) 45 MG one time a day for depression (3/19/24) -Lamotrigine (Lamictal-anticonvulsant used for mood stabilization) 100 MG twice a day (8/12/25) -Clonazepam (Klonopin-antianxiety) 1 MG in the morning for anxiety (7/30/25) -Clonazepam 1.5 MG at bedtime for anxiety (7/30/25) Review of March 2025 through January 2026 MARs indicated the psychotropic medications were administered as ordered by the physician. Review of the following MD and NP progress notes from February 2025 to January 2026 failed to indicate documentation that a GDR was attempted or a rationale for why a GDR was clinically contraindicated for the Resident as follows: -NP Progress Note, dated 2/14/25, moods and behaviors are stable. Continue Remeron, Effexor, Clonazepam. -NP Progress Note, dated 2/18/25, patient stable on exam. Seen by psych with recommendation to increase Lamotrigine to 50 mg twice a day. Continue Clonazepam, Effexor and Remeron. -NP Progress Note, dated 3/14/25, moods are stable. Continue Lamotrigine, Clonazepam, Effexor and Remeron. -NP Progress Note, dated 4/18/25, moods are stable. Continue Lamotrigine, Clonazepam, Effexor and Remeron. -NP Progress Note, dated 5/2/25, patient stable on exam. Continue Lamotrigine, Clonazepam, Effexor and Remeron. -NP Progress Note, dated 5/9/25, moods are stable. Continue Lamotrigine, Clonazepam, Effexor and Remeron. -MD Progress Note, dated 6/18/25, review of systems negative for psych. Continue current psychotropic medications. -NP Progress Note, dated 7/14/25, moods and behaviors are stable. Continue current psychotropic medications. -NP Progress Note, dated 9/5/25, moods and behaviors are stable. Continue current psychotropic medications. -NP Progress Note, dated 9/19/25, continue all current prescription medication and monitor. -MD Progress Note, dated 10/1/25, review of systems negative for psych. Continue current psychotropic medications. -NP Progress Note, dated 11/14/25, seen by psych on 11/10/25 with no new recommendations. review of systems negative for psych. Continue current psychotropic medications. -MD Progress Note, dated 11/30/25, review of systems negative for psych. Continue all current prescription medication and monitor. -NP Progress Note, dated 1/9/26, moods and behaviors are stable. Continue all current prescription medication and monitor. -NP Progress Note, dated 1/13/26, anxiety disorder stable. Continue with all current prescription medication and monitor. During an interview on 1/20/26 at 2:00 P.M., the DON reviewed Resident #6's medical record. She said she could not find any documentation from either the Physician or NP to indicate an evaluation for a potential GDR of psychotropic medications was conducted or any documentation of a clinical rationale that a GDR was contraindicated. She said she was not aware that prescribers had to document this information in the medical record.

Based on observations, interviews, and records reviewed, the facility failed to ensure a reasonable accommodation was made for two Residents (#66 and #81), out of 25 residents on the facility's Unit 4. Specifically, the facility failed to ensure the call system was accessible to the Residents to call for staff assistance. Findings include:Review of the facility's policy titled Call Lights: Accessibility and Timely Response Policy, revised 1/2025, indicated, but was not limited to, the following:-All residents will be educated on how to call for help by using the resident call system.-Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.-Staff will ensure the call light is within reach of residents and secured, as needed.-The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.Resident #66 was admitted to the facility in October 2024 with diagnoses including cognitive impairment.Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated Resident #66 was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated the Resident required assistance from staff for activities of daily living and able to ambulate with supervision or touching assistance.Review of Resident #66's Care Plan indicated, but was not limited to, the following:-Focus: I am at risk for falls r/t (related to) gait/balance problems, history of falls.-Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Resident #81 was admitted to the facility in June 2024 with diagnoses including Alzheimer's Disease and seizures.Review of the MDS assessment, dated 11/27/25, indicated the BIMS was not conducted as the Resident is rarely/never understood. Further review of the MDS indicated the Resident was dependent on staff for activities of daily living and not ambulatory.Review of Resident #81's Care Plan indicated, but was not limited to, the following:-Focus: I am at risk for falls r/t Confusion, Gait/balance problems, Incontinence, Psychoactive drug use, Unaware of safety needs-Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 1/14/26 at 8:10 A.M., the surveyor observed Resident #66 lying in bed with the bed in low position. The Resident's call light and his/her roommate's (Resident #81) call light were secured above his/her bed, out of reach of the Resident. On 1/14/26 at 4:23 P.M., the surveyor observed Resident #81 lying in bed. The Resident's call light and his/her roommate's (Resident #66) call light were secured above his/her roommate's bed, out of reach of Resident #81.On 1/15/26 at 8:22 A.M., the surveyor observed Resident #66 lying in bed. The Resident's call light and his/her roommate's call light were secured above his/her bed, out of reach of the Resident.During an interview on 1/15/26 at 10:06 A.M., Certified Nursing Assistant (CNA) #1 said Resident #66 and Resident #81 should have their call lights within reach and do not have an alternative device in place to call for help (handbell, etc.). CNA #1 and the surveyor went to the Residents' room and observed both residents' call lights secured to the wall and out of reach of Resident #66, who was still lying in bed. CNA #1 said she did not know why the call lights would be there and that Resident #66 should have the call light within reach.During an interview on 1/20/26 at 9:08 A.M., the Director of Nursing said all residents' call lights should be within reach.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of new wounds for one Resident (#28), out of a total sample of 18 residents. Specifically, for Resident #28, the facility failed to notify the physician of the discovery of two areas of deep tissue injury (pressure-induced damage to underlying tissues while the skin surface might remain intact; typically resulting from sustained pressure and/or shear forces, which disrupt blood flow and lead to tissue damage).Findings include:Review of the facility's policy titled Pressure Injury Prevention and Management Policy, revised 5/2025, indicated, but was not limited to, the following:-The attending physician will be notified of:i. The presence of a new pressure injury upon identification.ii. The progression towards healing, or lack of healing, of any pressure injuries weekly.Resident #28 was admitted to the facility in January 2025 with diagnoses including moderate protein-calorie malnutrition and Alzheimer's Disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, indicated Resident #28 was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Further review of the MDS assessment indicated the Resident had two unstageable pressure injuries presenting as deep tissue injury that were not present upon admission/readmission to the facility.Review of Resident #28's Progress Notes indicated that on 12/13/25, Nurse #2 observed two areas on the Resident's left buttocks, deep purple in color and non-blanchable. The nurse documented that area #1 measured 3 cm (centimeters) by 0.25 cm with no depth and area #2 was a 1 cm round area. Nurse #2 indicated she cleansed the areas and applied Eucerin cream. Review of Resident #28's Skin Assessment, dated 12/13/25, indicated the following:-Left buttocks- 2 new areas. #1- 3 cm Lx 0.25 cm W 0 depth. #2 - dime sized area 0 depth 1 cm round. Deep purple, non-blanchable.Review of Resident #28's Physician's Orders indicated treatment and monitoring orders for the Resident's left buttock wounds were implemented on 12/29/25. Review of Resident #28's physician and nurse practitioner progress notes failed to indicate the physician or nurse practitioner were notified of the discovery of a new pressure injury on 12/13/25.Review of Resident #28's consultant wound physician progress notes indicated the Resident's left medial buttock deep tissue injury was first assessed by the consultant wound physician on 12/26/25. Review of Resident #28's medical record failed to indicate the Resident's attending physician was notified of the discovery of the new pressure injury identified on 12/13/25. During an interview on 1/15/26 at 1:01 P.M., the Infection Control Nurse (who oversees the unit where Resident #28 resides) said he was not sure when he became aware of the area or why the attending physician was not notified. The Infection Control Nurse said he was not sure why the Resident did not have any new orders implemented for monitoring and/or treatment of the deep tissue areas until 16 days after they were initially discovered. During an interview on 1/20/26 at 7:13 A.M., Nurse #2 said when a new skin area is discovered, the nurse should document the area in a Skin Assessment and notify the attending physician. Nurse #2 said she did not place a call to the physician or after-hours consulting service but documented the areas in the physician communication log for the physician to review later. Nurse #2 could not find documentation in the physician communication log that the physician was notified. During an interview on 1/20/26 at 9:08 A.M., the Director of Nursing said when a new skin area is discovered, the nurse should notify the attending physician or after-hours coverage even if the information is passed on in shift report.The surveyor attempted to reach Resident #28's attending physician by phone on 1/20/26 but did not receive a return call.Refer to F686

Based on interview and record review, the facility failed to ensure professional standards of care were met for one Resident (#3), out of a total sample of 18 residents. Specifically, the facility failed to ensure there was a physician's order for the flushing (using a syringe to gently push sterile liquid into the catheter to clear blockages from mucous, blood clots, or debris, ensuring it drains urine properly) of a Foley catheter.Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling 9324 titled Accepting, Transcribing, and Implementing Prescriber Orders, dated as last revised April 11, 2018, indicated but was not limited to the following:-It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication. -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.-In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Catheter Irrigation, dated as reviewed/revised December 2024, indicated but was not limited to the following:-Urinary catheters shall be irrigated by a licensed nurse using sterile technique, under the orders of the physician.-Routine irrigation is not recommended.-Orders shall include the type and amount of irrigating solution or medication. Resident #3 was admitted to the facility in September 2025 with diagnoses including type II diabetes, enlarged prostate, retention of urine, and urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, included Section H0100 Appliances which indicated Resident #3 had an indwelling catheter. Review of Resident #3's Nurse Progress Notes indicated that his/her Foley catheter was flushed on the following dates: 1/11/26, 1/9/26 at 23:09 and at 7:27, and 1/2/26. Review of Resident #3's January 2026 Physician's Orders failed to indicate there was an order for flushing the Foley catheter.During an interview on 1/13/26 at 2:45 P.M., Nurse #3 said Resident #3 has needed his/her Foley catheter flushed recently. Nurse #3 said that flushes for a Foley catheter require a Physician's order to indicate the amount and type of fluid to use. Nurse #3 said Foley catheter flushes should be documented on the resident's Treatment Administration Record (TAR). During an interview on 1/15/26 at 3:43 P.M., Unit Manager (UM) #1 said any resident needing Foley catheter flushes would have an order indicating the type and amount of solution to be used. UM #1 reviewed the physician's orders and said that Resident #3 did not have an order to flush his/her Foley catheter.On 1/16/26 at 4:12 P.M., the surveyor placed a call to Physician #2 to inquire for lack of an order to flush Resident #3's Foley catheter. As of the end of survey, no call was received. During an interview on 1/20/26 at 8:21 A.M., the Director of Nursing (DON) said Foley catheter flushes required a physician's order. The DON said she could not believe the order was missed as it was on the facility's order set for Foley catheters. The DON said Foley catheter flushes should have been documented on the TAR.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to ensure a treatment cart was locked when not in direct supervision of a licensed nurse on one of four units. Findings include: Review of the facility's policy titled Storage of Medications, undated, included but was not limited to:- The facility stores all drugs and biologicals in a safe, secure, and orderly manner.- Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.- Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. On the following dates and times, the surveyor observed the Unit Three treatment cart to be unlocked and unattended with residents and outside vendors in the vicinity:- 1/15/26 at 10:11 A.M.,- 1/15/26 at 10:20 A.M.,- 1/15/26 at 10:30 A.M.,- 1/15/26 at 10:47 A.M.,- 1/15/26 at 2:03 P.M.,- 1/15/26 at 2:18 P.M., and- 1/15/26 at 2:28 P.M. The surveyor observed the Unit Three treatment cart to be unlocked for a total of 36 minutes between 10:11 A.M. and 10:47 A.M. on 1/15/26. Additionally, the surveyor observed the Unit Three treatment cart to be unlocked for a total of 25 minutes between 2:03 P.M. and 2:28 P.M. on 1/15/26. During an interview on 1/16/26 at 10:42 A.M., Nurse #1 said the treatment cart should be locked at all times. During an interview on 1/16/26 at 1:22 P.M., the Director of Nursing (DON) said treatment carts should always be locked when not in use or in direct supervision of the nurse. The DON and the surveyor reviewed the observations made throughout the survey. The DON said the treatment cart should have been locked.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included a diagnosis of atrial fibrillation (irregular heartbeat) with an order for Xarelto (anticoagulant), the facility failed to ensure the Physician and Nurse Practitioner completed a review of his/her total program of care, including reviewing for accuracy Resident 1's medications, as a result he/she did not receive Xarelto for 13 days.Findings Include:Review of the Facility's Policy titled, Medication Reconciliation Policy, dated as revised January 2025, indicated the following:-the facility reconciles medication to ensure that the resident is free of any significant medication errors.-medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff.Resident #1 was admitted to the Facility in June 2025, diagnoses included right femoral (thigh bone) fracture, heart failure, atrial fibrillation (irregular heart rate), aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart), hypertension and hyperlipidemia (high cholesterol).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated his/her discharge medications orders included but not limited to the following:-Rivaroxaban (Xarelto, an anticoagulant) 20 milligrams (mg) tablet, one tablet (20 mg total) by mouth dailyReview of Resident #1's Nurse Practitioner (NP) Progress Notes, dated 06/09/25, 06/10/25, 06/13/25 and 06/16/25 indicated that Resident #1 had a diagnosis of atrial fibrillation and he/she was seen and examined. The Notes indicated that Resident #1's medications were reviewed and reconciled and to see Medication Administration Record (MAR). The Notes indicated that Resident #1's assessments/plans were to continue current medications for his/her diagnosis of atrial fibrillation. However, further review of Resident #1's NP Progress Notes indicated that Xarelto was not listed under his/her medications.Review of Resident #1's Physician admission Progress Note, dated 06/11/25 indicated that Resident #1 had a history of atrial fibrillation and he/she was on Xarelto. The Note indicated Resident #1's assessments/plans were to continue current medications and current management for his/her diagnosis of atrial fibrillation. However, further review of the Note indicated that although it included a list of Resident #1's medications, it did not include Xarelto.During an interview on 7/16/25 at 10:39 A.M., the Nurse Practitioner (NP) said she reviewed Resident #1's Hospital Discharge Summary and saw him/her on 06/09/25, 06/10/25, 06/13/25 and 06/16/25. The NP said she could not recall if Xarelto was listed on Resident #1's physician orders or medication list and said, I plead the fifth and will not further comment.During an interview on 7/16/25 at 11:04 A.M., the Physician said he saw Resident #1 once (could not recall date), he reviewed his/her Hospital Discharge Summary, and he/she was on Xarelto for atrial fibrillation. The Physician said the medication list in his progress notes was not a reconciliation list of medications. The Physician said he was not aware that Resident #1 had not received his/her Xarelto until he/she was sent to the Hospital ED. The Physician said the On-call provider reviewed, reconciled and approved Resident #1's admission orders with the admitting nurse and that the admitting nurse had not transcribed Xarelto onto Resident #1's admission orders. During an interview on 7/15/25 at 2:45 P.M., the Director of Nursing (DON) said Resident #1 had been seen by the Physician and the Nurse Practitioner after his/her admission. The DON said she reviewed Resident #1's Physician and Nurse Practitioner progress notes which included he/she had atrial fibrillation and to continue current medications, but the DON said, Xarelto was not listed under his/her medications. The DON said she spoke with the Physician, and he said that he reviewed Resident #1's Hospital paperwork, saw that Resident #1 was on Xarelto, but that he had not done a comparison to the medications that were entered into PCC by the admitting nurse. The DON said the NP told her that she (NP) had looked at Resident #1's Hospital paperwork, but said that she had not done a formal comparison of his/her medication orders.The DON said it was her expectation that the Physician and Nurse Practitioner reviewed and reconciled residents' orders against their Hospital Discharge Summary, that their orders entered in Point Click Care (PCC, electronic medical record system) match and residents' medications should be documented accurately in the residents' Physician and NP progress notes.On 07/15/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 06/26/25, which addressed the area(s) of concern as evidenced by:A. Resident #1 is no longer in the Facility.B. On 06/19/25, the Director of Nursing and [NAME] President of Operations completed a house audit on all residents admitted in the past 30 days to ensure medications were ordered and administered per Hospital Discharge paperwork.C. On 06/19/25, a Root Cause Analysis Summary was completed on the medication error.D. The Facility implemented a Triple Check Protocol on all resident admissions and re-admission orders.E. On 6/26/25, the Director of Nursing provided education to the Physician and Nurse Practitioner on admission Orders, the Facility's Triple Check Protocol to ensure residents' medications are accurately reconciled upon admission and that the primary care Physician and Nurse Practitioner will review residents' Hospital Discharge paperwork ensuring that medications listed in their progress notes are accurate.F. The Pharmacy Consultant will complete a medication reconciliation for all new admissions that process will be on-going.G. The Director of Nursing and/or designee will conduct daily audits on residents' admission paperwork to ensure that the Physician/Nurse Practitioner accurately documents residents' admission medications in their progress and admission notes for two weeks, then weekly for four weeks, the audits will continue monthly or until overall compliance is achieved. H. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for six months or until compliance is achieved.I. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Hospital Discharge Summary included a diagnosis of atrial fibrillation (irregular heart beat) with an order for Xarelto (anticoagulant), the Facility failed to ensure he/she was free from significant medication errors, when upon admission Resident #1's physician orders were not accurately reconciled and transcribed by nursing staff, he/she was not administered Xarelto for thirteen days, placing him/her at increased risk for adverse reactions. Findings Include:Review of the Facility's Policy titled, admission Assessment and Follow Up: Role of the Nurse, dated May 2023, indicated nursing would reconcile the list of medications from the medication history, admitting orders, and the discharge summary from the previous institution, according to established procedures.Review of the Facility's Policy titled, Medication Reconciliation Policy, dated as revised January 2025, indicated the following:-the facility reconciles medication to ensure that the resident is free of any significant medication errors.-medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff.-admission processes: compare orders to hospital records, obtain clarification orders as needed, and transcribe orders in accordance with procedures for admission orders.Review of Resident #1's Medication Variance Report, dated 06/18/25, indicated that Resident #1's medication as ordered for Xarelto 20 mg daily was missed during transcription of his/her admission orders and on 24-hour check by the 11:00 P.M.-7:00 A.M. nurse. The Report indicated that Resident #1 had not received his/her Xarelto medication for 13 days, his/her physician was notified, and he/she was transferred to the Hospital Emergency Department for evaluation.Review of an article in Drugs.com the Official Website, dated 07/25/24, indicated Xarelto (rivaroxaban) class of medications called factor Xa inhibitors (used as anticoagulants, blood thinners). It works by blocking the action of a certain natural substance that helps blood clots to form. Xarelto is used to treat or prevent blood clots (venous thromboembolism, or VTE), blood clots can occur in the legs (deep vein thrombosis, DVT) or the lungs (pulmonary embolism, PE). The Website further indicated Xarelto is also used to help prevent strokes or serious blood clots in adults who have atrial fibrillation, (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body, and possibly causing strokes) that is not caused by heart valve disease.Resident #1 was admitted to the Facility in June 2025, diagnoses included right femoral (thigh bone) fracture, heart failure, atrial fibrillation (irregular heart rate), aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart), hypertension and hyperlipidemia (high cholesterol).Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated his/her discharge medications orders included but not limited to the following:-Rivaroxaban (Xarelto, an anticoagulant) 20 milligrams (mg) tablet, one tablet (20 mg total) by mouth dailyReview of Resident #1's Nurse Progress Note, dated 06/18/25, indicated that at approximately 7:50 A.M. he/she was SOB, O2 Saturation was 86% on room air, his/her right arm was flaccid with weakness, and he/she was leaning to his/her right. The Note indicated that O2 (four liters) was applied to Resident #1 via nasal cannula, and an order was obtained to send him/her to the Hospital ED for evaluation and treatment per the Nurse Practitioner.During an interview on 7/15/25 at 1:25 P.M., (which included review of her written statement) Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 06/05/25 and had done Resident #1's admission that night. Nurse #1 said she reviewed Resident #1's Hospital Discharge paperwork, verified all medication orders with the on-call provider, then entered them into the Point Click Care (PCC, electronic medical record system) from his/her hospital medication list. Nurse #1 said she thought she had entered all of Resident #1's medications including his/her order for Xarelto and said she had no clue that she had not entered the order for Xarelto. Nurse #1 said she must have missed entering the Xarelto order because she could have been distracted by being called away to attend to another resident.During an interview on 7/17/25 at 8:56 A.M., (which included review of her written statement) Nurse #2 said she worked the 11:00 P.M. to 7:00 A.M. shift on 06/05/25 into 06/06/25 and there were two new admissions on the previous shift (3:00 P.M. to 11:00 P.M.). Nurse #2 said she completed one of the admissions and had started to do the second check on Resident #1's admission orders. Nurse #2 said she was called away by the Certified Nurse Aide (CNA) on the unit because the CNA needed assistance with another resident. Nurse #2 said she informed the on-coming shift nurse (could not recall the exact name) that she was not able to complete the second check on Resident #1's admission orders.During an interview on 7/15/25 at 12:41 P.M., (which included review of her written statement) the Unit Manager said the staff nurse on the unit is responsible for new admissions, which includes completing all physician orders and assessments. The Unit Manager said the nurse is responsible for reconciling medication orders from residents' hospital discharge paperwork, verifying orders with the Physician and entering all orders into PCC. The Unit Manager said the 11:00 P.M. to 7:00 A.M. shift nurse does a second check on all new admission orders that were entered in PCC.The Unit Manager said on 06/06/25 she received report from the11:00 P.M. to 7:00 A.M. nurse (Nurse #2) and Nurse #2 did not tell her that she (Nurse #2) had not completed the second check on Resident #1's admission orders. The Unit Manager said she had not reviewed Resident #1's admission orders on 06/06/25 and that she should have.During an interview on 7/15/25 at 2:45 P.M., the Director of Nursing (DON) said on 06/18/25 Resident #1 was sent to the Hospital ED for change in his/her condition and his/her Family had called the facility asking if he/she had been on Xarelto while there. The DON said she reviewed Resident #1's Hospital Discharge Summary which indicated that he/she had an order for Xarelto. The DON said she then reviewed Resident #1's admission orders and said his/her order for the Xarelto had not been transcribed into PCC.The DON said she spoke with the admitting nurse (Nurse #1) and Nurse #1 said that she must have missed entering Resident #1's Xarelto order into PCC and did not know how it could have happened. The DON said Nurse #2 said that she started reviewing Resident #1's admission orders and that she had not completed the second check because she was pulled away for another resident's needs. The DON said Nurse #2 said that she could not recall if she had told the on-coming shift nurse she had not completed the second check on Resident #1's admission orders.The DON said it was her expectation that nurses transcribe all resident's admission medication orders correctly when entering them into PCC. The DON said the second nurse should fully complete the second check on all residents' admission orders and if the nurse is unable to complete the second check, the nurse must inform the Unit Manger and the on-coming shift nurse.The DON said the nurse on the unit is responsible for completing new admissions and entering all orders into PCC and the 11:00 P.M. to 7:00 A.M. nurse is responsible for completing a second check by reviewing residents Hospital Discharge paperwork against all new admission orders that were entered in PCC to ensure accuracy.On 07/15/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 06/26/25, which addressed the area(s) of concern as evidenced by:A. Resident #1 is no longer in the Facility.B. On 06/19/25, the Director of Nursing and [NAME] President of Operations completed a house audit on all residents admitted in the past 30 days to ensure medications were ordered and administered per Hospital Discharge paperwork.C. On 06/19/25, a Root Cause Analysis Summary was completed on the medication error.D. The Facility implemented a Triple Check Protocol on all resident admissions and re-admission orders.E. On 6/18/25 through 6/25/25, the Director of Nursing provided education to all Licensed Nursing staff on the Facility's Medication Reconciliation Policy, Triple Check Protocol and admission Order Verification Form.F. The Pharmacy Consultant will complete a medication reconciliation for all new admissions that process will be on-going.G. The Director of Nursing and/or designee will conduct daily audits on residents' admission paperwork to ensure that nurses are correctly entering medication orders into Point Click Care and the Pharmacy consultant has reconciled residents' admission medications for two weeks, then weekly for four weeks, the audits will continue monthly or until overall compliance is achieved. H. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for six months or until compliance is achieved.I. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physicians' orders included the administration of Methadone (opioid, narcotic) 10 milligrams (mg) daily, the Facility failed to ensure he/she was free from a significant medication error, when on 02/25/25 nursing staff did not properly identify the resident's name or dosage on the medication bottle and administered another residents' methadone to him/her. As a result of Resident #1 being administered 110 mg of Methadone (not 10 mg as ordered), he/she was transferred to the Hospital Emergency Department (ED) for evaluation and required treatment for adverse side effects related to an overdose of Methadone. Findings Include: Review of the Facility's Policy titled, Administering Medications, undated, indicated the following: -only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so; -medications are administered in accordance with prescriber orders; -the individual administering medications verifies the resident's identity before giving the resident his/her medications; -the individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication; -medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nurses. Review of the Facility's Policy titled, Medication Error, dated March 2024, indicated the following: -it is the policy of the facility to assure that each medication administered to our resident has been prescribed by a licensed physician or equivalent; -noncompliance with the exact medication order is considered a medication error; -medication errors include: omission, wrong drug, wrong patient, wrong dose, wrong time, wrong route, given not charted, extra dose found, documentation error and transcription. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/27/25, indicated that on 02/25/25 Resident #1 mistakenly received the wrong dose of Methadone in error. The Report indicated that Resident #1 received 110 mg of Methadone instead of his/her physician ordered 10 mg of Methadone. The Report indicated that Resident #1's Physician was notified and he/she was transferred to the Hospital ED for evaluation and monitoring. The Report indicated that the Nurse was administering scheduled medications to Resident #1 when the incorrect bottle of sealed premeasured Methadone was retrieved and administered to Resident #1 in error. The Report indicated that the Nurse mistakenly retrieved a bottle of Methadone that was labeled for another resident (later identified as Resident #3) and administered the incorrect dose of Methadone to Resident #1. The Report indicated that the Nurse noted her error during narcotic count with the oncoming shift. Review of drug information specific to Methadone via Drugabuse.com, dated 08/08/2024, indicated Methadone is a long-acting opioid agonist that works by reducing the effects of other opioid's. Methadone can, however, be misused when someone takes it in a way other than prescribed or by taking more than prescribed. If someone takes more than prescribed (intentionally or unintentionally), there is an increased risk of overdose due to potential respiratory depression. Signs and symptoms of Methadone overdose include difficulty waking up, slowed or shallow breathing, vomiting, decreased heart rate, extreme drowsiness, or sleepiness, mental confusion, difficulty awakening, low blood pressure and slurred speech. Review of Resident #1's Hospital Discharge Summary, dated 02/26/25, indicated that Resident #1 presented to the ED for an accidental overdose of Methadone. The Summary indicated that upon arrival at the ED, Resident #1 complained of increased somnolence (sleepiness) and nausea which resolved with Zofran (receptor antagonist used for nausea and vomiting). The Summary indicated that Resident #1 received 110 mg of Methadone instead of his/her 10 mg of Methadone and was admitted to the Telemetry Unit (continuous tracking of your hearts electrical activity) for monitoring and an EKG (electrocardiogram - test that measures the electrical waves in the heart) testing every four hours due to such a high dose of Methadone. Resident #1 was admitted to the Facility in November 2024, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, adjustment disorder with anxiety, depression, psychoactive substance abuse, cirrhosis of liver, portal hypertension, atrial fibrillation, chronic viral hepatitis C, obstructive sleep apnea and morbid obesity. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact. Review of Resident #1's Medication Administration Record (MAR) and Physician Orders, dated February 2025, indicated that he/she had an active physician's order for Methadone 10 mg daily. Review of Resident #3's Physician Orders, dated February 2025, indicated that he/she had an order for Methadone 110 mg by mouth once daily, for pain. Review of Resident #1's Medication Variance Report, dated 02/25/25, indicated that Resident #1 received 110 mg of Methadone instead of his/her 10 mg dose of Methadone in error. The Report indicated Resident #1's Physician was notified and he/she was transferred to the Hospital ED for evaluation. Review of Resident #1's Nurse Progress Note, dated 02/25/25, indicated that he/she was inadvertently given an extra 100 mg of Methadone and was transferred to the Hospital ED immediately. Review of Resident #1's Provider Progress Note, dated 02/25/25, indicated that he/she received an extra 100 mg of Methadone in error and was transferred to the Hospital ED. During an interview on 04/01/25 at 11:15 A.M., Resident #1 said that on 02/25/25, he/she was administered 110 mg of Methadone in error and had to go to the hospital for treatment. Resident #1 said that he/she experienced lethargy and nausea from the overdose of Methadone. Resident #1 said that he/she is anxious now every time the nurse administers his/her medications because he/she is afraid that the nurse may give him/her the wrong medication and that he/she looks at the medications in the cup to be sure the medications are correct. During an interview on 04/01/25 at 12:10 P.M., Nurse #3 said that on 02/25/25 at approximately 7:15 A.M. she did narcotic count with Nurse #1. Nurse #3 said that during the count, they discovered that the narcotic count was incorrect for Resident #1's Methadone. Nurse #3 said she and Nurse #1 looked in the narcotic drawer and noticed that Resident #3's Methadone 110 mg bottle for the 02/25/25 dose was missing, and that Resident #3 was at the hospital and would not have received his/her Methadone dose that morning. Nurse #3 said that was when Nurse #1 realized that she had administered Resident #3's Methadone (110 mg) to Resident #1 in error. Nurse #3 said that Resident #1's Methadone 10 mg bottle for the 02/25/25 dose was still in the narcotic drawer when she did narcotic count with Nurse #1. During a telephone interview on 04/02/25 at 11:16 A.M., (which included review of her interview conducted and documented by the Director of Nurses), Nurse #1 said she worked the 11:00 P.M. to 7:00 A.M. shift on 02/25/25. Nurse #1 said that there were three residents on the unit who received Methadone. Nurse #1 said that Methadone was stored in a separate secured narcotic drawer and each resident had individual bottles with their name, dose and date to be administered on it, that were separated in the narcotic drawer by resident. Nurse #1 said she went into the narcotic drawer, saw the date of 02/25/25 on a Methadone bottle and took it out of the draw, but did not look at the dosage or residents name on the bottle when she removed it from the drawer. Nurse #1 said that she went to Resident #1's room and administered the Methadone to him/her, again without looking at the dosage or residents name on the bottle prior to administering it to him/her. Nurse #1 said that during narcotic count at the end of her shift with Nurse #3, they discovered that Resident #1's Methadone count was incorrect and that was when she realized that Resident #1 had received the wrong dose of Methadone. Nurse #1 said she had administered Resident #3's Methadone 110 mg to Resident #1 in error. Nurse #1 said she should have looked at the Methadone bottle to see whose name was on the bottle and checked the dosage of Methadone but had not. Nurse #1 said she just looked at the date on the bottle and did not follow the proper procedures for medication administration. During an interview on 04/01/25 at 3:30 P.M., the Director of Nurses (DON) said she was made aware of Resident #1's medication error on 02/25/25 by Nurse #1. The DON said that Nurse #1 informed her that she had administered 110 mg of Methadone to Resident #1 in error. The DON said that Nurse #1 said she did not look at the name or dose that was on the Methadone bottle. The DON said it was her expectation that nurses follow the rights of medication administration, read the label on the medication bottle to be sure that the medication is for the correct resident and that the dose is correct prior to administering any medications to residents. On 04/01/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 02/25/25, Resident #1 was assessed by nursing and transferred to the Hospital ED for evaluation and treatment. B. On 02/25/25 Nurse #1 was educated by the Director of Nurses on the Facility's Policy and Procedure on Medication Administration. C. On 02/25/25, a Methadone Storage Audit was completed and each resident on Methadone and each resident now has an individual zippered storage bag with their name on it and all of their individual Methadone bottles secured in the sealed bag. D. On 02/26/25, a Quality Assurance Performance Improvement (QAPI) Committee meeting was held regarding medication administration and reduction of medication errors. E. On 02/27/25, a Root Cause Analysis Summary was completed on medication errors. F. On 03/10/25, Licensed staff were educated by the Corporate Nurse on the Facility's Medication Administration Policy and the Medications for Addiction Treatment (MAT) Policy. G. On 03/25/25, the Facility's Controlled Substance Administration and Accountability Policy and Procedure and Medication Error Policy was revised by the Regional Nurse Consultant. H. The Unit Manager and/or designee will conduct weekly audits on Methadone Storage to ensure that each resident on Methadone has an individual zippered bag with their name on it and their Methadone bottles are in the bag. Audits will be done weekly for 3 months and will continue until overall compliance is achieved. I. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting for three months or until compliance is achieved. J. The Director of Nursing and/or designee are responsible for overall compliance

Based on observation, interview and record review, the facility failed to ensure the pain medication was administered as ordered by the physician to adequately control pain for one Resident (#183) out of a sample of 19 residents. Findings include: Review of the facility policy, titled Pain assessment and Management, dated May 2023, indicated but was not limited to the following: - Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. -Review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medications relieve the resident's pain. -Identifying the causes of pain: Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including neurological conditions such as multiple sclerosis, neuropathy, headache, head trauma, and post stroke syndrome. -Implementing pain management strategies: implement the medication regime as ordered, carefully documenting the results of the interventions. -If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall consider reconsider approaches and make adjustments as indicated. -Reporting: Report the following information to the physician or practitioner: Prolonged, unrelieved pain despite care plan interventions. Resident #183 was admitted to the facility November 2023 with the chronic pain, polyneuropathy (damage to the nerves), anxiety disorder and Cerebral vascular disorder (stroke, CVA) with hemiplegia Paralysis of one side body). During an interview on 11/16/23 at 2:36 P.M., Resident #183 said he/she has a lot of pain at night, it has been every night, and I must ask for pain meds and then they don't work. She said last night her pain was 6-7 /10 in left leg and her arm just aches. She said some nights the pain is 10/10. Every night since she has been here, she has so much pain at night. Resident's spouse was present, and he/she said he/she calls every night in the middle of the night and the morning because he/she is in pain. They both can't understand why they can't give him/her scheduled pain medication at night. Resident #183 said it's the muscle spasms in the left leg. Review of Resident ##183's care plan initiated, 11/11/23 indicated but was not limited to the following: -The resident has chronic neuropathic pain -The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review. -Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain -Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. -Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. -Identify, record and treat the resident's existing conditions which may increase pain and or discomfort neuropathies, parathesia related stroke. -Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. -Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. -Monitor/record pain characteristics every shift and PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Review of Resident ##183's care plan initiated, 11/9/23 indicated but was not limited to the following: -I have left side Hemiplegia/Hemiparesis related to / Stroke. -I, the resident, will remain free of complications or discomfort related to Hemiplegia/Hemiparesis through review date. -Give medications as ordered. Monitor/document for side effects and effectiveness. -Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Review of Resident #183's physician orders indicated the following current orders: -Acetaminophen 325 milligrams (MG), give 650 mg by mouth every six hours as needed for moderate pain (4-6). -Baclofen 5 mg, give 5 mg by mouth as needed for muscle spasms once a day. -Baclofen 5 mg, give 5 mg by mouth at bedtime for muscle spasms. -Buprenorphine Transdermal Patch weekly, apply one patch transdermally one time a day every Thursday for pain. -Gabapentin 200 mg by mouth three times a day for diabetes mellitus neuropathy -Lidocaine external patch 4%, apply to left knee topically every 12 hours as needed for pain. -Oxycodone 10 mg, give one tablet by mouth every four hours as needed for severe pain (7-10). -Oxycodone 5 mg, give one tablet by mouth every four hours as needed for moderate pain (4-6). -Voltaren external gel 1%, apply to left shoulder topically as needed for pain three times daily. Review of the Medication Administration Record (MAR) for 11/1/23 through 11/20/23, indicated the following: -Oxycodone tablet 5 mg, give one tablet by mouth every four hours as needed for moderate pain (4-6). -11 times oxycodone was administered correctly as ordered by the physician. -3 times oxycodone was administered for a pain level below parameters of moderate pain 4-6. -16 times oxycodone 5 mg was administered outside physician parameters with a reported pain level 8-10 (should have administered physician prescribed Oxycodone 10 mg). A total of 19 out of 30 administrations of oxycodone 5 mg was administered outside of physician ordered parameters. Further review of the MAR from 11/1/23 through 11/20/23 indicated the following: -Baclofen 5 milligrams at bedtime for muscle spasms administered nightly as ordered. -Buprenorphine Transdermal patch applied as physician ordered. -Gabapentin 200 milligrams by mouth three times a day administered as physician ordered -Acetaminophen 650 mg was only administered on 11/7, 11/9, 11/12, 11/17 and 11/19. -Lidoderm patch 4% applied to left knee topically every 12 hours as needed for pain, never applied. -Baclofen 5 milligrams as needed for muscle spasms once a day, initiated 11/15/23 was not administered. -Voltaren Gel 1% applied to left shoulder topically as needed for pain three times daily, initiated 11/15/23, never applied. Review of Physician History and Physical, dated 11/9/23, indicated but was not limited to the following: -Pain level 8 -Musculoskeletal-left hemiparesis, chronic pain -chronic pain syndrome, continue with oxycodone, Baclofen, and Buprenorphine patch -polyneuropathy, continue gabapentin. Review of the Physician Assistant (PA) progress notes dated 11/17/23, 11/14/23, 11/10/23, and 11/7/23 indicated but was limited to: -Pain: Patients pain is currently controlled. Continue current pain medications. -Chronic pain syndrome with history of diabetic neuropathy: Patient is on buprenorphine patch as well as oxycodone and Tylenol. She started on low dose-dose gabapentin on 10/25/2023 at 200 mg, three times a day. However, this was lowered due to daytime somnolence and then resumed due to increased neuropathic pain. During an interview on 11/17/23 at 2:09 P.M., Resident #183 said he/she had a lot of pain last night. Resident started rubbing his/her left thigh. Resident said he/she never get Lidoderm patches, she was told they don't have an order for them. Resident said he/she has some in the drawer that was brought in from home. Resident also said he/she has never got any pain relief gel on the left shoulder. Review of Resident #183's November nursing notes indicated the following: -11/20/23 at 2:37 P.M., Resident complained of leg pain, as needed oxycodone given orally at 8:00 A.M. and 1:30 P.M. Pain level on MAR was 8 and 8 respectfully, resident should have received two doses of oxycodone 10mg and was given two doses of 5 mg. -11/19 at 12:11 A.M., As needed oxycodone 5 milligrams given three times today with positive effect. MAR indicates only two doses of Oxycodone were administered. Pain level on MAR was 9 and 8, Resident should have received two doses of oxycodone 10mg and was given two doses of 5 mg. -11/16/23 at 3:52 P M, Resident worked with skilled therapy, complained of back and leg pain, requested pain medication, oxycodone given at 8:05 A.M. and 12:05 P.M. with some effect. Resident requested additional medication and was informed it was too early. Pain level on MAR was 8 and 8 respectfully, resident should have received two doses of oxycodone 10mg and was given two doses of 5 mg. -11/15/23 at 2:39 P.M., Resident worked with skilled therapy, complained of all over pain and back pain and requested oxycodone, as needed oxycodone given orally at 8:30 A.M. and 12:50 P.M., with some effect. Pain level on MAR was 8 and 8 respectfully, resident should have received oxycodone 10mg and was given two doses of 5 mg. -11/13/23 at 2:45 P.M., Resident complained of pain throughout shift, requested medication, as needed oxycodone 5 milligrams given at 8:10 A.M. and 12:45 P.M., worked with skilled therapy. Pain level on MAR was 5 and 9 respectfully, resident received oxycodone 5 mg twice, should have received 10 mg with the pain level of 9. -11/11/23 at 2:51 P.M., Resident up in chair most of shift, complained of pain and anxiety, as needed Ativan and oxycodone given orally with some effect, resident requesting pain medication within two hours, explained to resident too early. Pain level on MAR was 8, resident should have received oxycodone 10mg and was given two doses of 5 mg. -11/9/23 at 2:28 P.M., Resident complained of pain, as needed Tylenol given at 8:30 A.M. with some effect, as needed Ativan and oxycodone 5 milligrams given at 12:30 P.M. with some effect, resident requested pain medication at 1:30 P.M. explained to resident it was too early. Pain level on MAR was 9, resident should have received oxycodone 10mg and was given two doses of 5 mg. -11/7/23 at 5:46 P.M., Seen by skilled speech, physical and occupational therapy. Complained of left sided times 2 and was medicated with 5 milligrams of oxycodone with effect. Pain level on MAR was 2 and 3, resident should have received oxycodone 5 mg twice, instead nurse signed off for one 5 mg and one 10 mg. -11/6/2023 at 34:9 P.M., Complained of left sided pain and requested pain medication, as needed oxycodone 5 milligram given at 8:00 A.M. and 12:00 noon. Pain level on MAR was 5 and 9 respectfully, resident received oxycodone 5 mg twice, should have received 10 mg with the pain level of 9. -11/21/23, summary of care note: pain: yes, pain scale 9, generalized all over pain. diagnosis chronic pain syndrome, pain management yes. During an interview on 11/21/23 at 2:24 P.M., Nurse #6 said when a resident complains of pain, she gave them pain medication for the lowest dose the physician had ordered. She said she always tried alternate pain control when options were available. The surveyor and the Nurse #6 reviewed the MAR and on 11/6/23, the recorded pain level was 0 and Nurse #6 signed she administered 5 mg of oxycodone (orders indicated give oxycodone 5 mg, one tablet by mouth every four hours as needed for moderate pain (4-6). Nurse #6 said the resident verbalized pain, so she gave her the lowest dose of pain medication which was Oxycodone 5 mg. During a telephonic interview on 11/21/23 at 2:34 P.M., Nurse #1 said Resident #183 knew his/her pain medication was due every four hours and he/she asked for it every four hours. She said she assessed the resident's pain level by asking the level of pain 0-10 and then assessed the pain further by looking at his/her respiration rate, facial grimacing, to decide if she is going to administer 5 mg or 10 mg of Oxycodone. Nurse #6 said Resident #183 was usually talking on the phone with his/her spouse and appeared comfortable. The surveyor reviewed the MAR over the phone, which indicated on nine occasions, Nurse #1 administered only 5 mg of oxycodone with a pain level documented of eight or nine (orders indicated give 10 mg, give one tablet by mouth every four hours as needed for severe pain 7-10). Nurse #1 said she had no explanation, it was her error, she should have given oxycodone 10 mg when the Resident said his/her pain level was above 7 as the physician ordered. During an interview on 11/21/23 at 2:46 P.M., the surveyor and the Director of Nurses reviewed the MAR and the multiple times Resident #183 was administered 5 mg of Oxycodone when he/she should have been administered 10 mg based on the physician orders and the Residents recorded level of pain. She said she was not aware this was happening, and she would have to look into it. The surveyor also reviewed the interview with Nurse #1 and the DON said the nurses should be following the physician orders for the administration of the pain medication. During an interview on 11/21/23 at 3:23 P.M., the DON provided documentation Resident #183 was being followed in risk meetings for pain. She said pain is pain and if resident reports pain, the nurses must follow the physician orders.

Based on observations, interviews, and meal test trays for 1 of 2 units, the facility failed to provide residents with meals that were prepared and served in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. Findings include: On 11/16/23 during the initial screening, the survey team identified 18 residents who expressed concerns with food palatability as follows: -Food was cold -Food was cold at dinner, and has been coming up after 6:30 P.M. -They cook it so much it has no flavor -The food was terrible, it's always cold, tastes terrible especially at dinner -Food was terrible, I have lost weight -Food was so-so, not very good, it was salty, the gravy has way to much salt -The food was always cold, worse on weekends, it comes up cold and has been coming later and later -Soup was cold -Evening meal was the worst Review of the November 2023, Resident Council meeting notes indicated but not limited to: -Soups are not very hot at supper. -Food carts come up very late. On 11/20/23 at 2:00 P.M., the surveyor conducted a Resident Group Meeting with 11 residents in attendance. 10 out 11 residents in attendance said all the meals come up late especially the dinner meal and the food was cold. On 11/20/23 at 5:08 P.M., the surveyor observed the dinner meal service in the main kitchen. The surveyor observed that the soup had been pre-poured into insulated bowls, covered with a lid and stacked on the tray line. At 6:13 P.M., the surveyor requested a house test tray to be sent to Unit 4. The main part of the meal (meatball submarine, corn, and potato salad) was plated on a room temperature plate and two metal bottoms because there were not enough insulated bottoms for two trays (one for a resident and one for the surveyor), the soup was in an insulated bowl with a cover. During an interview on 11/20/23 at 6:14 P.M.,Cook #2 said that there were not enough insulated bottoms. On 11/20/23 at 6:16 P.M., the surveyor observed the food truck leave the kitchen and arrived on the unit at 6:19 P.M. The food truck was delivered and left in the hallway. At 6:26 P.M the test tray was conducted, and the food temperatures were obtained by Cook #2 utilizing his thermometer. Cook #2 declined to taste the test tray. The surveyor tasted the food. -Meatballs with sauce registered 121.8 degrees F, tepid, bland, sauce was thin and bland. -Potato Salad registered 74.1 degrees F, was not cold, bland, potatoes were firm, difficult to [NAME] with a fork. -Yellow corn registered 99.1 degrees F, was lukewarm, bland, gummy texture. -Pea Soup registered 108.1 degrees F, was separated with the peas on the bottom of the bowl and a clear viscous liquid on top, bland and was not hot. During an interview on 11/20/23 at 6:35 P.M., Resident #63 said the potato salad was hard as a rock, it would have been nice if they cooked the potatoes. During an interview on 11/21/23 at 10:00 A.M., Resident #5 said described the previous evening's meal (chicken salad) as terrible with no flavor, the soup was lukewarm water with no flavor and the potatoes in the potato salad were hard. During an interview on 11/20/23 at 6:28 P.M., Cook #2 said he would not want too eat the food; he prefers it right out of the oven.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain the main kitchen floor in a sanitary manner, specifically floor tile grout from build dirt and food particles, the walls free from food stains and the dish room floor (located in the main kitchen) from cracked, broken tiles, missing grout and incomplete tiling under the dish machine and sinks allow a build up of water and food particles. 2. Ensure prep table was cleaned and sanitized after contact with raw hamburger, dietary staff performs proper hand hygiene after handling raw meat and handling ready to eat foods to prevent cross contamination and dietary staff with facial hair wear beard protectors while preparing lunch meal service. Finding include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. -2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. -6-501.12 Cleaning, Frequency and Restrictions. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. 1. During the initial tour of the main kitchen on 11/16/2023 at 8:00 A.M., the surveyor observed the main kitchen floor to be dirty with debris, including particles of food scattered through out the kitchen floor, heavier under the prep tables, sinks and steam table. In addition, the dish washer area located in the main kitchen floor had large amounts of wet food particles trapped in broken/missing tiles under the dishwasher and the decaying grout between the floor tiles. The yellow wall tiles as you enter the kitchen by the dish washing area were soiled three feet high with a splattered brown substance. Two of the observed dishwashing racks were observed to have a build up of a brown sticky/oily substance. The rolling rack that contained multiple plastic racks of clean glasses, had build up food particles and stains. During an interview on 11/16/2023 at 8:42 A.M., the Food Service Manager (FSM) said the floor was not cleaned last night, and they need to do a better job cleaning under the tables. He said the dish room floor is hard to keep clean because of the grout condition, and under the dish machine it looks like the tile work was not completed. He said those two dishes washing racks need to be thrown away and the rolling racks should be cleaned. 2. On 11/17/23 at 11:46 A.M., the surveyor observed lunch meal service and made the following observation: A. Cook #1 was observed forming raw hamburger with gloved hands into patties on the prep table. The surveyor observed small pieces of raw hamburger fall onto the prep table. After completing the task of forming the raw hamburger, Cook #1 removed her gloves and did not wash her hands. She was then observed to remove multiple containers of prepped salad food items of the prep table and return them to the refrigerator. She returned to the prep table and placed a plate on the prep table with the three visible pieces of raw hamburger still on the table. The surveyor stopped her and asked her about the prep table condition with the three small pieces of hamburger. During an interview on 11/17/2023 at 12:05 P.M., Cook #1 said she should have washed her hands after handling the hamburger and sanitized the prep table before starting her next task. B. Dietary Aide #3 was observed preparing the trays for meal service. As he moved around the kitchen, he was observed constantly placing both gloved hands on the back of his jeans and pulling them up. As meal plating service started, he was observed with the same gloved hands open a bag of rolls and place a roll on a resident's lunch meal plate. The surveyor stopped the dietary aide from plating a second dinner roll with same gloved hands. The surveyor brought the hand hygiene concern to the FSM attention. During an interview on 11/17/23 at 12:15 P.M., the FSM said he should not be touching the ready to eat foods with same gloves he had on setting up tray line and touching his clothing. C. The FSM and Dietary Aide #2 were observed to have facial hair and were not wearing beard protectors while preparing, plating and assembling the trays for the lunch meal. During an interview on 11/17/23 at 11:46 A.M., Dietary Aide #2 said he never wears a beard protector, he said they don't have them here.

Based on observations, interviews and records reviewed for one Resident (Resident #51) of 19 sampled residents, the facility failed to notify the Residents physician of a potential need to alter treatment. Specifically, for Resident #51, the facility failed to notify the physician of an unscheduled medication administration and failed to obtain physician guidance/orders per facility policy. Findings include: Review of the facility's policy titled Medication Error Policy and Procedures, dated May 2023, indicated, but was not limited to: -It is the policy of this facility to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. -It is the policy of this facility to assure that each medication administered to our resident has been prescribed by a licensed physician or equivalent. Noncompliance with the exact medication order or the state and federal regulation is considered a medication error. -Med errors include by [sic] not limited to: omission, wrong drug, wrong dose, wrong time, wrong route, given not charted, extra dose found, documentation error, and transcription. -Guidelines: a. Each nurse is mandated to report suspected Med errors too his/her supervisor b. The nurse is responsible for completing the medication incident report c. The nurse is responsible for notifying the physician and family d. Notification of the supervisor and MD should be done as soon as the error is discovered so immediate action can be done Review of Breztri Manufacturers Recommendations indicated but was not limited to: -Breztri should be taken as 2 puffs, 2 times each day. Do not use Breztri more often than prescribed Resident #51 was admitted to the facility in September 2023 with the following diagnoses: bronchiectasis (a condition in which airways of the lungs remain permanently damaged and widened) and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease which causes obstructed airflow from the lungs). Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/23, indicated Resident #51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 11/20/23 at 4:12 P.M., the surveyor observed Resident #51 standing at an unlocked and unattended medication cart with three inhalers and one bottle of acidophilus (a probiotic) on top of the medication cart. The surveyor observed Resident #51 take two puffs from one of the inhalers (Breztri 160 micrograms (mcg)/9mcg/4.8 mcg (used to decrease inflammation in the lungs) then place the inhaler back on top of the medication cart and walk away. During an interview on 11/20/23 at 4:13 P.M., Nurse #4 identified the Resident as Resident #51. Nurse #4 said the inhalers on top of the medication cart belonged to Resident #51 and he/she recognized the inhalers as their own which prompted him/her to use the inhaler. Review of Resident #51's physician orders included but were not limited to: - Breztri 160 micrograms (mcg)/9mcg/4.8 mcg two puffs inhaled oral two times per day related to COPD, scheduled for 9 A.M and 9 P.M. Review of Resident #51's November 2023 Medication Administration Record (MAR) indicated the Breztri inhaler had been administered on 11/20/23 at 9 A.M. and again at 9 P.M. as scheduled. Further review of the November 2023 MAR indicated no additional Breztri administrations were documented on 11/20/23. Review of Resident #51's progress notes failed to indicate the physician was notified the Resident had received an unscheduled administration and failed to indicate physician guidance/orders had been obtained to administer Breztri at 9 P.M. on 11/20/23. During an interview on 11/21/23 at 10:58 A.M., the Director of Nurses (DON) said there is no medication error report for the unscheduled dose of Breztri and an investigation is ongoing. During an interview on 11/21/23 at 1:56 P.M., the DON said she spoke with nurse that worked the evening shift on 11/20/23 and the Nurse did administer the 9 P.M. dose of Breztri and did not update the physician of the additional dose. The DON said a medication error report had not been initiated at the time.

Based on policy review,observation, record review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for one Resident (#58), out of 18 sampled residents. Specifically, the facility failed to ensure: For Resident #58, a care plan was developed to address the Resident's use of a palm guard (a splint used to prevent fingers from digging in to the palm of the hand, to prevent skin damage and prevent further deformity). Findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plan, included, but was not limited to: -The comprehensive, person-centered care plan will: -Include measurable objectives and timeframes; -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Reflect treatment goals, timetables and objectives in measurable outcomes; -Assessment of residents is ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Resident #58 was admitted to the facility in October 2019 with diagnoses including rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment, dated 9/28/23, indicated Resident #58 required extensive assistance with all activities of daily living and had functional limitation in range of motion on both sides of his/her upper extremities. Review of an Occupational Therapy Evaluation and Plan of Care, dated 4/18/23, indicated Resident #58 had skin irritation on his/her left hand due to a rheumatoid arthritis contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and recommended implementation of a palm guard to decrease risk of skin breakdown. Review of Physician's orders indicated: -Palm guard, apply to left hand one time a day for contracture (4/25/23) -Palm guard, remove from left hand one time a day for contracture (4/26/23) Review of May 2023 through November 2023 Medication/Treatment Administration Records indicated the right palm guard was applied and removed as ordered by the physician. During an interview on 11/20/23 at 9:55 A.M., Resident #58 said he/she wears a palm guard on his/her left hand every night. Review of comprehensive care plans failed to indicate a person-centered care plan was developed for the use of a palm guard to the left hand. During an interview on 11/21/23 at 11:00 A.M., the Staff Development Coordinator said Resident #58 has contractures and has used a palm device for quite a while. She reviewed the Resident's comprehensive care plans and said no care plan had been developed for the use of the palm guard, but should have been.

Based on observation and staff interview, the facility failed to ensure that accident hazards were minimized for residents on the fourth-floor unit, specifically Resident #51, where staff failed to ensure medications were secure, attended to, and not accessible to residents. Findings include: Review of the facility's policy titled Storage of Medications, dated May 2023, indicated but was not limited to: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. -Unlocked medication carts are not left unattended. On 11/20/23 at 4:06 P.M., on the fourth-floor unit, Nurse #4 was observed leaving three inhalers and one bottle of acidophilus on top of an unlocked and unattended medication cart. Nurse #4 walked away from the medication cart and entered the medication room leaving medications unsecured and unattended. On 11/20/23 at 4:12 P.M., the surveyor observed a Resident standing at the unlocked medication cart with three inhalers and one bottle of acidophilus (a probiotic) on top of it. The surveyor observed Resident #51 take two puffs from one of the inhalers (Breztri 160 micrograms (mcg)/9mcg/4.8 mcg (used to decrease inflammation in the lungs). During an interview on 11/20/23 at 4:13 P.M., Nurse #4 identified the resident as Resident #51. Nurse #4 said the inhalers on top of the medication cart belonged to Resident #51 and he/she recognized the inhalers as their own which prompted him/her to use the inhaler. Nurse #4 said the medication cart should have been locked and medication should not be left out while unattended. During an interview on 11/20/23 at 5:29 P.M., the Director of Nurses (DON) said medication and treatment carts should be locked when unattended and medication should never be left on top of the carts making them accessible to residents.

Based on observations, interviews, and policy reviewed the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and only authorized personnel were permitted access. Specifically, the facility failed to: 1. Maintain locked medication and treatment carts on one of four units, and 2. Store medication according to manufacturers guidelines in one of two medication carts reviewed; and 3. Ensure only authorized personal had access to medication on one of four units Findings include: Review of the facility's policy titled Storage of Medications, dated May 2023, indicated but was not limited to: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. -Drug containers that have missing, incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storage. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. -Unlocked medication carts are not left unattended. -Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents. -Medications requiring refrigeration are stored in refrigerator locked in the drug room at the nurses' station or other secured location. On 11/20/23 at 3:55 P.M., the surveyor observed the 4th floor treatment cart unlocked and unattended. The surveyor observed the treatment carts drawers which included: -One tube of Care All muscle rub (pain relieving cream) -Povidone Iodine Swabs (antiseptic to help prevent the risk of skin infection) -One box of Aspercreme Lidocaine patches (used to treat pain) -One box of Dynarex L-Mesitran Soft (wound gel with medical grade honey) -Two bottles of Triamcinolone cream 0.1% (steroidal cream) -One tube of Clobetasol Propionate cream (decreases inflammation of skin) -One bottle Nyamyc 100,000 units (antifungal) -One tube of Biofreeze (pain reliever) On 11/20/23 at 3:58 P.M., the surveyor conducted the medication storage observation on the 4th floor with Nurse #4. The surveyor observed: -One bottle of Leader Acidophilus (a probiotic) in the top drawer -Three inhalers loose in the 3rd drawer of the cart and not stored in the dispensing box: a.Breztri 160 micrograms (mcg)/9mcg/4.8 mcg (used to decrease inflammation in the lungs) b.Budesonide and Formeterol Fumarate Dihydrate 160mcg/4.5 mcg (used to improve lung function) c.Albuterol Sulfate 90 mcg (used to treat wheezing and shortness of breath) -The albuterol sulfate 90 mcg inhaler was unlabeled On 11/20/23 at 4:06 P.M.,Nurse #4 left one bottle of Acidophilus and the three inhalers (noted above) on top of the medication cart, left the medication cart unlocked and walked away, Nurse #4 then entered the medication room. During an interview on 11/20/23 at 3:58 P.M., Nurse # 4 said medication and treatment carts should be locked when unattended. Nurse #4 said some forms of Acidophilus could be stored at room temperature. The surveyor and Nurse #4 reviewed the medication label which indicated it should be refrigerated after being opened. Nurse #4 said the inhalers should not be stored loosely in the cart, should be in their own bag or box and should have been labeled with at least the resident name. During an interview on 11/20/23 at 5:29 P.M., the Director of Nurses (DON) said medication and treatment carts should be locked when unattended and medication should never be left on top of the carts accessible to residents. The DON said medication should be stored according to manufacturers guidelines, should not be loose in the cart, and should be labeled with the resident's name and open date.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was readmitted to the Facility after a seven day acute hospital stay, the Facility failed to ensure nursing provided care and services that met professional standards of practice related to the readmission process, including medication reconciliation and resident assessment. Findings include: Review of the Facility Policy titled Reconciliation of Medications on Admission, undated, indicated the purpose is to ensure medication safety by accurately accounting for the resident's medication, routes and dosages upon admission and readmission. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of medications that includes the drug name, dosage, frequency, route, and indication for use. Medication reconciliation reduces medication errors and enhance resident safety. The Policy indicated to gather information needed to reconcile the medications list; -approved medication reconciliation form; -discharge summary form from the referring facility; -admission/readmission order sheet; -all prescription and supplement information from the resident/family during the medication history; and -most recent medication administration record (MAR), if this is a readmission. Resident #1 was admitted to the Facility in December 2022, diagnoses included osteomyelitis (infection of the bone) of the neck requiring treatment with intravenous medications, diabetes mellitus, hypertension, and malnutrition. 1) Review of Resident #1's Physicians Orders, dated 1/05/23, indicated he/she was to be administered; -Duloxetine (antidepressant) Capsule Delayed Release 30 milligrams (mg), give two capsules (for a total of 60 mg) by mouth in the morning for depression. Review of Resident #1's Hospital Discharge Summary, dated 1/23/23, indicated his/her discharge medication list included the following; -Duloxetine (antidepressant) Capsule Delayed Release 30 milligrams (mg), give one capsule by mouth in the morning (daily) for depression (which was a decrease in dosage from his/her previous physician's orders). Review of Resident #1's Physician's (MD) Progress Note/Visit, dated 1/24/23, indicated that a medication reconciliation was completed and discussed with nursing. Review of the Physician's Note/Visit, electronically signed and dated 1/28/23, also indicated Resident #1 was to be administered Duloxetine 30 mg by mouth daily. However, review of Resident #1's Medication Administration Record, dated 1/24/23 and 1/25/23, indicated he/she was administered Duloxetine Capsule Delayed Release 30 mg, two tablets (60) mg in the morning. 2) Review of Resident #1's Medical Record, including Physician's Orders and Nursing Progress Notes, indicated there was no documentation to support a Medication Reconciliation Form, Nursing Assessments of Resident #1, including risks assessments, such as falls or skin assessment were completed by nursing for Resident #1's upon his/her readmission to the facility on [DATE], after a seven day Hospital Stay. During an interview on 2/21/23 at 4:29 P.M., Nurse #2 said she was Resident #1's nurse upon readmission from the Hospital, after being on a medical leave for approximately one week. Nurse #2 said she could not remember if she completed a medication reconciliation form for Resident #1 and said she did not even know if the Facility used a form for medication reconciliation. Nurse #2 said all she usually has time for while completing a readmission for a resident, is to put the medications in the computer and perform a skin check. Nurse #2 said, they tell me to just do the medications and the skin check and the nurse of the next shift will take care of the rest. Nurse #2 said the 7:00 A.M. to 3:00 P.M. (day) shift nurses will typically perform the necessary assessments because there are more staff on during that shift to help. During an interview on 2/21/23 at 1:01 P.M., Nurse #1 said any nurse that readmits a resident should do a fall assessment, skin assessment, and a clinical evaluation of the resident. During an interview on 3/09/23 at 11:06 A.M., Nurse #1 said she was unable to locate a readmission note, fall assessment, skin assessment, or clinical evaluation for Resident #1 from when he/she was readmitted on [DATE] from the hospital. Nurse #1 said the readmitting nurse (later identified as Nurse #2), should have reconciled his/her medications with his/her Physician (which included completion of the reconciliation form), written a Nurse Progress Note, reassessed his/her fall risk and skin condition, upon readmission to the Facility. During an interview on 3/09/23, the Director of Nurses (DON) said she was unable to find any documentation that Nurse #2 wrote a Nursing Progress Note, reconciled medications, or assessed Resident #1 upon readmission to the Facility. The DON said it is the Facility's expectation that all nursing staff, admitting or readmitting a resident, will reconcile medications with the Physician and said it is expected that the readmission nurse also do skin, fall, and pain assessments within 24 hours from admission.

Based on records reviewed and interviews for one of three residents (Resident #1), the Facility failed to ensure the staff implemented and followed their policy related to when to test a resident who presented with signs and symptoms associated with Covid-19 infection (an acute respiratory illness in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). On 8/16/22 Resident #1 reported to nursing that he/she had nasal congestion and that he/she ached all over, however, nursing failed to immediately test him/her for Covid-19. Despite several requests from a Family Member starting on 8/16/22, to test Resident #1 for Covid-19, he/she was still not tested by the Facility. On 8/18/22, the Family Member tested Resident #1 with a home test kit and he/she tested positive at that time. Findings Include: Review of Facility Policy titled, Covid Testing, dated as revised 7/25/22, indicated the following; -Binax all residents that are symptomatic; -Test immediately; -Symptomatic individuals should be quarantined pending the results of test; -Symptoms of Covid-19 include fever or chills, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. Review of Massachusetts Department of Public Health (DPH) Memorandum, titled Updates to Long-Term Care Surveillance and Outbreak Testing, dated 6/10/22, indicated Long Term Care Facilities should be conducting testing as needed under the following circumstances; testing symptomatic staff and residents. Resident #1 was admitted to the Facility in April 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/19/22 at 9:46 A.M., Resident #1's Family Member said that on 8/15/22, Resident #1 started with obvious symptoms associated with Covid-19. The Family Member said Resident #1 was at high risk for contracting and possibly having more difficulty recovering from Covid-19 related to his/her illnesses. The Family Member said she asked the nurses on Resident #1 multiple time to test him/her for Covid-19, but was told no. The Family Member said there should have been no reason that Nursing did not test him/her for Covid-19. The Family member said, Nurse #1 and Nurse #2 told her that their hands were tied and that they needed to follow the Policy. The Family Member said that on 8/18/22, she went to the Facility and tested Resident #1 for Covid-19 with a home Covid-19 testing kit and he/she tested positive, and reported it to nursing. The Family Member said only then did the Facility test Resident #1 for Covid-19. Review of Resident #1's Nursing Progress Note, dated 8/16/22, indicated at 1:50 P.M., Resident #1 complained of nasal congestion and cold symptoms. The Note indicated that Resident #1 was found on the floor in his/her bedroom, was transferred to the Hospital Emergency Department for evaluation, and his/her temperature at the time of transfer was 99.7 degrees Fahrenheit (F). During an interview on 9/21/22 at 1:25 P.M., Nurse #2 said Resident #1's Family Member called him on 8/16/22 and requested he test Resident #1 for Covid-19 upon his/her return from the Hospital Emergency Department. Nurse #2 said he did not feel Resident #1 had symptoms of Covid-19 and said he/she just had some cold symptoms. Nurse #2 said the Family Member continued to demand he test Resident #1 for Covid-19. Nurse #2 said he tried to direct Resident #1's Family Member to the Director of Nurses (DON). Nurse #2 said that he went to both the Administrator and DON, and said they told him not to test Resident #1 for Covid-19. Nurse #2 said that the Administrator and the DON told him they do not test Residents for Covid-19 for just cold symptoms. Review of Resident #1's Nursing Progress Note, dated 8/17/22, indicated that on 8/16/22, during the 3:00 P.M.- 11:00 P.M. shift, Resident #1 returned to the Facility. The Note indicated Resident #1 had nasal congestion and he/she reported to Nurse #2 that he/she ached all over. Review of Resident #1's Nursing Progress Note, dated 8/17/22, at 7:20 A.M., indicated his/her temperature was 100.4 degrees F, he/she presented with cold symptoms, nasal congestion and he/she voiced having chills. Review of Resident #1's Nursing Progress Note, dated 8/17/22 at 2:34 P.M., indicated he/she still continued with nasal congestion. Review of Resident #1's Medical Record indicated there was no documentation to support he/she was tested for Covid-19 on 8/16/22 or 8/17/22, despite his/her complaints of not feeling well and his/her symptoms. On 8/18/22, Family Member went to the Facility and tested Resident #1 for Covid-19 with a home Covid-19 testing kit and he/she tested positive, the test results were reported to nursing, and that was when the Facility tested Resident #1 for Covid-19. Review of Resident #1's Nursing Progress Note, dated 8/18/22 at 4:45 P.M., indicated that Resident #1 was Binax tested by Nursing staff and he/she was positive for Covid-19. Review of the Facility's Covid-19 Observation and Tracking Form, dated 8/18/22, indicated two additional residents residing on Resident #1's unit, tested positive for Covid-19 (on 8/18/22) as a result of facility's outbreak testing. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/22 at 10:49 A.M., Nurse #1 said it was the Facility Policy to test any Resident who exhibits one or two symptoms of Covid-19. Nurse #1 said some symptoms of Covid-19 would include fever, sore throat, diarrhea, cough, congestion, and headache. Nurse #1 said there were no Covid-19 testing supplies available on the unit. Nurse #1 said she remembered that when Resident #1's nasal congestion started, that it came on suddenly. Nurse #1 said she was not certain why she had not tested Resident #1 for Covid-19. During an interview on 10/04/22 at 12:08 P.M., Nurse #4 said she remembers an in-service for Nursing staff about not testing Residents for Covid-19 anymore. Nurse #4 said the Facility Policy seems to change every few days. Nurse #4 said communication in the building was not very good. During an interview on 10/04/22 at 11:55 P.M., Nurse #5 said it came down from the ranks that we were told not to test Residents for Covid-19 because the Hospitals were not testing anymore. Nurse #5 said it was a handwritten memo, a for your information (FYI) type of paper, Nurse #5 said she could not recall who told her. During an interview on 9/20/22 at 11:39 A.M., the Assistant Director of Nurses (ADON), said per the Facility Policy, some signs and symptoms of Covid-19 are cold like symptoms, shortness of breath, diarrhea, vomiting, and sore throat. The ADON said a temperature 100.4 degrees F would of significant concern and she said as far as she knew it was Resident #1's Family Member who brought in her own Covid-19 test kit to test Resident #1. During an interview on 9/26/22 at 2:06 P.M., the Director of Nurses (DON) said that if a resident had a new cough or new fever, she said staff would usually not test the Resident for Covid-19. The DON said they would call the Physician and notify the Physician of the residents change in condition. The DON said she did not feel as if Resident #1 exhibited signs and symptoms of Covid-19 and said in hindsight they could have tested him/her. On 9/20/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidence by: A) On 8/18/22, Resident #2 tested positive for Covid-19. Treatment was provided as ordered by his/her Physician and he/she currently remains stable. B) On 8/19/22, the Facility had an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the identified issues and discuss the plan of correction. C) On 8/19/22, the Director of Nurses (DON) and Designee audited all Residents Nursing Progress Notes to ensure no signs and symptoms of Covid-19 were missed and no additional Residents required Covid-19 testing. D) On 8/19/22, the DON and Assistant Director of Nurses (ADON) began education for all licensed Nursing Staff to identify Covid-19 signs and symptoms promptly. Education is ongoing with staff including Agency Nursing and Per Diem Staff. E) On, 8/19/22, the DON and ADON began Covid-19 Outbreak education, including hand hygiene and proper use of personal protective equipment (PPE) with positive and potentially affected Residents. F) On 8/19/22, the DON, PPE Coaches and/or Designee began on-going surveillance and auditing of all staff for proper hand hygiene, donning and doffing PPE. G)The DON and/or Designee will report non-compliance at monthly QAPI meetings. H) The DON and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled Residents (Resident #1), the Facility failed to ensure they implemented an effective COVID-19 (an acute respiratory illness in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) surveillance testing program in order to identify and prevent the transmission of COVID-19 as required, when on 8/16/22, Resident #1 reported to Nursing signs and symptoms, identified and consistent with Covid-19 but was not tested for Covid-19 until 8/18/22, when his/her Family Member tested Resident #1 with a home Covid-19 test kit and he/she tested positive. Findings Include: Review of Facility Policy titled, Covid Testing, dated as revised 7/25/22, indicated the following; -Binax all residents that are symptomatic; -Test immediately; -Symptomatic individuals should be quarantined pending the results of test; -Symptoms of Covid-19 include fever or chills, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. Review of Massachusetts Department of Public Health (DPH) Memorandum, titled Updates to Long-Term Care Surveillance and Outbreak Testing, dated 6/10/22, indicated Long Term Care Facilities should be conducting testing as needed under the following circumstances; testing symptomatic staff and residents. Resident #1 was admitted to the Facility in April 2021. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/19/22 at 9:46 A. M., Resident #1's Family Member said that on 8/15/22, he/she started with obvious symptoms associated with Covid-19. The Family Member said Resident #1 was at high risk for contracting and could possibly have more difficulty recovering from Covid-19 related to his/her illnesses. The Family Member said she asked nursing multiple times to test Resident #1, but was told no. The Family Member said, Nurse #1 and Nurse #2 told her that their hands were tied and that they needed to follow the Policy. The Family Member said she could not understand why Resident #1 was not tested especially when he/she exhibited and documentation in his/her recorded indicated symptoms associated with Covid-19. Review of Resident #1's Nursing Progress Note, dated 8/16/22, indicated at 1:50 P.M., Resident #1 complained of nasal congestion and cold symptoms. The Note indicated that Resident #1 was found on the floor in his/her bedroom, was transferred to the Hospital emergency room for evaluation, and his/her temperature at the time of transfer was 99.7 degrees Fahrenheit (F). During an interview on 9/21/22 at 1:25 P.M., Nurse #2 said Resident #1's Family Member called him on 8/16/22 and requested he test Resident #1 for Covid-19 upon his/her return from the Hospital Emergency Department. Nurse #2 said he did not think Resident #1 had symptoms of Covid-19 and said he/she just had some cold symptoms. Nurse #2 said the Family Member continued to demand he test Resident #1 for Covid-19 and said he tried to direct the Family Member to the Director of Nurses (DON). Nurse #2 said that he went to both the Administrator and DON, and said they told him not to test Resident #1 for Covid-19, and that they said they do not test Residents for Covid-19 for just cold symptoms. Review of Resident #1's Nursing Progress Note, dated 8/17/22, indicated that on 8/16/22, during the 3:00 P.M.- 11:00 P.M. shift, Resident #1 returned to the Facility. The Note indicated Resident #1 has nasal congestion and he/she reported to nurse that he/she ached all over. Review of Resident #1's Nursing Progress Noted, dated 8/17/22, at 7:20 A.M., indicated his/her temperature was 100.4 degrees F, he/she was presenting with cold symptoms, nasal congestion and he/she voiced having chills. Review of Resident #1's Nursing Progress Note, dated 8/17/22 at 2:34 P.M., indicated he/she continued with nasal congestion. Further review of Resident #1's Medical Record, indicated that despite his/her complaints of cold symptoms, and presenting with a fever, he/she was not tested by Nursing on 8/16/22 or 8/17/22 for Covid-19. On 8/18/22, the Family Member went to the Facility and tested Resident #1 for Covid-19 with a home Covid-19 testing kit and he/she tested positive, and only then did the Facility test him/her. Review of Resident #1's Nursing Progress Note, dated 8/18/22 at 4:45 P.M., indicated that Resident #1 was Binax tested by Nursing staff for Covid-19 and he/she was positive. Review of the Facility's Covid-19 Observation and Tracking Form, dated 8/18/22, indicated two additional Residents residing on Resident #1's unit, tested positive for Covid-19 (on 8/18/22) as a result of facility's outbreak testing. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/22 at 10:49 A.M., Nurse #1 said it was the Facility Policy to test any Resident for Covid-19 who exhibited one or two signs and symptoms of Covid-19. Nurse #1 said some Covid-19 signs and symptoms included fever, sore throat, diarrhea, cough, congestion, and headache. Nurse #1 said there were no Covid-19 testing supplies available on the unit. Nurse #1 said she remembered that when Resident #1's nasal congestion started, that it came on suddenly. Nurse #1 said she was not certain why she had not tested Resident #1 for Covid-19. During an interview on 10/04/22 at 12:08 P.M., Nurse #4 said she remembers an in-service for Nursing staff about not testing Residents for Covid-19 anymore. Nurse #4 said the Facility's Policy seems to change every few days. Nurse #4 said communication in the building was not very good. During an interview on 10/04/22 at 11:55 P.M., Nurse #5 said it came down from the ranks we were told that we were not testing Residents for Covid-19 because the Hospitals were not testing. Nurse #5 said it was a handwritten memo, a For you information(FYI), but Nurse #5 said she could not recall who told her. During an interview on 9/20/22 at 11:39 A.M., the Assistant Director of Nurses (ADON), said per the Facility Policy, some signs and symptoms of Covid-19 are cold like symptoms, shortness of breath, diarrhea, vomiting, and sore throat. The ADON said a temperature of 100.4 degrees F would be of significant concern and she said as far as she knew it was Resident #1's Family Member who brought in her own Covid-19 test kit to test Resident #1. During an interview on 9/26/22 at 2:06 P.M., the Director of Nurses (DON) said that if a Resident had exhibited a new cough or new fever, she said staff would usually not test the Resident. The DON said they would call the Physician and notify the Physician of the Residents change in condition. The DON said she did not feel as if Resident #1 exhibited signs and symptoms of Covid-19. The DON said in hindsight they could have tested him/her for Covid-19. On 9/20/22, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addresses the areas of concern as evidence by: A) On 8/18/22, Resident #2 tested positive for Covid-19. Treatment was provided as ordered by his/her Physician and currently remains stable. B) On 8/19/22, the Facility had an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the identified issues and discuss the plan of correction. C) On 8/19/22, the Director of Nurses (DON) and Designee audited all Residents Nursing Progress Notes to ensure no signs and symptoms of Covid-19 were missed and no additional Residents required Covid-19 testing. D) On 8/19/22, the DON and Assistant Director of Nurses (ADON) began education for all licensed Nursing Staff to identify Covid-19 signs and symptoms promptly. Education is ongoing with staff including Agency Nursing and Per Diem Staff. E) The DON and/or Designee will audit Nursing Progress Notes daily for two weeks and then weekly until compliance is met to ensure Residents exhibiting signs and symptoms of Covid-19 are tested promptly. F) The DON and/or Designee are responsible for overall compliance.

Based on observations, record review, and interviews, the facility failed to maintain an infection control program designed to prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Implement proper infection prevention and control measures when providing high contact care to residents during a COVID-19 outbreak; and 2. Conduct contact tracing for 3 out of 3 staff who tested positive for COVID-19. Findings include: 1. During an interview on 9/9/21 at 9:30 A.M., the Administrator and Director of Nurses (DON) said during the facility's surveillance testing on 8/20/21, two staff (CNAs) tested positive for COVID-19; and on 8/28/21, one additional staff (CNA) tested positive for COVID-19. The DON said the facility had three units. She said staff was wearing full PPE (mask, goggles, gowns and gloves) for high contact care (bathing, toileting, hygiene, transfers and changing clothing or linen) on Unit 2 and Unit 4. On 9/9/21 at 11:25 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 providing high contact care to two Residents (#2 and #3) in the room they shared on Unit 4. CNA #1 was wearing eye protection and a surgical mask. CNA #1 assisted Resident #2 in and out of the bathroom, and disposed of soiled linens/clothing without the required PPE (gown and gloves) and without performing hand hygiene. CNA #1 was observed transferring Resident #2, and then begin caring for Resident #3 without performing hand hygiene and without putting on PPE. CNA #1 was observed providing direct, contact care to Resident #3 that included physical care, dressing, transfers, hygiene, and toileting. During an interview on 9/9/21 at 11:55 A.M., CNA #1 said she was aware that she should have put on PPE (gown and gloves) before she cared for the residents and that she should have changed her PPE between residents. CNA #1 said Resident #2 had asked to go to the bathroom and she went to assist the Resident. The CNA said that one thing lead to another and she did not put on any PPE and subsequently ended up caring for both residents without stopping and putting on any PPE. She failed to follow COVID-19 strategies to prevent the potential transmission of infections, including COVID-19. 2. During an interview on 9/9/21 at 12:55 P.M., the Administrator and the Director of Nurses (DON) said the DON was responsible for the Infection Control program. The DON said the facility presently had no resident positive cases of COVID in the facility. She said that during the weekly surveillance testing two staff tested positive for COVID-19 on 8/20/21 and the last staff tested positive on 8/28/21. During an interview on 9/9/21 at 12:55 P.M., the DON and Administrator were asked if they had documentation of doing contact tracing on the three staff persons. The Administrator said one of the three staff had been on vacation and that the other staff was young. The DON agreed the staff was young. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease Pandemic, updated 2/21/21, indicated to create a process to respond to COVID-19 exposures among Healthcare Personnel and others. Healthcare facilities should have a process for notifying the health department about suspected or confirmed cases and should establish a plan for how exposures in a healthcare facility will be investigated and manages and how contact tracing will be performed. The plan should address who was responsible for identifying contacts, how notification will occur and what actions and follow-up are recommended for those who were exposed. The DON and Administrator could provide no evidence of having completed contact tracing.

Based on observations, record review, and interviews, the facility failed to provide an environment that was free from accident hazards for 3 Residents (#17, #22, and #49), out of a total sample of 17 residents, and for residents on 2 Units (Unit 3 and Unit 4), out of 3 Units. Specifically, the facility 1.) Failed to implement the plan of care for Resident (#17) who required a two person assist for bed positioning, resulting in a fall and the Resident sustaining fractures of the femur (long bone of leg) and tibia (lower leg); and 2.) Failed to secure medications left at the bedside of two Residents (#22, #49); 3.) Failed to secure a medication cart containing many potentially harmful items on 1 Unit (Unit 4- dementia unit), out of 4 Units; and 4.) Failed to lock the clean utility rooms which contained many potentially harmful substances, and sharp items on 2 Units (Unit 3 and Unit 4), out of 3 Units. Findings include: 1. Resident #17 was admitted to the facility in March 2020 with diagnoses which included a history of falls, legally blind, obesity, muscle weakness, insulin dependent diabetes, schizoaffective disorder, and major depression disorder. Resident #17 had a fall and sustained a left hip fracture requiring surgery in February 2021. Review of the Health Care Facility Report System (HCFRS) entry, dated 7/25/21 at 10:15 P.M., indicated that Resident #17 sustained a fall out of bed. Certified Nursing Assistant (CNA) #9 was providing P.M. care with one assist. As the CNA turned the Resident on his/her side to place an incontinent pad underneath, Resident #17's leg rolled over the bed and he/she fell on to the floor sustaining a fractured femur and tibia. Review of the nurse's note, dated 7/25/21, indicated that Resident #17 was sent to the hospital emergency room and the hospital notified the facility that the Resident sustained a fracture. Type of fracture was not documented. Resident #17 remained in the hospital until discharged back to the facility on [DATE]. Review of the hospital note, dated 7/30/21, indicated Resident #17 sustained a left nondisplaced distal femur and proximal tibia fractures. Resident #17 was not considered a surgical candidate and the hospital treated him/her with a knee immobilizer, recommended physical therapy, and non-weight bearing. Review of the medical record indicated that Resident #17 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of the Activities of Daily Living (ADL)/Mobility care plan intervention for toileting, indicated that Resident #17 was incontinent of bowel and bladder, and totally dependent on two staff for all toileting needs, date initiated 3/26/20 and revised on 5/8/20. Review of the Falls Risk Assessment indicated he/she was a high risk for falls: 6/3/21 Resident score 16 = high risk 7/25/21 Resident score 13 = high risk 8/8/21 Resident score 22 = high risk Review of the CNA care card titled, ADL Plan of Care, undated, indicated Resident #17 was dependent on staff for mobility, was non-ambulatory, and required two person assists for positioning. Review of the Occupational Therapy (OT) and Physical Therapy (PT) Evaluation and Treatment plan after Resident #17's fall which resulted in a left hip fracture in February 2021, dated 2/11/21, indicated that for bed mobility, roll left and right, and required substantial/maximal assistance. Review of the facility's policy titled Managing Falls and Fall Risk Policy Statement, revised November 2020, included a section titled Resident-Centered Approaches to Managing Falls and Fall Risk, which indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Review of the facility's Activities ADL/Resident Assessment Flow Sheets for January 2021 (prior to first fracture), July 2021, and August 2021, indicated the section for positioning and bed mobility required two plus person physical assist. Flow sheets are completed by the CNA's each shift and the CNA's documented on all three shifts consistently that Resident #17 was a two person assist and totally dependent. During an interview on 8/5/21 at 10:50 A.M., the Assistant Director of Nursing said that Resident #17 had always required a two person assist to transfer and/or reposition in bed as the Resident weighed over 200 pounds (lbs.). She said that the Resident does not ambulate, but occasionally agreed to get out of the bed and into a chair, but that was before this fall with fracture. The Resident is now in bed. During an interview on 8/5/21 at 1:10 P.M., Nurse #4 said that Resident #17 has always required two people to reposition since admission. During an interview on 8/5/21 at 1:14 P.M., CNA #3 said that she has been caring for Resident #17 since admission and two staff are required to reposition and transfer since his/her admission last year. During an interview on 8/5/21 at 1:17 P.M., CNA#4 said that Resident #17 always requires two staff to reposition since she started caring for him/her months ago. During an interview on 8/5/21 at 1:20 P.M., Nurse #5 said that Resident #17 has always required two staff to reposition. During an interview on 8/10/21 at 9:15 A.M., Resident #17 said that he/she could not remember what happened the night of his/her fall. During an interview on 8/10/21 at 9:33 A.M., the Minimum Data Set (MDS) Nurse said that Resident #17 required two staff for repositioning, prior to and after the July 2021 fall. This was consistent with the coding on the MDSs with reference dates of 3/4/21 and 6/3/21. Section G - title Functional Status, indicated Resident #17 required two plus staff for positioning/bed mobility. This was consistent with staff interviews and documentation. During an interview on 8/10/21 at 11:20 A.M., the Director of Rehab said that they are providing Physical Therapy for Resident #17 since he/she returned from the hospital and has been a two person assist since admission. During an interview on 8/11/21 at 11:45 A.M., CNA #9 said Resident #17 was a two person assist for repositioning. On the night of the fall, CNA #9 said that she was the only aide to perform last rounds, as the other aide left the unit at 9:00 P.M. leaving her alone from 9:00 P.M.-11:00 P.M. to complete last rounds. She said she wanted to be sure the Resident was taken care of before the end of her shift. During an interview on 8/11/21 at 2:37 P.M., CNA #8 said she was not on the unit with CNA#9 on the night of Resident #17's fall with injury; she was on a different unit. Review of the staffing sheet verified CNA #8's statement. The Director of Nurses documented on 8/4/21 on the Fall Risk care plan, revised on 3/12/21 and on 7/25/21, and indicated that the intervention was CNA educated on following care plan and level of assistance for resident. She also implemented two persons at all time for repositioning. Documentation and interviews were consistent that Resident #17 had been a two person assist since admission. This was not a new intervention. 34145 2. On 8/5/21 at 8:40 A.M., the surveyor observed a bottle of Ketoconazole cream (a topical treatment used to treat skin infections), and a tube of Lidocaine cream (topical anesthetic), both with prescription labels affixed to the outside, on a shelf in Resident #22's room. An over-the-counter tube of Cortisone cream (topical steroid used to treat inflammation) was also observed on the shelf. Potential side effects of Ketoconazole include anaphylaxis (life threatening allergic reaction); Lidocaine has a fatal side effect if too much of the medicine is absorbed through the skin. On 8/5/21 at 11:04 A.M., a large tube of pain relief cream was observed on Resident # 49's bedside table. The pain relief cream has a fatal side effect if too much of the medicine is absorbed through the skin. On 8/5/21 at 11:15 A.M., the surveyor brought Unit Manager #3 to Residents #22 and #49's room to observe the treatments left at the bedside. The Unit Manager said that all of the treatment items observed at the Residents' bedside should be locked in the treatment cart, and not left at the bedside where wandering residents can access it. 3. Review of the Matrix for Providers completed by the Director of Nursing and provided to the survey team on the first day of survey (8/5/21), indicated that 18 of 26 Residents residing on Unit 4 were identified as having a diagnosis of Alzheimer's dementia/ dementia. On 8/5/21 at 8:35 A.M., the surveyor observed an unlocked treatment cart positioned outside of the nursing station on Unit 4. On 8/5/21 at 8:58 A.M., the surveyor informed Nurse #2 and Nurse #9 that the cart was unlocked and unattended. Nurse #2 said that the treatment cart is supposed to be locked at all times. Nurse #2, Nurse #9, and the surveyor reviewed all of the items in each drawer of the cart as follows: The first drawer included: 1 tube of Nystatin cream (antifungal medication) 1 bottle of Nystatin powder The second drawer contained: 2 tubes of Santyl (enzyme used to remove dead skin tissue) 2 tubes of Clobidesol cream (steroid) 1 tube of Estradiol cream (estrogen) 1 tube of hydrocortisone cream (steroid) The third drawer included: 1 bottle of Betadine (antiseptic) Dermaseptin (protective ointment) 1 box of lancets (small needles used for blood testing) The fourth drawer contained: 1 box of lancets 1 box of alcohol prep pads The fifth drawer contained: 1 bottle of hydrogen peroxide (antiseptic) 1 box of lancets On 8/10/21 from 9:19 A.M. to 10:15 A.M., the surveyor observed an unlocked treatment cart positioned outside of the nursing station on Unit 4. During the observation, several staff members (two CNAs, two nurses, one housekeeper, and one maintenance staff) and two wandering residents passed by the unlocked and unattended treatment cart multiple times. During an interview on 8/10/21 at 10:15 A.M., the Assistant Director of Nursing and Nurse #8 said that the treatment cart should be locked at all times so residents cannot accidently ingest the medications and/or make contact with caustic substances. 4. On 8/11/21 at 9:10 A.M., the surveyor observed the following items unsecured and easily accessible to residents in the unlocked, clean utility room on Unit 4: -30 disposable razors -2 metal nail clippers -7 bottles of antiperspirant -4 bottles of mouthwash -8 bottles of shaving cream -4 bottles of Peri cleanser -8 bottles of skin and hair cleanser -13 bottles of alcohol based hand sanitizer -1 bottle of nail polish remover On 8/11/21 at 9:20 A.M., the surveyor observed the following items unsecured and easily accessible to residents in the unlocked clean utility room on Unit 3: -2 bottles of nail polish remover -5 bottles of Peri cleanser -5 bottles of skin and hair cleanser -3 bottles of mouth wash -8 bottles of alcohol based hand sanitizer -A&D ointment -4 bottles of shaving cream -6 bottles of deodorant -a box of disinfecting wipes During interviews with Unit Manager #2 and #3 on 8/11/21 at 9:21 A.M., and 9:24 A.M. respectively, they said that the clean utility rooms should be locked at all times. 44572

Based on records reviewed and interviews, for one of five sampled residents (Resident #4), who was severely cognitively impaired and unable to consent, the Facility failed to adequately protect and prevent Resident #4 from being sexually abused by Resident #1. When over an eight month period (10/2018 through 5/2019), Resident #1 who was also severely cognitively impaired, would kiss Resident #4, touch Resident #4's breasts, place Resident #4's hand on his/her (Resident #1) groin area and put his/her (Resident #1) hands down Resident #4's pants. Findings include: The Facility's Policy titled, Abuse Policy, dated 03/14/2018, indicated that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse, to insure that all alleged violations of Federal or State laws which involve abuse are reported immediately to the Executive Director and that the Facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director. The Policy indicated that: - abuse is unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm; -residents must not be abused by anyone including other residents; -sexual abuse includes sexual coercion or sexual assault. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #4 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #1 and Resident #4 both had invoked Health Care Proxies and lacked the capacity to make decisions due to dementia. A physician progress notes [REDACTED].#1 had been making inappropriate sexual gestures towards other residents, staff and visitors. The Note indicated Resident #1 befriended a resident (identified as Resident #4) and attempted to enter his/her room at night, grope him/her in the day room and make gestures towards him/her. A Nurse Progress Note, dated 1/3/19, indicated Resident #1 made several attempts of inappropriate touching, kissing and gestures towards a resident (identified as Resident #4). A Nurse Progress Note, dated 1/11/19, indicated Resident #1 made inappropriate comments to a resident (identified as Resident #4). A Nurse Progress Note, dated 2/6/19 and 2/12/19, indicated Resident #1 was inappropriate to a resident (identified as Resident #4), attempting to kiss him/her while reaching for his/her bottom. Nurse Progress Notes, dated 2/21/19 and 3/19/19, indicated Resident #1 had inappropriate behaviors with a resident (identified as Resident #4). The Note indicated Resident #1 attempted to put Resident #4's hand on his/her groin. A Nurse Progress Note, dated 3/3/19, indicated Resident #1 attempted to touch a resident (identified as Resident #4) groin area when the nurse was not watching. A Nurse Progress Note, dated 3/25/19, indicated Resident #1 made inappropriate sexual comments to a resident (identified as Resident #4). A Nurse Progress Note, dated 5/13/19, indicated Resident #1 was found with a resident (identified as Resident #4) in his/her room, lying on the bed with Resident #4's pants half down. An Interdisciplinary Care Plan Conference Report, dated 4/18/19, indicated Resident #1 continued with inappropriate sexual behaviors with a resident (identified as Resident #4) and required constant monitoring by staff to mitigate behavior. Review of Resident #1's Behavioral Record, dated 1/2019 through 5/20/19, indicated Resident #1 had 123 episodes of inappropriate sexual behaviors and sexual gestures towards residents and/or female staff. The Record indicated Resident #1's inappropriate behaviors were documented as: gestures made with his/her mouth and hands, attempting to kiss a resident (identified as Resident #4), grabbing his/her (Resident #4) bottom, trying to touch his/her (Resident #4) chest, attempting to put his/her hand on Resident #4 groin and using sexual language. The Record indicated Resident #1 required constant supervision due to inappropriate behaviors. The Surveyor interviewed Certified Nurse Aide (CNA) #1, CNA #2, CNA #3, CNA #5 and an Activity Assistant on 7/29/19 and 7/30/19. CNA #1, CNA #2, CNA #3, CNA #5 and the Activity Assistant said they saw Resident #1 kiss Resident #4 on the lips, put his/her hand down the front of Resident #4 pants, touch Resident #4's crotch area, put his/her hands down Resident #4's shirt, touch Resident #4 breasts and take Resident #4's hand and put it on his/her (Resident #1's) crotch area. CNA #1, CNA #2, CNA #3, CNA #5 and the Activity Assistant said Resident #1 would talk inappropriately to Resident #4 and say words to the effect of I want to take you in my room, [***] you, and have oral sex. CNA #1, CNA #2, CNA #3, CNA #5 and the Activity Assistant said Resident #1 made sexually inappropriate gestures with his/her fingers and hands, would stick his/her tongue out and wink at Resident #4 while rubbing his/her hand on his/her own crotch area. CNA #1, CNA #2, CNA #3, CNA #5 and the Activity Assistant said they could not recall the specific dates and times these behaviors occurred, but said Resident #1 had these behaviors daily and said they reported these behaviors to the Nurse and Unit Manager. The Surveyor interviewed Nurse #1 at 1:35 P.M. on 7/29/19. Nurse #1 said she saw Resident #1 kiss Resident #4 on the lips, caress Resident #4's breasts, put Resident #4's hand on his/her groin area, make lots of inappropriate gestures toward Resident #4 like sticking out his/her tongue and licking his/her lips, putting his/her finger inside the other hand and made a V with his/her fingers and licking in between his/her fingers. Nurse #1 said Resident #1 would verbally tell Resident #4 he/she wanted to suck his/her breasts. Nurse #1 said she documented these behaviors in Resident #1's behavior sheet and said these behaviors occurred daily. Nurse #1 said she thought these behaviors were consensual between both residents and said she did not consider it abuse. The Surveyor interviewed Nurse #2 at 2:05 P.M. on 7/29/19. Nurse #2 said she saw Resident #1 touch Resident #4's breasts and say to Resident #4 words to the effect I want you to suck my genitalia. Nurse #2 said she was told by the Director of Nurses to document these behaviors on Resident #1's behavior sheet. Nurse #2 said she did not consider this abuse and said she was unsure if it would be considered consensual because both residents had dementia. The Surveyor interviewed the Unit Manager at 3:18 P.M. on 7/29/19 and at 2:25 P.M. on 7/30/19. The Unit Manager said she saw Resident #1 kiss Resident #4 on the lips, touch Resident #4's breasts, put Resident #4's hand on his/her crotch area and put his/her hands down Resident #4's pants. The Unit Manager said she did not consider this abuse and said she was unsure if Resident #1 and Resident #4 were able to consent because of their severe dementia. The Unit Manager said she documented Resident #1's behaviors on his/her behavior sheet as inappropriate sexual behaviors and gestures and said she did not recall discussing the details of Resident #1's inappropriate sexual behaviors and gestures with the Director of Nurses because she was too embarrassed. The Surveyor interviewed the Director of Nurses (DON) at 1:30 P.M. on 7/30/19. The DON said the behaviors she was aware that Resident #1 had were, touching Resident #4 on the shoulder area, touching leg/thigh area, blowing kisses and making gestures with his/her hands. The DON said she was unaware that Resident #1 had made any inappropriate sexual contact with Resident #4 and did not know why staff did not report the inappropriate sexual behaviors to her. The DON said Resident #1 and Resident #4 were unable to consent to these behaviors because of their severe dementia.

Based on observations, interviews and record review the facility staff failed to ensure adequate supervision to prevent accidents by not implementing care plan interventions, for one Resident (#65), in a total sample of 18 Residents. Findings include: Resident # 65 was admitted to the facility in 1/2013 with diagnoses of dementia, neuroleptic induced parkinsonism, and abnormal posture. A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE] indicated Resident #65 was dependent of two staff for bed mobility, transfer between surfaces and toileting, he/she was also dependent on one staff member for dressing, eating, and hygiene. The MDS also indicated the Resident had limited range of motion for the upper and lower extremities on both sides. A review of nursing progress notes indicated that on 6/17/19 Resident #65 had fallen forward out of his/her reclining wheelchair. The Resident landed on the left side of his/her face. The Resident was sent to the hospital and received sutures to the lacerated left eye. A review of the hospital discharge paperwork indicated the Resident had a 5 centimeter laceration under the left lower eyelid which extended laterally, with a noted concern for possible involvement of the tear duct. The resident was administered intravenous (IV) [MEDICATION(S)] (1 milligram) for pain control and then demonstrated increased hyperactive behavior and was given 1 milligram of IV [MEDICATION(S)] (an antipsychotic). A plastic surgeon was consulted to repair the laceration with sutures and prescribed an ophthalmic ointment twice a day for seven days. A review of the falls follow-up assessment indicated that on 6/17/19 at 10:15 A.M. Resident #65 fell out of the highback reclining wheelchair, which was not reclined, and sustained a laceration to the left eye and a hematoma to the left forehead. The incident follow-up indicated that the plan of care for the Resident was not followed to recline the Resident after eating due to the Resident having a lack of trunk support. On 6/18/19 at 12:35 P.M. the daughter of Resident #65 was interviewed. The daughter said that the Resident had fallen the day prior because he/she was left sitting straight up in the reclining wheel chair after breakfast. The daughter said that there was not enough staff on the unit which contributed to the fall the previous day. The daughter said that the Resident had a facial laceration in which a flap of skin to the left of the eye was hanging down and needed to be sutured by a plastic surgeon. The surveyor and the daughter observed Resident #65 in bed on 6/18/19 at 12:35 P.M. The Resident had a large purplish/yellow discoloration to the left forehead. The Resident was noted to have sutures from the corner of the left eye, which was swollen, making it difficult for Resident #65 to open his/her left eye when the daughter was speaking. Certified Nursing Assistant (CNA) #2 was interviewed on 6/20/19 at 2:30 P.M. CNA #2 said that she was on the fourth floor unit as a CNA when Resident #65 fell . She said that she had been down the hall doing menu selections with Residents and walked by and saw the Resident on the floor with staff around him/her. She said she did not get the Resident out of bed that morning and did not feed him/her breakfast. CNA #1 was interviewed on 6/20/19 at 2:45 P.M. The CNA said that she was working on the fourth floor the day Resident #65 fell . She said that CNA #2 had arrived on the unit some time during breakfast and CNA #1 had been on the unit alone for a period of time. CNA #1 said she had assisted in getting Resident out of bed and had fed the Resident breakfast that morning. She said that Resident #65 was to sit straight up in the recliner chair to have breakfast. She said that she was in the unit dining room with the Resident, had finished feeding the Resident and was asked by a rehabilitation staff member to held with another Resident. CNA #1 said that CNA #2 was in the unit dining room when she left. CNA #1 said that she did not recline the wheelchair of Resident #65 after the Resident was done eating. She said that with only two CNAs on the unit it was difficult to ensure that all the care was provided appropriately. She said that if there had been more staff she would have been able to finish care for Resident #65, by reclining the wheelchair, prior to moving on to help another resident.

Based on observations, record review and interviews the facility staff failed identify risk factors to prevent a heel pressure injury from occurring for 1 Resident (#12) in a total sample of 18 Residents and failed to assess and document the area after it developed. Findings include: Resident #12 was admitted to the facility in 03/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12, diagnosed with diabetes and assessed at high risk for pressure injury, developed an area due to resting his/her heel on the bottom bar of the overbed tray table and on the side of the wheelchair where the leg rests should be, while not wearing foot wear. The wheelchair Resident #12 was using had no foot pedals and both feet were not protected from injury. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 had severe cognitive impairment, required assistance of two staff for bed mobility and transfers between surfaces. He/She could not ambulate and required assistance from one staff member for mobility in the wheelchair. On 6/14/19 at 11:30 A.M. Resident #12 was observed sitting in a high back wheelchair, with a foot buddy cushion not attached properly to the leg rests, with one end of the cushion lying on the ground. The right heel was wrapped with a gauze wrap. A review of the nursing progress notes indicated that on 4/25/19 Resident #12 was found to have a fluid filled blister on his/her right heel. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated that the fluid filled blister area measured 7 centimeters (cm) in diameter. A review of the wound evaluation from the wound specialist, dated 5/21/19, indicated that Resident #12 had an unstageable pressure wound to the right heel with necrotic (dead, black) tissue. The wound measured 10 cm in length by 10 cm in width. The wound bed was 90% necrotic and 10% slough (dead yellow/white/gray tissue) and the wound edges were unattached. The wound specialist recommended a treatment to cleanse the wound, use skin prep to the wound edges, apply honey hydrogel (honey-based wound gel that hydrates and protects the wound) liberally on gauze over wound, cover with dry pad and wrap with gauze. A review of the wound evaluation from the wound specialist, dated 6/18/19 indicated the wound was 100% necrotic and the wound edges were unattached. The wound specialist recommended a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was observed by the surveyor on 6/20/19 at 8:10 A.M., 10:13 A.M. and 4:18 P.M. to not be wearing a sock on the right foot. On 6/20/19 at 4:28 P.M. Nurse #1 and Nurse #3 were interviewed. The nurses said that they were unaware that Resident #12 was to have anything protective on the right foot, as indicated by the wound specialist on 6/18/19. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the documentation indicated that the daily observations were not marked as completed on the following days: 5/23/19, 5/24/19, 5/25/19, 5/27/19, 5/28/19, 5/30/19, 5/31/19, 6/1/19, 6/2/19, 6/3/19, 6/6/19, 6/7/19, 6/10/19, 6/12/19, 6/14/19, 6/15/19, 6/17/19 and 6/19/19. On 6/21/19 at 4:50 P.M. Nurse #5 was interviewed. The nurse said that Resident #12 obtained the right heel pressure area from rubbing his/her foot against the side of the wheelchair and the legs of the tray table. The nurse said that the Resident would do this all the time when sitting in the wheelchair. Nurse #5 was asked about the documentation for daily observations of the right heel area. The nurse reviewed the observation history report and said that if the documentation was not there, then the nurses probably did not did not do the observations. A review of the facility's pressure area investigation following the development of the right heel blister on 4/25/19 indicated that Resident #12 was at high risk for developing pressure areas due to immobility and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This section indicated that Resident #12 rested his/her heel on the leg stand of the over the bed table and on the wheelchair, where leg rests would be. A review of the risk for skin breakdown care plan for Resident #12, dated as initiated on 4/3/18, did not include any information regarding the Resident resting or rubbing his/her heels on the over the bed table legs or the wheelchair. There were no interventions on the documentation that would have indicated the facility staff assisted in preventing the Resident from rubbing his/her heels on surfaces to avoid a pressure injury. A review of the care plan for the right heel blister, dated 4/25/19, indicated that new interventions were put into place to prevent further skin breakdown including: removing the tray table when not in use, a referral for diabetic shoes to reduce pressure/friction and to off load both heels when in bed. On 6/21/19 at 4:30 P.M. Surveyor #2 and Nurse #4 observed Resident #12 lying in bed with the right heel directly (no sock) on the bed. The right heel was observed to have a large area approximately 5 cm by 5 cm with necrosis and inflamed around the borders. There were two additional reddened areas on the outside of the right foot. A pillow was observed between the legs of Resident #12, but it was not offloading pressure to either heel. Nurse #4 said that the right heel was not off loaded. Nurse #4 and Nurse #5 attempted to reposition Resident #12, when they picked up his/her foot off the bed the Resident jumped, winced and displayed discomfort.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent Certified Nurse Aide (CNA) #1 from misappropriating and cashing one of Resident #1's bank checks in the amount of $150.00. Findings include: The Facility's Abuse Policy, dated 3/14/18, indicated it was the policy of the Facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident's property and to ensure that all alleged violations of Federal or State laws which involved the alleged violations are reported immediately to the Executive Director of the Facility and to the State agencies, in accordance with existing State law. Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE], indicated he/she was cognitively intact. The Facility's Internal Investigation Report, dated 4/20/18, indicated that at 3:15 P.M. on 4/17/18, Resident #1 reported to the Administrator that one of his/her checks, #1504, was written out to CNA #1 for $150.00 and that he/she did not given consent to CNA #1 to write out a check. The Report indicated that the local Police Department was immediately contacted. -The Report indicated that, on 4/20/18, CNA #1 met with the DON, the Administrator, and a local Police Officer and CNA #1 said that Resident #1 gave her the check for words to the effect, everything she (CNA #1) had done over the past 6 months. The Report indicated that CNA #1 said she should not have accepted the gift and should not have cashed Resident #1's check. The Report indicated that the Police Officer said that because of the scanned images of the check, and an admission that CNA #1 cashed Resident #1's check, that was enough evidence to summons CNA #1 to court. The Surveyor interviewed Resident #1 at 10:00 A.M. on 7/16/18. Resident #1 told the Surveyor that, on 4/17/18, while reviewing his/her bank statements, he/she noticed that there was a check made payable to CNA #1 that was not in his/her handwriting, and was cashed, in the amount of $150.00. Resident #1 said CNA #1 forged his/her signature on the check and that he/she had not given consent for CNA #1 to write out a check in her (CNA #1's) name or cash his/her check. The Surveyor interviewed the Administrator at 4:20 P.M. on 7/16/18. The Administrator said CNA #1 admitted that she cashed Resident #1's check, in the amount of $150.00. The Administrator said CNA #1 told him that Resident #1 had given the check to her (CNA #1) as a gift, for all of the hard work she had done for Resident #1. The Surveyor interviewed Resident #1's Power of Attorney (POA) at 4:40 P.M. on 7/18/18. The POA said Resident #1's check, #1504 dated 3/16/18, for $150.00 was made out paid to the order of CNA #1, but was not in Resident #1's handwriting and Resident #1's name was misspelled. The POA said Resident #1 would never give a check to anyone and said Resident #1 would never let another person fill out the check for him/her. The Police Report, dated 5/10/18, indicated that the Police Detective viewed the Surveillance photograph's from Resident #1's bank and he was able to positively identify the suspect as the accused CNA #1, by comparing the photographs to CNA #1's Registry of Motor Vehicle (RMV) photograph. The Police Report, dated 5/15/18, indicated that CNA #1 admitted that she took Resident #1's check and wrote out the check to herself, and said that she needed the money to buy items for her son. The Police Report, dated 5/20/18, indicated that CNA #1 was being summonsed for a hearing for uttering a false check, for larceny under $250.00, for forgery of a check and for larceny under $250.00/false pretenses. Although CNA #1 did not return the Surveyor's calls or respond to a letter sent to her address that was on file, the Administrator and the Police Report indicated that CNA #1 said she cashed Resident #1's check and Resident #1 said it was done without his/her knowledge or consent.

Based on record review, observation and interview, the facility failed for 1 Residents (#3) of a total sample of 20 residents, to ensure that each resident receive proper care and supervision to prevent accidents. Findings include: Resident #3 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. An admission Fall Risk Evaluation was conducted on 10/9/14, with a score of 10 or above representing a high risk for falls, Resident #3 scored a 21, and was identified at High Risk. The Resident's admission Minimum Data Set assessment dated [DATE], indicated a brief interview of mental status (BIMS) score of 13 of 15, with mood indicators for delirium and depression, who required extensive assistance for daily activities of living and had a history of [REDACTED]. Review of the clinical record on 8/25/15, indicated fall incidents where by care interventions were not properly followed to ensure safety and to alert staff to avoid falls. The Resident experienced falls which including some of the following: On 12/23/14, the Resident experienced an unwitnessed fall at 4:15 P.M., as he/she was found on the floor near the bathroom. No injury was revealed after X-rays results of 12/24/14 and 12/15/14. Although due to an increase in complaints of pain, a follow-up X-ray was performed on 1/6/15 and the Resident was identified with a right trochanteric fracture. Investigative documentation of the Resident's fall indicated the Resident had attended activities earlier in the afternoon and had been in bed for a nap prior to the fall. The Resident was heard from the hallway, yelling for help when found on the floor. According to investigative information the Resident's call light had been on; chair alarm was noted on chair, however the bed alarm was not properly operating as the clip was broken and there was no alarm box present. The facility failed to properly implement and a follow the resident's plan of care to prevent falls and potential injury. On 2/1/15 Resident #3's roommate called for help as the resident was found sitting on the floor at 7:45 A.M. attempting to reach the bathroom. The bed alarm sounded and there was no injury reported. New intervention to include that 11:00 P.M. -7:00 A.M. shift to assist with toileting at end of rounds. Care needs included pain medications for discomfort, at risk for constipation requiring bowel medications, which increased the need for prompt toileting due to weakness and assistance On 2/6/15 at 11:25 P.M. the Resident was heard calling for help and found on the floor at end of bed. Investigative documentation indicated that the Resident's bed alarm did not sound, as it was not engaged in the on position and attached to the Resident. Although the treatment book indicated the alarm had been checked and signed for 2/6/15, the 3:00 P.M.-11:00 P.M. shift. Nursing incident documentation for the 2/6/15 unwitnessed fall indicated the resident had no complaints, vitals within normal range with scratch noted on hip and eye area. Family and physician were notified of fall incident on the morning of 2/7/15. The incident report indicated that bed bolsters and a floor mat would be added to interventions to prevent reoccurrence. Review of nurses notes dated 2/7/15 indicated the Resident had a small bruise on his/her forehead and complained of hip pain. Nursing documentation dated 2/7/15 indicated the family had visited at noon and did not want the resident sent out for further evaluation. On 2/7/15, 3:00 P.M.-11:00 P.M. nurses note documented the resident with nausea and vomiting. On 2/8/15, the resident was noted as alert, responsive, no nausea or vomit, neuro and vitals within normal but had complaints of headache with facial grimacing. Pain medication was given with positive effect . Later a separate nurses note, dated 2/8/15, documented that the Resident had lethargy, and right outer orbit of eye was ecchymotic. The physician consult resulted in sending the Resident out for an evaluation. Hospital discharge summary indicated the resident was diagnosed with [REDACTED]. The facility failed to properly implement and a follow the resident's plan of care to prevent falls and potential injury. The bed alarm was discontinued 2/17/15 and a motion detector alarm was initiated. During interview with the Consultant Nurse #1 on 8/26/15 at 5:15 P.M., regarding the incidents with ineffective alarms, the facility provided a copy of in-service education conducted for nursing staff on 2/26/15. The education/training included alarm/alarm boxes devices are to be checked for function and placement at a minimum of once every shift and prior to placement on a resident. Broken clips/improper functioning alarm devices are to be reported to the charge nurse. Further record review indicated Resident #3 experienced a significant change in status, and the MDS assessment dated [DATE] indicated cognitive decline (BIMS of 1/15) and decline in activities of daily living, non ambulatory, decline in urinary and bowel continence, significant weight loss with addition of hospice services. A nurses note dated 6/22/15 indicated the Resident had a fall at 3:15 P.M., with no injury noted. Hospice staff present in room. A Fall Risk Evaluation dated 7/18/15 identified the Resident as a High Risk for falls due to a history of falls with scores of 18, impaired cognition, poor safety awareness and weakness. Care interventions to remain free of falls included chair alarm, low bed, call light/call light pad, motion detector, bed bolsters, floor mats. A nurses note dated 7/20/15, indicated Resident #3 was found on the floor on 7/18/15 at 1:55 P.M., with arms on the bed and knees on the floor mat next to the bed, a small bruise was noted on the lower left leg. Review of the investigative documentation dated (incorrect date of 5/18/15) for the fall on 7/18/15, indicated that the motion sensor in the resident's room did not sound when the resident fell towards the floor, although it was turned on and last checked at 7:00 A.M. During interview on 8/28/15 at 8:25 A.M., Nurse Aide #1 said the motion sensor batteries were not working upon checking the alarm device during first morning rounds of (7:00 A.M.-3:00 P.M.) shift on 7/18/15 and had notified the nurse that the batteries needed to be replaced. The nurse was reminded again during the shift the alarm device required replacement batteries. Further documentation review indicated the Resident had been using the bed pan prior to the fall and attempted to remove it unassisted which may have contributed to the fall out of the bed. According to investigative findings, verified through interview, the batteries were not replaced until after the Resident was found on the floor mat. The facility failed to properly implement the use of safety devices such as an effective alarm and a follow the resident's plan of care to prevent falls and potential injury. Review of the plan of care on 8/28/15 included additional interventions added after the fall on 7/18/15, of a second motion sensor/hallway monitor and an additional floor matt. Incident follow-up also indicated nursing staff are to remain with the resident to assist with the removal of bedpan.