Every finding on record at Royal Meadow View Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided care and treatment in accordance with acceptable standards of practice, when on 04/07/26, Nurse #1 provided a Bisacodyl (laxative) suppository to Certified Nurse Aide (CNA) #1 to administer rectally to Resident #1, which was not within a CNA's scope of practice or job description and per the facility, was not a procedure that CNAs could perform.Findings include:The Facility Policy, titled Administering Medications, undated, indicated medications would be administered in a safe and timely manner, and only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so . Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), indicated that on 04/07/26 at 06:00 A.M., Nurse #1 gave Certified Nurse Aide (CNA) #1 a suppository (medication administered by rectal insertion) to administer to Resident #1. The Report indicated that CNA #1 then administered the suppository.Review of Mass.gov article titled, Massachusetts Certified Nurse Aide (CNA) Curriculum Frameworks, dated released on April 2026, indicated the CNA Scope of Practice and Bowel Management, that CNAs play a vital collaborative role in patient care, but invasive procedures like suppository administration are prohibited.The article indicated that nursing facilities must establish strict protocols for bowel management, indicating while CNAs may assist with toileting or perineal care, any invasive bowel intervention requires direct experiential training, a specific Physician or Nurse Practitioner Order, and execution by Licensed Staff.Review of the Floor Nurse Job Description, dated as signed by Nurse #1 on 12/01/25, indicated Nurse #1 was responsible for ensuring that all personnel assigned to him would comply with the written policies and procedures established by the Facility, and would prepare and administer medications as ordered by the physician. Review of the Certified Nurse Aide (CNA) Job Description, dated as signed by CNA #1 on 01/15/26, indicated that essential duties and responsibilities of a Certified Nursing Assistant did not consist of medication administration.Resident #1 was admitted to the Facility in November 2023, diagnoses included Multiple Sclerosis, constipation, and morbid obesity. Review of Resident #1's Bowel Care Plan, reviewed with his/her quarterly Minimum Data Set Assessment (MDS) dated [DATE], indicated he/she required bowel management by nursing staff.Review of Resident #1's Physician's Order Summary Report indicated he/she had a Physician's order, dated 09/13/25 for Bisacodyl (laxative) Rectal Suppository 10 milligrams (mg) insert one suppository rectally one time a day for constipation.During a telephone interview on 06/08/26 at 10:12 A.M., Certified Nurse Aide (CNA) #1 said that on 04/07/26 at 06:00 A.M., she and CNA #2 were conducting incontinence rounds on the unit, and she knew Resident #1 needed a suppository. CNA #1 said she knew Nurse #1 was very busy so she offered to administer the suppository and said Nurse #1 handed one to her. CNA #1 said she and CNA #2 then completed care for Resident #1 and she inserted the suppository into his/her rectum. CNA #1 said she did not know she was not allowed to administer suppositories in the Facility.During a telephone interview on 06/08/26 at 10:28 A.M., CNA #2 said that on 04/07/26 at 06:00 A.M., she and CNA #1 provided care to Resident #1, and at that time CNA #1 administered a suppository to Resident #1. CNA #2 said she knew only licensed nurses were allowed to administer medications, but said she did not stop CNA #1 from administering the suppository.During a telephone interview on 06/08/26 at 10:44 A.M., Nurse #1 said that on 04/17/26 at 06:00 A.M., CNA #1 offered to administer Resident #1's scheduled suppository. Nurse #1 said he knew that only licensed nurses were qualified to administer medications, but he handed CNA #1 the suppository anyway.During an interview on 06/08/26 at 12:36 P.M., the Director of Nurses (DON) said Nurse #1 should not have given a suppository to CNA #1 to administer, because medication administration was outside of the CNA scope of practice, and CNA #1 should not have administered the suppository to Resident #1.On 06/08/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 05/06/26, which addressed the area(s) of concern as evidenced by:A. 04/09/26, Resident #1 was interviewed regarding the incident, emotional counseling was provided, and an assessment indicated he/she had no ill effects as a result of CNA #1 administering a suppository.B. 04/09/26, The Administrator opened and completed a grievance for Resident #1 regarding the event.C. 04/09/26, The Administrator notified Local Police and the Department of Public Health of the event.D. 04/09/26, The Facility Leadership conducted a Root Cause Analysis and developed a plan to prevent future medication administration by unlicensed staff.E. 04/10/26, The Unit Managers conducted a Facility wide audit to identify any residents who received suppositories or invasive treatments and/or care from staff involved. No further concerns were identified.F. 04/10/26, Unit Managers conducted initial customer service rounds on the units.G. 04/16/26, QAPI Meeting was conducted and the Facility Leadership met to follow up on their corrective action plan to prevent future medication administration by unlicensed staff.H. 04/21/26, The Director of Nurses and Unit Managers re-educated all nursing staff to the Facility Policy for medication administration, specifically that only licensed staff can administer any medications, and medication administration is outside the scope of practice for CNAs.I. 04/21/26, The Administrator conducted an initial team meeting with the 11:00 P.M., to 07:00 A.M., nursing staff to focus on improving communication and work flow.J. 05/05/26, The Director of Nurses/designee conducted competencies with CNAs and Licensed staff to reinforce that only licensed staff can administer medications.K. The DON/designee will continue to conduct customer service rounds weekly for four weeks, then monthly for four months, then quarterly thereafter until substantial compliance is met to ensure quality customer service and quality of care.L. The DON/designee will conduct random competencies of a minimum of 10% of nursing staff to validate staff understanding, reinforce accountability, and ensure sustained compliance with the scope of practice weekly for four weeks and then monthly.M. The Administrator/designee will meet with 11:00 P.M., to 07:00 A.M., nursing staff weekly for four weeks to focus on any workflow and leadership concerns.N. Results of competencies, meetings, and audits will continue to be reviewed through the monthly Facility QAPI process to evaluate effectiveness of interventions and determine the need for continued monitoring or additional corrective action.O. The DON/designee are responsible for ongoing compliance.

Based on observations, record review and interview, the facility failed to identify and assess the use of pillows and a blanket tucked under a fitted sheet on both sides of the bed, as well as the use of a geri-chair (a reclining chair) directly next to the bed as a potential restraint for one Resident #74 out of a total sample of 20 Residents.Findings include:Review of the facility policy titled Restraint Free Environment Policy, dated and revised May 2025, indicated the following:- It is the policy of this facility that each resident shall attain or maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience that limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints.- A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a physical restraint.- Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints.Resident #74 was admitted to the facility in November 2025 with diagnoses including paranoid schizophrenia, bipolar disorder, epilepsy (a brain disorder causing seizures) and dementia. Review of Resident #74's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to participate in the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that the Resident does not use restraints. On 1/29/26 at 8:16 A.M., the surveyor entered Resident #74's bedroom, the surveyor observed Resident #74 sleeping on his/her left side in his/her bed. On both sides of the bed, padded side rails were in use. On the right side and left side on the perimeter of the mattress there was a significant hump tucked underneath the fitted sheet running the majority of the length of the mattress after the side rails. The surveyor lifted the sheet revealing pillows and blankets stuffed under the fitted sheet. Additionally, a geri-chair was placed directly next to the right side of Resident #74's bed.During an interview on 1/29/26 at 8:20 A.M. at Resident #74's bedroom doorway, Certified Nursing Assistant (CNA) #1 said Resident #74 is fully dependent on staff for Activities of Daily Living, CNA #1 then said the Resident can often become restless while he/she is in bed and he/she tried to get out of bed on his/her own. The surveyor asked CNA #1 to observe Resident #74 in his/her bed, the surveyor and CNA #1 observed the significant humps tucked under the sheets of the left and right side of Resident #74's bed. CNA #1 said there should not be anything tucked under his/her sheets as it is not allowed. CNA #1 said the night shift staff must have done it.During an interview on 1/29/26 at 8:22 A.M., Unit Manager #1 said Resident #74 is a fall risk as he/she is unpredictable and likes getting out of bed. The surveyor and Unit Manager #1 then observed Resident #74 in bed, and she removed two pillows roughly two-feet long in length from under the fitted sheet on the right side of the Resident's bed as well as a bunched-up blanket from under the fitted sheet on the left side of Resident #74's bed. Unit Manager #1 then proceeded to say it looks like a restraint to me and it was probably the night staff from the previous night. Unit Manager #1 said she has never seen it before, and it is not something staff members should be doing.Review of Resident #74's physician's orders failed to indicate an order for the use of pillows or blankets tucked under fitted sheets or any use of a potential restraint.Review of Resident #74's clinical admission assessment dated [DATE] indicated that the Resident does not use a restraint while in the facility.Review of Resident #74's fall risk evaluations dated 11/18/25, 12/29/25 and 1/16/26 indicated that the Resident scored a 15, 16 and 16 respectively indicating that he/she is at risk for falls.Review of Resident #74's care plan for high risk of falls dated and revised 12/2/25 did not indicate the use of pillows or blankets tucked under fitted sheets or the use of a geri-chair being next to the bed to be used as a potential restraint.Review of Resident #74's potential for pressure ulcer development care plan dated and revised 11/20/25 did not indicate the use of pillows or blankets as positioning devices as interventions.Further review of Resident #74's care plans also failed to indicate the use of pillows or blankets tucked under fitted sheets or the use of a geri-chair being next to the bed to be used as a potential restraint.Further review of Resident #74's medical record failed to indicate that a restraint assessment or a device assessment for the use of potential restraints was present.Review of a nursing progress note dated 1/29/26 at 6:25 A.M. written by Nurse #3 who worked the overnight shift prior indicated the following:- Resident was up for most of the night making noises. Slept at 1am and woke up at 4am. This nurse administered neb (nebulizer) per doctor's order, pt (patient) tolerated tx (treatment) well. No signs of sob (shortness of breath)/discomfort noted this shift.During a telephone interview on 1/29/26 at 11:07 A.M., CNA #3said he worked the previous overnight shift, he continued to say he is unfamiliar with Resident #74 and did not stuff pillows or blankets under his/her sheets.During a telephone interview on 1/29/26 at 11:11 A.M., CNA #2 said he worked the previous night on Resident #74's floor. CNA #2 said Resident #74 will need help getting out of bed however when he/she is hyper he/she can get out of bed. CNA #2 said Resident #74 was yelling last night until past midnight. CNA #2 said stuffing pillows or blankets under fitted sheets is not allowed.The surveyor attempted to call Nurse #3 who worked the night prior on 1/29/26 at 11:16 A.M. and on 1/30/26 at 9:12 A.M. but did not receive a response.Telephone interview with CNA #2 and #3 did not provide any indication as to why pillows and a blanket were tucked under Resident #74's fitted sheet or why a geri-chair was directly next to the Resident's bed.During an interview on 1/29/26 at 12:38 P.M., the Director of Nursing (DON) said the facility is a restraint-free facility and we should not be stuffing anything under fitted sheets to prevent residents from getting out of bed.During a follow-up interview on 1/29/26 at 2:00 P.M., Unit Manager #2 said all signs point to the overnight staff who stuffed pillows and blankets underneath Resident #74's sheets and she has never seen anything like that before. Unit Manager #2 then said Resident #74 is schizophrenic and he/she has the ability to roll over and move his/her body and he/she can flip him/herself over from side-to-side in the bed. Unit Manager #2 then said Resident #74 has no problems with his/her skin and currently has no skin issues. Unit Manager #1 said Resident #74 also has epilepsy and has a seizure history, so the facility uses padded side rails for that, not stuffing pillows and blankets under fitted sheets.During an email correspondence with the Director of Nursing on 1/30/26 at 12:15 P.M., the DON said she identified the CNA (CNA #5) who put the pillows and blanket under Resident #74's fitted bedsheet. The surveyor attempted to call CNA #5 on 1/30/26 at 12:39 P.M. and on 2/4/26 at 8:44 A.M., but CNA #5 did not answer and the voicemail box was full not allowing the surveyor to leave a voicemail.

Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated food, that staff did not store personal drinks with resident food and ingredients, and that staff did not serve undercooked unpasteurized eggs. Findings include: Review of the facility's policy titled 'Food Preparation and service', undated, indicated, but was not limited to, the following: - Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. - The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: o Unpasteurized eggs - until all parts of the egg (yolks and whites) are completely firm (160 degrees Fahrenheit). - Only pasteurized shell eggs will be cooked and served when: a. Residents request undercooked, soft-served or sunny side up eggs. Review of the facility's policy titled 'Labeling and Dating Inservice', undated, indicated, but was not limited to, the following: - Proper labeling and dating ensure that all foods are stored, rotated, and utilized in a First in First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. - All foods should be dated upon receipt before being stored. - Leftovers must be labeled and dated with the date they are prepared and the use-by date. - The manufacturer's expiration date, when available, is the use by for unopened items. Review of the current United States Department of Agriculture (USDA) food safety guidelines indicate that undercooked or raw unpasteurized eggs should not be consumed as they pose a significant risk for Salmonella (a potentially serious bacterial food-borne infection), especially for those who are elderly and/or immuno-compromised (those with a weakened immune systems). The surveyor made the following observations during the initial kitchen walkthrough on 1/28/25 at 7:07 A.M.: - Deli ham partially wrapped but undated in the walk-in refrigerator. - A container labeled plain chicken no salt no spicy but undated in the walk-in refrigerator. - A container of biscuit/dough wrapped but undated in the walk-in refrigerator. - A container labeled corn bread dated 1/21 and 1/23 in the walk-in refrigerator. - A container with an open package of hotdogs inside dated 1/21 and 1/23 in the walk-in refrigerator. - Two open containers of apple juice dated 1/9 and 12/12 in the walk-in refrigerator. - A bottle of kombucha in the walk-in freezer near resident food and ingredients. During an interview on 1/28/25 at 7:14 A.M., Dietary Staff #1 said the kombucha belonged to him. On 1/28/25 at 7:25 A.M., the surveyor made the following observations in the Meadows Unit kitchenette refrigerator: - One bottle of orange juice open but undated. On 1/28/25 at 7:34 A.M., the surveyor made the following observations in the View Unit kitchenette refrigerator: - One bottle of apple juice, open but undated. - One bottle of orange juice open but undated. - A sandwich dated 1/21 with a use-by date of 1/23. On 1/28/25 at 7:34 A.M., the surveyor observed a sign on the outside of the View Unit kitchenette refrigerator which indicated the following: - All items in the fridge and freezer must be dated with the date opened! Opened items are only good for 3 days! Anything without a date will be thrown away. On 1/14/25 at 8:20 A.M., the surveyor made the following observations in the third-floor kitchenette refrigerator: - One bottle of cranberry juice, open and dated 12/31. - One bottle of orange juice open but undated. On 1/28/25 at 8:26 A.M., the surveyor observed a Resident eating breakfast, the Resident had cut into his/her fried egg and the yolk was soft and runny. On 1/28/25 at 8:52 A.M. the surveyor observed a Resident tray on the food truck, the plate had a fried egg on it, the yolk was soft and runny. During an interview and observation on 1/28/25 at 8:20 A.M., Dietary Staff #1 said that this morning multiple residents requested, and were served, fried eggs that were either over-easy or over-medium, meaning the yolk was still runny. The surveyor and Dietary Staff #1 observed the box eggs in the walk-in refrigerator, the box or eggs failed to indicate that the eggs were pasteurized. Dietary Staff #1 said the box did not say whether the eggs were pasteurized or not and that those were the only eggs served today. During an interview on 1/28/25 at 9:04 A.M., the Food Service Director (FSD) said pasteurized eggs will have a P stamped on them and a record of the eggs will be kept in the egg box. The FSD said that unpasteurized eggs should be cooked over-hard meaning the yolk is a pale yellow and there is no viscosity. The FSD said that undercooked unpasteurized eggs pose potential for food borne illness and that four residents ask for over-easy eggs every day. During an interview on 1/28/25 at 9:02 A.M., the Corporate FSD said there was no indication that the eggs in the facility were pasteurized. The Corporate FSD said staff should not be keeping personal drinks in the freezer, that all food items should be labeled and dated when opened, and that juices should be discarded seven days after opening. The corporate FSD said that nurses should date juices when opened and that the juices on the unit should have been dated. During a follow-up interview on 1/20/25 at 11:20 A.M. the Corporate FSD said that the Labeling and Dating Inservice is consistent with the facilities standing policy regarding food labeling.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, 1a.) For Resident #76, the facility failed to implement enhanced barrier precautions. 1b.) For Resident #24, the facility failed to implement enhanced barrier precautions. 2.) For Resident #26, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care. 3.) The facility failed to sanitize shared resident equipment between resident uses. Findings include: 1.) Review of facility policy titled 'Enhanced Barrier Precautions', undated, indicated: - The facility will provide care and resources as recommended by current guidelines that are needed to protect residents from infection that may be caused by MDRO's (multi-drug resistant organisms). - Enhanced Barrier Precautions are recommended for residents at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). - Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities. Review of sign titled Enhanced Barrier Precautions, which is posted at the room entrance door for residents on enhanced barrier precautions, indicated, but was not limited to: - Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: dressing, changing linens, providing hygiene, changing briefs or assisting with toileting, device care/use of urinary catheter. 1a.) Resident #76 was admitted to the facility in October 2024 with diagnoses including Parkinson's disease, enlarged prostate, and retention of urine. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated that Resident #76 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #76 had an indwelling catheter. Review of Resident #76's active physician's order, initiated 1/29/25, indicated: - Staff to maintain enhanced barrier precautions related to indwelling catheter, every shift for infection control. Review of Resident #76's plan of care related to enhanced barrier precautions, revised 11/29/24, indicated: - Focus: Staff to maintain enhanced barrier precautions related to indwelling catheter - Intervention: Staff will maintain my enhanced barrier precautions. - Intervention: Use of gown and gloves prior to direct care. On 1/29/25 at 7:48 A.M., the surveyor observed CNA #5 in Resident #76's room. There was a sign posted at his/her doorway titled 'Enhanced Barrier Precautions'. CNA #5 said he was going to wash up Resident #76. The surveyor watched from the door as CNA #5 retrieved a pink basin and towels wearing gloves and no precaution gown. CNA #5 closed the privacy curtain. On 1/29/25 at 7:52 A.M., the surveyor entered Resident #76's room and observed CNA #5 washing the Resident wearing only gloves and no precaution gown. The surveyor also observed CNA #5 remove his/he brief and assisted Resident #76 to roll in bed. During an interview on 1/29/25 at 7:25 A.M., Unit Manager #3 said Resident #76 requires enhanced barrier precautions because he/she has an indwelling urinary catheter. Unit Manager #3 said staff must wear a precaution gown and gloves during high contact resident care activities such as washing up and providing hygiene or incontinence care. Unit Manager #3 then went into the room to observe CNA #5 providing care and tells him he needs to be wearing a precaution gown. Unit Manager came back to the surveyor and said CNA #5 should have been wearing a precaution gown because he was washing up Resident #76 for the morning but was not. During an interview on 1/29/24 at 9:53 A.M., the Director of Nursing (DON) said resident's require enhanced barrier if they have an indwelling urinary catheter. The DON said staff needs to wear a precaution gown, in addition to gloves, while providing hygiene or washing up any resident on enhanced barrier precautions. 1b.) Resident #24 was admitted to the facility in April 2024 with diagnoses including obstructive uropathy and urinary retention. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated that Resident #24 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated Resident #24 had an indwelling catheter. Review of Resident #24's active physician's order, initiated 5/1/24, indicated: - Staff to maintain enhanced barrier precautions related to urinary catheter, every shift for infection control. Review of Resident #24's plan of care related to enhanced barrier precautions, revised 11/29/24, indicated: - Focus: Staff to maintain enhanced barrier precautions related to indwelling catheter - Intervention: Staff will maintain my enhanced barrier precautions. - Intervention: Use of gown and gloves prior to direct care. On 1/28/25 at 9:36 A.M., the surveyor observed a certified nurse assistant (CNA) in Resident #24's room changing bed linens wearing gloves and no precaution gown. There was a sign posted at his/her doorway titled 'Enhanced Barrier Precautions'. During an interview on 1/29/25 at 7:25 A.M., Unit Manager #3 said residents requires enhanced barrier precautions if they have an indwelling urinary catheter. During an interview on 1/30/25 at 9:49 A.M., CNA #7 said staff are required to wear a precaution gown, in addition to gloves, when changing linens and making beds if a resident is on enhanced barrier precautions. During an interview on 1/30/25 at 11:17 A.M., Unit Manager #3 said staff are required to wear a precaution gown, in addition to gloves, when changing linens and making beds if a resident is on enhanced barrier precautions. During an interview on 1/30/25 at 1:50 P.M., the Director of Nursing (DON) said staff are required to wear a precaution gown, in addition to gloves, when changing linens and making beds if a resident is on enhanced barrier precautions. 2.) Review of facility policy titled 'Hand Hygiene', revised December 2024, indicated: - Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to attached hand hygiene table. - Hand Hygiene Table: Condition: Before applying and after removing personal protective equipment (PPE), including gloves. Resident #26 was admitted to the facility in April 2020 with diagnoses including multiple sclerosis and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/27/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #26 had a stage four pressure ulcer. On 1/29/25 at 1:29 P.M., the surveyor observed Nurse #10 and Wound Nurse #1 perform wound dressing change on Resident #26's stage four sacral pressure ulcer. Wound Nurse #1 cleanses the wound bed which contained a large amount of drainage wearing gloves. Wound Nurse #1 then removed soiled gloves and applied a new pair of gloves without sanitizing her hands. Wound Nurse #1 continued to cleanse the wound bed again. During an interview on 1/29/25 at 1:40 P.M., Wound Nurse #1 said she should have sanitized her hands after she removed the soiled gloves and before applying new gloves but did not. 45763 3.) Review of the CDC (Centers for Disease Control and Prevention) Recommendations for Disinfection and Sterilization in Healthcare Facilities indicated the following: - 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices - 4.a. Process noncritical patient-care devices using a disinfectant and the concentration of germicide listed in Table 1. - 4.b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. - 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). On 1/28/25 from 4:22 P.M to 4:46 P.M. the surveyor made the following observations: Nurse #2 entered a resident room with a vitals machine, the nurse then obtained the Resident's vitals using a blood pressure cuff and pulse oximeter. The nurse then left the room without disinfecting the vitals machine and plugged the vitals machine into an outlet in the hallway. Nurse #2 then took the same vitals machine and without disinfecting it brought it into a different resident room. Nurse #2 then, using the same contaminated blood pressure cuff and pulse oximeter, obtained vitals on the other Resident. During an interview on 1/28/25 at 4:54 P.M. Nurse #2 said she should have disinfected the vitals machine between the two residents but did not. During an interview on 1/29/25 at 3:59 P.M., the Director of Nursing (DON) was unaware that shared equipment must be sanitized between use on each resident.

Based on observations, interviews, and record review, the facility failed to provide residents with pressure ulcers necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two Residents (#7 and #26) out of total sample of 21 residents. Specifically: 1.) For Resident #7, the facility failed to implement treatment recommendations by the consultant Wound Physician for a.) a Stage IV pressure wound of the left ischium and b.) an unstageable pressure injury of the lower sacrum. 2.) For Resident #26, the facility failed to implement treatment recommendations by the consultant Wound Physician for a stage IV pressure ulcer of the sacrum. Findings include: Review of the facility policy titled 'Wound Treatment Management', revised January 2025, indicated: - Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 1.) Resident #7 was admitted to the facility in April 2010 with diagnoses including Multiple Sclerosis and dementia. Review of the Minimum Data Set Assessment (MDS) assessment, dated 12/4/24, indicated Resident #7 was severely cognitively impaired as evidenced by a score of eight out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #7 is dependent on staff for all activities of daily living and had two existing pressure areas. During an interview on 1/29/25 at 7:02 A.M., the surveyor observed Resident #7 resting in bed on an air mattress (a device utilized to reduce pressure on the body). Resident #7 said that he/she has wounds and the staff is taking care of them. Review of Resident #7's care plan related to pressure ulcers, initiated 8/3/23 and revised 11/13/24, indicated: - Focus: Resident has Stage 4 pressure ulcer on left ischium and lower sacrum and potential for further pressure ulcer development r/t (related to) immobility. (initiated 8/3/23, revised 11/13/24). - Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing daily. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor). 1a.) Review of the consultant Wound Physician documentation, dated 7/15/24, indicated: - Stage IV pressure wound of the left ischium, full thickness. - Primary Dressings: Mesalt sheet apply once daily. - Secondary Dressing: Superabsorbent gelling fiber with silicone BDR (border dressing) and faced, apply once daily. Review of the July 2024 Treatment Administration Record (TAR), indicated: - Left buttock - cleanse with normal saline, pat dry and apply Santyl and Mupirocin to wound bed f/b (followed by) calcium alginate rope lightly packed into wound bed and covered with DPD (dry protective dressing) every day and evening shift for wound, (active 4/23/24 through 7/22/24). - Santyl External Ointment 250 UNIT/GM (gram): Apply to left buttocks topically every day shift for wound, (active 3/2/24 through 8/20/24). - Mupirocin External Ointment 2%, Apply to left buttock topically every day and evening shift for wound care, (active 3/19/2024 through 10/22/2024). The physician orders failed to include the use of Mesalt, the use of the superabsorbent gelling fiber and included the use of Santyl and Mupirocin, which were not recommended by the wound physician. Review of the Skin/Wound Note, dated 7/15/24, indicated: - Resident seen by wound MD on 7/15/24. New order to pack wound with Mesalt rope in place of calcium alginate rope and d/c (discontinue) ointments. Review of the physician's orders indicated that the Mupirocin Ointment was not ended until 10/22/24 and the Sanyl Ointment was not ended until 8/20/24. Review of the consultant Wound Physician documentation, dated 7/22/24, 7/29/24 and 8/5/24, indicated: - Stage IV pressure wound of the left ischium, full thickness. - Primary Dressings: Plurogel apply once daily; Mesalt sheet apply once daily. - Secondary Dressing: Superabsorbent gelling fiber with silicone BDR and faced apply once daily. Review of the July 2024 and August 2024 TAR indicated: - Left buttock - cleanse with normal saline, pat dry lightly pack Mesalt into wound bed and covered with DPD (dry protective dressing), every day and evening shift for wound care (Active 7//22/224 through 9/11/2024) . - Santyl External Ointment 250 UNIT/GM: Apply to left buttocks topically every day shift for wound -(Active 3/2/24 through 8/20/24). - Mupirocin External Ointment 2%, Apply to left buttock topically every day and evening shift for wound care, (Active 3/19/2024 through 10/22/2024). The orders failed to indicate the use of Pluorgel and the superabsorbent gelling fiber, included the use of Santyl and Mupirocin and indicated treatments to be completed twice daily as opposed to once daily as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 8/12/24, 8/19/24, 8/26/24, 9/2/24 and 9/9/24, indicated: - Stage IV pressure wound of the left ischium, full thickness. - Primary Dressings: Mesalt sheet apply once daily. - Secondary Dressing: Superabsorbent gelling fiber with silicone BDR and faced apply once daily. Review of the August 2024 and September 2024 TAR indicated: - Left buttock - cleanse with normal saline, pat dry lightly pack Mesalt into wound bed and covered with DPD (dry protective dressing), every day and evening shift for wound care, (active 7/22/224 through 9/11/2024). - Santyl External Ointment 250 UNIT/GM: Apply to left buttocks topically every day shift for wound, (active 3/2/24 through 8/20/24). - Mupirocin External Ointment 2%, Apply to left buttock topically every day and evening shift for wound care, (active 3/19/2024 through 10/22/2024). The orders failed to indicate the use of the superabsorbent gelling fiber, included the use of Santyl ointment (through 8/20/24) and mupirocin and indicated treatments to be completed twice daily instead of once daily as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 9/16/24, 9/27/24, 9/30/24, 10/7/24 and 10/14/24, indicated: - Stage IV pressure wound of the left ischium, full thickness. - Primary Dressings: Mesalt sheet apply once daily. - Secondary Dressing: Superabsorbent gelling fiber with silicone BDR and faced apply once daily. Review of the September 2024 and October 2024 TAR indicated: - Left ischium - cleanse with normal saline, pat dry lightly pack Mesalt into wound bed and cover with DPD, skin prep peri wound every day shift for wound care, (active 9/18/2024 through 10/22/2024). - Mupirocin External Ointment 2%, Apply to left buttock topically every day and evening shift for wound care, (active 3/19/2024 through 10/22/2024). The orders failed to include the use of Superabsorbent gelling fiber and included the use of Mupirocin which was not indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 10/21/24 and 10/28/24, indicated: - Stage IV pressure wound of the left ischium, full thickness. - Primary Dressings: Mesalt sheet apply once daily. - Secondary Dressing: Superabsorbent gelling fiber with silicone BDR and faced apply once daily. Review of the October 2024 TAR indicated: - Left ischium - Cleanse with NS, pat dry, lightly pack with Mesalt f/b DPD (followed by dry protective dressing), every day shift for wound care, (Active10/23/24 through 11/11/2024). The orders failed to include the use of the super absorbent gelling fiber as indicated by the wound physician. 1b.) Review of the consultant Wound Physician documentation, dated 7/22/24, 7/29/24 and 8/5/24, indicated: - Unstageable DTI (deep tissue injury) of the lower sacrum. - Primary Dressings: Xeroform gauze apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the July 2024 and August 2024 TAR indicated: - Lower Sacrum - Cleanse with NS (normal saline) and pat dry, apply Xeroform gauze and cover with DPD twice daily every day and evening shift for wound care, (active 7/24/24 through 8/20/24). The orders failed to indicate the use of Superabsorbent gelling fiber with silicone as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 8/12/24, indicated: - Unstageable DTI of the lower sacrum. - Primary Dressings: Xeroform gauze apply twice daily. Mupirocin 2% topical apply once daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the August 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Xeroform gauze and cover with DPD twice daily, every day and evening shift for wound care, (active 7/24/24 through 8/20/24). The orders failed to indicate the use of Mupirocin and Superabsorbent gelling fiber per the Wound Physician. Review of the consultant Wound Physician documentation, dated 8/19/24, indicated: - Unstageable (due to necrosis) of the lower sacrum. - Primary Dressings: Mupirocin topical 2% apply twice daily, Alginate calcium apply twice daily, Santyl apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the August 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Mupirocin and Santyl f/b Calcium Alginate and cover with DPD twice daily. every day and evening shift for wound care, (active 8/20/24 through 9/11/24). The orders failed to indicate the use of Superabsorbent gelling fiber per the Wound Physician. Review of the consultant Wound Physician documentation, dated 8/26/24, 9/2/24 and 9/9/24, indicated: - Unstageable (due to necrosis)of the lower sacrum. - Primary Dressings: Mupirocin topical 2% apply twice daily, Alginate calcium apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the August and September 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Mupirocin and Santyl f/b (followed by) Calcium Alginate and cover with DPD twice daily, every day and evening shift for wound care, (active 8/20/2024 through 9/11/2024). The orders failed to indicate the use of the Superabsorbent gelling fiber and indicated the use of Santyl which was not indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 9/16/24 and 9/27/24, indicated: - Unstageable (due to necrosis) of the lower sacrum. - Primary Dressings: Mupirocin topical 2% apply twice daily, Alginate calcium apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the September 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Mupirocin, f/b Calcium Alginate and cover with superabsorbent gelling fiber border dressing, skin prep peri wound. every day shift for wound care, (active 9/12/2024 through 10/15/2024). The orders indicated that treatments were completed once daily instead of twice daily as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 9/30/24, 10/7/24, and 10/14/24, indicated: - Unstageable (due to necrosis) of the lower sacrum. - Primary Dressings: Mupirocin topical 2% apply twice daily, Alginate calcium apply twice daily, Santyl apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the September and October 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Mupirocin, f/b Calcium Alginate and cover with superabsorbent gelling fiber border dressing, skin prep peri wound. every day shift for wound care, (active 9/12/24 through 10/15/24). The orders indicated that treatments were only completed once daily and failed to include the use of Santyl as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 10/21/24, 10/28/24, 11/4/24 and 11/11/24, 11/18/24, 11/25/24, and 12/2/24, indicated: - Stage IV of the lower sacrum. - Primary Dressings: Mupirocin topical 2% apply twice daily, Alginate calcium apply twice daily, Santyl apply twice daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the October and November 2024 TAR indicated: - Lower Sacrum - Cleanse with NS and pat dry, apply Mupirocin and Santyl, f/b calcium alginate and cover with Superabsorbent gelling fiber border dressing, skin prep to peri wound every day shift for wound care, (active 10/16/24 through 10/22/24). - Lower Sacrum -Cleanse with NS, pat dry, apply Mupirocin and Santyl to wound bed f/b calcium alginate, cover with DPD, every day shift for wound care, (active 10/23/2024 through 12/10/2024). The orders indicated that treatments were only completed once daily and failed to include the use of the Superabsorbent gelling fiber as of 10/23/24, as indicated by the Wound Physician. Review of the consultant Wound Physician documentation, dated 12/9/24, 12/16/24, 12/23/24, 12/30/24, 1/13/2,5 indicated: - Stage IV of the lower sacrum. - Primary Dressings: Alginate calcium with silver, apply once daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the December 2024 and January 2025 TAR indicated: - Lower sacrum - Cleanse with NS, pat dry f/b calcium alginate with silver to wound bed, cover with DPD every day and evening shift for wound care, (active 12/11/24 through 1/9/25). - Lower sacrum - Cleanse with NS, pat dry f/b calcium alginate with silver to wound bed, cover with DPD every day shift for wound care, (active 1/10/25 through 1/22/25). The orders failed to indicate the use of the Superabsorbent gelling fiber and failed to clarify the Wound Physicians recommendation to change the dressing daily instead of twice daily. Review of the consultant Wound Physician documentation, dated 1/20/25 and 1/27/25, indicated: - Stage IV of the lower sacrum. - Primary Dressings: Collagen powder apply once daily. - Secondary dressing: Superabsorbent gelling fiber with silicone bdr and faced apply twice daily. Review of the January 2025 TAR indicated: - Lower sacrum - Cleanse with NS, pat dry f/b collagen powder to wound bed, cover with DPD every day shift for wound care, (active 1/23/25). The orders failed to indicate the use of the super absorbent gelling fiber and failed to clarify the Wound Physicians recommendation to change the dressing daily, or twice daily. During an interview on 1/30/25 at 11:10 A.M., the Wound Physician said he comes into the building weekly and rounds with staff who then input his recommendations into the electronic health record as orders. The Wound Physician said that there is a difference in absorption between a standard dry protective dressing and the super absorbent gelling fiber. The Wound Physician said he was never notified that his treatment orders were not being implemented and he would expect staff to notify him if they were not implementing his treatment recommendations. During an inteview on 1/30/25 at 11:25 A.M., Wound Nurse #1 said that she or another staff rounds with the Wound Physician and inputs his reccomendations into the electronic health records as orders. 48990 2.) Resident #26 was admitted to the facility in April 2020 with diagnoses including multiple sclerosis and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/27/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS also indicated Resident #26 had a stage four pressure ulcer. Review of consultant Wound Physician documentation, dated 11/11/24, 11/25/24, 12/2/24, 12/9/24, 12/16/24, 12/23/24, 12/30/24, 1/6/25, 1/13/25, 1/20/25, and 1/27/25, indicated: - DRESSING TREATMENT PLAN - Primary Dressing(s): Mupirocin topical 2% apply twice daily; Alginate calcium apply twice daily: Packing.; Santyl apply twice daily. - Secondary Dressing(s): Superabsorbent gelling fiber w/ silicone bdr (border) & faced apply twice daily and as needed soilage. - Peri Wound Treatment: Skin prep apply twice daily. Review of Resident #26's active physician's orders indicated: - WOUND CARE: Lower sacrum - Cleanse with NS, pat dry, apply Mupirocin and Santyl ointment f/b loosely packing calcium alginate to fit area of wound, cover with DPD, every day and evening shift for wound care AND as needed for loss of dressing integrity, initiated 1/9/25 - May have wound consult/treat PRN, initiated 4/26/22. Review of physician progress notes, dated 11/27/24 and 1/14/25, indicated: - Pressure injury of sacral region, stage 4. - Wound care to continue. Follow up with wound management. Review of Resident #26's physician's orders, dated 11/11/24 to 1/27/25, failed to indicate application of skin prep to the peri-wound of the sacral stage four pressure ulcer. Further review indicated this order included DPD (dry protective dressing), instead of a superabsorbent gelling fiber with silicone border. Review of Resident #26's skin/wound progress notes, dated 12/3/24, 12/10/24, 12/17/24, 12/23/24, 12/30/24, 1/6/25, 1/13/25, 1/27/25, indicated Resident #26's sacral wound was assessed by the wound physician and there were no new orders are recommended. This progress note instructed the reader to refer to wound consultant wound care documentation for full report. On 1/29/25 at 1:19 P.M., the surveyor observed Nurse #10 gather supplies for Resident #26's stage four sacral pressure ulcer wound dressing change. Nurse #10 initially gathered a comfort foam dry protective dressing. Wound Nurse #1 came to double check the dressing supplies and changed the comfort foam dry protective dressing for a superabsorbent gelling fiber with silicone border dressing. Wound Nurse #1 said either dressing could be applied because the physician order was for a dry protective dressing. Wound Nurse #1 said the only reason she was changing the dressing was because it was a different type of dry protective dressing that was covered by the Resident's insurance. On 1/29/25 at 1:29 P.M., the surveyor observed Nurse #10 and Wound Nurse #1 perform wound dressing change on Resident #26's stage four sacral pressure ulcer. Wound Nurse #1 cleansed the sacral pressure ulcer with normal saline, applied mupirocin and santyl ointment, loosely packed the wound with calcium alginate, and covered with a superabsorbent gelling fiber with silicone border dressing. Wound Nurse #1 did not apply skin prep to the peri-wound. During an interview on 1/29/25 at 1:40 P.M., Wound Nurse #1 said she is responsible for transcribing the physician's orders into the electronic medical record. Wound Nurse #1 said she usually transcribes and implements every wound consultant treatment recommendation unless there are concerns. Wound Nurse #1 said every wound consultant treatment recommendation should be addressed by the facility, and if it is not implemented it should be documented. Wound Nurse #1 said put in an order for a dry protective dressing, instead of a superabsorbent gelling fiber with silicone border dressing, because she wanted to make sure if the facility ran out of superabsorbent gelling fiber with silicone border dressings they could put on a different type of dressing. Wound Nurse #1 said she never clarified if they could substitute any dry protective dressing with wound physician or another physician but probably should have. Wound Nurse #1 said she was unaware the wound physician had recommended skin prep twice a day to the peri-wound. Wound Nurse #1 said she didn't know how she missed it because it was clearly in every recent wound consultant treatment plan recommendation. Wound Nurse #1 said this treatment recommendation was never addressed and should have been implemented but was not. During a telephone interview on 1/30/25 at 11:10 A.M., the Wound Physician said he comes in once a week and rounds with Wound Nurse #1. The Wound Physician said he expects Wound Nurse #1 to implement his orders, and if it is not implemented, he would expect to be notified. The Wound Physician said he was never notified the staff are not following/implementing his recommended orders. The Wound Physician said there is a difference between a superabsorbent gelling fiber with silicone border dressing and a dry protective dressing because the superabsorbent gelling fiber with silicone border dressing promotes absorption. The Wound Physician said he would have expected to be notified if the facility was using a dry protective dressing instead of a superabsorbent gelling fiber with silicone border dressing but never had been. During an interview on 1/29/25 at 2:55 P.M., the Director of Nursing (DON) said every wound consultant treatment recommendation should be addressed by the facility, and if it is not implemented it should be documented. The DON said the superabsorbent gelling fiber with silicone border dressing and skin prep should have been implemented as recommended by the Wound Physician. The DON said if there were any concerns with the superabsorbent gelling fiber with silicone border dressing or the skin prep, it should have been addressed and documented in the record.

Based on observation, record review and interview, the facility failed ensure services provided met professional standards of quality for one Resident (#7) out of a total of 21 sampled residents. Specifically, the facility failed to implement wound treatments initiated by the consultant Wound Physician. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility policy titled 'Wound Treatment Management', revised January 2025, indicated: - Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Resident #7 was admitted to the facility in April 2010 with diagnoses including Multiple Sclerosis and dementia. Review of the Minimum Data Set Assessment (MDS) assessment, dated 12/4/24, indicated Resident #7 was severely cognitively impaired evidenced by a score of 8 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #7 was dependent on staff for all activities of daily living and had two existing pressure areas. During an interview on 1/29/25 at 7:02 A.M., the surveyor observed Resident #7 resting in bed on an air mattress (a device utilized to reduce pressure on the body). Resident #7 said that he/she had wounds and the staff was taking care of them. Review of Resident #7's care plan related to skin integrity, initiated 1/6/25, indicated: - Focus: Resident has actual impairment to skin integrity r/t (related to) trauma of the L (left) upper shin. - Intervention: Administer treatments as ordered and monitor for effectiveness. Review of the consultant Wound Physician documentation, dated, 9/30/24, 10/7/24, 10/14/24, and 10/21/24 indicated: - Non-Pressure Wound of the left upper shin Full Thickness. - Primary Dressings: Xeroform gauze apply once daily for. - Secondary Dressing: Gauze island with bdr (border) apply once daily. Review of the September and October 2024 treatment administration records indicated: - Left upper shin - Cleanse with NS (normal saline), pat dry, apply xeroform to wound bed f/b (followed by) DPD (dry protective dressing) every day shift for wound care, (active 10/23/2024 through 1/9/2025). The orders indicated no treatments were implemented for Resident #7's shin until 10/23/24; 22 days after he/she was first seen by the Wound Physician. During an interview on 1/30/25 at 11:10 A.M., the Wound Physician said that he rounds once a week at the facility with staff who then input his treatment reccomendations as orders into the electronic health record. The Wound Physician said that he would expect to be notified if the facility was not implementing his orders. During an inteview on 1/30/25 at 11:25 A.M., Wound Nurse #1 said that she or another staff would round with the Wound Physician and then input his treatments as orders into the clinical record.

Based on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#26) out of a total sample of 21 residents. Specifically, the facility failed to revise the comprehensive care plan relating to tube feeding and risk for choking upon the care plan review following the completion of two quarterly assessments. Findings include: Review of the facility policy titled 'Comprehensive Person-Centered Care Plan, dated May 2023, indicated, but was not limited to: - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The IDT includes: b. a licensed nurse who has responsibility for the resident; c. a nurse aide who has responsibility for the resident d. a member of the food and nutrition services staff; f. other appropriate staff or professionals determined by the resident's needs or as requested by the resident. - The comprehensive, person-centered care plan will: h. incorporates identified problem areas; i. incorporate risk factors associated with identified problems; k. reflects the resident's expressed wishes regarding care and treatment goals. - Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of the interdisciplinary process. - Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. - The Interdisciplinary Team must review and update the care plan: b. when the desired outcome is not met; d. at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 12/27/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS further indicated Resident #26 required set up assistance with eating and indicated he/she did not receive tube feeding. Review of the quarterly Minimum Data Set (MDS) assessment, dated 9/25/24, indicated Resident #26 required set up assistance with eating and indicated he/she did not receive tube feeding. Review of Care Plan Review History in electronic record indicated Resident #26's comprehensive care plan was reviewed with the IDT on 10/11/24 and 12/30/24. Review of Resident #26's physician's order, initiated 12/17/24, indicated: - House diet, Dysphagia Advanced/Ground texture, Thin consistency, for finger foods. Review of Resident #26's physician's orders, dated 9/15/24 to 1/31/25, failed to indicate any tube feeding orders. Review of Resident #26's plan of care related to altered nutrition and risk for choking, revised 12/30/24, indicated: - Resident Will Be Free of Choking Episodes While Eating. Resident #26 will follow this POC (plan of care) and remain safe while eating. - Intervention: Keep head of bed elevated 45 degrees during meal and thirty minutes after eating. - Intervention: Elevate the Resident HOB (head of bed) 45 degrees during and thirty minutes after tube feeding. - Intervention: Encourage him/her to follow POC with regards to elevating the HOB with all PO (by mouth) intake. On 1/28/25 at 8:42 A.M., the surveyor observed Resident #26 lying completely flat in bed with a plate of food resting on his/her chest. The plate contained toast, scrambled eggs, and a biscuit. Resident #26 was coughing causing bits of scrambled eggs to propel into the air. On 1/29/25 at 8:32 A.M., the surveyor observed Resident #26 lying completely flat in bed with a plate of food resting on his/her chest. The plate contained bread, ground ham, and scrambled eggs. On 1/29/25 at 12:23 A.M., the surveyor observed Medical Records Staff #1 set up Resident #26's lunch tray in his/her room. The surveyor entered the room immediately after the staff member left the room. Resident #26 was lying completely flat with a plate of food resting on his/her chest. The plate contained a sandwich containing ground turkey and gravy, spiral noodles, and cook carrots. Resident #26 said he/she does not like the meal and would like to speak with the Dietitian because he/she would like a diet upgrade from dysphagia advanced to regular texture. Resident #26 said he/she never elevates the head of bed because the pain in his/her bottom from a pressure would increases. Resident #26 said he/she does not want any changes in his/her pain medication, and just wants to lay flat. During a follow up interview on 1/30/25 at 7:49 A.M., Medical Records Staff #1 said she dropped off Resident #26's tray and she didn't let anyone know the Resident was laying flat while eating because it's her norm. Medical Records Staff #1 said she offered to elevate the head of bed, but Resident #26 declined. During an interview on 1/30/25 at 7:33 A.M., Certified Nurse Assistant (CNA) #7 said Resident #26 is physically unable to bend his/her body to elevate the head of bed. CNA #7 said the nurses, therapy, and everybody knows. CNA #7 said because of this they go in frequently to check on him/her to make sure he/she isn't choking. CNA #7 says Resident #26 eats only by mouth. During an interview on 1/20/25 at 7:40 A.M., Unit Manager #3 said Resident #26 has not received tube feeding since she started working at the facility in September and eats by mouth. Unit Manager #3 said Resident #26 always eats lying completely flat in bed because of the pain from arthritis in his/her back when the head of bed is elevated and is working with therapy for this. The surveyor and Unit Manager #3 reviewed Resident #26's care plan for the above interventions of keeping the head of bed elevated during meals and tube feeding. Unit Manager #3 said the care plan should have been revised because the interventions were not applicable but was not. Unit Manager #3 said nursing, along with the IDT, is responsible to revise care plans at least quarterly during the care plan meetings. During an interview on 1/30/25 at 8:37 A.M., the Dietitian said Resident #26 is on a dysphagia advanced diet because he/ is at risk for choking/aspiration because he/she always lays completely flat in bed during meals. The Dietitian said she does not remember when or if Resident #26 ever received tube feeding and only eats by mouth. The surveyor and the Dietitian reviewed Resident #26's care plan for the above interventions of keeping the head of bed elevated during meals and tube feeding. The Dietitian said the entire IDT is responsible to revise care plans at least quarterly during the care plan meetings. The Dietitian said the last care plan meeting was 12/30/24 and she would have expected those interventions to be revised because they are not appropriate for the Resident. During an interview on 1/30/25 at 8:52 A.M., Occupational Therapist (OT) #1 said she was the OT who worked with Resident #26. OT #1 said Resident #26 has been unable to tolerate the head of bed being elevated over 20 degrees for about six months. OT #1 said she does not remember when or if Resident #26 ever received tube feeding and only eats by mouth. OT #1 said a specific goal was to increase flexion so Resident #26 could tolerate the head of bed being elevated to a safe level for his/her diet to be able to be upgraded safely. OT #1 said Resident #26 does not like the current dysphagia advanced diet. The surveyor and OT #1 reviewed Resident #26's care plan for the above interventions of keeping the head of bed elevated during meals and tube feeding. OT #1 said therapy is not involved in the care plan meetings/process, but had communicated the inability to tolerate the head of bed being elevated the nursing and even provided care giver education on how to successfully elevate the head of bed to 20 degrees. OT #1 said she would have expected nursing to revise those interventions because they have not been appropriate interventions for at least six months. During an interview on 1/30/25 at 11:36 A.M., the MDS Coordinator said she does not attend care plan meetings and that nursing, activities, and social services are responsible for revising care plans during the quarterly care plan meetings. During an interview on 1/30/25 at 1:16 P.M., Speech Therapist (ST) #1 said she was the ST who worked with Resident #26. ST #1 said Resident #26's diet cannot be advanced as requested because the Resident is unable to tolerate the head of bed being elevated more than 20 degrees. ST #1 said she does not remember when or if Resident #26 ever received tube feeding and only eats by mouth. The surveyor and ST #1 reviewed Resident #26's care plan for the above interventions of keeping the head of bed elevated during meals and tube feeding. ST #1 said she would have expected nursing to revise those interventions because they have not been appropriate interventions for at least six months. During an interview on 1/30/25 at 1:53 P.M., the Director of Nursing (DON) said care plans should be reviewed at least quarterly following the MDS schedule. The DON said Resident #26 had been known to lay completely flat during meals since at least the end of May 2024. The DON said she would expect Resident #26's care plan to include her noncompliance and should have been revised.

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for one dependent Resident (#55) out of a total sample of 21 residents. Specifically, for Resident #55, the facility failed to: 1a.) Provide set-up assistance and supervision with meals. 1b.) Provide assistance with nail care. Findings Include: Review of the facility policy titled 'Activities of Daily Living (ADLs)', undated, indicated, but was not limited to, the following: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. - A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (minimum data set). Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions: a. Independent - Resident completed activity with no help or staff oversight at any time during the last 7 days. b. Supervision - Oversight, encouragement or cueing provided 3 or more times during the last 7 days. c. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. d. Extensive Assistance - While resident performed part of activity over the last 7 days, staff provided weight-bearing support. e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. Resident #55 was admitted to the facility in January 2025 with diagnoses of dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/25, indicated that Resident #55 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated the Resident required supervision or touching assistance for eating and substantial/maximal assistance with personal hygiene. 1a.) Review of Resident #55's ADL care plan indicated that the Resident required substantial assistance with ADL care related to diagnoses of Parkinson's and dementia, with the following intervention: - Eating: set up with supervision, initiated 1/17/25. Review of Resident #55's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 1/11/25, indicated that the Resident presented with impairments in balance, fine motor coordination, mobility, strength, attention, problem solving, interpersonal habits and interpersonal routines/behavior resulting in limitations and/or participation restrictions in the areas of self-care and that Resident #55 required supervision or touching assistance with eating. On 1/28/25 at 9:31 A.M., the surveyor observed Resident #55 eating in his/her room, there were no staff in the room or within eyesight of the Resident and the Resident was attempting to open his/her milk but was unable to. On 1/28/25 at 12:42 P.M., the surveyor observed Resident #55 eating in his/her room, there were no staff in the room or within eyesight of the Resident and the Resident's milk was not opened. On 1/29/25 at 8:42 A.M., the surveyor observed Resident #55 eating in his/her room, there were no staff in the room or within eyesight of the Resident. The surveyor observed Resident #55 drop a full glass of milk onto his tray spilling it on his/her meal and clothes. On 1/30/25 at 8:31 A.M., the surveyor observed Resident #55 eating in his/her room, there were no staff in the room or within eyesight of the Resident. On 1/30/25 at 8:57 A.M., the surveyor observed Resident #55 eating in his/her room, there were no staff in the room or within eyesight of the Resident. During an interview on 1/30/25 at 9:00 A.M., Certified Nurse Assistant (CNA) #2 said CNAs know the level of assistance residents need from the handover verbally given to them by previous staff. CNA #2 said Resident #55 needs help with everything. During an interview on 1/30/25 at 8:47 A.M., the Director of Rehab (DOR) said Resident #55 was supposed to be supervised with eating and that she would expect a staff member to be in the Resident's room throughout the entire meal to provide cueing. The DOR said that the Resident's need for supervision was communicated with nursing. During interviews on 1/30/25 at 9:06 A.M. and 10:10 A.M., Unit Manager #1 said the level of assistance residents need was outlined in their Kardex and given verbally in report. Unit Manager #1 was unaware that Resident #55 required supervision with eating. Review of Resident #55's Kardex failed to indicate what level of assistance the Resident required with eating. During an interview on 1/30/25 at 10:29 A.M., the Director of Nursing (DON) said she would expect residents to receive the level of assistance as determined by the rehabilitation department. 1b.) Review of Resident #55's ADL care plan indicated that the Resident required substantial assistance with ADL care related to diagnoses of Parkinson's and dementia, with the following intervention initiated on 1/17/25: - Hygiene - Oral: moderate assist Personal: Substantial assist Toilet: dependent Review of Resident #55's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 1/11/25, indicated that the Resident presented with impairments in balance, fine motor coordination, mobility, strength, attention, problem solving, interpersonal habits and interpersonal routines/behavior resulting in limitations and/or participation restrictions in the areas of self-care and that Resident #55 required substantial/maximal assistance with personal hygiene. On 1/28/25 at 9:31 A.M., the surveyor observed that Resident #55's fingernails were elongated and protruding, the surveyor approximated that the nails were between an eighth and a quarter of an inch beyond the Resident's nail bed. On 1/29/25 at 12:33 P.M., the surveyor observed that Resident #55's fingernails were elongated and protruding, the surveyor approximated that the nails were between an eighth and a quarter of an inch beyond the Resident's nail bed. During an interview and observation on 1/29/25 at 1:01 P.M., CNA #1 said CNAs check residents' nails every day during care and that Resident #55 typically allows staff to assist with grooming. CNA #1 observed Resident #55's nails and offered to cut them; the Resident accepted the CNA's offer. On 1/29/25 at 1:03 P.M., the surveyor observed Nurse #1 tell Resident #55 that his/her nails were a little long. During an interview on 1/29/25 at 1:05 P.M., Nurse #1 said that Resident #55 can't trim his/her own nails and needs help from staff to do so. During an interview on 1/29/25 at 4:03 P.M., the Director of Nursing (DON) said staff should be offering assistance with nail care, and that staff should notice what the resident's needs were every time staff provided care. The DON said that if residents refuse care that this should be documented. Review of Resident #55's electronic medical record failed to indicate that the Resident had refused nail care.

Based on observations, interviews and record review, the facility failed to maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#76) out of a total sample of 21 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag and tubing was not placed directly on the floor. Findings include: Review of facility policy titled 'Catheter Care, Urinary', undated, indicated: - Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. Resident #76 was admitted to the facility in October 2024 with diagnoses including Parkinson's disease, enlarged prostate, and retention of urine. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated that Resident #76 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #76 had an indwelling catheter and was required partial/moderate assistance for bed mobility, toileting, and transfer tasks. Review of Resident #76's physician's order, initiated 12/18/24, indicated: - Catheter size: 16 Fr 10ml balloon Specify Catheter type: indwelling, as needed for catheter, initiated 12/18/24. - Catheter Care every shift, every shift for catheter, initiated 12/18/24. Review of Resident #76's plan of care related to his/her indwelling catheter, revised 10/25/24, failed to indicate it should not directly touch the floor. This plan of care indicated: - Goal: Resident #76 will show no s/sx of urinary infection through the review date. - Intervention: Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident #76's medical record, including progress notes and care plans, failed to indicate Resident #76 manages, touches, or moves catheter drainage bag since admission to the facility in October 2024. On 1/28/25 at 8:51 A.M., the surveyor observed Resident #76 in bed eating breakfast on his/her rolling bedside table. The rolling bedside table wheels were directly on top of the urinary drainage bag which was laying on the floor. The urinary drainage bag and tubing was not attached to the bedframe and was laying directly on the floor below the rolling bedside table. This urinary catheter bag was being compressed on the floor by the rolling bedside table wheels and the tubing was also directly on the floor. The urinary drainage bag was half full of clear, yellow urine. Resident #76 said the urinary drainage bag and tubing was often on the floor. Resident #76 said his/her urinary drainage bag is often broken and leaks sometimes. Resident #76 said he never touches his/her urinary catheter drainage bag or tubing and is dependent on staff for this because he physically cannot reach it. On 1/28/25 at 12:43 P.M., the surveyor observed Resident #76 in his/her wheelchair. There was a urinary catheter drainage bag was hanging underneath his/her wheelchair and approximately one inch of the urinary drainage bag was directly touching the floor. On 1/28/25 at 2:21 P.M., the surveyor observed Resident #76 in his/her wheelchair. There was a urinary catheter drainage bag was hanging underneath his/her wheelchair and approximately one inch of the urinary drainage bag was directly touching the floor. On 1/29/25 at 7:45 A.M., the surveyor observed Resident #76 in bed with his/her urinary catheter drainage bag and tubing not attached to the bed frame and laying directly on the floor. It was half full of clear, yellow urine. During an interview on 1/29/25 at 7:48 A.M., the surveyor and CNA #5 observed Resident #76's urinary catheter drainage bag and tubing laying directly on the floor. CNA #5 said the urinary drainage bag and tubing should never lay on the floor or directly touch the floor because of infection control concerns. During an interview on 1/29/25 at 7:57 A.M., Unit Manager #3 said urinary catheter drainage bags and tubing should never be directly touching the floor. Unit Manager #3 said Resident #76 does not manage his own catheter and is not known to touch or move it. Unit Manager #3 said Resident #76's urinary catheter drainage bag must be replaced because it was contaminated by laying directly on the floor. During an interview on 1/29/24 at 9:53 A.M., the Director of Nursing (DON) said urinary catheter drainage bags and tubing should never be directly touching the floor.

Based on observation, record review and interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for one Resident (#55) out of a total sample of 21 residents. Specifically, the facility failed to assess Resident #55 for risk of entrapment from bed rails prior to installation. Findings include: Review of the facility policy titled 'Bed Safety', undated, indicated, but was not limited to, the following: - Our facility shall strive to provide a safe sleeping environment for the resident. 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Food and Drug Administration) (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position Resident #55 was admitted to the facility in January 2025 with diagnoses of dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/25, indicated that Resident #55 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. On 1/28/25 at 4:16 P.M., Resident #55 was observed in bed, the Resident's bed was equipped with side rails on both sides. Review of Resident #55's electronic medical record indicated a photograph of Resident #55 in bed, the Resident's head was near his/her bed's side rail. On 1/30/25 at 8:31 A.M., Resident #55 was observed sitting on the side of his/her bed, the Resident's bed was equipped with side rails on both sides. During an interview on 1/29/25 at 3:02 P.M., Nurse #1 said side rails assessments should be completed on admission. During an interview on 1/29/25 at 3:07 P.M., Unit Manager #1 said he would expect a side rail assessment to be completed as soon as side rails were implemented. During a follow-up interview on 1/29/25 at 3:22 P.M., Unit Manager #1 said that an initial side rail assessment for Resident #55 was completed today, after the surveyor brought the concern to his attention and 20 days after admission; Unit Manager #1 said that he would have expected the side rail assessment to have been completed sooner. During an interview on 1/29/25 at 4:01 P.M., the Director of Nursing (DON) said side rails should not be used until a side rail assessment has been completed. During an interview on 1/30/25 at 9:49 A.M., the Director of Maintenance said nursing completes the initial side rail assessment and that the maintenance department assesses all beds for risk of entrapment annually and when there is a new admission. The Director of Maintenance said the maintenance department assessed Resident #55's bed for risk of entrapment prior to Resident #55's admission, but that he could not find evidence that it was inspected after Resident #55's admission so one was completed today, after the surveyor brought the concern to the attention of the facility.

Based on record review, policy review, and interview, the facility failed to ensure residents were free of unnecessary medications and were properly assessed for possible adverse reactions to psychotropic medications for two residents (#47 and #22) out of a total of 21 sampled residents. Specifically: 1.) For Resident #47, the facility failed to ensure the use of as needed (PRN) psychotropic medications were limited to 14 days for one Resident (#47). 2). For Resident #22, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility policy titled 'Use of Psychotropic Medication', dated December 2024, indicated: - Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). - PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and for a limited duration, (i.e. 14 days). - Residents who receive an antipsychotic medication have an AIMS test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. 1.) Resident #47 was admitted to the facility in June 2022 with diagnoses including unspecified dementia with agitation and anxiety disorder. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #47 is severely cognitively impaired and requires assistance with bathing, dressing and toileting. The MDS also indicated Resident #47 received psychotropic medications. On 1/28/25 at 7:53. A.M., the surveyor observed Resident #47 in bed continuously calling out Help me! Help me! I'm dead! Review of the physician's orders indicated: - Lorazepam (an anti-anxiety medication) Intensol Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 4 hours as needed for anxiety, initiated 12/30/24, without a stop date. Review of the January 2025 Medication Administration Record (MAR) indicated doses of lorazepam were administered to Resident #47 on 1/15/25 at 10:01 A.M., 1/21/25 at 8:00 A.M., 1/22/25 at 6:31 A.M. and 5:58 P.M., 1/28/25 at 8:00 A.M., and 1/29/24 at 7:39 A.M. During an interview on 1/30/25 at 8:33 A.M., Unit Manager #2 said that as needed psychotropic medications should have a 14 day stop day. Unit Manager #2 and the surveyor then reviewed Resident #47's physicians orders. Unit Manager #2 said that she was going to speak with the physician about scheduling Resident #47's lorazepam. 2.) Resident #22 was admitted to the facility in March 2024 with diagnoses that included heart failure, Alzheimer's Disease, and chronic kidney disease. Review of Resident #22's most recent Minimum Data Set (MDS) assessment, dated 12/24/24, indicated that Resident #22 had a Brief Interview for Mental Status score of two out of 15, indicating that Resident #22 had severe cognitive impairment. The MDS Assessment further indicated that Resident #22 received an antipsychotic medication. Review of Resident #22's active physician's orders indicated: - Seroquel (an antipsychotic medication) extended release 150 milligrams every 24 hours, initiated 3/9/24. - Seroquel 25 milligrams a day, initiated 4/11/24. - Seroquel 25 milligrams in the afternoon, initiated 10/11/24. Review of Resident #22's assessments indicated that the most recent AIMS assessment was completed on 1/23/24. Review of Resident #22's psychotropic medication care plan, dated as revised 9/11/23, indicated that [Resident #22] takes Seroquel for psychotic condition with delusions. On 1/29/25 at 2:16 P.M., the surveyor and Unit Manager #2 reviewed Resident #22's medical record and Unit Manager #2 said the most recent AIMS assessment was completed on 1/23/24. During an interview on 1/30/25 at 11:30 A.M., the Director of Nursing (DON) said that she would expect that an AIMS assessment is completed every 6 months for a resident who is receiving antipsychotic medications.

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in one out of three medication carts observed. Findings include: Review of the facility policy titled 'Storage of Medications', revised October 2024, indicated: - The facility shall store all drugs and biological in a safe, secure, and orderly manner. - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 1/30/25 at 6:50 A.M., the surveyor and Nurse #3 observed the following in the Court unit medication cart: - One vial of heparin sodium (porcine) injection solution 5000 UNIT/ML (milliliter), open and undated. - Two vials of insulin glargine subcutaneous solution 100 UNIT/ML, open and undated. During an interview on 1/30/25 at 7:05 A.M., Nurse #3 said the insulin and heparin should have been dated when opened because they have a shortened expiry date once opened. During an interview on 1/30/25 at 11:28 A.M., the Director of Nursing (DON) said heparin an insulin vials should be dated when opened because they have a shortened expiry date once opened.

Based on observations, interviews, and record review, the facility failed to maintain accurate medical records for two Residents (#26 and #22), out of a total sample of 21 residents. Specifically: 1.) For Resident #26, the physician and nurse practitioner inaccurately documented the Resident's code status as do not resuscitate (DNR) when the Resident's code status indicated to attempt resuscitation (full code). 2.) For Resident #22, the facility inaccurately documented the Resident's physician's order as a full code (attempt resuscitation) when the Resident's Medical Orders about Life-sustaining Treatment (MOLST) indicated the Resident was DNR, do not intubate (DNI). Findings include: Review of the most recent Minimum Data Set (MDS) assessment, dated 12/27/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS further indicated: - Advanced Directions: Do Not Resuscitate: not checked (no). 1.) Review of Resident #26's Medical Orders about Life-Sustaining Treatment (MOLST), dated 5/20/23, indicated: - Cardiopulmonary Resuscitation: Attempt Resuscitation. Review of Resident #26's physician order, initiated 12/8/24, indicated: - Code Status: FULL CODE HCP (healthcare proxy) invoked. Review of Resident #26's resident information banner in electronic medical record, on 1/29/25 at 11:46 A.M., indicated: - Code Status: FULL CODE HCP invoked. Review of Resident #36's plan of care related to advanced directives, revised 9/26/24, indicated: - MOLST form was completed and reflects full code. - MOLST/Advanced Directives will be discussed with HCP as needed to ensure decisions are accurately documented. Review of nurse practitioner progress notes, dated 6/4/24, 6/20/24, 6/27/24, 7/25/24, 8/1/24, 8/6/24, 9/5/24, 10/29/24, 11/7/24, 11/14/24, 11/21/24, 12/3/24, and 1/14/25, indicated: - Code Status: DNR. Review of physician progress notes, dated 8/28/24, 11/27/24, and 12/24/24, indicated: - Code Status: DNR. During an interview on 1/29/25 at 11:28 A.M., Unit Manager #3 and the surveyor reviewed Resident #26's advanced directives in his/her medical record. Unit Manager #3 said Resident #26 is a full code and resuscitation should be attempted if necessary. Unit Manager #3 said the physician and nurse practitioner's documentation for DNR is inaccurate. During an interview on 1/29/25 at 2:55 P.M., the Director of Nursing (DON) said she would expect the physician and nurse practitioner to document the correct code status. 50338 2.) Resident #22 was admitted to the facility in March 2024 with diagnoses that included heart failure, Alzheimer's disease, and chronic kidney disease. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 12/11/24, indicated he/she scored a two out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. The MDS further indicated the Resident's code status was DNR (Do Not Resuscitate) and DNI (Do Not Intubate). Review of Resident #22's physician order, dated 12/4/23, indicated Full Code, Health Care Proxy activated. Review of Resident #22's MOLST (Medical Orders for Life Sustaining Treatment), dated 3/15/24, indicated the Resident is a DNR, DNI, Transfer to Hospital. During an interview on 1/29/25 at 2:09 P.M., Unit Manager #2 said the MOLST should match the physician order, so the nurses are clear on what the code status is for that Resident. Unit Manager #2 reviewed Resident #22's MOLST with the surveyor and said it does not match the physician order. During an interview on 1/30/25 at 11:47 A.M., the Director of Nurses (DON) said the MOLST should match the physician order.

Based on record review and interviews, the facility failed to develop and implement person-centered care plans for one Resident (#28) out of a sample of 21 residents. Specifically, for Resident #28, the facility failed to implement the plan of care for providing supervision/assistance and adaptive equipment to the Resident while eating. Findings include: A review of the facility policy titled 'Comprehensive Person-Centered Care Plan', dated May 2023, indicated the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive care plan will: - Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - Incorporate identified problem areas. - Incorporate risk factors associated with identified problems. - Aid in preventing or reducing decline of the resident's functional status and or/functional levels. Resident #28 was admitted to the facility in March 2019 with diagnoses including paranoid schizophrenia, legal blindness, and malnutrition. A review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/24, indicated a Brief Interview for Mental Status (BIMS) score of six out of a possible 15 indicating moderate cognitive impairment. The MDS also indicated that Resident #28 received a mechanically altered diet and had severely impaired vision. On 1/28/25 at 9:00 A.M., the surveyor observed Resident #28 seated in a chair in his/her room eating breakfast. The meal was served on a regular plate. There were no staff present in the room. On 1/29/25 at 9:02 A.M. and 9:17 A.M., the surveyor observed Resident #28 sitting up in his/her bed eating breakfast. The meal was served on a regular plate. There were no staff present in the room. A review of Resident #28's physician's orders, dated 10/29/24, indicated: - House diet: dysphagia advanced/ground texture, thin consistency, lip plate (adaptive equipment to allow increased independence for a disabled person to eat). A review of Resident #28's Activities of Daily Living (ADL) care plan, dated 3/27/24, indicated that he/she required supervision/assist for eating. A review of Resident #28's nutritional care plan, dated as revised 12/5/24, indicated that he/she would be monitored for signs and symptoms of dysphagia (difficulty swallowing foods or liquids). The care plan failed to indicate that Resident #28 required an altered diet or that he/she required a lip plate for meals. During an interview and on 1/29/25 at 2:05 P.M., Unit Manger #2 said she was unaware that Resident #28's care plan indicated he/she required supervision/assist for eating and that he/she had an order to have a lip plate for meals. During an interview on 1/30/25 at 11:15 A.M., the Director of Nurses said she would expect a care plan for a Resident to receive supervision/assist with eating to be followed.

Based on observation and interview, the facility failed to provide a dignified dining experience for residents residing on the dementia unit. Findings include: 1.) On 1/28/25 at 8:47 A.M., the surveyors observed the breakfast meal on the View Unit (a secured unit where residents with dementia reside). There were four tables where three residents were seated. Two of the three tables had served two residents, and the remaining residents were watching their tablemates eat. The following observations was made: - At 8:52 A.M., one Resident asked a staff person if the tray she was carrying belonged to him/her. The Resident continued to sit and watch his/her tablemates eat. 2.) On 1/29/25 at 8:40 A.M., the surveyors observed 16 total residents in the View Dining room waiting for their breakfast meal. Two residents at a table of four had been served their meals while the rest of the residents waited. The following observations were made: - At 8:42 A.M., staff continued to serve residents at different tables while other residents watched their tablemates eat. - At 8:44 A.M., eight total residents were waiting for their meals and for the 2nd breakfast truck to arrive. Five residents were seated at tables watching their tablemates eat. - At 8:48 A.M., the 2nd breakfast truck arrived and one Resident who had been watching his/her tablemates eat since 8:40 A.M., said mine!? as the staff delivered his/her meal. - At 8:49 A.M., one resident at a table who was waiting for his/her meal reached across and took his/her tablemates' milk and began to drink it. - At 8:50 A.M., four total residents were waiting for their meals to be served, two of which were seated at tables watching their tablemates eat. 3.) On 1/29/25 at 12:40 P.M., the surveyor observed the lunch meal in the View Unit Dining room. The following observations were made: - At 12:46 P.M., the first resident at a table of four was served his/her meal. The last resident at the table was served at 12:52 P.M. - At 12:42 P.M. the first resident at a table of four was served his/her meal. The last resident at the table was served at 12:53 P.M. - At 12:43 P.M., the first resident at a table of four was served his/her meal. The last resident at the table was served at 12:58 P.M. - At 12:45 P.M. two residents were served their meals at a table of three. The last resident was served at 12:53 P.M. 4.) On 1/30/25 at 8:46 A.M., the surveyor observed the Breakfast meal. A total of 17 residents were seated in the dining room. The following observations were made: - At 8:48 A.M., the first resident at a table of four was delivered his/her meal. The last resident at the table was served at 8:56 A.M. - At 8:50 A.M., the first resident at a table of four was served his/her meal. The last resident at the table was served at 9:01 A.M. - At 8:52 A.M., the first resident at a table of three was served his/her meal. The last resident at the table received his/her meal at 8:58 A.M. - At 8:55 A.M., the first resident at a table of four was served his/her meal. The last resident at the table was served at 9:04 A.M. - At 8:59 A.M., the first resident at a table of three was served his/her meal. The last resident at the table was served at 9:04 A.M. During an interview on 1/30/25 at approximately 11:30 A.M., the Director of Nursing said that residents should be served their meals simultaneously and that the View Unit has had difficulty in doing so as the residents can be unpredictable and may not sit at the same tables consistently.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive, without a pulse, without respirations, and although his/her advanced directives indicated he/she was a Full Code (in the event of cardiac or respiratory arrest, attempts at resuscitation will be initiated) the Facility failed to ensure nursing staff adequately assessed Resident #1 for signs of irreversible death and followed facility policy, before initiating and attempting to perform cardiopulmonary resuscitation (CPR). Findings include: The Facility Policy, titled Sequential Assessment - MA Facilities Only, dated [DATE], indicated the Sequential Assessment purpose is to guide the decision-making of the Registered Nurse and the Licensed Practical Nurse (the nurse) in initiating or withholding cardiopulmonary resuscitation (CPR) when a patient or resident in a long-term facility with 24-hour skilled nursing staff on duty has experienced a cardiac arrest. The Policy indicated this allows the withholding of CPR with completion of the following nursing assessment: In the event of an unwitnessed patient or resident cardiac arrest, the nurse is expected to immediately conduct a Sequential Assessment of the patient or resident and to initiate CPR without delay unless there is a valid Do Not Resuscitate (DNR - a medical order written by a doctor if a patient's breathing stops or if the patient's heart stops beating indicates not to perform CPR) order or all the following clinical signs are present: No response when the patient or resident is tapped on the shoulder and asked, Are you all right; No respirations as determined by opening the airway using the head tilt-chin lift maneuver and observing for the rise and fall of the chest wall while listening and feeling for breath for at least 30 seconds; No pulse as determined by palpation of the carotid or auscultation of the apical pulse for at least 30 seconds; Dilated bilateral pupils that are unresponsive to bright light; and Dependent lividity - if Rigor Mortis is present, as determined by the presence of hardening of the muscles or rigidity of the jaw, shoulders, elbows or knees, then a finding of dependent lividity is not required. Dependent lividity is defined as a reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death. Also called livor mortis, rigor mortis, a stiffening of the body usually occurs several hours after death. Review of Study.com Academy lesson, dated [DATE], titled Rigor Mortis Stages, Timeline and Causes, indicated Rigor Mortis is a postmortem (occurring after death) phenomenon that causes muscles to become hard and immobile after death. Rigor Mortis starts quickly and progresses gradually but takes about two hours to become noticeable in small muscles. Rigor Mortis moves from the head, down to the trunk areas of the body. Resident #1 was admitted to the Facility with Alzheimer's Disease, hypertension, diabetes, heart disease, gastro-esophageal reflux, anxiety, and substance dependence. During telephone interview on [DATE] at 1:58 P.M., Nurse #1 said on [DATE], approximately at 7:00 A.M. a Certified Nurse Aide (CNA) informed him Resident #1 needed to be assessed. Nurse #1 said he immediately went to Resident #1's room, assessed Resident #1 who was noted to be cold to the touch, that he used a stethoscope to listen to Resident #1's chest/neck area, that there was no pulse present and Resident #1 was not responding to his verbal cuing. Nurse #1 said Nurse #2 (who joined him in assessing Resident #1) turned Resident #1's body, that Resident #1 body was stiff, and it was difficult to turn him/her. Nurse #1 said he was unable to hear breaths sounds. Nurse #1 said he had started CPR and Resident #1's body was stiff when he was administering chest compressions. Nurse #1 said Resident #1 was not responding to the administration of CPR, and even though 911 had been called, Emergency Medical Services (EMS) had not yet arrived to the Facility so he stopped chest compressions, and left Resident #1 alone to inquire where EMS was. Nurse #1 said when he stepped out of Resident #1's room the EMS arrived at the Facility. Nurse #1 said he was unaware of the Facility's Sequential Assessment Policy or when to withhold CPR on a Resident whose status was a Full Code. During telephone interview on [DATE] at 10:01 A.M., Nurse #2 said on [DATE] she had arrived at the Facility for her 7:00 A.M. to 3:00 P.M. shift when she had observed Nurse #1 in Resident #1's room performing chest compressions and was told a Code Blue had already been initiated. Nurse #2 said Nurse #1 informed her Resident #1 was unresponsive and asked her to get the Code Cart. Nurse #2 said she did not assess Resident #1 other than to palpate his/her carotid pulse and assist with administration of chest compressions to Resident #1. Nurse #2 said she did not assess Resident #1 for signs of dependent lividity. Nurse #2 said she was unaware of the Facility's Sequential Assessment Policy or when to withhold CPR on a Resident whose status was a Full Code. During interview on [DATE] at 10:10 A.M., the Unit Manager said on [DATE], sometime after the start of the day shift, she was informed by Nurse #1 that Resident #1 had passed away. The Unit Manager said she went to assess Resident #1 and noted, he/she had no color, that his/her hands, and that the inner aspects of his/her legs and feet were bluish in color. The Unit Manager said Resident #1 was completely stiff and not moving. The Unit Manager said she did not perform any other assessment since Nurse #1 said Resident #1 was deceased , and left his/her room at that time. The Unit Manager said it was sometime later, thinks it was approximately 10 minutes (or less) later (exact time unknown) and she returned to Resident #1's room and observed the code cart and the AED (Automated External Defibrillator) in Resident #1's room had been brought in. The Unit Manager said she entered Resident #1's room and was informed by nursing staff that they ]had tried to revive Resident #1 with CPR without any success. During interview on [DATE] at 10:12 A.M., the Regional Nurse Consultant said she was informed on [DATE] by Emergency Medical Services (EMS) that upon their arrival, no staff members were present in Resident #1's room, and that Resident #1 already had signs of Rigor Mortis and was deceased . The Regional Nurse Consultant said it was her expectation that staff follow the Facility's Code Blue Policy, the Facility's Sequential Assessment Policy and know when to initiate and/or withhold CPR from a resident. Review of the Fire Department Patient Resident Incident Run Sheet Report, dated [DATE] at 7:13 A.M., indicated the Facility called 911, EMS related to resident (later identified as Resident #1) who had been found unresponsive. The Report indicated upon Emergency Medical Technicians (EMTs) arrival to Resident #1's room, Resident #1 was found unresponsive, pulseless and upon examination by EMTs, Resident #1 had Rigor Mortis in his/her jaw and lividity on the posterior portions of his/her arms. The Report indicated a Facility Staff member said Resident #1 had been a Full Code, that he had started CPR for 30 minutes then stopped resuscitation efforts. The Emergency Medical Services (EMS) Report indicated their cardiac monitor confirmed Resident #1 heart rate as asystole (indication that electrical and mechanical activity of the heart stops) and the time of Resident #1's death was called at 7:24 A.M. Review of the Emergency Medical Technician (EMT) #1's written Statement, dated [DATE] at 1:00 P.M., indicated upon assessment of Resident #1, he/she was found to have Rigor Mortis present in his/her mandible (jaw), as well as lividity present on the posterior (back) of his/her arms. The Statement indicated Resident #1 had been pronounced deceased shortly after EMT's assessment due to obvious signs of death. During interview on [DATE] at 5:09 P.M., Certified Nurse Aide (CNA) #1 said on [DATE] that sometime early in the morning, he had provided Activities of Daily Living (ADL) care to Resident #1, although he could not recall the exact time, said it was probably sometime between 5:30 A.M. and 6:00 A.M., without any concerns. During interview on [DATE] at 5:25 P.M., the Administrator said she was informed on [DATE] by EMS that upon their arrival to the Facility a Code Blue was not active, Resident #1 was alone in his/her room. and upon their assessment of Resident #1 he/she had Rigor Mortis to his/her jaw line. The Administrator said EMS informed her that Resident #1 had probably been deceased for approximately an hour and half prior to their arrival. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the areas of concerns as evidenced by: A. [DATE], Resident #1 was pronounced deceased by EMS at the Facility. B. [DATE], The Facility's Regional Nurse assessed all residents for the potential to be adversely affected by concern area resident's code status, resident records to verify MOLST is accurate, completed, matches resident's Code Status and is kept at the front of resident charts per policy and posting on spine of chart removed and was reviewed by the Director of Nurses. C. Starting [DATE] and going forward, the Unit Manager/Designee will Audit resident charts monthly to verify that a MOLST has been completed and placed in front of the resident's chart. D. [DATE], the Facility's Regional Nurse added Sequential Assessment to staff and agency orientation. E. [DATE] through [DATE], Code Blue and Overhead paging of Code Blue Education provided by Facility's Educator to all staff . F. [DATE] through [DATE], Sequential Assessments (with-holding CPR), Emergency Procedures and MOLST Guidelines Education provided by Facility's Staff Educator for all Licensed Nurses. G. [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], Mock Code Blue drills were conducted by Regional Nurse and or a Designee, they will continue to be conducted weekly starting [DATE] for four weeks, then monthly times three months, and then quarterly until substantial compliance is achieved. H. Effective February 2024, the Facility's Staff Educator/Designee on a quarterly basis will test Licensed Nurses, both staff and agency to ensure ongoing competence related to Code Blue and CPR. I. [DATE], QAPI Meeting was conducted and concerns were discussed with committee and were shared with the Medical Director. The acting Director of Nurses will bring the results of the audits to the monthly QAPI meetings, for review and discussion until substantial compliance is achieved. J. The Administration and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose advanced directive indicated he/she was Full Code, (staff to attempt Cardiopulmonary Resuscitation, CPR in the event of cardiac or respiratory arrest) the Facility failed to ensure that nursing staff were competent related to facility policy and procedures in the event of an emergency situation with the need to initiate a Code Blue, which included nursing response, resident assessment and use of necessary life-saving equipment. When on [DATE], at approximately 7:00 A.M., after Nurse #1 found Resident #1 unresponsive, without a pulse or respirations, Nurse #1 did not stay with the resident, Code Blue was not overhead page to alert staff per Facility Policy, and nursing staff were unaware of how to use the Automated External Defibrillator (AED). Findings include: The Facility Policy, titled Code Blue in House Emergency Response Policy and Procedure, dated [DATE], indicated that Code Blue is called for life threatening emergencies, including but not limited to, cardiac arrest and respiratory arrest. The Facility Policy indicates the Nurse will respond immediately and will determine the extent of the emergency. The Policy indicated if the resident is not breathing, and has no heartbeat, the nurse will instruct the other staff member to bring in the emergency cart, page Code Blue along with the location three times. The Policy indicated after determining the resident's Code Status, CPR will be immediately started by the first nurse responding to the emergency. The Policy indicated the nurse in charge will instruct specific staff to call 911 and take notes during the code and note what was done and what time. The Facility Policy, titled Use and Care of an Automatic External Defibrillator, dated [DATE], indicated if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall imitate CPR immediately unless: It is known that a Do Not Resuscitate (DNR) Order that specially prohibits CPR and/or external defibrillation exists for that individual or there are obvious signs of irreversible death (Rigor Mortis). Resident #1 was admitted to the Facility with Alzheimer's Disease, hypertension, diabetes, heart disease, gastro-esophageal reflux, anxiety, and substance dependence. Review of the Emergency Medical Technician (EMT) #1 Written Statement, dated [DATE] at 1:00 P.M., indicated the initial dispatch call to the Facility was for a resident who has passed out or passed on (he was unsure exactly which), that dispatch was unable to determine the facility's chief complaint and was unable to reach the Facility for further information. The Statement indicated upon arrival Facility staff informed him (EMT #1) that Resident #1 was not in cardiac arrest and Resident #1 was in his/her room. The Statement indicated EMT #1 found Resident #1 unresponsive, pulseless and an AED was found at his/her bedside that had been opened, but had not been turned on or applied to Resident #1. The Statement indicated Facility staff informed him (EMT #1) Resident #1 did not have a pulse, that CPR had been initiated by nursing staff for 30 minutes, nursing could not feel a pulse, and that chest compressions had been stopped The Statement indicated staff informed (EMT #1), Resident #1 was a Full Code. During telephone interview on [DATE] at 1:58 P.M., Nurse #1 said after being told by a Certified Nurse Aide that he needed to check on Resident #1, he went to Resident #1's room, determined he/she was unresponsive, had no pulse, was cold to the touch and was not breathing. Nurse #1 said he left Resident #1's room to go to the Nursing Station to call Code Blue but the Facility phone did not work. Nurse #1 said he then tried to call 911 and the 911 dispatcher said they were unable to hear and/or understand him and would call back. Nurse #1 said at this point he informed Nurse #2 to bring the code cart in Resident #1's room. Nurse #1 said during this time there was no staff member with Resident #1. Nurse #1 said the Code Cart along with the AED were brought into Resident #1's room, but the AED would not turn on so he continued administering CPR to Resident #1. Nurse #1 said at one point Nurse #2 left the room to call the Physician and he was alone in Resident #1's room. Nurse #1 said Resident #1 was not responding to CPR, Emergency Medical Services (EMS) had not arrived to the Facility, so he stopped doing chest compressions, left Resident #1's room, leaving him/her alone to inquire where EMS were. Nurse #1 said EMS arrived after he left Resident #1's room. Nurse #1 said he was unaware of the Facility's CPR Policy. During telephone interview on [DATE] at 9:32 A.M., Nurse #2 said on [DATE] she worked the day shift, and when she arrived on the unit at the start of she shift, she had observed Nurse #1 in Resident #1's room performing chest compressions to him/her and that Nurse #1 informed her Resident #1 was unresponsive and had instructed her to get the Code Cart. Nurse #2 said she had gone to look for Resident #1's Medical Chart to confirm Resident #1's Code Status, but was unable to locate it. Nurse #2 said after determining Resident #1 was a Full Code she proceeded to Resident #1's room with the Code Cart and the Automated External Defibrillator (AED). Nurse #2 said the AED was not working when she tried to turn it on. Nurse #2 said Resident #1 did not have a carotid pulse upon assessment and that she performed chest compressions on Resident #1. Nurse #2 said since they were unable to get a pulse on Resident #1, and it seemed like EMS was not coming, herself and Nurse #1 stopped chest compressions. Nurse #2 said she was unaware of the Facility's Code Blue Policy. During interview on [DATE] at 10:10 A.M., the Unit Manager said on [DATE], sometime after the start of the day shift, she was informed by Nurse #1 that Resident #1 passed away. The Unit Manager said when she went to assess Resident #1, she did not see a Code Cart or an AED in Resident #1's room at that time. The Unit Manager said after she assessed him/her, there was a question regarding what Resident #1's Code Status was, so she brought Resident #1's Medical Chart to the Administrators office for them to review. During interview on [DATE] at 10:12 A.M., the Regional Nurse Consultant said she was informed on [DATE] by Emergency Medical Services (EMS) that the call made to 911 by Facility staff was difficult to understand and/or that the connection was disrupted, and it was unclear what their emergency entailed. The Regional Nurse Consultant said when she interviewed Nurse #1 regarding the events of [DATE], Nurse #1 said he had not called for help from other staff after assessing and finding Resident #1 unresponsive, that he left the room leaving Resident #1 alone to call 911, had a difficulty time communicating with 911 and was unable to call a Facility Code Blue since the Facility phone was not working. The Regional Nurse Consultant said Nurse #1 said he started compressions on Resident #1 and then stopped compressions prior to the EMS arrival since he was unable to find signs of life and left the room to inquire where EMS were. The Regional Nurse Consultant said it was her expectation that nursing staff were competent on how to respond in an emergency medical situation, that they implemented and followed Facility's Code Blue Policy, the Facility's Sequential Assessment and know when to initiate and/or withhold CPR. On [DATE], the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the areas of concerns as evidenced by: A. [DATE], Resident #1 was pronounced deceased by EMS at the Facility. B. [DATE], The Facility's Regional Nurse assessed all residents for the potential to be adversely affected by concern area resident's code status, resident records to verify MOLST is accurate, completed, matches resident's Code Status and is kept at the front of resident charts per policy and posting on spine of chart removed and was reviewed by the Director of Nurses. C. Starting [DATE] and going forward, the Unit Manager/Designee will Audit resident charts monthly to verify that a MOLST has been completed and placed in front of the resident's chart. D. [DATE], the Facility's Regional Nurse added Sequential Assessment to staff and agency orientation. E. [DATE] through [DATE], Code Blue and Overhead paging of Code Blue Education provided by Facility's Educator to all staff . F. [DATE] through [DATE], Sequential Assessments (with-holding CPR), Emergency Procedures and MOLST Guidelines Education provided by Facility's Staff Educator for all Licensed Nurses. G. [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], Mock Code Blue drills were conducted by Regional Nurse and or a Designee, they will continue to be conducted weekly starting [DATE] for four weeks, then monthly times three months, and then quarterly until substantial compliance is achieved. H. Effective February 2024, the Facility's Staff Educator/Designee on a quarterly basis will test Licensed Nurses, both staff and agency to ensure ongoing competence related to Code Blue and CPR. I. [DATE], QAPI Meeting was conducted and concerns were discussed with committee and were shared with the Medical Director. The acting Director of Nurses will bring the results of the audits to the monthly QAPI meetings, for review and discussion until substantial compliance is achieved. J. The Administration and/or Designee are responsible for overall compliance.

Based on observations, record review and interview, the facility failed to ensure that; 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For 2 Residents (#50 and #86) the facility failed to provide care when requested out of a total of 27 residents sampled. Findings include: 1. On 2/27/24, at 7:30 A.M., the surveyor observed that there was one Certified Nurse's Aide (CNA) working on the Court Unit. The surveyor also observed there were 18 residents currently residing on the Court Unit. During an interview on 2/27/24 at 9:58 A.M., The Director of Nursing said that staffing the units has been an ongoing challenge. Review of the facility assessment dated as reviewed 10/25/23, indicated that the average daily census in the building is between 80 and 90 residents per day. Further review indicated that the amount of Certified Nurse's Aides (CNA's) needed to care for the residents, at the acuity level of the residents as determined by the facility, is 33 full time equivalents (FTE) per day. Review of the facility document titled Detailed Census Report dated February 2024, indicated that the average daily census ranged between 91 and 97 residents per day. Higher than the Facility Assessment predicted. Review of the actual worked staffing hours for the month of February 2024 indicated that the number of CNA staff daily ranged from 18 to 24, significantly below the 33 the facility assessed was need to adequately care for the residents. During an interview on 2/29/24 at 9:49 A.M., Nurse #7 said that it is very difficult to provide care when there is only one Certified Nurse's Aide (CNA) on the unit. During an interview on 2/29/24 at 9:52 A.M., CNA #1 said that he was the only CNA on the unit and he was not able to do everything that the residents needed on the unit. CNA #1 said that he had 18 residents on the unit and he was responsible for all of their activities of daily living except for a few that could help themselves. 2. Resident #50 was admitted to the facility in November 2023 with diagnoses including anxiety and depression. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #50 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on 2/29/24 at 9:53 A.M., Resident # 50 said that one CNA is not enough and residents are waiting a long time to get care. Resident #50 said that sometimes it is impossible to get help. 3. Resident #86 was admitted to the facility in September 2023 with diagnoses including cancer and traumatic brain injury. Review of the Minimum Data Set, dated dated dated [DATE], indicated that Resident #86 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on 2/29/24 at 9:55 A.M., Resident #86 said that he/she doesn't get the care he/she needs due to insufficient staffing on the unit. Resident #86 said that he/she doesn't get showers as often as he/she would like, and often has to wait long periods of time before a CNA answers his/her call light. Resident #86 said that he/she has to wheel him/herself out to the hallway to find help. During an interview on 2/29/24 at 10:25 A.M., with the Director of Nursing and the Administrator. The Administrator was unable to say if the staffing levels were adequate to provide care to the residents. The Administrator also said that she did not know what the ratios of direct care staff to residents was or should be according to the facility assessment. The Administrator then said that she reviews the staffing every day and is aware that sometimes staffing is lower than it should be because of call outs. The Administrator said that no new initiative had been put in place to enhance recruitment of CNA staff. The Director of Nursing then said that the acuity levels of the residents had actually increased over the past several months since the Facility Assessment was reviewed.

Based on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of two units. Findings include: A group meeting was held on 2/28/24 at 11:00 A.M. During this meeting, 12 out of 12 participants said the food was not hot when it was served to them. A test tray was completed on 2/28/24 on the Meadows Unit at 12:27 P.M. with the following findings using the facility thermometer: *Meatloaf was 90 degrees Fahrenheit and tasted warm. *Green beans were 80 degrees Fahrenheit and tasted luke warm and bland. *Potatoes were 84 degrees Fahrenheit and tasted luke warm and bland and had a grainy/gritty texture. *Apple pie was 60 degrees Fahrenheit and tasted cold with a gummy texture. *Milk was 40 degrees Fahrenheit and tasted cold. *Apple juice was 50 degrees Fahrenheit and tasted cold. A test tray was completed on 2/28/24 on the Dementia Unit at 12:56 P.M. with the following findings: *Meatloaf was 135.1 degrees Fahrenheit and tasted warm. *Green beans were 123.4 degrees Fahrenheit and tasted luke warm and bland. *Potatoes were 132.6 degrees Fahrenheit and tasted warm with a grainy/gritty texture. *Apple pie was 52.3 degrees Fahrenheit and had a gummy, undercooked texture. *Milk was 55 degrees Fahrenheit. *Apple juice was 54.4 The Dietitian provided results of a recent test tray the facility completed on 12/5/23 to the surveyor. The results were: *Hot dog:140 degrees Fahrenheit in the kitchen and 110 degrees Fahrenheit when tasted on the unit. *Roasted potato: 145 degrees Fahrenheit in the kitchen and 91 degrees Fahrenheit when tasted on the unit. *Carrots: 132 degrees Fahrenheit in the kitchen and 91 degrees Fahrenheit when tasted on the unit. *Sliced pears: 67 degrees Fahrenheit in the kitchen and 70 degrees Fahrenheit when tasted on the unit. *Milk: 40 degrees Fahrenheit in the kitchen and 60 degrees Fahrenheit when tasted on the unit. *Cranberry juice: 39 degrees Fahrenheit in the kitchen and 41 degrees Fahrenheit when tasted on the unit. During an interview on 2/29/24 at 8:56 A.M. the Registered Dietitian (RD) said she collaborates with the Food Service Director to conduct test trays periodically. The RD said the metrics used to evaluate test trays are outlined on the test-tray form, and that hot foods should be greater than 120 degrees Fahrenheit and cold foods should be less than 50 degrees Fahrenheit. 41105

Based on interview and review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 2023, the facility staff failed to ensure an effective QAPI plan was in place. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) dated June 2023 indicated the following: The QAA (Quality Assessment and Assurance) program committee will prioritize topics for PIPs (Performance Improvement Projects) based on current needs of the residents and our organization. Review of all the 12 months of QAPI meeting minutes for 2023 failed to indicate a prioritizing process was implemented, failed to indicate that a root cause analysis was completed for identified problems and failed to indicate the tracking of outcomes for any interventions put in place to determine their effectiveness. Review of the Quarterly December 2023 QAPI meeting minutes failed to indicate that, for known areas of concern, a performance improvement plan was implemented to ensure the following: 1. Adequate staffing. 2. Food quality. 3. Environmental concerns/needed repairs. 4. Continuation of the water management program. During an interview on 2/27/24 at 1:00 p.m., the Maintenance Director said he could not speak to the water management program. The Maintenance Director was unable to say if the facility had a water management program or how the facility assesses the risk of legionella in the facility. During an interview on 2/27/24 at 2:00 p.m., the Maintenance Director provided the surveyor with a facility risk assessment for legionella. The risk assessment was dated 2/27/24 and the Maintenance Director said he and the Administrator completed the assessment today. During an interview on 2/29/24 at 11:28 A.M., the Director of Maintenance (DOM) he conducts monthly environmental unit rounds on each unit and addresses areas that need to be fixed himself. The DOM said he notifies the administrator verbally and will make recommendations for outside vendors if he can't fix issues in the building. During an interview on 2/29/24 at 12:01 P.M., the Administrator said that she was not aware of the environmental or water management program issues and relied on the head of maintenance to let her know of issues within his department. The Administrator also said that she was aware of the concerns with staffing and food quality but there was no QAPI in place for either.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure Resident #1 was free from abuse when it was reported by two staff members that they witnessed Nurse #1, on two separate occasions, interact with Resident #1 in a verbally abusive and threatening manner. Findings include: Review of the Facility's Policy and Procedure titled, Abuse, Neglect, Misappropriation of Resident Property and Involuntary Seclusion, dated as revised on 1/09/2019, indicated each resident has the right to be free from abuse and must not be abused by anyone, including staff. Resident #1 was admitted to the Facility in July 2021. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 2/02/22, indicated he/she experienced delusions, disorganized thinking and during a brief interview for mental status was evaluated as having severe cognitive impairment. During an interview on 4/28/22 at 09:00 A.M., the Executive Director and Director of Nursing (DON) said during a facility investigation in March 2022, that was being conducted related to Nurse #1, additional historical information regarding allegations that Nurse #1 had verbally abused Resident #1 on at least two separated occasions, was reported to them by Nurse Aide #1 and Certified Nurse Aide (CNA) #1 (which had not been previously reported to either of them). The Executive Director and the DON said Nurse Aide #1 and CNA #1 could not provide the exact date(s) of the alleged incidents, but they were thought to have occurred during October or November of 2021, and were not immediately reported by the two staff members. The Executive Director and the DON said once they became aware of the allegations of abuse, immediate action was taken to ensure Nurse #1 would not provide care for residents at the Facility. During an interview on 5/03/22 at 01:20 P.M., Nurse Aide #1 said during the 03:00 P.M. to 11:00 P.M. shift sometime around October 2021 or November 2021 (unable to recall exact date), she witnessed an incident between Nurse #1 and Resident #1, and said Nurse #1 was verbally abusive towards him/her. Nurse Aide #1 said Nurse #1 approached Resident #1, who was seated in a wheelchair, then leaned forward close to his/her face and screamed at Resident #1. Nurse Aide #1 said Nurse #1 screamed at Resident #1 words to the effect of you're [OBSCENITY] ing trash, you mother [OBSCENITY] , you're a pain in my ass, you're my least favorite, you're really old, I don't know why you're still alive. Nurse Aide #1 said as Nurse #1 walked away, Resident #1 immediately stood up and said words to the effect of your mother, you should go to hell. Nurse Aide #1 said Nurse #1 replied back and said to Resident #1 words to the effect of I should not be talking with you, you're useless and pointless. Nurse Aide #1 said she would have cried if Nurse #1 had spoken to her in the same manner as she did to Resident #1. Nurse Aide #1 said she did not immediately report the incident to anyone, but said she did report it to Certified Nurse Aide #1 the following day. During an interview on 4/08/22 at 02:05 P.M., Certified Nurse Aide (CNA) #1 said one day in the fall of 2021 (October or November, exact date unknown), Nurse Aide #1 came to her, appeared frightened, and told her that she witnessed Nurse #1 verbally abusing Resident #1. CNA #1 said approximately a month after Nurse Aide #1 told her about the incident, she then said she had witnessed Nurse #1 verbally abuse Resident #1 during a 03:00 P.M. to 11:00 P.M. shift. CNA #1 said she heard Nurse #1 say to Resident #1 words to the effect of I hate you, shut up, why aren't you quiet, you need to go upstairs to the second floor unit. I don't know why you're on this floor. You're supposed to be upstairs with the crazy people. CNA #1 said Nurse #1 was referring to a unit where mainly cognitively impaired residents resided. CNA #1 said she did not immediately report the incident to anyone. During an interview on 4/28/22 at 11:55 A.M., Resident #1 was unable to provide information regarding the alleged incidents of verbal abuse. A reasonable person with intact cognitive functioning would have experienced emotional harm as a result of verbal abuse.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure staff implemented and followed their Abuse Policy, when two staff members failed to immediately report allegations of verbal abuse to the Executive Director or designee. When during the course of a facility investigation it was determined that a staff member witnessed and failed to report an incident in which Nurse #1 verbally abused Resident #1, that had occurred in October 2021, therefore placing Resident #1 and other residents at risk for the potential to be abused. Approximately one month later, a second staff member witnessed Nurse #1 verbally abusing Resident #1, and also failed to immediately report the incident. Findings include: Review of the Facility's Policy and Procedure, titled Abuse Policy, revised on 1/9/19, indicated an employee who suspects an alleged violation shall immediately notify the Executive Director or his/her designee. During an interview on 4/28/22 at 09:00 A.M., the Executive Director and Director of Nursing (DON) said during a facility investigation in March 2022, that was being conducted related to Nurse #1, additional historical information regarding allegations that Nurse #1 had verbally abused Resident #1 on at least two separated occasions, was reported to them by Nurse Aide #1 and Certified Nurse Aide (CNA) #1. The Executive Director and Director of Nursing (DON) said the incidents Nurse Aide #1 and CNA #1 reported to them in March 2022, had not been previously reported to either of them. The Executive Director and DON said Nurse Aide #1 and CNA #1 could not provide the exact date(s) of the alleged incidents, but had reported that they thought they had occurred sometime during October or November of 2021. The The Executive Director and DON said the allegations should have been reported immediately. The Executive Director and DON said that once they became aware of the allegations, immediate action was taken to ensure Nurse #1 would not provide care to residents at the Facility. During an interview on 5/03/22 at 01:20 P.M., Nurse Aide #1 said during the 03:00 P.M. to 11:00 P.M. shift sometime around October 2021 or November 2021 (unable to recall exact date), she witnessed an incident between Nurse #1 and Resident #1, and said Nurse #1 was verbally abusive towards him/her. Nurse Aide #1 said she saw Nurse #1 approached Resident #1, who was seated in a wheelchair, that Nurse #1 leaned forward close to Resident #1's face and screamed at him/her. Nurse Aide #1 said Nurse #1 screamed at Resident #1 words to the effect of you're [OBSCENITY] ing trash, you mother [OBSCENITY] , you're a pain in my ass, you're my least favorite, you're really old, I don't know why you're still alive. Nurse Aide #1 said she did not immediately report the incident to anyone. Nurse Aide #1 said the following day she told Certified Nurse Aide (CNA) #1 about the incident. Nurse Aide #1 said CNA #1 encouraged her to report the alleged incident to a Supervisor or the Director of Nurses. Nurse Aide #1 said she did not immediately report the incident fearing action against Nurse #1 would not be taken. Nurse Aide #1 said she was aware that allegations of abuse needed to be immediately reported. During an interview on 4/08/22 at 02:05 P.M., Certified Nurse Aide (CNA) #1 said one day in the fall of 2021 (October or November, exact date unknown), Nurse Aide #1 came to her, appeared frightened, and told her that she witnessed Nurse #1 verbally abusing Resident #1. CNA #1 said she encouraged Nurse Aide #1 to report the incident, because she had witnessed it. CNA #1 said she did not report what Nurse Aide #1 told her to anyone. CNA #1 said approximately a month after Nurse Aide #1 told her about the incident she had witnessed also witnessed Nurse #1 verbally abuse Resident #1 during a 3:00 P.M. to 11:00 P.M. shift. CNA #1 said she heard Nurse #1 say to Resident #1 words to the effect of I hate you, shut up, why aren't you quiet, you need to go upstairs to the second floor unit. I don't know why you're on this floor. You're supposed to be upstairs with the crazy people. CNA #1 said she did not immediately report the incident to anyone. CNA #1 said she was aware that all allegations of abuse needed to be immediately reported.

Based on observation, record review and interview, the facility failed to identify and address significant weight losses for 3 Residents (#36, #59 and #62) out of a total of 20 sampled residents. 1. Resident #36 was admitted in 02/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutrition care plan for Resident #36 indicated the following: - Resident # 36 is at nutrition risk due to increased nutrition needs, inadequate oral intakes, unintentional weight loss due to [CONDITION(S)], picky eating, increased nutrition needs. - Monitor/record/report to physician as needed for signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 pounds in one week, >5% in 1 month, >7.5% in 3 months, >10 % in 6 months Review of the Weight and Vitals Summary indicated the following: 1/19/2021: 117 lbs (pounds) 1/21/2021: 115.2 lbs 2/14/2021: 100.3 lbs 3/3/2021: 108.9 lbs 3/24/2021: 103.4 lbs 4/18/2021: 107 lbs Review of the weights indicated that Resident #36 had a weight loss of 14.9 lbs from 1/21/2021 to 2/14/2021, a significant weight loss of 12.9% in 24 days. Review of the progress notes failed to indicate that the significant weight loss was addressed. Review of the Nutrition Assessments indicated that Resident #36 was evaluated by the Dietitian on 4/1/2021, 46 days after the initial weight loss was identified. The Dietitian documented an intervention of increasing Nepro (a supplement) to twice a day for weight gain. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's clinical record failed to indicate that any interventions were put in place before 4/2/2021, which was 47 days after the significant weight loss was identified. During an interview on 2/17/22 at 10:04 A.M., the Dietitian said that he comes to the facility on ce a week and reviews weights and discusses with nursing any changes in the residents. The Dietitian said that sometimes he struggles to address weight loss because he does not have enough time in the facility and that communication can sometimes be an issue. The Dietitian said he provides both verbal and written recommendations to nursing. The Dietitian also said that Resident #36 sometimes receives supplements at [CONDITION(S)] and sometimes refuses them. 2. Resident #62 was admitted in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident's care plans did not indicate that Resident #62 had a care plan for nutrition. Review of Resident #62's Weight and Vitals Summary indicated the following: 8/30/21: 167 lbs (pounds) 9/22/21: 162 lbs 10/1/21: 147.4 lbs 11/1/21: 142 lbs 12/2/21: 132 lbs 1/6/22: 130 lbs Review of the weights indicate that Resident #62 had a weight loss from 9/2/21 to 10/1/21 of 14.6 lbs, a 9% significant weight loss in one month. Resident #62 continued to have a decline in weight from 11/1/21 to 12/2/21 of 10 lbs, which is a 7% significant weight loss in one month. Review of the Nutrition Assessment, dated 10/28/21, indicated that Resident #62 had lost 19.2 lbs in 1 month related to avoiding meals for fear of food being tampered with. The documentation also indicated that Resident #62 reports eating less than 75% of meals. The intervention implemented at that time was to continue the diet as ordered and re-educated as needed. There was no indication on who would carry out the education or that nursing was made aware. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This occurred 41 days after the initial weight loss was identified. During an interview on 2/17/22 at 10:04 A.M., the Dietitian said that he comes to the facility on ce a week and reviews weights and discusses with nursing any changes in the residents. The Dietitian said that sometimes he struggles to address weight loss because he does not have enough time in the facility and that communication can sometimes be an issue. The Dietitian said he provides both verbal and written recommendations to nursing. The Dietitian said that Resident #62 often has delusions and is afraid to eat the food. The Dietitian said he does not work with the Psych Nurse Practitioner directly, but is in communication with the Nurse Practitioner. The Dietitian said that Resident #62 was started back on supplements recently and likes them. 3. Resident #59 was admitted to the facility in August 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's most recent Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and is independent with eating. Due to Resident #59's cognition, he/she was unable to participate in the interview process. Review of Resident #59's weights indicated: 10/4/21: 137.4 lbs 11/4/21: 134.4 lbs 12/21/21 124.4. lbs a loss of 8% of his/her total body weight since 10/4/21. No re-weigh was obtained to confirm Resident #59's weight loss per the facility policy. Review of the Nutrition Care plan, initiated 5/6/21, indicated Resident #59 was at risk for weight loss and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Dietitian note, dated 12/30/21, indicated that Resident #59 is offered snacks and encouraged to finish meals as needed. Due to the Resident's age and impaired cognition some weight loss may be unavoidable going forward. The Dietitian's note indicated that Resident #59 required supervision to assist with meals. There was no evidence in the clinical record indicating that Resident #59 had behaviors of refusing meals or wanting to lose weight. On 2/15/22 at 8:53 A.M. the surveyor observed Resident #59 eating breakfast in bed without supervision or assistance. Resident #59 was very thin and frail. On 2/16/22 at 8:26 A.M. the surveyor observed Resident #59 in bed. Resident #59's breakfast was in front of him/her without supervision or assistance. Resident #59 was asleep with the fork in his/her hand and his/her meal was untouched. On 2/17/22 at 8:12 A.M. the surveyor observed Resident #59 eating breakfast alone in his/her room without supervision. Resident #59 was very slowly placing very small amounts of food on the fork before lifting the fork to his/her mouth. During an interview on 2/17/22 at 10:04 A.M., the Dietitian said that Resident #59 was on [MEDICATION(S)] (a medication used as an appetite stimulant) and took supplements daily. Review of Resident #59's physicians orders indicated that he/she was not currently prescribed [MEDICATION(S)] and that the nutritional supplements had been in place since October 2020. The Dietitian said that he comes to the facility on ce a week and reviews weights and discusses with nursing any changes in the residents. The Dietitian said that sometimes he struggles to address weight loss timely because he does not have enough time in the facility and that communication can sometimes be an issue. During an interview with Unit Manager #2 on 2/17/22 at 8:16 A.M., she said that the care plan indicating that Resident #59 refuses meals to lose weight was inaccurate and she did not know why it was written that way. She said that even though Resident #59 takes a long time to eat his/her meals, Resident #59 consistently eats almost 100%. Unit Manager #2 said Resident #59 never refuses meals in order to lose weight and is independent with eating. Unit Manager #2 said she was not aware that the Dietitian's assessments for 2021 indicated that Resident #59 was being assisted or supervised for meals. Unit Manager #2 said that she did not know why interventions such as magic cups, or other fortified foods have not been attempted to address Resident #59's weight loss. During an interview with the Psychiatric Nurse Practitioner on 2/2/22 at 10:03 A.M., she said that she recalled working with Resident #59 but had no recollection of Resident #59 having any behaviors of refusing meals to lose weight or wanting to lose weight.

Based on record review and interview, the facility failed to provide supervision during a meal, resulting in a fall with injury for 1 Resident (#41) out of a total sample of 20 residents. Findings include: Resident # 41 was admitted to the facility in 10/19 with diagnoses including dementia, [CONDITION(S)] and dysphagia (trouble swallowing). Review of Resident #41's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of Resident #41's MDS indicated the Resident had no hallucinations, delusions or behaviors and requires extensive assistance with physical assistance for transfers and walking in the room and requires supervision with one person assistance for eating. Review of Resident #41's Activities of Daily Living (ADLS) care plan dated 6/5/21 indicated: Resident #41 care needs are met by staff; dependent with ADLS; assist with transfers, ambulation and toileting; supervision with eating. Throughout the day on 2/16/22, Resident #41 was observed with a bandage on his/her head. Review of Resident #41's medical record indicated the following: -Incident/ Accident report dated 2/15/22: Resident had unwitnessed fall on the floor during dinner time. No reason given why he/she was getting up. Sustained a laceration on the scalp. -Incident/Accident/ Event Documentation Form dated 2/15/22: Approximately 3 minutes prior the Resident was in his/her wheelchair and food tray on his/her table. -Witness Statement dated 2/15/22: During the supper at around 17:45 (5:45 P.M.), the writer heard a loud sound and rushed towards the direction of the sound. Resident was discovered laying on his/her side on the floor beside his/her wheelchair and dinner table. -An undated, unsigned document: On February 15th, 2022 at approximately 5:45 P.M., the Resident was in his/her wheelchair out by nurse's station eating his/her dinner with his/her bedside table in front of him/her. Nurse heard a loud sound and found the Resident face first on floor with a forehead laceration. The Resident was sent to ER for evaluation and treatment. The Resident returned to the facility with 4 dissolvable sutures to his/her forehead. During an interview on 2/17/22 at 10:04 A.M., Unit Manager #2 said Resident #41 is generally alert and confused and that he/she has had numerous falls. Unit Manager #2 said the Resident had an unwitnessed fall earlier in the week and required sutures. Unit Manager #2 said the Resident needs supervision with meals. During an interview on 2/17/22 at 10:36 A.M., Nurse #1 said he was the nurse working when Resident #41 fell and needed sutures. Nurse #1 said the fall happened towards the end of dinner and the Resident was sitting in his/her wheelchair near the nurse's station. Nurse #1 said the Resident had been left unsupervised briefly towards the end of dinner so the staff could collect resident trays and provide assistance with meals to other residents. Nurse #1 acknowledged the Resident requires supervision at meals and was not supervised when he/she fell .

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had been evaluated in the Hospital Emergency Department (ED) after a fall in the Facility, and was diagnosed with a contusion of his/her right elbow, the Facility failed to ensure nursing notified Resident #1's Physician to obtain orders to treat his/her pain. On 07/07/21, upon return from the ED, Resident #1 requested pain medication from Nurse #1 and was told by Nurse #1 he/she did not have any pain medications available, Resident #1 continued to request pain medication from Nurse #1 throughout the night, but was told he/she had no orders for pain medication. Despite Resident #1's complaints of pain and repeated requests for pain medication, Nurse #1 did not contact the Physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The Facility's policy titled, Change in Condition, dated 06/15/15, indicated that a resident who had a clinical change or change in condition, a licensed nurse would perform appropriate clinical observations and data collection and report to the physician as indicated. Resident #1 was admitted to the Facility in March 2019, his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact and able to make his/her own health care decisions. The Facility's Internal Investigation, dated 07/07/21, indicated that Resident #1 had an unwitnessed fall during the day on 07/06/21, required an evaluation at the Hospital Emergency Department (ED), and returned to the Facility during the overnight shift (11:00 P.M. to 7:00 A.M.) on 07/07/21. The Investigation indicated that Resident #1 did not receive his/her medications upon return, as ordered by the Physician. The Investigation indicated Nurse #1 made a medication error by not administering Resident #1's medications when he/she returned from the ED. The Investigation indicated Nurse #1 reported she was unable to access Resident #1's Electronic Health Record (EHR) and that she failed to ask other nursing staff for assistance to reactivate Resident #1's EHR to ensure Resident #1 received his/her medications. Review of the Incident Report, dated 07/07/21, indicated that Resident #1 told staff (later identified as Nurse #2) he/she did not receive his/her medications when he/she returned to the Facility last night. Review of the Investigation Follow-up Incident/Accidents Form, dated 07/08/21, indicated that Nurse #1 said she did not give Resident #1 his/her medications because she could not see them in the EHR. Review of the Hospital Emergency Department Medical Record, dated 07/06/21, indicated Resident #1 had a contusion of his/her right elbow from a fall. During an interview on 07/28/21 at 9:20 A.M., Nurse #1 said about 20 minutes after Resident #1 returned from the hospital, he/she asked for his/her pain medication, so she reviewed Resident #1's record and told him/her that he/she did not have any pain medication available at that time. Nurse #1 said she could tell Resident #1 was really upset because he/she was swearing, threatening her, and throwing things. Nurse #1 said she felt bad for Resident #1 but said there was nothing she could do for Resident #1. Nurse #1 said she did not call anyone, including the physician. During an interview on 07/28/21 at 11:40 A.M., Resident #1 said when he/she arrived at the Facility sometime after midnight on 07/07/21, he/she asked Nurse #1 if he/she could have his/her pain medications, he/she said Nurse #1 told him/her that he/she did not have any medications available. Resident #1 said words to the effect of, My elbow was killing me so I rang the call bell and asked Nurse #1 again for my pain medications, but Nurse #1 said she did not know how to look up my medication orders. Resident #1 said that around 2:00 A.M., he/she went to the nursing station and told Nurse #1 that he/she wanted his/her pain medications, but Nurse #1 said she was unable to give him/her medications because there was nothing available for him/her to have. Resident #1 said that around 4:00 A.M., he/she went back to the nursing station and asked Nurse #1 if she figured out how to look up his/her medication orders yet, but Nurse #1 said she still didn't know how to look up his/her orders. Resident #1 said words to the effect of, My elbow was throbbing and kept me awake all night. Resident #1 said that the next morning, he/she told Nurse #2 that he/she did not receive his/her medications including his/her pain medications, when he/she returned to the Facility because Nurse #1 said she didn't know how to look at his/her physician orders. Review of Resident #1's medical record indicated there was no documentation to support that his/her Physician was notified of his/her complaints of unmanaged pain on 07/07/21. During an interview on 07/28/21 at 1:30 P.M., the Director of Nursing (DON) said that the morning of 07/07/21, she was notified that Resident #1 did not receive his/her bedtime medications after returning to the Facility from the ED. The DON said Nurse #1 failed to assess, treat, and contact Resident #1's Physician on 07/07/21, when he/she complained of ongoing pain throughout the night on 07/07/21.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Physician's orders included scheduled and as needed pain medication, had been evaluated in the Hospital Emergency Department (ED) after a fall in the Facility, and was diagnosed with a contusion of his/her right elbow, the Facility failed to ensure nursing adequately treated and managed Resident #1's pain, when on 7/07/21, after he/she returned from the ED, Nurse #1 did not administer pain medications to Resident #1 because she did not know how to reactivate Resident #1's Electronic Health Record (EHR) upon his/her return from the Hospital. Resident #1 was upset, crying, and unable to sleep, due to untreated and uncontrolled pain. Findings include: Review of The Facility's Policy titled, Medication Orders, dated November 2020, indicated that each resident must be under the care of a Licensed physician and his/her current orders must be maintained in the clinical record of each resident. The Facility's Policy titled, Pain - Clinical Protocol, undated, indicated that: -Nursing staff would assess each individual for pain when there is a new onset of pain or worsening of existing pain, -Nursing staff would identify the nature and severity of pain, -Staff and the physician would evaluate how pain was affecting mood, activities of daily living, sleep, and the resident's quality of life, -With input from the resident and/or advocate, the physician and staff would establish goals of pain treatment and the physician would order appropriate non-pharmacological and medication interventions to address the individual's pain, -Staff would discuss significant changes in levels of comfort with the Attending Physician who would consider adjusting interventions accordingly. Resident #1 was admitted to the Facility in March 2019, his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact and able to make his/her own health care decisions. Review of Resident #1's comprehensive Plan of Care (POC) related to Pain, initiated 12/23/20 and revised 06/25/21, indicated he/she had chronic pain related to Neuralgia (stabbing, burning, and often severe pain due to an irritated or damaged nerve) and required staff interventions to respond immediately to any complaints of pain, and to monitor, record, and report any signs or symptoms of pain. Review of the Hospital Emergency Department Medical Record, dated 07/06/21, indicated Resident #1 had a contusion of his/her right elbow from a fall. The Facility's Internal Investigation, dated 07/07/21, indicated that Resident #1 had an unwitnessed fall during the day on 07/06/21, required evaluation at the Hospital Emergency Department (ED), and returned to the Facility during the overnight shift (11:00 P.M. to 7:00 A.M.) on 07/07/21. The Investigation indicated that Resident #1 did not receive his/her pain medications as ordered by the Physician. The Investigation indicated Nurse #1 made a medication error by not administering Resident #1's pain medications when he/she returned from the ED. The Investigation indicated Nurse #1 reported she was unable to access Resident #1's Electronic Health Record (EHR) and that she failed to ask other nursing staff for assistance to reactivate Resident #1's EHR to ensure Resident #1 received his/her pain medications. Review of the Incident Report, dated 07/07/21, indicated that Resident #1 told a staff member (later identified as Nurse #2) that he/she did not receive his/her medications when he/she returned to the Facility last night. Review of the Investigation Follow-up Incident/Accidents Form, dated 07/08/21, indicated that Nurse #1 said she did not give Resident #1 his/her medications because she could not see them in the EHR. Review of Resident #1's Physician's Order Summary Report, dated 07/06/21, indicated that he/she was scheduled to receive the following pain medications at bedtime: -[MEDICATION(S)] (narcotic medication used to treat moderate to severe pain) 50 milligrams (mg) -[MEDICATION(S)] (anti-epileptic medication used to treat nerve pain) 1200 mg for trigeminal neuralgia (nerve condition characterized by facial pain) The Order Summary Report, dated 07/06/21, indicated Resident #1 could receive the following topical pain medications as needed (PRN) for pain: - Bio Freeze Colorless Gel (used to treat minor aches and pains of muscles and joints) 4%, to be applied to the affected area every six hours for shoulder pain - Muscle Rub Cream 10-15 %, to be applied to the affected area every six hours for pain - [MEDICATION(S)] Gel (used to treat joint pain) 1%, to be applied to affected area every six hours for elbow pain The Order Summary Report, dated 07/06/21, indicated that a pain assessment would be completed every shift for Resident #1. Review of Resident #1's Medical Record indicated that there was no documentation to support that a pain assessment was completed for Resident #1 during the overnight shift beginning on 07/06/21. Review of Nurse #2's Progress Note, dated 07/06/21 at 10:41 P.M., indicated Resident #1 called the Facility and spoke to her and said that he/she would be discharged from the ED soon, and that he/she had concerns about missing his/her bedtime medications. The Note indicated Nurse #2 obtained a physician's order for Resident #1 to receive his/her medications upon return to the Facility. Review of the Physician Verbal Order, dated 07/06/21, received and documented by Nurse #2, indicated that staff could give Resident #1 his/her hour of sleep (bedtime) medications upon return to the Facility tonight. The Order indicated the pain medications listed were to be administered for one time only included: [MEDICATION(S)] 50 mg and [MEDICATION(S)] 1200 mg. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (which was incorrectly dated and timed). The Order indicated the pain medications listed to be administered for one time only were: [MEDICATION(S)] 50 mg and [MEDICATION(S)] 1200 mg. Review of Nurse #1's Progress Note, dated 07/07/21, at 2:00 A.M., indicated Resident #1 returned to the Facility after an evaluation at the Hospital, with no new orders, no medication changes and no discharge instructions. During an interview on 07/28/21 at 9:20 A.M., Nurse #1 said Nurse #2 told her that Resident #1 would be discharged from the hospital with a new medication order. Nurse #1 said she reviewed Resident #1's medication orders and did not see any new orders for Resident #1. Nurse #1 said about 20 minutes after Resident #1 returned from the hospital, he/she asked for his/her pain medication, so she reviewed Resident #1's record and told him/her that he/she did not have any pain medication available at that time. Nurse #1 said she could tell Resident #1 was really upset because he/she was swearing, threatening her, and throwing things. Nurse #1 said she felt bad for Resident #1 but said there was nothing she could do for Resident #1. Nurse #1 said she did not call anyone. Nurse #1 said that during shift report the next morning, she told Nurse #2 that Resident #1 was upset because he/she did not get his/her pain medications. During an interview on 07/28/21 at 11:40 A.M., Resident #1 said that on 07/06/21, when he/she was in the Hospital ED, he/she called the Facility and spoke to Nurse #2 to ensure that he/she would receive his/her evening medications when he/she returned to the Facility. Resident #1 said that Nurse #2 told him/her that she would obtain an order from the physician so he/she could have his/her medications when he/she returned to the Facility. Resident #1 said when he/she arrived at the Facility sometime after midnight on 07/07/21, he/she asked Nurse #1 if he/she could have his/her pain medications, he/she said Nurse #1 told him/her that he/she did not have any medications available. Resident #1 said words to the effect of, My elbow was killing me so I rang the call bell and asked Nurse #1 again for my pain medications, but Nurse #1 said she did not know how to look up my medication orders. Resident #1 said that around 2:00 A.M., he/she went to the nursing station and told Nurse #1 that he/she wanted his/her pain medications, but Nurse #1 said she was unable to give him/her medications because there was nothing available for him/her to have. Resident #1 said that around 4:00 A.M., he/she went back to the nursing station and asked Nurse #1 if she figured out how to look up his/her medication orders yet, but Nurse #1 said she still didn't know how to look up his/her orders. Resident #1 said words to the effect of, My elbow was throbbing and kept me awake all night. Resident #1 said that the next morning, he/she told Nurse #2 that he/she did not receive his/her medications including his/her pain medications, when he/she returned to the Facility because Nurse #1 said she didn't know how to look at his/her physician orders. Review of Resident #1's Medical Record indicated there was no documentation to support that his/her Physician was immediately notified after he/she was upset and crying, unable to sleep and reported ongoing pain multiple times throughout the night to Nurse #1. During an interview on 08/10/21 at 10:00 A.M., Certified Nurse Aide (CNA) #1 said that he worked during the overnight shift (11:00 P.M. to 7:00 A.M.) beginning on 07/06/21 into 07/07/21 and recalled Resident #1 speaking with Nurse #1 after he/she returned from the Hospital. CNA #1 said he saw Resident #1 come out of his/her room twice and said he heard Resident #1 ask Nurse #1 for his/her medications, and heard Nurse #1 tell Resident #1 that he/she did not have any medications available to him/her at that time. CNA #1 said that while Resident #1 was asking for his/her medications his/her voice was rising as he/she insisted on wanting his/her medications. CNA #1 described Resident #1's behavior as, kind of losing it. Review of Nurse #2's Progress Note, dated 07/07/21, indicated that at about 7:30 A.M., Resident #1, who was upset and crying, said that he/she did not sleep at all, and that he/she did not receive his/her bedtime medications last night. During an interview on 07/28/21 at 10:00 A.M., Nurse #2 said that when she arrived to work on 07/07/21, around 7:00 A.M., Resident #1 told her that he/she did not receive his/her medications when he/she returned from the Hospital, causing him/her words to the effect of, a ton of pain and that he/she was unable to sleep at all. During an interview on 07/28/21 at 1:30 P.M., the Director of Nursing (DON) said that the morning of 07/07/21, she was notified that Resident #1 did not receive his/her bedtime medications after returning to the Facility from the ED. The DON said the Facility's EHR system required staff to change a resident's status when they leave and return from a medical leave of absence. The DON said that Nurse #1 said she was unable to reactivate Residents #1's MAR because she didn't know how to change Resident #1's EHR status to show he/she returned to Facility which would have enabled her to access his/her EHR details. The DON said Nurse #1 should have asked other nursing staff, either in the building or on call, for assistance with reactivating Resident #1's EHR to ensure he/she received his/her medications. The DON said Nurse #1 failed to assess, treat, and contact Resident #1's Physician on 07/07/21, when he/she complained of ongoing pain throughout the night on 07/07/21.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had been transferred to the Hospital Emergency Department (ED) for an evaluation after a fall in the Facility, when he/she had not returned in time for his/her scheduled bedtime medications to be administered, the evening shift nurse obtained a onetime order from the physician for Resident #1's bedtime medications to be administered upon return to the Facility, the Facility failed to ensure Resident #1 was free from a significant medication error, when upon his/her return, the medications were not administered. On 07/07/2021, after Resident #1 returned to the Facility, Nurse #1 did not administer Resident #1's scheduled bedtime medications and/or his/her as needed pain medication because she did not know how reactivate Resident #1 in the Electronic Health Record (EHR), as a result Resident #1, who requested the medications several times during the overnight shift from nursing, was upset, crying, and was unable to sleep due to untreated and uncontrolled pain. Findings include: Review of The Facility's Policy titled, Medication Orders, dated November 2020, indicated that each resident must be under the care of a Licensed Physician and his/her current orders must be maintained in the clinical record of each resident. Resident #1 was admitted to the Facility in March 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was cognitively intact and able to make his/her own health care decisions. Review of Resident #1's comprehensive Plan of Care (POC) related to Pain, initiated 12/23/20 and revised 06/25/21, indicated he/she had chronic pain related to Neuralgia (stabbing, burning, and often severe pain due to an irritated or damaged nerve) and required staff interventions to respond immediately to any complaints of pain, and to monitor, record, and report any signs or symptoms of pain. Review of Resident #1's comprehensive POC related to Seizures, initiated 02/19/21 and revised 06/25/21, indicated Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's POC related to Behavioral Health issues, initiated 02/19/21 and revised 06/25/21, indicated Resident #1 used [CONDITION(S)] medications related to a history of Borderline Personality Disorder and [CONDITION(S)], and required staff interventions to administer medications order by the physician, and monitor and document side effects and/or effectiveness. The Facility's Internal Investigation, dated 07/07/21, indicated that Resident #1 had an unwitnessed fall during the day on 07/06/21, required an evaluation at the Hospital Emergency Department (ED), and returned to the Facility during the overnight shift (11:00 P.M. to 7:00 A.M.) on 07/07/21. The Investigation indicated that Resident #1 did not receive his/her medications upon return, as ordered by the Physician. The Investigation indicated Nurse #1 made a medication error by not administering Resident #1's medications when he/she returned from the ED. The Investigation indicated Nurse #1 reported she was unable to access Resident #1's Electronic Health Record (EHR) and that she failed to ask other nursing staff for assistance to reactivate Resident #1's EHR to ensure Resident #1 received his/her medications. Review of the Incident Report, dated 07/07/21, indicated that Resident #1 told a staff member (later identified as Nurse #2) that he/she did not receive his/her medications when he/she returned to the Facility last night. Review of the Investigation Follow-up Incident/Accidents Form, dated 07/08/21, indicated that Nurse #1 said she did not give Resident #1 his/her medications because she could not see them in the EHR. Review of the Hospital Emergency Department Medical Record, dated 07/06/21, indicated Resident #1 had a contusion of his/her right elbow from a fall. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (narcotic used to treat moderate to severe pain) 50 milligrams (mg) - [MEDICATION(S)] (anti-epileptic used to treat nerve pain) 1200 mg - [MEDICATION(S)] (hormone used to help treat insomnia) 6 mg - [MEDICATION(S)] (benzodiazepine used to treat anxiety) 1 mg - [MEDICATION(S)] (anti-diabetic) 1000 mg - [MEDICATION(S)] (insulin) 24 units - [MEDICATION(S)] (antidepressant and used to treat nerve pain) 50 mg - Trazadone (antidepressant)100 mg - [MEDICATION(S)] (antidepressant) HCl 100 mg - [MEDICATION(S)] (anticonvulsant) 200 mg - [MEDICATION(S)] (antibiotic) 550 mg - [MEDICATION(S)] (proton pump inhibitor) 20 mg Review of Nurse #2's Progress Note, dated 07/06/21 at 10:41 P.M., indicated Resident #1 called the Facility and spoke to her and said that he/she would be discharged from the ED soon, and that he/she had concerns about missing his/her bedtime medications. The Note indicated Nurse #2 obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Verbal Order, dated 07/06/21, received and documented by Nurse #2, indicated that staff could give Resident #1 his/her hour of sleep (bedtime) medications upon return to the Facility tonight. The Order indicated the medications listed to be administered for one time only were: [MEDICATION(S)] 50 mg, [MEDICATION(S)] 1200 mg, [MEDICATION(S)] 6 mg, [MEDICATION(S)] 1 mg, [MEDICATION(S)] 1000 mg, [MEDICATION(S)] 24 units, [MEDICATION(S)] 50 mg, Trazadone 100 mg, [MEDICATION(S)] HCl 100 mg, [MEDICATION(S)] 200 mg, [MEDICATION(S)] 550 mg, [MEDICATION(S)] 20 mg. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (which was incorrectly timed and dated). The Order indicated the following medications listed to be administered for one time only were: [MEDICATION(S)] 50 mg, [MEDICATION(S)] 1200 mg, [MEDICATION(S)] 6 mg, [MEDICATION(S)] 1 mg, [MEDICATION(S)] 1000 mg, [MEDICATION(S)] 24 units, [MEDICATION(S)] 50 mg, Trazadone 100 mg, [MEDICATION(S)] HCl 100 mg, [MEDICATION(S)] 200 mg, [MEDICATION(S)] 550 mg, [MEDICATION(S)] 20 mg. Review of Nurse #1's Progress Note, dated 07/07/21, at 2:00 A.M., indicated Resident #1 returned to the Facility after an evaluation at the Hospital, with no new orders, no medication changes and no discharge instructions. During an interview on 07/28/21 at 9:20 A.M., Nurse #1 said Nurse #2 told her that Resident #1 would be discharged from the hospital with a new medication order. Nurse #1 said she reviewed Resident #1's medication orders and did not see any new orders for Resident #1. Nurse #1 said about 20 minutes after Resident #1 returned from the hospital, he/she asked for his/her medications, so she reviewed Resident #1's record and told him/her that he/she did not have any medications available at that time. Nurse #1 said she could tell Resident #1 was really upset because he/she was swearing, threatening her, and throwing things. Nurse #1 said she felt bad for Resident #1 but said there was nothing she could do for Resident #1. Nurse #1 said she did not call anyone. Nurse #1 said that during shift report the next morning, she told Nurse #2 that Resident #1 was upset because he/she did not get his/her medications. During an interview on 07/28/21 at 11:40 A.M., Resident #1 said that on 07/06/21, when he/she was in the Hospital ED, he/she called the facility and spoke to Nurse #2 to ensure that he/she would receive his/her evening medications when he/she returned to the Facility. Resident #1 said that Nurse #2 told him/her that she would obtain an order from the physician so he/she could have his/her medications when he/she returned to the Facility. Resident #1 said when he/she arrived at the Facility sometime after midnight on 07/07/21, he/she asked Nurse #1 if he/she could have his/her medications, and said Nurse #1 told him/her that he/she did not have any medications available. Resident #1 said words to the effect of, My elbow was killing me so I rang the call bell and asked Nurse #1 again for my medications, but Nurse #1 said she did not know how to look up my medication orders. Resident #1 said that around 2:00 A.M., he/she went to the nursing station and told Nurse #1 that he/she wanted his/her medications, but Nurse #1 said she was unable to give him/her medications because there was nothing available for him/her to have. Resident #1 said that around 4:00 A.M., he/she went back to the nursing station and asked Nurse #1 if she figured out how to look up his/her medication orders yet, but Nurse #1 said she still didn't know how to look up his/her orders. Resident #1 said words to the effect of, My elbow was throbbing and kept me awake all night. Resident #1 said that the next morning, he/she told Nurse #2 that he/she did not receive his/her medications including his/her pain medications, when he/she returned to the Facility because Nurse #1 said she didn't know how to look at his/her physician orders. Review of Resident #1's Medical Record indicated there was no documentation to support that his/her Physician was immediately notified after he/she was upset and crying, unable to sleep and reported ongoing pain multiple times throughout the night to Nurse #1. During an interview on 08/10/21 at 10:00 A.M., Certified Nurse Aide (CNA) #1 said that he worked during the overnight shift (11:00 P.M. to 7:00 A.M.) beginning on 07/06/21 into 07/07/21 and recalled Resident #1 speaking with Nurse #1 after Resident #1 returned from the Hospital. CNA #1 said he saw Resident #1 come out of his/her room twice and said he heard Resident #1 ask Nurse #1 for his/her medications, and heard Nurse #1 tell Resident #1 that he/she did not have any medications available to him/her at that time. CNA #1 said that while Resident #1 was asking for his/her medications his/her voice was rising as he/she insisted on wanting his/her medications. CNA #1 described Resident #1's behavior as, kind of losing it. Review of Nurse #2's Progress Note, dated 07/07/21, indicated that at about 7:30 A.M., Resident #1, who was upset and crying, said that he/she did not sleep at all, and that he/she did not receive his/her bedtime medications last night. During an interview on 07/28/21 at 10:00 A.M., Nurse #2 said that when she arrived to work on 07/07/21, around 7:00 A.M., Resident #1 told her that he/she did not receive his/her medications when he/she returned from the Hospital, causing him/her words to the effect of, a ton of pain and that he/she was unable to sleep at all. During an interview on 07/28/21 at 1:30 P.M., the Director of Nursing (DON) said that the morning of 07/07/21, she was notified that Resident #1 did not receive his/her bedtime medications after returning to the Facility from the ED. The DON said the Facility's EHR system required staff to change a resident's status when they leave and return from a medical leave of absence. The DON said that Nurse #1 said she was unable to reactivate Residents #1's MAR because she didn't know how to change Resident #1's EHR status to show he/she returned to Facility, which would have enabled staff access to his/her EHR details. The DON said Nurse #1 should have asked other nursing staff, either in the building or on call, for assistance with reactivating Resident #1's EHR to ensure he/she received his/her medications. The DON said Nurse #1 failed to assess, treat, and contact Resident #1's Physician on 07/07/21, when he/she complained of ongoing pain throughout the night on 07/07/21.

Based on interviews and records reviewed, the Facility failed, for one of three sampled residents (Resident #1), to assess Resident #1 for use of bed rails, failed to obtain informed consent from Resident #1 or his/her representative for the use of bed rails, and failed to prevent entrapment in a bed rail, when Resident #1's right hand became trapped between the bed rail and the mattress resulting in his/her thumb being fractured. Findings include: The policy titled Bed Safety, dated 12/2007, indicated that if bed rails were used, there would be an interdisciplinary assessment of the resident, consultation with the attending physician, input from the resident and/or legal representative, and consent would be obtained for the use of side rails from the resident or the resident's legal representative prior to the use of bed rails. Resident #1 was admitted to the Facility 5/2010, [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], indicated Resident #1 was cognitively impaired, and required total assistance with transfers and bed mobility. Review of Resident #1's medical record indicated there was no assessment for the use of bed rails or signed consent for use of bed rails prior to 9/3/17. The Surveyor interviewed the Director of Nurses at 1:22 P.M. on 3/29/18. The Director of Nurses confirmed there was no assessment for the use of bed rails or signed consent for use of bed rails prior to 9/3/17 for Resident #1. The Incident/Accident Report, dated 9/3/17, indicated Resident #1 was found at 7:15 A.M., in bed with his/her right hand between the mattress and the bed rail, and the underside of his/her hand was bruised. The Surveyor interviewed Nurse #1 at 10:41 A.M. on 3/29/18. Nurse #1 said that at approximately 7:30 A.M. on 9/3/17 she found Resident #1 in bed, lying on his/her back, with his/her right hand stuck between the bed rail and the mattress on his/her right side. Nurse #1 said the bed rail was snug up against the mattress, and she moved Resident #1's hand from between the mattress and the bed rail and noticed bruising at the underside of his/her hand. Nurse #1 said Resident #1 did not have any signs or symptoms of pain, and the Physician and Resident #1's family was notified. Review of Resident #1's medical record indicated his/her right thumb was bruised and swollen, and there were no other accidents or incidents between 9/3/17 and 9/5/17. The Progress Notes, dated 9/5/17, indicated Resident #1's thumb was slightly swollen and bruised, he/she was examined by the Nurse Practitioner, and an X-ray was ordered for Resident #1's right thumb. The Radiology Report, dated 9/5/17, indicated Resident #1 had a mildly displaced fracture at the base of his/her thumb.

Based on record review, facility policy and staff interviews, the facility failed to fully investigate an injury of unknown origin for one Resident (#11) out of a sample of 19 Residents. Findings include: For Resident #11 the facility failed to fully investigate an injury of unknown origin. The clinical record was reviewed on 3/16/17. Resident #11 was admitted to the facility in 2/2017 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 had a severely impaired cognitive status with a brief interview of mental status (BIMS) of 1, which indicates significant cognitive impairment. The MDS further indicated that Resident #11 required extensive assistance of 2 staff for transfers and an extensive assist of one for ambulation. Review of the facility document titled Event Summary Report and dated 3/5/2017, indicated that on 3/5/2017 at 7:10 A.M. Certified Nurses Aide (CNA) informed Resident #11's nurse that he/she had a 6 centimeter (cm), by 5 cm bruise on the left side of his back from an unknown cause. On 3/7/2017, an X-ray of the left ribcage was ordered by the physician secondary to increased bruising on the left side of his/her ribcage. An X-ray performed in the facility and the results indicated multiple rib fractures of the 8th through 10th ribs. Resident #11 was then sent to the hospital for further evaluation and returned the same evening with a [DIAGNOSES REDACTED]. On 3/9/2017, a physicians order for a complete blood count was obtained and completed. The results of the test indicated the Resident had a significant drop in his/her hematocrit and hemoglobin, indicting he/she was losing blood. Resident #11 was sent to the hospital on [DATE], secondary to acute loss of blood. Review of the hospital document titled Surgical Consultation and dated 3/9/2017, indicated that a Computed tomography scan (a scan of the body that uses special x-ray equipment to help detect a variety of diseases and conditions) of the chest, abdomen and pelvis demonstrated multiple rib fractures, left pleural effusion consistent with chylous effusion suggestion of [MEDICATION NAME] duct transsection, possible small posterior splenic hematoma. Review of the facility document titled Witness Interview Record and dated 3/5/17, at 7:30 A.M., indicated that CNA #1 said she worked on 3/4/2017 and toileted him/her sometime before 3 P.M. and did not see any bruising on his/her back. CNA #1 then said she worked 3/5/2017, and at 7:10 A.M. she observed a discolored area on Resident #11's back and reported it to the nurse. Review of the facility document titled Witness Interview Record and dated 3/4/17, at 7:10 A.M., indicated that Nurse #3 said a CNA showed her a bruised area on the Resident's left posterior ribcage. Review of a facility document dated 3/7/17, indicated that CNA #2 said she did not see a bruise on Resident #11 when she worked 3/3/17, 3/4/17, 3/5/17, on the 11 P.M.-7 A.M. shift. CNA #2 said she became aware of the bruise on 3/6/17, when she was told of it in the morning. Review of a facility document dated 3/10/17, indicated that CNA #3 worked 3/4/2017, 3 P.M.- 11 P.M., and that she and another CNA put Resident #11 to bed. During an interview on 3/16/17, at 8:20 A.M., the Director of Nursing (DON) said that she was unable to determine the cause of the injury. She also said that the investigation into the cause of the bruise did not include a conclusion as to whether abuse had occurred. During an interview on 3/16/17, at 9:25 AM., the DON said if the Resident had sustained a fall, she didn't see how he/she would have been able to get up on his/her own after suffering such an injury but her investigation concluded that staff denied knowing anything about a fall, or any other potential cause for the injury, on or before 3/5/2017. Review of the facility policy OPS311-MA Abuse Prohibition-State of Massachusetts and dated revised 11/28/16, indicated in section 6.3 that injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. Review of the facility document titled Event Summary Report and dated 3/5/2017, indicated that on page 2 of 3 the space after the question Was there alleged abuse? was left blank, the space after the Summary of interviews with staff having possible contact with the resident over the past 24-48 hours prior to the discovery of the injury is left blank, and on page 3 of 3, the space after the Summary of Investigation Root cause/conclusion is left blank.

Based on records review and interviews for 1 of 3 sampled Residents, Resident #1, the Facility failed to obtain treatment orders for a urinary tract infection in a timely manner, and Resident #1 was transferred to the Hospital and he/she died nine days later with causes of death that [MEDICAL CONDITION] secondary to a urinary tract infection. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Facility's Policy titled Physician/Mid-level Provider Notification indicated that upon identification of a patient who has a change in condition or abnormal laboratory values (such as blood and urine), a licensed nurse will perform appropriate clinical observations and data collection and report to physician/mid-level provider. An Admission Nursing Assessment, dated [DATE], indicated Resident #1 had an indwelling urinary catheter. A nurse's progress note, dated [DATE] and timed at 4:26 P.M., indicated Resident #1 was in and out of alertness throughout the day, was difficult to arouse, had labored breathing, amber colored urine, and there was blood on his/her genital area. The note indicated the Nurse Practitioner was notified and an order for [REDACTED]. A laboratory result report electronically faxed to the facility on [DATE] at 10:17 P.M. indicated Resident #1's urinalysis was abnormal. A laboratory order form completed by the Facility staff on [DATE] indicated that only a urinalysis was ordered, no culture and sensitivity. Nurse's progress notes, dated [DATE] and timed at 5:39 A.M. and 12:42 P.M., indicated Resident #1's urinalysis results were received but the urine culture was still pending. Family Member #1 was interviewed on [DATE] at 11:45 A.M. Family Member #1 said when he/she visited Resident #1 on [DATE], Resident #1 appeared delirious and was talking about monsters. Family Member #1 said he/she asked a nurse if the Resident #1's urine results were back and a nurse told him/her the results weren't back because it was a weekend, or words to that effect. A nurse's progress note, dated [DATE] and timed at 10:31 A.M., indicated Resident #1's urinary catheter was draining cloudy amber urine with clots and staff were awaiting Resident #1's urine culture results. There was no documentation to indicate the Physician was notified of the changes in Resident #1's urine characteristics. The Director of Nursing was interviewed on [DATE] at 12:15 P.M. The Director of Nursing said nurses should have notified the Physician about Resident #1's abnormal urinalysis results but didn't because they were waiting for Resident #1's urine culture results to come back. The Director of Nursing was interviewed on [DATE] at 9:19 A.M. and said the nurse made a mistake on the lab form and did not order a urine culture for Resident #1. A laboratory order form completed by Facility staff on [DATE] did not include a urine culture. The Director of Nursing said the Facility did not follow the Nurse Practitioner's orders. The Nurse Practitioner was interviewed on [DATE] at 9:30 A.M. The Nurse Practitioner said she was not aware that the Facility had not obtained the urine culture. The Nurse Practitioner did not recall speaking to anyone about Resident #1's urinalysis results, but expected to be notified when Resident #1's urinalysis results came back abnormal. Nurse #1 was interviewed on [DATE] at 12:45 P.M. Nurse #1 said she obtained orders for a urinalysis and urine culture on [DATE] because Resident #1 was having a change of status and she suspected he/she had a urinary tract infection, or words to that effect. Nurse #1 said when she returned to the facility on [DATE] she observed Resident #1's status was further declining and through report and documenation review found that nobody called the Physician to report Resident #1's abnormal urinalysis per Facility policy or checked on his/her urine culture. A nurse's progress note, dated [DATE] and timed at 11:08 A.M., indicated Resident #1 was unable to open his/her eyes without stimuli, had amber colored urine, was shaking, and had an elevated body temperature of 102.6 degrees (normal body temperature is 98.6 degress). The note indicated the Nurse Practitioner was notified and an order was obtained to transfer Resident #1 to the hospital. Emergency Department records, dated [DATE], indicated Resident #1's temperature was 101 degrees and he/she had a urinary tract infection of which symptoms met the Systemic [MEDICAL CONDITION] Response Syndrome (an [MEDICAL CONDITION] state of the whole body in response to infection). Resident #1 was admitted to the Hospital and died on [DATE]. Hospital Records indicated Resident #1's cause of death [MEDICAL CONDITION] secondary to a urinary tract infection.

Based on records review and interviews for 1 of 3 sampled Residents, Resident #1, the Facility failed to notify the Physician of abnormal urinalysis results in a timely manner. Findings include: Facility Policy titled Physician/Mid-level Provider Notification indicated upon identification of a patient who has a change in condition or abnormal laboratory values (such as blood and urine), a licensed nurse will perform appropriate clinical observations and data collection and report to physician/mid-level provider. A nurse's progress note, dated [DATE] and timed at 4:26 P.M., indicated Resident #1 was dificult to arouse, had labored breathing, his/her urine was amber and he/she had blood on his/her genital area. The note indicated the Nurse Practitioner was notified and an order urinalysis and urine culture was given. The laboratory result report was electronically faxed to the facility on [DATE] at 10:17 P.M. and indicated Resident #1's urinalysis was abnormal. There was no indication the Physician was notified of Resident #1's abnormal urinalysis results. The Director of Nursing was interviewed on [DATE] at 12:15 P.M. The Director of Nursing said nurses should have notified the Physician about Resident #1's abnormal urinalysis results but they didn't because they were waiting for Resident #1's urine culture results to come back. The Director of Nursing was interviewed on [DATE] at 9:19 A.M. and said the nurse made a mistake on the lab form and did not order a urine culture for Resident #1. A laboratory order form completed by Facility staff on [DATE] did not include a urine culture. The Director of Nursing said the Facility did not follow the Nurse Practitioner's orders. The Nurse Practitioner was interviewed on [DATE] at 9:30 A.M. The Nurse Practitioner said she was not aware that the Facility had not obtained the urine culture. The Nurse Practitioner did not recall speaking to anyone about Resident #1's urinalysis results, but expected to be notified when Resident #1's urinalysis results came back abnormal. A nurse's progress note, dated [DATE] and timed at 11:08 A.M., indicated Resident #1 was unable to open his/her eyes without stimuli, had amber colored urine, was shaking, and had an elevated body temperature of 102.6 degrees. The note indicated the Nurse Practitioner was notified of Resident #1's condition and lab results. Orders were obtained for Resident #1 to be transferred to the hospital. Hospital Emergency Department documentation indicated on [DATE] indicated Resident #1 was found to have a urinary tract infection. Resident #1 was admitted to the hospital and died nine days later. Hospital Records indicated Resident #1's cause of death [MEDICAL CONDITION] secondary to a urinary tract infection.

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 received adequate supervision when he/she was observed by staff to eat non-edible items, a behavior first noted by staff during November 2011. On 3/31/12 Resident #1 was evaluated at the Hospital and required emergent removal of a foreign body from Resident #1's airway and on 4/11/12, it was determined that Resident #1 had multiple foreign bodies which required surgical removal from the stomach and small intestine. In addition, the Facility failed to lock the clean utility rooms containing hazardous items, for two of the Facility's three resident units. The findings include: 1. The Guardianship documentation, dated 7/17/08, indicated that Resident #1 had a Guardian appointed on this date. The Guardianship paperwork was approved by the court again on 3/6/12. The quarterly Minimum Data Set assessment, dated 1/30/12, indicated that Resident #1 had intact short-term memory; and poor decision making ability. The assessment indicated that Resident #1 had behavioral symptoms not directed at others, which occurred one to three times per week. The care plan, dated 5/11/11, indicated that Resident #1 exhibited the behavior of ingesting food and fluids but was to have nothing by mouth. The care plan was computerized and printed care plan, but hand written on the care plan was, "(plus) objects." The date this was added was not indicated on the care plan. The care plan interventions, dated 5/11/11, indicated that staff were to document each episode (of eating or drinking), keep food and fluids away from Resident #1, continue on-going family education regarding risks and benefits (of not following recommended restriction), remove non-edible but frequently ingested objects from Resident # 1's room, and staff were to continue "frequent" checks. Though the care plan included the intervention to address Resident #1 eating non-edible items as of 5/11/11, there was no documentation within the record to indicate when the behavior was first noted, (the first nurse's note documentation the behavior was in November 2011). The Surveyor interviewed Unit Manager #1 at 3:25 P.M. on 6/7/12. The Surveyor interviewed Nurse #1 at 5:20 P.M. on 6/7/12. The Surveyor interviewed Nurse #2 at 2:55 P.M. on 6/7/12. The Surveyor interviewed Nurse #3 at 4:10 P.M. on 6/7/12. The Surveyor interviewed Nurse #4 at 6:08 P.M. on 6/7/12. The Surveyor interviewed Nurse #5 at 11:11 A.M. on 6/12/12 and Nurse #6 at 11:45 A.M. on 6/12/12. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #6 said that Resident #1 was not to eat anything by mouth due to aspiration and difficulty swallowing. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, and Nurse #4 said that Resident #1 was to have all nutrition and hydration through a gastrostomy tube (tube inserted into the stomach through the abdominal wall for the purpose of providing artificial nutrition and hydration). Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, and Nurse #4 said that when Resident #1 was first admitted to the Facility, Resident #1's behaviors included eating and drinking despite the physician's orders [REDACTED]. Unit Manager #1 said that Resident #1 would take food from other residents food trays, the food carts, and the trash and would attempt to eat them. Nurse #1 said that Resident #1 attempted to take coffee from his/her roommate and when staff turned away from Resident #1, he/she would attempt to get something to drink on a consistent basis during Resident #1's admission period. Nurse #1 said that though she never observed Resident #1 take cups from the trash, the Guardian informed Nurse #1 that Resident #1 told the Guardian he/she obtained cups from the trash when questioned. Nurse #1 did not specifically recall when she was informed by the Guardian of this behavior or whether Resident #1 told the Guardian what he did with the cups. Nurse #4 said that Resident #1 was known to drink from the faucet in his/her room. Nurse #4 said that during Resident #1's admission period, she observed on one occasion where Resident #1 was found in the dark in his/her bathroom and when Nurse #4 entered the bathroom, Resident #1 was observed to be chewing and swallowing a paper napkin. Nurse #4 did not recall the date this occurred. Nurse #4 said that the napkin had to be forcibly removed from Resident #4 because it was clear to Nurse #4 that Resident #1 was choking on the napkin, because Resident #1 was coughing while attempted to swallow the napkin before it could be removed from Resident #1's mouth. Nurse #4 did not recall whether the incident was documented in the nurse's notes, but thought that she documented the incident. Review of Resident #1's record did not include any documentation referencing this incident as reported to the Surveyor by Nurse #4. There was no indication that Resident #1's behaviors were evaluated by the facility interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety The psychiatric consultation, dated 9/29/11, indicated that Resident #1's history included schizophrenia, history of subdural hematoma with craniotomy, and left basal ganglia infarct. The evaluation indicated that Resident #1 lacked the ability to sustain focus and had impaired comprehension, and lacked the ability to make informed decisions; and had impaired judgment; and was known to attempt to consume liquids orally despite the restrictions and concerns related to aspiration. The nurse's note, dated 11/2/11, indicated that Resident #1 was observed, "multiple times," attempting to pick paper scraps off the floor and put them into his/her mouth. The note indicated that Resident #1's Guardian was informed of the behavior. There was no indication that Resident #1 was immediately evaluated by a physician for the behavior of placing non-food items in his/her mouth. The physician progress notes [REDACTED].#1 (Primary Care Physician) on this date. The progress note indicated that Physician #1 documented that there was a concern that Resident #1 was observed eating non-edible things such as paper. There was no documentation within the note to indicate what the plan was regarding Resident #1 eating non-edible items. There was no indication that Resident #1's behaviors were evaluated by the facility interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety The care plan was updated on 11/14/11, to include the intervention that Resident #1's room was to be checked for food by two nurses every shift. The treatment records indicated that as of 11/14/11, the nursing staff documented that two nurses checked Resident #1's room every shift for food due to Resident #1's non-compliance with NPO (nothing by mouth) status. There was no documentation to indicate the room was checked for non-edible items which Resident #1 could place in his/her mouth. The nurse's note, dated 11/16/11, indicated that at 2 P.M., Resident #1's Guardian was contacted by Unit Manager #1, regarding Resident #1's behavior of, "eating non-eatable(sic) stuff," and that the staff wanted Resident #1 to be evaluated by the Facility's consulting psychiatrist. The note indicated that the Guardian requested that the staff wait one week to determine whether the behavior continued and if it did, the Guardian would take Resident #1 to Resident #1's psychiatrist in the community. There was no documentation to indicate that a physician evaluated Resident #1 or that a physician was consulted regarding Resident # 's behavior of eating non-edible items. The nurse's note, dated 11/17/11, indicated that at 11:50 A.M., Resident #1 was observed (by Nurse #2) chewing on something and when the nurse asked Resident #1 to spit the item out, Resident #1 had increased anger and it was noted that Resident #1 had small piece of paper or cardboard-like substance in his/her mouth, which Resident #1 swallowed. The note indicated that Resident #1's Guardian was informed of the incident. The nurse's note, dated 11/26/11, indicated that Resident #1 was observed eating from supper trays that were in the food cart. The note indicated that Resident #1 was redirected and reinforced that Resident #1 was NPO status. The physician progress notes [REDACTED].#1 on this date, but did not include any documentation regarding Resident #1's behavior of eating non-edible items such as paper. The nurse's note, dated 1/1/12, indicated, Resident #1's Guardian informed the Facility that Resident #1 informed the Guardian that Resident #1 ate food from the supper trays the night before. The note indicated that Resident #1 had audible wheezing and congestion, the note indicated that the physician was to be notified and that staff were educated to provide frequent checks. The plan of care did not indicate what "frequent checks" meant. There was no indication that the behaviors were evaluated by the the interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety. There was no documentation to indicate that Resident #1's level of supervision was re-evaluated given Resident #1's know behavior of eating non-edible items and eating and drinking food items. The nurse's note, dated 2/2/12, indicated that, Resident #1 was found to be drinking water out of the sink in the bathroom. The nurse's noted, dated 2/8/12, indicated that, Resident #1 was observed eating paper off of the floor and refused to spit the paper out. The note indicated that Resident #1 became agitated when asked to spit the paper out and swallowed it. The note indicated that Resident #1 was educated on importance of NPO status. There was no indication that Resident #1's behaviors were evaluated by the interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety. The Surveyor reviewed the psychiatric communication book entries, dated from November 2011 to 2/9/12. There was no documentation to indicate that the psychiatrist was asked to evaluate Resident #1 for the behavior of eating non-edible items. The psychiatric evaluation, dated 2/9/12, indicated that Resident #1's treatment plan was reviewed for the benefits versus risks of Prolixin (anti-psychotic) and clozapine (anti-psychotic) use. The evaluation indicated that Resident #1 had improved cognition, decreased paranoia, and that Resident #1's mood was well regulated. The evaluation indicated that Resident #1's phonation and ambulation were impaired and that Resident #1 was not able to assist with decisions due to his/her neuro-degenerative condition. The nurse's note, dated 2/15/12, indicated that, during the 3 P.M. to 11 P.M. shift, Resident #1's Guardian told a nurse that while providing care to Resident #1, the Guardian found a fuse in Resident #1's stool/underwear. The note indicated that Resident #1 had no distress or complaints of pain and that the plan was for the nurse to continue to monitor Resident #1. There was no documentation to indicate that a physician was notified of the incident or that Resident #1 was evaluated by a physician after a fuse was found in Resident #1's underwear/stool. Nurse #1 said that one evening (2/15/12), the Guardian showed Nurse #1 a metal and glass fuse which was mixed with feces. Nurse #1 said that the Guardian told Nurse #1 that he found the fuse in Resident #1's underwear and feces when cleaning Resident #1. The nurse's note, dated 2/22/12, indicated that Resident #1 was reviewed at IDT (interdisciplinary team) meeting at 10:40 A.M. The note indicated that Resident #1 continued to be non-compliant with NPO status; and took food and fluids off other residents' trays; and picked up lint and paper off the floor. The note indicated that Resident #1 was redirected with limited effect and that the physician and the Guardian were aware. The note indicated that at 1:15 P.M. Resident #1 was observed to have balloon strings, "lots of them" in his/her mouth. The note indicated that the nurse removed the items from Resident #1's mouth and in response, Resident #1 became agitated and grabbed at and scratched the nurse's arm. The note indicated that Resident #1 was provided education and then went into his/her room. The note indicated that Resident #1 was then observed to enter the bathroom in Resident #1's room and drink water from the faucet. The note indicated that the nurse attempted to redirect Resident #1 "away." The note indicated that the Guardian and the nurse practitioner were informed. On 2/22/12, the care plan was updated to include frequent checks by staff, which was an intervention in place since May 2011. There was no intervention to indicate the level of supervision that was necessary to ensure that Resident #1 was not able to consume food and non-food items, whether intentional or unintentional. Nurse #2 said that Resident #1 was observed at least once or twice a week picking up paper wrappers from straws and punch hole papers and placing them in his/her mouth. Nurse #1 said that she observed Resident #, "every once in awhile" or words to that effect, pick tissue paper off of the floor and put it into his/her mouth. Nurse #2 said that Resident #1 would become agitated when staff attempted to remove the items. Nurse #3 said that Resident #1 was observed to pick up things off the floor and place them into his mouth and when staff attempted to get the things out of Resident #1's mouth before they could be swallowed, Resident #1 would become agitated with staff when they tried to stop Resident #1. Nurse #3 said that the behaviors occurred, "a lot," which was defined by Nurse #3 as having occurred whenever Resident #1 thought no one was watching him. Unit Manager #1 said that Resident #1 was observed to go through the garbage at least three to four times a week and needed to be redirected away from the trash. Unit Manager #1 said that Resident #1 was observed eating paper and that there was no way, despite staffs attempt to redirect Resident #1 to stop the behavior. Nurse #6 said that Resident #1 was observed trying to remove items from the trash can attached to the medication cart. Nurse #6 said that in addition to trying to get food or fluids to eat and drink, Resident #1 would place anything he could get into his/her mouth, which included the trash from medication cart. Nurse #6 said that she did not always write a nurse's note when she observed Resident #6 eating non-food items. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #6 said that Resident #1 was able to propel him/herself throughout the nursing unit and lobby, and was allowed in his/her room without supervision from staff. Unit Manager #1, Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said that Resident #1 was not consistently supervised when in his/her room, on the nursing unit, or in the lobby at all times, and therefore the staff would not always know when Resident #1 placed items in his/her mouth or consumed food or non-food items. The dysphagia evaluation, dated 2/29/12, indicated that Resident #1 had a gastrostomy tube since April 2011 and was to have nothing by mouth (NPO). The evaluation indicated that Resident #1 had been provided regular texture food items by the Guardian and that Resident #1 was witnessed eating non-food items recently. The note indicated that the nursing staff informed the Speech Language Pathologist that Resident #1 was found with ribbon hanging out of Resident #1's mouth. The psychiatric evaluation, dated 3/8/12, indicated that Resident #1 was evaluated for increased sialorrhea (increased production of saliva) due to medication. The evaluation indicated that thought and behavior were well controlled and that Resident #1 was prone to putting, "anything" in his mouth now that Resident #1 was allowed oral nutrition. The evaluation indicated that this behavior can be better controlled by controlling his/her exposure to objects. The evaluation indicated the room had been checked regularly. The plan was to, "avoid (resident) having access to objects putting (him/her) at risk for choking." The Surveyor interviewed the Psychiatrist at 11:10 A.M. on 6/7/12. The Psychiatrist said that the first time he was aware of a concern that Resident #1 put non-food items in his/her mouth, according to the evaluation, was on 3/8/12. The Psychiatrist said that he discussed Resident #1's condition and history with Resident #1's Guardian, who was also a family member. The Psychiatrist said that the Guardian never informed him that he observed Resident #1 was eating non-food items. The Psychiatrist said that based on the information he was provided from staff, Resident #1 was putting non-food items in his/her mouth. The Psychiatrist said that he instructed staff that Resident #1's room needed to be "clear" of things that Resident #1 could potentially place in Resident #1's mouth. There was no documentation to indicate how the Facility planned to prevent Resident #1 from having access to objects putting Resident #1 at risk for choking or how the staff planned to control Resident #1's exposure to objects, in accordance with the psychiatrist's evaluation. There was no indication that Resident #1's behaviors were evaluated by the facility interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety or prevent injury to his/herself from consuming food and non-edible items. The nurse's note, dated 3/31/12, indicated that Resident #1 approached the nurses (later identified as Nurse #1 and Nurse #3) and pointed toward his/her throat. The note indicated that Resident #1 was trying to say that he/she possibly had something in his/her throat. The note indicated that Resident #1 did not appear to be in any distress. The note indicated that nothing was felt in the throat when touched and there were no acute changes in condition noted with Resident #1. The note indicated that the Guardian visited Resident #1, informed the Guardian that he/she ate a cap to a coffee cup and that it was stuck in his/her throat. The nurse's note indicated that the Guardian took Resident #1 to the Hospital for an evaluation. The Hospital History and Physical, dated 4/1/12, indicated that Resident #1 was admitted for possible aspiration after swallowing a piece of a coffee lid. The note indicated that Resident #1 was emergently transferred to the operating room for emergent removal of the foreign body. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 2:10 P.M. on 6/7/12; CNA #2 at 2:25 P.M. on 6/7/12; CNA #3 at 2:40 P.M. on 6/7/12. The Surveyor interviewed CNA #4 at 4:45 P.M. on 6/7/12 and CNA #5 at 5:03 P.M. on 6/7/12. CNA #1 said that she was never informed that Resident #1's room was to be free of items he/she could eat or place in his/her mouth. CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 said that that Resident #1 was able to be in his room and was able to be anywhere Resident #1 wanted on the unit without staff present. CNA #2, CNA #4, and CNA #5 said that they were informed by the nurses that the staff needed to watch Resident #1 because Resident #1 put food and non-edible items in his/her mouth. CNA #3 said that she recalled observing Resident #1 bend down and touch the floor but never observed Resident #1 put non-food items in his/her mouth. CNA #3 said that she recalled being aware that the staff needed to monitor Resident #1 because Resident #1 liked to take food off of other residents' food trays or from the food cart. CNA #3 said that she was informed that staff were to ensure that food was not left around for Resident #1 to eat or drink. CNA #3 said that it never occurred to CNA #3 that Resident #1 would eat non food items, and only learned of the behavior after Resident #1 was hospitalized (on 3/31/12). CNA #1, CNA #2, CNA #3, and CNA #5 said that there was no scheduled monitoring or staff member assigned to supervise Resident #1. CNA #2 said that unless Resident #1 told a staff member that he/she ate something (food of non-edible item) or unless Resident #1 was witnessed by staff, the staff would not know every time Resident #1 ate something he/she should not. There was no documentation to indicate that Resident #1 was evaluated by the primary care physician any time after 11/29/11. The Surveyor interviewed the Director of Nurses (DON) and the Administrator at 10:50 A.M. on 6/7/12, and at various other times during the survey. The DON said that on 4/1/12, it was determined that Resident #1's physician had examined any of his residents since November 2011, including Resident #1. The DON said that corrective action was taken regarding the concern. The Surveyor interviewed the Primary Care Physician (Physician #1) at 2:55 P.M. on 6/7/12. Physician #1 said that it was possible that staff contacted a covering physician or nurse practitioner regarding Resident #1's behavior of eating non-food items or placing non-edible items in his/her mouth. Physician #1 said that he was never informed that a fuse was found in Resident #1's stool or underwear or that Resident #1 was found chewing on balloon strings. Physician #1 said that those incidents were so unusual that he was certain he would recall having been informed, but did not. Physician #1 said that the only reasonable interventions would be to remove items from the environment that could potentially be placed in the mouth and to provide 24-hour supervision. The radiology report, dated 4/11/12, indicated that the exam was obtained because Resident #1 complained of abdominal pain with a question of a foreign body. The report indicated that a crucifix and probably rosary beads, two paper clips, and portions of a ball point pen were in Resident #1's stomach and extending into the small intestines. The report indicated that in addition, a "good deal" of material was in the stomach, including the possibly of beazor (hard undigestible material). The report indicated that upon retrospective review of a previous computed tomography, from August 2011, it did suggest a beazor in the stomach at that time. The operative report, dated 4/11/12, indicated that Resident #1 ingested multiple products, including paper, plastic, paperclips, and surgical gloves which were unable to be removed via laryngoscope. The report indicated that a laparotomy was performed and a, "large amount of debris was removed from Resident #1's stomach, which included plastic, paperclips, paper and gloves. The Gastroenterology report, dated 4/13/12, indicated that a retrospective review of a computed tomography of the chest from 4/3/12 was completed. The report indicated that there was sufficient view of the abdomen which indicated that the abdomen was distended, there were likely foreign bodies, in addition to a large amount of porous material. The Hospital provided the Surveyor with photographs of the items removed from Resident #1's stomach on 4/11/12. The photographs indicated that the contents included gloves, fabric, plastic, paper clips, tags from clothing, paper, cardboard, and two heart shaped decorations. 2. The Surveyor toured resident unit #1 on 6/26/12 at 10:00 A.M. and again at 11:20 A.M. The Surveyor observed, at both times, that the clean utility room was unlocked and the door was ajar. The Surveyor observed that the wall cabinets inside the room were unlocked and stored twin blade razors, alcohol preparation wipes, instant hand sanitizers, antibiotic jellies, bacitracin, antifungal creams and denture tablets. In addition, an unlocked treatment cart was stored in the room, which held residents' personal prescription medications, including antibacterial and antifungal ointments. The Surveyor toured resident unit #2 on 6/26/12 at 3:20 P.M.. The Surveyor observed that the clean utility room was unlocked. The Surveyor observed that the wall cabinets inside the room were unlocked and stored alcohol preparation wipes, instant hand sanitizer, bacitracin, antifungal creams and hydrogen peroxide. The DON was interviewed in 6/26/12 at 4:10 P.M. The DON said that the clean utility rooms in the Facility were required to be locked to prevent residents from having access to these (potentially hazardous) items.

Based on record review and interviews for one of three sampled residents (Resident #1) the Facility failed to ensure that the care plan was implemented when Resident #1 was observed by staff to eat non-edible items, a behavior first noted by staff during November 2011. The Psychiatrist evaluated Resident #1 on 3/8/12, and recommended that Resident #1's behavior could be controlled by controlling his exposure to objects and that the plan was to, "avoid (Resident #1) having access to objects putting (Resident #1) at risk for choking." There was no indication that this occurred and Resident #1 was allowed unlimited access to items he/she could place in his/her mouth. On 3/31/12 Resident #1 was evaluated at the Hospital and required emergent removal of a foreign body from Resident #1's airway and on 4/11/12, it was determined that Resident #1 had multiple foreign bodies in the stomach and small intestine which required surgical removal. The findings include: The care plan, dated 5/11/11, indicated that Resident #1 exhibited the behavior of ingesting food and fluids but was to have nothing by mouth. The care plan was computerized and printed care plan, but hand written on the care plan was, "(plus) objects." The date this was added was not indicated on the care plan. The care plan interventions, dated 5/11/11, indicated that staff were to document each episode (of eating or drinking), keep food and fluids away from Resident #1, continue on-going family education regarding risks and benefits (of not following recommended restriction), remove non-edible but frequently ingested objects from Resident # 1's room, and staff were to continue "frequent" checks. Though the care plan included the intervention to address Resident #1 eating non-edible items as of 5/11/11, there was no documentation within the record to indicate when the behavior was first noted, (the first nurse's note documentation the behavior was in November 2011). The care plan indicated 11/8/11 it was updated to include having a suction machine at the bedside; and on 11/14/11 for Resident #1's room to be checked by two nurses every shift. The care plan did not indicate what staff were to be checking for. The Surveyor interviewed Unit Manager #1 at 3:25 P.M. on 6/7/12. The Surveyor interviewed Nurse #1 at 5:20 P.M. on 6/7/12. The Surveyor interviewed Nurse #2 at 2:55 P.M. on 6/7/12. The Surveyor interviewed Nurse #3 at 4:10 P.M. on 6/7/12. The Surveyor interviewed Nurse #4 at 6:08 P.M. on 6/7/12. The Surveyor interviewed Nurse #5 at 11:11 A.M. on 6/12/12 and Nurse #6 at 11:45 A.M. on 6/12/12. Nurse #4 said that during Resident #1's admission period, she observed on one occasion where Resident #1 was found in the dark in his/her bathroom and when Nurse #4 entered the bathroom, Resident #1 was observed to be chewing and swallowing a paper napkin. Nurse #4 did not recall the date this occurred. Nurse #4 said that the napkin had to be forcibly removed from Resident #4 because it was clear to Nurse #4 that Resident #1 was choking on the napkin, because Resident #1 was coughing while attempting to swallow the napkin before it could be removed from Resident #1's mouth. Nurse #4 did not recall whether the incident was documented in the nurse's notes, but thought that she documented the incident. Nurse #2 said that Resident #1 was observed at least once or twice a week picking up paper wrappers from straws and punch hole papers and placing them in his/her mouth, but did not specifically recall when these incidents occurred. Nurse #1 said that she observed Resident #1, "every once in awhile" or words to that effect, pick tissue paper off of the floor and put it into his/her mouth. Nurse #3 said that Resident #1 was observed to pick up things off the floor and place them into his/her mouth and when staff attempted to get the things out of Resident #1's mouth before they could be swallowed, Resident #1 would become agitated. Nurse #3 said that the behaviors occurred, "a lot," which was defined by Nurse #3 as having occurred whenever Resident #1 thought no one was watching him/her. Unit Manager #1 said that Resident #1 was observed to go through the garbage at least three to four times a week and needed to be redirected away from the trash. Unit Manager #1 said that Resident #1 was observed eating paper and that there was no way, despite staffs attempt to redirect Resident #1, to stop the behavior. Nurse #6 said that Resident #1 was observed trying to remove items from the trash can attached to the medication cart. Nurse #6 said that in addition to trying to get food or fluids to eat and drink, Resident #1 would put anything he/she could into his/her mouth, which included the trash from medication cart. Nurse #6 said that she did not always write a nurse's note when she observed Resident #6 eating non-food items. The nurse's note, dated 11/2/11, indicated that Resident #1 was observed, "multiple times," attempting to pick paper scraps off the floor and put them into his/her mouth. The nurse's note, dated 11/17/11, indicated that Resident #1 was observed (by Nurse #2) chewing on something and then the nurse asked Resident #1 to spit the item out, Resident #1 had increased anger and it was noted that Resident #1 had small piece of paper or cardboard-like substance in his/her mouth, which Resident #1 swallowed. The nurse's note, dated 2/8/12, indicated that, Resident #1 was observed eating paper off of the floor and refused to spit the paper out. The note indicated that Resident #1 became agitated when asked to spit it out and swallowed the paper. The nurse's note, dated 2/15/12, indicated that, during the 3 P.M. to 11 P.M. shift, Resident #1's Guardian told a nurse (later identified as Nurse #1) that while providing care to Resident #1, the Guardian found a fuse in Resident #1's stool/underwear. The note indicated that Resident #1 had no distress or complaints of pain and that the plan was for the nurse to continue to monitor Resident #1. Nurse #1 said that one evening (2/15/12), the Guardian showed Nurse #1 metal and glass fuse which was mixed with feces. Nurse #1 said that the Guardian told Nurse #1 that he found the fuse in Resident #1's underwear and feces when cleaning Resident #1. The nurse's note, dated 2/22/12, indicated that Resident #1 was reviewed at IDT (interdisciplinary team) meeting at 10:40 A.M. The note indicated that Resident #1 continued to be non-compliant with NPO status; and took food and fluids off other residents' trays; and picked up lint and paper off the floor. The note indicated that Resident #1 was redirected with limited effect and that the physician and the Guardian were aware. The note indicated that at 1:15 P.M. Resident #1 was observed to have balloon strings, "lots of them" in his/her mouth. The note indicated that the nurse removed the items from Resident #1's mouth and in response, Resident #1 became agitated and grabbed at and scratched the nurse's arm. The note indicated that Resident #1 was provided education and then went into his/her room. The note indicated that Resident #1 was then observed to enter the bathroom in Resident #1's room and drink water from the faucet. The note indicated that the nurse attempted to redirect Resident #1 "away." On 2/22/12, the care plan was updated to include frequent checks by staff, which was an intervention in place since May 2011. There was no intervention to indicate the level of supervision that was needed to ensure that Resident #1 was not able to consume food and/or non-food items, whether intentional or unintentional. The psychiatric evaluation, dated 3/8/12, indicated that Resident #1 was evaluated for increased sialorrhea (increased production of saliva) due to medication. The evaluation indicated that thought and behavior were well controlled and that Resident #1 was prone to putting, "anything" in his mouth now that Resident #1 was allowed oral nutrition. The evaluation indicated that this behavior can be better controlled by controlling his/her exposure to objects. The evaluation indicated the room had been checked regularly. The plan was to, "avoid (resident) having access to objects putting (him/her) at risk for choking." The Surveyor interviewed the Psychiatrist at 11:10 A.M. on 6/7/12. The Psychiatrist said that the first time he was aware of a concern that Resident #1 put non-food items in his/her mouth, according to the evaluation, was on 3/8/12. The Psychiatrist said that he discussed Resident #1's condition and history with Resident #1's Guardian, who was also a family member. The Psychiatrist said that the Guardian never informed him that he observed Resident #1 was eating non-food items. The Psychiatrist said that based on the information he was provided from staff, Resident #1 was putting non-food items in his/her mouth. The Psychiatrist said that he instructed staff that Resident #1's room needed to be "clear" of things that Resident #1 could potentially place in Resident #1's mouth. There was no documentation to indicate how the Facility planned to prevent Resident #1 from having access to objects putting Resident #1 at risk for choking or how the staff planned to control Resident #1's exposure to objects, in accordance with the psychiatrist 's evaluation. There was no indication that Resident #1's behaviors were evaluated by the facility interdisciplinary team to determine the level of supervision needed to ensure Resident #1's safety or prevent injury to his/herself from consuming food and non-edible items. Unit Manager #1, Nurse #1, Nurse #2, Nurse #3, Nurse #4, Nurse #5, and Nurse #6 said that Resident #1 was able to propel him/herself throughout the nursing unit and lobby, and was able be able in his/her room without supervision from staff. Unit Manager #1, Nurse #1, Nurse #2, Nurse #4, Nurse #5, and Nurse #6 said that Resident #1 was not consistently supervised when in his/her room, on the nursing unit, or in the lobby, and therefore the staff would not always know whether Resident #1 placed items in his/her mouth or consumed food or non-food items. The nurse's note, dated 3/31/12, indicated that during the day Resident #1 had approached the nurse and pointed toward his/her throat and that the Guardian took Resident #1 to the Hospital for an evaluation. The Hospital History and Physical, dated 4/1/12, indicated that Resident #1 was emergently transferred to the operating room for removal of the foreign body. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 2:10 P.M. on 6/7/12; CNA #2 at 2:25 P.M. on 6/7/12; CNA #3 at 2:40 P.M. on 6/7/12. The Surveyor interviewed CNA #4 at 4:45 P.M. on 6/7/12 and CNA #5 at 5:03 P.M. on 6/7/12. CNA #1 said that she was never informed that Resident #1's room was to be free of items he/she could eat or place in his/her mouth. CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 said that that Resident #1 was able to be in his room and was able to be anywhere Resident #1 wanted on the unit without staff present. CNA #2, CNA #4, and CNA #5 said that they were informed by the nurses that the staff needed to watch Resident #1 because Resident #1 put food and non-edible items in his/her mouth. CNA #3 said that she recalled observing Resident #1 bend down and touch the floor but never observed Resident #1 put non-food items in his/her mouth. CNA #3 said that she recalled being aware that the staff needed to monitor Resident #1 because Resident #1 liked to take food off of other residents' food trays or from the food cart. CNA #3 said that she was informed that staff were to ensure that food was not left around for Resident #1 to eat or drink. CNA #3 said that it never occurred to CNA #3 that Resident #1 would eat non food items, and only learned of the behavior after Resident #1 was hospitalized (on 3/31/12). CNA #1, CNA #2, CNA #3, and CNA #5 said that there was no scheduled monitoring or staff member assigned to supervise Resident #1. CNA #2 said that unless Resident #1 told a staff member that he/she ate something (edible or non-edible) or unless Resident #1 was witnessed by staff, the staff would not know when Resident #1 ate something he/she should not, including food and non-food items. The radiology report, dated 4/11/12, indicated that the exam was obtained because Resident #1 complained of abdominal pain with a question of a foreign body. The report indicated that a crucifix and probably rosary beads, two paper clips, and portions of a ball point pen were in Resident #1's stomach and extending into the small intestines. The report indicated that in addition, a "good deal" of material was in the stomach, including the possibly of beazor (hard undigestible material). The report indicated that upon retrospective review of a previous computed tomography, from August 2011, it did suggest a beazor in the stomach at that time. The operative report, dated 4/11/12, indicated that Resident #1 ingested multiple products, including paper, plastic, paperclips, and surgical gloves which were unable to be removed via laryngoscope. The report indicated that a laparotomy was performed and a, "large amount of debris was removed from Resident #1's stomach, which included plastic, paperclips, paper and gloves. The [MEDICATION NAME] report, dated 4/13/12, indicated that a retrospective review of a computed tomography of the chest from 4/3/12 was completed. The report indicated that there was sufficient view of the abdomen which indicated that the abdomen was distended, there were likely foreign bodies, in addition to a large amount of porous material. The Hospital provided the Surveyor with photographs of the items removed from Resident #1's stomach on 4/11/12. The photographs indicated that the contents included gloves, fabric, plastic, paper clips, tags from clothing, paper, cardboard, and two heart shaped decorations. See F 323.