Every finding on record at Royal Norwell Nursing & Rehabilitation Center LLC

Based on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for three Residents (#40, #13, #21), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #40, to administer medications per physician's orders and crushing guidelines. Specifically, measure an accurate dose of MiraLAX per physician's order, administer Depakote DR per physician's order, and administer Seroquel and Zyprexa tablets per medication guidelines;2. For Resident #13, to ensure expired Lansoprazole (liquid compound for gastro-esophageal reflux disease (GERD)) was taken out of use/destroyed and not used for daily administration for 24 days after the use by date;3. For Resident #13, to ensure the Resident was administered the prescribed enteral water bolus (form of hydration that is delivered into the digestive system) via a gastrostomy tube (G-tube - a tube inserted into the stomach through which hydration and nutrition is provided); and4. For Resident #21, to verify a physician's order for a continuous glucose monitoring device and accurately document implementation of the order for 11 months. Findings include:1. Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's 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. -In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber. Review of the facility's policy titled Crushing Medications, dated as last revised May 2025, indicated but was not limited to the following: -Medications should be crushed in accordance with standards of practice for safety and accuracy in medication administration. -Liquids and other alternative forms of medication shall be considered before crushing a medication. -Medications that typically should not be crushed include, but are not limited to Enteric-Coated medications, Sustained Release or Extended Release medications. Resident #40 was admitted to the facility in March 2025 with diagnoses which include anxiety, schizophrenia, and depressive disorder with psychotic features. Review of the Minimum Data Set (MDS) assessment, dated 11/20/25, indicated he/she score 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Additionally, the MDS indicated he/she took antipsychotic, anti-anxiety, and antidepressant medications. Review of the Physician's Orders indicated but were not limited to the following: -Guardianship in place. -May crush medications or open caps per medication guidelines. -Polyethylene Glycol 3350 Oral Powder (MiraLAX-for constipation) 17Gram (GM)/Scoop give one scoop by mouth in the morning for constipation. -Depakote Delayed Release (DR) (anticonvulsant and used as a mood stabilizer) 250 milligram (mg) give two tablets by mouth one time a day for mood stabilizer. -Seroquel Tablet (antipsychotic) 25mg give three tablets by mouth two times a day for agitation. -Zyprexa Tablet (antipsychotic) 10mg give one tablet by mouth two times a day for Schizophrenia. On 11/25/25 between 8:27 A.M. and 8:38 A.M., the surveyor observed Nurse #2 administer medications as follows: -Nurse #2 poured Resident #40's morning medications including three Seroquel 25mg tablets and one Zyprexa 10mg tablet. -Nurse #2 was unable to locate the Depakote DR tablets, the medication was omitted and left unsigned on the Medication Administration Record (MAR). -Nurse #2 poured some MiraLAX powder from the bottle into a small clear plastic medication cup to approximately the 20ml line. -Nurse #2 proceeded to crush all the poured medications together and mix with applesauce. -Nurse #2 poured the MiraLAX powder from the medication cup into a small cup with approximately four to five ounces of water. The Surveyor reconciled the medications administered with the physician's orders and the MAR. Nurse #2 had left the Depakote DR unsigned during the medication pass and it was now signed as administered. Review of Drugs.com instructions for use indicated Seroquel tablets are coated, should be swallowed whole, with or without food, and do not crush, chew, or break it. Review of Drugs.com instructions for use indicate Zyprexa tablets should be taken exactly as prescribed. Tablets are coated and should be swallowed whole, with or without food. Review of the MiraLAX instructions for use label indicated the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section in cap). Stir and dissolve in any four to eight ounces of beverage (cold, hot or room temperature), then drink. Review of Resident #40's profile and special instructions in the medical record indicated he/she took their medications whole with thin liquids. During an interview on 11/25/25 at 12:32 P.M., while standing at the medication cart with the surveyor, Nurse #2 said she crushed the pills because her report sheet says the Resident takes them crushed. She said she was unsure if the Seroquel or Zyprexa should be administered as whole tablets, she just crushed them because that's what the paper says. Additionally, she said you are supposed to use the cap of the MiraLAX bottle to measure the dose, but then you would have to leave it uncovered, so she just pours some into the med cup and then into a plastic cup when she is ready to give it. She said the order doesn't have an amount of liquid to mix in, but this cup is enough (holding a four-to-six-ounce plastic cup). Nurse #2 said she was unable to find the Depakote earlier and that was why she did not give it during the med pass. When asked why it was signed off now, she said she got it from the other nurse. She said, sometimes things end up in the wrong med cart. During an interview on 11/25/25 at 12:35 P.M., Nurse #3 said she did not give Nurse #2 a card of Depakote this morning. Nurse #2 was still standing at her medication cart with the surveyor and was asked to provide the surveyor with the card of Depakote used to administer the dose this morning (Depakote DR 250mg two tablets). Nurse #2 opened the second drawer of the medication cart (the drawer where the active cards for medication administration were kept) and was unable to locate the card of Depakote. Nurse #2 then opened and closed the third drawer and finally opened the fourth/bottom drawer. Nurse #2 started to look through all the over stock medication cards in the bottom drawer looking for the Depakote card. After several minutes, a card of Depakote DR was located. The card had one tablet punched out of the card. Nurse #2 proceeded to punch two tablets out of the card allowing them to fall into the bottom of the medication cart. The Surveyor observed this action, heard the foil pop, and the pills hit the bottom of the metal cart. Nurse #2 immediately said she was not popping the pills right now. Nurse #2 then started to stand up with the card of Depakote DR that now had three pills punched from the card. The surveyor asked Nurse #2 to remove the cards and retrieve the pills from the bottom of the medication cart. Nurse #2 picked up the other medication cards where the Depakote DR card was and removed two Depakote DR pills from the bottom of the medication cart. There were no other loose pills in the bottom of the medication cart. During a follow up interview on 11/25/25 at 12:37 P.M., Nurse #2 said this was the card of Depakote and she again said she did not just pop those pills. She said she administered the Depakote whole because they cannot be crushed. When asked what she administered to Resident #40 she opened the MAR and said he/she gets two in the morning. During an interview on 11/25/25 at 2:27 P.M., the Director of Nurses (DON) said MiraLAX should always be measured with the cap of the bottle up to the line on the cap, Seroquel and Zyprexa cannot be crushed, and the Depakote should have been marked as not given, a note written, and physician notified if the medication was not available. Additionally, she said medication should be administered per the physician's orders and the resident profile and report sheet should match indicating if medication is to be crushed or not and anything that should not be crushed would need a specific order to crush it of an alternative was not available. 2. Resident #13 was admitted to the facility in March 2025 with diagnoses which include gastroesophageal reflux disease (GERD). Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to the following: -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the Physician's orders indicated but were not limited to the following: -Lansoprazole Oral Suspension 3mg/milliliter (ml) give 10ml via G-Tube (feeding tube inserted directly into the stomach) one time a day for GERD (10/20/25) On 11/25/25 at 12:15 P.M., the surveyor observed one bottle of Lansoprazole Suspension in the North Unit Medication Fridge with a Beyond Use Date of 11/1/25 written on the label from the Pharmacy. Review of the Medication Administration Record indicated Resident #13 had been administered the Lansoprazole daily as ordered. Review of the National Library of Medicine (NIH.gov) website indicated Lansoprazole Suspension should not be used beyond the Use By date indicated by the pharmacy. During an interview on 11/25/25 at 12:15 P.M., Nurse #3 said that was the only bottle they had and they have been using it. She said she did not realize it was expired and would have to call the pharmacy for a new one. During an interview on 11/25/25 at 2:27 P.M., the DON said the Lansoprazole Suspension has a short shelf life and it should not have been administered after 11/1/25, since it was expired. 3. Review of the facility's policy titled Assisted Nutrition and Hydration – Enteral Feeding, dated as revised January 2025, indicated but was not limited to the following: -Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. -The facility will ensure each resident is offered sufficient fluid intake to maintain proper hydration and health -The physician will be responsible for ordering the appropriate enteral feeding Resident #13 was admitted to the facility in March 2025 with diagnoses including traumatic brain injury and dysphagia (difficulty swallowing liquid or food). Review of the Minimum Data Set (MDS) assessment, dated 11/12/25, indicated Resident #13 had a feeding tube and the portion of the total calories the Resident received through a feeding tube was 51% or more. Review of the care plans indicated Resident #13 was dependent on the G-tube including but not limited to the following interventions: -Administer water flushes as ordered -Diet NPO (nothing by mouth) Review of the Physician's Orders indicated Resident #13 had the following orders related to the feeding tube: -Diet NPO (11/18/25) -Give 200 milliliters (ml) water bolus 4 times a day (11/13/25) -For nutritional supplement give 80 ml/hr (hour) Jevity 1.5 (liquid meal replacement) from 6:00 PM to 6:00AM (8/26/25) On 11/25/25 at 12:02 P.M. the surveyor observed the following: -Nurse #2 and the surveyor entered Resident #13's room and observed a graduated container (used to measure the volume of liquid) with 200ml of water on Resident #13's bedside table. There was a 60ml piston syringe (type of syringe with a plunger that pushes fluid of the barrel or draws fluid into it) placed inside the container. Resident #13's feeding tube was exposed and there was a towel placed underneath it. Clinical Coordinator #1 was in the room, standing at Resident #13's bedside. She said she would like to observe Nurse #2 administer the water bolus to Resident #13. -Nurse #2 raised the height of Resident #13's bed, took the piston syringe and drew 60ml of water into the syringe. -Nurse #2 placed the syringe into Resident #13 feeding tube and administered the water by depressing the plunger of the syringe. -Nurse #2 removed the syringe from the feeding tube and placed it inside the container and drew 60ml of water into the syringe. -Nurse #2 placed the syringe into Resident #13's feeding tube and administered the water by depressing the plunger of the syringe. -Nurse #2 removed the syringe, placed it back into the container, removed the towel from under the feeding tube, covered Resident #13 with a sheet, lowered the bed to the floor, and said she had completed the administration. -Nurse #2 went to exit the room and Clinical Coordinator #1 asked if she could intervene because Nurse #2 did not administer the correct amount of water. Clinical Coordinator made Nurse #2 aware of the error, reviewed proper administration technique and had Nurse #2 administer the remaining 80ml of water to Resident #13. During an interview on 11/25/25 at 12:09 P.M., Nurse #2 said she only administered 120ml of water and the Resident was supposed to receive 200ml. Nurse #2 said she did not realize the syringe only held 60ml of water. During an interview on 11/25/25 at 12:14 P.M., Clinical Coordinator #1 said she had to intervene because the Resident did not receive the proper amount of water. She said Nurse #2 should have placed the syringe into the feeding tube without the plunger and poured the measured amount of water into the syringe in the feeding tube to ensure the Resident received the prescribed amount. Review of Nurse #2's G-Tube/Enteral Feeding Competency Evaluation completed on 10/16/25, indicated she demonstrated proper administration of medications via a G-tube. During an interview on 11/25/25 at 3:09 P.M., the DON said Nurse #2 should have administered the amount of water the physician ordered. She said it is essential that the proper amount of water is administered because this is his/her only source of hydration and is unable to eat or drink anything by mouth. 4. Review of 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. Resident #21 was admitted to the facility in July 2020 and has diagnoses including diabetes mellitus type 2. Review of the MDS assessment, dated 9/16/25, indicated Resident #21 was cognitively intact as evidenced by a BIMS score of 15 out of 15, had diabetes and received insulin daily. Review of the medical record included but was not limited to the following Physician's Order: - FreeStyle Libre 2 Sensor Miscellaneous (Continuous Glucose System Sensor) Inject 1 application subcutaneously (under the skin) one time a day every 14 days for diabetes (11/7/24) Review of [NAME] Freestyle Libre Continuous Glucose Monitoring (CGM- https://www.freestyle.[NAME]/us-en/home.html) guidelines, included but was not limited to: -the Libre CGM is a small sensor-based system that provides real-time glucose readings day and night, without fingersticks; -The sensor is applied to the back of the upper arm with a simple, disposable device called an applicator. When the sensor is applied, a small (5 millimeter) filament (needle) is inserted just under the skin and held in place with a small adhesive pad; -There is a needle (sharp) in the applicator to insert the filament in the back of your upper arm so the sensor can monitor your glucose; -The sensor lasts up to 14 days and it is recommended to rotate application site of the sensor between arms. Review of the MAR/Treatment Administration Records (TAR) from December 2024 through November 2025 indicated Resident #21 had a FreeStyle Libre2 sensor applied subcutaneously every 14 days as follows: -12/5/24, 12/19/24 -1/2/25, 1/16/25, 1/30/25 -2/13/25, 2/27/25 -3/13/25, 3/27/25 -4/10/25, 4/24/25 -5/8/25, 5/22/25 -6/5/25, 6/19/25 -7/3/25, 7/17/25, 7/31/25 -8/14/25, 8/28/25 -9/11/25, 9/25/25 -10/9/25, 10/23/25 -11/6/25, 11/20/25 On 11/24/25 at 7:51 A.M., the surveyor observed Resident #21 seated on the bed in his/her room wearing a short-sleeved shirt. The Resident's upper arms were exposed, and no continuous glucose monitoring device was observed on either of his/her arms. During an interview on 11/25/25 at 7:51 A.M., Nurse #2 reviewed the medical record and noted the active order for the FreeStyle Libre2 sensor and said she was not aware he had one and checks his/her capillary blood glucose (CBG) using a fingerstick. Nurse #2 and the surveyor went to the Resident's room. Resident #21 said he/she does not have a continuous glucose monitoring device and lifted up the short sleeves on either arm. No device was noted. During an interview on 11/25/25 at 11:17 A.M. and 12:02 P.M., the DON reviewed Resident #21's medical record. She noted the physician's order for the FreeStyle Libre2 and the MAR/TARs that indicated the device had been applied according to physician's orders. She said Resident #21 never had a Libre device because his/her insurance would not pay for it. The DON said the physician's orders are inaccurate and there should not be an order for the FreeStyle Libre2 device. She said nursing should not have signed off that the device was applied every 14 days for nearly a year when the Resident did not have the device. During an interview on 11/25/25 at 2:35 P.M., NP #1 reviewed Resident #21's medical record. He said the Resident does not have a FreeStyle Libre2 device and there should not be an order for one. He said he should have picked up on that and discontinued it.

Based on observation and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws. Specifically, the facility failed to ensure:1. The Medication Cart remained locked when not in view and/or proximity of the nurse;2. For Resident #40, MiraLAX (medication for constipation) was not left at the bedside; and3. For Resident #50, crushed Ativan (controlled substance/anti-anxiety medication) was double locked and not crushed until administered. Findings include:Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to the following:-Unlocked medication carts are not left unattended.-Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.-Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received.-Schedule II-V controlled medications are stored in separately locked compartments. Security access to controlled medication is separate from access to non-controlled substances.-Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to the following:-Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.-During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. Review of the facility's policy titled Crushed Medications, dated as last revised May 2025, indicated but was not limited to the following:-Crushed medication shall be administered immediately. The nurse shall verify the resident is available and ready for his/her medication prior to crushing medications. If unable to administer a medication that has been crushed, the nurse shall discard the medication. 1. The surveyor made the following observations on the locked North Unit:-11/24/25 at 3:02 P.M., Short hall medication cart unlocked and unattended in the hallway next to nurses' station.-11/25/25 from 8:04 A.M. through 8:09 A.M., Long hall medication cart was unlocked and unattended. Residents were wandering around the unit. Nurse #2 was in and out of resident rooms and the medication cart was not in view/proximity of her.-11/25/25 at 8:14 A.M., Long hall medication cart was left unlocked and unattended in the hallway near the nurses' station while Nurse #2 entered a Resident's room with her back to the hallway she then administered medications.-11/25/25 at 8:25 A.M., Long hall medication cart was unlocked and unattended in the hallway next to nurses' station.-11/25/25 at 8:38 A.M., Nurse #2 left the medication cart unlocked and unattended in the hallway and went in the medication room behind a closed door.-11/25/25 at 10:15 A.M., Medication cart left unlocked and unattended next to nurses' station. A resident came by and placed a fork on the medication cart and another resident, walking slowly in hallway, was near the medication cart. At 10:18 A.M., Nurse #2 returned to her medication cart. -11/25/25 at 10:34 A.M., Long hall medication cart was unlocked, the nurse walked down the hallway, leaving it unattended. At 10:37 A.M., Nurse #2 returned to her med cart, picked up the water pitcher and walked away from the cart again, leaving it unlocked and unattended. Unlicensed staff and residents were walking around the unit. During an interview on 11/25/25 at 10:38 A.M., Nurse #2 said she usually locks it every time she walks away so the residents can't get into the medications, especially on a dementia unit. She said she has been trying but forgot. During an interview on 11/25/25 at 12:37 P.M., Nurse #2 said the medication cart should always be locked. During an interview on 11/25/25 at 2:27 P.M., the Director of Nurses (DON) said the medication cart should be locked anytime it is not in view of the nurse. 2. Resident #40 was admitted to the facility in March 2025 with diagnoses which include schizophrenia, anxiety, and major depressive disorder with psychotic symptoms. Review of the Physician's Orders indicated he/she had a Guardian in place. During the Medication Pass, the surveyor observed the following:-On 11/25/25 between 8:27 A.M. and 8:38 A.M., Nurse #2 poured the medications for Resident #40, including MiraLAX (a powdered medication mixed with water) and then entered the room for administration.-During Medication Administration, Resident #40 said they did not want the drink. With some encouragement, Resident #40 agreed to take the medication drink.-Resident #40 was administered the pill form medications crushed in applesauce. He/she took a couple small sips of the MiraLAX to swallow the mixture and handed the cup back to the nurse.-Nurse #2 placed the cup, half full of the MiraLAX medication mixture, on the breakfast tray and exited the room. During an interview on 11/25/25 at 12:35 P.M., Nurse #2 said she should not have left the medication at the bedside. She said sometimes she will leave a supplement drink at the bedside and come back to make sure they drank it, but she should not have left the MiraLAX on the table, she should have stayed while he/she drank it. During an interview on 11/25/25 at 2:27 P.M., the DON said no medication should be left at the bedside, the nurse should stay with the resident until they take the medications. 3. Resident #50 was admitted to the facility in April 2019 with diagnoses which include dementia and anxiety. Review of the Physician's Orders indicated but were not limited to the following:-Ativan 1 milligram (mg) by mouth in the morning for anxiety. The surveyor observed the following on the South Unit:-11/25/25 at 11:38 A.M., the Short Hall medication cart was in the hallway, next to the nurses' station. The Nurse was not visible at or around the nurse's station and was not in view of the medication cart.-Nurse #5 returned to the medication cart with an ice cream cup, placed the ice cream on top of the medication cart, walked away again, then returned with a cup of water.-11/25/25 at 11:40 A.M., Nurse #5 opened the top drawer of the medication cart and removed a one-ounce clear plastic medication cup with white powder in it. She took the cup, the ice cream, and the water and left the nurses' station to administer the medication. During an interview on 11/25/25 at 11:45 A.M., Nurse #5 said the cup of white powder was Resident #50's Ativan. She said she crushed it and left it in the top drawer until he/she was ready for it. She said it should not have been left in the medication cart crushed and unlabeled after it was removed from the narcotic drawer. During an interview on 11/25/25 at 2:27 P.M., the DON said medications should not be pre-poured and left in the top of the medication cart. Additionally, she said narcotics should be locked in the narcotic drawer and removed when ready to administer.

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for two Residents (#71 and #25) out of a sample of 17 residents. Specifically, the facility failed:1. To ensure that the staff wore the indicated personal protective equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when entering the room for Resident #71 on Contact Precautions (measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of methicillin-resistant Staphylococcus aureus (MRSA)); and 2. For Resident #25, to provide hand hygiene prior to meals.Findings include:1. Resident #71 was admitted to the facility in April 2024 with diagnoses including venous insufficiency. Review of the Minimum Data Set (MDS) assessment, dated 9/12/25, indicated Resident #71 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the Resident is cognitively intact. Review of Resident #71's Physician's Orders, dated 11/11/25, indicated staff maintain contact precautions related to colonized MRSA in leg wounds every shift.On 11/24/25 at 8:00 A.M., the surveyor observed a three-tiered cart containing PPE outside the Resident's room with a yellow sign taped to the wall above the name plate indicating: -STOP CONTACT PRECAUTIONS-EVERYONE MUST:-Clean their hands, including before entering and when leaving the room-PROVIDERS AND STAFF MUST ALSO -Put on gloves before room entry-Discard gloves before room exit-Put on gown before room entry-Discard gown before room exit-Do not wear the same gown and gloves for the care of more than one person-Use dedicated or disposable equipment. Clean and disinfect the reusable equipment before use on another personReview of the facility's policy titled Infection Control Guidelines for Nursing Procedures, undated, indicated but was not limited to the following:-Contact transmission is infection spread through direct contact with an infectious person (e.g., touching during a handshake) or with an article or surface that has become contaminated. Microorganisms can remain on the surface for 9-11 days if not properly cleaned. These include MRSA. -Infection control measures for contact precautions include:-standard precautions infection control measures, and -patient placement based on infection-PPE, including gloves and gown for all interactions that may involve contact with the residents or their environment. On 11/24/25 at 8:07 A.M., the surveyor observed Certified Nursing Assistant (CNA) #6 enter Resident #71's room with no PPE on or hand hygiene completed. CNA #6 went to assist the Resident in the bathroom and shut off the call bell. CNA #6 was observed touching Resident #71's wheelchair and wheeling the Resident in his/her wheelchair. Resident #71 asked CNA #6 to wipe his/her buttocks and CNA #6 was observed touching the Resident. During an interview on 11/24/25 at 8:20 A.M., CNA #6 said she had to enter the room to make sure the Resident was safe and only assisted him/her and did not provide morning care for the Resident. She said she wasn't sure if the sign outside the room was for him/her and if it was current. She said the Resident did not have a catheter or infection.On 11/24/25 at 9:27 A.M., the surveyor observed CNA #1 enter Resident #71's room without completing hand hygiene and touched the Resident's tray table and picked up his/her breakfast tray and brought it down the end of the hall and placed it in the food truck. During an interview on 11/24/25 at 9:30 A.M., CNA #1 said no PPE is required to pick up or drop off meal trays to residents on contact precautions. During an interview with an observation on 11/24/25 at 10:22 A.M., the surveyor observed Nurse #3 in Resident #71's room administering medications with no PPE worn. Nurse #3 was observed touching Resident #71's bed and hands. She said PPE was not required for medication administration since she was not providing care near the infected areas. She said PPE was required if she was going to change his/her wound dressings. During an observation with interview on 11/24/25 at 10:28 A.M., the surveyor observed the Staff Development Coordinator (SDC) entering the Resident's room with cranberry juice, touching the Resident's environment and person. She said PPE was only needed for direct care of the Resident and she did not breach any infection control procedure. During an observation with interview on 11/25/25 at 9:11 A.M., the surveyor observed CNA #5 at the Resident's bedside touching the tray table and Resident's bed. She said that if she is going to answer a call bell or assist the Resident with something simple, she doesn't need to wear PPE. She said if she was going to bring the Resident to the bathroom she would need PPE.During an observation with interview on 11/25/25 at 10:27 A.M., the surveyor observed the Business Office Manager in Resident #71's room leaning against his bed, resting her hand on the footboard. She said that the Resident was on contact precautions, which were to be utilized by staff providing care. She said she was not providing care, so she did not need to adhere. She said touching and making contact with the Resident's bedsheets and bed did not violate any contact precautions and was acceptable. During an observation with interview on 11/25/25 at 10:49 A.M., Nurse #4 entered Resident #71's room, turned off his/her call light and touched his/her tray table in the room. He said contact precautions do not require PPE for medication administration.During an interview on 11/25/25 at 11:00 A.M., Resident #71 said sometimes staff do wear gowns and gloves and he/she said it was related to wounds on his/her legs. He/she said they were not sure when the staff were supposed to wear gowns and gloves and there are staff that come and help him/her and do not have the yellow gowns on. During an interview on 11/25/25 at 12:15 P.M., the Director of Nurses (DON) said anyone entering the room with a resident on contact precautions should wear all the required PPE as described on the signage posted outside the room. She said it is not only required for care but also touching the resident or the resident's environment. She said all staff members should have been wearing gowns and gloves during their interactions. 2. Resident #25 was admitted to the facility in 2019 with diagnoses including unspecified intestinal obstruction. Review of the MDS assessment, dated 10/23/25, indicated the Resident scored 11 out of 15 on the BIMS assessment, indicating moderate cognitive impairment. The MDS also indicated the Resident had an ostomy appliance (a device used to collect waste from surgical openings in the intestines or bladder). On 11/24/25 at 8:23 A.M., the surveyor observed the Resident receive his/her breakfast tray from staff. Staff delivered the tray and assisted with putting sugar on the cereal and then left. Resident #25's hands appeared soiled with a brown, odorous substance on his/her fingers and under his/her nails. Resident #25 began to eat an English muffin with jelly, bacon, and two hard boiled eggs with his/her soiled hands. During an interview on 11/24/25 at 8:33 A.M., Resident #25 said he/she has stomach problems and sometimes the ostomy bag leaks and he/she tries to stop it and will use a sheet or try to clean it up. He/she said the staff usually manage his/her ostomy bag, but his/her hands do end up soiled at times. He/she said staff do not offer or assist him/her with hand hygiene prior to meals. During an interview with observation on 11/25/25 at 9:26 A.M., the surveyor observed the Social Worker take Resident #25's tray from the food truck and deliver it to the Resident. The surveyor observed her place down the tray and assist the Resident with finding a spoon. Resident #25's hands appeared visibly soiled and stained with a brown, odorous substance. The Social Worker said she helps pass meals at times and she has never provided hand hygiene to residents. She said she would hope staff do it during morning care but cannot be certain. She said there is not a process she is aware of. Resident #25 began to eat his/her breakfast with his/her hands.During an interview on 11/25/25 at 9:25 A.M., CNA #5 said the staff pass out the meals to each resident after the nurse has checked the trays. She said there are no wipes on trays and there is no current process for providing or offering hand hygiene to residents eating in their room. She said she knows Resident #25 does have soiled hands at times because of complications with his/her ostomy status. She said there might be some independent residents who complete hand hygiene prior to meals, but it is not something that staff assist as part of passing meals. She said she has not seen any wipes on trays or how they would offer hand hygiene to residents in their rooms. During an interview on 11/25/25 at 12:20 P.M., the DON said hand hygiene should be completed for all residents prior to the meal pass. She said there is risk of infection if a resident is eating with his/her hands soiled from his/her ostomy bag.

Based on records reviewed and interviews for one of three sampled residents (Resident #3), whose care plan indicated he/she required a Hoyer lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) for transfer and Geri-sleeves (stocking like sleeve to protect fragile skin) to both upper extremities to minimize skin injury, the facility failed to ensure staff consistently implemented and followed interventions from his/her care plan, when on 12/07/24, Resident #3, was manually lifted and transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #2 and CNA #3 instead of utilizing the Hoyer lift, he/she also did not have the geri-sleeve on his/her right upper extremity, and as a result he/she sustained a skin tear to the right wrist which required four steri-strips to close the wound. Findings include: Review of the Facility Policy titled Comprehensive Person-Centered Care Plan, dated May 2023, indicated that a comprehensive person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. The Policy further indicated that the comprehensive, person-centered care plan will include the following; -Include measurable objectives and timeframe's; -Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being; -The facility will ensure that the services provided are arranged are delivered by individuals who are qualified and have the skills, experience and knowledge to do a particular task; -Aid in preventing or reducing decline in the resident's functional status and/or functional level; and -Care Plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Resident #3 was admitted to the Facility in February 2022, diagnoses include dementia, adult failure to thrive, history of falls, and anxiety. Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], indicated he/she had significantly impaired cognition, severely impaired decision-making ability, rarely able to make self-understood or understand others and was dependent for all care. Review of Resident #3's Care Plan titled Activities of Daily Living (ADL), dated as last revised 12/03/24, indicated he/she transferred via Hoyer lift with the assistance of two staff members. Review of Resident #3's Care Plan titled Risk for Impaired Skin Integrity, dated as last revised 12/03/24, indicated to apply geri-sleeves to both upper extremities and they may be removed for care. Review of Resident #3's CNA Care Kardex, indicated he/she required the use of a Hoyer lift for transfers and geri-sleeves were to to be applied to both upper extremities. During an interview on 01/06/25 at 2:42 P.M., CNA #2 said she was consistently assigned to work on Resident #3's unit, was aware of the need and how to access resident care Kardex's in the computer, but had not done so that day. CNA #2 said that she had an accident with Resident #3 when she transferred him/her with CNA #3. CNA #2 said she told Nurse #2 that she was not aware that Resident #3 required a Hoyer lift for transfers, that she and CNA #3 manually lifted and transferred him/her from the bed into the wheelchair. CNA #2 said after the transfer was done Resident #3 had a cut on his/her right arm. CNA #2 said Resident #3's left geri-sleeve was put on him/her, but she was unable to find the right arms geri-sleeve. During a telephone interview on 01/13/25 at 11:22 A.M., CNA #3 said that she was asked to help CNA #2 transfer Resident #3 from the bed to the wheelchair. CNA #3 said she did not ask CNA #2 how Resident #3 transferred and said she thought CNA #2 knew how he/she transferred. CNA #3 said that after they manually lifted and transferred Resident #3 into his/her wheelchair, they noticed he/she had a skin tear on his/her right wrist. CNA #3 said that Resident #3 did not have a geri-sleeve on his/her right arm, and only had one on his/her left arm. During an interview on 01/06/25 at 11:26 A.M., Nurse #2 said that she was administering medications when CNA #2 and CNA #3 brought Resident #3 out of his/her room and notified her of the skin tear he/she sustained during the transfer. Nurse #2 said that she could not recall how the CNA's said they transferred Resident #3 into his/her wheelchair, but said she obtained statements from each of the CNA's at that time. Review of the Facility Incident Report file, dated 12/07/24, indicated that although the report reflected that Resident #3 sustained a skin tear during at transfer, there were no statements from CNA #2 or CNA #3 included in the report file. During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that she was unaware that Resident #3 was manually lifted and transferred on the day of the incident by two CNA's and that they had not known that he/she required a Hoyer lift. The DON said that Resident #3 should have been transferred via the Hoyer lift according to his/her care plan and as indicated on the CNA Kardex. The DON said that it is the Facility's expectation that all certified and licensed nursing staff must be aware of each of their assigned residents' physical status before assisting them with ADL care. On 01/06/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. 12/07/24, Nursing immediately assessed Resident #3 for injuries, four Steri-strips were applied to his/her right wrist. B. 12/09/24, The DON initiated re-education for Certified Staff on the requirement to review the CNA Kardex, how to locate a residents physical status and how they are to be transferred. C. 12/09/24, the DON and Administrator initiated the requirement for completion of new competencies for all certified staff on the proper use of the mechanical lifts. D. 12/09/24, the Administrator revised the Policy titled Using a Mechanical lift, to include that at least two trained (certified and competent) staff members are required to safely use a mechanical lift. E. 12/10/24, the DON, Administrator and Nursing Managers were educated on individual staff members scopes of practice. If the staff member is not certified (completed new competency) to use a mechanical lift, they are not able to assist any staff member with a transfer. F. 12/13/24, the DON/designee will audit CNA competency through visualization and validate quizzes. Audits will occur weekly x 4 weeks, monthly x 3 months, and quarterly thereafter until compliance is reached. G. 12/17/24, the DON and Unit Managers added that staff will complete competency/training upon hire, and annually on the use of the mechanical lift device, including the inspection of slings for integrity and clasps prior to transfer. H. 12/19/24, the areas of concern and data collected were presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting. I. The Administrator and Director of Nurses will be responsible for overall compliance.

Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #3), who both required a Hoyer Lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) with the assistance of two staff members, the facility failed to ensure that necessary assistive devices were utilized properly and appropriately during transfers in order to maintain resident safety and prevent incidents/accidents resulting in injuries. 1) On 12/09/24, Certified Nurse Aide (CNA) #1 and Activity Assistant (AA) #1 (who was not a certified nurse aide or competent in mechanical lift transfers) did not check to see if the lower straps of the Hoyer lift sling/pad were properly connected to the Hoyer lift device, and during the transfer Resident #1 slid onto the floor, hitting his/her head. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a laceration (open wound) to the back of his/her head related to the fall, which required one (1) staple to close. 2) On 12/07/24, CNA #2 and CNA #3, manually lifted and transferred Resident #3, instead of using a Hoyer lift as required, he/she sustained a skin tear to his/her right wrist during the transfer, which required four (4) steri-strips to close the wound. Findings include: Review of the Facility Policy titled, Mechanical Lift, dated 05/2023, indicated the following: -At least two (2) staff are needed to safely move a resident with a mechanical lift; and -Staff must be trained and demonstrate competency using the specific machines or devices utilized by the Facility. Further review of the Policy indicated the following steps (not all-inclusive) are essential in proper use of a mechanical lift; -Measure the resident for proper sling size and purpose; -Test the lift controls, ensure the emergency release feature works; -Place the appropriate sling beneath the resident; -Attach the sling straps to the sling bar; -Make sure the sling is securely attached to the clips and that is it properly balanced; -Before resident is lifted, double check the security of the sling attachment; -Examine all hooks, clips, and fasteners; and -Check the stability of the straps and ensure that the sling bar is securely attached. 1) Resident #1 was admitted to the Facility in 09/2015, diagnoses include right sided hemiparesis (weakness) related to a cerebral vascular accident (CVA), vascular dementia, chronic pain, and seizure disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she had moderate cognitive impairment and was dependent with all transfers, including to and from his/her bed to his/her wheelchair. Review of Resident #1's Care Plan titled Activities of Daily Living, reviewed and renewed with his/her November 2024 MDS, indicated he/she required a Hoyer lift for all transfers. Review of the Facility Incident Report, dated 12/09/24, indicated that at approximately 9:53 A.M. during a mechanical lift transfer from bed to wheelchair, the Hoyer lift pad became unattached from the device, Resident #1 fell out of the Hoyer pad onto the floor and struck his/her head. The Report further indicated that he/she required transport to the Hospital ED for evaluation and treatment of a head laceration and required one (1) staple to close the wound. During a telephone interview on 01/10/25 at 10:10 A.M., Certified Nurse Aide (CNA) # 1 said that on 12/09/24, Resident #1 was on her assignment, and she had placed the Hoyer pad beneath him/her to prepare for the transfer from his/her bed to the wheelchair. CNA #1 said she went into the hallway to find a staff member to ask for assistance. CNA #1 said that she saw Activity Aide (AA) #1 and asked her to assist with the Hoyer lift transfer. CNA #1 said she did not know that the second staff member assisting with a Hoyer lift transfer had to be certified (completed a competency) in using the mechanical lift device. CNA #1 said that she had already attached the Hoyer pad to the actual Hoyer lift and said she had instructed AA #1 to guide Resident #1's legs as they transferred him/her out of the bed. CNA #1 said she had not noticed that one of the sling straps was not connected correctly and said as she was lowering Resident #1 down towards the wheelchair, one of the lower straps on the pad unlatched and Resident #1 slid to the floor hitting his/her head. During an interview on 01/06/25 at 10:03 A.M., Activity Aide (AA) #1 said that she had been on the unit passing out newspapers when CNA #1 came out of Resident #1's room and asked for help. AA #1 said she did not ask CNA #1 what she needed assistance with and just went into the room to help. AA #1 said that's when CNA #1 asked her to help with a transfer, that she just needed to hold up and guide Resident #1's legs during the Hoyer lift transfer. AA #1 said as CNA #1 was turning the Hoyer lift toward the wheelchair, she heard something snap and Resident #1 slid to the floor hitting his/her head. AA #1 said that she had not been certified (had not completed a competency) to use the Hoyer lift. During an interview on 01/06/25 at 10:59 A.M., Nurse #1 said she was not aware that CNA #1 had asked AA #1 to assist with Resident #1's transfer. Nurse #1 said that only staff who had been certified to use the Hoyer lift can assist in such a transfer. During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that only staff that have passed a competency on working the Hoyer lift are allowed to operate or assist in the transfer utilizing a Hoyer lift, which AA #1 had not done. 2.) Resident #3 was admitted to the Facility in February 2022, diagnoses include dementia, adult failure to thrive, history of falls, and anxiety. Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], indicated he/she had significantly impaired cognition, severely impaired decision-making ability, rarely able to make self-understood or understand others and was dependent for all care. Review of Resident #3's Care Plan titled Activities of Daily Living, dated as last revised 12/03/24, indicated he/she transferred via Hoyer lift with the assistance of two staff members. Review of Resident #3's CNA Care Kardex, indicated he/she required the use of a Hoyer lift for transfers. During an interview on 01/06/25 at 2:42 P.M., CNA #2 said she was consistently assigned to work on Resident #3's unit, was aware of the need and how to access resident care Kardex's in the computer, but had not done so that day. CNA #2 said that she had an accident with Resident #3 when she transferred him/her with CNA #3. CNA #2 said that when she and CNA #3 manually lifted and transferred him/her from the bed into the wheelchair, after the transfer was done Resident #3 had a cut on his/her right arm. CNA #2 said she was not aware that Resident #3 required the use of a Hoyer lift for transfers. During a telephone interview on 01/13/25 at 11:22 A.M., CNA #3 said that she was asked to help CNA #2 transfer Resident #3 from the bed to the wheelchair. CNA #3 said she did not ask CNA #2 how Resident #3 transferred, that she thought CNA #2 knew how he/she transferred, and said she did not know Resident #3 was a Hoyer lift transfer. CNA #3 said that after they manually lifted and transferred Resident #3 into his/her wheelchair, they noticed a skin tear on his/her right wrist. During an interview on 01/06/25 at 11:26 A.M., Nurse #2 said that she was administering medications when CNA #2 and CNA #3 brought Resident #3 out of his/her room and notified her of the skin tear he/she sustained during the transfer. Nurse #2 said that she could not recall how the CNA's said they transferred Resident #3 into his/her wheelchair, but said she got statements from each of the CNA's at that time. Review of the Facility Incident Report file, dated 12/07/24, indicated that although the report reflected that Resident #3 sustained a skin tear during at transfer, there were no statements from CNA #2 or CNA #3 included in the report file. During an interview on 01/06/25 at 3:03 P.M., the Director of Nurses (DON) said that she was unaware that Resident #3 was manually lifted and transferred on the day of the incident by two CNA's and that they had not known that he/she required a Hoyer lift. The DON said that it is the Facility's expectation that all certified and licensed staff must be aware of each of their assigned residents physical status and needs before assisting them with care. On 01/06/25, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. 12/07/24, Nursing immediately assessed Resident #3 for injuries, four Steri-strips were applied to his/her right wrist. -12/09/24, Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital ED, he/she required one (1) staple to close the laceration and returned to the Facility. B. 12/09/24, the Director of Maintenance inspected both Hoyer Lifts for integrity, no abnormal findings or defects noted. The Director will continue to inspect mechanical devices and slings monthly. C. 12/09/24, the DON measured all residents requiring the use of a Hoyer lift were measured for appropriate sizing. Resident care plans were audited to ensure they were updated with appropriate mode of transfer and with proper pad/sling to use for all residents that require a Hoyer lift. D. 12/09/24, The DON initiated re-education for Certified Staff on the requirement to review the CNA Kardex, how to locate a residents physical status and how they are to be transferred. E. 12/09/24, the DON and Administrator initiated the requirement for completion of new competencies for all certified staff on the proper use of the mechanical lifts. F. 12/09/24, the Administrator revised the Policy titled Using a Mechanical lift, to include that at least two trained (certified and competent) staff members are required to safely use a mechanical lift. G. 12/10/24, the DON, Administrator and Nursing Managers were educated on individual staff members scopes of practice. If the staff member is not certified to use a mechanical lift, they are not able to assist any staff member with a transfer. H. 12/13/24, the Administrator/designee will randomly audit maintenance inspection sheets to ensure compliance. Weekly times four weeks, monthly for 3 months, and quarterly thereafter until compliance is achieved. I. 12/13/24, the DON/designee will audit CNA competency through visualization and validate quizzes. Audit will occur weekly x 4 weeks, monthly x 3 months, and quarterly thereafter until compliance is reached. J. 12/17/24, the DON and Unit Managers added that staff will complete competency/training upon hire, and annually on the use of the mechanical lift device, including the inspection of slings for integrity and clasps prior to transfer. K. 12/19/24, the areas of concern and data collected were presented at the Facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting. L. The Administrator and Director of Nurses will be responsible for overall compliance.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice specific to following physician's orders for two Residents (#19 and #48) in a sample of 18 residents. Specifically, the facility failed: 1. For Resident #19, to follow physician's orders to discontinue an antipsychotic medication timely; and 2. For Resident #48, to ensure staff implemented physician's orders for: a. air mattress settings; b. 1:1 (one to one) supervision with oral intake; and c. fall mat to side of his/her bed. Findings include: 1. Review of the facility's policy for Medication and Treatment Order and Administration Policy, undated, indicated the following: -orders for medications and treatments will be consistent with principles of safe and effective order writing -verbal orders must be recorded immediately in the resident's chart by the person receiving the order Resident #19 was admitted to the facility in May 2018 with a diagnosis of dementia. Review of the medical record indicated Resident #19 had an order for Abilify (an antipsychotic) 2.5 milligrams (mg) one time a day, start date 6/7/24. Review of a Psychiatric Nurse Practitioner's Progress Note, dated 9/15/24, indicated a recommendation to stop the Abilify. Review of a nursing progress note, dated 9/19/24, indicated the antipsychotic was no longer needed, as recommended by the Psychiatric Nurse Practitioner and the medical Nurse Practitioner and the Health Care Proxy were aware and in agreement. Review of the medical record indicated the order to discontinue the Abilify was not implemented until 10/11/24, three weeks later. During an interview on 10/17/24 at 10:35 A.M., Unit Manager #2 said she had written the nursing progress note on 9/19/24. She said the process was the team would have meetings with the Psychiatric Nurse Practitioner and recommendations would be made. She said the Director of Nurses (DON) would then tell her what to write in a progress note and the DON would be the one to physically discontinue the order in the electronic medical record. During an interview on 10/17/24 at 12:05 P.M., the DON said recommendations were made from behavior rounds regarding antipsychotic medications and if approved by the primary physician, the orders would be implemented. She said she was responsible for making the changes in the electronic medical record. She said she had not been at the behavior meeting on 9/13/24 and that was why the changes had not been implemented timely. 46562 2. Resident #48 was admitted to the facility in October 2022 with the following diagnoses: dementia, dysphagia (difficulty swallowing), and repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 8/7/24, indicated Resident #48 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS indicated Resident #48 was dependent on staff to eat. Review of Resident #48's Physician's Orders indicated but was not limited to: -Air mattress: pressure set per resident's most recent weight; +/- 10 pounds. Document weight. Check placement and function every shift, 10/8/24 -1:1 supervision during oral intake. Ensure complete clearance of mouth prior to next bite. Alternate liquids/solids, encourage to re-swallow if food still present. Position at 90 degrees for 30-40 minutes with meals for dysphagia, 10/17/23 -Fall mat to left side of bed when resident is in bed, every shift for safety, dated 10/3/24 a. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated May 2023, indicated but was not limited to: -Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of Resident #48's weight record indicated his/her most recent weight was obtained on 10/3/24, and he/she weighed 135 pounds. On the following dates of survey, the surveyor observed Resident #48 in bed with his/her air mattress set at approximately 350 pounds: -10/15/24 at 10:37 A.M. -10/16/24 at 8:28 A.M. -10/17/24 at 8:47 A.M. -10/17/24 at 9:06 A.M. -10/17/24 at 3:31 P.M. During an interview on 10/17/24 at 3:34 P.M., Certified Nursing Assistant (CNA) #7 said she was not sure how the air mattress settings worked and did not know what Resident #48's air mattress should be set at. During an interview with observation on 10/17/24 at 3:39 P.M., the surveyor and Nurse #5 observed Resident #48 in bed with his/her air mattress set at approximately 350 pounds. Nurse #5 said the Resident's physician's orders gave instruction for the air mattress. Nurse #5 reviewed Resident #48's record and said his/her most recent weight was 135 pounds and the order indicated the air mattress settings should be set within 10 pounds of his/her weight. During an interview with observation on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48's air mattress should be set plus or minus ten pounds of their current weight. The surveyor and Unit Manager #2 observed the Resident in his/her bed with the air mattress set at approximately 350 pounds. Unit Manager #2 said the Resident did not weigh 350 pounds and the air mattress setting was incorrect. During an interview on 10/17/24 at 4:20 P.M., the DON said air mattresses should be set at the correct settings and physician's orders should be followed. b. On 10/17/24 at 8:47 A.M., the surveyor observed Resident #48 lying in bed with his/her bed positioned between 45 and 60 degrees. Resident #48 was eating his/her breakfast alone and was pulling him/herself forward to grab the food from the breakfast tray. Resident #48 was not observed alternating liquids with solids. During an interview on 10/17/24 at 9:01 A.M., CNA #4 said Resident #48 required assistance with meals, should have been positioned at 90 degrees, and should not have been eating his/her breakfast alone. During an interview on 10/17/24 at 9:03 A.M., Nurse #4 said Resident #48 required 1:1 supervision and assistance with meals. Nurse #48 said he/she should be sitting upright at a 90-degree angle and should not have been left alone with his/her breakfast. During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48 had a history of dysphagia and required 1:1 supervision with meals and should be positioned at 90 degrees when eating and for at least 30 minutes after. During an interview on 10/17/24 at 4:20 P.M., the DON said all physician's orders should be followed including those for feeding and assisting residents with meals. c. On the following dates of survey, the surveyor observed Resident #48 in bed with no fall mat on the side of his/her bed: -10/15/24 at 10:37 A.M. -10/16/24 at 8:28 A.M. -10/17/24 at 8:47 A.M. -10/17/24 at 9:06 A.M. -10/17/24 at 3:31 P.M. During an interview on 10/17/24 at 3:34 P.M., CNA #7 said interventions to keep Resident #48 safe while in bed included a low bed and making sure the call light was within reach. CNA #7 did not know about an intervention for a floor mat to the left side of the bed. During an interview with observation on 10/17/24 at 3:39 P.M., the surveyor and Nurse #5 observed Resident #48 in his/her bed with no floor mat on the side of the bed. Nurse #5 said she was not aware of an order to keep a floor mat on the side of Resident #48's bed. Nurse #5 and the surveyor reviewed the physician's orders and Nurse #5 said there was an order for a fall mat to the left side of the bed and one should have been in place. During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said Resident #48 should have a floor mat on the left side of the bed when he/she was in bed per physician's orders. During an interview on 10/17/24 at 4:20 P.M., the DON said Resident #48 had an order for a floor mat to the left side of his/her bed as a fall intervention and the floor mat should have been in place when he/she was in bed. The DON said all physician's orders should be followed.

Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #36, the facility failed to ensure an allegation of sexual abuse was investigated. Findings include: Review of the facility's policy titled Abuse Policy, dated May 2023, indicated, but is not limited to: -Identification: Reporting of suspected alleged violations shall be encouraged by staff. Incidents of alleged violations shall be reviewed by the facility's Quality Assessment and Assurance Committee for detection of patterns and trends. -Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation. -Policy and Procedure: A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed. B. The supervisor is to initiate the following steps: 1. Immediate investigation into the alleged incident 2. Interview staff member implicated. Get a written statement 3. Interview other staff members 4. Interview with resident or resident witnesses C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours D. Final reports to be submitted to the Department of Public Health within five business days of the initial report. Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being). Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to: -Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information. During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a reportable for Resident #36 in the last six months. During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected the facility should ensure the resident is safe and fully investigate the potential abuse. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to investigate. During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be investigated. During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been investigated. During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been investigated and it should have been.

Based on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for one Resident (#21), out of a total census of 70 residents, to ensure safe storage of medications and biologicals according to current standards of practice. Findings include: Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing dugs and biologicals are locked when not in use. Review of the facility's policy titled Self-Administration of Medications, dated May 2023, indicated but was not limited to the following: -If the staff determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. -Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party. Resident #21 was admitted to the facility in June 2023 with diagnoses including pain, diabetes, and heart failure. Review of the Minimum Data Set (MDS) assessment, dated 8/28/24, indicated that Resident #21 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Review of Resident #21's medical record indicated that on 8/6/24, a Self-Administration of Medication evaluation was completed for the Resident. The evaluation indicated that Resident #21 was not approved for self-administration of medications and may not keep medications at the bedside. On the following dates/times of survey, the surveyor observed two bottles of eye drops on Resident #21's nightstand and three bottles of eye drops and one bottle of acetaminophen (an over-the-counter pain/fever reliever) on the Resident's windowsill: -10/15/24 at 9:40 A.M., -10/16/24 at 12:28 P.M., -10/16/24 at 4:49 P.M., and -10/17/24 at 9:12 A.M. During an interview on 10/16/24 at 12:28 P.M., Resident #21 said that his/her family provides eye drops and acetaminophen to him/her and that he/she administers his/her own eye drops and acetaminophen. Resident #21 said that he/she does not record the date and time he/she administers the medications anywhere. During an interview on 10/16/24 at 4:49 P.M., Nurse #1 said that Resident #21 was not able to self-administer medications. Nurse #1 said that the Resident should not have any medications in his/her room and that his/her medications should be stored in the medication cart. During an interview on 10/17/24 at 9:25 A.M., Unit Manager #2 said that Resident #21 is not able to self-administer medications and should not have any medications in his/her room. During an interview on 10/17/24 at 4:20 P.M., the Director of Nursing said that no medications should be left out at the bedside. The Director of Nursing said that Resident #21 is not able to self-administer medications and should not have any medications in his/her room.

Based on observation, interview, and policy review, for one Resident (#36), of 18 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, for Resident #36, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms to residents with increased risk). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance titled Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated but was not limited to: -Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. -EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing -EBP are indicated for residents with any of the following: a. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -EBP should be used for any residents who meet the above criteria, wherever they reside in the Facility Review of the facility's policy titled Enhanced Barrier Precautions, undated, indicated but was not limited to: -Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism as well as those at increased risk of multidrug-resistant organism 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 the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precaution sign indicated but was not limited to: -In addition to standard precautions Staff and Providers must: -Clean hands prior to entering and when exiting the room -Wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and chronic ulcer of lower extremities. Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #36's orders indicated but were not limited to: -Staff to maintain enhanced barrier precautions related to (wounds) every shift for infection control, dated 10/15/24 Review of Resident #36's care plan indicated but was not limited to: -Staff to maintain enhanced barrier precautions related to auto-immune induced wounds and lower extremity wounds, revised 10/15/24 On the following dates of the survey, an EBP Precaution Sign was posted at the entrance to Resident #36's room: -10/15/24, -10/16/24, and -10/17/24 On 10/16/24 at 9:57 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 assisting Resident #36 with personal hygiene. CNA #1 was not wearing a gown. On 10/16/24 at 10:34 A.M., the surveyor observed CNA #1 and CNA #3 transferring Resident #36 from his/her bed to the wheelchair, neither employee was wearing a gown. On 10/17/24 at 10:10 A.M., the surveyor observed CNA #5 assisting Resident #36 with personal hygiene. CNA #5 was only wearing gloves and had not donned a gown. On 10/17/24 at 10:36 A.M., the surveyor observed two hospice consultants assisting Resident #36 with personal hygiene, both consultants were only wearing gloves and had not donned a gown. During an interview on 10/17/24 at 10:17 A.M., CNA #5 said the precaution sign was intended for the nurses during wound care. During an interview on 10/17/24 at 10:40 A.M., Unit Manager #2 said Resident #36 required EBP for high contact care and included the use of gloves and a gown. During an interview on 10/17/24 at 4:20 P.M., the Director of Nurses (DON) said Resident #36 required EBP for high contact care activities and staff should have donned gloves and a gown.

Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure an allegation of sexual abuse was reported timely to the state agency as required. Findings include: Review of the facility's policy titled Abuse Policy, dated May 2023, indicated but was not limited to: -Identification: Reporting of suspected alleged violations shall be encouraged by staff. -Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation. -Policy and Procedure: A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed. B. The supervisor is to initiate the following steps: 1. Immediate investigation into the alleged incident. 2. Interview staff member implicated. Get a written statement. 3. Interview other staff members. 4. Interview with resident or resident witnesses. C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours. D. Final reports to be submitted to the Department of Public Health within five business days of the initial report. Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being). Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to: -Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information. Review of the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged abuse had been reported. During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a reportable for Resident #36 in the last six months. During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected the facility should ensure the resident is safe and report the allegation to the state agency. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to report it. During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be reported to the State agency through HCFRS. During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been reported to the State agency. During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been reported and it should have been.

Based on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to implement policies and procedures for alleged abuse. Specifically, the facility failed to investigate and report an allegation of sexual abuse. Findings include: Review of the facility's policy titled Abuse Policy, dated May 2023, indicated but was not limited to: -Identification: Reporting of suspected alleged violations shall be encouraged by staff. Incidents of alleged violations shall be reviewed by the facility's Quality Assessment and Assurance Committee for detection of patterns and trends. -Reporting: An employee who suspects an alleged violation shall immediately notify the Executive Director (ED) or his/her designee. The ED shall also notify the appropriate State agency in accordance with state law. The results of all investigations must be reported immediately to the ED or his/her designee and to the appropriate State agency, as required by State law with initial report submitted within two hours and follow up within five working days of the violation. -Policy and Procedure: A. If a family member, resident or staff reports an incident of abuse/mistreatment/neglect, it is to be reported to the Director of Nursing Services (DNS) or manager immediately and an Incident/Accident report is to be completed. B. The supervisor is to initiate the following steps: 1. Immediate investigation into the alleged incident. 2. Interview staff member implicated. Get a written statement. 3. Interview other staff members. 4. Interview with resident or resident witnesses. C. Send initial report to the Department of Public Health (DPH) immediately but no later than two hours. D. Final reports to be submitted to the Department of Public Health within five business days of the initial report. Resident #36 was admitted to the facility in June 2018 with the following diagnoses: vascular dementia and post-traumatic stress disorder (PTSD, a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being). Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #36's incident report and fall packet, dated 5/16/24, indicated but was not limited to: -Resident #36 was being assessed after being found on the floor and he/she reported to Nurse #3 that someone had just molested him/her. Nurse #3 indicated that Resident #36 could not provide any additional information. Review of the Health Care Facility Reporting System (HCFRS, a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) failed to indicate the alleged abuse had been reported. During an interview on 10/17/24 at 12:06 P.M., the Director of Nurses (DON) said the facility did not have a record of a reportable incident for Resident #36 in the last six months. During an interview on 10/17/24 at 1:22 P.M., Unit Manager #2 said when any form of abuse is alleged or suspected, the facility should ensure the resident is safe, report the allegation to the state agency, and fully investigate the potential abuse. Unit Manager #2 said anytime there is a suspicion or allegation, the facility should follow the policy to investigate and report it. During an interview on 10/17/24 at 2:29 P.M., the Administrator said she was unaware of the alleged abuse. The Administrator said all allegations of abuse should be investigated and reported to the State agency through HCFRS. During an interview on 10/17/24 at 2:57 P.M., the Administrator said the alleged abuse had not been investigated or reported. During an interview on 10/17/24 at 4:20 P.M., the DON said the allegation had not been investigated or reported and it should have been.

Based on observation, interview, and record review, the facility failed to promote the rights of one Resident (#60) to have fluids of choice, in a total sample of 18 residents. Specifically, the facility restricted the fluids of Resident #60, despite the removal of the order for a fluid restriction three weeks prior. Findings include: Resident #60 was admitted to the facility in March 2024 with diagnoses of hard of hearing, polydipsia (excessive thirst), and dementia. Review of the medical record indicated Resident #60 had an activated Health Care Proxy. Review of the Minimum Data Set (MDS) assessment, dated 9/18/24, indicated Resident #60 was cognitively intact, scoring 13 out of 15 on the Brief Interview for Mental Status. Review of the medical record indicated Resident #60 had exhibited behaviors of taking drinks off of the nurse's medication carts, taking cups to fill with water from the faucet or the toilet, and constantly asking for drinks. Review of the care plans for Resident #60 indicated a Focus for behavior management for a new repetitive behavior of continuously asking for water, drinking excessive amounts of water from the faucet, toilet and other people's cups (initiated 9/13/24) with the following Approaches: -educate Resident on the importance of drinking from appropriate sources; encourage use of personal tumbler to drink fluids from (initiated 10/11/24) -encourage self-calming behaviors such as breathing exercises, meditation, guided imagery (initiated 9/13/24) -ensure my labelled cup is filled with fluids (initiated 10/11/24) -establish boundaries and limits with the Resident (initiated 9/13/24) -known to drink out of the toilet, re-direct when this occurs (initiated 9/18/24) -remind to drink from tumbler filled with liquids when I ask for more water (initiated 10/11/24) Review of the care plans for Resident #60 indicated a Focus for potential for fluid volume overload related to psychogenic polydipsia (initiated 10/14/24) with the following Approaches: -educate on the importance of self-limiting fluid intake to minimize the risk of fluid overload (initiated 10/14/24) -known to be non-adherent with diet orders (initiated 10/14/24) -monitor for signs and symptoms of fluid overload (initiated 10/14/24) -family is aware of polydipsia as evidenced by drinking soda when living with them (initiated 10/14/24) -obtain and monitor laboratory work as ordered (initiated 10/14/24) -provide Resident with their own tumbler cup labeled with name to encourage drinking from appropriate sources (initiated 10/14/24) Review of the Physician's Orders indicated as of the time of the survey (10/15/24) the Resident did not have a fluid restriction (discontinued 9/24/24) and was on thin liquids as of 10/14/24. Review of the nursing progress notes indicated on 9/24/24 the Resident had been seen by the Nurse Practitioner and the Resident had continued to be non-compliant with the fluid restriction. The Nurse Practitioner had discontinued the fluid restriction related to the Resident refusing and the Resident drinking from the toilet. Following the discontinuation of the fluid restriction on 9/24/24 the following nursing progress notes were written: -10/5/24: Resident was very behavioral, non-compliant with fluid restriction -10/9/24: Resident continues excessively drinking water from anywhere, staff are continuously trying to redirect to try to restrict fluid intake -10/11/24: Nursing provided Resident with a large tumbler labelled with name to encourage drinking from appropriate sources -10/14/24: meeting with Health Care Proxy, Nurse Practitioner, and nursing with new order to discontinue thickened liquids related to Resident non-compliance and Resident/family wishes for thin liquids On 10/16/24 at 1:15 P.M., the surveyor observed Resident #60 ask Nurse #2 for ginger ale. Unit Manager #2 provided Resident #60 with a 5-ounce cup of ginger ale. At 1:26 P.M., the surveyor observed Resident #60 ask Nurse #2 for more ginger ale. Nurse #2 told Resident #60 they can have one more small cup of ginger ale, but not until 2:00 P.M. (attempting to set a boundary, as indicated in the care plan) and gave him/her another 5-ounce cup. At 1:43 P.M., the surveyor observed Resident #60 approach Nurse #2 and ask for ginger ale. The Nurse reminded the Resident of the plan to return at 2:00 P.M. and the Resident said he/she did not have a clock in their room. On 10/16/24 at 4:21 P.M., the surveyor observed Resident #6 approach Nurse #6 and ask for ginger ale. The Nurse informed Resident #60 they would get ginger ale with dinner and said, Not right now. Resident #60 was unable to hear Nurse #6 and continued to ask while telling the nurse that he/she could not hear them. The Nurse was observed to tell Resident #60 that there was no ginger ale. At 4:24 P.M., Nurse #6 gave Resident #60 a 5-ounce cup of water, the Resident repeatedly asked if there was ginger ale and the nurse responded No, no, no. Can you hear that? The Resident responded, You told me to wait until 4:30 P.M., and the Nurse responded, You have to wait until dinner. At this time, the surveyor observed a drink cart on the unit with a bottle of ginger ale. The Nurse was not observed to check if there was water in the designated tumbler. At 4:36 P.M., Resident #60 asked a Certified Nursing Assistant (CNA) for a drink and the CNA told the Resident to ask the nurse. The Resident asked Nurse #6 who told the Resident to go watch television. The Resident said, Never mind and walked away. Neither the CNA nor the Nurse were observed to check the Resident's tumbler to make sure it had water. At 4:52 P.M., the surveyor observed Resident #60 asking Unit Manager #2 for ginger ale. Unit Manager #2 told the Resident No. At 4:58 P.M., the surveyor observed Nurse #6 to have her medication cart across (blocking) the doorway of Resident #60's room. Unit Manager #2 and Nurse #6 were in the room with Resident #60. Resident #60 asked if he/she could go see what time it was, Unit Manager #2 replied, No, we know what time it is, it's 4:58 P.M., it's not time yet, you have to wait until 5:00 P.M. Unit Manager #2 filled the blue tumbler with water. Resident #60 asked if he/she could have ice in their drink and the Unit Manager replied, Nope, we don't have any. Unit Manager #2 told Nurse #6 that Resident #60 can have any amount of water, but not any amount of ginger ale or juice because he/she was diabetic. At 5:00 P.M., Resident #60 attempted to leave the room and Unit Manager #2 said, You can't leave. At 5:02 P.M., Resident #60 asked Nurse #6 when dinner was and the Nurse responded, You have to stop asking me, I need to tend to other people. At 5:03 P.M., Unit Manager #2 was observed bringing Resident #60 their dinner meal with ginger ale. During an interview with observation on 10/17/24 at 2:10 P.M., the surveyor observed Resident #60 having difficulty hearing the surveyor who had to get very close and speak loudly. The Resident said he/she did not have a clock in their room. The surveyor did not observe a clock in the Resident's room. During an interview on 10/17/24 at 12:39 P.M., CNA #2 and CNA #5 said Resident #60 had behaviors of looking for water and sneaking drinks and that redirection did not work. They said the only thing that worked was giving the Resident what they wanted for a drink. During an interview on 10/17/24 at 1:49 P.M., the Social Worker said Resident #60 had an increased obsession with drinking water following a stroke. He said the Resident would continuously ask staff for water. He said the family had decided during a meeting to remove the fluid restriction, but he was not sure if this had improved the Resident's behaviors. During an interview on 10/17/24 at 2:15 P.M., Nurse #4 said he was assigned to care for Resident #60 on this day, but he was unfamiliar with the Resident. He said during the shift there had been a question of if Resident #60 had a fluid restriction, but the Resident did not have any fluid restrictions and the Resident liked to have ice with their water. During an interview on 10/17/24 at 2:35 P.M., Unit Manager #2 said all Resident #60 wanted to do was drink fluids. She said the fluid restriction was discontinued a couple of weeks prior. She said they give the Resident a cup and fill it with water. She said the staff try to restrict sugary drinks because the resident had a diagnosis of diabetes, but that the Resident was not on a diabetic diet with any restrictions. She said diet ginger ale was available for the Resident. She said she tried to limit the ginger ale intake the previous day because the Resident had had too much already. She said there was no tracking to say how much the Resident had or an order to indicate how much fluid was too much. She said she was telling the Resident not to leave the room yesterday because the Resident did not really want to know what time it was, the Resident wanted to go to the drink cart and grab a drink and was trying to manipulate the staff. She said the Resident did not need to know what time it was because herself and the maintenance man had told the Resident what time it was. She said she had not looked to see if the Resident had a clock in their room. The Unit Manager said the staff cannot stop the Resident from drinking, but the staff had to use common sense on how much they were going to give the Resident to drink. During an interview on 10/18/24 at 8:00 A.M., the Director of Nurses said the staff were still trying to determine what approaches worked for Resident #60 to decrease the Resident interrupting nurses while passing medications to other residents. She said that although she could not speak directly to why the staff had attempted to limit the drinks for the Resident on 10/16/24 she thinks the staff and the Unit Manager were probably trying to limit the amount of fluids the Resident was having because they knew he/she had too much fluids already. She said there was no fluid restriction and no tracking for fluid intake. She said the best approach right now really came down to quality of life and this was what the staff should be focused on.

Based on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#5), of 18 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance. Findings include: Review of the facility's policy titled Resident Call System, undated, indicated but was not limited to: -When in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers. Resident #5 was admitted to the facility in March 2017 with diagnoses including dementia and history of falling. Review of the Minimum Data Set (MDS) assessment, dated 9/4/24, indicated a Brief Interview for Mental Status (BIMS) for Resident #5 was not completed as the Resident is rarely/never understood. Further review of the MDS indicated that the Resident was dependent on staff for activities of daily living and able to ambulate with supervision or touching assistance. Review of Resident #5's Care Plan indicated, but was not limited to, the following: -Focus: I am at risk for falls r/t (related to) deconditioning, gait instability, dementia, decreased awareness of safety needs, wandering behavior, and use of antidepressant medication. h/o (history of) epidemic vertigo, muscle weakness -Approaches: Be sure [Resident #5]'s call light is within reach and encourage [Resident #5] to use it for assistance as needed. [Resident #5] needs prompt response to all requests for assistance. On 10/15/24 at 10:00 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach. On 10/16/24 at 10:26 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach. On 10/16/24 at 11:56 A.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach. On 10/16/24 at 4:28 P.M., the surveyor observed Resident #5 lying in bed and the call light cord was gathered and clipped above the bed and out of the Resident's reach. During an interview on 10/16/24 at 4:40 P.M., Nurse #1 said the call light should not be out of reach and should be where the Resident can reach it at all times. During an interview on 10/17/24 at 3:00 P.M., the Director of Nursing said that call lights or an alternative means of contacting staff, such as hand bells, should be accessible to residents at all times. During an interview on 10/17/24 at 4:07 P.M., Unit Manager #2 said that call lights should be within reach for all residents.

Based on record review, document review, policy review, and interview, the facility failed to follow professional standards of practice in nursing for the care and monitoring of a peripherally inserted central catheter (PICC) and/or midline catheter. Specifically, the facility failed: 1. To obtain physician's orders and provide appropriate nursing interventions for 2 out of 2 PICC lines and 2 out of 2 midline catheter devices for one Resident (#20), out of a total sample of three residents with peripheral lines in place during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm and an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT- blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC; and 2. For one Resident (#39), out of a total sample of two residents currently residing in the facility with a PICC or midline device in place, to provide care and treatment of the PICC. Specifically, the facility failed to ensure the PICC dressing change was performed correctly, three of three lumens of the PICC were flushed correctly, the needleless connector of one of three lumens was primed before being changed according to facility policies and PICC protocol/standards of practice. The facility also failed to have complete orders in place for care of the Resident's PICC. It was determined the Immediate Jeopardy began on 10/10/22 and was identified on 9/13/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy (IJ) and the IJ templates to the Facility Administrator on 9/13/23. Findings include: 1. Review of the facility's policy titled Central Line Policy, revised June 2022, indicated but was not limited to the following: -The purpose of this procedure is to outline the protocol when caring for residents that have a midline (thin, soft tube that is placed into a vein at the level of the armpit) used for IV treatments or peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart). -Enter standing orders including but not limited to: a. monitoring the site for signs and symptoms of IV related complications b. catheter lumen flushing c. dressing orders d. tubing change frequency Review of the facility's document titled, Pharmscript Infusion Intravenous (IV) Access Line Maintenance Protocol, dated December 2018, indicted but was not limited to the following: Midline: -Maintenance, Flush Each Lumen - Non-Valved every 12 hours with normal saline (NS) 10 milliliters (mL's), 3 mL 10 units/mL heparin [blood thinner that prevents harmful clots from forming in blood vessels], valved 10 mL NS every week -Transparent Dressing Change - Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Changes - On admission, every week, and as needed Administration Set Changes - primary, every 24 hours PICC: -Maintenance, Flush Each Lumen - Non-valved every 12 hours with NS 10 mL, 5 mL 10 units/mL heparin, valved 10 mL NS every week, Intermittent Non-Valved - 10 mL NS, 5 mL 10 units/mL heparin -Transparent Dressing Change - Insertion, then weekly and as needed, measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Device - On admission, then weekly and as needed -Administration Set Changes - primary, every 24 hours Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTI). Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance with bed mobility, and was receiving an anticoagulant (blood thinner) and antibiotic. Review of the medical record failed to indicate a comprehensive care plan was developed and implemented for care and treatment of the PICCs/Midline devices inserted or for the Resident's history of chronic embolism and thrombosis. a. Midline Placement #1 (10/10/22) Review of the Bard PowerMidline Instructions for Use (IFU), revised November 2016, indicated but was not limited to the following: The PowerMidline Catheters are indicated for short term access to the peripheral venous system for selected intravenous therapies, blood samples, and power injection of contrast media. Warnings: -Do not use the catheter if there is any evidence of mechanical damage or leaking. The potential exists for serious complications including the following: -Air embolism, catheter emboli, catheter occlusion, catheter related sepsis, exterior site infection, exterior site necrosis, hematoma, phlebitis, perforation of vessels, thromboembolism, venous thrombosis Suggested Catheter Maintenance: Dressing Changes: -Assess the dressing the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. -During dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing Flushing: -Flush each lumen of the catheter with 10 mL of sterile saline every 12 hours or after each use. In addition, lock each lumen of the catheter with sterile saline. Upon confirmation of patency, administration of medication should be given in a syringe appropriately sized for the dose. Do not infuse against resistance. Occluded or Partially Occluded Catheter: -Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If it has been determined that a catheter is occluded with blood, a de-clotting procedure per institution protocol may be appropriate. Review of a Nurse Practitioner's (NP) Note, dated 10/7/22 (4:55 P.M.), indicated but was not limited to the following: -Resident has a past medical history significant for DVT on Eliquis (apixaban- blood thinner), frequent hospitalization s, and recurrent urinary tract infections. -Urinalysis positive, awaiting culture results for antibiotic treatment. Review of Physician's Orders indicated the following: -May insert peripheral IV, schedule midline placement if unable, may place PICC line for IV antibiotic therapy every shift for 1 day, 10/9/22 -Cefepime HCL solution, 2 gm/100 mL, use 100 mL intravenously every 12 hours related to pseudomonas aeruginosa, for 10 days, give 2 gm/100 ml IV every 12 hours for 10 days, 10/9/22 Review of the Midline Insertion Record, dated 10/10/22, indicated a single lumen PowerMidline catheter was placed into the cephalic vein of the Resident's left arm at 11:05 A.M. for non-vesicant (does not irritate tissues) therapy greater than 14 days. Review of a Nurse Progress Note, dated 10/14/22 (3:08 P.M.), indicated but was not limited to the following: -Resident's left upper extremity Midline leaking. Nurse #11 indicated the dressing was wet and when flushed fluid could be seen at the entrance to the site. The MD was notified, and an order was obtained to have a new one (midline) inserted. -No further assessment of the site was documented by Nurse #11. Nurse #11 was unavailable for interview and was unable to be reached by phone by the surveyor. Review of the October 2022 Medication Administration Record (MAR) indicated Nurse #9 administered the first dose of the IV cefepime on 10/10/22 as per her initials after the Midline catheter placement. Eight total doses of the antibiotic were administered from 10/10/22 to 10/14/22. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy. b. Midline Placement #2 (10/14/22) Review of Physician's Orders indicated the following: -May replace Midline to left upper extremity related to leakage, may miss dose until IV replaced, 10/14/22 -Cefepime HCL solution 2 gm/100 mL, use 100 mL intravenously every 8 hours related to pseudomonas aeruginosa for 7 days, give 2 gm/100 mL IV every 8 hours for 7 days (start once line placed), 10/14/22 Review of a Nurse Practitioner's Note, dated 10/14/22 (5:29 PM.), indicated but was not limited to the following: -Resident on a seven day course of Cefepime, his/her midline leaking and awaiting a midline change. -Cefepime frequency increased to every 8 hours for another 7 days for a total of 10 days. Review of the Midline Insertion Record, dated 10/14/22, indicated a single lumen Midline catheter was placed in the cephalic vein of the Resident's right arm at 9:00 P.M. for non-vesicant therapy less than six days. Review of the October 2022 MAR indicated the cefepime was administered six times from 10/15/22 through 10/16/22 (three times a day for each day). Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy. c. Power Injectable PICC Placement #1 (10/18/22) Review of Bard PowerPICC Instructions for Use (IFU), revised November 2010, indicated but was not limited to the following: The PowerPICC SV is indicated for short- or long-term peripheral access to the central venous system for intravenous therapy, blood sampling, power injection of contrast media, and allows for central venous pressure monitoring. Contraindications: -Previous episodes of venous thrombosis -Do not use the catheter if there is any evidence of mechanical damage or leaking. Damage to the catheter may lead to rupture, fragmentation, possible embolism, and surgical removal. Possible Complications: -Air embolism, bleeding, cardiac arrhythmia, cardiac tamponade, catheter embolism, catheter occlusion, catheter related sepsis, endocarditis, exit site infection, exit site necrosis, hematoma, phlebitis, thromboembolism, venous thrombosis Dressing Changes: -Assess the dressing in the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. During all dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing. Flushing: -Flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, lock each lumen of the catheter with heparinized saline. Occluded or partially Occluded Catheter: -Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If the lumen will neither flush nor aspirate and it has been determined that the catheter is occluded with blood, a de-clotting procedure per institution may be appropriate. Review of [NAME] Nursing Procedures, eighth edition, dated 2019, indicated but was not limited to the following: Peripherally Inserted Central Catheter (PICC) Use: Flushing a PICC: -Review the patient's medical records to confirm the type and size of the catheter and the location of the catheter tip, because the flush protocol depends on the type and size of the catheter. -Inspect the entire infusion system for clarity of the solution, integrity of the system (such as absence of leakage), accurate flow rate, expiration dates of the solution and administration set. Performing a PICC Dressing Change: -Inspect the catheter-skin junction and surrounding area and palpate through intact dressing for redness, tenderness, swelling, and drainage. Pay attention to the patient's reports of pain. -Use a sterile tape measure to measure the external length of the catheter from hub to skin entry to make sure the catheter hasn't migrated. Special Considerations: -Assess the catheter insertion site daily by inspection and palpation through the transparent semi-permeable dressing to discern tenderness. Look at the catheter and cannula pathway, and check for bleeding, redness, drainage and swelling. Ask the patient about pain associated with therapy. -For catheters that aren't being used routinely, flush non-valved catheters at least every 24 hours and valved catheters at least weekly. Flush the catheter with preservative free normal saline solution; lock with heparin (10 units/mL) if applicable. -Encourage the patient to report changes in the catheter site or any new discomfort Complications: -PICCs are associated with higher rates of DVT than other central venous access devices owing to insertion into the veins with a smaller diameter and greater movement of the upper extremity. -PICC insertion sites at the antecubital fossa have higher rates of DVT than mid-upper arm insertion sites. Infection and catheter breakage on removal are other possible complications. Documentation: -For flushing, document the site's appearance as well as the date, time, and type and amount of flush solution used. Document patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of blood return upon aspiration. Document whether the patient experienced pain or discomfort during flushing. Note patient teaching performed. Review of Physician's Orders indicated the following: -Replace 10 cm midline in the right arm due to leak one time only for leak, 10/17/22 -Take the Midline out, not functioning replaced with PICC line, 10/18/22 -Insert a PICC line for administration of cefepime for UTI, 10/18/22 Review of the PICC Insertion Record, dated 10/18/22, indicated a single lumen, non-valved (neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting) Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at 12:40 P.M. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice. Review of the October 2022 MAR indicated the cefepime was restarted and administered by Nurse #9 per her initials after the PICC was inserted on 10/18/22 at approximately 2:00 P.M. Review of a Nurse Progress note, dated 10/18/23 (4:40 P.M.), indicated but was not limited to the following: -He/she had a PICC line inserted today and midline removed due to leaking, continues with his/her cefepime IV. The surveyor was unable to locate documentation in the medical record to indicate details of the previously placed midline leaking. Review of the Nurse Practitioner's note, dated 10/19/22 (9:49 P.M.), indicated but was not limited to the following: -Midline had been changed to a PICC line due to a second midline malfunction. Review of Physician's Orders indicated the following: -Flush each lumen with 10 mL of normal saline every 8 hours whenever lumen is locked with no infusion, currently running every 8 hours, start 10/22/22, (4 days after the PICC was placed) Further review of the physician's order failed to indicate the proper flushing protocol for the non-valved PICC line per facility protocol and manufacturer's IFUs which indicated to flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, to lock each lumen of the catheter with heparinized saline (keeps the catheter open and free of clots). Review of Physician's Orders indicated the following: -May remove PICC line from RUE, no longer in use, one time only for completed antibiotics for 1 day, 10/26/22 Review of a Nurse Progress Note, dated 10/30/22 (10:29 P.M.), indicated but was not limited to the following: -Resident to have a midline catheter placed in the morning by the contracted vascular access nurse for a slight right upper lobe infiltrate (when a substance denser than air, e.g., pus, edema, blood, lingers within the lung). During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said all IVs need orders to include flushing, changing the tubing, changing the dressing, and checking for signs and symptoms of infection. She said managers usually enter the orders, but nursing staff are responsible as well. Nurse #9 said documentation also includes progress notes and if the resident tolerated the medication well and if there are any signs and symptoms of infection. She said she had administered the antibiotic via the Resident's Midline catheter and/or PICC at least seven times last October but didn't notice there were no orders for the care and treatment of them, so she didn't enter them (the orders). She said the purpose of monitoring and assessing is because you want to keep the resident safe, it's the health of the patient, to assess for signs and symptoms of infection and DVT. Nurse #9 said the danger of a DVT is that it can block their arteries or lead to a stroke or go to the heart. She said proper care and treatment could help prevent any complications. d. Power Injectable PICC Placement #2 (11/1/22) Review of Physician's Orders indicated the following: -Ceftriaxone Sodium solution reconstituted, 1 gm IM stat for pneumonia, 10/30/22 -Ceftriaxone Sodium solution reconstitution 1 gm, use 1 gm intravenously one time a day for pneumonia until 11/3/22, start 10/30/22 -May insert midline to administer Ceftriaxone every shift for pneumonia for 1 day, 10/30/22 Review of a Procedure Note for Vascular Access Device Insertion, dated 10/31/22, indicated but was not limited to the following: -Resident was somnolent on assessment, not baseline per care team. Patient unable to consent for midline, discussed to establish peripheral IV in interim as patient may be sent to hospital. -Peripheral IV inserted. Patient with bilateral upper extremity edema. Review of a Nurse Progress Note, dated 10/31/22 (12:05 P.M.), indicated but was not limited to the following: -He/she is very swollen, he/she has been for a few days (note did not indicate where). Lasix (diuretic) was increased. -Right now he/she is completely out of it. Has a UTI and pneumonia and did not even flinch when they put the IV in his/her right hand. -NP was made aware, and the Resident was sent out to the hospital. Review of a Nurse Practitioner's Note, dated 11/1/22 (6:39 P.M.), indicated but was not limited to the following: -Resident was transferred back from the Emergency Department (ED) on 10/31/22 and was negative for any acute findings but was treated in the ED for a possible UTI. -Was started on PO cefpodoxime and returned to the facility with instructions to transition to IV cefepime if needed. -Patient currently complaining of dysuria (pain or burning sensation while passing urine), states he/she was told by the ED he/she had a bad UTI while in the ED, patient requesting cefpodoxime to be changed to IV cefepime. Review of the PICC Insertion Record, dated 11/1/22, indicated a single lumen, non-valved, Power Injectable PICC was inserted at 6:57 P.M. into the basilic vein in the Resident's left arm. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFU, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice. Review of a Nurse Progress Note, dated 11/3/22 (6:38 P.M.), indicated but was not limited to the following: -Resident was sent to the hospital due to possible left arm infiltration. Review of the hospital's History and Physical Nurse Practitioner's Note, dated 11/3/22, indicated but was not limited to the following: -Patient has a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), morbid obesity, DVT, suprapubic catheter, chronic pain, and recurrent UTIs and returned to the hospital for evaluation of pain and swelling in the left arm, most significantly at the site of the PICC. -Patient had a right sided PICC line two months ago and had superficial thrombus in the right arm at that time, suspect both DVTs are related to the PICC lines. Interestingly, the patient tells me that he/she feels that the swelling in his/her left upper extremity (LUE) began over a week ago, prior to PICC placement, though he/she admits this worsened after the PICC was inserted. -On arrival at the ED, a bilateral upper extremity (BUE) duplex showed an acute occlusive left DVT involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins. -The PICC line was removed immediately and a Heparin (blood thinner) drip was started. While it does make sense that the PICC line would be the causative factor in this DVT formation, it does not explain the bilateral nature of these findings. A vascular surgery consult was conducted. Review of a Hospital Care Management note, dated 11/8/22, indicated but was not limited to the following: -Resident had been assessed for discharge needs. The patient was on antibiotics for a UTI and was at the hospital for BUE DVTs and now has a tunneled subclavian central line for IV antibiotics. Unable to use BUE due to DVTs. Palliative NP met with the patient who is agreeable to hospice. Review of the Hospital Discharge Summary, dated 11/8/22, indicated but was not limited to the following: -The admission extended from 11/3/22 through 11/8/22. -The patient recently, on 10/31/22, had a PICC line placed at the SNF to begin treatment with IV cefepime for a pseudomonas UTI. He/she returned to the hospital on 11/3/22 from SNF with swelling and pain to his/her left arm, most significantly at the site of the PICC. On arrival at the ED, a BUE duplex (diagnoses DVTs and venous insufficiency) showed extensive bilateral DVTs. The patient has been seen by palliative care regarding poor quality of life and frequent hospitalization s. The discharge diagnosis was acute bilateral upper extremity DVTs and a follow up recommendation with hospice. The patient was discharged back to the SNF on Apixaban. During an interview on 9/11/23 at 12:27 P.M., Resident #20 said he/she remembered last October and when he/she was sent to the hospital. The Resident said the IVs were big and didn't feel right the whole time and were painful to him/her in the left arm. The Resident said he/she had to stay in the hospital and that's what he/she was trying to avoid. Resident #20 said it was an aide who discovered the swelling and told the nurse but didn't remember much more. During an interview on 9/11/23 at 11:38 A.M., Nurse #4 said potential problems of a PICC/Midline could include occlusion, clotting, and infection. She said orders would need to be in place for monitoring on the MAR or TAR but said the October 2022 MAR and TAR did not reflect that other than an order to flush on 10/22/22 when it was locked. Unit Manager (UM) #1 entered the nurses' station and said there should have been orders placed for the care and treatment of the PICC/Midline devices last October and November but weren't. She said staff need to know what kind of line it is to know what orders to enter, and it should have been care planned but wasn't. During an interview on 9/11/23 at 12:33 P.M., the Director of Nurses (DON) said she was relatively new to the facility and UM #2 would know better but the orders should have been entered with the IV insertion order and the Resident monitored for signs and symptoms of adverse events. She said the type of IV access would determine the treatment orders. She said if the documentation was not in the electronic record, then it was not done. UM #2 entered the DON's office and said she reviewed the Resident's record, and the orders were not there, there was nothing. She said the point of monitoring is to prevent any adverse events from occurring. The DON said there should have been a care plan in place but wasn't. During an interview on 9/12/23 at 3:00 P.M., the Medical Director (MD) said he was assigned to Resident #20 who had a history of a suprapubic catheter for chronic urinary retention, a long history of multidrug resistance use for UTIs, a hypercoagulable condition, chronic pain, heart failure, tobacco dependency, morbid obesity, was relatively immobile, monthly hospitalization s for the past year, and had a history of clots in both arms. He said at one point he/she had a clot in his/her leg as well and required IV access for multidrug-resistant organisms (MDRO) UTIs. He said the Resident was on Eliquis prior and would need, per the hematologist, lifelong anticoagulation after DVTs. He said he/she was at risk for clots and was on Eliquis. He said he wasn't sure who was responsible for entering the bundled orders (group of orders pertaining to the care and treatment of a midline/PICC). He said the orders should be entered to monitor the insertion site for no infection, nothing abnormal around the site, infiltrate, or clotting. The MD said whenever a patient requires a PICC line or Midline there would be a lot of active monitoring from his nurse practitioners to make sure the patient is doing well, that there's a response to treatment. Nursing staff would document monitoring and assessment of the site daily as well as in conjunction with the NPs. He said Resident #20 got a clot in his/her arm at the site of the PICC and, looking back now, there was a delay in diagnosing the clot when the patient had pain and swelling. He said one of his colleagues put another line in then sent him/her back to the hospital where a bilateral upper extremity duplex was done and showed extensive DVTs, and now we know why there's pain and swelling. He said he did not know there weren't any orders for monitoring, and it was obviously suboptimal. The MD said there should be adequate monitoring to avoid any complications or adverse events. During an interview on 9/12/23 at 4:20 P.M., the DON said there was nothing in the old records regarding paper documentation for the central lines, someone did look, and they didn't find it. She said she had no documentation to provide to the surveyor that the facility had identified the issue and conducted a plan of correction or educational piece. She said the expectation would be for whoever the nurse was that took the PICC/Midline insertion order, to enter the orders for the care and treatment of a central line to include things such as monitoring for swelling, redness, signs and symptoms of infection, flushing, dressing changes, changing the tubing, and monitoring for migration. She said nursing staff are expected to properly assess and monitor the site to avoid any potential adverse outcomes. No further documentation was provided to the surveyor prior to exiting the facility. See F694 27189 2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following: -Needleless Connector Changes: On admission, every week and as needed. -Administration Set Changes: Every 24 hours -Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed. -Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days. Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following: -Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached. Review of the [NAME] NURSING PROCEDURES - 9th Ed. (2023)- Flushing a PICC indicated but was not limited to the following: - While maintaining the sterility of the syringe tip, attach a prefilled 10-mL syringe containing preservative-free normal saline solution to the needleless connector. -Unclamp the catheter and slowly aspirate for a blood return that's the color and consistency of whole blood. -If you don't obtain a blood return, take steps to locate an external cause of obstruction. -If you obtain a blood return, slowly inject preservative-free normal saline solution into the catheter. -Don't forcibly flush the device. -Further evaluate the device if you meet resistance. Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis. Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on [DATE] with a PICC in place for the continued administration of Intravenous (IV) antibiotics. Review of the Hospital Discharge Summary, dated 9/12/23, indicated that the Resident was to receive four doses of intravenous (IV) antibiotics (9/13/23 through 9/16/23), and then the PICC was to be removed (on 9/16/23) after the last dose of the antibiotic had been administered. Review of the September 2023 Physician's Orders for the PICC line indicated the following: -Flush each lumen with 10 milliliters (mls) of normal saline every 8 hours, when lumen is locked with no infusion currently running. Discontinue once the line has been pulled. -Occlusive dressing supplies at bedside in the event the line is dislodged. Discontinue once line has been pulled. -Change PICC line catheter transparent dressing upon admission and every 7 days. -Flush catheter lumen pre- and post- medication administration with 10 mls of Normal saline every evening shift until 9/16/23. Line to be pulled after last dose given on 9/16/23. -Maintain emergency clamp at bedside at all times. -Monitor PICC line catheter every shift for signs/symptoms of IV related complications. Discontinue once line has been pulled. Further review of the Physician's orders failed to indicate the following: -Measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Device - On admission, then weekly and as needed -Adminis[TRUNCATED]

Based on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) and/or midline catheter device in accordance with the facility policy/protocols. Specifically, the facility failed: 1. For one Resident (#20), who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), out of a total sample of three residents with peripheral lines in place, to ensure physician's orders were in place and implemented for the care and treatment of two out of two midline catheters and two out of two PICCs to include monitoring for signs and symptoms of intravenous (IV) related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort by the Resident per professional standards of practice and facility policy during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm resulting in an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT) (blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC; and 2. For one Resident (#39), out of a total sample of two residents currently residing in the facility with a PICC or midline device in place, to provide care and treatment of the PICC. Specifically, the facility failed to ensure the PICC dressing change was performed correctly, three of three lumens of the PICC were flushed correctly, the needleless connector of one of three lumens was primed before being changed according to facility policies and PICC protocol/standards of practice. The facility also failed to have complete orders in place for care of the Resident's PICC. It was determined the Immediate Jeopardy began on 10/10/22 and was identified on 9/13/23. The Department of Public Health sent a Notice of Determination of Immediate Jeopardy (IJ) and the IJ templates to the Facility Administrator on 9/13/23. Findings include: 1. Review of the facility's policy titled Central Line Policy, revised June 2022, indicated but was not limited to the following: -The purpose of this procedure is to outline the protocol when caring for residents that have a midline (thin, soft tube that is placed into a vein at the level of the armpit) used for IV treatments or peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart). -Enter standing orders including but not limited to: a. monitoring the site for signs and symptoms of IV related complications b. catheter lumen flushing c. dressing orders d. tubing change frequency Review of the facility's document titled, Pharmscript Infusion Intravenous (IV) Access Line Maintenance Protocol, dated December 2018, indicated but was not limited to the following: Midline: -Maintenance, Flush Each Lumen - Non-Valved every 12 hours with normal saline (NS) 10 milliliters (mL), 3 mL 10 units/mL heparin [blood thinner that prevents harmful clots from forming in the blood vessels], valved 10 mL NS every week -Transparent Dressing Change - Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Changes - On admission, every week, and as needed Administration Set Changes - primary, every 24 hours PICC: -Maintenance, Flush Each Lumen - Non-valved every 12 hours with NS 10 mL, 5 mL 10 units/mL heparin, valved 10 mL NS every week, Intermittent Non-Valved - 10 mL NS, 5 mL 10 units/mL heparin -Transparent Dressing Change - Insertion, then weekly and as needed, measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Device - On admission, then weekly and as needed -Administration Set Changes - primary, every 24 hours Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs). Review of the Minimum Data Set (MDS) assessment, dated 8/2/23, indicated Resident #20 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance with bed mobility, and was receiving an anticoagulant (blood thinner) and antibiotic. Review of the medical record failed to indicate a comprehensive care plan was developed and implemented for care and treatment of the PICCs/midline catheter devices inserted from 10/10/22 through 11/3/22 or for the Resident's history of chronic embolism and thrombosis. a. Midline Placement #1 (10/10/22) Review of the Bard PowerMidline Instructions for Use (IFUs), revised November 2016, indicated but was not limited to the following: The PowerMidline Catheters are indicated for short term access to the peripheral venous system for selected intravenous therapies, blood samples, and power injection of contrast media. Warnings: -Do not use the catheter if there is any evidence of mechanical damage or leaking. The potential exists for serious complications including the following: -Air embolism, catheter emboli, catheter occlusion, catheter related sepsis, exterior site infection, exterior site necrosis, hematoma, phlebitis, perforation of vessels, thromboembolism, venous thrombosis Suggested Catheter Maintenance: Dressing Changes: -Assess the dressing the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. -During dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing Flushing: -Flush each lumen of the catheter with 10 mL of sterile saline every 12 hours or after each use. In addition, lock each lumen of the catheter with sterile saline. Upon confirmation of patency, administration of medication should be given in a syringe appropriately sized for the dose. Do not infuse against resistance. Occluded or Partially Occluded Catheter: -Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If it has been determined that a catheter is occluded with blood, a de-clotting procedure per institution protocol may be appropriate. Review of a Nurse Practitioner's (NP) Note, dated 10/7/22 (4:55 P.M.), indicated but was not limited to the following: -Resident has a past medical history significant for DVT on Eliquis (apixaban- blood thinner), frequent hospitalization s, and recurrent urinary tract infections. -Urinalysis positive, awaiting culture results for antibiotic treatment. Review of a Nurse Progress Note, dated 10/9/22 (11:32 P.M.), indicated but was not limited to the following: -Message sent to the attending physician that the patient refused PO (by mouth) antibiotics while awaiting the culture and requested IV antibiotics because the hospital said he/she would die of sepsis if not treated with IV antibiotics instead of PO ones. Review of Physician's Orders indicated the following: -May insert peripheral IV, schedule midline placement if unable, may place PICC line for IV antibiotic therapy every shift for 1 day, 10/9/22 -Cefepime HCL solution, 2 gm/100 mL, use 100 mL intravenously every 12 hours related to pseudomonas aeruginosa, for 10 days, give 2 gm/100 ml IV every 12 hours for 10 days, 10/9/22 Review of the Midline Insertion Record, dated 10/10/22, indicated a single lumen PowerMidline catheter was placed into the cephalic vein of the Resident's left arm at 11:05 A.M. for non-vesicant (does not irritate tissues) therapy greater than 14 days. Review of a Nurse Progress Note, dated 10/14/22 (3:08 P.M.), indicated but was not limited to the following: -Resident's left upper extremity Midline leaking. Nurse #11 indicated the dressing was wet and when flushed, fluid could be seen at the entrance to the site. The MD was notified, and an order was obtained to have a new one (midline) inserted. No further assessment of the site was documented by Nurse #11. Nurse #11 was unavailable for interview and was unable to be reached by phone by the surveyor. Review of the October 2022 Medication Administration Record (MAR) indicated Nurse #9 administered the first dose of the IV cefepime on 10/10/22 as per her initials after the Midline catheter placement. Eight total doses of the antibiotic were administered from 10/10/22 to 10/14/22. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy. b. Midline Placement #2 (10/14/22) Review of Physician's Orders indicated the following: -May replace Midline to left upper extremity related to leakage, may miss dose until IV replaced, 10/14/22 -Cefepime HCL solution 2 gm/100 mL, use 100 mL intravenously every 8 hours related to pseudomonas aeruginosa for 7 days, give 2 gm/100 mL IV every 8 hours for 7 days (start once line placed), 10/14/22 Review of a Nurse Practitioner's Note, dated 10/14/22 (5:29 PM.), indicated but was not limited to the following: -Resident on a seven day course of Cefepime, his/her midline leaking and awaiting a Midline change. -Cefepime frequency increased to every 8 hours for another 7 days for a total of 10 days. Review of the Midline Insertion Record, dated 10/14/22, indicated a single lumen midline catheter was placed into the cephalic vein of the Resident's right arm at 9:00 P.M. for non-vesicant therapy less than six days. Review of the October 2022 MAR indicated the cefepime was administered six times from 10/15/22 through 10/16/22 (three times a day each day). Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's midline device including adequate monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per professional standards of practice and facility policy. c. Power Injectable PICC Placement #1 (10/18/22) Review of Bard PowerPICC Instructions for Use (IFUs), revised November 2010, indicated but was not limited to the following: The PowerPICC SV is indicated for short- or long-term peripheral access to the central venous system for intravenous therapy, blood sampling, power injection of contrast media, and allows for central venous pressure monitoring. Contraindications: -Previous episodes of venous thrombosis -Do not use the catheter if there is any evidence of mechanical damage or leaking. Damage to the catheter may lead to rupture, fragmentation, possible embolism, and surgical removal. Possible Complications: -Air embolism, bleeding, cardiac arrhythmia, cardiac tamponade, catheter embolism, catheter occlusion, catheter related sepsis, endocarditis, exit site infection, exit site necrosis, hematoma, phlebitis, thromboembolism, venous thrombosis Dressing Changes: -Assess the dressing in the first 24 hours for accumulation of blood, fluid, or moisture beneath the dressing. During all dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. Periodically confirm catheter placement, tip location, patency, and security of dressing. Flushing: -Flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, lock each lumen of the catheter with heparinized saline. Occluded or partially Occluded Catheter: -Catheters that present resistance to flushing and aspiration may be partially or completely occluded. Do not flush against resistance. If the lumen will neither flush nor aspirate and it has been determined that the catheter is occluded with blood, a de-clotting procedure per institution may be appropriate. Review of a Nurse Progress note, dated 10/16/22 (2:58 P.M.), indicated but was not limited to the following: -Midline to RUE [right upper extremity] intact/flushes well. Review of Physician's Orders indicated the following: -Replace 10 cm midline in the right arm due to leak one time only for leak, 10/17/22 -Take the Midline out, not functioning replaced with PICC line, 10/18/22 -Insert a PICC line for administration of cefepime for UTI, 10/18/22 Review of the PICC Insertion Record, dated 10/18/22, indicated a single lumen, non-valved (neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting) Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at 12:40 P.M. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice. Review of the October 2022 MAR indicated the cefepime was restarted and administered by Nurse #9 per her initials after the PICC was inserted on 10/18/22 at approximately 2:00 P.M. Review of a Nurse Progress note, dated 10/18/22 (4:40 P.M.) indicated but was not limited to the following: -He/she had a PICC line inserted today and midline removed due to leaking, continues with his/her cefepime IV. The surveyor was unable to locate documentation in the medical record to indicate details of the previously placed midline leaking. Review of a Nurse Practitioner's Note, dated 10/19/22, indicated but was not limited to the following: -Midline had been changed to a PICC line due to a second midline malfunction. Review of Physician's Orders indicated the following: -Flush each lumen with 10 mL of normal saline every 8 hours whenever lumen is locked (when IV is not connected to a running line) with no infusion currently running, start 10/22/22, (4 days after the PICC was placed) Further review of the physician's order failed to indicate the proper flushing protocol for the non-valved PICC line per facility protocol and manufacturer's IFUs which indicated to flush each lumen of the catheter with 10 mL of saline every 12 hours or after each use. In addition, to lock each lumen of the catheter with heparinized saline (keeps the catheter open and free of clots). Review of Physician's Orders indicated the following: -May remove PICC line from RUE, no longer in use, one time only for completed IV antibiotics for 1 day, 10/26/22 Review of a Nurse Progress Note, dated 10/30/22 (10:29 P.M.), indicated but was not limited to the following: -Resident to have a Midline catheter placed in the morning by the contracted vascular access nurse for a slight right upper lobe infiltrate (when a substance denser than air, e.g., pus, edema, blood, lingers within the lung). During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said all IVs need orders to include flushing, changing the tubing, changing the dressing, and checking for signs and symptoms of infection. She said managers usually enter the orders, but nursing staff are responsible as well. Nurse #9 said documentation also includes progress notes and if the resident tolerated the medication well and if there are any signs and symptoms of infection. She said she had administered the antibiotic via the Resident's Midline catheter and/or PICC at least seven times last October but didn't notice there were no orders for the care and treatment of them so she didn't enter them (the orders). She said the purpose of monitoring and assessing is because you want to keep the resident safe, it's the health of the patient, to assess for signs and symptoms of infection and DVT. Nurse #9 said the danger of a DVT is that it can block their arteries or lead to a stroke or go to the heart. She said proper care and treatment could help prevent any complications. d. Power Injectable PICC Placement #2 (11/1/22) Review of Physician's Orders indicated the following: -Ceftriaxone Sodium solution reconstituted, 1 gm IM stat for pneumonia, 10/30/22 -Ceftriaxone Sodium solution reconstitution 1 gm, use 1 gm intravenously one time a day for pneumonia until 11/3/22, start 10/30/22 -May insert midline catheter to administer Ceftriaxone every shift for pneumonia for 1 day, 10/30/22 Review of a Procedure Note for Vascular Access Device Insertion, dated 10/31/22, indicated but was not limited to the following: -Resident was somnolent on assessment, not baseline per care team. Patient unable to consent for midline, discussed to establish peripheral IV in interim as patient may be sent to hospital. Peripheral IV with bilateral upper extremity edema. Review of a Nurse Progress Note, dated 10/31/22 (12:05 P.M.), indicated but was not limited to the following: -He/she is very swollen, he/she has been for a few days (note did not indicate where). Lasix (diuretic) was increased. -Right now he/she is completely out of it. Has a UTI and pneumonia and did not even flinch when they put the IV in his/her hand. -NP was made aware, and the Resident was sent out to the hospital. Review of a Nurse Practitioner's Note, dated 11/1/22 (6:39 P.M.), indicated but was not limited to the following: -Resident transferred back from the Emergency Department (ED) on 10/31/22 and was negative for any acute findings but was treated in the ED for a possible UTI. -Was started on PO cefpodoxime and returned to the facility with instructions to transition to IV cefepime if needed. -Patient currently complaining of dysuria (pain or burning sensation while passing urine), states he/she was told by the ED he/she had a bad UTI while in the ED, patient requesting cefpodoxime to be changed to IV cefepime. Review of the PICC Insertion Record, dated 11/1/22, indicated a single lumen, non-valved, Power Injectable PICC was inserted into the basilic vein in the Resident's left arm at approximately 6:57 P.M. Review of the medical record failed to indicate orders had been entered and implemented for the care and treatment of the Resident's Power Injectable PICC device including adequate monitoring for signs and symptoms of IV related complications, proper catheter lumen flushing per facility protocol and manufacturer's IFUs, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort per facility policy and professional standards of practice. Review of a Nurse Progress Note, dated 11/3/22 (6:38 P.M.), indicated but was not limited to the following: -Resident was sent to the hospital due to possible left arm infiltration. Review of the hospital's History and Physical Nurse Practitioner Note, dated 11/3/22, indicated but was not limited to the following: -Patient has a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), morbid obesity, DVT, suprapubic catheter, chronic pain, and recurrent UTIs and returned to the hospital for evaluation of pain and swelling in the left arm, most significantly at the site of the PICC. -Patient had a right sided PICC line two months ago and had superficial thrombus in the right arm at that time, suspect both DVTs are related to the PICC lines. Interestingly, the patient tells me that he/she feels that the swelling in his/her left upper extremity (LUE) began over a week ago, prior to PICC placement, though he/she admits this worsened after the PICC was inserted. -On arrival at the ED, a bilateral upper extremity (BUE) duplex (diagnoses DVTs and venous insufficiency) showed an acute occlusive left DVT involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins. -The PICC line was removed immediately and a Heparin (blood thinner) drip was started. While it does make sense that the PICC line would be the causative factor in this DVT formation, it does not explain the bilateral nature of these findings. A vascular surgery consult was conducted. Review of a Hospital Care Management note, dated 11/8/22, indicated but was not limited to the following: -Resident had been assessed for discharge needs. The patient was on antibiotics for a UTI and was at the hospital for bilateral upper extremity (BUE) DVTs and now has a tunneled subclavian central line for IV antibiotics. Unable to use BUE due to DVTs. Palliative NP met with the patient who is agreeable to hospice. Review of the Hospital Discharge Summary, dated 11/8/22, indicated but was not limited to the following: -The admission extended from 11/3/22 through 11/8/22. -The patient recently, on 10/31/22, had a PICC line placed at the SNF to begin treatment with IV cefepime for a pseudomonas UTI. He/she returned to the hospital on 11/3/22 from SNF with swelling and pain to his/her left arm, most significantly at the site of the PICC. On arrival at the ED, a BUE duplex showed extensive bilateral DVTs. The patient has been seen by palliative care regarding poor quality of life and frequent hospitalization s. The discharge diagnosis was acute bilateral upper extremity DVTs and a follow up recommendation with hospice. The patient was discharged back to the SNF on Apixaban. During an interview on 9/11/23 at 12:27 P.M., Resident #20 said he/she remembered last October and when he/she was sent to the hospital. The Resident said the IVs were big and didn't feel right the whole time and were painful to him/her in the left arm. The Resident said he/she had to stay in the hospital and that's what he/she was trying to avoid. Resident #20 said it was an aide who discovered the swelling and told the nurse but didn't remember much more. During an interview on 9/11/23 at 11:38 A.M., Nurse #4 said potential problems of a PICC/Midline could include occlusion, clotting, and infection. She said orders would need to be in place for monitoring on the MAR or TAR but said the October 2022 MAR and TAR did not reflect that other than an order to flush on 10/22/22 when it was locked. Unit Manager (UM) #1 entered the nurses' station and said there should have been orders placed for the care and treatment of the PICC/Midline devices last October and November but weren't. She said staff need to know what kind of line it is to know what orders to enter, and it should have been care planned but wasn't. During an interview on 9/11/23 at 12:33 P.M., the Director of Nurses (DON) said she was relatively new to the facility and UM #2 would know better but the orders should have been entered with the IV insertion order and the Resident monitored for signs and symptoms of adverse events. She said the type of IV access would determine the treatment orders. She said if the documentation was not in the electronic record, then it was not done. UM #2 entered the DON's office and said she reviewed the Resident's record and the orders were not there, there was nothing. She said the point of monitoring is to prevent any adverse events from occurring. The DON said there should have been a care plan in place but wasn't. During an interview on 9/12/23 at 3:00 P.M., the Medical Director (MD) said he was assigned to Resident #20 who had a history of a suprapubic catheter for chronic urinary retention, a long history of multidrug resistance use for UTIs, a hypercoagulable condition, chronic pain, heart failure, tobacco dependency, morbid obesity, was relatively immobile, monthly hospitalization s for the past year, and had a history of clots in both arms. He said at one point the Resident had a clot in his/her leg as well and required IV access for multidrug-resistant organisms (MDRO) UTIs. He said the Resident was on Eliquis prior and would now need, per the hematologist, lifelong anticoagulation after DVTs. He said he/she was at risk for clots and was on Eliquis. He said he wasn't sure who was responsible for entering the bundled orders (group of orders pertaining to the care and treatment of a midline/PICC). He said the orders should be entered to monitor the insertion site for no infection, nothing abnormal around the site, infiltrate, or clotting. The MD said whenever a patient requires a PICC line or Midline there would be a lot of active monitoring from his nurse practitioners to make sure the patient is doing well, that there's a response to treatment. Nursing staff would document monitoring and assessment of the site daily as well as in conjunction with the NPs. He said Resident #20 got a clot in his/her arm at the site of the PICC and, looking back now, there was a delay in diagnosing the clot when the patient had pain and swelling. He said one of his colleagues put another line in then sent him/her back to the hospital where a bilateral upper extremity duplex was done and showed extensive DVTs, and now we know why there's pain and swelling. He said he did not know there weren't any orders for monitoring, and it was obviously suboptimal. The MD said there should be adequate monitoring to avoid any complications or adverse events. During an interview on 9/12/23 at 4:20 P.M., the DON said there was nothing in the old records regarding paper documentation for the central lines, someone did look, and they didn't find it. She said she had no documentation to provide to the surveyor that the facility had identified the issue and conducted a plan of correction or educational piece. She said the expectation would be for whoever the nurse was that took the PICC/Midline insertion order, to enter the orders for the care and treatment of a central line to include things such as monitoring for swelling, redness, signs and symptoms of infection, flushing, dressing changes, changing the tubing, and monitoring for migration. She said nursing staff are expected to properly assess and monitor the site to avoid any potential adverse outcomes. No further documentation was provided to the surveyor prior to exiting the facility. 27189 2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following: -Needleless Connector Changes: On admission, every week and as needed. -Administration Set Changes: Every 24 hours -Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed. -Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days. Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following: -Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached. Review of the [NAME] NURSING PROCEDURES - 9th Ed. (2023)- Flushing a PICC indicated but was not limited to the following: - While maintaining the sterility of the syringe tip, attach a prefilled 10-mL syringe containing preservative-free normal saline solution to the needleless connector. -Unclamp the catheter and slowly aspirate for a blood return that's the color and consistency of whole blood. -If you don't obtain a blood return, take steps to locate an external cause of obstruction. -If you obtain a blood return, slowly inject preservative-free normal saline solution into the catheter. -Don't forcibly flush the device. -Further evaluate the device if you meet resistance. Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis. Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on [DATE] with a PICC in place for the continued administration of Intravenous (IV) antibiotics. Review of the Hospital Discharge Summary, dated 9/12/23, indicated that the Resident was to receive four doses of intravenous (IV) antibiotics (9/13/23 through 9/16/23), and then the PICC was to be removed (on 9/16/23) after the last dose of the antibiotic had been administered. Review of the September 2023 Physician's Orders for the PICC line indicated the following: -Flush each lumen with 10 milliliters (mls) of normal saline every 8 hours, when lumen is locked with no infusion currently running. Discontinue once the line has been pulled. -Occlusive dressing supplies at bedside in the event the line is dislodged. Discontinue once line has been pulled. -Change PICC line catheter transparent dressing upon admission and every 7 days. -Flush catheter lumen pre- and post- medication administration with 10 mls of Normal saline every evening shift until 9/16/23. Line to be pulled after last dose given on 9/16/23. -Maintain emergency clamp at bedside at all times. -Monitor PICC line catheter every shift for signs/symptoms of IV related complications. Discontinue once line has been pulled. Further review of the Physician's orders failed to indicate the following: -Measure upper arm circumference and exterior catheter length with each dressing change and as needed -Needleless Connector Device - On admission, then weekly and as needed -Administration Set Changes - primary, every 24 hours On 9/13/23 at 1:00 P.M., the surveyor observed Resident #39's PICC. The dressing had been changed on 9/6/23 (while the Resident had been in the hospital). The transparent dressing was intact and the antimicrobial disc (used in hospitals) and securement device was visible beneath the transparent dressing. The dressing was due to be changed by the facility 9/13/23 (today). During an observation and interview on 9/13/23 at 3:15 P.M., Nurse #3 and Nurse # 5 said that they had just completed the PICC dressing change. Nurse #3 said that she was going to change the needleless connectors and flush the three lumens. The surveyor made the following observations: -Nurse #3 changed the first needleless connector, attached the prefilled syringe of saline and flushed the first lumen. Nurse #3 was unable to remove the other two needleless connectors despite multiple attempts. Although she was unable to change the connectors, she was able to flush the lumens. Nurse #3 did not prime the first needleless connector prior to flushing the lumen and did not check for a blood return with the flushes for three of three lumens as required. -Under the transparent dressing, the insertion cite was covered with a piece of gauze. The surve [TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill set for providing the necessary care and treatment for residents with a peripherally inserted central catheter (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and/or midline catheter (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) device per facility policy and acceptable standards of practice and to ensure nursing practice by nursing students and their supervising nurse were adhered to for the administration of medications. Specifically, the facility failed: 1. For Resident #20, who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), to ensure physician's orders were in place and implemented for the care and treatment of 2 out of 2 midline catheters and 2 out of 2 PICC lines to include monitoring for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and any reports of pain or discomfort by the Resident during the timeframe of 10/10/22 through 11/3/22. This resulted in the Resident experiencing pain and swelling in his/her left arm resulting in an extended hospital stay from 11/3/22 through 11/8/22 with a diagnosis of acute extensive bilateral upper extremity deep vein thromboses (DVT) (blood clot in a deep vein) with extension into the subclavian vein and an occlusive left arm DVT involving one of the brachial veins and left axillary vein surrounding the PICC; 2. For Resident #39, to conduct, upon hire and annually, competencies and training for all licensed nursing staff to provide the appropriate care and treatment for residents with a PICC and/or midline catheter device; and 3. For Resident #16, a. to ensure nursing practice by nursing students, and supervision of nursing students adhered to the parameters issued by the Massachusetts Board of Registration in Nursing (BORN), and b. to ensure orientation to the patient care environment that aligns with the individual student academic preparation and competencies was provided to one unlicensed Nurse (Graduate Nurse #1), as required. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with acceptable standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 1. Review of the Facility Assessment (a document with a competency-based approach provided by the facility assessing the capability of the facility and its population), last updated in August 2023 and reviewed by Quality Assurance and Performance Improvement (QAPI) Committee on 4/19/23, indicated the following: Part 1- Our Resident Profile: Special Treatments and Conditions - IV medications Part 3.3: Staff Training and Competencies - Only Nurses -IV competencies, IV Pump Program, Central Line Dressing, Medication Administration Review of the Licensed Orientation Checklist for New Hires, undated, indicated the following: Treatments: -IVs - Peripheral vs. PICC line, care of, measurement of, admission documentation, weekly dressing change Review of the Competency Record - To be Completed on Hire and Annually, undated, indicated the following: IV Competencies: -IV pump programming and troubleshooting, central line dressing, documentation Review of the facility's policy titled Legal Aspects of Infusion Therapy for Nurses, revised 2019, indicated but was not limited to the following: -Purpose: To identify licensed personnel who are designated by the facility to perform infusion therapy. -Policy: Nurses administering infusion therapies will practice within the scope of practice for their licensure as established in the State Nurse Practice Act, and within their clinical level of competency as established by the facility training and competency evaluation programs. -Scope of Practice for Specific Infusion Therapy for Nursing Functions: Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, change IV tubing and needleless connection devices, observing and reporting on catheter patency, insertion site, complications, and resident reaction to treatment. -Facility /Administration Responsibilities for IV Therapy: Providing education or verifying qualifications of the staff that will be providing infusion therapy. This may include IV fundamental classes, precepting and/or clinical competency evaluations. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs). Review of the medical record indicated Resident #20 had two midline catheters placed on 10/10/22 and 10/14/22 and two PICC lines placed on 10/18/22 and 11/1/22 for antibiotic therapy. The midline/PICCs were not appropriately monitored by nursing staff for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and for any reports of pain or discomfort by the Resident per facility policy and professional standards of practice. Resident #20 was admitted to the hospital from 11/3/22 through 11/8/22 after complaints of pain and swelling in the left arm, most significantly at the site of the PICC. Upon arrival to the emergency department (ED), a bilateral upper extremity (BUE) duplex (test used to evaluate blood clots and venous insufficiency) showed an acute occlusive left deep vein thrombosis (DVT) involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins. The PICC line was removed immediately, and a Heparin (blood thinner) drip was started. During an interview on 9/12/23 at 10:05 A.M., the surveyor reviewed the IV Education Binder with the Director of Nursing (DON). The binder contained 25 nursing staff certificates of IV training by six outside educational institutions, however, the surveyor was unable to determine the content of the training and if it included the care and treatment for a resident with a PICC and/or midline catheter device for 22 out of 25 certificates reviewed. No IV competencies were included in the education binder. The DON said the staff development coordinator (SDC) was no longer at the facility and a new SDC was still learning and transitioning. The DON said she was not able to verify the training content for the outside educational institutions and said it would still be the facility's responsibility to verify the competencies anyway. The DON said, thus far, she could not locate any central line IV competencies for nursing staff. On 9/12/23 at 10:35 A.M., the DON provided the surveyor with a list of current licensed nursing staff at the facility. There were 37 listed. Review of the IV Competency binder provided to the surveyor by the DON, for three out of three Nurses (#9, #10, #11) reviewed that had cared for Resident #20 in October of 2022 during the time he/she had a PICC and/or midline catheter device, failed to indicate documentation that any of them were included. Furthermore, review of Nurse #9, Nurse #10, and Nurse #11's personnel files also did not indicate documentation of the required IV competencies. During an interview on 9/12/23 at 10:38 A.M., the surveyor reviewed the IV Competency binder with the DON. Review of the binder indicated 13 of 37 current staff were included and did not contain a complete record of all the required IV competencies to be validated by the facility. The DON said she was unable to locate any other documentation of the IV competencies that were required and said all licensed nursing staff should have been checked off that they were competent. During an interview on 9/12/23 at 12:59 P.M., Nurse #9 said she needed education and competencies to care for a resident with a central line. She said it's not often that she cares for a resident that has one. Nurse #10 and Nurse #11 were unavailable for interview and were not reachable by phone. During an interview on 9/12/23 at 4:20 P.M., the DON said nursing staff were expected to properly assess and monitor the site to avoid any potential adverse outcomes. During an interview on 9/12/23 at 5:19 P.M., the Administrator said the orientation checklist is the same for new or experienced nurses and the facility was not able to provide to the surveyor a complete record of nursing PICC/midline competencies and proper training. No further documentation was provided to the surveyor prior to exiting the facility. 27189 2. Review of the facility's policy titled Infusion Intravenous (IV) Access Line Maintenance Protocol, dated 12/1/18, indicated but was not limited to the following: -Needleless Connector Changes: On admission, every week and as needed. -Administration Set Changes: Every 24 hours -Transparent Dressing Changes: Insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed. -Dressing Changes: Gauze should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days. Review of the facility's competency for: Changing the Needleless Connector on an IV Catheter (dated 2/2014) indicated but was not limited to the following: -Primes needleless connector with prescribed flushing agent while maintaining sterility, leaves syringe attached. Resident #39 was admitted to the facility in May 2016 with diagnoses including diabetes, chronic non-pressure ulcer of the right calf, and cellulitis. Record review indicated that on 9/3/23, Resident #39 was sent to the hospital and admitted with diagnoses including septic shock with organ failure, acute kidney injury. and bacteremia presumed secondary to left foot blister lesion. The Resident returned to the facility on [DATE] with a PICC in place for the continued administration of Intravenous (IV) antibiotics. During an observation and interview on 9/13/23 at 3:15 P.M., Nurse #3 and Nurse # 5 were in Resident #39's room and told the surveyor they had just completed the PICC dressing change. Nurse #3 said that she was going to change the needleless connectors and flush the three lumens. The surveyor made the following observations: Nurse #3 completed the procedure; however she was unable to change all three needleless connectors (1 of 3 was changed) and she did not prime the first needleless connector that was changed prior to flushing the lumen and did not check for a blood return prior to flushing the catheter for 3 of 3 lumens as per the facility policy/protocols. At this time, the surveyor observed that under the transparent dressing, the insertion cite was covered with a piece of gauze. The surveyor brought her observation to the attention of Nurse #3 and Nurse #5 and asked the rationale for applying the gauze. Nurse #5 said it was provided in the dressing change kit (piece of gauze that contained a slit-resembles a drain sponge) so we applied it. During an interview on 9/14/23 at 8:25 A.M., the surveyor informed the Staff Development Coordinator (SDC) of her observations of the PICC flushing by Nurse #3 and Nurse #5 and the gauze present under the transparent dressing. The SDC said that the gauze should not be applied because the insertion site is no longer visible for assessment. She further said that when a PICC is flushed the procedure is that the nurse assess for a blood return and that the needleless connectors should be primed before it is changed. Review of Nurse #3's education file indicated that she completed a Comprehensive Intravenous (IV) Therapy course 10/9/19. Further review of her education file failed to indicate that she had annual competencies, as required per the facility policy/protocols, addressing the proper care and treatment of the PICC. During an interview on 9/14/23 at 1:27 P.M., Nurse #5 said that she had helped Nurse #3 with the Resident's PICC dressing change on 9/13/23. She further stated that they performed the dressing change together and that she did perform some of the steps in the procedure (hands on). The surveyor asked about any certifications/competencies in IV therapy, specifically proper care and treatment of a PICC. Nurse #5 said that she is not IV certified/had no competencies completed. During an interview on 9/14/23 at 3:35 P.M., the SDC said that a nurse who has not had any training in IV therapy/proper and treatment of a PICC, should not participate (hands on) with any part of the dressing change. She said that she explained this to Nurse #3 and Nurse #5 yesterday. The SDC again said that Nurse #5 should have not performed any part of the PICC dressing change. During an interview on 9/14/23 at 4:00 P.M., the Regional Nurse and the President of Operations said that there was no annual competency for proper care and treatment of a PICC for Nurse #5. The facility failed to complete annual competencies for proper care and treatment of a PICC and failed to ensure nurses were evaluated for competency to provide proper care and treatment of a PICC. 34145 3. Review of the facility's policy titled Graduate Nursing Policy, revised 6/9/23, included but was not limited to: -Section 25 of Chapter 20 of the Acts of 2020 continues the authorization of nursing practice by graduates and students in their last semester of nursing education programs in accordance with guidance from the Massachusetts Board of Registration in Nursing (BORN). It is expected the order will expire March 31, 2024. Individuals who are graduates of a registered nursing or practical nursing program approved by BORN and individuals who are nursing students attending the last semester of BORN approved registered nursing or practical nursing program are authorized to practice nursing and are exempt from the prohibitions against the unlicensed practice of nursing specified in G.L. c. SS 80, 80A and 80B provided that: 1. The individuals are employed by or providing health care services at the direction of a licensed health care facility, are directly supervised by a licensed nurse while providing health care services, and the health care services are provided in response to the impact of staffing due to the COVID State of Emergency; and 2. The employing licensed health care facility has verified that the individual is a graduate of a BORN approved registered nursing or practical nursing program or that the individual is a nursing student in his or her last semester at a BORN approved registered nursing or practical nursing program. Pursuant to the legislation, nursing practice by nursing students, and supervision of nursing students must adhere to the following parameters issued by the Board: 1. Nursing students in their last semester and graduate nursing students must practice under the direction and supervision of a licensed nurse, performing tasks within the scope of practice of the supervising nurse of equal or higher educational preparation; 2. Direct supervision includes but is not limited to the supervising licensed nurse being physically present in the health care practice setting and readily available where nursing students and graduate nursing students are practicing; 3. Nursing students and graduate nursing students must be assigned tasks by the supervising nurse and seek assistance immediately when he or she encounters patient care situations that are beyond his or her competency and level of academic preparation; 4. The employing licensed health care facility provides nursing students with an orientation to the patient care environment that aligns with the individual student academic preparation and competencies; 5. The employing licensed health care facility or licensed health care provider provides nursing students with policies that support their practice in the clinical setting where they are assigned; and 6. The employing licensed health care facility or health care provider ensures that patients are informed that such individuals are nursing students. Resident #16 was admitted to the facility in July 2023 with diagnoses including chronic kidney disease-stage and hypertension. a. Review of the medical record indicated a 9/6/23 Progress Note written by Nurse #6 indicated Resident #16 received additional medication at approximately 9:25 A.M. No further information related to the additional medication was documented in the note. During an interview on 9/11/23 at 7:21 A.M., Nurse #6 said she was doing a morning medication pass with Graduate Nurse #1 on 9/6/23 at 9:30 A.M. on the North Unit. Nurse #6 said she checked Resident #175's Physician's orders in the computer with the Graduate Nurse, popped 13 pills into a plastic cup, signed off the medications on the Medication Administration Record, wrote Resident #175's name, room and bed number on the medication cup, and told Graduate Nurse #1 to give the medications to the Resident in the A bed. She said the Graduate Nurse took the medication cup into the room and came out and said she gave the medication to the wrong Resident. Nurse #6 said she remained at the medication cart during the entire time the Graduate Nurse was in the Residents' room, and did not directly supervise or observe her give the medication to the wrong Resident or hear her verify the identity of the Resident prior to giving the medications to Resident #16 instead of Resident #175. Nurse #6 said she thought Graduate Nurse #1 was a newly hired Registered Nurse, and not a graduate nurse that required direct supervision. During an interview on 9/12/23 at 10:57 A.M., Graduate Nurse #1 said she graduated from nursing school in May 2023, but has not passed the board exam and is not a Registered Nurse yet. She said she worked on the North unit on 9/6/23 with Nurse #6 and administered medications to a few Residents, including Resident #16. She said when Nurse #6 gave her the plastic cup with medications in it, she thought she said to bring them to the resident in the window bed. She said she did not ask the resident his/her name or verify the resident's identify prior to administering the medication. Graduate Nurse #1 said after the resident swallowed the medications, she saw Resident #16's name on a water bottle on the over bed table and immediately realized she gave the medication to the wrong resident. During interviews on 9/8/23 at 2:00 P.M. and 9/14/23 at 3:00 P.M., the Director of Nursing (DON) said on 9/6/23 at 9:30 A.M., Graduate Nursing Student #1 administered 13 doses of medication to Resident #16 in error. She said the medications were meant for Resident #16's roommate (Resident #175). The DON said Graduate Nurse #1 had not had a competency assessment for medication administration. She provided the surveyor a copy of the Medication Error Form, investigation (including a blank Medication Administration Competency Evaluation), and Resident #175's Medication Administration Record. The documents indicated medications administered to Resident #16 by the Graduate Nursing Student in error on 9/6/23 were: -Citalopram Hydrobromide (antidepressant) 20 milligrams (mg) -Hydrochlorothiazide (antihypertensive) 12.5 mg -Amlodipine Besylate (antihypertensive) 10 mg -Aspirin (anticoagulant) 81 mg -Colace (laxative) 100 mg -Depakote Sprinkles (anticonvulsant) 125 mg, give 4 capsules to equal 500 mg -Folic Acid (vitamin used to treat anemia) 1 mg -Labetalol HCI (beta blocker) 200 mg -Losartan Potassium (antihypertensive) 100 mg -Metformin HCI ER (antidiabetic) 750 mg b. Review of Graduate Nurse #1's employment and education file failed to indicate any competency assessments for medication administration had been conducted.

Based on observations, interviews, and record review, the facility failed to maintain an environment free of accident hazards for two Residents (#71 and #64), out of a total sample of 24 residents, and for 5 out of 9 identified facility smokers, Residents (#34, #22, #2, #28, and #51). Specifically, the facility failed to ensure: 1. For Resident #71, had effective interventions implemented to prevent three unwitnessed falls, one of which resulted in a five-day hospitalization for a subdural hematoma (a pool of blood between the brain and its outermost covering) and comminuted mildly displaced nasal bone fracture (a fracture in which the bone is broken in several fragments. This type of fracture is typically caused by severe trauma/injury); 2. For Resident #64, hazardous items were not left at the bedside; and 3. For Residents #34, #22, #2, #28, and #51, smoking was conducted in a safe manner per the facility policy. Findings include: 1. Review of the facility's policy titled Managing Falls and Fall Risk Policy Statement, undated, included but was not limited to: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; Resident-Centered Approaches to Managing Falls and Fall Risk: -The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -Position-change alarms may be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner; -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions; and -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Resident #71 was admitted to the facility in August 2023 with diagnoses including repeated falls, traumatic subdural hemorrhage with loss of consciousness, fracture of thoracic spine: T11-T12 vertebra, multiple fractures of ribs, left side, contusion of front wall of thorax, contusion of left hip, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 8/8/23, indicated Resident #71 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance of two staff for bed mobility and transfers, had wandering behavior, was unsteady while walking, experienced falls within the past six months prior to admission, and had one fall with injury since admission to the facility. Review of the medical record indicated an 8/1/23 Admission Fall Risk Evaluation/Note. The instructions indicated if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The Fall Risk Evaluation Note indicated a fall risk score of 21 (high risk). Review of comprehensive care plans included but was not limited to: -Focus: Risk for falls (8/2/23) -Approaches: Determine Resident's ability to transfer (8/2/23); Evaluate fall risk on admission and as needed (8/2/23); If fall occurs, alert provider (8/2/23); If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol (8/2/23); If Resident is a fall risk, initiate fall risk precautions (8/2/23) -Goal: Resident will be free of falls (8/2/23) The comprehensive care plan for risk of falls failed to indicate any interventions had been developed to prevent falls. Review of the medical record and fall incident reports and investigations indicated Resident #71 had three unwitnessed falls as follows: -On 8/4/23 at 5:40 A.M., staff heard a loud bang and the Resident was found on the floor in his/her bedroom. The Resident sustained a skin tear to left elbow. The Resident stated he/she was trying to go to the bathroom. The medical record failed to identify any interventions in place at the time of the fall. Review of comprehensive care plans failed to indicate any new interventions were developed to prevent Resident #71 from having future falls. On 8/9/23 at 11:00 P.M., staff heard the Resident scream and was found on the floor lying on his/her back. A head strike was confirmed, and the Resident complained of headache. A hematoma was found on the back of the Resident's head. Review of staff statements indicated the Resident said he/she was trying to go to the bathroom. The physician was notified and the Resident was sent to the hospital. Medical record review failed to identify any interventions in place at the time of the fall. Review of the Emergency Department Provider Notes and the Discharge Planning Assessment Note, dated 8/10/23, indicated but was not limited to the following: -A computerized tomography scan (CT scan- a series of X-ray images) was performed and revealed no fractures, and the prior subdural hematomas (identified in July 2023, prior to admission to the facility) had slightly increased. The Resident was discharged back to the facility on [DATE]. Review of a Fall Risk Evaluation Note, dated 8/10/23, indicated Resident #71 remained a high fall risk with a score of 19. Review of comprehensive care plans identified a new intervention to assist the Resident with ambulation and transfers, utilizing therapy recommendations (8/10/23). Medical record review indicated no therapy recommendations had been identified. On 9/6/23 at 2:30 A.M., staff heard a loud thud coming from Resident #71's room. The Resident was found by staff on the floor face down in a large pool of blood. The Resident told staff, I was going to the bathroom. A laceration was noted to the bridge of the Resident's nose, and [NAME] red bleeding noted from both nostrils. The Resident's physician was notified, 911 was called, and the Resident was transported to the hospital for evaluation and treatment. Medical record review failed to identify any interventions in place at the time of the fall. Review of the Hospital Discharge Summary, dated 9/11/23, indicated Resident #71 presented to the hospital after a recurrent unwitnessed fall, and was found to have forehead lacerations, nasal fracture, and small acute-subacute right-sided subdural hematoma. The summary indicated Emergency Medical Service documentation noted the Resident was walking to the bathroom when he/she lost his/her footing and fell to the ground landing face first. A facial CT showed comminuted mildly displaced nasal bone fracture, and multiple facial lacerations. The trauma surgeon/trauma team reviewed the comminuted nasal bone fracture and indicated no immediate intervention, but the Resident should follow up with plastic surgery 2 weeks after the event for assessment. Resident #71 returned to the facility on [DATE] after a five-day hospitalization (9/6/23 to 9/11/23). Review of comprehensive care plans failed to indicate any new interventions had been developed to prevent Resident #71 from future falls. During an interview on 9/7/23 at 8:41 A.M., Nurse #3 said Resident #71 was sent out to the hospital on 9/6/23 after having a fall with a possible nasal fracture and facial lacerations. She said the Resident thinks he/she can walk safely on his/her own but can't. During an interview on 9/13/23 at 1:00 P.M., Unit Manager #2 reviewed Resident #71's medical record. She said a care plan with interventions should have been developed with interventions to prevent falls upon admission to the facility, especially considering the Resident's history of recurrent falls with major injury. She said each time the Resident had a fall, interventions should have been developed, added to the care plan, and implemented but were not. Unit Manager #2 said she was concerned about the lack of interventions and documentation regarding the Resident's risks and falls. During a subsequent interview on 9/14/23 at 10:14 A.M., Unit Manager #2 said she has reviewed Resident #71's medical record and incident reports and said the Resident's falls are clearly related to the Resident's need to use the bathroom. She said the Resident should have been placed on a toileting program after the first fall in an effort to prevent him/her from getting up on his/her own and falling. During an interview on 9/14/23 at 10:50 A.M., Resident #71's son said Resident #71 has only been at the facility a few weeks and has had multiple falls. He said he cannot understand why the facility can't do something to prevent the falls. 2. Resident #64 was admitted to the facility in May 2023 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance and mild cognitive impairment. Review of the most recent MDS assessment, dated 8/30/23, indicated that Resident #64 had severe cognitive impairment as evidenced by a BIMS score of 4 out of 15 and required extensive assist for personal hygiene. The Resident resides on a secure unit with wandering residents. On 9/7/23 at 9:15 A.M., the surveyor observed a bottle of mouthwash on Resident #64's nightstand unsecured and accessible to all residents. On 9/7/23 at 9:40 A.M., the surveyor observed residents wandering in the hallway. On 9/8/23 at 9:41 A.M., the surveyor observed residents wandering in the hallway. On 9/8/23 at 9:50 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. Residents were wandering in the hallway. On 9/11/23 at 7:36 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. On 9/11/23 at 9:22 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. On 9/11/23 at 12:56 P.M., the surveyor observed residents wandering in the hallway. On 9/12/23 at 10:27 A.M., the surveyor observed a bottle of mouthwash on the Resident's nightstand unsecured and accessible to all residents. Additionally, at this time the surveyor observed other residents wandering in the hallway. According to manufacturer's specifications, mouthwash should be stored in a safe place. If more mouthwash is swallowed than the recommended amount used for rinsing, get medical help or contact Poison Control Center right away. During an interview on 9/12/23 at 10:33 A.M., Nurse #3 said the mouthwash should not be on top of the Resident's nightstand; it should be stored secured in the Resident's top drawer of their nightstand or dresser in a wash basin. 43935 3. Review of the facility's policy titled Smoking policy and procedure, dated as revised October 2022, indicated but was not limited to the following: -Independent Smoker: those assessed by the interdisciplinary team (IDT) to be able to safely smoke in the designated smoking area without staff supervision. Residents must keep all smoking materials at designated secure areas. -Supervised Smoker: those assessed by the IDT to require a staff member accompany them during smoking for safety at designated times. All smoking materials will be stored and handed out by staff. - No resident is allowed to keep lighters, matches or other lighting materials on their person or in their rooms. - A specific care plan will be designed to meet the individual needs of the residents. All safety interventions will be included in this care plan, such as a smoking apron, adaptive devices, etc. - Each unit is responsible for escorting supervised residents to the designated smoking area until they are escorted back into the facility safely. Review of the List of Residents Who Smoke indicated but was not limited to the following: - Supervised smokers: Residents #34, #22, and #51 - Independent smokers: Residents #28 and #2 Review of the current smoking care plan for Resident #34 indicated but was not limited to the following: - Resident requires supervision with smoking (3/13/23) - Resident utilizes a smoking apron (3/13/23) Review of the current smoking care plan for Resident #22 indicated but was not limited to the following: - Resident requires supervision while smoking (8/22/20) - Resident requires a smoking apron while smoking (8/22/20) - Observe clothing and skin for signs of cigarette burns (8/22/20) Review of the current smoking care plan for Resident #51 indicated but was not limited to the following: - Supervised smoking (4/10/23) - Utilize smoking apron (10/21/20) Review of the current smoking care plan for Resident #28 indicated but was not limited to the following: - Resident often hides smoking materials on own person and attempts to smoke in non-smoking areas of the facility (3/13/23) Review of the current smoking care plan for Resident #2 indicated but was not limited to the following: - Educate resident on the facility smoking policy (10/21/20) During an interview on 9/7/23 at 9:25 A.M., Resident #34 said he/she is an active smoker, has recently been educated on the facility smoking policy and has supervised smoke breaks four times a day. He/She said the activity assistants take them to smoke and are responsible for storing their cigarettes and lighters, and he/she uses an apron during smoking to prevent potential burns. During an observation with interview on 9/7/23 at 1:18 P.M., Activity Assistant (AA) #1 said Resident #34 wears a smoking apron. The surveyor observed AA #1 place an apron over the Resident's legs only, and not secure the apron up around the neck of the Resident to cover their body. She said supervised smoking is four times a day and managed by the activity department. She said independent smokers keep their own cigarettes and has seen independent smokers with their own lighters but she doesn't know the process since she is only responsible for maintaining supervised smokers' smoking materials. During an observation with interview on 9/8/23 at 11:44 A.M., the surveyor observed Resident #28 enter the smoking area and pull both a pack of cigarettes and a lighter from his/her right shorts pocket. He/she said they are an independent smoker and can smoke whenever they chose to do so in the enclosed courtyard. He/she said the facility does not provide a lighter to him/her and he/she maintains their own smoking materials. On 9/8/23 at 1:28 P.M., the surveyor observed Resident #2 enter the Resident smoking area and remove both a cigarette and a lighter from a black zipper pouch. The Resident declined to discuss the storage of his/her cigarettes and lighter but did state that they were an independent smoker. On 9/8/23 at 1:56 P.M., the surveyor entered the Residents' smoking area and observed Resident #34, Resident #22, and Resident #2 smoking, there were no staff members present in the smoking area at this time. Resident #34 had a smoking safety apron draped over his/her lap. Resident #22 was not observed to have a smoking safety apron in place. During an observation with interview on 9/8/23 at 1:59 P.M., AA #2 returned to the Resident smoking area and said he stepped away to transport Resident #51 back to their room following their cigarette. He said supervised smokers have their cigarettes and lighters stored in the atrium under lock and key and managed by activity staff. He said the independent smokers are responsible for managing their own cigarettes and lighters. He said there is no list to go by on which Residents require a smoking apron and which ones do not and he just goes by memory. He said Resident #34 requires one but did not identify Resident #22 as requiring a smoking apron. The surveyor observed Resident #22 with 3 burn marks in the shape of a cigarette burn on the right leg of his/her black pants during this smoking observation, however Resident #22 did not have a smoking apron on as indicated in his/her plan of care. On 9/12/23 at 10:39 A.M., the surveyor observed Resident #51 smoking in the designated area with a smoking apron draped over his/her legs. The smoking apron was not secured up around the Resident's leg to protect the upper portion of the body. The surveyor observed Resident #51 to have cigarette ashes on his/her shirt. During an interview on 9/12/23 at 11:04 A.M., Nurse #4 said both independent and supervised smokers reside on her unit. She said she has never had an independent smoker request a lighter or smoking materials from her while she has been on duty. She said there was no cigarettes or lighters available to supply to the smokers in the nurses' station or locked in the medication room and she believes that even though they are not supposed to keep their own smoking materials that they do. During an interview on 9/12/23 at 11:12 A.M., Nurse #7 said she had independent smokers on her assignment. She said she has not had an independent smoker request any smoking materials from her. During an interview on 9/12/23 at 11:57 A.M., the Director of Nurses was made aware of the surveyor's observations of resident smoking. She said residents who wear smoking aprons should have them secured up around their necks and covering both the upper portion of their body and their legs. She said staff should be following the individualized care plans for smoking and using safety aprons for those who are designated as requiring them. She said supervised smokers should not be left alone unsupervised at any time while smoking, as they were on 9/8/23. She said independent smokers are not supposed to have their lighters on their person and they should be getting lighters from the nurses; lighters are in a locked box at the nurses' station. She said the facility struggles with the independent smokers and they are aware that the independent smokers procure their own lighters and the smoking process is a work in progress. She said the facility smoking policy is not being followed as it should be. 48695

Based on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness. Specifically, the facility failed to: 1. Ensure staff wore hair restraints in the main kitchen, during meal preparation and service, per the Food Code of the Food and Drug Administration (FDA) to prevent hair from contacting food; and 2. Properly label and/or store food items in the main kitchen's alcove, walk-in refrigerator, and two of two double door refrigerators so it was used by the use-by date or discarded. Findings include: 1. Review of section 2-402.11 of the Food and Drug Administration (FDA) Food Code, dated 2013, indicated but was not limited to the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. During the initial tour of the kitchen on 9/7/23 at 8:50 A.M., the surveyor observed the Food Service Director (FSD) in the main kitchen serving breakfast at the tray line. The FSD's hair was tied in front into two long pigtails extending down past her shoulders. A hair restraint was observed covering the crown of her head, not the pigtails while serving the food to help prevent potential contact with exposed food. During an interview on 9/7/23 at 8:30 A.M., the FSD said her hair restraint should have been covering all her hair while serving food. 2. Review of the facility's policy titled Labeling and Dating Inservice, undated, indicated but was not limited to the following: Importance of Labeling and Dating: -Proper labeling and dating ensures that all foods are stored, rotated, and utilized in First In First Out manner. This will minimize waste and ensure that items that are passed their due date are discarded. -Food labels must include the food item name, the date of preparation/receipt/removal from freezer, and the use by date as outlined in the attached guidelines. -Leftovers must be labeled and dated with the date they are prepared and the use by date. -Date of preparation or opening is considered Day 1 when establishing the use by date. -Guidelines apply, regardless of storage location. -All Ready-to Eat, Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 40 degrees or less, will be labeled and dated with the prepared date (Day 1) and a use by date (Day 7). Review of the facility document titled Food Storage and Retention Guide, undated, indicated but was not limited to the following: Ready to Eat/Prepared Foods: (Food in a form that is edible without additional preparation to achieve food safety. Examples - leftovers, deli salads, cut produce) -Up to 7 days, Day 1 is the day of preparation Raw Meat/Poultry: -All poultry - 1-2 days -Beef or pork roasts - 3-5 days During the initial tour of the kitchen with the FSD on 9/7/23 at 9:09 A.M., the surveyor observed the following: Main Alcove off Kitchen: -Large rectangular pan filled with cooked brownie, not labeled with food item name, date of preparation, or use-by date During an interview on 9/7/23 at 9:09 A.M., the FSD said the brownie pan should have been labeled. Walk-In Refrigerator: -Small to medium sized ham portion wrapped in plastic wrap, dated 9/1, unclear if prepared date or use-by date -Seven trays of single serve ready-to-eat portions of applesauce/fruit, not labeled -One clear opened plastic bag of spinach tied in a knot, undated -One open box of raw hotdogs with the packaging seal open, potentially exposing the contents to environmental contaminants, not labeled During an interview on 9/7/23 at 9:10 A.M., the FSD said the hot dog packaging should not have been left open and should have been labeled. She said the hotdogs and ham should be tossed as well as the spinach which should have been labeled. The FSD said the trays of applesauce and fruit should have been labeled as to when they were prepared but weren't. Double Door Refrigerator #1: -One large plastic bucket filled with prepared chocolate pudding, dated 9/2/23, unclear as to if the prepared date or use-by date -One bag of opened shredded mozzarella, dated 8/9, unclear as to if the prepared date or use-by date -One plastic container of cut cantaloupe, not labeled -Deli turkey slices wrapped in plastic wrap, dated 9/1, unclear as to if the prepared date or use-by date -One large plastic container of hard-boiled eggs, dated 9/2, unclear as to if the prepared date or use-by date During an interview on 9/7/23 at 9:16 A.M., the FSD said the mozzarella was past date and disposed of it. She said the turkey slices were not properly labeled and should be disposed of as well as the cantaloupe. The FSD said the chocolate pudding was no longer good and disposed of it as well as the eggs. Double Door Refrigerator #2: -One plastic pouring container of apple juice, not labeled During an interview on 9/7/23 at 9:23 A.M., the FSD said the apple juice should have been labeled with the pour date and was only good for five days. During a follow up observation visit to the kitchen on 9/13/23 at 8:20 A.M., the walk-in refrigerator was inspected to ensure that foods were being labeled and dated as required. A large metal rack was stored in the walk-in which housed numerous large metal baking sheet pans/trays. The trays contained various food items, one being a large roast beef (dated 9/10). Stored directly below the roast beef was a tray containing individual salads that had been prepared for the lunchtime meal. The Kitchen Consultant #1 was made aware of the defrosted roast beef stored over the salads. He immediately removed the salad trays and discarded the entire tray. During an interview on 9/13/23 at 8:30 A.M., Kitchen Consultant #1 said that the staff should not have stored the roast beef above the salads due to the potential for contamination.

Based on interview, record review, policy review, and review of the quality assurance and performance improvement (QAPI) plan, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and developed and implemented an appropriate corrective action plan to ensure satisfactory outcomes. Specifically, the facility failed to: 1. Track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance and Performance Improvement Plan; and 2. For Resident #20, conduct performance improvement activities that included the identification of adverse events related to two out of two peripherally inserted central catheters (PICCs) (long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and two out of two midline (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) catheter devices used to receive intravenous (IV) antibiotics during the timeframe of 10/10/22 through 11/3/22. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated March 2023, indicated the following: - Scope and Design: The scope of the QAPI program includes all systems of care and management practices. The ongoing and comprehensive plan will address clinical care, quality of life, resident choice, and care transitions through data collection, analysis, planning, implementation, and evaluation. - Performance Improvement Projects: Conduct performance improvement projects (PIPs) that are designed to take a systemic approach to review and improve care or service in areas that we identify as needing attention. - Conduct PIPs that will improve care and service delivery, increase efficiency, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. - An important aspect of your PIPs is to determine the effectiveness of our performance improvement activities and whether improvement is sustained. During an interview with the Administrator and the Director of Nursing on 9/14/23 at 12:15 P.M., the Administrator discussed some of the concerns that were identified during the annual recertification (mail delivery, grievance policy, and pressure ulcer) and had already brought them to the QAPI team; however there was no tracking method, written goals, quarterly or previous annual comparison on any of these projects to demonstrate progress that has been made. The Administrator was unable to speak of any current QAPI projects or PIPs or to show any documentation of these projects or progress towards the goals. The Administrator said she was new to the facility in March 2023 and could not measure its success or track performance to ensure improvements were achieved and sustained because there were no completed projects. She said she needed to come up with a better plan to track the progress of the projects and document them accordingly. 42742 2. Resident #20 was admitted to the facility in September 2022 with diagnoses including Behcet's disease (rare disorder causing inflammation of blood vessels), chronic peripheral venous insufficiency, morbid obesity, type II diabetes mellitus, chronic diastolic heart failure (CHF), peripheral vascular disease (PVD), chronic embolism and thrombosis of deep veins of left lower extremity, and recurrent urinary tract infections (UTIs). Review of the medical record indicated Resident #20 had two midline catheters placed on 10/10/22 and 10/14/22 and two PICC lines placed on 10/18/22 and 11/1/22 for antibiotic therapy. The midline/PICCs were not appropriately monitored by nursing staff for signs and symptoms of IV related complications, catheter lumen flushing, dressing orders, needleless connector change frequency, tubing change frequency, and for any reports of pain or discomfort by the Resident per facility policy and professional standards of practice. Resident #20 was admitted to the hospital from 11/3/22 through 11/8/22 after complaints of pain and swelling in the left arm, most significantly at the site of the PICC. Upon arrival to the emergency department (ED), a bilateral upper extremity (BUE) duplex (test used to evaluate blood clots and venous insufficiency) showed an acute occlusive left deep vein thrombosis (DVT) involving one of the paired brachial veins and left axillary vein surrounding the PICC line. Central extension of nonocclusive thrombus into the left subclavian vein surrounding the PICC was also seen. A new acute occlusive right sided DVT of the right subclavian vein was also noted, along with acute occlusive superficial thrombosis involving the left basilic and cephalic veins. On 9/11/23 at 2:10 P.M., the surveyor requested documentation from the Director of Nursing (DON) that the facility had identified the adverse events related to the Resident's PICC/midline catheters and reported, investigated, and analyzed the data and information related to the adverse events to ensure improvements were realized and sustained. The DON said she didn't think she had any documentation to indicate the facility had identified the issue, attempted to correct it, or provided education to its nursing staff but would keep looking. During an interview on 9/12/23 at 4:20 P.M., the DON said there was no documentation she could provide to the surveyor. She said there was no plan of correction or educational piece. She said she was not here at the time and was not aware of it until the surveyor brought it to her attention. She said nursing staff are expected to monitor the site to avoid any potential adverse outcomes. During an interview on 9/12/23 at 5:19 P.M., the Administrator said the process was not followed for the documentation piece from last October and November. She said she believes they were aware, but the documentation piece was missing for a plan of correction or QAPI project. No further documentation was provided to the surveyor prior to exiting the facility.

Based on document review, policy review, record review, and interviews, the facility failed to maintain an infection prevention and control program as indicated in their infection control plan and policies. Specifically, the facility failed to maintain a complete and accurate system of surveillance and to analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program. Findings include: Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated but was not limited to the following: - outcome surveillance (incidence and prevalence of healthcare acquired infections) are used to measure the effectiveness of the infection prevention and control program (IPCP) - surveillance tools are used for recognition of infection occurrence, record the frequency and numbers, detect outbreaks and epidemics, and monitor adherence to the IPCP - data gathered during surveillance is used to oversee infections and spot trends - the IP [Infection Preventionist] (or designee) records absolute numbers of infections and analyzes the data by manually calculating infections per 1000 resident days - rates are calculated with adjustment for units and bed capacity and infection rates are calculated for comparison for each unit and the entire facility - monthly rates can be plotted graphically or side by side to allow for trend comparison - the analysis process allows for screening of clinically significant rates of infection - the Medical Director will help design data collection instruments, infection reports and antibiotic usage forms - criteria will be used to determine sporadic cases of infection versus outbreaks During an interview on 9/8/23 at 1:07 P.M., the Director of Nurses (DON) said the facility uses the laboratory supplied surveillance line listing to document the surveillance of their potential or actual infections. She said the staff development coordinator (SDC) was assisting her with the tasks associated with the IPCP. She said the facility uses McGeer criteria to determine if an illness rises to the level of a true infection and have McGeer checklists for verification of criteria being met. Review of the facility provided laboratory surveillance line listings and McGeer criteria sheets indicated but were not limited to the following: May 2023 - Resident #44: category: skin (S), date of onset: 5/1/23; symptoms: drainage, redness, warmth; site: left great toe; status: healthcare acquired infection (HAI); count (required): blank The surveillance data for Resident #44 was incomplete on the line listing and the completed McGeer checklist indicated the criteria was inaccurately completed indicating criteria for infection was not met. July 2023 - Resident #69: category: S; date of onset: 7/21/23; symptoms: redness, pain, swelling; site: not identified; status: HAI; count (required): Yes - Resident #3: category: upper respiratory infection (URI); date of onset: 7/10/23; symptoms: cough, congestion; status: HAI; count (required): Yes - Resident #20: category: URI; date of onset: 7/6/23; symptoms: cough, phlegm, change in lung sounds; status: HAI; count (required): Yes - Resident #20: category: URI; date of onset: 7/21/23; symptoms: cough, phlegm, change in lung sounds; status: HAI; count (required): Yes Review of the McGeer criteria checklist in use by the facility, indicated but was not limited to the following: Syndrome: Cellulitis, soft tissue, or wound infection (Skin) Criteria: Must fulfill at least 1 of the criteria. 1. Pus at wound, skin, or soft tissue site 2. At least four of the following: - New or increasing sign or symptom - Heat (warmth) at affected site - Redness (erythema) at affected site - Swelling at affected site - Tenderness or pain at affected site - Serous drainage at the affected site 2A. At least one of the following (can be counted as part of the four in criteria #2) - Fever - Leukocytosis - Acute changed in mental status - Acute functional decline Syndrome: Bronchitis/Tracheo-bronchitis (URI) Criteria: Must fulfill 1, 2, AND 3. 1. Chest X-ray not performed, or negative for pneumonia or a new infiltrate 2. At least two of the following criteria - New or increased cough - New or increased sputum production - Oxygen saturation (O2 sat) <94% on room air, or >3% decrease from baseline O2 sat - New or changed lung exam abnormalities - Pleuritic chest pain - Respiratory rate >25 breaths/min 3. At least one of the following criteria - Fever - Leukocytosis - Acute mental status change - Acute functional decline The McGeer criteria checklist completed for Resident #69 indicated the criteria for infection was not met on criteria review (requiring four symptoms) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance. The McGeer criteria checklist completed for Resident #3 indicated the criteria for infection was not met on criteria review (requiring all 3 criteria to be met) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance. The McGeer criteria checklist completed for Resident #20 on 7/6/23 indicated the criteria for infection was not met on criteria review (requiring all 3 criteria to be met) but was inaccurately checked as criteria met and inaccurately counted as an infection on the facility line listing surveillance, as was the McGeer checklist completed for this Resident on 7/21/23. During an interview on 9/12/23 at 12:06 P.M., the DON and SDC reviewed the discrepancies between the surveillance line listings and McGeer criteria checklists for all four Residents and said the information did not match and the documents were not completed accurately but could not explain how the discrepancies may have occurred. Neither the DON nor the SDC could provide any tracking or trending information or speak to how trends of infections would be identified in the facility. The DON said there are no documented HAI rates for the facility completed monthly, no data comparisons from unit to unit or month to month and no overall analysis completed that she is aware of at the facility level and the lab provides them with look back data quarterly based off of the surveillance line listings submitted to the lab. She said there may be infection tracking and trending and analysis information available through the Quality Assurance Performance Improvement (QAPI) committee, but that the facility does not have an infection control committee. Neither the DON nor the SDC could speak to a potential increase or fluctuation in the facility HAI numbers or provide any plotting or trending of infections within the facility. The DON said she would review the QAPI information with the Administrator and provide the surveyors with any further information they could find. During an interview on 9/13/23 at 10:47 A.M., the Administrator and the DON said the facility does not use their surveillance data in a manner to identify trends or potential outbreaks and the only information they have available is the quarterly lab look back information and no data analysis is completed monthly or in live time. The Administrator said the IPCP is not being followed the way it should be and the facility is lacking any evidence of data analysis or trending for actual or potential infections and outbreaks within the facility.

Based on records reviewed and interviews, for two of four sampled residents (Resident #2 and Resident #3), who were severely cognitively impaired, the Facility failed to prevent Resident #1 from physically abusing Resident #2 on multiple occasions and subjected Resident #3 to unwanted sexual contact. -On 2/3/19, Resident #1 hit Resident #2, with an object resulting in a skin tear to his/her left forearm, Resident #2 was visibly upset by the incident. -On 2/5/19, Resident #1 struck Resident #2 with a closed fist in the groin area. -On 2/20/19, Resident #1 was found in Resident #2's room and Resident #2 stated that Resident #1 attacked him/her and tried to pull him/her out of bed. -On 1/14/19, Resident #1 kissed Resident #3 on the forehead while he/she was lying in bed. Findings include: The Facility's Policy titled, Abuse Policy, dated 03/14/2018, indicated that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse, to insure that all alleged violations of Federal or State laws which involve abuse are reported immediately to the Executive Director and that the facility will investigate each alleged violation thoroughly and report the results of all investigations to the Executive Director. The Policy indicated that: -abuse is unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm. - residents must not be abused by anyone including other residents. -if a resident to resident, residents will be separated until circumstances can be investigated; The Facility's Policy titled, Resident to Resident Altercations, dated as revised 12/2007, indicated all altercations including those that may represent resident-to-resident abuse shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services and to the Administrator. The Policy indicated to: -identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -make any necessary changes in the care plan approaches to any or all of the involved individuals; -document in the resident's clinical record all interventions and their effectiveness and; -complete a Report of Incident/Accident form and document the incident, findings and any corrective measures taken in the resident's medical/clinical record. 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 1/8/19, indicated Resident #1 had severe cognitive impairment, had wandering behaviors and required supervision with ambulation. Resident #2 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, dated 1/30/19, indicated Resident #2 had severe cognitive impairment, had wandering behaviors and required supervision with ambulation. A Nurse Progress Note, dated 2/3/19, indicated that at approximately 5:30 A.M., staff responded to a loud noise in room [ROOM NUMBER], Resident #2 was sitting in his/her bed and reported that Resident #1 had hit him/her in his/her sleep. The Note indicated that upon assessment, Resident #2 was noted to have a one centimeter skin tear on his/her left arm. Review of the Health Care Facility Reporting System (HCFRS) indicated the Facility submitted a report that at approximately 5:30 A.M. on 2/3/19, Resident #1 hit Resident #2 while he/she was sleeping causing a one centimeter skin tear to his/her left arm. The Hospital Emergency Department Report, dated 2/03/19, indicated Resident #1 presented with altered mental status, aggressive behavior and paranoid personality disorder after he/she apparently attacked his/her roommate with an ice scraper or cane. The Report indicated that Resident #1 was medically cleared, appeared confused with dementia with no evidence of [MEDICAL CONDITION], and he/she was being discharged back to the Facility. The Surveyor interviewed CNA #1 at 4:00 P.M. on 3/12/19. CNA #1 said that she heard Resident #1 speaking in Spanish and went into his/her room to check on him/her. CNA #1 said when she entered the room, Resident #2 was in a panicked state, was very upset and told her that he/she had been in a deep sleep and woke up to Resident #1 hitting him/her with a stick. CNA #1 said Resident #2 was bleeding from a cut to his/her arm and said she yelled out for Nurse #1. CNA #1 said she saw a black stick like object similar to a back scratchier in the room and said she told the Supervisor what happened. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 3/12/19. Nurse #1 said that Certified Nurse Aide (CNA) #1, who was in Resident #1 and Resident #2's room, was calling out her name, so she went to see what CNA #1 needed. Nurse #1 said when she entered the room, she observed that Resident #2 was bleeding from a skin tear on his/her left arm. Nurse #1 said Resident #2 said Resident #1 hit him/her. Nurse #1 said she saw a long black object in the room, said she notified the Supervisor of the incident and said that Resident #1 was transferred to the hospital because he/she was still agitated. 2. A Nurse Progress Note, dated 2/05/19, indicated that Resident #1 had an order for [REDACTED].#2 in the groin. The Note indicated Resident #1 was transferred to the hospital for psychological evaluation. Review of the Health Care Facility Reporting System (HCFRS) indicated the Facility submitted a report that at approximately 11:15 A.M. on 2/05/19, Resident #1 struck Resident #2 in the lower abdomen. The Hospital Emergency Department Report, dated 2/7/19, indicated that Resident #1 presented to the emergency department from a nursing home after being aggressive towards another patient and punching him/her in the groin. The Surveyor interviewed the Activity Aide at 2:08 P.M. on 3/18/19. The Activity Aide said that she was providing 1:1 supervision for Resident #1 in the dining area. The Activity Aide said Resident #1 said he/she needed to go to the bathroom, she let him/her go and followed him/her shortly after he/she left the dining area. The Activity Aide said she heard a verbal altercation between Resident #1 and Resident #2, went into Resident #2's room, and physically intervened between the two residents, who were yelling at each other. The Activity Aide said Resident #1 reached his/her arm around her and hit Resident #2 in the groin area. The Activity Aide said she called out for help, that a nurse and Director of Nurses came to Resident #2's room and said she went back to the dining area. The Activity Aide said she was unaware Resident #1 had previous altercations with Resident #2 and said she did not know why Resident #1 was on 1:1 supervision. Although the facility implemented 1:1 supervision as an intervention to prevent Resident #1 from physically assaulting Resident #2, this intervention was not effective as he/she was still able to assault Resident #2, and staff providing the 1;1 supervision were unaware of why it had been implemented. 3. A Nurse Progress Note, dated 2/20/19, indicated that at approximately 6:30 P.M., Resident #2 was heard yelling loudly in his/her room and said that Resident #1 had attacked him/her and was yelling at staff to get him/her (Resident #1) the hell out of here, or words to that effect. A Nurse Progress Note, dated 2/20/19, indicated that Resident #1 returned to the facility, from the hospital, at 4:00 P M., had been pacing the unit with intrusive wandering into other resident's rooms. The Note indicated at approximately 6:30 P.M. was found in his/her previous room (that he/she had shared with Resident #2) sitting in a chair rubbing his/her head with a reddened tender area noted to right side of forehead. The Note indicated that Resident #1 was sent to the Hospital Emergency Department for evaluation. Review of the Health Care Facility Reporting System (HCFRS), indicated that the Facility reported that at approximately 7:00 P.M. on 2/20/19, Resident #2 was heard yelling from his/her room and when staff entered the room, Resident #1 was sitting in a chair and Resident #2 said that Resident #1 had attacked him/her and tried to pull him/her out of his/her bed so he/she pushed Resident #1 away. The Surveyor interviewed Nurse #3 at 2:22 P.M. on 3/18/19. Nurse #3 said that she heard yelling coming from Resident #2's room and when she entered the room, she found Resident #1 rubbing his/her head and Resident #2 said that Resident #1 had attacked him/her. Nurse #3 said Resident #1 had just returned from a geripscychiatric (dealing with the treatment of [REDACTED].#2. Nurse #3 said she did not know if Resident #1 was on 1:1 supervision. Nurse #3 said Resident #1 wandered around the unit and we kept an eye on him/her. Nurse #3 said she was unaware Resident #1 had previous altercations with Resident #2. Nurse #3 said she did not report the incident to anyone and said she did not complete an incident report. Nurse #3 said the Facility did not have a 3:00 P.M. - 11:00 P.M. Supervisor to report the incident to and said she transferred Resident #1 to the Hospital Emergency Department. The Surveyor interviewed Nurse #2 at 12:49 P.M. on 3/21/19. Nurse #2 said Resident #1 was readmitted to the Facility from the hospital on [DATE] and said Resident #1 returned to the same unit as Resident #2. Nurse #2 said Resident #1 was not on 1:1 supervision when he/she returned from the hospital. The Surveyor interviewed the Director of Nurses (DON) at 4:45 P.M. on 3/12/19. The DON said she was unaware that Resident #1 was returning back from the Hospital because the Hospital did not notify the Facility. The DON said she did not know why the staff readmitted Resident #1 back to the unit where Resident #2 resided and said he/she should not have been. 4. Resident #3 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) Assessment, dated 12/6/19, indicated Resident #3 had moderate cognitive impairment and required extensive assist with activities of daily living. A Nurse Progress Note, dated 1/14/19, indicated a nursing assistant reported that Resident #1 was witnessed kissing Resident #3. Review of the Health Care Facility Reporting System (HCFRS) indicated that the Facility reported that at approximately 7:00 P.M. on 1/14/19, Resident #1 was found in Resident #3's room kissing him/her on the forehead. The Report indicated Resident #3 did not want Resident #1 to kiss him/her again. The Surveyor interviewed the Unit Manager at 2:25 P.M. on 3/12/19. The Unit Manager said CNA #2 reported to her that she witnessed Resident #1 go over to Resident #3 while he/she was lying in bed and kiss him/her. The Unit Manager said she reported the incident to the Director of Nurses. The Surveyor interviewed CNA #2 at 9:26 A.M. on 3/25/19. CNA #2 said she saw Resident #1 in Resident #3's room and said she saw Resident #1 kiss Resident #3 while he/she was lying in bed. The Surveyor interviewed the Director of Nurses (DON) at 2:45 P.M. on 3/19/19. The DON said that Resident #1 went into Resident #3's room and kissed her/him on the forehead. The DON said Resident #3 did not mind it and said Resident #3 said he/she did not want Resident #1 to kiss him/her again.

Based on records reviewed and interviews, for one of four sampled residents (Resident #2), the Facility failed to maintain his/her safety and prevent accidents/injuries, when Resident #1 who required 1:1 supervision due to aggressive behaviors sought out and physically attacked Resident #2 on more than one occasion, resulting in Resident #2 sustaining a skin tear to his/her left arm. Findings include: 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 1/08/19, indicated Resident #1 had severe cognitive impairment, had wandering behavior and required supervision with ambulation. Resident #2 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, dated 1/30/19, indicated Resident #2 had severe cognitive impairment, had wandering behavior and required supervision with ambulation. Resident #2's Dementia with Cognitive Loss Care Plan, dated 1/23/19, indicated Resident #2 had short and long-term memory deficits and wandered around the unit. Interventions included not to argue with him/her, to re-approach if agitated or try another caregiver. A Nurse Progress Note, dated 2/03/19, indicated that at approximately 5:30 A.M., staff responded to a loud noise in room [ROOM NUMBER], Resident #2 was sitting in his/her bed and reported that Resident #1 had hit him/her in his/her sleep. The Note indicated that upon assessment, Resident #2 was noted to have a one centimeter skin tear on his/her left arm. The Hospital Emergency Department Report, dated 2/3/19, indicated Resident #1 presented with altered mental status, aggressive behavior and paranoid personality disorder after he/she apparently attacked his/her roommate with an ice scraper or cane. The Report indicated that Resident #1 was medically cleared, appeared confused with dementia with no evidence of [MEDICAL CONDITION],and he/she was being discharged back to the Facility. Review of Resident #1's Physician Orders, dated 2/04/19 through 2/19/19, indicated 1:1 supervision. Review of Resident #1's Physician Orders, dated 2/03/19 through 2/28/19, indicated [MEDICATION NAME] (used for impulsivity, agitation and aggression) sprinkles 125 milligrams daily. The Surveyor interviewed CNA #1 at 4:00 P.M. on 3/12/19. CNA #1 said that she heard Resident #1 speaking in Spanish and went to his/her room. CNA #1 said when she entered the room, Resident #2 was in a panicked state, was very upset and told her that he/she had been in a deep sleep and woke up to Resident #1 hitting him/her with a stick. CNA #1 said Resident #2 was bleeding from a cut to his/her arm and said she yelled out for Nurse #1. CNA #1 said she saw a black stick like object similar to a back scratchier in the room and said she told the Supervisor what happened. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 3/12/19. Nurse #1 said that Certified Nurse Aide (CNA) #1, who was in Resident #1 and Resident #2's room, was calling out her name, so she went to see what CNA #1 needed. Nurse #1 said when she entered the room, she observed that Resident #2 was bleeding from a skin tear on his/her left arm. Nurse #1 said Resident #2 said Resident #1 hit him/her. Nurse #1 said she saw a long black object in the room, said she notified the Supervisor of the incident and said that Resident #1 was transferred to the hospital because he/she was still agitated. The Surveyor interviewed the Nursing Supervisor at 3:21 P.M. on 3/18/19. The Nursing Supervisor said that Nurse #1 informed her that Resident #1 had hit Resident #2 and caused a skin tear to his/her left forearm. The Nursing Supervisor said that she saw an ice scraper in Resident #1's room, said that Resident #1 used the ice scraper to hit Resident #2 and said she reported this to the Director of Nurses. 2. Resident #1's Behavioral Symptoms Care Plan, updated 2/04/19, indicated Resident #1 had behavioral symptoms related to dementia, frequently needed redirection to respect personal physical boundaries with other residents and was aggressive at times. Interventions included: determine possible antecedents to behavior such as noise, roommate, comfort triggers and to address as needed; keep resident separated from roommate when necessary due to escalating behaviors; monitor resident frequently secondary to risk for upsetting others and when agitated, guide away from source of stress and move to a quieter setting in his/her room. Resident #2's Psychosocial Well-Being Care Plan, dated 2/4/19, indicated Resident #2 was at risk for post trauma syndrome and interventions included: encourage resident to verbalize feelings and fears; keep resident safe by separating from roommate and provide comfort and reassurance. A Nurse Progress Note, dated 2/05/19, indicated that Resident #1 had an order for [REDACTED].#2 in the groin. The Note indicated Resident #1 was transferred to the hospital for psychological evaluation. The Surveyor interviewed the Activity Aide at 2:08 P.M. on 3/18/19. The Activity Aide said that she was providing 1:1 supervision for Resident #1 in the dining area. The Activity Aide said Resident #1 said he/she needed to go to the bathroom, she let him/her go and followed him/her shortly after he/she left the dining area. The Activity Aide said she heard a verbal altercation between Resident #1 and Resident #2, went into Resident #2's room, and physically intervened between the two residents, who were yelling at each other. The Activity Aide said Resident #1 reached his/her arm around her and hit Resident #2 in the groin area. The Activity Aide said she called out for help, that a nurse and Director of Nurses came into Resident #2's room and she went back into the dining area. The Activity Aide said she was unaware that Resident #1 had previous altercations with Resident #2 and said she did not know why Resident #1 was on 1:1 supervision. 3. A Nurse Progress Note, dated 2/20/19, indicated that at approximately 6:30 P.M., Resident #2 was heard yelling loudly in his/her room and said that Resident #1 had attacked him/her and was yelling at staff to get him/her (Resident #1) the hell out of here, or words to that effect. A Nurse Progress Note, dated 2/20/19, indicated that Resident #1 returned to the facility from the hospital at 4:00 P.M., has been pacing the unit with intrusive wandering into other resident's rooms. The Note indicated at 6:30 P.M. was found in his/her previous room (that he/she had shared with Resident #2) sitting in a chair rubbing his/her head with a reddened tender area noted to right side of forehead. The Note indicated that Resident #1 was sent to the Hospital Emergency Department for evaluation. The Surveyor interviewed Nurse #3 at 2:22 P.M. on 3/18/19. Nurse #3 said that she heard yelling coming from Resident #2's room and when she entered the room, she found Resident #1 rubbing his/her head and Resident #2 said that Resident #1 had attacked him/her. Nurse #3 said Resident #1 returned the facility and was readmitted to the same unit as Resident #2. Nurse #3 said she did not know if Resident #1 was on 1:1 supervision. Nurse #3 said Resident #1 wandered around and we kept an eye on him/her. Nurse #3 said she was unaware Resident #1 had a history of [REDACTED].#2. Nurse #3 said she did not report the incident to anyone and said she did not complete an incident report. Nurse #3 said the Facility did not have a 3:00 P.M. - 11:00 P.M. Supervisor to report the incident to and said she transferred Resident #1 to the Hospital Emergency Department. The Surveyor interviewed Nurse #2 at 12:49 P.M. on 3/21/19. Nurse #2 said Resident #1 was not on 1:1 supervision when he/she returned from the hospital. Nurse #2 said she was not Resident #1's nurse the evening and said she had not reported the incident to anyone. The Surveyor interviewed the Director of Nurses (DON) at 4:45 P.M. on 3/12/19. The DON said she was unaware that Resident #1 was returning back from the Hospital because the Hospital did not notify the Facility. The DON said she did not know why the staff readmitted Resident #1 back to the unit where Resident #2 resided and said Resident #1 should not have been readmitted to the unit where Resident #2 resided.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) the Facility failed to overhead page an emergency code in order to initiate immediate staff response and assistance when Resident #1 hemorrhaged during a dressing change for a vascular ulcer on his/her right lower leg. The Facility failed to utilize alternative first aid interventions when Nurse #1's application of pressure did not control Resident #1's bleeding while he/she experienced rapid and severe blood loss that left blood on his/her wall, wheelchair, bed, floor and was described by staff as to have appeared to look like a crime scene. The Facility failed to immediately call 911 to activate the Emergency Medical System (EMS) when Resident #1 had severe projectile bleeding, as described by staff. Resident #1 continued to hemorrhage and died by the time Emergency Medical Technicians (EMTs) arrived. Findings Include: The Facility Policy titled, In House Emergency Response Policy and Procedure, undated, indicated that to ensure that residents are provided with timely staff intervention in the event of any kind of medical emergency and a Code Blue should be called for life threatening emergencies, including hemorrhaging. The Facility Policy titled, First Aid Treatment, dated ,[DATE], indicated that in addition to providing basic first aid intervention, contact (EMS) or advanced medical personnel immediately for the following situations:, which included severe bleeding. The Policy indicated that procedures for basic first aid intervention were located in the facility First Aid Manual/Guide Book and a copy of the manual is kept at each nurse's station with the first aid kit. The Red Cross and American Heart Association Updated Guidelines, posted [DATE], indicated that; the revised guidelines stress the importance of stopping severe bleeding as a critical first aid skill and while direct pressure is still the first line of defense, the guidelines acknowledge the important role tourniquets and [MEDICATION NAME] agents play in stopping life-threatening bleeding when standard measures fail or are not possible. The guidelines indicate tourniquets can be effective for severe external limb bleeding, and have been found to control bleeding effectively in most cases. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was alert and oriented. Resident #1's medical [DIAGNOSES REDACTED]. Blood Laboratory Results, dated [DATE], indicated that Resident #1's International Normalized Ratio (INR) (blood clotting test, the higher the number the thinner the blood and longer it takes to clot) was at a supratherapeutic level of 4.72 and noted to be critically high (reference range is 2XXX,[DATE].0) and, on [DATE] Resident #1's INR was 1.91. An Incident/Accident Report, dated [DATE], indicated that at 9:00 P.M. on [DATE], during a routine dressing change, Resident #1 began to bleed profusely. Nurse #1 applied direct pressure. 911 was called. Resident #1 became unresponsive and exhibited no signs of life when Emergency Medical Services (EMS) arrived. A Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated that Resident #1's preference was to be transferred to the hospital. The Surveyor interviewed Nurse #1 at 3:40 P.M. on [DATE]. Nurse #1 said, on [DATE] at approximately 9:00 P.M., Resident #1 was seated, in the wheelchair in his/her room located on the South Unit, with his/her right leg in a dependent (down) position and when she removed Resident #1's old dressing on a wound located just above the ankle on his/her right leg, Resident #1's leg started to immediately bleed and it was like projectile bleeding, or words to that effect. Nurse #1 said that blood was everywhere and as she held pressure to Resident #1's leg with her hand, blood continued to spew around it, or words to that effect. Nurse #1 said she grabbed a towel to see if it would help, screamed for help, and lifted Resident #1's leg up to slightly higher than waist level as best as she could. Nurse #1 said Resident #1 remained seated in the wheelchair and she continued to scream for help. Nurse #1 said, approximately 30 seconds later, Certified Nurse Aide (CNA) #1 responded and she told CNA #1 to call a Code Blue and CNA #1 ran out of the room. Nurse #1 said she did not hear a Code Blue paged. Nurse #1 said Nurse #3 and the Assistant Director of Nursing (ADON) were the first nurses to respond. This was not consistent with Nurse #2, Nurse #3, and the ADON's recall of the event. Nurse #1 said Nurse #3 helped apply pressure and elevate Resident #1's leg. Nurse #1 said when Nurse #2 got the room, she went to call 911 and then Nurse #2 returned with the code cart. Nurse #1 said Resident #1 was unresponsive, they put an oxygen mask on him/her and when the Emergency Medical Technicians (EMTs) arrived they said he/she was pulseless. Nurse #1 was unable to demonstrate to the Surveyor how to overhead page a Code Blue. A Statement, dated [DATE] and signed by Nurse #1, indicated that upon removal of dressing, projectile bleeding at a rapid speed was coming from resident's leg, she immediately began to apply pressure to the leg with a towel however it would not stop. The Statement indicated that she called for help and instructed the aide to run and get all the nurses for help. This was not consistent with what Nurse #1 told the Surveyor during the interview on [DATE]. The Surveyor interviewed CNA #1 at 11:55 A.M. on [DATE]. CNA. #1 said Nurse #1 called her for help and when she went into Resident #1's room he/she was seated in a wheelchair, there was blood on the floor, and he/she was bleeding a lot. CNA #1 said Nurse #1 told her to go get the other nurse. CNA #1 said when she went to the East Unit she could not find the nurse, so she used a phone to call a nurse on the North Unit and told her they needed help on the South Unit. The Surveyor interviewed CNA #1 at 4:08 P.M. on [DATE]. CNA #1 said that Nurse #1 did not tell her to call a Code Blue. The Surveyor interviewed Nurse #2 at 3:10 P.M. on [DATE]. Nurse #2 said that, on [DATE] during her 3:00 P.M.-11:00 P.M. shift on the North Unit, she was at the nurse's station and received a phone call from CNA #1 who asked her if she knew where Nurse #3 was. Nurse #2 said she could tell that the call came from the East Unit because it showed on the phone. Nurse #2 said she told CNA #1 that she did not know where Nurse #3 was, questioned if CNA #1 needed anything, and CNA #1 told her Nurse #1 needed Nurse #3. Nurse #2 said that CNA #1 did not speak with any urgency or relay that there was an emergency. Nurse #2 said she went to the South Unit where Nurse #1 was to see what Nurse #1 needed. Nurse #2 said as she walked down the hall, she met up with Nurse #3 and CNA #1 and they walked down the hall casually because she had no indication from CNA #1 that she should be hurrying. Nurse #2 said CNA #1 did not page Code Blue. Nurse #2 said when she got to the South Unit she called for Nurse #1 and when she arrived in Resident #1's room she observed Nurse #1 applying pressure to Resident #1's right leg and Resident #1 was seated in his/her wheelchair with his/her right leg on the leg rest which was in the dependent (down) position. Nurse #2 said Resident #1's color appeared gray and there was a huge pool of blood on the floor around Resident #1's wheelchair, blood on the wall, and it looked like a crime scene, or words to that effect. Nurse #2 said she checked Resident #1's carotid pulse and there was no pulse present at that time. Nurse #2 said she went to call 911, and returned to Resident #1's room with the code cart. Nurse #2 said even though Resident #1 was unresponsive, blood was still gushing everywhere, or words to that effect. The Surveyor interviewed Nurse #3 at 2:14 P.M. on [DATE]. Nurse #3 said, on [DATE], he worked a 3:00 P.M. -11:00 P.M. shift and during the shift, he was off the unit walking towards the main dining room and he saw CNA #1 who told him to come with her and grabbed his hand and pulled him. Nurse #3 said when he went into Resident #1's room he observed Nurse #1 bent down with towels. Nurse #3 said Resident #1's eyes were opened but he/she was not verbally responsive and he observed blood soaking through the towels so much so that it was bubbling up through approximately 6 towels. Nurse #3 said there was blood all over the floor, wheelchair, and walls and it was a pretty horrific scene, or words to that effect. Nurse #3 said he went across the hall to get the code cart. This was not consistent with what Nurse #1 and Nurse #2 told the Surveyor. Nurse #3 said he told Nurse #1 to continue to apply pressure to Resident #1's leg and had thought about attempting to get Resident #1 onto the floor but then thought it would be worse to do because doing so could raise Resident #1's heart rate and it may have been unsafe with the blood on the floor. Nurse #3 said they could have tried to use a blood pressure cuff in the code cart as a tourniquet but didn't try it because everything happened so fast. Nurse #3 said he learned as a nurse that when someone bleeds out, it happens within minutes, or words to that effect. The Surveyor interviewed the Assistant Director of Nursing (DON) at 4:15 P.M. on [DATE]. The ADON said she left the faciity on [DATE] just before 9:00 P.M. and shortly after leaving the Facility she got a call from Nurse #3 asking her to return to the Facility and when she arrived back at the Facility, a fire truck was just getting there. The ADON said when she got to Resident #1's room she observed Resident #1 seated in a wheelchair and Nurse #1 on her knees in front of Resident #1 with towels wrapped around his/her right lower leg while applying pressure and Resident #1 had an oxygen mask on. The ADON said there was a lot of blood underneath Resident #1 and there were blood saturated towels on the floor. The ADON said the EMTs came in approximately five minutes later, found that Resident #1 had no signs of life, and they left the Facility. The ADON said she did not expect staff to have handled Resident #1's incident any differently than they did because everyone was focused on stopping the bleeding, questioning if they were going to attempt to resuscitation, and the incident happened fast. A Statement, dated ,[DATE] and signed by the ADON, indicated that she left the Facility at approximately 8:55 P.M. and just after 9:00 P.M. she was notified to return to the Facility due to an emergency so she drove back to the Facility as fast as she could. The Statement indicated that she made it back there as a fire truck was pulling into the parking lot and when she got to the room there was a large amount of blood on the floor, a nurse was holding several towels in place and applying pressure. The Statement indicated that Resident #1 was unresponsive when she arrived, she could not obtain a carotid pulse, and the Paramedics entered the room shortly after, assessed for signs of life and were unable to detect a heart beat. The Surveyor interviewed the Director of Nursing (DON) at 12:23 P.M. on [DATE]. The DON said there were no first aid kits or First Aide Manual/Guide Books available at any of the Nurse's Stations. This is not consistent with the Policy titled First Aid Treatment. The DON provided the Surveyor with Code Cart Checklist that contained an inventory list of the contents inside the code cart. The inventory list did not include a tourniquet, intravenous start kit, or gauze wrap. The Surveyor interviewed Resident #1's Wound Physician at 12:34 P.M. on [DATE]. The Wound Physician said Resident #1's bleeding was likely from an artery from the way it was described to him by staff. The Wound Physician said that although direct pressure should work, applying direct pressure can be difficult to do and nurses think they are applying enough pressure but actually may not be and use of a tourniquet is always an option for uncontrolled bleeding.

Based on records reviewed and interviews for one of three sampled residents, Resident #1, the Facility failed to overhead page a Code Blue to ensure immediate response by licensed staff assistance and support during a medical emergency. The Facility failed to utilize alternative first aid interventions for Resident #1's severe bleeding and rapid blood loss which could not be controlled by use of direct pressure and was described by staff as a horrific scene where Resident #1's blood on the floor, wheelchair, walls, and bed. Resident #1 lost consciousness, continued to hemorrhage and died . Findings Include: The Facility Policy titled, In House Emergency Response Policy and Procedure, undated, indicated that to ensure that residents are provided with timely staff intervention in the event of any kind of medical emergency and a Code Blue should be called for life threatening emergencies, including hemorrhaging. The Facility Policy titled, First Aid Treatment, dated ,[DATE], indicated that in addition to providing basic first aid intervention, contact (EMS) or advanced medical personnel immediately for the following situations:, which included severe bleeding. The Policy indicated that procedures for basic first aid intervention were located in the facility First Aid Manual/Guide Book and a copy of the manual is kept at each nurse's station with the first aid kit. The Red Cross and American Heart Association Updated Guidelines, posted [DATE], indicated that; the revised guidelines stress the importance of stopping severe bleeding as a critical first aid skill and while direct pressure is still the first line of defense, the guidelines acknowledge the important role tourniquets and [MEDICATION NAME] agents play in stopping life-threatening bleeding when standard measures fail or are not possible. The guidelines indicate tourniquets can be effective for severe external limb bleeding, and have been found to control bleeding effectively in most cases. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was alert and oriented. Resident #1's medical [DIAGNOSES REDACTED]. An Incident/Accident Report, dated [DATE], indicated that at 9:00 P.M. on [DATE], during a routine dressing change, Resident #1 began to bleed profusely. Nurse #1 applied direct pressure. 911 was called. Resident #1 became unresponsive and exhibited no signs of life when Emergency Medical Services (EMS) arrived. A Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated [DATE], indicated that Resident #1's preference was to be transferred to the hospital. The Surveyor interviewed Nurse #1 at 3:40 P.M. on [DATE]. Nurse #1 said, on [DATE] at approximately 9:00 P.M., Resident #1 was seated, in the wheelchair in his/her room located on the South Unit, with his/her right leg resting on the leg rest in a dependent (down) position and when she removed Resident #1's old dressing on a wound located just above the ankle on his/her right leg, Resident #1's leg started to immediately bleed and it was like projectile bleeding, or words to that effect. Nurse #1 said that blood was everywhere and as she held pressure to Resident #1's leg with her hand, blood continued to spew around it, or words to that effect. Nurse #1 said she grabbed a towel to see if it would help, screamed for help, and lifted Resident #1's leg up to slightly higher than waist level as best as she could. Nurse #1 said Resident #1 remained seated in the wheelchair and she continued to scream for help. Nurse #1 said, approximately 30 seconds later, Certified Nurse Aide (CNA) #1 responded and she told CNA #1 to call a Code Blue and CNA #1 ran out of the room. Nurse #1 said she did not hear a Code Blue paged. Nurse #1 said Nurse #3 and the Assistant Director of Nursing (ADON) were the first nurses to respond. This was not consistent with Nurse #2, Nurse #3, and the ADON's recall of the event. Nurse #1 said Nurse #3 helped apply pressure and elevate Resident #1's leg. Nurse #1 said when Nurse #2 got the room, she went to call 911 and then Nurse #2 returned with the code cart. Nurse #1 said Resident #1 was unresponsive, they put an oxygen mask on him/her and when the Emergency Medical Technicians (EMTs) arrived they said he/she was pulseless. Nurse #1 was unable to demonstrate to the Surveyor how to overhead page a Code Blue. A Statement, dated [DATE] and signed by Nurse #1, indicated that upon removal of dressing, projectile bleeding at a rapid speed was coming from resident's leg, she immediately began to apply pressure to the leg with a towel however it would not stop. The Statement indicated that she called for help and instructed the aide to run and get all the nurses for help. This was not consistent with what Nurse #1 told the Surveyor during the interview on [DATE]. The Surveyor interviewed CNA #1 at 11:55 A.M. on [DATE]. CNA. #1 said Nurse #1 called her for help and when she went into Resident #1's room he/she was seated in a wheelchair, there was blood on the floor, and he/she was bleeding a lot. CNA #1 said Nurse #1 told her to go get the other nurse. CNA #1 said when she went to the East Unit she could not find the nurse, so she used a phone to call a nurse on the North Unit and told her they needed help on the South Unit. The Surveyor interviewed CNA #1 at 4:08 P.M. on [DATE]. CNA #1 said that Nurse #1 did not tell her to call a Code Blue. The Surveyor interviewed Nurse #2 at 3:10 P.M. on [DATE]. Nurse #2 said that, on [DATE] during her 3:00 P.M.-11:00 P.M. shift on the North Unit, she was at the nurse's station and received a phone call from CNA #1 who asked her if she knew where Nurse #3 was. Nurse #2 said she could tell that the call came from the East Unit because it showed on the phone. Nurse #2 said she told CNA #1 that she did not know where Nurse #3 was, questioned if CNA #1 needed anything, and CNA #1 told her Nurse #1 needed Nurse #3. Nurse #2 said that CNA #1 did not speak with any urgency or relay that there was an emergency. Nurse #2 said she went to the South Unit where Nurse #1 was to see what Nurse #1 needed. Nurse #2 said as she walked down the hall, she met up with Nurse #3 and CNA #1 and they walked down the hall casually because she had no indication from CNA #1 that she should be hurrying. Nurse #2 said CNA #1 did not page Code Blue. Nurse #2 said when she got to the South Unit she called for Nurse #1 and when she arrived in Resident #1's room she observed Nurse #1 applying pressure to Resident #1's right leg and Resident #1 was seated in his/her wheelchair with his/her right leg on the leg rest which was in the dependent (down) position. Nurse #2 said Resident #1's color appeared gray and there was a huge pool of blood on the floor around Resident #1's wheelchair, blood on the wall, and it looked like a crime scene, or words to that effect. Nurse #2 said she checked Resident #1's carotid pulse and there was no pulse present at that time. Nurse #2 said she went to call 911, and returned to Resident #1's room with the code cart. Nurse #2 said even though Resident #1 was unresponsive, blood was still gushing everywhere, or words to that effect. The Surveyor interviewed Nurse #3 at 2:14 P.M. on [DATE]. Nurse #3 said, on [DATE], he worked a 3:00 P.M. -11:00 P.M. shift and during the shift, he was off the unit walking towards the main dining room and he saw CNA #1 who told him to come with her and grabbed his hand and pulled him. Nurse #3 said when he went into Resident #1's room he observed Nurse #1 bent down with towels. Nurse #3 said Resident #1's eyes were opened but he/she was not verbally responsive and he observed blood soaking through the towels so much so that it was bubbling up through approximately 6 towels. Nurse #3 said there was blood all over the floor, wheelchair, and walls and it was a pretty horrific scene, or words to that effect. Nurse #3 said he went across the hall to get the code cart. This was not consistent with what Nurse #1 and Nurse #2 told the Surveyor. Nurse #3 said he told Nurse #1 to continue to apply pressure to Resident #1's leg and had thought about attempting to get Resident #1 onto the floor but then thought it would be worse to do because doing so could raise Resident #1's heart rate and it may have been unsafe with the blood on the floor. Nurse #3 said they could have tried to use a blood pressure cuff in the code cart as a tourniquet but didn't try it because everything happened so fast. Nurse #3 said he learned as a nurse that when someone bleeds out, it happens within minutes, or words to that effect. The Surveyor interviewed the Assistant Director of Nursing (ADON) at 4:15 P.M. on [DATE]. The ADON said she left the faciity on [DATE] just before 9:00 P.M. and shortly after leaving the Facility she got a call from Nurse #3 asking her to return to the Facility and when she arrived back at the Facility, a fire truck was just getting there. The ADON said when she got to Resident #1's room she observed Resident #1 seated in a wheelchair and Nurse #1 on her knees in front of Resident #1 with towels wrapped around his/her right lower leg while applying pressure. The ADON said Resident #1 had an oxygen mask on. The ADON said there was a lot of blood underneath Resident #1 and there were blood saturated towels on the floor. The ADON said the EMTs came in approximately five minutes later, found that Resident #1 had no signs of life, and they left the Facility. A Statement, dated ,[DATE] and signed by the ADON, indicated that she left the Facility at approximately 8:55 P.M. and just after 9:00 P.M. she was notified to return to the Facility due to an emergency so she drove back to the Facility as fast as she could. The Statement indicated that she made it back there as a fire truck was pulling into the parking lot and when she got to the room there was a large amount of blood on the floor, a nurse was holding several towels in place and applying pressure. The Statement indicated that Resident #1 was unresponsive when she arrived, she could not obtain a carotid pulse, and the Paramedics entered the room shortly after, assessed for signs of life and were unable to detect a heart beat. The ADON said she did not expect staff to have handled Resident #1's incident any differently than they did because everyone was focused on stopping the bleeding, questioning if they were going to attempt to resuscitation, and the incident happened fast. The Surveyor interviewed the Director of Nursing (DON) at 12:23 P.M. on [DATE]. The DON said there were no first aid kits or First Aide Manual/Guide Books available at any of the Nurse's Stations. This is not consistent with the Policy titled First Aid Treatment. The DON provided the Surveyor with Code Cart Checklist that contained an inventory list of the contents inside the code cart. The inventory list did not include a tourniquet, intravenous start kit, or gauze wrap. The Surveyor interviewed Resident #1's Wound Physician at 12:34 P.M. on [DATE]. The Wound Physician said Resident #1's bleeding was likely from an artery from the way it was described to him by staff. The Wound Physician said that although direct pressure should work, applying direct pressure can be difficult to do and nurses think they are applying enough pressure but actually may not be and use of a tourniquet is always an option for uncontrolled bleeding.

Based on observation, record review and interview, the facility failed to identify a significant weight loss and implement interventions for 1 resident, (#3), out of a total of 15 sampled residents. Findings include: For Resident #3, the facility failed to identify a significant weight loss of 8.8% in one month and failed to implement interventions to address said weight loss. Resident #3 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Resident #3's most recent MDS dated [DATE] indicated that he/she scored a 7 out of 15 regarding cognitive status, (indicating severe cognitive impairment), and that he/she requires assistance with bathing, dressing and and toileting. Review of the facility's Weight Assessment and Intervention Policy, undated, indicated the following: - Any weight change of greater than 3 lbs between consecutive weekly weights and 5 lbs between consecutive monthly weights necessitates a re-weigh within 24 hours with the licensed staff present to verify accuracy. - Significant weight changes are defined as 5% or more within 30 days, 7-1/2% or more within 90 days, 10% or more within 180 days. - If a weight loss meets the definition of significant, the MD will be notified. - Care Plan interventions will consider: severity of change, medical diagnoses, ADL status, medications, psychological status, family input, resident preferences and input from direct caregivers. - Interventions for undesirable weight loss should focus first on food. Liquid nutritional supplements per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase reweigh. Interdisciplinary team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants or medications as appropriate. Review of Resident #3's initial Nutritional Status care plan dated 2/6/17 indicated a long term goal for his/her weight to be 160 lbs +/- 5 lbs. The careplan included approaches of house diet, no salt packet restriction suggested by dietician, independent/supervision with feeding and that Resident #3 at times throws tray items, (which consistently was cups and rarely food), honor food preferences and dislikes, encourage all fluids, [MEDICATION NAME] as ordered, monitor weights as ordered and document accurate % meal intakes. Review of the physician's orders [REDACTED]. Review of Resident #3's clincal record indicated that he/she was admitted to the facility weighing 166.2 lbs. Further review of Resident #3's weights indicated he/she had been weighed twice for the month of 2/2017. The weights were documented as follows: 2/2/17: 167 lbs 2/28/17: 152.2 lbs. Resident #3 had lost 14.8 lbs in 26 days which is a significant weight loss of 8.8% of his/her total body weight. Resident #3 was not re-weighed within 24 hours per policy. There was no evidence that Resident #3's physician was notified about his/her weight loss until 3/29/17; 31 days after the 14.8 lb weight loss was documented. Additionally, his/her careplan was not updated until 4/13/17 to indicate that Resident #3 had had a weight loss, and no new interventions to address the weight loss were implemented until 4/6/17 when the Dietician recommended the use of house supplements 2 times a day. During interview with Unit Manager #1 on 5/24/17 at 8:30 A.M., she said that Resident #3's food intake is monitored and that breakfast is his/her best meal. She said that Resident #3's overall intake is variable and at times he/she still throws items from his/her tray and that staff do encourage him/her to eat. She said that Resident #3 had had a number of UTI's and that had impacted his/her appetite. Unit Manager #1 also said that the scale used to measure Resident #3's weights has not been changed and that Resident #3's weight loss was first monitored by staff at weekly risk meetings beginning on 3/23/17; 24 days after Resident #3's weight loss occurred. Unit Manager #1 was first employed by the facility in early March and said she was not aware that Resident #3's original weight was 166 lbs. During direct observations of the breakfast meal on 5/24/17 between 8:26 A.M., and 9:07 A.M., the surveyor noted that Resident #3 had 1 staff person enter his/her room once to provide encouragement for the meal. At 9:07 A.M., a CNA entered the room and removed the breakfast tray which had 80% of the meal still in place. Resident #3 told the CNA that he/she was finished and the CNA did not offer encouragement or an alternative meal to promote increased intake. During interview with the Dietician on 5/22/17 at 2:11 P.M., she said that she was not made aware of Resident #3's February weight loss and she said that she was surprised it was not addressed at that point, or words to that effect. The Dietician's notes indicated weight loss review on 3/20/17; 20 days after the weight loss was documented. The note dated 3/20/17 suggested weekly monitoring; an intervention which had already been implemented and done since 3/1/17. During a follow up interview with the dietician on 5/24/17 at 9:11 A.M., she said that she had been monitoring Resident #3 as having stable weights for the month of 3/2017. Resident #3's weights during 3/2017 ranged from 152-153, and he/she did not return to his/her careplanned goal weight of 160 lbs +/- 5 lbs. She said that she and the staff had looked into whether or not Resident #3's use of [MEDICATION NAME] had impacted his/her weight, and that Resident #3's labs were stable. Resident #3's clinical record indicated the prescribed dosage of [MEDICATION NAME] had not been altered since initially ordered in 10/2016. The dietician went on to say that Resident #3 had been prescribed [MEDICATION NAME], (a medication used to treat depression, but also increases appetite), and that the dosage had been reduced. Resident #3's clinical chart indicated that the [MEDICATION NAME] was reduced on 3/6/17 secondary to increased lethargy; after the weight loss occurred. The surveyor reviewed dietician's notes and facility interventions with the Dietician. It was not until 4/6/17 did the Dietician recommend the use of house supplement 2 times per day as a new intervention to address Resident #3's weight loss; 37 days after the weight loss occurred. During interview with Resident #3's Physician on 5/24/17 at 1:30 P.M., he said that he was not aware of Resident #3's weight loss in February and also said, I did not specifically address weight loss, or words to that effect. The Physician's notes indicated that on 3/16/17, he had recommended Resident #3's intake be monitored; an intervention which had been in place since 2/6/17, as indicated in Resident #3's careplan. He said that the use of [MEDICATION NAME] could not account for the amount of weight Resident #3 lost. The facility failed to identify and notify the Dietician and the Physician of a significant weight loss for Resident #3 in a timely manner. Furthermore, the facility did not implement new interventions in an attempt to address Resident #3's weights until 4/6/17; 37 days after the weight loss.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #2), who was assessed at high risk for falls due to poor safety awareness, intermittent confusion, gait and balance problems and decreased muscular coordination, the facility failed to maintain Resident #2's safety, to prevent a fall with injury. On 12/30/16, Resident #2 experienced an unwitnessed fall from his/her wheelchair, struck his/her head on the floor, and was diagnosed with [REDACTED]. Certified Nurse Aide #2 said she did not attach an alarm to Resident #2 while he/she was in the wheelchair, because she was not aware Resident #2 required an alarm. Findings include: The Fall Risk Assessment, dated 11/03/16, indicated Resident #2's total fall risk score was 11 (total of 10 or more indicates high risk for falls), prevention protocol should be initiated and documented in resident's interdisciplinary plan of care. The Assessment indicated Resident #2 risk factors included: poor vision (with or without glasses) Parkinson's Disease, osteoarthritis, anti-hypertensive's medications, balance problems while standing and walking, change in gait pattern, decreased muscular coordination, unstable while turning, and he/she required an assistive device with ambulation. The Facility's Policy titled Alarms and Safety Monitoring Devices, undated, indicated assess residents for appropriateness of using a personal alarm or monitoring device in bed and wheelchair, and alarms will be checked for placement and functioning each shift. The Nurse's Note, dated 11/04/16, indicated Resident #2 was very confused, and had bed and chair alarm in place for safety. The Nurse's Note, dated 11/05/16, indicated Resident #2 was sitting in wheelchair by nursing station, he/she made several attempts to get up without assistance, was unable to be redirected, and was combative with staff and disruptive on unit. The Note indicated the Director of Nurses was informed of Resident #2's behaviors and continued safety concerns, and Resident #2 would to be moved to another unit so safety can be maintained. Resident #2's Activity of Daily Living Plan of Care Card (provides information on individual resident care and safety needs for Certified Nurse Aides), undated, indicated Resident #2's safety measures included; bed and chair alarms, non-skid strips at bedside to bathroom, and wedge cushion for wheelchair. The Nurse's Note, dated 11/06/16, indicated Resident #2 made several attempts to transfer and ambulate on his/her own, was redirected to wait for assistance, and Resident #2's bed and chair alarms to be in place at all times. Resident #2's physician's orders [REDACTED]. The Fall Risk Assessment, updated 11/07/16, indicated Resident #2's total fall risk score was 16, additional risk factors included intermittent confusion and history of 1 to 2 falls in the the last three months. Resident #2's Plan of Care for Falls, dated 11/07/16, indicated interventions included; chair alarm when out of bed, verbal reminders not to transfer and/or ambulate without assistance, assure floor is free of glare, liquids, foreign objects, environment free of clutter, proper well maintained footwear, and non-skid strips placed by bedside The Fall Risk Assessment, updated 11/15/16, indicated Resident #2's total fall risk score was 17, with an additional risk factor of ambulatory and incontinence noted. Resident #2's Plan of Care for Falls, updated 11/15/16, indicated additional intervention included; Resident #2 to be toileted and up in wheelchair prior to breakfast Resident #2's Treatment Administration Record (TAR), dated 12/01/16 through 12/31/16, indicated chair alarms on at all times while in chair. The Fall Risk Assessment, updated 12/12/16, indicated Resident #2's total fall risk score was 21, due to a history of three or more falls in the last three months. Review of Resident #2's record indicated he/she fell [DATE], 11/15/16, and 12/12/16. Resident #2's Plan of Care for Falls, updated 12/19/16, indicated additional interventions included: wedge cushion for wheelchair, neurology consult, and psychiatric services to follow resident. The Nurse's Note, dated 12/30/16 at 2:35 P.M., indicated Resident #2 was found face first on the ground out by the nurses station by a Certified Nurses Aide (CNA). The Note indicated, Resident #2 was not responding to commands, CNA called for help, Resident #2 became responsive, and stated he/she was going for a walk at the time of the incident. The Note indicated, Resident #2 was observed to have a bump of the right side of his/her forehead, denied having pain to his/her head or any where else, 911 was initiated, and Resident #2 remained unmoved until emergency medical services arrived. The Situation Background Appearance and Review (SBAR) Communication Form, dated 12/30/16, indicated Resident #2 fell while self ambulating, struck his/her head on the floor, and complained of right upper and lower extremity pain, and back pain. The Incident/Accident Report, dated 12/30/16, indicated at approximately 2:00 P.M., Resident #2 experienced an unwitnessed fall from his/her wheelchair and was observed lying prone (flat, face down) on the floor in front of the nursing station. The Report indicated, there were no safety devices or alarms on Resident #2's wheelchair at the time of the fall. The Report indicated, contributing factors included Resident #2 frequently tried to get up out of the wheelchair. Resident #2's TAR, dated 12/30/16, indicated his/her wheelchair alarm was documented as being in place on the day shift. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 12:00 P.M., on 3/13/17. CNA #2 said on 12/30/16 she worked the day shift and Resident #2 was on her assignment and said Resident #2's wheelchair did not have an alarm. CNA #2 said toward the end of her shift at approximately 1:30 P.M., while completing her documentation around the corner from the nursing station she heard Resident #2 fall and went to check on him/her. CNA #2 said she did not put an alarm on Resident #2's wheelchair, said she did not know Resident #2 required an alarm. CNA #2 said she did not review Resident #2's Plan of Care Card, said she did not get report from the nurse that Resident #2 required a chair alarm. The Surveyor interviewed Nurse #1 at 12:18 P.M., on 3/16/17. Nurse #1 said he was the treatment nurse on Resident #2's unit on 12/30/16. Nurse #2 said the treatment nurse was responsible for checking for placement and function of safety alarms Nurse #2 said he documented Resident #2's alarm was in place on 12/30/16, said he visualized it at the start of his shift, but said he could not explain why at the time of Resident #2's fall, why the alarm was not on Resident #2's wheelchair. Nurse #2 said after Resident #2 was transferred to the hospital, he found Resident #2's wheelchair alarm on his/her nightstand, and placed it back on Resident #1's wheelchair in anticipation of his/her return to the facility. On 3/09/17, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #2 was discharged from the Facility on 1/04/17. B) The Facility completed new fall risk assessments, dated 1/03/17 through 2/01/17, on all residents. C) The Director of Nurses, Assistant Director of Nurses, Staff Development Coordinator, and Regional Nurse Consultant conducted chart audits, dated 1/03/17 through 2/01/17, on all units. The Audits identified residents who required alarms and those residents were re-evaluated for the continued use and appropriateness of an alarm. The Audits included review and updates to the nursing Plans of Care and CNA Care Cards to assure accurate identification of the type of alarm(s) required and when alarm(s) should be in use by residents. D) The Facility audits identified that the Activity of Daily Living Plan of Care Card, which were kept in the CNA documentation binders were not readily accessible and have chosen to utilize a Kardex system, available at the nursing station. E) The Staff Development Coordinator and Regional Nurse Consultant conducted educational in-services, dated 1/10/17 through 2/28/17, for all licensed staff related to; nursing roles and responsibilities, license staff and supervision of CNA's, physical assessment of a resident post event, unwitnessed falls and neurological assessment requirements, incident/accident reporting, and conducting an event investigation. F) The Facility implemented new CNA Care Card Kardex's for all units and a Safety Station. The Staff Development Coordinator conducted in-services, dated 1/10/17 through 2/28/17, related to the Kardex's and Safety Station. The In-service indicated CNA Care Cards will be maintained in a Kardex (flip file) for easy reference of all staff and that it is the unit nurses' responsibility to update the Care Card with changes in the Plan of Care for the resident. The In-service indicated that the CNA's must review the Care Card at the start of each shift and contact the unit nurse for questions related to inconsistent information on the Care Card. The In-Service indicated the Safety Station will be located in the reception office where additional safety devices will be available for staff to access, including off hours. G) The Staff Development Coordinator conducted mandatory in-services, dated 1/10/17 through 2/28/17, related to Alarms. The In-service material included; at the beginning of each shift licensed staff must go around and check all residents who require alarms on bed and/or chair, licensed staff must check each alarm to make sure it is operating correctly, check that placement of the alarm on bed and/or chair is correct, and complete documentation on alarm sheet. The Assistant Director of Nurses and the Staff Development Coordinator will monitor for compliance. H) The Staff Development Coordinator conducted mandatory in-services, dated 1/10/17 through 2/28/17, related to additional safety measures. The In-service indicated when completing end of shift documentation, CNA's must utilize the apex (open, unobstructed area) between the north and south units which provides better viewing of residents in common areas. I) The Facility will continue to conduct Performance Improvement (PI) meetings to monitor falls, appropriate use of alarms, staff compliance with alarm checks, Plan of Care and Kardex updates, and safety interventions in an effort to reduce falls. The PI Committee will continue to review findings with additional measures implemented as needed.

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #2), who was assessed at high risk for falls, the Facility failed to ensure that safety interventions in his/her plan of care were implemented and monitored by direct care staff. On 12/30/16, Resident #2, was transferred to a wheelchair, his/her personal chair alarm was not put in place, Resident #2 experienced an unwitnessed fall, struck his/her head on the floor, and was transferred to the hospital. Resident #2 was diagnosed with [REDACTED]. Findings include: The Fall Risk Assessment, dated 11/03/16, indicated Resident #2's total fall risk score was 11 (total of 10 or more indicates high risk for falls), prevention protocol should be initiated and documented in resident's interdisciplinary plan of care. The Assessment indicated Resident #2's risk factors included: poor vision (with or without glasses) [MEDICAL CONDITIONS], anti-hypertensive's medications, balance problems while standing and walking, change in gait pattern, decreased muscular coordination, unstable while turning, and he/she required an assistive device with ambulation. The Facility's Policy titled Alarms and Safety Monitoring Devices, undated, indicated assess residents for appropriateness of using a personal alarm or monitoring device in bed and wheelchair, and alarms will be checked for placement and functioning each shift. The Nurse's Note, dated 11/05/16, indicated Resident #2 was sitting in wheelchair by nursing station, he/she made several attempts to get up without assistance, was unable to be redirected, was combative with staff, and disruptive on unit. The Note indicated, the Director of Nurses was informed of Resident #2's behaviors and continued safety concerns, and Resident #2 will moved to another unit so his/her safety can be maintained. The Nurse's Note, dated 11/06/16, indicated Resident #2 made several attempts to transfer and ambulate on his/her own, was redirected to wait for assistance, bed and chair alarms to be in place at all times. Resident #2's physician's orders [REDACTED]. Resident #2's Activity of Daily Living Plan of Care Card (provides information on individual resident care and safety needs for Certified Nurse Aides), undated, indicated Resident #2's safety measures included; bed and chair alarms, non-skid strips at bedside to bathroom, and wedge cushion for wheelchair. The Fall Risk Assessment, updated 11/07/16, indicated Resident #2's total fall risk score was 16, additional risk factors included intermittent confusion and history of 1 to 2 falls in the the last three months. Resident #2's Plan of Care for Falls, dated 11/07/16, indicated interventions included; chair alarm when out of bed, verbal reminders not to transfer and/or ambulate without assistance, assure floor is free of glare, liquids, foreign objects, environment free of clutter, proper well maintained footwear, and non-skid strips placed by bedside The Fall Risk Assessment, updated 11/15/16, indicated Resident #2's total fall risk score was 17, with an additional risk factor of ambulatory and incontinence noted. Resident #2's Plan of Care for Falls, updated 11/15/16, indicated additional intervention included; Resident #2 to be toileted and up in wheelchair prior to breakfast. Resident #2's Treatment Administration Record (TAR), dated 12/01/16 through 12/31/16, indicated chair alarm on at all times while in chair. The Fall Risk Assessment, updated 12/12/16, indicated Resident #2's total fall risk score was 21, due to a history of three or more falls in the last three months. Resident #2's Plan of Care for Falls, updated 12/19/16, indicated additional interventions included: wedge cushion for wheelchair, neurology consult, and psychiatric services to follow resident. The Nurse's Note, dated 12/30/16 at 2:35 P.M., indicated Resident #2 was found face first on the ground out by the nurses station by a Certified Nurses Aide (CNA). The Note indicated, Resident #2 was not responding to commands, CNA called for help, Resident #2 became responsive, and stated he/she was going for a walk at the time of the incident. The Note indicated, Resident #2 was observed to have a bump of the right side of his/her forehead, denied having pain to his/her head or any where else, 911 was initiated, and Resident #2 remained unmoved until emergency medical services arrived. The Situation Background Appearance and Review (SBAR) Communication Form, dated 12/30/16, indicated Resident #2 fell while self ambulating, struck his/her head on the floor, and complained of right upper and lower extremity pain, and back pain The Incident/Accident Report, dated 12/30/16, indicated at approximately 2:00 P.M., Resident #2 experienced an unwitnessed fall from his/her wheelchair and was observed lying prone (flat, face down) on the floor in front of the nursing station. The Report indicated, there were no safety devices or alarms on Resident #2's wheelchair at the time of the fall. The Report indicated, contributing factors included Resident #2 frequently tried to get up out of the wheelchair. Resident #2's TAR, dated 12/30/16, indicated his/her wheelchair alarm was documented as being in place on the day shift. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 12:00 P.M., on 3/13/17. CNA #2 said on 12/30/16 she worked the day shift that Resident #2 was on her assignment and said Resident #2's wheelchair did not have an alarm on it. CNA #2 said at approximately 1:30 P.M., she heard Resident #2 fall and went to check on him/her. CNA #2 said she did not put an alarm on Resident #2's wheelchair, said she did not know Resident #2 required an alarm. CNA #2 said she did not review Resident #2's Plan of Care Card, said she did not get report from the nurse that Resident #2 required a wheelchair alarm. The Surveyor interviewed Nurse #1 at 12:18 P.M., on 3/16/17. Nurse #1 said he was the treatment nurse on Resident #2's unit on 12/30/16. Nurse #2 said the treatment nurse was responsible for checking for placement and function of safety alarms Nurse #2 said he documented Resident #2's alarm was in place on 12/30/16, said he visualized it at the start of his shift, but said he could not explain why at the time of Resident #2's fall, why the alarm was not on Resident #2's wheelchair. Nurse #2 said after Resident #2 was transferred to the hospital, he found Resident #2's wheelchair alarm on his/her nightstand, and placed it back on Resident #2's wheelchair in anticipation of his/her return to the facility. On 3/09/17, the Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #2 was discharged from the Facility on 1/04/17. B) The Facility completed new fall risk assessments, dated 1/03/17 through 2/01/17, on all residents. C) The Director of Nurses, Assistant Director of Nurses, Staff Development Coordinator, and Regional Nurse Consultant conducted chart audits, dated 1/03/17 through 2/01/17, on all units. The Audits identified residents who required alarms and those residents were re-evaluated for the continued use and appropriateness of an alarm. The Audits included review and updates to the nursing Plans of Care and CNA Care Cards to assure accurate identification of the type of alarm(s) required and when alarm(s) should be in use by residents. D) The Facility audits identified that the Activity of Daily Living Plan of Care Card, which were kept in the CNA documentation binders were not readily accessible and have chosen to utilize a Kardex system, available at the nursing station. E) The Staff Development Coordinator and Regional Nurse Consultant conducted educational in-services, dated 1/10/17 through 2/28/17, for all licensed staff related to; nursing roles and responsibilities, license staff and supervision of CNA's, physical assessment of a resident post event, unwitnessed falls and neurological assessment requirements, incident/accident reporting, and conducting an event investigation. F) The Facility implemented new CNA Care Card Kardex's for all units and a Safety Station. The Staff Development Coordinator conducted in-services, dated 1/10/17 through 2/28/17, related to the Kardex's and Safety Station. The In-service indicated CNA Care Cards will be maintained in a Kardex (flip file) for easy reference of all staff and that it is the unit nurses' responsibility to update the Care Card with changes in the Plan of Care for the resident. The In-service indicated that the CNA's must review the Care Card at the start of each shift and contact the unit nurse for questions related to inconsistent information on the Care Card. The In-Service indicated the Safety Station will be located in the reception office where additional safety devices will be available for staff to access, including off hours. G) The Staff Development Coordinator conducted mandatory in-services, dated 1/10/17 through 2/28/17, related to Alarms. The In-service material included; at the beginning of each shift licensed staff must go around and check all residents who require alarms on bed and/or chair, licensed staff must check each alarm to make sure it is operating correctly, check that placement of the alarm on bed and/or chair is correct, and complete documentation on alarm sheet. The Assistant Director of Nurses and the Staff Development Coordinator will monitor for compliance. H) The Staff Development Coordinator conducted mandatory in-services, dated 1/10/17 through 2/28/17, related to additional safety measures. The In-service indicated when completing end of shift documentation, CNA's must utilize the apex (open, unobstructed area) between the north and south units which provides better viewing of residents in common areas. I) The Facility will continue to conduct Performance Improvement (PI) meetings to monitor falls, appropriate use of alarms, staff compliance with alarm checks, Plan of Care and Kardex updates, and safety interventions in an effort to reduce falls. The PI Committee will continue to review findings with additional measures implemented as needed.

Based on record review, staff interview and observation, the facility failed to ensure that Residents maintain acceptable parameters of nutritional status, including body weight, for 2 Residents (#8 & #15) of 15 sampled Residents. Findings include: 1. For Resident #15, the facility failed to use the admission weight to complete the initial comprehensive assessment and failed to accurately assess the Resident's significant weight loss in order to implement interventions to promote weight gain. Resident #15 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. The Resident's admission Minimum Data Set (MDS), with an assessment reference date of 7/24/15 and signed as completed on 7/30/15, indicated that the Resident scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) indicating that the Resident was intact cognitively, required set up at meals, was 63 inches tall, weighed 121 pounds, received a therapeutic diet and [MEDICATION NAME] daily. The Resident had a physician's orders [REDACTED]. Review of the weight documentation for Resident #15 indicated the following: 7/20/15-121.2 pounds (#) 7/21/15-123.7 # 7/22/15-121.5 # 7/23/15-122.4 # Review of the facility dietitian's initial/comprehensive assessment dated [DATE], indicated that the Resident's height was 65 inches tall (MDS indicated 63 inches tall) and the weight used for the assessment was 115 pounds, different than the 122 pounds documented on the same date. The dietitian also identified on the assessment that the Resident had a Stage III pressure ulcer, bilateral lower extremely [MEDICAL CONDITION], was independent for eating and had no swallowing issues. The Resident's calorie and protein needs were calculated based on 115 pounds and not on the initial weight of 122 pounds. The dietitian documented that the Resident's intake was adequate to meet the Resident's nutritional needs based on a calculation of 115 pounds. The dietitian initiated a nutrition care plan on 7/23/15 that identified that the Resident had impaired nutrient utilization related to [DIAGNOSES REDACTED]. The interventions included No added salt diet, monitor weights weekly (daily weight were ordered), monitor labs as ordered, document meal % intake, monitor skin condition and notify RD of changes, honor food preferences and dislikes, encourage fluids, [MEDICATION NAME] as ordered. Further review of the weight documentation indicated the following: From 7/23/15 to 8/17/15 Resident #15's weight declined from 122.4# to 111.4#, representing an 11 pound significant weight loss (8.9% loss within 30 days). The Resident weighed 112 pounds at discharge on 8/21/15. There was no documented evidence that the Resident was assessed at the time of the significant weight loss nor were there any interventions put into place to promote weight gain. The facility dietitian was interviewed on 7/18/16 at 10:00 A.M. and said that she should have used the admission weight of 121 pounds, but could not identify where she obtained the 115 pound weight used in the comprehensive nutritional assessment. She also said she could not recall why she did not assess the weight loss.

Based on record review and staff interview, the facility failed to ensure that Residents received adequate supervision and assistance devices to prevent falls for 1 (#15) of 15 sampled Residents. Findings include: For Resident #15, the facility failed to implement an identified intervention (bed alarm) for the Resident who had a fall with injury. Resident #15 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. The Resident's admission Minimum Data Set (MDS) signed as completed on 7/30/15, indicated that the Resident scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) indicating cognitively intact, required extensive assistance for transfer and ambulation with physical assist of 1 person, was identified as not steady during transition and walking and only stabilize with staff assistance and requiring a walker or wheelchair for mobility. The Resident was identified as incontinent of bladder and had fallen at home prior to admission. Review of the Interim/admission care plan, dated 7/17/15, indicated that the Resident had potential for falls. Approaches included: -keep call bell in reach -orthostatic precautions -encourage use of call light -encourage participation in supervised activities -instruct on safety measures -physical therapy referral -mobility alarm (bed alarm) -assess Resident's foot wear. The Resident had a physician's orders [REDACTED]. The medication nurse completed a Fall Risk Assessment on 7/19/15, which indicated that the Resident was at high risk for falls. A second care plan dated 7/20/15 was generated by the physical therapist indicated that the Resident was at risk for falls due to a decreased functional mobility secondary to decrease strength, decreased endurance, falls, decreased cognition and decrease safety awareness. The approaches included physical therapy 5-6 times a week, for 4 weeks. Review of the Resident/Family Education Record in the clinical record indicated on 7/20/15 at 9:30 A.M., the nurse documented that she attempted to orient the Resident to the call bell system and pt is very confused, doesn't know why he/she is here. Review of the nurses' notes and the facility investigation indicated that the resident sustained [REDACTED].M. It was documented that two nurses heard a noise from Resident #15's room and upon entering observed the Resident sitting on the floor. The Resident was observed to have a hematoma on the left side of the forehead. The Resident's HCP was called and requested that the Resident remain at the facility and be monitored, the MD agreed. At 9:30 A.M. the Resident began to complain of left hip pain. An X-ray was obtained and showed a fracture of the greater trochanter. The Resident was sent to the emergency room and returned the same day with a [DIAGNOSES REDACTED]. Review of the facility internal investigation first identified that the Resident had removed the bed alarm and placed it on the chair, however further review of the investigation indicated that on 8/10/15 the 11-7 nurse had documented in a statement (regarding the fall of 8/5/16) that a 11-7 Certified Nurse Aide (CNA) had removed the pad alarm from the Resident's bed and placed it on the Resident's wheel chair and not the Resident. The CNA saw that the Resident was sleeping soundly so the CNA left the Resident in bed but failed to put the alarm back on the Resident's bed. The alarm remained on the wheel chair. As a result, when the Resident got out of bed there was no alarm to warn the staff that the Resident was out of bed unattended and subsequently fell . Interview with the Director of Nurses on 7/14/16 at 2:00 P.M. reviewed the incident with the surveyor and said that the CNA failed to put the pad alarm back on the bed when the Resident remained in bed sleeping.

Based on observation, record review and staff interview, the facility failed to ensure that 1 (#4) sampled Resident, in a total sample of 15 Residents, received appropriate treatment and services to increase range of motion (ROM) and prevent avoidable contractures. Findings include: Resident #4 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the 6/23/16 significant change Minimum Data Set (MDS) assessment indicated that the Resident was cognitively impaired and required extensive assistance from facility staff for all activities of daily living (ADL). The Resident was coded as not having contractures. During Medication Administration Observation for Resident #4 on 7/13/16 at 9:10 A.M., the Resident complained to the Medication Nurse #1 that he/she had 10 out of 10 left knee pain and was administered [MEDICATION NAME] (narcotic). Medication Nurse #1 said that the Resident had new complaints of left knee pain for the past couple weeks. At the time of the Medication Administration Observation the Unit Manager and a CNA (who had finished providing care) were observed repositioning the Resident on his/her back in preparation for the medication administration. The Resident was observed lying on his/her back with the left knee pulled up toward his/her chest. Review of the clinical record and the Medication and Treatment Administration Records (MAR/TAR) on 7/13/16 indicated that Resident #4 was assessed and received pain medication for a new complaint of 10/10 left knee pain with effective relief on 7/6/16, 7/7/16, 7/9/16, 7/10/16, 7/12/16, and 7/13/16. There was no documented assessment in the clinical record that the Resident had any contractures. On 7/15/16 at 9:50 A.M. the Physical Therapist (PT) and Occupational Therapist (OT) were interviewed. Both Therapists' said that they began working at the facility in April and have never been asked to screen Resident #4. The PT said that the last time that the Resident was on active case load was in September 2015 and was not observed with contractures. The Surveyor asked how they (therapy staff) would be made aware if a Resident was developing contractures or other functionality issues. The PT said that they are made aware during Quality of Life Rounds held every Thursday with the Director of Nurses (the Unit Managers do not attend) and Director of Activities or via a nursing request for a rehabilitation screen. On 7/15/16 at 10:30 A.M., the Resident's primary CNA #1 was asked about the care that she provided for Resident #4. CNA #1 said that the Resident is totally dependent for care and that she washes and dresses the Resident and drains the urinary catheter at the beginning and end of the shift. CNA #1 said the Resident is transferred out of bed using a mechanical lift and requires positioning. CNA #1 was asked about the Resident's left knee mobility said that he/she has been complaining of left knee pain and was unable to straighten the knee for weeks. CNA #1 said that the Nurses are aware that the Resident cannot straighten his/her knee. CNA #1 was asked if she provides any ROM exercises for the Resident's extremities said no. The current CNA care card (which provides care guidance to Certified Nurse Aide staff) was reviewed with CNA #1. The care card failed to identify that Resident #4 had contractures. No range of motion exercises were identified to be completed by the CNA staff. The Surveyor observed CNA #1 provide assistance with care on 7/15/16 at 10:35 A.M. Resident #4 was observed with the left knee pulled upward toward his/her chest and the right leg flexed at the hip. The Resident was asked by the CNA to straighten the left knee and and attempted to so and was unable. The Resident said that it hurt. The Resident was asked by the Surveyor if staff exercised his/her legs and the Resident said no. On 7/15/16 at approximately 2:30 P.M., the Surveyor observed Resident #4's wound treatment completed by the Wound physician. During this observation the Resident was observed positioned on his/her side for wound care with the left knee pulled up into the chest. The physician was asked how long the Resident's knee was contracted and he said a few weeks. On 7/18/16 at approximately 3:00 P.M., the Director of Nurses (DON) and the Regional Nurse were interviewed and asked about the Resident's contractures. The DON provided a Care Plan for Mobility (not previously observed in the record) with an initial date of 3/16/16 and last reviewed 6/29/16 that indicated that the Resident had impaired mobility related to contractures on the bilateral lower extremities (BLE). Interventions included: - PT/OT as ordered (no request for screen per interview with PT) - Assess/monitor/report: contracture, pain, weakness, immobility, swelling and weight loss (No assessment of the Resident's BLE contractures identified in the clinical record) - Assess/monitor/provide wheel chair - Gentle ROM to BLE with AM care (not completed per interview) - Hospice CNA to assist with mobility and ROM as necessary (the resident was not on Hospice) The Surveyor asked the DON when the bilateral contractures developed and said that she would need to check. The DON was unable to explain when the Resident was last screened by therapy.

Based on record review and interviews, the facility failed to ensure for 1 Resident (#8) in a total sample of 15, that the Resident received appropriate treatment and services to restore as much bladder function as possible. Findings include: For Resident #8, the facility failed to follow the Urologist's recommendations, a straight catheter was reinserted, and the Resident developed a urinary tract infection. Resident #8 was admitted to the facility 4/2016 with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment with a reference date of 4/23/16, indicated that the Resident was cognitively impaired and was dependent on facility staff for most activities of daily living and had a catheter. Review of the 4/19/16 hospital discharge summary indicated that the resident had a Foley catheter in place because he/she had failed a voiding trial twice. The summary indicated a repeat voiding trial can be tried in a week or so, especially if his/her mobility improves. Review of the clinical record indicated that on 4/25/16 the evening shift nurse indicated that the Resident was visited by the physician who wanted the Resident seen by the Urologist, as soon as possible, due to the failed voiding trials at the hospital. On 4/26/16 the day shift nurse's note indicated that the Urology appointment was scheduled for 5/5/16. Review of the 5/5/16 night shift nurse's note indicated that the Resident's Foley catheter was removed at 5:00 A.M. as ordered prior to the Urology appointment scheduled at 12:10 P.M. that day. Review of the 5/5/16 Urologist report indicated that the Resident reported he/she was doing fine until a month ago when he/she developed shingles that affected ambulation. The Urologist indicated that [MEDICAL CONDITION] developed in the context of shingles associated with constipation. Both are better now. Patient so far is unable to void (following catheter removal) but PVR (post void residual measured by a bladder scan machine) only 237 cc's (cubic centimeters) and the patient is comfortable. I will recommend waiting till the bladder is fuller before we replace the catheter, Will give another 4 to 6 hours to try and spontaneous voiding. I will see him/her again if the catheter needs to be replaced. The Urologist recommendations included: Replace Foley only if unable to void associated with pain or if PVR is larger than 500 cc's. On 5/6/16 the day shift nurse reported that the Resident's catheter was discontinued the previous day and that the Resident did not void overnight. The nurse indicated that fluids were encouraged with poor effect. The Nurse completed a straight catheterization (without a physician order) and obtained 400 cc of hematuria (bloody urine).The Resident was not assessed with [REDACTED]. There was no documented explanation why the nurse staff completed a straight catheterization of the Resident in the absence of pain or a bladder scan for PVR's of greater than 500 cc's (as ordered). On 5/7/16 the day shift nurse indicated that the resident had very poor fluid intake and that the Resident had not voided. The nurse indicated that there was no abdomen distention or pain. Per the treatment administration record (TAR) The nurse indicated that she attempted to straight catheterize (without an order) many times and the resident refused. The physician was called. According to the 5/7/16 evening shift nurse's note the physician visited (no progress note was available) and was aware of urine retention. The physician gave new orders to straight catheterize the Resident daily if the urine output is less than 400 cc's. Review of the 5/8/16, 5:30 P.M. nurse's note indicated that the resident had no output since 1:00 P.M. and continues with poor fluid intake. No pain was reported. The nurse indicated that a urine analysis was positive and a urine culture was pending. The nurse also indicated that the physician was called because there were two orders in the chart, one to straight catheterize if less than 400 cc and another to replace the catheter if the resident was unable to void. A covering Nurse Practitioner (NP) returned the call and indicated if the Resident had no urine output for 6 hours to straight catheterize. If urine output greater than 250 cc's leave the catheter in. On 5/8/16 at 6:50 P.M. the Resident was catheterized with more than 250 cc's (no exact amount was recorded) and the catheter was left in. Review of the 5/10/16 evening shift Nurse's note indicated that the physician was called about the urine culture and the physician gave new orders to begin the antibiotic, [MEDICATION NAME] for five days for treatment of [REDACTED]. Unit Manager #3 was interviewed on 7/18/16 at 11:00 A.M. and asked why the Urologist's recommendations were not followed, The Unit Manager could not explain. UM #3 was asked if a bladder scan was available to measure PVR's, she said yes it is now but could not explain when the machine was made available for Resident use. On 7/19/16 at approximately 11:00 A.M. the physician was interviewed. The physician was asked about the Urologist's 5/5/16 recommendations. The physician said that the recommendations were not implemented as ordered because the facility had no machine (bladder scanner) to record the post void residuals. The physician said that the Resident had been treated for [REDACTED].

Based on record review, staff interview and observation the facility failed to provide timely treatment and effective interventions for a Resident that developed an avoidable pressure wound for 1 (#12) of 3 sampled Residents with pressure sores, from a total sample of 15 Residents. Findings include: Resident #12 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) signed as completed on 4/11/16, indicated that the Resident had BIMS score of 15 of 15 indicating that the Resident was cognitively intact, required extensive assistance for bed mobility and transfer with assist of two people, had limited range of motion in lower extremities and used a wheel chair for mobility. The MDS also identified that the Resident was at risk for developing a pressure area and had a pressure relieving device in the chair and bed. Review of the Norton Plus Skin Risk Assessment, dated 4/6/16, indicated that the Resident was at moderate risk for developing a pressure area with a score of 11. Review of the nurse's note dated 4/14/16 at 9:09 A.M., indicated that the Resident received new bilateral KAFO (Knee ankle foot orthotic) braces to replace the previous orthotic's that were not working properly. The Resident had received Physical Therapy (PT) services starting 4/21/16 and was discharged from service on 5/20/16. The PT documented that the Resident was recently fitted for a Bilateral KAFO braces and was tolerating wearing the braces for 8 hours a day without redness, swelling or discomfort. There was no documented evidence that staff were trained about the plan to don/doff the braces in order to ensure carry over of services. The nurse documented on 5/31/16 at 4:29 P.M. that the Resident was transferred to the South unit. On 5/31/16 at 11:50 P.M. Unit Manager (UM) #2 documented that the Resident had developed a circular area to the side of the left thigh with a beefy red center with pale yellow slough, edges dark, drainage sero sang, no odor. No wound measurements were recorded at this time. The MD was notified and a new order for a treatment was obtained. The MD also requested that the wound physician be contacted. A new care plan was developed on 5/31/16 identifying a new Stage II pressure ulcer located on the left back thigh. The approaches (interventions) included: -turn and reposition with device at least every two hours as tolerated by Resident -keep clean and dry -treat as ordered -notify MD if treatment ineffective -report signs and symptoms of infection -dietary to assess protein, calories, vitamins and mineral supplements -air mattress in place -bilateral braces as ordered -wound MD consult and PT eval as needed. No other assessment of the Resident's pressure ulcer status was completed until 6/8/16 when the Unit Manager (UM) #2 completed a Body Check Observation Report (weekly skin assessment). The UM indicated that the Resident's skin was warm, dry, normal color, normal skin turgor with a left thigh abrasion (not a pressure ulcer as previously assessed), with no drainage or signs and symptoms of infection. On 6/10/16 the Wound physician evaluated and identified that Resident #12 had a stage II pressure wound measuring 1.5 X 13 X 0.1 cm (centimeters) to the left posterior thigh. The physician also documented that the area had macerated tissue (due to excess moisture) and moderate serous drainage. The physician documented that he spoke with nursing and PT staff to evaluate the pressure applied by the KAFO brace and the need for foam padding. There was no documented evidence that foam padding was previously considered by facility staff. On 6/22/16 UM #2 completed a weekly skin assessment and again indicated that the back of left thigh area was healing, with no drainage or signs and symptoms of infection. On 6/24/16 the Wound physician saw the Resident again and identified that there was no change to the pressure wound and to continue the treatment. On 6/29/16 the Unit Manager completed a weekly skin assessment and documented no change in assessment. The UM provided no measurements of the Resident's wound (the UM indicated in interview on 7/13/16 at 1:00 P.M. that she completes measurements of the wounds on a weekly basis). The Resident was not seen by the Wound physician on 7/1/16. On 7/6/16 the Unit Manager documented on the weekly skin assessment for Resident #12 that the left thigh was scabbed over, no drainage or signs or symptoms of infection. (There were no additional assessments of the wound between 6/29/16 and 7/6/16.) On 7/8/16 the Wound physician documented that the Resident's wound was now documented as a Stage III wound measuring 2 X 2 X 0.3 cm with moderate serous drainage which required debridement and a change in the wound care treatment orders to add the [MEDICATION NAME] agent Santyl daily. The physician recommended that the physical therapist evaluate the brace for padding (this is the second time the physician recommended paddding to the brace) to relieve undue pressure as the Resident gets out of bed and then sits most of the day. On 7/11/16 the Physical Therapy Aide (PTA), not a licensed PT, assessed the Resident's brace and documented that the Resident agreed with the plan to adjust padding on left brace secondary to skin complications (a stage III pressure wound). There was no indication who was responsible for adjusting the padding and no documented evidence that training was provided to staff. Review of the Nurse's notes on 7/11/16 failed to identify any of the recommendations made by the PTA. During unit tour on 7/12/16 at 8:30 A.M. UM #2 identified that Resident #12 had a stage I (and not a stage III as previously identified) on the left back thigh secondary to pressure from the leg brace and was being seen by the Wound physician. The Unit Manager said that the Resident did not always like to remove the brace while sitting in the wheel chair. On 7/12/16 at 11:20 A.M., the day shift nurse documented that the Resident was seen by the PT who recommended for the Resident to only wear bilateral braces during transfer and ambulation and to remove them (to relieve pressure) while in bed or in the wheel chair. On 7/15/16 at 9:50 A.M. the PT was interviewed and said that when the Resident had worn the brace 24 hours a day it produced pressure on the thigh and since the brace is off, except when transferring, the area is improving. On 7/15/16 at 3:00 P.M. the Wound physician was interviewed and said that the wound had developed due to pressure on the thigh from the brace. The Physician said that he recommended padding/foam with no result from recommendations made on 6/10/16. The physician stated that he made a second recommendation for padding on 7/8/16 and the padding was adjusted sometime after that. The physician said that the Resident agreed to remove the brace while in bed or in the wheel chair. The physician said that the area looked better that day.

Based on record review, observation, resident and staff interviews, the facility failed to ensure that 1 resident (#9), in a total sample of 15, received adequate supervision and effective interventions to prevent 10 skin tears in 8 months. Findings include: Resident #9 was admitted to the facility in may 2013 with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) assessment dated [DATE], the resident was alert and oriented, and required extensive assistance of staff for transfers, ambulation, dressing, locomotion on and off the units, toilet use and personal hygiene. The MDS indicated the resident had not fallen, was incontinent of bowel and bladder and did not have any skin problems. The medical record was reviewed on 6/30/14. The record indicated from 11/1/13 through 6/26/14 the resident sustained [REDACTED]. The facility had implemented an interim plan of care for actual skin impairment dated 6/23/14 and updated on 6/26/14. The care plan indicated the resident has three skin tears. One skin tear was identified on 6/23/14, on the right elbow and the 2 others were on the the left forearm and the right forearm. The plan of care indicated that the resident had a history of [REDACTED]. The goals were to heal the skin tears, to be free of symptoms of infection, to not have pain and to be free of further skin integrity issues. The interventions included assistance with mobility and transfers as needed, provide incontinence care as needed, ensure proper body alignment, diet as order and promote intake, observe skin condition with daily care and report any changes and report to physician for orders to treat as indicated, keep skin clean and dry, monitor laboratory results as ordered, weekly review by skin team. There were no interventions that addressed the prevention of skin tears for this resident. Further record review indicated the resident had sustained the following skin tears: 1. On 11/1/13, the treatment administration record indicated that the resident had two skin tears, one to the left calf and the second to the left forearm that were resolving. There was no analysis as to how these skin tears developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. 2. On 12/17/13 and 12/18/13, the nurses notes indicated that a physician's orders [REDACTED]. There was no analysis as to how these skin tears developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. 3. On 1/18/14, the nurse's note indicated the certified nursing assistant notified the nurse of a left forearm skin tear. The skin tear was 8.5 cm (centimeter) long. The physician was notified and ordered a xerofoam gauze and protective covering was obtained to treat the actual skin tear. There was no analysis as to how this skin tear developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. 4. On 3/5/14 at 4:30 P.M., the resident sustained [REDACTED]. The area required steri strips and a dressing. The incident/accident report did not indicate any further investigation or education, only that the resident refuses interventions. 5. On 4/14/14, the nurse's note indicated identifying a skin tear to the left lower arm. The nurse's note indicated it was below a skin tear the resident had sustained on 3/5/14. The skin tear was documented as 3 inches long and requiring steri strips. There was no analysis as to how this skin tear developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. 6. On 6/23/14, the nurse's note indicated the resident was being transported via wheelchair at 3:00 P.M. and staff noted a skin to the right elbow. The skin tear was 4 cm by 4 cm. The nurse obtained physician orders [REDACTED]. There was no analysis as to how this skin tears developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. 7. On 6/26/14, the clinical record indicated that the resident had two skin tears one on the left and the other on the right forearms. The areas were added to the plan of care, but the record failed to identify when the skin tears had occurred. There was no analysis as to how these skin tears developed, how to prevent further skins from happening and no interventions were put into place to reduce the reoccurrences of skin tears. During observation on 6/29/14 at 1:30 P.M., the resident was brought out in a wheelchair and placed in the hallway. The resident was seated in the hallway approximately 3 minutes when he/she called to a staff and asked to be brought back to his/her room. The staff brought the resident to the room and the resident was observed seated in wheelchair and looking out the window. The resident had on a sweater and two gauze protective covering were observed on the resident's right and left forearm. The resident was calm and was not observed moving his/her extremities about. On 6/30/14 at 8:30 A.M., the resident was in room and was being fed breakfast by the staff. The resident's arms were under the blankets. During interview on 6/30/14 at 2:00 P.M., the Director of Nurses said she did not have all the accident/incident reports for all the skin tears. She was able to provide reports for 1/18/14, 3/5/14 and 6/23/14, but not for the 11/1/13, 12/17/13, 12/18/213, 4/14/14 and 6/26/14 skin tears. Review of the incident/accident reports indicated that the staff did not know the cause of the skin tears that had been identified on 1/18/14 and 6/23/14, but indicated the 3/5/14 skin tear occurred while the staff were boosting the resident in bed. None of the incident/accident reports indicated a change to the plan of care and no interventions were implemented to prevent further skin tears. The 1/18/14 and 3/5/14 report indicated the resident "refused any interventions," but did not indicate what the resident refused. During interview on 7/1/14 at 10:10 A.M., the resident was in his/her room alone. The surveyor observed gauze on the resident's left forearm, but could not see the right. The resident engaged in conversation and said his/her skin was fragile and during care he/she would get some of the skin tears. The resident said he/she was not disagreeable to protecting his/her skin as he/she was "old" and did not need any more problems. During interview on 7/1/14 at 11:00 A.M., the Staff Developer said the resident refused interventions. The surveyor inquired what the resident had refused and the Staff Developer said Geri-sleeves. During a subsequent interview on 7/1/14 at 11:10 A.M., the surveyor discussed the skin tears with the Director of Nurses. She said that there was not any more information to review. She said she could not locate a number of the incident/accident reports and investigations for all the skin tears. She said that she could not locate information that showed evidence that the facility staff had identified environmental hazards that could have caused these skin tears, evaluate the causes of these skin tears and implement interventions to reduce further skin tears.