Every finding on record at Royal Wood Mill Center

Based on observations, interviews, and record review, the facility failed to provide services that meet professional standards of quality as evidenced by failing to implement physician's orders for one Resident (#30), out of a total sample of 23 residents. Specifically, for Resident #30, the facility failed to implement a physician's order to administer Pyridostigmine Bromide (a medication to treat orthostatic hypotension/low blood pressure).Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #30 was admitted to the facility in March 2026 with diagnoses including hypertension (high blood pressure), orthostatic hypotension (blood pressure drops abnormally when a person moves from lying or sitting to standing), and chronic kidney disease.Review of the most recent Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident #30 had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.Review of Resident #30's active physician orders, dated 3/10/26, indicated: Pyridostigmine Bromide Oral Tablet 60mg (milligrams). Give 60mg by mouth four times a day for postural orthostatic. Scheduled for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.During an interview on 8/24/26 at 8:38 A.M., Resident #30 said he/she has not been receiving his/her Pyridostigmine blood pressure medication daily and said he/she did not receive it this morning and has not had his/her blood pressure taken since yesterday.Review of Resident #30's Electronic Medication Administration Record (EMAR) indicated the medication was not administered and contained the following documentation:3/24/26 8:00 A.M., 9=Other / See Nurse Notes.Review of the Nursing Progress notes dated 3/24/26, indicated the following: Pyridostigmine Bromide Oral Tablet 60mg unavailable from pharm (pharmacy) MD aware N.N.O (no new orders).During an interview and observation on 3/24/26 at 12:21 P.M., the surveyor asked to see Resident #30's Pyridostigmine Bromide medication. Nurse #1 removed the bottle of Pyridostigmine Bromide from the medication cart. The bottle was dated as dispensed 3/10/26 and was open.During an interview on 3/24/26 at 12:24 P.M., Nurse #1 said she did not administer the scheduled 60mg of Pyridostigmine at 8:00 A.M., because the Resident had low blood pressure not because the medication wasn't available and said she must have documented it incorrectly in the EMAR (Electronic Medication Administration Record). The surveyor then asked to see the documented blood pressure and parameters for withholding the blood pressure medication and Nurse # 1 said she has been a nurse for a while and knows that a blood pressure medication shouldn't be given if the blood pressure is too low and said Resident #30's blood pressure was 94/68 at 8:00 A.M. Nurse #1 said there are no parameters in place for holding the medication and she just knows not to give it. Nurse #1 said she spoke to the Medical Director this morning and notified her that Resident #30's blood pressure was low and that the medication was not administered.Review Resident #30's Medical Record indicated the last documented blood pressure was dated 3/23/26 and was 113/74.During an interview on 3/25/26 at 11:16 A.M., the Medical Director said Resident #30 should have been administered the 8:00 A.M., medication and said she was not aware of the medication not being administered yesterday morning due to low blood pressure. The Medical Director said she received a call yesterday afternoon about adding blood pressure parameters and said the Resident's blood pressure must be checked prior to administering the medication and documented in the medical record. The Medical Director said she was not aware of blood pressure parameters not being in place and said staff should have been checking the blood pressure prior to administration. During an interview on 3/25/26 at 12:24 P.M., the Director of Nurses (DON) said Nurse #1 should not have withheld the medication and should have contacted the physician for parameters. The DON said she would expect orders to be in place for monitoring blood pressures with parameters prior to administration and said Nurse #1 should not be withholding a blood pressure medication without notifying the physician and should not document that the medication was not available when it was available for administration.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, with known behaviors of being intrusive and rummaging, the Facility failed to ensure they provided an environment free from accident hazards, when Resident #1 was able to get a hold of and consumed an object not meant for human consumption.Findings include:The Facility Policy, titled Safety and Supervision of Residents, dated as revised 05/2025, indicated the Facility would strive to provide an environment as free from accident hazards as possible, and resident supervision was a core component of the systems approach to safety.The Facility Policy, titled Meal Supervision and Assistance, dated 01/2025, indicated residents would be provided meals in the location of his/her preference and with adequate supervision and assistance to prevent accidents.Resident #1 was admitted to the Facility in November 2012, diagnoses included stroke, schizophrenia, anxiety, and dementia.Review of Resident #1's Activities of Daily Living (ADLs) Care Plan, dated as initiated 03/27/24 and renewed with his/her Quarterly Assessments on 12/03/25, indicated he/she required supervision when eating.Review of Resident #1's Behavior Care Plan, dated as initiated 11/20/20 and renewed with his/her Quarterly Assessments on 12/03/25, indicated he/she had known behaviors of being intrusive and rummaging.Review of Resident #1's Health Status Note, dated 01/28/26, indicated he/she was found unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by nursing, and he/she was transferred to the Hospital Emergency Department via 911.Review of the Ambulance Run Report, dated 01/28/26 indicated 911 paramedics continued CPR, applied the LUCAS device (robotic device that performs chest compressions) and that when intubation (tube inserted into the airway) was attempted, a foreign body was removed from Resident #1's airway which appeared to be a piece of plastic wrap with some food product wrapped up inside it. The Report indicated resident suffered sudden cardiac arrest (witnessed by roommate, who reported resident stood up, vomited and fell forward to floor).During an interview on 03/09/26 at 11:16 A.M., Certified Nurse Aide (CNA) #1 said that on 01/28/26 Resident #1 wanted to have lunch in his/her room, so she assisted him/her to eat in his/her room. CNA #1 said Resident #1 was tired that day, became drowsy as he/she ate, said he/she did not want to eat anymore. CNA #1 said she moved his/her food tray which was on his/her tray table out of his/her reach by pushing it across the room. CNA #1 said she removed all covers and any wrappings from the food from the room and left the room to assist another resident. CNA #1 said Resident #1 was not coughing or having any issues swallowing at breakfast or lunch that day and had no problem talking or communicating with her. CNA #1 said Resident #1 was not in any distress when she left his/her room.During an interview on 03/09/26, CNA #2 said that on 01/28/26 at 12:20 P.M., she found Resident #1 lying face down on the floor in his/her room and immediately called to nursing for help.During an interview on 03/09/26 at 2:45 P.M., Nurse #1 said that on 01/28/26 at 12:20 P.M., she heard CNA #2 yell for help because Resident #1 was on the floor. Nurse #1 said Resident #1 was lying face down on the floor and there was vomit under him/her. Nurse #1 said Resident #1 was not breathing, had no pulse, Code Blue was initiated and 911 was called. Nurse #1 said when nursing suctioned Resident #1's airway, a white substance was removed that resembled mashed potatoes. During an interview on 03/09/26 at 12:09 P.M., The Director of Nurses (DON) said the Facility was not able to identify exactly where the plastic wrap came from, or when or how Resident #1 was able to get it, because he/she was supervised at all times when eating. The DON said Resident #1 should not have been able to get a hold of or ingest plastic wrap, but somehow, he/she had.On 03/09/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 02/01/26, which addressed the area(s) of concern as evidenced by:A. 01/29/26, the Facility conducted an Ad-Hoc Quality Assurance Performance Improvement meeting, which indicated the Facility Leadership developed an action plan to correct the deficient practice, and ensure that staff would provide continual supervision for all residents who require assistance with meals to prevent choking incidents.B. 01/29/26, the Director of Nursing/designee audited all resident care plans to identify residents who require supervision for meals due to cognitive impairment to ensure supervision is provided.C. 01/29/26, The DON/Unit Managers provided a list of residents who require assistance/supervision to the nursing staff. This practice will be ongoing and updated.D. 01/29/26, The SDC/designee provided education to all nursing staff that residents requiring supervision and/or assistance with meals due to impaired cognition are not to be left alone and that their tray is to be removed when the meal is finished and staff leaves the room.E. 01/30/26, The Facility leadership conducted a Root Cause Analysis to review the findings of their internal investigation, try to determine the cause of the incident, and prevent similar incidents.F. 01/30/26, The Facility removed plastic wrap from the kitchen and replaced it with other forms of food covering.G. The SDC added the protocol for dining supervision and/or assistance to the new nursing staff orientation and annual education.H. The Facility's Administrator educated dietary staff that going forward, plastic wrap will no longer be used, and that alternative covers will be used when food or beverages need to be covered.I. The Administrator, SDC, DON, and Unit Managers will conduct audits on the units daily for two weeks, weekly for four weeks, and then monthly until substantial compliance is achieved to ensure there is no plastic wrap found on the meal trays, and that food is not left with residents who require supervision due to cognitive impairment.J. Results of audits will be presented to QAPI.K. The DON/designee are responsible for ongoing compliance.

Based on observation, record review and interview, the facility failed to ensure medical records were complete and accurate for 4 residents, (#40, #30, #2 and #268) out of total of 20 sampled Residents. Specifically: 1. For Resident #40, the facility failed to accurately document an order and implementation related to oxygen use. 2. For Resident #30 the facility inaccurately documented that they took blood pressures on the correct arm. 3. For Resident #2, the facility inaccurately documented that they applied both seizure pads in the Resident's bed. 4. For Resident #268, the facility inaccurately documented that the air mattress settings were set correctly. Findings include: Review of the Charting and Documentation policy, undated, indicated: Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #40 was admitted to the facility in January 2025 with diagnoses including acute respiratory failure with hypoxia and type II diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #40 is cognitively intact evidenced by a score of 14 out of 15 in the Brief Interview for Mental Status Exam. The MDS also indicated Resident #40 requires assistance with bathing and dressing. Additional review of the MDS indicated Resident #40 was on oxygen therapy. During an interview on 4/6/25 at 7:59 A.M., the surveyor Resident #40 was seated in his/her wheelchair in his/her room not wearing oxygen. Review Resident #40's physicians orders indicated: O2 @ 1-4L /min via nasal cannula continuous to maintain O2 (oxygen) sats (saturations) greater than 90%, initiated 1/14/25. Review of Resident #40's care plans indicated: Focus: The resident requires oxygen therapy r/t (related to) respiratory failure, pulmonary collapse and OSA (obstructive sleep apnea), initiated 1/15/25. Interventions: Oxygen settings: The resident has 02 @ 1-4L/min as ordered. See MAR (Medication Administration Record). On 4/6/25 at 11:46 A.M., the surveyor observed Resident #40 asleep in bed, not wearing oxygen. During an interview on 4/6/25 at 1:08 P.M., Resident #40 was observed in his/her room seated in his/her wheelchair, not wearing oxygen. Resident #40 said he/she doesn't wear oxygen and hasn't since being in the facility. During an interview on 4/7/25 at 8:25 A.M., Nurse #3 said that Resident #40 is on oxygen PRN (as needed). On 4/7/25 at 7:33 A.M., the surveyor observed Resident #40 seated in his/her wheelchair in the lobby area, not wearing 02. During an interview on 4/7/25 at 9:52 A.M., Unit Manager #1 said that Resident #40 utilizes oxygen PRN. Unit Manager #1 and the surveyor reviewed Resident #40's physicians orders and Unit Manager #1 said that the order was transcribed in error and it should be PRN. Review of the January 2025, February 2025, March 2025 and April 2025 MAR indicated nursing staff were signing off on all three shifts that Resident #40 was receiving continuous oxygen daily from admission through 4/7/25; after Unit Manager #1 said that the oxygen order was written incorrectly. During an interview on 4/8/25 at 8:36 A.M., The Director of Nursing (DON) said that Resident #40's oxygen order should have been PRN and nurses should be paying attention to the orders and documenting medications/treatments that are implemented. 43807 2. Resident #30 was admitted to the facility in December 2024 with diagnoses including end stage renal disease, dependence on renal dialysis and an arteriovenous fistula. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 9 out of a possible 15 indicating moderate cognitive impairment. A review of Resident #30's April 2025 physician's orders indicated the following: -No blood pressure on right arm every shift. Start date, 12/9/24. A review of Resident #30's vitals: blood pressure indicated the following: -4/4/25, 9:35 P.M., 150/54 mmHg (millimeters of mercury) (Sitting r/arm). -2/7/25, 5:15 A.M., 134/68 mmHg (millimeters of mercury) (Lying r/arm). -2/6/25, 2:08 P.M., 150/78 mmHg (millimeters of mercury) (Sitting r/arm). -1/17/25 10:46 P.M., 110/60 mmHg (millimeters of mercury) (Lying r/arm). -1/6/25-6:54 A.M., 130/70mmHg (millimeters of mercury) (Lying r/arm). -1/5/25-2:45 P.M., 134/67 mmHg (millimeters of mercury) (Lying r/arm). -1/4/25-12:50 A.M., 116/56 mm/Hg (millimeters of mercury) (Lying r/arm). -1/3/25-1:43 P.M., 110/53 mm/Hg (millimeters of mercury) (Lying r/arm). -1/2/25- 5:50 P.M., 113/57 mm/Hg (millimeters of mercury) (Lying r/arm). -1/1/25- 8:45 P.M., 100/50 mm/Hg (millimeters of mercury) (Sitting r/arm). A review of Resident #30's January 2025 Medication Administration Record (MAR) indicated Nurses documented they took the Residents blood pressure on the left arm on 1/17/25 evening shift, 1/6/25 night shift, 1/5/25 day shift, 1/4/25 night shift,1/3/25 day shift, 1/2/25 evening shift, 1/1/25 evening shift. A review of Resident #30's February 2025 MAR indicated Nurses documented they took the Resident's blood pressure on the left arm on 2/7/25 night shift, 2/6/25 day shift. A review of Resident #30's April 2025 MAR indicated Nurses documented they took the Resident's blood pressure on the left arm on 4/4/25 day shift. During an interview and medical record review on 4/7/25 at 12:47 P.M., the Director of Nurses and Unit Manager #1 said the Nurses document accurately in the medical record. They both said Nurses should not document that they took blood pressures on the left arm when they took blood pressures on the right arm. 3. Resident #2 was admitted to the facility in April 2000 with diagnoses including epilepsy and epileptic syndromes with complex and partial seizures. A review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. A review of Resident #2's April physician's orders indicated the following: -Seizure pads to bilateral side rails. Check placement every shift. Order date, 12/21/22. On 4/7/25 at 7:35 A.M., and 9:40 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail. On 4/8/25 at 3:35 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail. A review of Resident # 2's Treatment Administration Record (TAR) indicated that staff had documented on 4/7/25 day shift and 4/8/25 night shift that the Resident had two seizure pads to bilateral side rails while in bed. During an interview 4/8/25 at 7:40 A.M., the Unit Manager #1 said Nurses should document accurately in the medical record. During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses said Nurses should document accurately in the medical record. The DON said Nurses should not document that the Resident has both seizure pads in bed when they only have one. 4. Resident #268 was admitted to the facility in February 2025 with diagnoses including type 2 diabetes. A review of the Minimum Data Set, dated dated dated [DATE]/5/25 did not indicate a Brief Interview for Mental Status score. Review of the care plan initiated on 2/24/25 indicated the Resident is not able to make their own health care decisions. Review of the care plan initiated on 2/26/25 indicated that the Resident has actual impairment to skin integrity as evidenced by a deep tissue injury to right 4th and 5th toe, deep tissue injury to the right lateral heel, deep tissue injury to the left great toe, 4th and 5th toes and a deep tissue injury to the left heel. Review of Resident #268's April 2025 physician's orders indicated the following: -Air Mattress-Pressure set per resident's most recent weight, plus or minus 10 pounds. Document weight. Check placement and function every shift. Order dated, 3/20/25. Review of Resident #268's most recent weight dated 4/6/25 indicated the Resident weighed 169.8 pounds. On 4/6/25 at 9:40 A.M., the surveyor observed the Resident in bed. The air mattress was set at 210. On 4/7/25 at 9:32 A.M., 12:12 P.M., the surveyor observed the Resident in bed. The air mattress was set at 320. On 4/8/25 at 3:36 A.M., the surveyor observed the Resident in bed. The air mattress was set to 320. A review of Resident # 268's Treatment Administration Record indicated that Nurses documented on 4/6/25 day shift, 4/7/25 day shift and 4/8/25 night shift that the air mattress was set per the Resident's weight plus or minus 10 pounds. During an interview on 4/8/25 at 7:51 A.M., the Unit Manager #2 said the Nurses should document accurately in the medical record. During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses said the Nurses should document accurately in the medical record.

Based on observation, record review, the facility failed to provide care in accordance with professional standards of care, and for one Resident (#30) out of a sample of 20 residents, the facility failed to follow physician's orders as indicated. Specifically: 1. The facility failed to ensure staff were awake and alert during the 11:00 P.M. - 7:00 A.M. shift. 2. The facility failed to ensure the nurse checked medications against the physician's order three times when dispensing a medication. 3. For Resident #30, the facility took blood pressures on his/her right arm while the physician's orders indicated not to do so. Findings include: 1. Review of the facility's Employee Handbook dated March 2017 indicated: Hours and Compensation: All employees working a shift of 6 hours or more will be entitled to a paid 15 minute rest break and an un-paid 30 minute meal break. Employees must clock in and out for their allotted meal break. Code of Conduct: As a company team member, employees are expected to accept certain responsibilities, follow acceptable business principles in matters of conduct, and exhibit a high degree of integrity at all times. This not only involves sincere respect for the rights and feelings of others, but also demands that employees refrain from any behavior that might be harmful to themselves, co-workers, residents, the company or that might be viewed unfavorably by current or potential customers or by the public at large. Types of behavior and conduct that the company considers inappropriate include, but are not limited to the following: Sleeping or loitering during working hours. During the Resident Group Interview on 4/7/25 at 11:00 A.M., six participating members reported that staff on the 11:00 P.M. - 7:00 A.M. shift sleep during the night on both the 1st and 2nd floor nursing units. One Resident said that he/she observes staff making beds by placing sheets and blankets over chairs. Another Resident said that they had reported this issue to the Administrative team, and although the incidents have improved, staff are continuing to sleep during the overnight shift. Review of the grievance dated 3/19/25 indicated: Description of Complaint: Staff sleeping. Resident stated these were concerns he/she had previously had but wanted [Administrator] to know. Summary of findings: Resident attended resident council in February and expressed concerns. DON educated staff. Second resident council meeting residents expressed improvement. Corrective Action: Education to be provided by Administrator. Resident assured Administrator will follow up. Resident agreeable to plan although he/she is discharging. Attached to the grievance was an in-service sheet indicating Education topic: Staff are not to sleep on shift. The sheet indicated two nurses and one Certified Nursing Aid (CNA) working the 3:00 P.M. - 11:00 P.M. and one nurse working the 11:00 P.M. - 7:00 A.M. were given the education. Review of the Resident Council Meeting Minutes for January 2025, February 2025 and March 2025 failed to include Resident reported concerns related to staff sleeping on the overnight shift. During an early morning visit on 4/8/25 at 3:00 A.M., the surveyors entered the building and observed the following: Upon entry to the first floor unit a high pitched, loud alarm sounded. The surveyors observed that no staff members responded to the alarm and a surveyor silenced the alarm. The surveyor then observed in the first floor dining room, that all the lights were off and the room was dark. The surveyor then observed CNA#2 with her head down on a rolled up blanket on a table sleeping. The surveyor then observed CNA #3 wrapped up in blankets, sitting in a chair with her feet elevated, sleeping. Upon entry to the second floor unit, no staff was observed at the Nurses station. All the residents were asleep, the surveyor found Nurse #1 and CNA #1 in the dining room sleeping. The dining room was dark, all the lights were turned off. CNA #1 was wrapped in linens and blankets. Nurse #1 was sitting and sleeping in a chair in the corner, she had no linens and blankets covering her. Both CNA #1 and Nurse #1 said they were sleeping because they were on their break. Review of the time cards punches for Nurse #1, CNA #1, CNA #2 and CNA #3 indicated they did not punch out during the 11:00 P.M. - 7:00 A.M., shift at any time for a scheduled break. During an interview on 4/8/25 at 4:19 A.M., the Administrator said that she began her employment at the facility in February 2025. The Administrator said that she believed that concerns related to staff sleeping at night were brought up during the January 2025 Resident Council meeting and were addressed by the Director of Nursing by providing education to staff. The Administrator said that resident's may have brought up the concerns again during the February 2025 Resident Council meeting, but she was not sure. The Administrator said that staff are to punch out when taking their breaks and CNA's should take turns and leave the unit while on break. The Administrator said that nurses are expected to be available 24 hours a day and should not be sleeping while on break. The Administrator said that Nurses and CNA's should not be sleeping on resident units. 36797 2. Review of the facility policy titled Administering Medications, dated August 2024, failed to indicate that the nurse is to check the medications against the physician's orders. During medication pass on 4/7/25, at 8:48 A.M., Nurse #3 told the surveyor that her medication cart computer was broken. Nurse #3 then said that she was stationing her medication cart near the nurse's station because she was using the computer at the nurse's station to pass medications. The surveyor then observed Nurse #3 read from the computer at the nurse's station. Nurse #3 then returned to the medication cart where she dispensed four medications into a medication cup from memory. The surveyor then observed Unit Manager (UM) #1 print out a list of 3 more medications and hand the list to Nurse #3. Nurse #3 dispensed the medications from the list. UM #1 then told Nurse #3 that she could not print out the remaining medications scheduled to be dispensed, wrote them out on a piece of paper and handed the hand written list to Nurse #3. Nurse #3 did not check the hand written note against the physician's orders in the computer for accuracy. Nurse #3 then dispensed the medications from the hand written list that UM #1 had written and administered all of the medications to the resident. During an interview on 4/7/25, at 9:03 A.M., Nurse #3 said that she is supposed to triple check each medication against the physician's order before administering the medications to the resident. Nurse #3 then said that she did not triple check medications while dispensing the medications. Nurse #3 also said that she depended upon UM #1 to accurately write down the scheduled medications and should not have. During an interview on 4/7/25 at 11:19 A.M. the Director of Nursing (DON) said that if a nurse's medication cart computer is not working then she is to print out the Medication Administration Record (MAR) for each resident before preparing the medications. The DON then said that it is the standard of practice for a nurse to check each medication 3 times against the physician's order during the dispensing of the medications to ensure accuracy. 43807 3. Resident #30 was admitted to the facility in December 2024 with diagnoses including end stage renal disease, dependence on renal dialysis and an arteriovenous fistula. A review of the facility policy titled 'Hemodialysis Access Care' dated 5/2023 indicated the following: -Care of AVFs (Arterio-Venous Fistula): -To prevent infection and/or clotting, do not use the access arm to take blood pressure. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status BIMS) score of 9 out of a possible 15 indicating moderate cognitive impairment. A review of Resident #30's April 2025 physician's orders indicated the following: -No blood pressure on right arm every shift. Start date, 12/9/24. A review of Resident #30's vitals: blood pressure indicated the following: -4/4/25, 9:35 P.M., 150/54 mmHg (millimeters of mercury) (Sitting r/arm). -2/7/25, 5:15 A.M., 134/68 mmHg (millimeters of mercury) (Lying r/arm). -2/6/25, 2:08 P.M., 150/78 mmHg (millimeters of mercury) (Sitting r/arm). -1/17/25 10:46 P.M., 110/60 mmHg (millimeters of mercury) (Lying r/arm). -1/6/25-6:54 A.M., 130/70mmHg (millimeters of mercury) (Lying r/arm). -1/5/25-2:45 P.M., 134/67 mmHg (millimeters of mercury) (Lying r/arm). -1/4/25-12:50 A.M., 116/56 mm/Hg (millimeters of mercury) (Lying r/arm). -1/3/25-1:43 P.M., 110/53 mm/Hg (millimeters of mercury) (Lying r/arm). -1/2/25- 5:50 P.M., 113/57 mm/Hg (millimeters of mercury) (Lying r/arm). -1/1/25- 8:45 P.M., 100/50 mm/Hg (millimeters of mercury) (Sitting r/arm). During an interview and medical record review on 4/7/25 at 12:47 P.M., the Director of Nurses and Unit Manager #1 said the Nurses should follow the physician's orders and not take blood pressure on Resident #30's right arm. Ref F842

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically: 1. The facility failed to ensure medication and treatment carts were locked while a nurse was not present and failed to ensure medications were not left unattended on top of the medication cart when a nurse was not present. 2. The facility failed to ensure medications were not left at the bedside for one Resident (#64) out of a total of 20 sampled Residents. Findings include: 1. Review of the facility policy titled Administering Medications, dated August 2024 indicated that during the administration of medications, the medication cart will be kept closed and locked when out of sight of the nurse. Further review indicated that no medications are to be left on top of the cart and all medications must be inaccessible to residents and other passers by. Review of the facility policy titled Storage of medications, not dated, indicated that unlocked medication carts are not left unattended. On 4/6/25, at 7:04 A.M., the surveyor observed the first floor medication carts and a treatment cart open and not in view of the nurse. Nurse #5 then left the area without securing the carts, while the oncoming nurse and 2 residents were in the hallway next to the open carts and had full access to them. On 4/7/25, at 9:08 A.M. the surveyor observed Nurse #4 walk away from the medication cart with an entire card of Rosuvastatin on top of the cart. During an interview on 4/07/25, at 9:08 AM Nurse #4 said she should not have left the card of medicine on top of the medication cart On 4/7/25 at 9:40 A.M., the surveyor observed Nurse #3 seated behind the nurses station. Nurse #3's medication cart was in the hallway, out of view and unlocked and unattended. Nurse #3 then entered the medication room and closed door behind her, while her medication cart continued to be unlocked and unsupervised. Nurse #3 exited the medication room and sat at the nurses station to continue her documentation. Unit Manager #1 arrived on the unit and then secured the medication cart. During an interview on 4/7/25 at 9:46 A.M., Nurse #3 said she did not lock the medication cart when she should have. On 4/7/25, at 10:03 A.M. the surveyor observed Nurse #6 enter a resident's room, on the second floor, to deliver medication. The surveyor observed that Nurse #6 had her back to the medication cart and the medication cart was unlocked. The surveyor also observed that there were two residents standing next to the medication cart, potentially having full access to it. During an interview on 4/7/25 at 10:11 A.M., Nurse #6 said that she should not have left the medication cart unlocked. On 4/7/25, at 10:16 A.M., the surveyor observed a treatment cart unlocked on first floor. 36876 2. Resident #64 was admitted to the facility in August 2024 with diagnoses including malignant neoplasm of unspecified kidney and urinary retention. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #64 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. During an interview on 4/6/25 at 9:18 A.M., the surveyor observed Resident #64 in bed and a cup of pills on his/her dresser. Resident #64 said the nurse had given him/her the medications and he/she told her that he/she would take the medications and then he/she went back to sleep. Review of the Medication Administration Record (MAR) for April 2025 on 4/6/25 at 10:17 A.M. indicated nursing had administered the following medications to Resident #64: HydroCHLOROthiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth in the morning for HTN amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth in the morning for HTN Colace Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day for Constipation Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 0.4 mg by mouth in the morning related to MALIGNANT NEOPLASM OF UNSPECIFIED KIDNEY traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Review of Resident #64's Self Administration of Medications assessment dated [DATE] indicated he/she was not able to administer his/her own medications or store medications at bedside. During an interview on 4/8/25, the Director of Nursing said that medications should not be left at bedside and the nurse should have administered Resident #64's medications.

Based on observation, policy 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. Specifically the facility failed to: 1. Ensure that nursing performed hand hygiene (HH) and changed a wound dressing in accordance of professional standards to prevent infection. 2. Ensure the nurse did not touch medications while dispensing. 3. Ensure personal protective equipment (PPE) was readily available to staff when needed. 4. For Resident #40, the facility failed to implement contact precautions after he/she developed symptoms and tested positive for Clostridioides difficile (C-Diff; a bacterium that causes an infection of the colon, the longest part of the large intestine). Findings include: 1. Review of the facility policy titled Dry, Clean Dressings, dated October 2023 indicated that hand hygiene is to be performed before and after glove changes. Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, dementia and depression. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. During a dressing change on 4/7/25, at 12:14 P.M., the surveyor observed the following: Nurse #4 donned gloves and gathered supplies from the treatment cart. Nurse #4 then doffed gloves and donned gloves without performing hand hygiene (HH) potentially contaminating the new gloves. Nurse #4 then poured saline onto gauze and cleaned the pressure ulcer with potentially contaminated gloves. Nurse #4 then doffed her gloves, went to the treatment cart to obtain skin prep and donned new gloves without performing HH potentially contaminating them. Nurse #4 then opened and applied skin prep to the skin surrounding the wound with potentially contaminated gloves on. Nurse #4 then doffed her gloves and donned new gloves without performing HH. Nurse #4 then continued the the wound treatment. Nurse #4 then doffed her gloves and donned new gloves without performing HH two more times during the application of the wound treatment. During an interview on 4/7/25, at 12:25 P.M., Nurse #4 said that she was supposed to perform HH before and after glove changes. During an interview on 4/7/25, at 1:48 P.M., the Director of Nursing said that HH is to be performed before donning and after doffing gloves. 2. During medication pass on 4/7/25, at 7:30 A.M. the surveyor observed Nurse #8 to open an acidophilus capsule with her bare hands potentially contaminating the medication. During an interview on 4/7/25 at 7:45 A.M. Nurse #8 said that she thought because she sanitized her hands it was ok to touch the pills. During an interview on 4/8/25, at 7:42 A.M. the Director of Nursing said that it is never okay to touch medication with bare hands. 3. On 4/6/25, at 7:04 A.M. the surveyor observed outside of room [ROOM NUMBER], a precaution sign for enhanced barrier precautions. The surveyor also observed that there was no PPE cart in the area for PPE to be readily available to staff when needed. During an interview on 4/08/25, at 7:42 A.M. the Director of Nursing said that it is the expectation that a PPE cart is positioned outside of a resident's room who is on enhanced barrier precautions so that PPE is readily available to the staff when needed. 36876 4. Resident #40 was admitted to the facility in January 2025 with diagnoses including acute respiratory failure with hypoxia and type II diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #40 is cognitively intact evidenced by a score of 14 out of 15 in the Brief Interview for Mental Status Exam. The MDS also indicated Resident #40 requires assistance with bathing and dressing. Review of the Clostridium Difficile (C-Diff) policy, undated, indicated: 9. Residents with diarrhea associated with C. difficile (i.e. residents who are colonized and symptomatic) are placed on Contact Precautions. 10. Residents with diarrhea and suspected C. difficile are placed on contact precautions while awaiting laboratory results. Review of the Nurse Progress Notes indicated: 3/28/2025: Resident reports having diarrhea for days.During 3-11 shift aide reports loose stool x1 will continue to monitor. 3/30/2025: No report of loose stools during shift. Sample picked up from lab. Awaiting further results 4/4/2025: Resident tested positive for C-Diff. [Physician] ordered Vancomycin 125 mg every 6 hrs for 6 weeks. Review of the physicians orders indicated: All staff must adhere to contact precautions (gown and gloves) every shift for precautions, initiated 4/6/2025; 48 hours after Resident #40 tested positive for C-Diff. During observations on 4/6/25 at 7:15 A.M., the surveyor observed Resident #40's room. There were no precaution signs or PPE cart indicating he/she was on precautions. During an interview on 4/6/25 at 7:59 A.M. Resident #40 said that he/she had been ill with C-Diff since last week. During the interview, the surveyor observed Unit Manager #1 place a precaution cart outside of Resident #40's room which included personal protective equipment. During an observation on 4/6/25 at approximately 10:00 A.M., the surveyor observed a sign had been posted outside of Resident #40's room indicating: Contact Precautions; Everyone must clean their hands with alcohol-based hand cleaner or soap and water before entering the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry if providing direct care or coming in contact with resident, resident clothing, bedding, etc. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one resident. Use dedicated or disposable equipment. Clean and disinfect re-usable equipment before use on another person. During an interview on 4/7/25 at 9:52 A.M., Unit Manager #1 said that residents should be placed on contact precautions for C-Diff when symptoms start and when the lab results come back positive. Unit Manager #1 said she did not work on Friday, (4/4/25), when Resident #40's results came back positive. Unit Manager #1 said she put the precaution cart in place, hung the sign and input orders for contact precautions for Resident #40 on 4/6/25; 48 hours after Resident #40 had a confirmed case of C-Diff. During an interview on 4/8/25 at 7:40 A.M., the Director of Nursing (DON) said that residents should be placed on contact precautions when there is suspicion of C-Diff and a lab pending.

Based on record review and interview, the facility failed to report an incident of resident to resident abuse to the state agency for one Resident (#11) out of a total sample of 20 residents. Findings include: Review of the facility policy titled Abuse Policy, undated, indicated the following: - The ED (executive director) shall also notify the appropriate state agency in accordance with the state law. - The results of all investigations must be reported immediately to the ED or his/her designee and the appropriate state agency, as required by state law. Resident #11 was admitted in November 2010 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #11 scored a three out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS indicated Resident #11 has verbal and physical behaviors. Review of the incident report, dated 9/29/24, indicated Resident #11 walked into another Resident's room and slapped the Resident on the side of the face. Review of the healthcare facility reporting system failed to indicate that the incident had been reported. During an interview on 4/7/25 at 8:40 A.M., the Director of Nursing said that she should have reported the resident to resident interaction to the state agency.

Based on record review and interview, the facility failed to thoroughly investigate an injury of uknown origin for one Resident (#18) out of a total sample of 21 residents. Specifically, Resident #18 was found to have a dislocated shoulder and the facility interviewed the staff on the morning shift of the incident, but no other staff that had taken care of Resident #18. Findings include: Review of the policy titled Abuse Policy, undated, indicated the following: -The facility shall take the following steps to prevent, detect, and report abuse, neglect, injuries of unknown source, and misappropriation of resident property. - Where the circumstances of the alleged violation warrants, the DNS or his/her designee, shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, no assumptions. - Interview staff members implicated. - Interview other staff members. Employee should document incident in a written statement. - Interview with resident or resident witnesses. Supervisor to document written statement from resident(s). Resident #18 was admitted in November 2023 with diagnoses including hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #18 scored a 1 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of an incident report, dated 6/20/24, indicated Resident #18 had malpositioning of the right shoulder and pain of a 6/10. An x-ray was completed and it was determined that Resident #18 had a dislocated shoulder. Review of the incident report indicated that two of the certified nursing aides were interviewed regarding the dislocated shoulder on the morning it was discovered. Review of the Resident interview with the social worker indicated that Resident #18 said I fell asleep, and when I woke up my shoulder was in pain. During an interview on 4/8/25 at 1:43 P.M., the Director of Nursing said that when an injury of uknown source occurs, she will typically interview everyone on the shift and would interview staff that were on the schedule days before the event occurred. Review of the incident report failed to indicate that staff were interviewed on any of the shifts from the day or night prior to Resident #18 waking up with pain with a dislocated shoulder. During an interview on 4/9/25 at 8:35 A.M., the Director of Nursing said that she should have investigated and interviewed staff from the shift the night prior to the incident.

Based on interviews and record review, for one of two sampled discharge residents (Resident #67), the facility failed to permit Resident #67 to return following an evaluation in the emergency department (ED) when on 02/10/25, the Facility considered Resident #67 discharged at the time of the transfer. Findings include: Review of the facility policy titled Transfer and Discharge (including AMA), dated revised January 2025, indicated that an emergent section 12 discharge authorizes temporary involuntary hospitalization for up to 72 hours. Further review indicated that the resident will be permitted to return to the facility upon discharge from the acute care setting if the resident's needs can be met by the facility. Resident #67 was admitted to the facility in February 2025 with diagnoses including disorganized schizophrenia, high blood pressure and schizoaffective disorder. Review of the progress note dated 2/7/25, indicated that Resident #67 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the progress notes dated 2/10/25, indicated that Resident #67 was agitated and destroying property inside his/her room, wandering into other resident's rooms and rummaging through their belongings, Further review indicated that Resident #67 left the facility by ambulance at 10:00 A.M. Review of the facility document titled Notice of Intent Not to Readmit Resident Following Hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice (Expedited Appeal), dated 2/10/25, indicated that the move is necessary for your own welfare and your needs cannot be met within the nursing facility. During an interview on 4/6/25 at 11:54 A.M. the Social Worker (SW) said that Resident #67 was not harming her/himself or others. The SW also said that the document titled Notice of Intent Not to Readmit Resident Following Hospitalization or Other Medical Leave of Absence from the Facility with Less than 30 Days' Notice (Expedited Appeal), dated 2/10/25, was transferred with the Resident at the time of discharge to the hospital because the facility considered Resident #67 to be discharged at the time of the transfer to the hospital. During an interview on 4/6/25 at 12:40 P.M., the SW said that no bed hold notice was sent with Resident #67 or given to the brother, who had financial power of attorney, because the facility was not allowing Resident #67 to return to the facility. The SW then said that at no time after the Resident was transferred to the hospital did the facility reach out to the hospital to inquire how Resident #67 was progressing and whether or not the facility might be able to meet the needs of the Resident once he/she was cleared by the hospital for return to the facility.

Based on record review and interview, the facility failed to update the plan of care after an incident of physical abuse for one Resident (#11) out of a total sample of 20 residents. Findings include: Review of the policy titled Abuse Policy, undated, indicated the following: - The facility shall take the following steps to prevent, detect, and report abuse, neglect, injuries of unknown source, and misappropriation of resident property. - ABUSE: unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm. - If the suspected perpetrator is another resident, the DNS (director of nursing services) or his/her designee, shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined. - Where the circumstances of the alleged violation warrants, the DNS or his/her designee, shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, no assumptions. - The ED (executive director) shall also notify the appropriate state agency in accordance with the state law. - The results of all investigations must be reported immediately to the ED or his/her designee and the appropriate state agency, as required by state law. Resident #11 was admitted in November 2010 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #11 scored a three out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS indicated Resident #11 has verbal and physical behaviors. Review of the care plan for Resident #11 indicates the following: - Resident has a behavior problem AEB (as evidenced by): cursing at others, screaming at others, accusatory towards others, verbally intrusive. Grabbing others, kicking others, pushing others, hitting others, physically aggressive toward others, physically intrusive (initiated 11/20/20) - Interventions: * 1:1 monitoring for safety PRN (as needed) (initiated 4/7/25) * Administer medications as ordered. (initiated 11/20/20) * Anticipate and meet the resident's needs to prevent frustration and behaviors (initiated 11/20/20) * Assist the resident to develop more appropriate methods of coping and interacting. Encourage him/her to express his/her feelings appropriately. (initiated 11/20/20) * Caregivers to provide opportunity for positive interaction and attention. Stop and talk with him/her when passing by (initiated 11/20/20) * Explain all procedures to the resident before starting and allow ample time for him/her to adjust to changes (initiated 11/20/20) * Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. (initiated 8/10/23) * Obtain MD ordered lab work when ordered to r/o (rule out) cause of increased confusion/agitation (initiated 9/27/22) * Provide a program of activities that is of interest and accommodates residents status (initiated 2/18/21) Review of the incident report, dated 9/29/24, indicated Resident #11 had walked into another Resident's room and slapped the other Resident on the side of the face. Review of the care plan failed to indicate that it had been reviewed or updated after the incident of abuse. During an interview on 4/8/25 at 1:40 P.M., the Director of Nursing said that it is facility protocol to update the plan of care after a resident to resident incident, but that she probably missed it and said the care plan should have been updated.

Based on record review and interview, the facility failed to follow a physician's order for air mattress settings for three Residents (#49, #17 and #268) out of a total sample of 20 residents. Findings include: Review of the policy titled Prevention of Pressure Ulcers/Injuries, dated May 2023, indicated the following: - Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of the facility policy titled Support Surface Guidelines, dated October 2023, indicated the following: - Any individual at risk for developing pressure ulcers may be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. - Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. - Support surfaces are modifiable. Individual resident needs differ. A review of the operator's manual titled 'Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System, item #14026' indicated the following: -Indications-The Med Aire Melody Alternating Pressure and Low Air Loss Mattress Replacement System, item #14026 is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. 1. Resident #49 was admitted to the facility in January 2022 with diagnoses including Parkinson's disease, dementia and chronic kidney disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #49 is severely cognitively impaired evidenced by a score of four out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #49 requires assistance with bathing and dressing. Review of the Support Surface Guidelines policy, dated October 2023 indicated: Use of a pressure ulcer risk scale such as the [NAME] or Braden Scale to help determine need for and appropriate type of pressure relieving devices. Refer to bed selection algorithm for support surface selection. On 4/6/25 at 7:49 A.M., the surveyor observed Resident #49 asleep in bed. Resident #49 was on an air mattress set at 200 lbs. Review of Resident #49's most recent weight obtained on 4/1/25 indicated he/she weighed 122 lbs. Review of the physicians orders indicated: Air Mattress - Pressure set per residents most recent weight; +/- 10 lbs. Document weight. Check placement and function every shift, initiated 1/28/25. Review of Resident #49's care plans indicated: Focus: Resident has potential for developing pressure ulcers r/t (related to) bowel and bladder incontinence, revised 1/23/23. Interventions: The resident requires pressure reducing devices on bed and wheelchair. Review of Resident #49's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 1/17/25 indicated he/she was at risk for developing pressure ulcers. On 4/7/25 at 7:28 A.M., the surveyor observed Resident #49 asleep in bed. The air mattress was set at 200 lbs. On 4/7/25 at 8:27 A.M., Unit Manager #1 was observed seated next to Resident #49 assisting him/her with the breakfast meal. Resident #49 was laying in bed and the air mattress was set to 200 lbs. Unit Manager #1 said that the air mattress should be set to Resident #49's weight. During an interview on 4/8/25 at 7:38 A.M., the Director of Nursing said that the expectation is for staff to set air mattresses at the correct setting. 41019 2. Resident #17 was admitted in April 2013 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #17 did not participate in the Brief Interview for Mental Status exam, but was moderately cognitively impaired. Review of the MDS indicated Resident #17 is dependent for all activities of daily living and mobility. Review of the most recent wound doctor evaluation, dated 4/2/25, indicated that Resident #17 has an unstageable wound of the left foot. Review of the current physician's orders indicate the following order: -Air mattress- pressure set per resident's most recent weight +/- 10 pounds. Document weight. Check placement and function every shift. Review of Resident #17's weight summary indicated his/her most recent weight, on 4/4/25, was 85 pounds. During an observation on 4/6/25 at 9:37 A.M., Resident #17's air mattress was set to 330 pounds of pressure. During an observation on 4/7/25 at 7:24 A.M., Resident #17 was lying in bed with the air mattress set at 280 pounds of pressure. During an observation on 4/8/24 at 7:54 A.M., Resident #17's air mattress was set to 280 pounds of pressure. During an interview on 4/9/24 at 8:37 A.M., the Director of Nursing said that she would expect staff to follow the physician's orders for air mattress settings. 43807 3. Resident #268 was admitted to the facility in February 2025 with diagnoses including type 2 diabetes. A review of the Minimum Data Set, dated dated dated [DATE] did not indicate a Brief Interview for Mental Status score. A review of the care plan initiated on 2/24/25 indicated the Resident is not able to make his/her own health care decisions. Further review of the care plan initiated on 2/26/25 indicated that the Resident has actual impairment to skin integrity as evidenced by an undetermined thickness deep tissue injury to the right 4th and 5th toe, an undetermined thickness deep tissue injury to the right lateral heel, an undetermined thickness deep tissue injury to the left great toe, 4th and 5th toes and an undetermined thickness deep tissue injury to the left heel. A review of Resident #268's April 2025 physician's orders indicated the following: -Air Mattress-Pressure set per resident's most recent weight, plus or minus 10 pounds. Document weight. Check placement and function every shift. Order dated, 3/20/25. A review of Resident #268's most recent weight dated 4/6/25 indicated the Resident weighed 169.8 pounds. On 4/6/25 at 9:40 A.M., the surveyor observed the Resident in bed. The air mattress was set at 210. On 4/7/25 at 9:32 A.M., and 12:12 P.M., the surveyor observed the Resident in bed. The air mattress was set at 320. On 4/8/25 at 3:36 A.M., the surveyor observed the Resident in bed. The air mattress was set at 320. During an interview and observation on 4/8/25 at 7:51 A.M., the surveyor and Unit Manager #2 observed the Resident in bed with the air mattress setting at 320. Unit Manager #2 said as per the physician's orders, the air mattress should be set at the Resident's current weight plus or minus 10 pounds. Unit Manager #2 said the air mattress should be set at 180. During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses said the Resident's air mattress should be set as per the physician's orders, the Resident's current weight plus or minus 10 pounds. The DON said the air mattress should be set at 180.

Based on observations, record review and interview, the facility failed to ensure three residents (#58, #17, and #2) were free from accidents and hazards including elopement and failed to ensure the appropriate interventions were implemented for safety. Specifically, 1. For Resident #58, the facility to a. prevent an elopement from a secured unit and b. perform a thorough investigation 2. For Resident #17, the facility failed to implement a falls intervention 3. For Resident #2, the facility failed to apply seizure pads to bilateral side rails as ordered Findings include: Review of the facility policy titled Resident Elopement and Wandering, dated June 2024, indicates the following: - Resident elopement is defined as that situation where a cognitively impaired resident or someone with impaired safety awareness actually leaves the facility premises/property without staff knowledge. - When the resident is located: - Nursing to assess the resident thoroughly and document findings in the medical record/nurses notes - Notify the MD, DON, Nurse Supervisor, Resident's legal representative/family - Investigate causal factors related to the elopement - Update the post elopement evaluation form & incident report - Update care plan - Reporting: the Executive Director or designee shall notify the state agency as required by law 1a. Resident #58 was admitted in November 2023 with diagnoses including frontotemporal neurocognitive disorder and unspecified psychosis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #58 scored a 7 out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the current care plan indicates the following: - Resident has a behavior problem AEB (as evidenced by): wandering, pacing (initiated 12/7/23) Review of the care plan failed to indicated Resident #58 was at risk for elopement prior to his/her elopement. Review of the elopement assessment, dated 6/4/24, indicated Resident #58 was not an elopement risk. Review of the incident report, dated 7/13/24, indicated Resident #58 had been seen outside of the facility and stated he/she was walking to the store. Resident #58 was returned to the facility and put on 15 minute checks and a wanderguard (a device applied to set off a door alarm if the Resident attempts to exit) was applied to Resident #58. During an interview on 4/7/25 at 8:33 A.M., the Director of Nursing said Resident #58 was on the first floor when it happened and he/she must have walked out the front door because it is unlocked. Review of the census report failed to indicate Resident #58 had been on the first floor since admission. During an interview on 4/7/25 at 10:55 A.M., Nurse #6 said that Resident #58 has been on the second floor since admission and she was at the facility when the elopement occurred, but could not recall how Resident #58 got out of the building. Nurse #6 said that Resident #58 could have gone out of the building with the smoking group and just started walking away when someone was not looking, but she is not sure. 1b. Review of the investigation report failed to include witness statements to recount the events that occurred on 7/13/24. During an interview on 4/7/25 at 8:33 A.M., the Director of Nursing said that when a Resident elopes from the facility, they would put the Resident on the second floor because the second floor is a locked and secured unit. The Director of Nursing said that she should have reported it and does not remember if she ever obtained witness statements. 2. Review of the policy titled Managing Falls and Fall Risk Policy Statement, undated, indicated the following: - The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors 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 approaches remain relevant. - 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. Resident #17 was admitted in April 2013 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #17 did not participate in the Brief Interview for Mental Status exam, but is moderately cognitively impaired. Review of the MDS indicated Resident #17 is dependent for all activities of daily living and mobility. Review of the falls care plan for Resident #17 indicated the following: - Resident is at risk for falls r/t (related to) decreased safety awareness d/t (due to) dementia and psychosis (initiated 11/4/20) * Anticipate and meet the resident's needs (initiated 12/18/22) * Bed and chair alarm in place at all times. Check every shift for functioning and placement (initiated 2/21/23) * Educate the resident/caregivers about safety reminders and what to do if a fall occurs (initiated 11/24/22) * RESOLVED: Encourage the resident not to furniture walk when in room. Educate him/her on the safety risks of doing so (initiated 3/19/22; resolved on 3/20/25) * Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility as tolerated (initiated 11/4/20) * Ensure that the resident is wearing the appropriate footwear when in wheelchair and when in bed (initiated 11/18/23) * Ensure the resident's call light is within reach and encourage him/her to use it for assistance as needed (initiated 4/3/23) * Follow facility fall protocol (initiated 11/4/20) * May use geri chair for enhanced comfort/positioning (initiated 3/18/25) * The resident requires total assistance with wheelchair mobility (initiated 11/4/20) * RESOLVED: Physical therapy evaluation (initiated 3/19/22; resolved on 3/24/22) * RESOLVED: Pt evaluate and treat as ordered or PRN (as needed) (initiated 5/24/23; resolved on 3/24/22) * RESOLVED: PT evaluated and treat as ordered or PRN (initiated 2/23/24; resolved 5/20/24) * RESOLVED: PT evaluate and treat as ordered or PRN (initiated 6/2/24; resolved 8/9/24) * RESOLVED: Rehab to screen resident to assess safety of furniture placement in room (initiated 3/19/22; resolved 6/23/22) * Remind resident to call staff for help and do not try to pick things up from the floor (initiated 5/23/23) Review of the fall risk assessment, dated 5/16/24, indicated Resident #17 was at risk for falls. Review of the incident report, dated 6/2/24, indicated Resident #17 fell in the unit dining room on his/her left side and was found face down. The fall was unwitnessed. Review of the care plan indicated that an intervention for PT to evaluate and treat was ordered on 6/2/24. Review of the rehab notes failed to indicate that PT ever evaluated or treated Resident #17. Review of the incident report, dated 6/22/24, indicated Resident #17 fell in his/her room at the bedside. Review of the care plan failed to indicated that it was revised or updated after the fall on 6/22/24. Review of the incident report, dated 12/11/24, indicated Resident #17 was found on the dining room floor face down. The fall was unwitnessed. During an interview on 4/8/24 at 1:41 P.M., the Director of Nursing said that usually the team will discuss falls the next day and will update the plan of care. The Director of Nursing said that rehab should have seen Resident #17 after his/her fall on 6/22/24, but did not. The Director of Nursing said that the rehab department attends the interdisciplinary team meetings and that Resident #17 should have been seen after discussing the fall. 43807 3. Resident #2 was admitted to the facility in April 2000 with diagnoses including epilepsy and epileptic syndromes with complex and partial seizures. A review of the most recent Minimum Data Set, dated dated dated [DATE] did not indicate a Brief Interview for Mental Status score because the Resident is rarely/never understood. A review of Resident #2's April 2025 physician's orders indicated the following: -Seizure pads to bilateral side rails. Check placement every shift. Order date, 12/21/22. On 4/7/25 at 7:35 A.M., and 9:40 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail. On 4/8/25 at 3:35 A.M., the surveyor observed the Resident sleeping in bed with one seizure pad on the left side rail. During an interview and observation on 4/8/25 at 7:40 A.M., the surveyor and Unit Manager #1 observed the Resident sleeping with one seizure pad on the left side rail. Unit Manager #1 found the other seizure pad on the Resident's dresser. Unit Manger #1 said as per the physician's orders, the Resident should always have two seizure pads on the side rails while in bed. During an interview on 4/8/25 at 7:53 A.M., the Director of Nurses (DON) said physician's orders should always be followed. The DON said Resident # 2 should always have two seizure pads while in bed because of his/her history of seizures. Ref to F842

Based on record review and interview, the facility failed to ensure specialized rehab services were provided in a timely fashion for one Resident (#28) out of a total sample of 20 residents. Findings include: Review of the facility policy titled Specialized Rehabilitative Services, not dated, indicated that the facility provides specialized rehabilitative services by qualified professional personnel. Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, contracture of muscle of left hand and dementia. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Further review indicated range of motion impairment on one side of upper extremity including wrist and hand. On 4/06/25, at 7:59 A.M. the surveyor observed Resident #28 lying in bed. The surveyor observed that Resident #28 had a severely contracted hand and fingers. The surveyor also observed that Resident was without a palm guard/splint on the left wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room. During an interview on 4/06/25, at 7:59 A.M. Resident #28 said that he/she used to have something on his/her hand but has not had one in a long time. Review of the admission documentation received by the facility from the Resident's prior nursing facility indicated that Resident #28 was receiving occupational therapy to address the contracture's of his/her left hand. Review of the occupational therapy discharge note from the prior facility, dated 1/20/25, indicated the following: a. Patient will safely wear least restrictive splinting/orthotic device during daily tasks without skin irritation and complaints of discomfort in order to improve PROM (passive range of motion) for adequate hygiene and inhibit abnormal positions. b. progress and response to treatment: patient made consistent progress throughout plan of treatment with donning of palm guard s/p (status post) PROM to L (left) digits tolerating 8 hrs (hours). c. D/C (discharge) recs (recommendations): Recommend continuation of splinting of L hand and PROM to LUE (left upper extremity) at new LTC (long term care) facility. Review of the progress note, from prior facility, dated 12/30/24, indicated the following: eMar - Medication Administration Note. Note Text: Apply palm guard to left. hand during AM care post hand hygiene as tolerated. every day shift check for placement, reapply as needed, check skin for integrity. unable to find. On 4/6/25 at 12:32 P.M., the surveyor observed Resident #28 without a palm guard/splint on the left wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room. On 4/7/25, at 12:14 P.M. the surveyor observed Resident #28 lying in bed without a palm guard/splint on the left wrist/hand. The surveyor was not able to locate a palm guard/hand splint in Resident #28's room. Review of the physician's orders dated April 2025 failed to indicate an order for a palm guard/hand splint. Further review failed to indicate an order for rehabilitation therapy. Review of the care plan failed to indicate the use of a palm guard/hand splint. During an interview on 4/07/25, at 2:33 P.M. the Director of Rehab (DOR) said he was not under the impression from nursing that Resident #28 had been receiving therapy at the previous facility so he did not look for and/or read any therapy notes from the previous facility. The DOR said that it is the responsibility of nursing to inform the rehab department when a resident is admitted who needs therapy, as all admissions are not automatically screened for potential therapy needs. The DOR said that Resident #28 should have been at least screened by therapy upon admission as he/she was receiving occupational therapy at his/her previous nursing home. During an interview on 4/08/25, at 8:35 A.M., Resident #28 said that he/she was given the palm guard yesterday and that before yesterday he/she did not have one since coming to the building. During an interview on 4/08/25 at 8:39 A.M., Nurse #7 said that prior to yesterday she had not seen a palm guard/hand splint on Resident #28. During an interview on 4/08/25, at 8:40 A.M., CNA #5 said that she is Resident #28's regular CNA and she has never seen a palm guard/hand splint for Resident #28 prior to today.

Based on record review and interviews, the facility failed to ensure staff implemented abuse policies and procedures for one Resident (#28) out of a total of 20 sampled Residents. Specifically, for Resident #28 staff failed notify facility administration of an accusation that a Certified Nurse's Aide (CNA) wrapped a remote cord around his/her neck. Findings include: Review of the facility policy titled Abuse, undated, indicated that any employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, dementia and depression. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Review of the progress notes dated 3/23/25 at 21:28 indicated that at around 7:00 P.M. Resident #28 accused CNA #2 of wrapping the call light cord around his/her neck. Review of the progress note dated 3/24/25, at 17:21 indicated that the Director of Nursing (DON) was notified at 4:00 P.M. that Resident #28's spouse reported that Resident #28 said that the evening prior a CNA had wrapped a call light cord around his/her neck. During an interview on 4/7/25 at 11:19 A.M. the Director of Nursing (DON) said that she had not been made aware of the accusation of abuse until the next afternoon on 3/24/25 at around 4:00 P.M The DON said that the nurse who first heard of the accusation of abuse should have reported it to administration immediately so the facility could report the allegation of abuse to the state agency within the 2 our timeframe and start the investigation of the allegation immediately.

Based on observation, policy review, and interview, the facility failed to ensure 1) medication rooms on two of two units were locked and secured while not in use and 2) medications were opened and dated on 2 of 3 sampled medication carts. Findings include: Review of the facility policy, Storage of Medications, dated May 2023, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 1) Medication rooms on two of two units were unlocked and not in a secured location while not in use. a. On 4/18/24 at 8:15 A.M., the surveyor observed the Arlington Unit medication room unlocked and unattended. There were residents and non-licensed staff members in the hallway. On 4/18/24 at 8:24 A.M., the surveyor entered the medication room without facility staff. The surveyor observed insulins, eye drops, intravenous medications, and over the counter medications. On 4/18/24 at 8:36 A.M., Nurse #1 arrived at the Arlington Unit medication room. Nurse #1 said the medication room door should be locked when unattended. The Arlington Unit medication room was observed unlocked and unattended for a total of 21 minutes. b. On 4/19/24 at 6:58 A.M., the surveyor observed the door to the medication room on the Pacific Unit was unlocked and ajar. There were no staff in the area to monitor the medication room. Nurse #3 arrived at 7:00 A.M. to begin his shift. Nurse #3 said that the door to the medication room should be locked and secured when not in use by the nurse. During an interview on 4/22/24 at 8:45 A.M., the Director of Nursing said medication rooms should be locked when unattended. 44095 2) Medications were opened and undated on two of three sampled medication carts. a. On 4/22/24 at 9:50 A.M., the surveyor observed on the Arlington Unit high side medication cart the following: - One vial humulin 70/30 insulin, opened and undated. - One vial lispro insulin, opened and undated. - One lantus solostar insulin pen, opened and undated. During an interview on 4/22/24 at 9:55 A.M., Nurse #2 said medications should be dated when opened. b. On 4/22/24 at 10:00 A.M., the surveyor observed on the Arlington Unit low side medication cart the following: - One basaglar insulin kwik pen, opened and undated. - One novolog insulin flex pen, opened and undated. During an interview on 4/22/24 at 10:02 A.M., Nurse #1 said medications should be dated when opened. During an interview on 4/22/24 at 10:04 A.M., the Director of Nursing said insulins should be dated when opened.

Based on observations, record review and interview the facility failed to ensure a reach in freezer containing food for preperation in the facility's main kitchen, was in a safe operable condition, ensuring that frozen food was frozen solid. Findings include: Review of the Food and Drug Administration document titled Storage Basics, dated as current 1/18/23 indicated the following: *Keep your appliances at the proper temperatures. Keep the refrigerator temperature at or below 40 (Fahrenheit) (4 C). The freezer temperature should be 0 (degrees) F (-18 C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. Review of the facility's policy, not dated, titled 'Refrigerator/Freezer Maintenance and Operation' indicated the following: *Refrigerators and freezers are closely monitored for proper operation and temperature. *Temperatures are recorded and units cleaned to ensure proper operation. *If any refrigerators/freezer is discovered to not maintain proper temperatures, the Maintenance Supervisor will check, assess and if needed, contact the service vendor to service the unit as quickly as possible. *Items that cannot be maintained in the affected unit will be stored properly in a functioning unit. If alternate storage is not available, then affected items will be discarded. Review of the facility's policy, titled 'Preventing Foodborne Illness-Food Handling', dated May 2023, indicated the following: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. 4. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit), and that freezers keep frozen food solid. During a tour of the kitchen on 4/18/24 at 7:04 A.M., with the Food Service Director (FSD), the following observations were made in the three-door reach-in freezer: - three individual containers of ice cream were soft and not frozen solid to touch. - one box of precooked french toast was soft and not frozen solid to touch. Review of the document titled 'Freezer Temperature Log', with the month and year blank, hanging on the door of the three-door reach-in freezer, indicated the following instructions corrective action of temperature greater than 0 degrees F. Further review of the Freezer Temperature Log, indicated the following temperatures, recorded by staff of the freezer including: - 17 out of the last 18 days (of April) recorded temperatures ranging between 4.1 degrees F and 16 degrees F, all of which were above 0 degrees F. in the A.M., and; - 15 out of last 18 days (of April) recorded temperatures ranging between 3.1 degrees F and 30 degrees F in the P.M. Further review of the document failed to have any written entries of correction actions for the recorded temperatures greater than 0 degrees F. During a return observation on 4/18/24 at 7:28 A.M., revealed the internal appliance thermometer of the three-door reach in freezer as 38.0 degrees F. During an interview on 4/18/24 at 7:35 A.M., the FSD director said that frozen food should be frozen solid. During an interview on 4/18/24 at 7:36 A.M., Cook #1 said the French toast removed from the freezer was soft and not solid and said the ice cream is not always frozen solid. During a follow-up observation on 4/18/24 at 2:15 P.M., of the three-door reach in freezer, the outside thermometer was 6 degrees F, and the internal thermometer was observed as 9 degrees. Food was stored in the freezer. An individual ice cream container's cover was touched and the cover could be pushed in indicating the ice cream was not frozen solid. During an interview on 4/18/24 at 2:18 P.M., the FSD said she checked the freezer four times during the day. The FSD said not all items in the freezer were frozen solid and that the vendor who services the freezer has been called to come out and look at the freezer.

Based on observation, record review and interview the facility failed to ensure food was stored and the kitchen was maintained, in accordance with professional standards for food service safety to prevent possible foodborne illness. Findings include: Review of the Food and Drug Administration document titled Storage Basics, dated as current 1/18/23 indicated the following: *Keep your appliances at the proper temperatures. Keep the refrigerator temperature at or below 40 (Fahrenheit) (4 C). The freezer temperature should be 0 (degrees) F (-18 C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. Review of the facility's policy, titled 'Preventing Foodborne Illness-Food Handling', dated May 2023, indicated the following: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 4. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit), and that freezers keep frozen food solid. 8. All food service equipment and utensils will be sanitized according to current guidelines, and manufacturer's recommendations. During a tour of the kitchen on 4/18/24 at 7:04 A.M., with the Food Service Director (FSD), the following observations were made in the three-door reach-in freezer: - three individual containers of ice cream, that were soft and not frozen solid to touch. - one box of frozen uncooked cookies, that was open, and the internal plastic wrap was left open leaving the cookies exposed and not secured. - one box of precooked French toast, that was open and not secure, with the French toast exposed. The precooked French toast was soft and not frozen solid to touch. During the observation with the FSD, Cook #1 placed a box of frozen precooked pancakes into the freezer, left unwrapped with the pancakes exposed. Review of the document titled 'Freezer Temperature Log', with the month and year blank, hanging on the door of the three-door reach-in freezer, indicated the following instructions corrective action of temperature greater than 0 degrees F. Further review of the Freezer Temperature Log, indicated the following temperatures, recorded by staff of the freezer including: - 17 out of the last 18 days (of April) recorded temperatures ranging between 4.1 degrees F and 16 degrees F, all of which were above 0 degrees F. in the A.M., and; - 15 out of last 18 days (of April) recorded temperatures ranged between 3.1 degrees F and 30 degrees F in the P.M. Further review of the document failed to have any written entries of correction actions for the recorded temperatures greater than 0 degrees F. During a return observation on 4/18/24 at 7:28 A.M., revealed the internal thermometer of the three-door reach-in freezer as 38.0 degrees F. During an interview on 4/18/24 at 7:35 A.M., the FSD said food stored in the freezer should be covered and secured and should not be left open to air, which could dry out the food. The FSD said that frozen food should be frozen solid. During an interview on 4/18/24 at 7:36 A.M., Cook #1 said the French toast removed from the freezer was soft and not solid and said the ice cream is not always frozen solid. Additionally, during the tour of the kitchen with the FSD on 4/18/24 at 7:17 A.M., the following was observed in the reach in refrigerator: -one package of plastic wrapped tortillas, not labeled or dated. -one cut tomato wrapped in plastic, not labeled, or dated. -one cut onion wrapped in plastic, not labeled, or dated. -eight small bowls of covered fruit, not labeled, or dated. The FSD said all items stored in the refrigerator are to be labeled and dated. In a second reach-in freezer, the surveyor observed: -one box of beef patties which was open, not wrapped, and exposed. During the tour the surveyor and FSD observed the ice machine and made the following observation: -the ice scoop holder hung on the wall next to the ice machine, had a small amount of standing water and black debris particles on the bottom. The FSD said it needs to be cleaned. During a follow-up observation on 4/18/24 at 2:15 P.M., of the three-door reach-in freezer the outside thermometer read 6 degrees F, and the internal thermometer read as 9 degrees. -An individual ice cream cover was touched; the cover could be pushed in indicating the ice cream was not frozen solid. During an interview on 4/18/24 at 2:18 P.M., the FSD said she checked the freezer four times during the day and did not record any temperatures below five degrees Fahrenheit. The FSD said not all items in the freezer were frozen solid and that the vendor who services the freezer has been called to come out and look at the freezer.

Based on observations, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#41), out of a total sample of 16 residents. Specifically, for Resident #41 the facility failed ensure nursing completed a PICC line dressing change as ordered by the physician on 4/18/24 and nursing failed to ensure the PICC line dressing allowed nursing to observe the insertion site (insertion site was covered by a 2x2 gauze pad). Findings include: Review of the facility policy, Central Venous Catheter Care and Maintenance, dated September 2023, indicated to provide a general procedure regarding central venous catheters. *Site Care and Observation Observe the insertion site every shift for signs and symptoms or intravenous (IV) related complications including but not limited to pain, redness/hematoma, swelling/edema/infiltration, and DVT (Deep Vein Thrombosis). -Monitor and assess insertion site and surrounding area every shift for signs and symptoms or IV related complications. *Dressing Change -Change PICC line catheter transparent dressing every 7 days. Resident #41 was admitted to the facility in October 2018 with diagnoses including paraplegia, diabetes, neuromuscular dysfunction of the bladder and osteomyelitis. Review of the Minimum Data Set (MDS) assessment, dated 4/10/24, indicated Resident #41 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she was cognitively intact. The MDS indicated he/she received an antibiotic and received intravenous medications. Review of the plan of care related to osteomyelitis indicated, dated as revised 3/14/24, indicated: - Monitor intravenous (IV) site to right upper extremity for signs/symptoms of IV related complications. Review of the plan of care related to intravenous medications, dated as revised 3/14/24, indicated the following interventions: - Monitor dressing at IV site daily. Change as ordered. See treatment administration record (TAR). - Monitor/document/report to physician signs or symptoms (s/sx) of infiltration at the site: edema at the insertion site, taut or stretched skin, blanching or coolness of the skin, slowing or stopping of the infusion, and/or leaking of IV fluid out of the insertion site. - Monitor/document/report to physician s/sx of infection at the right upper extremity (RUE) PICC site: drainage, inflammation, swelling, redness and/or warmth Review of the physician's order, dated 3/14/24, indicated: - PICC line to right upper extremity, every 7 day dressing change: change transparent dressing, change all needleless connectors and change all lumen caps (prime new needless connectors with saline prior to connecting). On 4/18/24 at 8:34 A.M., 4/19/24 at 8:46 A.M., and 4/22/24 at 8:54 A.M., the surveyor observed Resident #41's PICC line dressing. The dressing was dated 4/16/24 and the insertion site was covered by a 2x2 gauze and therefore staff were unable to assess the insertion site. Review of the Treatment Administration Record (TAR), dated April 2024, indicated nursing changed the transparent dressing on 4/18/24. However, based on observations on 4/18/24, 4/19/24, and 4/22/24 the dressing was dated 4/16/24. During an interview on 4/22/24 at 8:59 A.M., Nurse #2 said she last changed Resident #41's PICC line dressing on 4/16/24. Nurse #2 said she did not know she should not have placed gauze over the insertion site during the dressing change. During an interview on 4/22/24 at 8:44 A.M., the Director of Nursing (DON) said Resident #41's PICC line dressing should be changed according to the physician's order. The DON said that nursing should not have placed gauze under the transparent dressing and nursing could not assess the insertion site.

Based on observation and interview, the facility failed to ensure staff respected resident room privacy for one Resident (#15) out of a total of 16 sampled residents. Findings include: Resident #15 was admitted to the facility in February 2021 with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, and unspecified psychosis. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #15 scored 5 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is severely cognitively impaired. On 4/19/24 at 6:50 A.M., a Certified Nursing Assistant (CNA) was observed standing in Resident #15's room in front of the shared closet space while Resident #15 slept in bed. The door to the closet was open and the CNA was putting on his/her jacket. Upon seeing the surveyor, the CNA left the room and walked down the hallway. The surveyor then observed a green purse, a phone plugged into the wall and charging, a plastic shopping bag and a food container on top of the bureau. At 7:03 A.M., the surveyor observed the same CNA enter Resident #15's room and then promptly exit the room holding a green purse and went through the stairwell. At 7:04 A.M., the surveyor observed that the phone and charger, plastic bag and food container were no longer in the room. During an interview on 4/19/24 at 9:39 A.M., Unit Manager #2 said that there is an area on the unit where staff are expected to leave their personal belongings. Unit Manager #2 said that staff should not be storing their personal belongings in resident rooms.

Based on observation, record review and interview the facility failed for one Resident (#58), out of a total sample of 16 residents, to remain free from a potential restraint. Specifically, the facility failed to identify and assess the use of a specialized low chair used by Resident #58 as a potential restraint. Findings include: Review of the facility's policy, titled 'Use of Restraint', dated November 2023 indicated the following: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary and the ongoing reevaluation for the need for restraints will be documented. Policy Interpretation and Implementation: 1 physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition; (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints including leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: c. Placing a resident in a chair that prevents the resident from rising. 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive interventions and a restrain (sic) is required to: a. treat a medical condition b. Protect the resident's safety; and c. help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a restraint assessment and review to determine the need for restraints the assessment shall be used to determine possible underlying causes of the problematic medical symptom to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve symptoms. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. they type of restraint, and period of time for the use of the restraint. 17. Care plans for residents and restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptom(s). 18. Care Plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. Resident #58 was admitted to the facility in December 2023 and has diagnoses including repeated falls, and unspecified dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 scored a 0 out of 15 on the Brief Interview for Mental Status exam, which indicates Resident #58 has severe cognitive impairment, used a manual wheelchair for mobility and was dependent on staff to sit to stand and required substantial maximum assistance with transfers. On 4/18/24 at 10:20 A.M., Resident #58 was observed in the dining/sitting room, seated in a chair that was lower than a standard chair height. The chair was equipped with wheels and was not consistent with a manual wheelchair and observed to be a specialized geri-chair. Resident #58 was alert and responded to the surveyor's greeting but was unable to participate in an interview. On 4/18/24 at 1:52 P.M., Resident #58 was observed in the sitting room, seated in a low chair. On 4/22/24 at 8:50 A.M., Resident #58 was observed seated in a low chair, at a table located in the sitting room. On 4/22/24 at 9:12 A.M., Resident #58 was observed seated in a low chair, which was slightly reclined. Resident #58 was observed sitting up and had both his/her feet on the floor. Review of Resident #58's medical record indicated the following: The active physician's orders failed to indicate an order for the use of the low chair. A care plan dated 3/13/24 with the focus of self- care performance deficit r/t (related to) difficulty initiating, sequencing, and completing tasks d/t (due to) dementia, indicated the interventions of a wheelchair. The Kardex (a document used by staff to guide daily care activities) failed to indicate the use of a low chair and indicated the use of a wheelchair. Further, Review of Resident #58's medical record failed to indicate an evaluation for the use of a physical restraint was completed. During an interview on 4/18/24 at 1:59 P.M., Nurse #1 said Resident #58 has resided at the facility for a few months. Nurse #1 said the Resident has confusion, had behaviors of exit seeking, used a wheelchair, and he/she can stand up but does not have good balance and needs to be assisted. During an interview on 4/22/24 at 8:58 A.M., CNA #1 said Resident #58 is a fall risk, has had some falls and has a bed and chair alarm. CNA #1 said Resident #58 can bear weight and can transfer with one or two staff. CNA #1 said Resident #58 was using a wheelchair but was leaning and was given the recliner chair about a month or so ago. CNA #1 said Resident #58 can use his/her feet to move the chair and that she has not seen Resident #58 try to get up from the low chair. During a subsequent interview on 4/22/24 at 9:08 A.M., CNA #1 said that she went to PT (physical therapy) downstairs and got the chair to give to Resident #58. CNA #1 said PT looked at Resident #58 in the chair. On 4/22/24 at 9:16 A.M., the surveyor observed CNA #1 assist Resident #58 to stand from the low chair. Resident #58 required assistance to stand from the chair and then sat back down. CNA #1 said Resident #58 is not as alert today and some days he/she will try to get up. During an interview on 4/22/24 at 9:56 A.M., The Director of Rehabilitation (DOR) said Resident #58 is on occupational therapy with the goal for Resident #58 to be more stable in his/her core. The DOR said Resident #58 has had multiple falls, is very impulsive, falls laterally (leaning to one side). The DOR said Resident #58 was using a regular manual wheelchair for mobility. The DOR said he did not know where the current low chair that Resident #58's is using came from and that he did not provide the low chair. The DOR said the low chair is more of a positioning seating system. The DOR said Resident #58's hips are not in a neutral position in the low chair, making it lower than a standard height chair which would make it more difficult to stand up from the chair. The DOR said Resident #58 can sit to stand from the wheelchair, using the parallel bar. The DOR said he did not know how long Resident #58 has been using the low chair, he did not assess the chair and it was not favorable as it was too low. During an interview on 4/22/24 at 10:57 A.M., the Director of Nursing said the low chair Resident #58 observed to using has not been assessed as a possible restraint and should be.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, was known to wander and put objects in his/her mouth, the Facility failed to ensure that he/she was provided with an adequate level of staff supervision and an environment that was free from safety hazards, when on 03/29/24 nursing staff failed to secure medications delivered from the pharmacy, left them unattended at the Nurses' Station, and Resident #1 gained accessed to and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, later that evening he/she required intubation and admission to the Hospital Intensive Care Unit. Findings include: The Facility Policy, titled Safety and Supervision of Residents, dated 11/2017, indicated the Facility would maintain an environment as free from accident hazards as possible, and resident safety, supervision, and assistance to prevent accidents were Facility-wide priorities. The Facility Policy, titled Storage of Medications, dated 05/2023, indicated the Facility would store all drugs and biologicals in a safe, secure, and orderly manner. Review of the Facility's Investigation Report, undated, indicated that on 03/29/24, sometime in the early morning, Resident #1 was found with two ripped open cards of medication (Seroquel and Risperidone) that were not secured. The Report indicated that it was unclear whether Resident #1 had ingested any of the medications, and he/she was transferred to the Hospital Emergency Department. Review of the Facility's Pharmacy Delivery Manifest, dated 03/29/24 and signed by Nurse #1 at 01:39 A.M., indicated the pharmacy had delivered five medications, which included: -Seroquel 150 mg (10 tablets) which were prescribed and ordered for Resident #2 and -Risperidone 1 mg (25 tablets) which were prescribed and ordered for Resident #3. Resident #1 was admitted to the Facility in April 2021, diagnoses included neurocognitive disorder, history of alcohol use, dementia, and substance use disorder. Review of Resident #1's Physician Order Summary Report, dated for March 2024, indicated he/she had physician's orders for the following: -Depakote (anticonvulsant, also used to treat anxiety), 250 mg, by mouth, three times daily, dated 03/28/24. -Lexapro (antidepressant), 5 mg, by mouth, once daily, dated 01/04/23. -Trazodone (antidepressant, also used to treat insomnia), 50 mg, by mouth, at bedtime, dated 03/06/24. -Resident #1 did not have physician's orders for Seroquel or Risperidone. Review of Resident #1's Behavior Care Plan, dated as revised on 03/20/24, indicated he/she had behaviors including intrusive wandering, rummaging, and chewing on his/her clothing. Interventions included staff would anticipate and meet his/her needs whenever possible. Review of Resident #1's Elopement and Wandering Care Plan, dated as revised on 03/11/24, indicated interventions including distracting him/her from wandering by offering pleasant diversions. Review of Resident #1's Nurse Progress Note, dated 03/29/24, indicated he/she was transferred to the Hospital Emergency Department after staff found him/her with pharmacy medication packages ripped open. Review of Resident #1's Hospital Discharge Summary, dated 04/06/24, indicated Resident #1 was admitted to the Hospital Emergency Department on 03/29/24, and was diagnosed with encephalopathy as a result of accidental ingestion and overdose of Seroquel and Risperidone at the Facility, and while in the Hospital Emergency Department, Resident #1's heart rate and blood pressure were elevated, he/she developed respiratory failure, and required intubation, ventilation, sedation, and was admitted to the Intensive Care Unit. The Discharge Summary indicated Resident #1 was extubated three days later on 04/01/24, and was discharged from the Hospital on 04/06/24 to a rehabilitation facility. During a telephone interview on 04/10/24 at 8:42 A.M., Nurse #1 said she was the nurse who worked the 11:00 P.M., (03/28/24) to 07:00 A.M., (03/29/24) shift on the unit where Resident #1 resided. Nurse #1 said Resident #1 was awake, wandering the unit, and had been wandering and standing over near the Nurses' Station throughout the shift. Nurse #1 said there was a pharmacy delivery that arrived at 01:39 A.M., and that there were only a few medications in the package, which were enclosed in a sealed red plastic bag. Nurse #1 said she did not secure the medications in the medication cart or in the units locked medication room, which was located directly behind the Nurses' Station, but said she left them in the red plastic bag on the desk at the Nurses' Station throughout the shift. Nurse #1 said she should have secured the medications, but had not. Nurse #1 said when she came back to the Nurses' Station at 06:00 A.M., Resident #1 was standing alone, near the Nurses' Station, the red plastic bag with the medications in it was torn open, and that multiple tablets of Risperidone and Seroquel tablets were missing from the medication cards. Nurse #1 said she found some pills on the floor, so she was unsure how many pills Resident #1 had ingested. Nurse #1 said Resident #1 was immediately transferred to the Hospital Emergency Department via 911. During a telephone interview on 04/09/24 at 11:24 A.M., Certified Nurse Aide (CNA) #1 said Resident #1 was known to wander intrusively, rummage through others' belongings, would eat others' food, would take anything that was left unsupervised, and was known to go behind the Nurses' Station and steal food. CNA #1 said that throughout the 11:00 P.M., (03/28/24) to 07:00 A.M., (03/29/24) shift, Resident #1 was wandering the unit and was difficult to redirect. During a telephone interview on 04/12/24 at 09:09 A.M., CNA #2 said Resident #1 was known to wander intrusively, would take things he/she found especially food, and was known to seek food to eat. CNA #2 said that on the 11:00 P.M., (03/28/24) to 07:00 A.M., (03/29/24) shift, Resident #1 was difficult to redirect and she had to help him/her back to bed several times throughout the night. During an interview on 04/09/24 at 07:46 A.M., and throughout the survey, the Director of Nurses (DON) said it was her expectation that nurses would secure all medications in the locked medication carts or locked medication room, but on 03/29/24 Nurse #1 had not done either and as a result, Resident #1, who was known to wander, rummage, eat things that he/she found, and required supervision, gained access to and ingested medications that were not prescribed to him/her, required transfer to the Emergency Department and admission to the Hospital.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was known to wander, rummage, and eat food he/she found, the Facility failed to ensure that medications were kept locked up (secured) or under direct supervision of nursing staff, when on 03/29/24, Nurse #1 left a medication package delivered from the Pharmacy unattended on the desk at the Nurses' Station, and as a result, Resident #1 was later found with the opened package and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, and later required intubation and admission to the Hospital Intensive Care Unit. Findings include: The Facility Policy, titled Storage of Medications, dated 05/2023, indicated the Facility would store all drugs and biologicals in a safe, secure, and orderly manner. Review of the Facility's Investigation Report, undated, indicated that on 03/29/24, sometime in the early morning, Resident #1 was found with two ripped open cards of medication (Seroquel and Risperidone) that were not secured. The Report indicated it was unclear whether Resident #1 ingested any of the medications, and he/she was transferred to the Hospital Emergency Department. Review of the Facility's Pharmacy Delivery Manifest, dated 03/29/24 and signed by Nurse #1 at 01:39 A.M., indicated the pharmacy had delivered five medications, which included: -Seroquel 150 mg (10 tablets) which were prescribed and ordered for Resident #2 and -Risperidone 1 mg (25 tablets) which were prescribed and ordered for Resident #3. Resident #1 was admitted to the Facility in April 2021, diagnoses included neurocognitive disorder, history of alcohol use, dementia, and substance use disorder. Review of Resident #1's Physician Order Summary Report, dated for March 2024, indicated he/she had physician's orders for the following: -Depakote (anticonvulsant, also used to treat anxiety), 250 mg, by mouth, three times daily, dated 03/28/24. -Lexapro (antidepressant), 5 mg, by mouth, once daily, dated 01/04/23. -Trazodone (antidepressant, also used to treat insomnia), 50 mg, by mouth, at bedtime, dated 03/06/24. -Resident #1 did not have physician's orders for Seroquel or Risperidone. Review of Resident #1's Nurse Progress Note, dated 03/29/24, indicated he/she was transferred to the Hospital Emergency Department after staff found pharmacy packages ripped open. Review of Resident #1's Hospital Discharge Summary, dated 04/06/24, indicated Resident #1 was admitted to the Hospital Emergency Department on 03/29/24, was diagnosed with encephalopathy as a result of accidental ingestion and overdose of Seroquel and Risperidone at the Facility, and while in the Hospital Emergency Department, Resident #1's heart rate and blood pressure were elevated, he/she developed respiratory failure, and required intubation, ventilation, sedation, and was admitted to the Intensive Care Unit. The Discharge Summary indicated Resident #1 was extubated three days later on 04/01/24, and was discharged from the Hospital on 04/06/24 to a rehabilitation facility. During a telephone interview on 04/10/24 at 8:42 A.M., Nurse #1 said she was the nurse who worked the 11:00 P.M., (03/28/24) to 07:00 A.M., (03/29/24) shift on the unit where Resident #1 resided. Nurse #1 said Resident #1 was awake, wandering the unit, and had been wandering and standing over near the Nurses' Station throughout the shift. Nurse #1 said there was a pharmacy delivery that arrived at 01:39 A.M., and that there were only a few medications in the package, which were enclosed in a sealed red plastic bag. Nurse #1 said she did not secure the medications in the medication cart or the units locked medication room, which was located directly behind the Nurses' Station, but said she left them in the red plastic bag on the desk at the Nurses' Station throughout the shift. Nurse #1 said she should have secured the medications. Nurse #1 said when she came back to the Nurses' Station at 06:00 A.M., Resident #1 was standing alone, near the Nurses' Station, the red plastic bag with the medications in it was torn open, and multiple tablets of Risperidone and Seroquel were missing from those medication cards. Nurse #1 said she saw that there were some pills on the floor so she picked them up, so she was unsure how many of the pills Resident #1 may have ingested. Nurse #1 said she called poison control, notified the physician, and that Resident #1 was immediately transferred to the Hospital Emergency Department via 911 for evaluation and monitoring. During a telephone interview on 04/09/24 at 11:24 A.M., Certified Nurse Aide (CNA) #1 said Resident #1 was known to wander intrusively, rummage through others' belongings, and to eat others' food, would take anything that was left unsupervised, and was known to go behind the Nurses' Station and steal food. During an interview on 04/09/24 at 07:46 A.M., and throughout the survey, the Director of Nurses (DON) said it was facility policy and her expectation that nurses secure all medications in the locked medication carts or locked medication room, but on 03/29/24 Nurse #1 had not done either, and as a result, Resident #1 had accessed and ingested medications that were not prescribed to him/her and required transfer to the Emergency Department and admission to the Hospital.

Based on observation, record review, policy review and interviews, the facility failed to provide 1 Resident (#23) with dental services out of a total sample of 21 residents. Specifically, the facility failed to follow up on a canceled oral surgery appointment resulting in infection, weight loss and continuous pain. Findings include: Review of the facility policy titled, Dental Services, revision date December 2016, indicated: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and emergency dental services are provided to our residents through: a. A contract agreement with a licensed dentist that comes to the facility. b. Referral to the resident's personal dentist; c. Referral to community dentists; d. Referral to other health care organizations that provide dental services. -Medicare and Medicaid residents will be billed for routine and emergency dental services. -Social Services representative or designee will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. Resident #23 was admitted to the facility in April 2013 with diagnoses including adult failure to thrive, cerebrovascular disease and dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status score of 9 out of a possible 15, indicating moderate cognitive impairment. Further review of the MDS indicated Resident #23 required extensive assistance for personal hygiene tasks, including oral care. During an observation on 3/01/23 at 8:06 A.M., Resident #23 was observed sitting up in a wheelchair being fed by a Certified Nursing Assistant (CNA). Resident #23 was observed to be making moaning noises while eating. During an interview on 3/03/23 at 8:06 A.M., CNA #5 was able to assist the surveyor with translation while the surveyor asked Resident #23 questions. Resident #23 was able to answer yes/no questions and could make motions or gestures. Resident #23 was asked if he/she had pain in his/her mouth and Resident #23 nodded his/her head yes and pointed to the left side of his/her face. The surveyor asked CNA #5 to ask Resident #23 if he/she was having bad pain in his/her mouth. Resident #23 nodded his/her head yes and motioned his/her hand in a way which CNA #5 was able to translate as throbbing. Resident #23 was asked if the pain was throbbing and he/she nodded yes. Resident #23 was asked where the pain was throbbing and motioned to his/her left side of the mouth. Review of Resident #23's medical record indicated the following: -A health status note dated 8/4/22, indicated Resident #23 began an antibiotic for a tooth infection. -A Dental Treatment note dated 8/19/22, indicated Resident #23 had mild swelling and inflammation of gingival in the area of the lower left molars. The Dental Treatment not indicated Resident #23 complained of throbbing pain on and off in this area and was very tender to palpation. The Dental Treatment note indicated a recommendation for Resident #23 to see an oral surgeon as soon as possible for x-ray, evaluation, and treatment. -A Physician order dated 8/19/22, indicated for Resident #23 to Rinse mouth and spit out with warm salt water three times a day for gum discomfort. -A health status note dated 8/23/22, indicated Resident #23 has an appointment scheduled on 8/30/22 for dental consult and follow up. -A health status note dated 8/29/22, indicated the oral surgeon's office called and rescheduled Resident #23's appointment to 9/26/22. Call placed to Son. -A health status note dated 9/26/22, indicated Resident #23 missed the oral surgery appointment on 9/26/22 due to his/her son not arriving to transport the Resident. The appointment was rescheduled for 10/14/22 and a voicemail was left for social worker so he could schedule transportation for the Resident. -A health status note dated 9/15/22, indicated Resident #23 continued to eat soup and had his/her diet changed to accommodate eating needs until he/she is able to have oral surgery. -Resident #23 was seen by dental services again on 9/26/22, and the Dentist indicated his/her oral tissue was inflamed and bleeds easily and had very poor oral hygiene. The Dentist notes also indicated Resident #23 does not brush his/her teeth due to pain in the left lower quadrant of his/her mouth. The Dentist noted the Director of Nursing said Resident #23 had an appointment with an outside dentist scheduled and asked the facility to please monitor Resident #23 for broken teeth, pain or discomfort. -A health status note dated 10/14/22, indicated Resident #23's son called the facility to cancel the scheduled dental appointment. -Resident #23's medical record failed to indicate any further discussion on rescheduling a oral surgery appointment. Review of a nursing note dated 2/16/23, indicated Resident #23 complained of oral pain and the oral exam showed a purulent (producing pus) area, requiring the use of an antibiotic for treatment of an infection in the same area of the mouth as documented during August 2022. During an interview on 3/02/23 at 12:22 P.M., Nurse #4 said Resident #23 had an appointment scheduled for the oral surgeon but had issues with insurance as well as Resident #23's son canceling an appointment. Nurse #4 said the mouth infections that Resident #23 has had are related to the surgery that has not occurred. Nurse #4 instructed the surveyor to speak with the Director of Nursing in regards to the appointment because she did not know anymore about the subject. During an interview on 3/03/23 at 8:37 A.M., Nurse #6 said Resident #23 has been having some dental issues and just finished an antibiotic for an infection. Nurse #6 then began a physician ordered oral care treatment with the surveyor present. Resident #23 said he/she had pain in the mouth and was resistant to an oral swab being placed in his/her mouth. During an interview on 3/3/23 at 8:14 A.M., CNA #5 was unable to find mouth care products for Resident #23. CNA #5 said staff does not brush Resident #23's teeth due to pain and he/she is only able to use mouth wash. During an interview on 3/2/23 at 1:09 P.M., The Director of Nursing (DON) said Resident #23 had an oral surgery consult booked but the Resident's son had canceled the appointment. The DON said Resident #23's son wants to go to the appointment with him/her and she will need to call him and see. The DON said the Resident's mouth infection is related to the dental work that needs to be completed. During an interview on 3/3/23 at 9:09 A.M., the Director of Social Services said that if a Resident has a legal guardian in place, that guardian needs to be informed of all treatment interventions and is responsible for making all treatment decisions. The Director of Social Services said Resident #23's Guardian was aware that Resident #23's son was going to take him/her to the oral surgeon appointment but was unaware if she was ever informed that the appointment was canceled as required. The Director of Social Services said the facility has had difficulties booking oral surgery appointments for residents with Medicaid insurance and who have a Guardian, however the Director of Social Services said the oral surgery office did not refuse to accept Resident #23. The Director of Social Services said Resident #23's son had agreed to pay for Resident #23's appointment but took the money back when he canceled the appointment and believes this may be a reason the appointment had not been rescheduled. The Director of Social Services said he was unaware if the facility attempted to rebook the oral surgery appointment, find a different oral surgeon that would accept Medicaid insurance or discussed covering the cost of Resident #23's dental treatment. During an interview on 3/3/23 at 10:33 A.M., Resident #23's Guardian said the dental problems have been an ongoing issue and the facility was trying to fix it. The Guardian at first could not remember why Resident #23 did not attend the scheduled oral surgery appointments but then remembered that the Resident's son canceled the appointments. The Guardian said she was never consulted prior to the Resident's son canceling the appointment and does not remember receiving a call back from the facility regarding rescheduling the appointment. The Guardian was unsure of the current status of the appointments and said, I think we could have done better. During interviews on 3/2/23 at 1:09 P.M., and 3/3/23 at 9:28 A.M., the DON said Resident #23 had an oral surgery appointment scheduled but the Resident's son had canceled the appointment. The DON was unable to say whether the Resident's Guardian was aware of the canceled appointment. The DON said she was unsure if any other attempt had been made to reschedule an appointment and said Resident #23's repeated mouth infections are related to the dental work that needs to be completed.

Based on observation, record review and interview the facility failed to identify a significant weight loss in a timely manner for 1 Resident (#23), out of a total sample of 21 residents. Findings include: Review of the facility policy titled; Weight Surveillance, undated, indicated the following: -Resident weights are an important indicator of nutritional status and overall health status. -Re-weights are to be obtained if there is a three-pound discrepancy from the previous weight. Licensed staff will do a re-weigh and notify unit manager if discrepancy is accurate. -Unit Manager will report to Physician, Dietician, MDS Coordinator and Responsible Person, any significant unplanned weight loss or weight gain. -Significant weight change is considered if 5% or more gain or loss within one month, 7.5% or more gain or loss in three months, or 10% or more gain or loss in six months. Resident #23 was admitted to the facility in April 2013, with diagnoses including adult failure to thrive, cerebrovascular disease and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated, 12/14/22, indicated a Brief Interview for Mental Status score of 9 out of a possible 15, indicating moderate cognitive impairment. Further review of the MDS indicated Resident #23 required extensive assistance for personal hygiene tasks and limited assistance for eating. Review of Resident #23's weight's summary indicated the following: 1/11/23: 110 lbs. (Standing) 1/16/23: 111.5 lbs. (Wheelchair) 1/23/23: 108.8 lbs. 2/1/23: 109 lbs. 2/6/23: 108.9 lbs. (Standing) 2/14/23: 107 lbs. (Standing) 2/20/23: 98.5 lbs. (Sitting) - -9.55 % Loss Since weight on 1/23/23 2/24/23: 101 lbs. (Standing) 2/25/23: 98.0 lbs. (Standing) 2/27/23: 98.8 lbs. (Wheelchair) 3/1/23: 103 lbs. Review of Resident #23's medical record indicated the following: -A Quarterly Nutritional assessment dated [DATE], indicated Resident #23 weighed 120.5 lbs.(pounds) with a Body Mass Index (BMI) of 28.0. Weight loss is not a goal at this time due to history of unintentional weight loss. Goals for Resident #23 maintain current weight without further unintentional weight loss and return to usual level of intakes. -Diet Order dated 10/20/22, for dysphagia mechanical soft. Send soup for lunch/dinner. Fortified cereal with breakfast. Fortified mashed potatoes with lunch. -A Nutrition care plan, revision date 12/13/22, indicated nutritional problem related to variable intake and history of significant weight loss due to dementia and tooth pain. Interventions include monitor Residents' weight as ordered and record. Notify MD with weight changes +/- 3 lbs in one week, +/- 5 Lbs. in one month. Monitor/Record/Report to MD emaciation, muscle wasting, significant weight loss 3 lbs 1 week, >5% in 1 month, >7.5% in 3 moths and >10% in 6 months. -A Quarterly Nutritional assessment dated [DATE], indicated nutrition diagnosis of history of inadequate oral intakes related to tooth pain and reduced appetite evidenced by variable/poor intake and a weight loss of 12.1% in 90 days. Most recent weight 108.1 lbs. -Review of documented meal percentages for the month of February 2023 revealed the following: - 9 documented times 76-100% of his/her meal. - 23 documented times 51%-75% of his/her meal. -40 documented times 26-50% of his/her meal. -11 documented times ate 0-25% of his/her meal. - Refused 1 meal. Review of documented meal percentages for the month of January 2023 revealed the following : -8 undocumented meal times -12 times 76-100% of meal. -14 times 51-75% of meal -40 time 26-50% -16 times 0-25% -Refused 3 meals. Review of the clinical record did not indicate that the significant weight loss, that occurred on 2/20/23, was identified or addressed. During an interview on 3/02/23 at 12:11 P.M., Nurse #4 said the expectation for weekly weights is to notify the physician of weight change +/- 3 lbs. Nurse #4 was unable to identify documentation regarding the weight loss being identified. During an interview on 3/03/23 at 10:32 A.M., Resident #23's legal guardian said she was not notified of the significant weight loss of Resident #23 and said Resident #23 appeared gaunt the last time she visited. During an interview on 3/03/23 at 11:28 A.M., the Dietitian said she works one day a week in the facility. The Dietitian said she will run a weight report if she has time but relies on nursing for communication regarding any new weight loss. The Dietitian said the cause of Resident #23's weight loss is his/her tooth pain. The Dietitian said she was not notified of the significant weight loss on 2/20/23.

Based on record review and interviews, the facility failed to 1) prevent 1 Resident (#9) from choking by providing the wrong diet and 2) failed to prevent 1 Resident (#26) from falling out of a total sample of 21 residents. Findings include: 1. Resident # 9 was admitted to the facility in March 2018, with diagnoses including dysphagia (difficulty swallowing) and dementia. Review of Resident #9's most recent Minimum Data Set, dated dated dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she has moderate cognitive impairment. The MDS also indicates Resident #9 requires supervision for self-feeding at meals. Review of the nursing note dated 1/26/23, indicated the following: Note Text: Roommate was heard asking for help in the hallway. Writer rushed to check what was going on and noted that (Resident #9) was unresponsive, drooling, and lips looked blue. Writer called for help and started to rescue resident. Solid pieces of sprouts were removed from resident's mouth. Resident was repositioned since he/she was seated at a 90 degree angle and after several attempts to empty his/her mouth, resident gained consciousness, and was put on oxygen, blood pressure was noted to be elevated 208/110/92 on left hand, 164/112/102 on right hand. 911 was called, resident left the facility conscious, in a stretcher at 12:38. Review of the incident report dated 1/26/23, indicated the following: *Nursing description: Roommate was heard asking for help during lunch time. writer found resident drooling, lips looked blue and unresponsive. Writer shouted for help, removed pieces of food in mouth, repositioned resident and continued to remove visible pieces of food. Resident was able to breathe, put on 02 (oxygen), VS (vital signs) taken. BP (blood pressure) noted to be elevated. 911 was called and resident was sent out to [NAME] General conscious but not at baseline. *Description: Solid foods removed from mouth, as (he/she) gained consciousness, resident was encouraged to cough hard. Kitchen supervisor informed due to texture of food noted, DON and doctor all aware. *Factors: texture of food Review of Resident #9's physician orders at the time of this incident indicated Resident #9 had been prescribed the following diet as of 5/8/17: *House diet, dysphagia mechanical soft (IDDSI Level 5) texture, written 5/8/17. The therapeutic diet form provided to the surveyor indicated a dysphagia mechanical soft (IDDSI Level 5) texture diet would consist of ground meat with pureed vegetables and fruits. Review of Resident #9's Activity of Daily Living care plan last revised 1/20/23, indicated an intervention written on 2/17/21 for the Resident to have supervision for meals. Review of Resident #9's Dehydration care plan last revised 1/20/23, indicated an intervention written 11/20/20 for the Resident to have supervision with po (by mouth) intake. Review of Resident #9's Kardex (a form indicating the level of assistance needed for tasks) indicated Resident #9 requires supervision for meals. During an interview on 3/2/23 at 11:55 A.M., Nurse #2 said she was Resident #9's nurse on the day of the above incident. Nurse #2 said she was called to Resident #9's room and when she arrived the Resident was choking on his/her lunch. Nurse #2 said Resident #9's lips were blue, he/she was not responsive, and she needed to call a code blue. Nurse #2 said she pulled brussels sprouts out of Resident #9's mouth. Nurse #2 said Resident #9 did not have supervision during his/her meal and did not have pureed vegetables as ordered. During an interview on 3/2/23 at 12:02 P.M., the Speech Language Pathologist (SLP) said she recently evaluated Resident #9 due to a choking incident. The SLP said during Resident #9's choking incident, the Resident had not been given the correct prescribed diet of pureed vegetables and had been given regular brussels sprouts. The SLP said she believed the meal ticket used by the kitchen did not match the physician orders which may have caused the wrong diet texture to be sent to the Resident. During an interview on 3/2/23 at 12:54 P.M., the Director of Nurses (DON) said Resident #9 was eating in his/her room alone when the choking incident occurred. The DON said she could not remember the food that had been taken out of Resident #9's mouth because it happened prior to her arriving at the Resident's room but said the incident report and investigation concluded the incident occurred due to the texture of food the Resident received. 2. Review of the facility policy titled, Managing Falls and Fall Risk Policy Statement, undated, indicated the following: *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. *The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history falls. Resident #26 was admitted to the facility in September 2019, with diagnoses including encephalopathy and diabetes. Review of Resident #26's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15, indicating he/she is cognitively intact. Review of a fall incident report dated 1/14/22, indicated the following: *Description of incident: pt. (patient) was unattended in hall bathroom and transferred (attempted) from toilet to wheelchair (wheelchair). *Clinical summary: pt is impulsive and non-compliant with asking for help. Care plan indicates pt needs constant supervision with toileting and this did not occur. Staff education provided immediately following incident. Review of Resident #26's Activity of Daily Living care plan last revised on 2/27/23, indicated the following interventions: *Toilet use: the resident is extensive assist of 2 with washing hands, adjusting clothing, cleaning self and providing incontinent care. Review of Resident #26's Functional Performance care plan last revised 2/27/23, indicated the following intervention: toileting/incontinent care: total assist of 1-2. During an interview on 3/2/23 at 8:31 A.M., the Director of Nursing said Resident #26 sustained a fall when he/she was left alone in the bathroom. The Director of Nursing said the Resident should not have been left alone and this is why the fall occurred.

Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#30) out of a total sample of 21 residents. Findings include: Resident #30 was admitted to the facility in June 2022, with diagnoses hemiplegia (paralysis) of the left side. Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. On 3/2/23 at approximately 8:30 A.M., Resident #30 was observed sitting in his/her wheelchair. Resident #30's right foot was pointing towards the ground and inward. When asked, Resident #30 was unable to move his/her ankle. Review of Resident #30's medical record failed to indicate any other neurological disorders that would affect his/her right lower extremity. Review of the physical therapy evaluation dated 6/8/22, indicated Resident #30 had full range of motion of his/her right lower extremity, was able to weight bear on his/her right leg as tolerated and had no contraindications to therapy or activity. The evaluation did not indicate Resident #30 had a contracture of his/her right ankle. Review of a physical therapy evaluation dated 1/9/23, indicated Resident #30 had a new impairment of range of motion to the right lower extremity and that his/her functional limitations were present due to contracture. The evaluation indicated the contracture was of the right ankle but that physical therapy would not be treating the contracture because nursing would be managing this impairment. During an interview on 3/2/23 at 2:12 P.M., Certified Nursing Assistant (CNA) #7 said she is familiar with Resident #30 and provides care to him/her often. CNA #7 said Resident #30's foot is always pointed inwards/down. CNA #7 said the Resident used to be able to move his/her right foot but has not been able to for quite some time. During an interview on 3/2/23 at 2:00 P.M., Nurse #1 said she is very familiar with Resident #30 but was unaware of any decrease in the Resident's range of motion of his/her right ankle. Nurse #1 and the surveyor observed Resident #30's right ankle and foot together and Nurse #1 acknowledged the Resident's foot turns inward and pointing towards the floor. Nurse #1 attempted to provide range of motion to the Resident's right ankle joint and as she did so the Resident said it was painful to move. Nurse #1 was unable to move the ankle joint in any direction and said it felt stuck. Nurse #1 said Resident #30 is in bed a lot and does not move and this may be the cause of the decrease in range of motion to his/her right ankle. Nurse #1 said this is a change of range of motion because Resident #30 used to be able to move his/her right ankle. Nurse #1 said she has no idea when this decrease in range of motion occurred and had not informed the Director of Nursing or the Director of Rehabilitation that Resident #30 had a change in status. During an interview on 3/2/23 at 2:15 P.M., the Director of Rehabilitation (DOR) said he had never received a referral from nursing regarding a decrease in range of motion for Resident #30. The DOR also said he was unaware the physical therapist knew about the Resident's right ankle contracture. The DOR said he would expect that he would have been told about Resident #30's new ankle contracture and that a new contracture would be treated and informed of whether the outcome would improve a resident's functional level. During an interview on 3/02/23 at 2:35 P.M., the Director of Nursing (DON) said she expects the nursing staff to make a referral to therapy if there is a decline in a resident's range of motion. The DON said she was unaware Resident #30 had a new right ankle contracture and that both physical therapy and the nursing staff were aware of it.

Based on record review, interview and observation, facility staff failed to ensure its physical environment was free of hazards, which resulted in 1 of 19 sampled residents (Resident #44) falling and sustaining a broken finger and abrasion to his/her knee. On 5/9/19, at approximately 10:27 A.M., Resident #44 was walking on the facility's patio when she stumbled on a broken and uneven area in the cement floor and fell . Orthopedic findings indicated Resident #44 was diagnosed with [REDACTED]. Findings include: Resident #44's care plan for fall risk, dated 1/30/19, indicated he/she was at risk for falls due to poor safety awareness secondary to a [DIAGNOSES REDACTED]. Resident #44's quarterly Minimum Data Set (MDS) assessment, dated 4/10/19, indicated: intact cognition, used a walker for ambulation, had no balance impairments, did not require staff supervision for ambulation off the unit, and had [DIAGNOSES REDACTED]. Resident #44's Falls Follow-Up Assessment, dated 5/9/19, indicated at 8:57 A.M. he/she fell on the outside patio by tripping on the broken concrete floor while looking for a seat. The Falls Follow-Up Assessment indicated Resident #44 had been ambulating with a walker and wore hard soled slippers at the time of the fall. The Falls Follow-Up Assessment indicated that the concrete needed to be repaired and maintenance staff were notified. Resident #44's Pain Assessment, dated 5/9/19, indicated he/she complained of acute and mild right knee pain. Resident #44's nurse's note, dated 5/9/19, indicated he/she was ambulating with walker on outside patio and tripped on broken concrete. Fall witnessed by residents, no head injury witnessed. Resident has small scrape on right knee. First aid provided. Maintenance notified. Resident #44's nurse's note, dated 5/10/19, indicated he/she complained of left wrist pain and that it was swollen and bruised. Staff informed the physician and the physician ordered an X-ray and orthopedic consultation. Resident #44's Radiology Report, dated 5/10/19, indicated possible avulsion fracture base of the first metacarpal. Resident #44's physician order, dated 5/13/19 indicated to treat a left knee abrasion and send to the orthopedist for consultation on a fifth metacarpal fracture. Resident #44's Orthopedic Consultation Report, dated 5/13/19, indicated a [DIAGNOSES REDACTED]. An avulsion fracture to the fifth metacarpal is an injury to the pinky bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone. The surveyor interviewed Resident #44 on 5/21/19 at 9:38 A.M. Resident #44 said she fell outside on the patio while walking. Resident #44 said she stepped into a hole on the patio floor which resulted in breaking his/her hand, a hurt ankle and a cut knee. Resident #44 said there were others residents present on the patio, but no staff. The surveyor observed Resident #44 wearing a splint on his/her left wrist. The surveyor observed the patio on 5/21/19 at 1:30 P.M. The patio floor was made of concrete and had approximately 6 areas where the concrete had eroded and left depressions approximately 1 inch deep and between 5 and 7 inches across. Some of these eroded areas were covered with soft floor mats and orange cones. The surveyor accompanied Resident #44 to the patio on 5/23/19 at 11:30 A.M. Resident #44 pointed to a mat covering an area of the floor and said he/she fell in a hole located under the mat. Resident #44 said that there was no mat covering this area at the time of the fall. Resident #44 told the surveyor to be careful when walking on the mat because it was still hazardous. The surveyor stepped onto the mat and his foot sunk approximately one inch into a depression. The surveyor lifted the mat and observed an irregular eroded area of concrete measuring approximately 2 inches deep x 1 to 5 inches wide x 5 feet long. Resident #44 said that this area of eroded concrete had been present since the Winter. Resident #44 said that she tripped on the hole then fell into a metal table, hitting his/her head on the side of the table, and landed on the patio floor. The surveyor observed that there were 6 residents on the patio at this time and they had full access to the covered, and uncovered, areas of eroded concrete. The surveyor interviewed Resident #56, who was sitting on the patio, on 5/23/19 at 11:35 A.M. Resident #56 said that he/she was sitting on the patio and witnessed Resident #44's fall. Resident #56 said that Resident #44 tripped and fell and tried to grab onto a table to steady himself/herself, but fell to the patio floor. The surveyor interviewed the Maintenance Director on 5/23/19 at 1:32 P.M. The Maintenance Director said the patio floor, made of cement, began to break up over the winter due to icing and the application of salt. The Maintenance Director said he was aware of the eroded concrete but had been unable to patch these areas either before, or since, Resident #44's fall due to inclement weather. The Maintenance Director said that he was unaware if residents had been restricted from the damaged areas of the patio during this time period. The surveyor interviewed the Unit Manager on 5/23/19 at 2:05 P.M. The Unit Manger said that on 5/9/19, Resident #44 entered the residential floor and told her that he/she fell on the patio, but did not strike his/her head. The Unit Manager said she assessed Resident #44 and determined he/she had an abrasion to a knee, but the wrist was not swollen. The Unit Manager said that the next day, on 5/10/19, Resident #44's wrist had become swollen and he/she was sent for an orthopedics consultation. The surveyor interviewed the Administrator at different times during the survey period. The Administrator said that the facility had developed a quality improvement project to repair the eroded concrete on the patio. The Administrator said that the facility was in the process of repairing the concrete. The surveyor toured the patio on 5/23/19 at approximately 8:30 A.M., accompanied by the Administrator, and observed cones and soft floor mats covering some of the eroded area of concrete flooring. As of that time, there had been no repairs made to the concrete and residents continued to use and have full access to the entire patio. At approximately 10:00 A.M. on 5/23/19, the surveyor observed the Maintenance Director on the patio repairing the damaged concrete and had cordoned the affected areas to restrict resident access.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at increased risk for dehydration, the Facility failed to ensure his/her fluid intake and output was adequately monitored, after he/she experienced several days of loose stools and increased lethargy. On 10/29/18, Resident #1 was transferred to the Hospital Emergency Department where he/she was admitted and treated for [REDACTED]. Findings Include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care, and implement prescribed medical regimens. The Rules and Regulations 9.03 define Standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility Policy titled Hydration-Clinical Protocol, revised 9/2012, indicated that the staff, with the Physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc.) that might reflect existing fluid and electrolyte imbalance. The Policy indicated that staff would report this information promptly to the attending Physician. The Policy indicated that the Physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those with prolonged vomiting, diarrhea, fever, use of diuretics (a medication which causes increased water to be expelled from the body via urine) and angiotensin-converting enzyme inhibitor (also known as an ACE inhibitor used to treat high blood pressure) medications, and those who are not eating or drinking well. Resident #1's physician's orders [REDACTED]. mouth three times per day, and an order for [REDACTED]. A Nurse Progress Note, dated 10/15/18, indicated that Resident #1 was observed to be lethargic and all his/her 9:00 P.M. oral medications were withheld due to increased lethargy. A Nurse Progress Note, dated 10/16/18, indicated that Resident #1 was lethargic, had a temperature of 100.5 (average temperature is 98.6), laboratory blood work results indicated that his/her ammonia level was elevated (increased ammonia levels can be caused by severe liver or kidney disease and can result in changes in behavior and consciousness). The Progress note indicated that Resident #1's Physician was notified and orders were obtained for Resident #1 to be administered [MEDICATION NAME]. A Nurse Progress Note, dated 10/18/18, indicated that Resident #1 was incontinent of a large amount of loose stool and continued on [MEDICATION NAME]. A Nurse Progress Note, dated 10/20/18, indicated that Resident #1 was incontinent of loose stools. A Nurse Progress Note, dated 10/21/18, indicated that Resident #1's appetite was poor. A Nurse Progress Note, dated 10/23/18, indicated that Resident #1 was incontinent of loose stools, he/she refused to get out of bed, required maximum assistance from staff with meals, appetite was poor and fluid intake was fair. A Nurse Progress Note, dated 10/23/18, indicated that Resident #1 had an extra large amount of loose stool. A Nurse Progress Note, dated 10/24/18, indicated that Resident #1 was incontinent of a large amount of loose stools. Resident #1's Blood Laboratory Report, dated 10/24/18, indicated that Resident #1's blood sodium (an electrolyte) level was elevated (high levels of sodium in the blood is known as [MEDICAL CONDITION] which results from dehydration). A Nurse Progress Note, dated 10/25/18, indicated that Resident #1 had a moderate amount of loose stool. A Nurse Progress Note, dated 10/26/18, indicated that Resident #1's appetite was poor at breakfast. A Nurse Progress Note, dated 10/28/18, indicated that Resident #1 ate 30% of his/her breakfast, refused lunch, and Resident #1 had been sleeping all afternoon. A Nurse Progress Note, dated 10/29/18, indicated that Resident #1 was observed to be unresponsive and could not be aroused. The Progress Note indicated that Resident #1 was transferred to the Hospital for evaluation. A Hospital Report, dated 10/29/18, indicated that Resident #1 was treated for [REDACTED]. The Surveyor interviewed Nurse #1 at 12:26 P.M. on 1/4/19. Nurse #1 said Resident #1 was at risk for dehydration but said she could not recall if nursing staff monitored Resident #1's fluid intake and output (I & O). The Surveyor interviewed Nurse #2 at 2:55 P.M. on 1/4/19. Nurse #2 said Resident #1 was at risk for dehydration but he could not recall if Resident #1's I & O's were monitored by nursing. The Surveyor interviewed the Unit Manager at 1:59 P.M. on 1/4/19. The Unit Manager said inadequate hydration, diarrhea, and medications such as [MEDICATION NAME] and [MEDICATION NAME] could put a resident at risk for dehydration and said Resident #1 was at risk for dehydration. The Unit Manager said she could not recall if Resident #1's I & O's were monitored, but said she would have monitored I & O's for Resident #1 to determine if intravenous fluids were needed. The Unit Manager said she thought Resident #1 was being properly hydrated because she asked the Certified Nurse Aides if he/she was drinking. The Surveyor interviewed the Director of Nurses (DON) at 2:27 P.M. on 1/4/19. The DON said Resident #1 was at risk for dehydration because he/she was on diuretic medications and [MEDICATION NAME] and said she sometimes directed staff to monitor I&O's for residents who were taking diuretics. The DON said that monitoring I&O's does not require a physician's orders [REDACTED].>Review of Resident #1's medical record indicated there was no documentation to support that nursing staff monitored Resident #1's I & O's to monitor for dehydration. The Surveyor interviewed Resident #1's Physician at 1:19 P.M. on 1/11/19. Resident #1's Physician said he was not aware if nurses monitored Resident #1's I & O's but said nurses should have monitored Resident #1's fluid intake and output. Resident #1's Physician said it would have been extremely important to monitor Resident #1's I & O's because the information could have changed the management of Resident #1's care and helped to determine treatment.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) the Facility failed to implement and develop a comprehensive plan of care that addressed Resident #1's risk for dehydration, related to the administration of diuretics, blood pressure, and laxative medications daily. On 10/29/18, Resident #1 was transferred to the Hospital Emergency Department after he/she was found to be unresponsive by staff. Resident #1 was admitted to the Hospital and treated for [REDACTED]. Findings Include: The Facility Policy titled Hydration-Clinical Protocol, revised 9/2012, indicated that the Physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those with prolonged vomiting, diarrhea, fever, use of diuretics (a medication which causes increased water to be expelled from the body via urine) and angiotensin-converting enzyme inhibitor (also known as an ACE inhibitor used to treat high blood pressure) medications, and those who are not eating or drinking well. Resident #1's medical record Face Sheet indicated he/she was admitted to the Facility in (MONTH) of (YEAR), medical [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED]. mouth three times per day, and an order for [REDACTED]. A Nurse Progress Note, dated 10/18/18, indicated that Resident #1 was incontinent of a large amount of loose stool and continued on [MEDICATION NAME]. A Nurse Progress Note, dated 10/20/18, indicated that Resident #1 was incontinent of loose stools. A Nurse Progress Note, dated 10/21/18, indicated that Resident #1's appetite was poor. A Nurse Progress Note, dated 10/23/18, indicated that Resident #1 was incontinent of loose stools, he/she refused to get out of bed, required maximum assistance from staff with meals, appetite was poor and fluid intake was fair. A Nurse Progress Note, dated 10/23/18, indicated that Resident #1 had an extra large amount of loose stool. A Nurse Progress Note, dated 10/24/18, indicated that Resident #1 was incontinent of a large amount of loose stools. Resident #1's Blood Laboratory Report, dated 10/24/18, indicated that Resident #1's blood sodium (an electrolyte) level was elevated (high levels of sodium in the blood is known as [MEDICAL CONDITION] which results from dehydration). A Nurse Progress Note, dated 10/25/18, indicated that Resident #1 had a moderate amount of loose stool. A Nurse Progress Note, dated 10/26/18, indicated that Resident #1's appetite was poor at breakfast. A Nurse Progress Note, dated 10/28/18, indicated that Resident #1 ate 30% of his/her breakfast, refused lunch, and Resident #1 had been sleeping all afternoon. A Nurse Progress Note, dated 10/29/18, indicated that Resident #1 was observed to be unresponsive and could not be aroused. The Progress Note indicated that Resident #1 was transferred to the Hospital for evaluation. A Hospital Report, dated 10/29/18, indicated that Resident #1 was treated for [REDACTED]. The Surveyor interviewed Nurse #1 at 12:26 P.M. on 1/4/19. Nurse #1 said Resident #1 was at risk for dehydration but said she could not recall if nurses monitored Resident #1's fluid intake and output (I & O). The Surveyor interviewed Nurse #2 at 2:55 P.M. on 1/4/19. Nurse #2 said Resident #1 was at risk for dehydration but he could not recall if Resident #1's I & O's were monitored by nursing. The Surveyor interviewed the Unit Manager at 1:59 P.M. on 1/4/19. The Unit Manager said Resident #1 was at risk for dehydration, could not recall if Resident #1's I & O's were monitored, but said she would have monitored I & O's for Resident #1 to determine if intravenous fluids were needed. The Unit Manager said she thought Resident #1 was being properly hydrated because she asked the Certified Nurse Aides if he/she was drinking. The Surveyor interviewed the Director of Nurses (DON) at 2:27 P.M. on 1/4/19. The DON said Resident #1 was at risk for dehydration because he/she was on diuretic medications and [MEDICATION NAME]. Review of Resident #1's Medical Record indicated that there was no documentation to support that the facility developed or implemented a Care Plan which indicated he/she was at risk for dehydration.

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 resident (#2) in a total sample of 16. Findings include: 1. The facility failed to provide the necessary care and services for the prevention and treatment of [REDACTED]. Resident #2 was identified during the entrance tour on 11/21/10 as having a stage IV pressure ulcer and Osteo[DIAGNOSES REDACTED]. The resident had been seen in the wound clinic on 11/1/10 at which time the sacral wound measured 8.5 centimeters x 8 centimeters and 4.8 centimeters in depth. Bone was exposed. A treatment was started of closed pulse irrigation. At 12:25pm on 11/21/10, resident #2 was observed lying in bed. A bowl of cereal and milk was observed on the over bed table. The resident was asked if the cereal was part of breakfast and replied "yes, but I was in too much pain to eat." The resident further stated that she was prescribed both [MEDICATION NAME] which was scheduled and [MEDICATION NAME] which was available every 4 hours as needed (PRN). The resident stated that the [MEDICATION NAME] was not working and that the [MEDICATION NAME] did not take the pain away. Resident #2, when asked to rate the pain stated that the pain level was a 10 (on a scale of 1 to 10 with 1 being the least amount of pain and 10 being excruciating pain.) Review of the medical record revealed a dietary note, dated 11/17/10 which documented that the resident had a 5% weight loss in the past 30 days and documents that "pain effects PO (oral) intake." Review of the medical record revealed that there was physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/22/10, this surveyor asked treatment nurse #1 for notification when the treatment to the resident's pressure ulcer would be done. At 1:30pm, treatment nurse #1 stated that the resident had complained of a pain level of a 10 and that the doctor's office had been called. Treatment nurse#1 stated that she had obtained an order to give the resident a second [MEDICATION NAME] before the treatment. At 2pm, treatment nurse #1 stated that the resident was anxious and therefore had been administered a PRN [MEDICATION NAME]. Treatment nurse #1 stated that the [MEDICATION NAME] needed to take effect before the treatment could be done. At 3pm on 11/22/10, treatment nurse #1 notified this surveyor that the treatment was going to be done. The physician's orders [REDACTED]. Upon removal of the old dressing, the wound was found to have fresh bleeding and undermining (which was not measured). Resident #2 began to voice "ow, ow" with more frequency and loudness as the treatment went on. Treatment nurse #2 would stop, ask the resident if she was okay and then resume the treatment. After 2/3 of the solution had been used, the resident stated "ow, ow" more forcibly than the previous statements of discomfort. Treatment nurse #1 stopped the pulse lavage and asked the resident if she was in pain. The resident stated "yes." Treatment nurse #1 told the resident "I know it's sensitive, we're almost done" and began to resume the treatment. This surveyor asked the resident if resident #2 could rate the pain at the present moment. Resident #2 replied that the pain was a 10 on a scale of 1 to 10. Treatment nurse #1 still had the pulse lavage handle ready to restart the treatment and was instructed by this nurse to stop the treatment. Treatment nurse #1 stated that she would call the doctor's office to see if an order could be obtained for better pain control. Interview with treatment nurse #1 on 11/22/10 following this treatment observation revealed that the resident had been given a PRN dose of [MEDICATION NAME] at 10:40am. When the treatment nurse #1 had called the physician's office at 1:30pm (before the treatment) an order had been obtained for [MEDICATION NAME] 1 tablet before the treatment which was given at 1:40pm, (this was not [MEDICATION NAME] 2 tabs as the treatment nurse had stated, as there was a 3 hour span between the 2 doses of 1 tab each time). On 11/23/10, during a follow up interview with treatment nurse #1, it was revealed that when the physician's office had been called on 11/22/10 after the treatment observation, a covering nurse practitioner was asked for a palliative pain consult and the resident's lack of pain control was explained. Treatment nurse #1 stated that the nurse practitioner had declined to give any further orders in order to not overstep the resident's primary nurse practitioner. (This meant that resident #2 had not received any further intervention to address a pain level of 10 out of 10 on 11/22/10 after the treatment.) Treatment nurse #1 was asked if the physician had been called. Treatment nurse #1 stated that the physician had not been called as calls to the physician's number during the day was answered by an answering service which routed calls to one of two nurse practitioners responsible for the residents during the day shift. The physician was available after 3pm if needed when the nurse practitioners were not on call. Treatment nurse #1 acknowledged the poor pain control for this resident and stated that the resident had refused the pulse lavage treatment on 11/23/10 secondary to pain. Treatment nurse #1 stated that the resident had originally reported on 11/23/10 a pain level of 5 (moderate pain) after the scheduled dose of MS Contin. However, the resident reported a pain level of 10 soon after and stated that it was because of movement (any movement causing an increase to a rating of 10 for pain.) The primary nurse practitioner for this resident arrived at the nursing facility on 11/23/10 at 2pm. Upon interview at 2:30pm, the nurse practitioner stated "....I gave them the order for the extra [MEDICATION NAME] yesterday." This surveyor shared her observations with the nurse practitioner regarding the level of pain the resident had experienced during treatment. The nurse practitioner stated ".... what (resident #2) needs is an increase in the MS Contin, I don't know why the resident agreed to the pulse lavage treatment.... the last time it was done, (the resident) had said it was extremely painful." Unit manager #1 approached this surveyor at 3:15pm. Unit manager #1 stated that the resident's primary care physician had called the facility to speak with the nurse practitioner. Unit manager #1 stated she took the opportunity to speak with the physician regarding the resident's pain. The physician had ordered the frequency of the PRN [MEDICATION NAME] to be changed to every 4 hours (previously every 6 hours) not to exceed 6 tabs in 24 hours. The Director of Nurses stated on 11/23/10 that the primary care physician should have been notified on 11/22/10 or the staff should have notified her to intervene (as the Director stated that if unable to reach the primary care physician that the medical director would have been called.) The Director of Nurses further confirmed that the resident should not have waited more than 24 hours to have pain, stated at an excruciating level, to be addressed.